Full text of Services for Crippled Children Under the Social Security Act : Title V, Part 2, Development of the Program, 1936-39, Bureau Publication No. 258

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U N IT E D STATES DEPA R TM EN T OF LABOR
F R A N C E S P E R K IN S , S e c re ta ry

C H I L D R E N ’S B U R E A U
K A T H A R IN E F . L E N R O O T , C h ie f

+

Services for Crippled Children
Under the Social Security Act
T itle y , Part 2

Development of Program, 1936-39

Bureau P ublication
No. 258

For sale by th e S u p erin ten d en t o f D ocum ents, W ashington, D . C.


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P ric e 15 c e n ts


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CONTENTS
P ag e

Letter of transmittal___________________________________________________
Development of program, 1936-39____________________________________
The social-security program for crippled children__________________
The children receiving service------------------------------------------------------Organization of State agencies-------------------------------------1---------------Registration of crippled children____________________________________
Admission procedure_______________________________________________
Conducting a crippled children’s clinic---------------------------------------------Services for children not in need of hospitalization-------------------------Arranging for hospital care_________________________________________
The crippled child in the hospital-------------------------------------------------Planning for aftercare-------------------------------------------Quality of service__________________________________________________
Crippled children in the United States------------------------------------------The children on State registers, 1938--------------------------------------------Distribution by sex. _ _______________________________________
Distribution by age_________________________________________
Distribution by race_________________________________________
Distribution by principal types of diagnosis----------------------------Classification of crippling conditions by diagnosis, 1939-----------------Services rendered crippled children---------------------------------Limitations of the crippled children’s program----------------------------------Advances to be sought_______________________________ ——-------------State summaries of progress, 1936—3 8 -------------------------------------------------Appendix.— Text of the sections of the Social Security Act relating to
grants to States for services for crippled children, as
amended by the Social Security Act Amendments of
1939..................................

V
1
3
6
8
12
13
14
16
17
17
21
25
28
30
31
34
36
38
41
43
47

92

TABLES
1. Federal payments to States for services for crippled children under the
Social Security Act, title V, part 2, for the fiscal years ended June
30, 1936, 1937, 1938, and 1939________________ . ________________
2. Growth of State registers of crippled children, September 30, 1936, to
December 31, 1939_____________________________________________
3. Number of crippled children on State registers, December 31, 1939,
and number per 1,000 population under 21 years (1930 census),
by State_________________________________
4. Sex of crippled children on State registers, by Sta'te, June 30, 1938__
5. Age distribution of crippled children on State registers, June 30, 1938,
and of general population under 21 years of age, 1930 census______
6. Age of crippled children on State registers, by State, June 30, 1938—
7. Race distribution of crippled children on State registers June 30, 1938,
and of general population under 21 years of age, 1930 census-------


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25

27
30
31
33
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IV

C o n te n ts
P age

8. Race of crippled children on State registers, by State, June 30, 1938_
9. Number of crippled children on State registers, by type of diagnosis,
June 30, 1938_________________________________________________
10. Number of crippled children on State registers, by type of diagnosis
and by State, June 30, 1938____________________________________
11. Number in specific diagnostic classifications, percent distribution, and
number per 10,000 population under 21 years; crippled children on
State registers, December 31, 1939_______________ ______________
12. Crippled children on State registers and services for crippled children,
calendar years 1938 and 1939___ _______________________________

35
36
37

38
40

CHARTS
1. Growth of State registers of crippled children, 1936-39______________
2. Number of crippled children on State registers, June 30, 1938, per 1,000
population under 21 years of age (1930 census), by State__________
3. Number of crippled children in specified age groups on State registers,
June 30, 1938, per 1,000 population in same age groups(1930 census).
4. Number of white and Negro crippled children on State registers, June
30, 1938, per 1,000 population of these races under 21 years of age
(1930 census) for selected States______________ __________________
5. Percentage distribution of crippled children, by diagnosis, December 31,
1939___________________________________________________________
6. Percentage of annual Federal allotments of funds for services for
crippled children, matched by States in the fiscal years 1937 and
1939, Social Security Act, section 512 (a )_________________________


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29
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36
39

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LETTER OF TRANSMITTAL
U n it e d St a t e s D e p a r t m e n t of La b o r ,
C h i l d r e n ’s B u r e a u ,

W a sh in g to n , D ecem ber 18, 1940.
M A D A M : There is transmitted herewith Children’s Bureau Publi­
cation No. 258, Services for Crippled Children Under the Social Security
Act; development of program, 1936-39. This bulletin includes a
description of the cooperative Federal-State program for services for
crippled children made possible by Federal grants to the States under
title V, part 2, of the Social Security Act (1935).
The Federal phases of the program have been administered by the
Crippled Children’s Division, Robert C. Hood, M. D.* Director, under
the supervision of Martha M. Eliot, M. D., Assistant Chief of the
Children’s Bureau.
Respectfully submitted,
K a t h a r i n e F. L e n r o o t , Chief.
H o n . F r a n c e s P e r k in s ,

Secretary o f Labor

v


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Services for Crippled Children
Under the Social Security Act
Development of Program, 1936-39
The year 1936 marked the beginning of a new stage in the care of
crippled children in the United States. Federal grants for services for
crippled children under the Social Security Act (approved August 14,
1935),1totaling approximately $732,500, went to the States for expendi­
ture during the 5-month period ending June 30, 1936.
The growth of medical science during the past 75 years and the
development of orthopedic and plastic surgery brought the possibility
of physical restoration to many children suffering from crippling
conditions. The efforts of private individuals and physicians treat­
ing crippled children had built up a system of hospital service and
community assistance for the care of crippled children that led first
to State action and in 1935 to Federal action to provide funds for
services for crippled children.
The White House Conference on Child Health and Protection (1930)
gave impetus to the growing movement through its evaluation of serv­
ices available in the United States for the care of crippled children and
of educational services available for handicapped children. Its
report, in addition to recommendations on the education and voca­
tional placement of crippled children, called for legal authorization
for a program to find crippled children, to provide expert orthopedic
diagnosis and proper facilities for hospitalization and medical care,
and to establish a Federal program of research in behalf of crippled
children, including a national bureau of information that could also
distribute Federal money to State services for crippled children.2
Testimony presented before the President’s Committee on Economic
Security in 1934 and before congressional committees in 1935 showed
that by 1934 some provision had been made in 37 States for a State
department or commission or a State hospital to provide medical
l 49 S ta t. 620.
» W h ite H ouse Conference on C hild H e alth a n d P ro tec tio n : T h e H andicapped C hild, p p . 177-178.
C e n tu ry Co. (now D . A p p leto n -C en tu ry C o.), N ew Y ork, 1933.

1


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2

S ervices i o t C rip p led C h ild re n

treatment and hospital care for crippled children, and 35 of these
States had made appropriations for this purpose. In only a few States,
however, were sufficient funds available to carry on broad programs,
including the finding of crippled children throughout the State and
providing diagnosis, medical and surgical treatment, and aftercare
services for such children.
The Social Security Act as approved August 14, 1935, included
authorization for an annual appropriation of $2,850,000 for grants to
the States to enable each State to extend and improve services for
crippled children, especially in rural areas and in areas suffering from
economic distress. Federal funds for grants to the States for this pur­
pose were made available in February 1936. The Children’s Bureau
of the United States Department of Labor was made responsible for
the administration of this part of the Social Security Act.3
The program thus inaugurated was the first instance of Federal
and State cooperation in providing medical care involving Federal
grants to the States. The policies and procedures developed for carry­
ing on the crippled children’s program deserve close study from many
standpoints. Among these are: (1) The relationships of the Federal
administrative agency to the State crippled children’s agencies; (2) the
relationship of the State agency to other State and local public agen­
cies and institutions giving some form of service to crippled children;
(3) the development of cooperative relationships with private agencies
serving children or seeking service for crippled children; (4) the selec­
tion and training of the staff of the State crippled children’s agency;
(5) the protection of the quality of care made available for crippled
children through the development of standards for the selection of
physicians, surgeons, and other professional workers in private prac­
tice engaged to give treatment to crippled children and through the
adoption of standards for the choice of hospitals, convalescent homes,
and foster homes to which children are sent for care; (6) the develop­
ment of community resources for providing care for crippled children
who do not need to be hospitalized; and (7) the development of after­
care services to meet the health and social needs of the child who has
been given medical treatment.
In 1938 the Interdepartmental Committee To Coordinate Health
and Welfare Activities submitted to the President and to the public
the report of the Technical Committee on Medical Care proposing a
national health program. The Committee included among its rec­
ommendations the expansion of the program for crippled children,
under part 2 of title V of the Social Security Act, to provide within
10 years $10,000,000 annually for services for crippled children, of
which one-half, or $5,000,000, would be the Federal contribution.
®F o r th e te x t o f p a r t 2 o f title V o f th e Social S ecu rity A ct, pro viding for g ra n ts to th e S ta te s fo r
services for crippled children, see a p p en d ix , p . 92.


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D e v e lo p m e n t o f P rogram , 1936-39

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The Social Security Act Amendments of 1939, approved August
10, 1939, opened a new period in the development of services for
crippled children by raising to $3,870,000 the annual amount author­
ized for Federal grants to the States and by providing that of this
amount $1,000,000 would be allotted, without a matching require­
ment, on the basis of the financial need of each State for assistance
in carrying out its State plan, after consideration of the number of
crippled children in need of service and the cost of service. Except
for limited payments to some States the additional grants under this
authorization were made to the States after January 1, 1940. This
publication deals with the development of the program of services
for crippled children under the Social Security Act as passed in 1935.
The Social Security Program for Crippled Children
According to the terms of the Social Security Act of 1935, the Secre­
tary of Labor allotted to the States the annual appropriation on the
basis of $20,000 to each State and the remainder according to the
need of each State as determined after consideration of the number
of crippled children in each State in need of service and the cost of
furnishing service. These funds under the 1935 act were made avail­
able for payment of half the total expenditure under approved State
plans; that is, matching by State and local funds was required. Funds
allotted to a State in any year remain available for payment until
the end of the second succeeding fiscal year. Payments to the States
are made in accordance with State plans for services for crippled chil­
dren submitted to the Chief of the Children’s Bureau and approved
when they are in accord with the requirements of the act.4
The States promptly took the necessary action to take advantage
of the cooperation offered by the Federal Government. Most of the
States found it necessary either to create an official crippled children’s
agency to administer the crippled children’s program or to reorganize
and strengthen an existing public agency. By June 30, 1937, every
State6had designated a State agency to administer crippled children’s
services. By March 24, 1939, every State had obtained the approval
of the Chief of the Children’s Bureau, as required by the act, for its
State plan for services for crippled children and was matching in whole
or in part the Federal funds offered for this purpose.
The steady expansion of the program is shown by the increase in
Federal payments to the States for each fiscal year. As the Federal
* F o r th e te rm s u n d e r w hich th e F e d e ra l g ra n ts to th e S ta te s fo r services fo r crip p led children a re
m a d e see th e te x t o f p a r t 2 o f title V o f th e Social S e c u rity A ct, (ap p endix, p. 92). See also C h ild ren ’s
B u re a u P u b lica tio n N o. 253, G ra n ts to S ta te s for M a te rn a l a n d C hild W elfare U n d er th e Social
S e c u rity A ct o f 1935 an d th e Social S ecu rity A ct A m en d m en ts o f 1939 (W ashington, 1940).
1 T h e te rm “ S ta te ” in clu d es A laska, H aw aii, a n d th e D is tric t o f C olum bia.


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4

Services fo r C rip p led C h ild ren

grants were matched by State expenditures for services for crippled
children, the total expenditure each year was at least twice the
Federal payments. The total expenditure—Federal and State—for
the fiscal year 1939 amounted to approximately $6,000,000. Amounts
paid on the basis of approved plans for the fiscal years ended June 30,
1936, 1937, 1938, and 1939, are shown in table 1, page 5.
The Children’s Bureau of the United States Department of Labor, as
the Federal agency designated to administer the crippled children’s
provisions of the Social Security Act, consults with State agencies in
the development of their programs, brings to them the advisory
service of nationally recognized leaders in the professions involved,
who serve as members of advisory committees to the Children’s
Bureau, and makes possible an exchange of experience among the
States in the handling of the various problems that arise in adminis­
tering the services. The present bulletin includes a summary of
developments for the country as a whole for the years 1936-39, and
brief summaries written by the State administrators at the close of
the fiscal year ended June 30, 1938.
The Social Security Act (title V, part 2) describes in general terms
the purpose for which the Federal grants are to be used—to enable
each State to extend and improve (especially in rural areas and in
areas suffering from severe economic distress), as far as practicable
under the conditions in such State, services for locating crippled
children and for providing medical, surgical, corrective, and other
services and care and facilities for diagnosis, hospitalization, and
aftercare for children who are crippled or who are suffering from con­
ditions that lead to crippling.6
The plan for services for crippled children submitted by the official
State agency to the Children’s Bureau is required by the act to
include provisions for such methods of administration as are necessary
for the efficient operation of the plan, and provisions for cooperation
with medical, health, nursing, and welfare groups and organizations
and with any agency in the State administering State laws providing
for vocational rehabilitation of physically handicapped children.
The two provisions just cited impose upon the Federal administrative
agency, the Children’s Bureau, and upon the State crippled children’s
agencies responsibility for seeing that the program is well adminis­
tered from the standpoint of service to children and that cooperation
is maintained with the professional groups and other agencies that
are concerned with these services.
« F o r a m ore extensive d escription o f th e ad m in istra tiv e d ev elo pm ent o f th e F e d e ra l-S tate program
of services fo r crippled ch ildren, see sections on F ed eral A d m in istration a n d Services fo r C rippled
C hildren in C h ild ren ’s B u re au P u b licatio n N o. 254, F ed eral a n d S ta te C ooperation in M a te rn a l an d
C hild-W elfare Services U n d er th e Social S ecu rity A ct (M a te rn a l a n d C hild-W elfare B ull. N o. 2),
W ashington, 1938.


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D e v e lo p m e n t o f P rogram , 1936—39

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Table 1.— F ed e ra l p a y m e n ts to S ta te s fo r services fo r c r ip p le d c h ild r e n
u n d e r th e S o c ia l S e c u r ity A c t, tit le V, p a r t 2, fo r th e fisca l y e a rs e n d e d
J u n e 30, 1936, 1937, 1938, a n d 1939
F e d e ra l p a y m e n ts u n d e r ap p ro v ed S ta te plans
S ta te 1
Fiscal y ear
1939

Fiscal y ear
1938

T o ta l______________ __________ $2,997,914.77 $2,691,869.82
A la b a m a .. __
_ _________________
A lask a_____________________ _______ ___
A rizo n a.
_
____
C alifo rn ia_____________________________
C o lo r a d o __ __________________________
D is tric t o f C olum bia _________________
F lo rid a ------------------ ------------------------------

Id a h o __________________________________

K an sas-----------------------------------------K e n tu c k y . __________ _____________ __
M a in e ____

_______________________

M assa c h u se tts_____
_______________
_
_____ ____ ________
M ichig an __
M in n eso ta___________________________M ississippi_____________________________
M isso u ri_______ ______________________
M o n ta n a ______________________________
N e b ra sk a ______________________________
N ew H am p sh ire --------

------------------------------------

73, 994. 89
6 , 424. 62
3 7 ,2 1 1 .0 5
90, 450. 01
101, 230. 83
5 9 ,3 7 4 .
17, 976.
4' 979.
44, 428.
58, 218.

59
69
27
97
54

93, 711.13
23, 339. 95
23, 475. 41
179, 890. 07
70, 298. 78
57,
56,
85,
35,
36,

78,
4,
38,
52,
115,

000. 00
9 2 5.19
203. 22
943. 32
700. 99

193.
050.
629.
328.
134.

Fiscal y ear
1936 (F eb.
1 -J u n e 30)

$2,011,606.04 $732, 492. 33
37, 442. 61
2, 115. 62
21, 662. 74

17, 846. 21
1, 250. 00
10 , 608. 00

33, 731. 23

13, 758. ÓÓ

48, 794. 60

9, 500. 00

663. 32
57, 494. 66

5, 586. 68
15, 495. 00

49
29
89
57
75

4, 993. 75
15, 816. 03
18, 216. 52
4, 900. 00
2 6 ,4 1 1 .6 5

8 , 000. 00

58, 776. 94
36, 810. 00
82, 267. 04

9, 726. 64
26, 520. 10

21, 979. 97
33, 735. 60
4 , 349. 16
34, 201. 66
57, 792. 89
22,
14,
21,
135,
31,

Fiscal y ear
1937

576.
209.
000.
000.
940.

94
12
00
00
49

68, 679. 47
44, 996. 80
83, 038. 28

32, 489. 44

25, 465. 72

12, 057. 36

61, 861.
83; 052.
100 , 000.
73, 583.
34, 654.

06
23

48, 404.
84, 667.
97, 819.
62, 599.
34, 851.

36,
61,
99,
95,
12,

21, 233.
37, 000.
14, 379.
2, 487.

00

02
91

62, 404. 98
45, 270. 46
51, 163. 92
999. 99
11,229. 59

58
70
20
86

39

033.
591.
999.
161.
606.

56
71
99
00
40

60, 980. 00
30, 069. 88
55, 775. 46
1 , 000. 00
11, 884. 74

53, 629. 83
18, 869. 93
16, 552. 38

86, 711. 66

2, 500. 00

00
00
00
08

24, 598. 00
7, 900. 00
25, 000. 00
1, 500. 00

N ew J e r s e y .. ------------- ----------------------------N ew M e x ic o ____________________ ___________
N ew Y o rk ---------------------------------------------------N o rth C aro lin a ----------- ---- --------------------------------

79,
24,
117,
96,
28,

723.
241.
661.
537.
493.

44
98
54
05
67

50, 906. 47
48, 904. 58
120, 308. 46
84, 710. 10
4 5 ,1 8 5 .1 2

O hio --------------- ---------------------------------------------------------O klahom a --------------- ----------------------------------------------

06
52
70
70
24

138,
93,
24,
131,
34,

786.
986.
257.
929.
545.

07
16
50
79
75

158, fO l. 76
61, 825. 00

44, 650. 00
21, 508. 33

P e n n sy lv a n ia . ________________________
R hode Is la n d __________________________

121, 497.
77, 543.
24, 379.
163; 267.
22, 157.

106, 609. 05
5, 000. 00

55, 639. 00
3, 000. 00

S o u th C a r o lin a ________________________
S o u th D a k o ta _________________________
T en n essee. --------------------------------------T exas__________________________________
U ta h -------- -------------------------------------------

64, 412.
23, 540.
45, 986.
122,191.
29, 999.

09
17
87
76
98

4 7 ,1 6 9.
29, 798.
35, 914.
119, 074.
29, 999.

24
78
27
85
99

37,
26,
21,
152,
29,

00
77
75
75
99

8, 300.
12, 010.
25, 593.
49, 999.
7, 500.

00
74
00
92
00

V erm o n t_______________ _____________
------------------------------V irginia --------------- ----------W ash in g to n ______________ ____
W est V irg in ia ..
— --------W isconsin_________
-W yom in g ______________________________

18, 409.
72, 040.
54, 540.
53, 672.
69, 475.
8 ,1 9 1 .

87
08
00
75
00
79

19, 233.
70, 663.
50, 516.
69, 121.
59, 843.
3, 588.

11
25
42
97

12, 217. 40
73, 297. 33
43, 923. 40
80, 330. 10
49, 508. 55
6,124. 15

6 , 665.
21, 672.
14, 915.
26, 268.
22, 258.
9, 772.

00
57
00
27
63
92

66

49

27,
74,
72,
11,

1 T h e te rm “ S ta te ” includes A laska, H aw aii, a n d th e D istric t o f C olum bia,


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089. 28
162. 72
789. 71
728. 44

863.
551.
947.
717.
999.

37, 494.
7, 500.
61, 213.
32, 086.

88

00
00
00

6

Services fo r C rip p led C h ild ren

In the development of this Nation-wide program for the care of
crippled children valuable experience has been accumulated showing
how public-health and public-welfare agencies, physicians, and public
and private hospitals, under State programs, with Federal participa­
tion, collaborate in furnishing medical care and how the quality of
care given in such a program may be safeguarded.
The Children Receiving Service
An account of the crippled children’s program would not tell the
whole story without some presentation of the letters that come from
crippled children and from their parents, revealing the need for medical
care, the distress of the parents and the child when the family cannot
pay for the care needed, and the fresh hope and courage that come to
the child when treatment has improved his condition. Since the
inauguration of the social-security program, these letters coming from
the States are being referred to the State crippled children’s agencies
with assurance that the child’s condition will be diagnosed, and in the
majority of cases remedial treatment can and will be given.
The following letters have been selected from hundreds that come
to the Children’s Bureau or are referred to the Bureau each year.
They illustrate some of the many problems associated with medical
care and aftercare, with which the State agency helps the child and
his family to cope.8
I have had that dreadful disease, infantile paralysis. I can’t walk without the
use of crutches. I get very lonely watching other children play since I can’t run
and play like other children. I don’t believe anyone would be happier than I, if
I could walk. * * * You can’t realize how much I will appreciate it if there is
anything you can do.
I am a poor man, the father of five children, and out of work. I have a crippled
daughteraged 15. She walks one mile to school every day on a crippled leg. It is
very painful at times. * * * Will you please have the doctors straighten her
leg? I don’t want my child to be a cripple all her life. She would be so happy if
she could walk like other girls.

* * It is said I can walk perfect some day. I do not have to use my
braces and crutches any more, but I walk with a limp. Mother and Dad are very
poor and cannot afford to send me to the hospital for proper care. I can be cured
if I get the proper treatment which we cannot afford. * * * I am 15 years
old and go to high school. Pretty soon I will have to help support the family.
I know that if I were cured I’d have a much better chance to get a job in the
business world.
I am writing to ask for help. I really need it because my father works on
W. P. A. and makes only $39.00 a month. He has to pay house rent, $12.50, and
8T h ese le tte rs h av e b een changed in c e rta in p a rtic u la rs so th a t th e a c tu a l s to ry o f a n y child is n o t

told.


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D e v e lo p m e n t o f P ro g ra m , 1936—39

7

feed four in the family. M y mother is not well. She has to stay home and take
care of me as I am crippled and have been for 4 years with osteomyelitis. I do not
get nearly enough nourishing food to eat. My father is providing the best he can
and that doesn’t half supply me. I need milk, food, and something to dress my
wound with. It has to be dressed twice a day. I am not sick enough to be in the
hospital for that. Home and clinic service is better for me than hospital care.
M y father has no way of taking me to and from the clinic as often as my leg needs
to be dressed. I haven’t had cod-liver oil in 6 weeks, although the doctor said I
should have it every day. Surgery has my leg improving, but without food I
can’t make it. During the snow, I was cold and caught cold in my leg because of
no fire. I am 15 years of age. I would also like to have some schooling to keep
my mind busy.
* * * If she were incurable I might be able to reconcile myself but such a
little thing is wrong. The heel cord of her right leg is paralyzed and has not
grown. That little leg is shorter and often pains her severely. She cannot run,
she limps badly and often stumbles and falls. She will only grow worse with
time. Yet several doctors have said she could probably be cured if she could
have the benefit of hospitalization, hydrotherapy, and the services of an expert
orthopedic doctor. * * * My husband manages to make enough to keep
us off the relief and that is all. * * * But I am not too proud to ask for help
for my baby. I didn’t suppose there was any use until recently I have been told
that the Social Security Act provided for operations for the cure of crippled
children.

Many letters come back to the Children’s Bureau, reporting on the
results of investigation of appeals and of treatment given crippled
children. A mother wrote:
* * * My child was born with a double harelip and cleft palate and has
already gone through two operations. He is ready to go through the third and
we have not money for it.

Within 2 months the answer came back:
Dr. --------- reported by letter that the baby is to return t o ----------- Hospital
at an early date.

Again:
We were very happy over our son. And then the time came when we found out
that our son is paralyzed on his right side. He limps a little and cannot use his
right arm. * * * He is such a fine, straight, and tall boy, 9 years old and
bright—in the 4th grade in public school.

A year later the report came back:
This patient was admitted to the State hospital and is now ready for discharge
* * * The right arm was treated by placing the shoulder and arm in a plaster
cast. Later both the arm and foot responded very well to physiotherapy, and
surgical procedure was found to be unnecessary. The patient’s condition is
markedly improved.

It i§ not always that the end of the story can be satisfactory. The
State agencies for the most part must use their limited funds for the
care of crippled children for whom some substantial degree of physical

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restoration is possible. For some conditions custodial care from some
other source is all that can be provided. In some States the legal
definition of crippled child is so limited that treatment cannot be
given to children above a fixed age limit or to those disabled from con­
ditions not included in the law—conditions that might be covered in
another State. Again the amount of crippled children’s funds or the
hospital facilities may be so limited that there is delay between diagno­
sis and treatment. However, thousands of crippled children are being
given treatment each month because of Federal-State cooperation
under the Social Security Act.
Organization of State Agencies
The earlier State programs for crippled children under the Social
Security Act had been placed under welfare departments, education
departments, health departments, or independent commissions, de­
pending on the emphasis given by the State group through whose
efforts the first legislation or appropriation was obtained. Before the
passage of the Social Security Act medical-care services of various
types assumed by the States had been most commonly associated
with hospital or institutional care of the sick and the physically and
mentally handicapped, and were usually administered by State welfare
departments. Health departments, State and local, had sometimes
been given responsibility for medical care for persons suffering from
communicable diseases.
With the development of public-health services made possible by
Federal grants under the Social Security Act, State health departments
were strengthened, many more local full-time health units were organ­
ized, and maternal and child-health services and other preventive
health services were greatly extended. Associated with these de­
velopments there has been an increasing tendency to place upon the
public-health agency the responsibility for the crippled children’s
program.
By December 1939 the official crippled children’s agencies designated
by the States were as follows: The department of health in 26 States;
the department of public welfare in 14 States; a crippled children’s
commission in 5 States; the department of education in 5 States; and
a university hospital in 1 State.
That the program for crippled children is primarily one of medical
care is recognized in the selection of those who compose the profes­
sional staffs of the State agencies—orthopedic surgeons, pediatricians,
other medical specialists, public-health nurses, medical-social workers,
and physical-therapy technicians. A count in December 1939 showed
that in 35 States physicians were serving as directors of the program
and in 4 States physicians were serving as assistant directors.

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In the local phases of the program—locating crippled children, con­
ducting diagnostic and treatment clinics, and supervising aftercare
services in the home—the State crippled children’s agencies receive
the assistance of local health departments, welfare departments, and
school authorities.
The principal responsibilities of the State crippled children’s agen­
cies are: (1) To locate children in need of care and to maintain a State
register of crippled children; (2) to arrange for the diagnosis and treat­
ment of crippled children at permanent clinic centers or, in sections of
the State where there are no permanent centers, at itinerant clinics;
(3) to arrange for surgical and medical care by orthopedic surgeons and
physicians at selected hospitals; (4) to arrange for treatment and care
for children living at home, who do not need operative care or treat­
ment in a hospital; (5) to place children, when necessary, in convales­
cent homes or foster homes; (6) to provide or arrange for physicaltherapy treatments when indicated, after the child has returned
home; (7) to provide public-health-nursing and medical-social serv­
ices to the family for the purpose of continuing the care of the child
and helping him to make a social adjustment in the family, at school,
and in the neighborhood; and (8) to refer the child for training to the
State vocational-rehabilitation service.
To provide the necessary procedures for carrying through such a
program was the first administrative task of the State crippled chil­
dren’s agencies. Those with several years of experience had an ad­
vantage, but for most the social-security funds made possible either
a new program or a much more complete and extensive program than
had existed before these funds became available.
The Children’s Bureau, through its Crippled Children’s Division
and its orthopedic, medical, public-health-nursing, and medicalsocial consultants and through conferences of State directors of
crippled children’s services, aids in developing administrative pro­
cedures. The Children’s Bureau Advisory Committee on Services
for Crippled Children, the conference of State and Territorial health
officers, and State advisory committees on crippled children’s services
have given advice throughout this period of rapid development.
The State director of the crippled children’s program is responsible
for the organization and administration of services to crippled chil­
dren, and for maintaining cooperative relationships with other agen­
cies, public and private, that are concerned with one phase or another
of the crippled children’s program.
The State agency is responsible for maintaining the quality of
medical care. This responsibility involves the development of
standards for the selection of professional personnel and of hospitals,
and the dissemination of information regarding the prevention


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and early treatment of crippling conditions or conditions that may lead
to crippling. Owing to the fact that the crippled children’s program
is one involving numerous problems requiring decisions of a medical
nature, some of the State agencies have found it desirable to employ
a physician with training and experience in either public-health work
or pediatrics to serve as director of the program. In a few States an
orthopedic surgeon serves as director or consultant on the State staff.
A few State agencies also have employed pediatric consultants to
advise on the general medical care of children.
Public-health nurses and medical-social workers on the State staff
serve as consultants in their respective fields in the development of
the State program and in the supervision of the local phases of the
program.
Certain local administrative duties—such as receiving the names of
crippled children to be examined, arranging for clinic sessions, and
handling the necessary admission, discharge, and aftercare pro­
cedures—are performed by local public-health personnel in some
States and by local welfare workers in others. For such duties it is
customary for the crippled children’s agency in the State health
department to use local health units and for the crippled children’s
agency in the State welfare department to use local welfare depart­
ments. Regardless of where the initial administrative responsibility
rests, it is becoming the accepted practice for the local public-health,
agency, if it is in charge of the local program, to request the local
welfare agency to investigate the social factors to be considered in
arranging for the care of the crippled child, and for the welfare agency,
if it is in charge of the local program, to call on the local public-health
agency to arrange for the health phases of the provision for the
crippled child. The State supervising nurse and the medical-social
worker advise the local workers on the health and social phases of the
program.
The local public-health nurse increasingly is including the care and
health supervision of crippled children in her general family health
service in the home. Trained to recognize slight deviations from the
normal, the public-health nurse is in a position to bring to the atten­
tion of parents the need of medical care for the slight clubfoot, for
the limp that may be due to congenital dislocation of the hip, or for
some other restricted use of the arms or legs. Her close and frequent
association with the families through her work in the home, in the
school, and at the clinic gives her the opportunity to explain the
various phases of the crippled children’s program and, if it is neces­
sary, to convince the parents of the advisability of bringing the child
to the diagnostic clinic. During visits in the home she may explain
the mother’s responsibility for eliminating hazards in the home that

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may cause falls and burns which may result in crippling. She may
explain also the need for teaching children to safeguard themselves,
the importance of prompt medical care, and the home care that is
needed for minor injuries.
To make possible effective cooperation in the crippled children’s
program on the part of the nursing staff of State and local health
agencies, the nurse on the staff of the State crippled children’s agency
frequently serves as consultant in orthopedic nursing for the division
of public-health nursing in the State health department. In this
capacity she is responsible for staff-education programs in orthopedic
nursing and, with the supervisor of local public-health nursing, plans
the emphasis that the crippled children’s service should have in the
local nurse’s program, to the end that adequate nursing supervision
and care shall be given to all crippled children.
Similarly, in several States the medical-social worker on the staff
of the State crippled children’s agency is in a position to serve in
a liaison capacity between the State crippled children’s agency and the
State public-welfare agency and to assist in the instruction of county
or local welfare workers in regard to the phases of the crippled chil­
dren’s program in which their services are needed. The medical-social
consultant can develop procedures with the State welfare agencies so
that the local welfare worker may furnish to the State crippled
children’s agency social information that is pertinent in the care of
crippled children. The local welfare worker frequently has the
opportunity to bring to the attention of parents of a crippled child
the diagnostic and treatment services that the State agency can pro­
vide. Her advice is needed frequently to help in working out a social
situation in the home that is impeding the medical treatment or the
progress of a crippled child.
In the early stages of the crippled children’s program in many States
it was necessary to have the State public-health nurse or the medicalsocial worker give direct service to children in many areas of the
State. With the development of local health and welfare services, it
is increasingly becoming possible to call on the local public-health
nurse and welfare worker for work with individual children, thus
freeing the State workers for consultation and educational services.
A physical-therapy technician of the State staff in a few States
supervises the physical-therapy treatments given under medical
direction to children at home and the physical-therapy instruction
given to public-health nurses and to parents. Because the number in
local areas is limited, some of the State agencies have found it neces­
sary to employ physical-therapy technicians and place them in dis­
tricts to give direct service to crippled children, in addition to giving
instruction to nurses and parents.
2 3 9 0 2 1 °— 41------ 2


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Registration of Crippled Children
The registration of crippled children is a basic service essential to
the determination of the scope of the program. It is the first step
in arranging for the care of the individual child.
The initial surveys conducted cooperatively by public and private
agencies have led to more systematic and continuous registration
procedure under the leadership of the State crippled children’s
agencies. The schools have long given assistance in finding crippled
children, not only children of school age but also younger children.
Provision has been made in a few States for current reports from the
schools to the State crippled children’s agency or, at its direction, to
a cooperating local agency.
With the rapid development of the local health departments and
welfare departments during the past few years, the public-health
nurses and the welfare workers who visit families in their homes
assist the State crippled children’s agency in carrying on a continuous
inquiry to find crippled children in need of care.
Arrangements have been made in the majority of the States to have
epidemiological reports of children affected by infantile paralysis come
systematically into the office of the State crippled children’s agency.
In a steadily increasing number of States information on congenital
abnormalities or birth injuries is being recorded on the birth certifi­
cates, and this information is transmitted by the State health depart­
ment to the State crippled children’s agency for prompt follow-up.
At the request of the Children’s Bureau, the United States Bureau
of the Census, on January 12, 1939, sent out with its standard birth
certificate a list of optional items for recording this information.
Usually it is easier to find crippled children in the cities than in
rural areas. However, it has been found that the people in rural
areas readily cooperate in reporting crippled children in need of care
when they know about the services for crippled children offered by
the State agency and know the steps to be taken in referring a child
for care. The State crippled children’s agencies are developing in­
formation services designed to reach all parts of the States and espe­
cially the local officials and groups that can be most helpful at this
stage of the program.
In 1936 the Children’s Bureau submitted to the State agencies
forms for quarterly reports on the registration of crippled children.
In 1938 an outline of points to be observed in establishing a State
register of crippled children was sent out, and in 1939 a simplified
form for quarterly reports of crippled children on State registers was
issued. A guide for recording the diagnosis of crippling conditions
based on the Standard Classified Nomenclature of Disease was sent


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to the States in 1937 and a similar guide in expanded form was
issued in 1938. The purpose of such a record system is to promote
essential uniformity and completeness of records within each State
and for all the States. In 1938 the Children’s Bureau obtained from
the State agencies special reports on the sex, race, age, and diagnosis
of crippled children on the State registers.
Each year the records are becoming more nearly complete and are
yielding more reliable information on the number of crippled children
in the United States and on the character of the crippling conditions
from which they are suffering.
The State registers of crippled children are not limited to children
accepted for care by the State agency. It is intended that these
registers shall include dll persons under 21 years of age, living
in the State, who are suffering from crippling conditions as
determined by a licensed physician under the definition given in
the State law or regulations, regardless of their economic status, their
need for medical care, or the availability of treatment. When com­
pleted the registers will provide a dependable answer to the question
frequently asked, “How many crippled children are there in the
United States?”
Admission Procedure
For each child to be given service by the crippled children’s agency
it is necessary to arrange for a diagnosis. In the centers where
diagnosis is made at permanent clinics at frequent intervals the
State agency often arranges with a local cooperating agency to have
the child brought in at an early date, or the State workers arrange with
the parents or others to bring the child to the clinic.
In rural areas where clinics are held at less frequent intervals the
names of children listed for diagnosis are held until the day for the
clinic is set, and then arrangements are made for bringing the children
in for examination. In cases where immediate examination is nec­
essary, arrangements are made frequently to bring the child to the
nearest permanent clinic or to the office of the nearest orthopedic
surgeon.
The initial diagnosis is made under the authority of the State
crippled children’s agency by an orthopedic surgeon, usually at a
permanent clinic or at a special clinic session arranged for outlying
areas by the State agency. Increasingly, under the supervision and
with the aid of the public-health nurse and the medical-social worker
on the State staff, the local nurse and welfare worker assist in gather­
ing the medical and social history essential to planning for the care
of the child.
The admission procedure is a crucial point in the crippled chil­
dren’s program from the standpoint of determining the child’s need

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and arranging for care. It is necessary to make clear to the parents
and to the child what can and should be done and how the State
agency can provide the care that will benefit the child.
During 1937 the Children’s Bureau made studies of intake pro­
cedures in several States. As a result of these studies, intake pro­
cedures have been clarified and improved by the State agencies.
Conducting, a Crippled Children's Clinic
The experience of the past 3 years has resulted in the development
of certain principles and procedures for the successful handling of a
crippled children s clinic. These principles may be summarized as
follows:
It is important to have a representative of the State agency or a
responsible person in the local health or welfare unit make plans for
the clinic well in advance of the day the clinic is to be held. The
cooperation and interest of local physicians and of the county medical
society should be enlisted from the start. Suitable notices of the
clinic should be sent to the individuals and groups directly concerned.
The children to attend should be selected on some well-defined basis
such as children most urgently in need of diagnosis and care. The
number should be limited to give the orthopedic surgeon and other
specialists time for thorough examinations. Not more than 50
children, depending on the types of cases, should be seen by each
examining orthopedist at an all-day clinic with sessions morning and
afternoon.
The families should be notified when the child is to be brought to
the clinic, and frequently transportation must be arranged. Lay
workers should be asked to assist in arranging for transportation
and for luncheon for children and parents who remain through the
luncheon hour.
It is desirable to have the clinic held in a local hospital, when
possible, either in a public hospital or in a hospital to which the State
agency sends children for care. A hospital will usually have clinic
facilities available and diagnostic aids such as X-ray. The clinic
preferably should be on the first floor to make it unnecessary to carry
crippled children upstairs.
At the entrance a receptionist, preferably the local public-health
nurse who is known to those attending the clinic, directs the parents
and crippled children to the waiting room and explains the service
that is to be given. The receptionist should be able to recognize
symptoms which may indicate a communicable disease, to answer
questions with regard to the service, and to put parent and child
at ease.


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The clinic should have a sufficiently large waiting room, a portion of
which may be screened off for interviewing parents prior to the exam­
ination of the child by the orthopedic surgeon. There should be at
least two examining rooms, well-lighted and not too cramped, and a
third room for dressing. There should be adequate facilities for the
surgeons and physicians to scrub their hands between examinations,
and toilet facilities should be near the waiting room.
The personnel conducting the clinic should include an orthopedic
surgeon, a plastic surgeon, a pediatrician, the State orthopedic-nursing
consultant, a medical-social consultant, a physical-therapy technician,
and clerical assistants as needed. State agencies should arrange to
have present at the clinics a representative of the State vocational-,
rehabilitation service.
The medical-social worker and the public-health nurse assist in
obtaining the social and medical history of the crippled child on
admission. A lay assistant may take the parent and child to the
dressing room and aid in preparing the child for examination. Drapes
are provided for the children, especially for the older girls.
The pediatrician should give a general physical examination and
record his findings and recommendations on the chart that goes to the
orthopedist. A public-health nurse should assist the pediatrician and
should give him the additional information available about the child.
The physical-therapy technician should test the muscle response of
the child.
The orthopedic or plastic surgeon should make the examination of
the crippling condition affecting the child. The surgeon and the
pediatrician should confer regarding the future care of the child. The
State and local public-health nurse, the State medical-social worker,
the local welfare worker, and the physical-therapy technician should
also be available to confer with the surgeon in planning for the care
of the child. After the surgeon has completed his examination, the
child is returned to the dressing room.
It is particularly important that the recommendations of the ortho­
pedist and the pediatrician be clearly interpreted to the parents and
that any plans for the future care of the child be clearly outlined so
that there will be no confusion as to the immediate steps to be taken.
Space should be reserved at the clinic so that the interviews with the
parents can be held in private. The orthopedic surgeon should dis­
cuss with the parents the care needed for the child. Whenever the
child is to be accepted for care by the State crippled children’s agency,
it is necessary for a medical-social worker to learn the attitude of the par­
ents toward the proposed treatment, the conditions in the home affect­
ing the child’s care, and the financial resources of the family. On the
basis of this information, decisions can be made as to the extent to

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which the State will need to give assistance and as to the plan for
hospitalizing the child or for carrying out any other recommenda­
tion which may have been made by the orthopedist, such as the pur­
chase of an appliance.
In some States, following the clinic session, the physician in charge
holds a conference with the other professional workers to review the
record of each child and to decide upon the follow-up responsibility to
be assumed by each worker.
When it has been decided that a child in need of care does not come
within the scope of the State crippled children’s program, the medicalsocial worker should advise the parents regarding the appropriate
agency to which they may turn for assistance.
Reports from the State crippled children’s agencies for the year
ended June 30, 1939, showed marked progress in the development of
clinics for the diagnosis and treatment of crippled children. Clinic
sessions were held regularly in 359 permanent clinic centers, and 519
itinerant clinics were held at various points in the States.
The number of itinerant clinics held for diagnostic service only was
442 and the number held for both diagnosis and treatment was 64.
Orthopedic surgeons were present at all clinics. At only 46 of the
itinerant clinics was there a pediatrician in attendance. Local
physicians attended the majority of the clinics and in 8 States local
physicians assisted with the general physical examinations of the
children.
Services for Children Not in Need of Hospitalization
Large numbers of crippled children examined in diagnostic clinics
do not need hospital care, although they need medical supervision and
other services. Generally speaking, only about 25 percent of the
children with orthopedic and other crippling conditions examined at
clinics are recommended for hospitalization. About 75 percent are in
need of services that can be given while they are living at home. The
latter is a difficult group to treat as these children are scattered and are
frequently far away from the medical centers where out-patient
treatment can most readily be given. The State agencies recognize
the special needs of this group and are endeavoring to make more
adequate services available for them, such as treatment clinics,
physical therapy, public-health nursing, and social service.
Administrative problems involved in providing medical care and
auxiliary services for this group of children are similar to those involved
in providing aftercare services for children who have had a period of
hospital care.


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Arranging for Hospital Care
If the surgeon recommends medical or surgical treatment involving
hospitalization, arrangements must be made as promptly as possible
for admission to a hospital. When the diagnostician can foresee the
probable length of hospitalization and convalescence, his opinion is
basic in making financial arrangements and in preparing the family and
the child for the period of separation. Careful explanation to the
parents and the child by the surgeon, followed up by the nurse and the
medical-social worker, is important in obtaining the active cooperation
of the family and of the child in the treatment to be given.
The State agency assumes the responsibility for hospitalization and
medical care on the basis of the examining physician’s recommenda­
tion and the social investigation. The State agency refers the child
to the surgeon or physician who is to take charge of the treatment and
designates the hospital to which the child is to go. As soon as a bed
becomes available, the parents are notified and arrangements are
made for the transportation of the child to the hospital. Increasingly
the medical and social data accumulated by the State agency in
advance of hospitalization are being made available to the surgeon
in charge.
In the few States in which county funds are used to pay for the
care given crippled children, the county court commits the child either
to the State crippled children’s agency or to a State hospital for
care. The commitment procedure in such States varies even between
counties. Studies made by the Children’s Bureau found procedure
generally to be informal in character, and frequently without provision
for giving the judge the estimated costs of medical care or social and
economic data on which to base his decision as to the child’s eligibility
for public care. In some of these States the State agency is arranging
to provide to the judge, through local workers, all available informa­
tion that will be of assistance to him in making his decision.
Study of admission procedures points to the desirability of placing
in one agency, the State crippled children’s agency, both the responsi­
bility for determining the need of care and the provision of that care.
The Children’s Bureau Advisory Committee on Services for Crippled
Children at its December 1938 meeting recommended that the State
crippled children’s agencies assume final administrative responsibility
for determination of eligibility for care and seek to eliminate courtcommitment procedures.
The Crippled Child in the Hospital
A major responsibility of the State crippled children’s agency for
the care of the crippled child who needs medical or surgical treatment
or both in the hospital is the selection of a competent physician or

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surgeon and of a well-equipped and well-run hospital. Hospitals
are selected in different parts of the State so that care may be given as
near as possible to the child’s home.
The kind of treatment given the child is the professional responsi­
bility of the physician or surgeon in charge. The increase in the
numbers of crippled children given treatment in all parts of the coun­
try and the increased numbers of various types of conditions accepted
for treatment provide a volume of medical experience that gives
promise of distinctly advancing medical knowledge of crippling condi­
tions and methods of treatment.
The crippled children’s program will benefit steadily from results
obtained in research as to the prevention of diseases that cause
crippling conditions and as to the means of preventing crippling in
case these diseases occur.
Many State crippled children’s agencies have had the assistance of
advisory committees in working out payments for medical and
surgical service and for hospital care. Surgical and medical fees
have been agreed upon that take into account the time required, the
responsibility involved, the special technical skill required for the
treatment of crippled children, the total amount of funds available
for all service, and the number of children to be accepted for care.
Through conferences with hospital administrators agreements are
reached on hospital charges to provide the quality of care necessary
for this type of service. The tendency is to arrange for hospital
charges on the basis of a flat rate covering all essential services except
surgeon’s fees and appliances, based on the average cost of ward
care of crippled children for both acute and chronic conditions.9
More satisfactory methods of uniform cost accounting in the hospitals
are needed, and these are being developed in accordance with uniform
accounting practices recommended by the American Hospital
Association.
The problem of the length of stay in the hospital directly affects the
number of children who can be cared for, as this stage of treatment
is the most expensive. Information as to conditions in the child’s
home and the extent to which aftercare service is available in the
convalescent home, in the foster home, or in the community after the
child returns to his own home is important for the physician or surgeon
to have in making his decision as to when the child is ready to leave
the hospital.
Planning for Aftercare
Planning for the aftercare of the child in advance of his discharge
from the hospital is essential if the benefit of the surgical and medical
treatment given is not to be nullified by poor care afterward.
* T h is p ractice is in accordance w ith th e re p o rt, “ H o sp ital C are for th e N e ed y ,” m ad e b y a jo in t
c o m m ittee o f th e A m erican H o sp ital A ssociation a n d th e A m erican P ublic W elfare A ssociation
in H o s p ita ls , Vol. 13, N o. 1 (J a n u a ry 1939), p p . 22-29.


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In recognition of the importance of planning for aftercare service
the Children’s Bureau during 1938 made studies of discharge policies
and procedures in several States.
Basic to a discharge plan are the medical recommendations for the
child in respect to appliances, dressings, medication, activity, and
diet. The plan should provide for further medical supervision,
nursing supervision, and physical-therapy treatments, as necessary.
The home situation in regard to income, housing, and the person who
is to care for the child should be taken into consideration. Intangible
factors such as the crippled child’s reaction to physical handicap and
the family’s rejection or oversolicitude should be recognized as affect­
ing the ultimate outcome. Educational opportunity at school, if
possible, or at home should enter into the plan. The child’s medical
and social needs should form the basis for joint planning by the
physician and the worker responsible for arranging to have plans
carried out. Consultation with the parents by the surgeon and other
professional personnel develops understanding and confidence in the
parents in regard to the aftercare that is essential if satisfactory results
are to be attained.
Some State agencies depend upon the medical-social worker in the
hospital for planning aftercare service. In the better-developed
State services the medical-social worker on the State staff is primarily
responsible for planning at this point with the assistance of the hospital
social worker, when available, the surgeon, and the local health and
welfare agencies which can report on the family situation and resources.
Some State agencies have developed plans whereby they are peri­
odically informed of the child’s condition and progress in the hospital
so that they will be able to provide for the child when he is ready to
leave. The home from which the patient comes and the resources of
his community in terms of medical, nursing, and social services
must be known to the State medical-social worker and to the hospital
social worker so that they will be able to aid the physician in plan­
ning for the aftercare of the child.
There are many problems to be worked out in aftercare service,
especially in rural areas. Recommendations regarding medical super­
vision may be difficult to carry out. Transportation represents a
serious obstacle when the child must be taken many miles for re-exami­
nation. As families seek the advice of local physicians concerning
their medical problems, it is necessary to keep the local physician
informed of the child’s progress and need for further care. The State
clinics held periodically in different parts of the State are being used
for follow-up medical examinations by specialists and for adjustment
of braces. Local physicians are invited to be present so that they may
be informed as to the recommendations of the orthopedic surgeon or
the pediatrician.

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20

Services /or Crippled, C h ild re n

The best place for a child to convalesce is his own home provided
that home is satisfactory for his care. If the home is not equipped
to provide for the needs of the crippled child during the convalescent
period, first consideration should be given to augmenting the resources
in the home to meet these needs. Such provision may be in the form
of increased family income, additional household equipment, addi­
tional (personal) assistance in the home, or instruction of the parents
so that they will fully understand how to care for the child. A home
may be satisfactory from all points of view except that it is removed
from a source of medical, nursing, or physical-therapy service.
If convalescence must be provided for outside the child’s own home,
the choice of convalescent home or foster home is based on the child’s
need. If the child continues to need an appreciable amount of regular
medical and nursing service, the convalescent home or institution is
indicated. It is being used as an extension of the hospital for periods
of care that are relatively short. The foster home, which more
nearly represents the natural family unit, is being used when and
where possible for longer periods of care.
Placing a child in a foster home for a relatively extended period
involves a responsibility that cannot be assumed lightly. The
selection of a foster home demands skill, training, and experience.
Not only must a prospective home qualify as a suitable foster home
for children but also it must be proved to be a suitable home for the
type of crippling condition from which the child is suffering and for
the crippled child who is to be placed. The State crippled children’s
agencies, recognizing the seriousness of the responsibility, are finding
it desirable to enlist the assistance of child-welfare agencies or childwelfare workers skilled in child placement to aid in finding suitable
foster homes for crippled children. Of the 51 State agencies reporting
for the fiscal year 1939, 30 reported the use of 81 convalescent homes
for crippled children, and 526 foster homes were used in 36 States.
Increasingly it is becoming possible to reduce the number of days of
hospital care by the more extensive use of convalescent and foster
homes.
In the hospital, during convalescence away from home, and after
the child’s return home, such schooling as it is possible to arrange for
the crippled child is important in order that his educational handicap
may be kept at a minimum. Where the school authorities have
special funds for the education of crippled children, special teachers,
special classes, and special schools can be provided. In many areas
it is necessary for the State agency representatives to make what
arrangements they can, with the aid of the school authorities and
volunteer agencies, to provide teaching service or transportation to
school.

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D e v e lo p m e n t o f P ro g ra m , 1936—39

21

Occupational-therapy activities in the hospital and the convalescent
home are an important factor in aftercare services. Vocational train­
ing for the crippled boy or girl 16 years of age or over is now available
in every State through the State vocational-rehabilitation service.
Quality of Service
The State crippled children’s agencies recognize that maintaining
a high quality of service is their most important administrative
responsibility.
Standards for professional personnel to be employed on the State
staff or to be engaged for the care of individual children have been
established in most of the States, based upon requirements for certi­
fication by various national boards of medical specialties or other
certifying bodies, such as the American Board of Orthopedic Surgery,
the American Board of Pediatrics, and the American Registry of
Physical Therapy Technicians, or on standards set by national organi­
zations, such as the National Organization for Public Health Nursing
and the American Association of Medical Social Workers. The
review of State plans each year shows that increasingly these standards
are being met in the selection of State staffs.
The qualifications of the surgeons providing services for crippled
children under State programs have been maintained at a high level.
Of the 535 orthopedic surgeons employed during the fiscal year 1939
by the State agencies, 68 percent were certified by the American
Board of Orthopedic Surgery, a substantial increase over the number
certified in the previous year. Forty-six percent of the specialists
in plastic surgery employed by State agencies were certified by the
American Board of Plastic Surgery or the American Board of Surgery.
Of 189 nurses employed under the crippled children’s program, 69
had completed an approved course in public-health nursing, 40 had
preparation in orthopedic nursing, and 18 had completed an approved
course in physiotherapy. Twenty-nine workers employed on State
staffs had completed an approved course in medical-social work.
The strengthening of the State administrative staff is a natural
corollary to the growing understanding that this is a program of
medical service and that the professional services of the State staff—
the orthopedic-nursing consultants, the medical-social workers, and
the physical-therapy technicians—are as essential to the care of the
crippled child as are surgical and hospital care, and must be considered
service charges, not administrative charges.
In many States, particularly in those where difficulties have been
encountered in finding resident personnel with the required qualifica­
tions, provisions have been made for further training of staff personnel.
A considerable number of public-health nurses have received training
in public-health nursing, in orthopedic nursing, and in physical

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22

Services fo r C rip p led C h ild re n

therapy. A number of medical-social workers and physical-therapy
technicians have likewise been given supplementary training in their
special fields to equip them for work with crippled children. During
the fiscal year 1939, 73 persons received training in some field from
crippled children’s funds. Thirty-five received training in orthopedic
nursing, 20 in public-health nursing, 14 in physiotherapy, and 4 in
medical-social work.
Several universities and schools of nursing have arranged their
nursing curricula to serve to best advantage the trainee who is taking a
special course in public-health nursing or in orthopedic nursing in order
that she may return to her State to serve as a consultant or to give
direct service to crippled children. Schools of social work and centers
for physical-therapy training have been interested in developing
courses adapted to the needs of medical-social workers and physicaltherapy technicians who are to work with crippled children.
The Social Security Act Amendments of 1939 included the require­
ment that the State plans for services for crippled children after
January 1, 1940, should include provision for the establishment and
maintenance of personnel standards on a merit basis. After consulta­
tion with the Federal agencies administering social-security programs
and with State officials, the Children’s Bureau issued recommended
standards for the establishment and maintenance of a merit system
of personnel administration, including qualifications for professional
employees in the crippled children’s program. These were issued for
the guidance of the State crippled children’s agencies.
The two orthopedic surgeons of recognized national standing em­
ployed as part-time consultants by the Children’s Bureau have assisted
the State crippled children’s agencies in establishing active technical
relationships with representatives of the medical profession within the
States and in clarifying such relationships between the States, the
Children’s Bureau, and the various national orthopedic organizations.
Their attendance at State and National medical meetings has con­
tributed also toward increased understanding of the Federal-State
services for crippled children by members of State and National
orthopedic organizations and of the medical profession everywhere.
During trips into various States the orthopedic consultants and the
regional medical consultants of the Children’s Bureau, accompanied by
surgeons participating in the State programs, have visited diagnostic
clinics, hospitals, and convalescent homes. During such visits the
discussions have resulted in suggestions and recommendations to the
State agencies, hospitals, and participating surgeons. These cover
such matters as: The location of future clinics and the inclusion in
clinics of qualified technical personnel for nonoperative as well as
operative orthopedic work; the desirability of medical review of

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D e v e lo p m e n t o f P ro g ra m , 1936—39

23

cases prior to authorization for treatment; the standardization of
hospital admission procedures; the extension of the program to treat­
ment of nonsurgical cases; the extension of pediatric and other con­
sultation services; the improved selection of types of cases to be
treated, with due regard to the possibility of physical restoration; the
careful consideration of the necessary duration of treatment; the
development of technical follow-up services, including adequate
instruction on aftercare for local workers; the closer medical super­
vision of follow-up care to insure maximum benefit to the patient;
and the maintenance of adequate technical records to cover each
successive phase of care.
Local practicing physicians are urged to attend the crippled chil­
dren’s clinics to observe the examinations made by orthopedic surgeons
and to discuss with the surgeons the cases referred to the clinic by
them. Several State agencies have also conducted lecture courses
for the instruction of local practicing physicians on the recognition of
early signs and symptoms of crippling conditions and cofiditions that
lead to crippling. Prompt treatment may prevent the development
of the crippling condition or may lessen the severity of the injury.
Descriptions of standards being established by the State agencies
for the approval of hospitals indicate that most of the States are
using approval by the American College of Surgeons as a basis for the
selection of a hospital. Registration by the American Medical
Association is also considered in deciding whether a hospital should
be used.
The State agencies, in establishing their hospital standards, are
making use also of the special requirements for the care of crippled
children included in the recommendations of the Children’s Bureau
Advisory Committee on Services for Crippled Children. The
standards recommended for hospital care of crippled children included
the employment on the hospital staff of the following:
An orthopedic surgeon certified by or eligible for certification
by the American Board of Orthopedic Surgery.
At least one physical-therapy technician registered by or
eligible for registration by the American Registry of Physical
Therapy Technicians. All physical-therapy technicians em­
ployed should be responsible to the surgeon in charge.
At least one qualified nurse with experience in pediatric and
orthopedic nursing.
At least one qualified medical-social worker.
The recommendations specify also that the physical-therapy equip­
ment should include a room equipped with at least an exercise table
and some form of radiant heat and that the hospital should provide


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24

Services fo r C rip p led C h ild re n

for the detection and isolation of children suffering from communicable
disease. A further recommendation calls for the regular inspection
for fire hazards of hospitals and convalescent homes used by State
agencies for crippled children and for the compliance of such institu­
tions with the minimum requirements of State law with respect to
fire protection.
Of the 561 hospitals used for crippled children during the fiscal year
1939, 90 percent were approved by the American College of Surgeons.
This is an improvement over the preceding year. On the recommen­
dations of advisory committees, Federal and State, the State agencies
started their programs by requiring approval by the American College
of Surgeons as one of the basic hospital standards. From observation
of the type of service provided by hospitals it is apparent that addi­
tional standards are needed to indicate whether a hospital is equipped
to handle services for crippled children. Each year hospital facilities
are improving, and more hospitals are meeting the established
standards.
Through the steadily growing interest in the crippled children’s
program, hospital staffs have been increased and strengthened, and
much needed equipment has been provided. Most of the State
agencies have endeavored to find qualified hospitals well distributed
throughout the State so that children may be cared for as near their
homes as possible. Progress in that direction is necessarily slow
because of the fact that orthopedists are generally located in the large
urban centers.
Study has been given by both the State crippled children’s agencies
and the Children’s Bureau to more definite standards for the approval
of convalescent homes and foster homes. The need for increasing and
improving convalescent homes remains one of the most important
problems to be faced in the future development of the crippled
children’s program.
Whenever possible the foster homes selected for crippled children
should be those conducted by graduate nurses. The State publichealth nurse needs to maintain watchful supervision over the crippled
child in the foster home to see that the foster mother understands the
care needed by the child and to make sure that the child receives
adequate medical supervision.
As it is desirable to return a convalescent child to his own home
as soon as his condition permits, the quality of care that can be given
by the parents and other members of the family is an important factor
in planning care for a crippled child. In addition to arranging for
augmenting the economic and physical resources of the home, if
necessary the State crippled children’s agency provides for educational
service to the family to be given by the public-health nurse who ex
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25

D e v e lo p m e n t o f P ro g ra m , 1936—39

plains the day-by-day care of the crippled child. It is becoming the
practice for the State public-health-nursing consultant to transmit to
the local public-health nurse the physician’s or surgeon’s instructions
for the care of each crippled child after his return home, and for the
local public-health nurse to visit the home periodically to watch the
child’s progress.
In many instances vocational guidance is given crippled children
approaching 16 years of age, when they will be referred to the State
vocational-rehabilitation service for training for some occupation.
The attendance of a representative of the State vocational-rehabilita­
tion service at diagnostic clinics conducted by the State crippled
children’s agency has tended to develop a very close cooperative work­
ing relationship in meeting the needs of the individual crippled child,
with the result that many crippled children are now being better
equipped for life, vocationally as well as physically and socially.
Crippled Children in the United States
The State registers of crippled children on December 31, 1939,
listed approximately 249,000 crippled children whose condition had
been diagnosed by a physician. These registers, as shown by table 2
and chart 1, have been built up quarter by quarter since 1936, as the
State crippled children’s agencies, with the aid of Federal funds,
developed their programs for locating crippled children and providing
diagnostic service.
Table 2.— G ro w th o f S ta te re g iste rs o f c r ip p le d c h ild r e n , S e p t. 30, 1936, to
D ec. 31, 1939

Q u a rte r ended—

J>ir»e 3 0 ’ 1Q37

/ 1 037

____________________________________________________

________________________________________________

N u m b e r of
crippled
children
registered
85, 000
97, 000
109, 000
119, 000
120 , 000
133, 000
146, 000
147, 000
156, 000
172, 000
199, 000
225, 000
237, 000
249, 000

N um ber
of S ta te s
re porting

34
36
37
39
43
44
47
49
50
50
50
51
51
51

The mounting registration figure is of interest in relation to esti­
mates heretofore made of the numbers of crippled children in the
United States. The White House Conference on Child Health and


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S ervices fo r C rip p led C h ild ren

26

Chart 1.— Growth of State Registers of Crippled Children, 1 9 3 6 -3 9
(Based on quarterly reports)
NUMBER

1936

1937

1938

1939

Protection, 1930, recognizing the limitations on the quantitative
material then available, estimated that, depending on the type of
crippling conditions covered, there were roughly 300,000 to 368,000
crippled children in the United States.10
More recent material (1935-36) made available through the Na­
tional Health Survey has supported the use of an estimate of about
330,000 children with impairments of an orthopedic nature.11
As the State registers are built up according to each State’s legal or
administrative definition of a crippled child, there is inevitably some
variation in the types of crippling conditions included. The State
registers so far include mainly children with orthopedic or plastic
impairments, probably because the care provided by the State agencies
is as yet chiefly for these conditions.
The number of crippled children registered in proportion to the
population under 21 years of age ranged from 9.7 for Illinois down to
10T h e H a n d ica p p e d C h ild , p p . 133—136.
11N a tio n a l H e a lth S u rv ey : Sickness a n d

M edical C are Series, B ull. N o. 4, T h e P rev a le n c e a nd
Causes o f O rthopedic Im p a irm en ts. U. S. P ublic H e alth Service, W ashington, 1938. T h is b u lletin (p. 1)
gives a n e stim ate o f 210,000 children u n d e r 15 years o f age w ith orthopedic im pairm ents; estim ates
for children 15 y ears o f age an d over h av e been m ad e on th e basis of ra te s published in ta b le 2 a nd
appendix ta b le B.


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27

D e v e lo p m e n t o f P ro g ra m , 1936—39

1.1 for Louisiana 12(table 3). Although the growth of registration was
marked during the years 1936-39, the low registration rates in many
States indicate that the process of finding crippled children is still
far from complete.
Table 3.— N u m b e r o f c r ip p le d c h ild e n o n S ta te re g iste rs, D ec. 31, 1939,
a n d n u m b e r p e r 1,000 p o p u la tio n u n d e r 21 y e a rs (1930 census'), b y S ta te

S ta te

N u m b er

N u m b er
p er 1,000
p o p u latio n
un d er
21 years

T o ta l, 51 S ta te s .

248, 627

5 .0

Illin o is____
N o rth C aro lin a _
M o n ta n a .
V e rm o n t. _ - -----M in n e s o ta .
A l a s k a __ __ . . --------N ew H a m p sh ire . _
D is tric t o f C o lu m b ia---H a w a ii____
D e la w a re . . . .
. ..
M a i n e ______ — -W y o m in g .
--------R h o d e Isla n d _ --------I d a h o _____
. . . -K a n sa s _____
K e n tu c k y __
O k la h o m a ___ . . . .
W isc o n sin ..
..
-----N ew M e x i c o ______ __
N ew Y o rk ____ __
O reg o n ___—
N ew J e r s e y . _
A rizona___ __
-- -N o rth D a k o ta
M ich ig an ________ —

26, 953
1 5,343
2 ,0 3 5
1, 252
9, 038

9. 7
9 .4
9 .3
9 .0
8. 8
8. 7
8. 7
8 .3

201

1 ,485
1, 207
1, 40 6
660
2 ,301
686

1 ,930
1 ,3 9 8
5 ,3 3 0
8 ,461
7,841
7, 929
1 ,392
29, 849
2, 243
10, 049
1,172
1, 980
1 1,304

S ta te

U ta h
C o lo ra d o ..

__

S o u th C arolina

8.0

7 .4
7 .4
7 .4
7. 2
7 .1
7.1
7 .1
7.1
6. 8
6. 7
6. 7
6. 7
6. 6
6 .1
6. 1

N u m b er

L o u isian a

. . .

. .

.

___

3, 249
' 173
4, 528
L302
2,155
3 ,0 0 1
5, 330
6 ,0 6 2
4 ,3 2 7
4 ,4 7 2
5, 282
7, 638
10; 174
2, 219
5 ,4 7 3
T, 005
2, 992
3 | 525
1,425
1 ,9 1 9
5 ,4 4 7
1 , 228
2, 587
2, 249
6 , 398
1, 022

N um ber
p e r 1,000
p o p u la tio n
under
21 years
5. 9
5. 7
5. 5
5. 4
5. 2
5 .0
4. 8
4. 7
4. 7
4. 6
4. 3
4. 2
3. 9
3. 5
3. 5
3. 3
3 .1
2. 9
2. 5
2. 2
2. 2
2.0
1 .8
1. 7
1 .6
1 .1

5. 9

Based on the December 31, 1939, registration rates of the States
showing the highest number of crippled children per 1,000 population
under 21 years of age, the probable count for the United States
will exceed 400,000 when the registration in each State is more
complete. This estimate applies to the 1939 coverage, that is, mainly
to children with orthopedic and plastic disabilities.
However, at the close of 1939, several States were about to under­
take programs of care for children with rheumatic heart disease,
which involves finding these children and listing them on State
registers. As the States broaden their programs to cover more types
of crippling conditions, the probable count of children with physical
handicaps shown on State registers will undoubtedly exceed the esti­
mates made of the numbers of children with orthopedic and plastic
impairments.
l! A lth o u g h L o u isiana h as b een p ro v id in g care for crippled children for som e tim e, th e official
p ro g ram was a d o p te d a n d th e reg ister estab lish ed d u rin g 1939.
239021°— 41-----3


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S ervices fo r C rip p led C h ild ren

The Children on State Registers, 1938
A special study of the composition of State registers was made
by the Children’s Bureau at the end of June 1938, when 46 States,13
Alaska, Hawaii, and the District of Columbia reported a total of
146,506 crippled children on the State registers. The number of
crippled children ranged from 156 in Alaska to 14,265 in North
Carolina. Chart 2 (p. 29) shows the numbers registered per 1,000 popu­
lation under 21 years of age as reported in the 1930 census. These
rates ranged from 0.5 in Connecticut to 8.8 in North Carolina. The
rate for the entire group of 46 States, Alaska, Hawaii, and the Dis­
trict of Columbia was 3.2.
The variations in the ratios of registered crippled children to child
population reflect primarily differences in the completeness of the
respective State registers, as explained below. A second important
factor is the lack of uniformity in the definition of a “crippled child.”
Although true variations in the incidence of crippling doubtless exist,
their influence is negligible in comparison with the other factors.
The completeness of the respective State registers may be influenced
to some extent by the maturity of the State programs, a few of which
have been in operation many years. Although 35 States had made
appropriations for the care and treatment of crippled children prior
to the passage of the Social Security Act, the amounts of money were
very inadequate in some of these States, and only 12 had State-wide
programs of the type made possible under the act. In a few States
the delay in the registration in large metropolitan areas has resulted
in comparatively low rates of crippled children registered.14
The term “crippled children” is variously defined in the several
States. A review of State laws reveals differences extending from a
definition limiting services to children with motor disabilities to a
broad definition under which services may be made available to all
physically handicapped children, except children whose chief disabil­
ity is incurable blindness or deafness or who are mentally deficient. A
few States specifically include conditions such as rheumatic heart dis­
ease and diabetes.
“ Texas and Louisiana did not report. Texas had not yet established a register, and Louisiana
at that time was not participating in the crippled children’s program under the Social Security Act.
14 A m ong th e o th e r facto rs affecting th e com pleteness o f th e S ta te registers w ere th e a m o u n ts o f
S ta te a n d local fu n d s av ailab le for m a tc h in g F ed eral funds, th e effort directed b y th e official agency
to th e locatio n o f crip p led children, th e co o p eratio n o f o th e r agencies a n d o f p riv a te physicians in re ­
p o rtin g crip p led ch ild ren , S ta te policies w ith re sp ec t to ages o f children accepted for care, a n d th e
strictn ess o f th e req u irem en ts for adm ission to th e register. A lthough diagnosis b y a licensed p h y si­
c ia n is now a p rereq u isite for re g istra tio n in all S ta te s a n d a lth o u g h undiagnosed cases m ad e u p only
4 p e rc e n t o f th e to ta l on Ju n e 30, 1938, th e percen tag e o f undiagnosed cases in a few S ta te s w as
su b sta n tia l.


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29

D e v e lo p m e n t o f P ro g ra m , 1936—39

Chart 2.— Number of Crippled Children on State Registers, June 3 0, 1938, per 1,000
Population Under 21 Years of A g e (1930 Census), by State 1
NU MB E R PER 1,000 POPULATI ON UNDER El

0

1

2

3

4

6

6

7

0

9

I------ 1
------ 1
------ 1
------ 1
------ 1
------ 1
------ 1
------ 1
------ 1
NORTH CAROLINA
D IS T R IC T OF COLUMBIA
MICHIGAN
VERM ONT
MINNESOTA
NEVADA
NEW HAMPSHIRE
A LA SK A
K EN TU C K Y
W ISCO N SIN
RHODE ISLAN D
MONTANA
KANSAS
OKLAHOMA
WYOMING
HAWAII
NORTH DAKOTA
V IR G IN IA
W ES T V IR G IN IA
M A S S A C H U S ET T S
NEW M EXICO
MAINE
IDAHO

■■■■■■

UTAH
FLO R ID A
ARIZO N A
WASHINGTON
IOWA
A LA B A M A
SO U TH CA RO LIN A
CO LO RAD O
M A RYLAN D
SO U TH DAKOTA
N EBRA SK A
IN DIAN A
D ELA W A R E
NEW YORK
M IS S IS S IP P I
C A LIFO R N IA
OHIO
M ISSOURI
TEN N ESSEE
PENNSYLVANIA
IL L IN O IS
NEW J E R S E Y
OREGON
A R K A N SA S
GEORGIA
C O N N ECT ICU T
l 7 -r.ni<ngina had no plan in operation and Texas had no official register as of this date.


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S ervices fo r C rip p led C h ild ren

30
D istribution by sex.

Of the total number of crippled children reported by all States,
approximately 55 percent were boys and 45 percent were girls; in
the 1930 census the percentages of boys and of girls under 21 in the
population were about equal (50.4 and 49.6, respectively). Table 4
shows some variation in the percentages of boys and of girls on the
registers of the several States, but without exception there were
more boys than girls. The percentage of boys ranged from 50 in
New York to 60 in Arkansas, Georgia, and Hawaii.
Table 4.— S ex o f c r ip p le d c h ild r e n o n S ta te reg iste rs, b y S ta te ,
J u n e 30, 1938
Sex rep o rte d
S ta te i

T o ta l n u m ­
b er

Sex n o t re ­
p o rte d

P e rc e n t d istrib u tio n
N um ber
B oys

T o t a l ______________
A labam a 2_____ ______ __ __
A laska
___________
_ _
A rizona___ __
A rkansas _ _ _ _
C aliforn ia________ ____ _____

146, 506

146,115

G irls
55

N um ber
45

391

4, 346
4, 332
58
42
14
156
154
56
44
2
704
704
57
43
655
655
60
40
2, 920
2, 788
55
45
132
1,163
1,163
54
46
280
280
54
46
192
______
186
D elaw are _ _ _ _ .
51
49
6
D is tric t o f C o lu m b ia _____
1 ,130
54
1,128
46
2
2 ,3 0 9
______
2 ,3 0 9
F lo rid a _ _
_
55
45
G eorgia _____
_ ______
860
860
60
40
884
H a w a ii____________________
883
60
40
1
862
862
55
45
2, 780
Illinois *________________
2, 765
56
44
15
In d ia n a ____
______
2, 781
2, 780
53
47
1
3, 505
3, 505
54
46
K a n sa s____ __ ._ _.
4, 617
4, 605
55
45
12
7, 590
7, 590
55
45
1 ,350
1,3 5 0
53
47
54
1, 637
46
L 637
M assach u setts _ _
_____
7, 041
55
7, 025
45
16
M ichigan __
_ _______
14, 225
14, 225
53
47
M in n e so ta ____________7, 083
7, 040
55
45
43
1, 693
1, 693
58
42
1 ,8 1 6
1,8 1 6
57
43
1,355
M o n ta n a .. _
__ _______
1,340
53
47
15
1 ,385
58
1,385
42
56
209
209
44
1 ,174
56
N ew H a m p sh ire ----------- __
44
1, 167
7
N e w j e r s e y ..
. _______
1, 506
1, 506
52
48
932
932
53
47
N ew Y o rk . __ __________
9, 346
9, 335
50
50
11
56
14, 265
14, 229
N o rth C aro lin a ___ __
44
36
N o rth D a k o t a __ ____ __ _
52
48
1,555
1 ,5 5 7
2
54
46
3, 645
3, 645
O klahom a . . .
_ _
5 ,860
58
5 ,8 0 7
42
53
O regon
_ _ _ ____
254
254
59
41
P e n n sy lv an ia. _ _________
4, 254
48
4, 254
52
R hode I s l a n d ___ __________
1 , 668
1 , 668
53
47
S o u th C arolina __ . . .
56
2, 974
44
2,9 6 9
5
S o u th D a k o ta ______________
791
791
53
47
Tennessee .
________
1 ,550
1 ,5 4 6
57
43
4
U ta h _______
___________
985
58
985
42
994
994
54
46
V irginia
__
__ __
5 ,3 8 5
54
5, 385
46
W ash in g to n . _ _____
2, 056
2, 056
53
47
3 ,8 7 8
W est V irg in ia____ __
____
3 ,8 6 7
55
45
11
7,435
7,435
53
47
466
469
W yom ing _______________ __
55
45
3
i L ouisiana a n d Texas d id n o t re p o rt. Texas h a d n o t y e t established a register, a n d L ouisiana was
n o t p a rtic ip a tin g in th e crippled ch ild ren ’s p ro g ram u n d e r th e Social S ecu rity A ct.
* In clu d ed 397 children for w hom eligibility h a d n o t b een d eterm in ed a s o f J u n e 30,1 9 3 8 .
< As o f Sept. 30, 1938.


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31

D e v e lo p m e n t o f P ro g ra m , 1936—39
D istribution by age.

The number and percentage of registered crippled children in each
of the various age groups are shown in table 5, together with the per­
centage distribution of children in the same age groups in the general
population. These figures indicate that only 17 percent of the cripTable 5.— A ge d is tr ib u tio n o f crip p le d c h ild r e n o n S ta te re g iste rs J u n e
30, 1938, a n d o f g e n e ra l p o p u la tio n u n d e r 21 y e a rs o f age, 1930 c e n su s
C hildren

P e rc e n t of
general
p o p u la tio n
u n d e r 21

Age group
N u m b er

P e rc e n t

146, 506
Age re p o rte d - _ _ __________________________________

143, 533

100

100

U n d er 1 y e a r- ___________ ____________________
1 y ear, u n d e r 5 ___
____— ------------------- ______
5 years, u n d e r 10 ______
10 years, u n d e r 15____ _______
_
--------15 years, u n d e r 2 0 . -----------------------20 y ears, u n d e r 2 1 -------- ---------------- --- ----------------

3, 308
20, 887
33, 531
42 ,827
36, 613
6 , 367

2

4
19
25
24
23
5

15
23
30
26
4

2, 973

pled children registered were under 5 years of age, whereas fully 30
percent fell in the age group 10 years but under 15. The following
tabulation of cumulative percentages also reveals differences in the
distribution by age groups of registered crippled children and of
children in the general population:

Age group

Under
Under
Under
Under
Under
Under

1 year_____________
5 years____________
10 years___________
15 years______ ____
20 years___________
21 years___________

C u m u la tiv e p e r c e n t d is tr ib u tio n
G eneral p o p u ­
C r ip p le d c h i l ­
la tio n u n d e r
d ren o n S ta te
r e g is te r s J u n e
21 (1930
30 , 1938
census)

17
40
70
96

4
23
48
72
95

100

100

2

___

Comparison of the age distribution of registered crippled children
with that of the entire population under 21 in 1930 shows that infants
and younger children were not yet proportionately represented on the
registers of crippled children. Children under 10 years of age made
up 48 percent of the total child population, but only 40 percent of
the children registered as crippled.
The difference between the age distribution of registered crippled
children and that of children in the general population is illustrated
in chart 3. Crippled children on the register included 1.6 children
under 1 year of age for every 1,000 children of the same age in the
general population. The corresponding rate for children 1 year but


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S ervices fo r C rip p led C h ild ren

32

under 5 is 2.4 and for children 5 years but under 10, 2.9; the rates
for crippled children 10 years but under 15, 15 years but under 20,
and 20 years but under 21 were 3.8, 3.4, and 3.0, respectively. Al­
though the low rates for very young children may reflect to some
extent the smaller number of annual births since 1930 and conse­
quent smaller number of children in the lower age groups, the extent
of the variations indicates that differences in the incidence of crip­
pling may have been operative. An unintentional selective emphasis
in locating crippled children or in compiling the registers may also
have been operating.
Chart 3.— Number of Crippled Children in Specified A g e Groups on State Registers, June
3 0 ,1 9 3 8 , per 1,000 Population in Same A g e Groups (1930 Census)
N U M B E R PER 1 , 0 0 0 P OPUL AT I ON

AGE GROUP

1

2

3

4

UNDER I Y EA R
I YEAR,UNDER 5
5 YEARS,U N D ER 10
10 YEARS,UN DER 15
15 Y E A R S , UNDER 20
20 Y E A R S , UNDER 21

Thus, since many State agencies had not yet perfected their pro­
cedures for obtaining information from birth certificates, the number
of congenital deformities and birth injuries may have been understated
in the younger age groups.
When the figures for crippled children on the various State regis­
ters are analyzed, wide variations are found in the proportions clas­
sified in the several age groups (table 6). The proportion of the
total number of children registered who were under 1 year of age varied
from less than 0.5 percent in Idaho, Massachusetts, and Rhode
Island to 14 percent in New Jersey and Ohio; the proportion in the
age group 1 year but under 5, from 5 percent in Massachusetts and
Nevada to 28 percent in Kentucky; in the age group 5 years but under
10, from 15 percent in Massachusetts to 43 percent in Ohio; in the
age group 10 years but under 15, from 13 percent in Ohio to 49 per­
cent in Virginia; in the age group 15 years but under 20, from 8
percent in Ohio to 40 percent in Washington; among children 20
but under 21 years of age, from none in Virginia to 12 percent in
North Carolina. The reasons for the variations are manifold and in
many cases reflect restrictions operative under State laws, local
practices, or activities of various organizations. The unusually high
proportion of infants on the registers in New Jersey and in Ohio (both
14 percent) apparently resulted from the fact that crippling conditions

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33

D e v e lo p m e n t o f P ro g ra m , 1936-39

diagnosed at birth were reported to the State agency on birth certifi­
cates as a matter of routine. The unusually low proportions of
children 15 years of age and over in Kentucky (10 percent) and in
Ohio (8 percent) resulted apparently, at least in part, from the fact
Table 6.— A ge o f c r ip p le d c h ild re n o n S ta te re g iste rs, b y S ta te ,
J u n e 30, 1938
Age rep o rted
P e rc e n t d istrib u tio n
S ta te 1

T o ta l.
A labam a 2________
A lask a___________
A rizo n a__________
A rk a n sa s________
C alifo rn ia________
C o lo ra d o ._______
C o n n ec tic u t_____
D e law are________
D is tric t o f C olum ­
b ia ____________
F lo rid a __________
G eo rg ia__________
H a w a ii__________
I d a h o ___________
Illinois 4_________
In d ia n a __________
Io w a _____________
K a n sa s__________
K e n tu c k y ________
M ain e ___________
M a ry la n d ________
M assa c h u se tts___
M ich ig an ________
M in n e so ta _______
M ississippi_______
M isso u ri_________
M o n t a n a . .^ _____
N e b ra sk a ________
N e v a d a __________
N ew H a m p s h ire ..
N ew J e rs e y ______
N ew M exico_____
N ew Y o rk . ______
N o rth C aro lin a__
N o rth D a k o ta ___
O h io ____________
O k la h o m a _______
O reg o n__________
P e n n sy lv a n ia ____
R h o d e Is la n d ____
S o u th C aro lin a__
S o u th D a k o ta ----T en n essee_______
U ta h _______ _____
V e rm o n t________
V irg in ia-------------W a s h in g to n .____
W est V irg in ia___
W isco n sin_______
W y o m in g _______

T o ta l
n u m b er

N u m b er

Age n o t

20
10
15
5
years, years, years,
U nder 1u nyear,
d e r years,
under under under under
1 y e ar
5
21
20
15
10

(num ber)

146, 506

143, 533

2

15

23

30

26

4

2, 973

4 ,3 4 6
156
704
655
2, 920
1,163
280
192

4, 194
143
702
590
2 ,655
1, 163
280
186

2
1
1

17

12
12

21
22

3
5
3
3
4
7

152
13

1
1

5
4

19
18

29
32

28
31
30
28
32
30
25
29

22
20

13
27

28
33
28
24

1
1
2

24

1, 130
2 ,3 0 9
860
884
862
2, 780
2, 781
3, 505
4, 617
7, 590
1 ,350
1 ,6 3 7
7, 041
14, 225
7, 083
1,693
1 , 816
1,355
1 ,385
209
1,1 7 4
1 ,5 0 6
932
9, 346
14, 265
1 , 557
3, 645
5, 860
254
4, 254
1,668

2 ,9 7 4
791
1 ,550
985
994
5, 385
2, 056
3 ,8 7 8
7,435
469

1 ,1 0 6
2, 303
860
877
860
2 , 668
2, 654
3, 505
4 ,5 7 0
7, 540
1 ,327
1 ,637
6 , 768
1 4,159
7, 054
1,693
1 ,816
1, 263
1,375
208
1 ,117
1, 506
892
9 ,1 6 4
13, 843
1, 515
3, 645
5 ,8 4 8
253
4 ,2 1 2
1, 634
2, 522
789
1, 526
985
879
5, 385
2, 048
3, 715
7, 435
464

4

(3)

10

1
2
1

13
17

22

4

17
16
17
19
19
14
28

22
21
20

1

3
9
1
6
2
1

(3)
1
1
6

4
2
2

4
1

12

21

19
5
14
10

19
19
12

17
5
15

24
25

27

22
22

30
28
27
15
22
21

27
26
23
32
32
28

14

20

21

1
1
1
1

15
13

23
24
19

10

17

14

22

1
2
1

15
11

17

(3>
3

10
16

1
1

17
15
15
17
15

3
1

4
1
1

3
1

10

13
13
12

22

43
28
22

26
25
22
22

27
22

26
17
16
25
22

23

39
32
34
30
31
29
31
27
28
26
29
32
34
30
29
27
27
28
33
36
31
23
36
29
29
32
13
24
29
33
32
30
26
33
32
29
49
26
32
28
27

25
14
30
28
20

15
24
24
26
23
29
28
19
17
30
10

17
19
38
30
33
18

2
2

4
3
5

22
20

19
30
29
25
8

27
34
23
27
23
27

22

27
23
15
40
25
28
33

6
6

7
2
112

1
6

127

5
<3>
3

47
50
23

2
8

3

6

273

66

29

3

2

22

30
15
19

2

65
265

5
1

92
10
1

4
3

57

3

40
182
422
42

2
6

12

3
<3)

5
2

<3>

6
6

7

12
1

42
34
452
2

2
1

24

4

115

7
4

163

4

5

8

6

i L o u isian a a n d T exas d id n o t rep o rt. T exas h a d n o t y e t established a register, a n d L ouisiana w as
n o t p a rtic ip a tin g in th e crip p led ch ild ren ’s p ro g ram u n d e r th e Social S ecu rity A ct.
s In c lu d e d 397 ch ild ren for w hom eligibility h a d n o t b een d eterm ined as of Ju n e 30, 133».
3 Less th a n 0.5 o f 1 percen t.
4 As o f S e p t. 30, 1938.


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Services fo r C rip p led C h ild re n

that 17 is the age limit above which children may not be accepted
for care by these State agencies. Although the registers are intended
to include all crippled children under 21 years of age regardless of
the age limit that may be observed by the State in providing treat­
ment, it is evident that such limits have had an effect on the com­
position of the registers.
D istribution by race.

The data presented in table 7 indicate that whereas 88 percent of
the total population under 21 years of age was classified in the 1930
census as white, 10 percent as Negro, and 2 percent as “other,” apTable 7.— R ace d is tr ib u tio n o f c r ip p le d c h ild r e n o n S ta te re g iste rs J u n e
30, 1938, a n d o f g e n e ra l p o p u la tio n u n d e r 21 y e a rs o f age, 1930 c e n su s
C hildren
N um ber

P e rc e n t o f
general
p o p u la tio n
u n d e r 21

P e rc e n t

T o ta l_____

146, 506

R ace re p o rte d ___

141, 205

100

100

W h ite ..............
N e g ro _______
O th e r_______

128, 648
10, 272
2, 285

91
7

88
10
2

R ac e n o t reported.

5 ,3 0 1

2

proximately 91 percent of the crippled children on State registers
in June 1938 were white, 7 percent were Negro, and 2 percent were
classified as “other.” This comparison indicates that approximately
one-third fewer Negroes were included on the registers of crippled
children than would be included if Negroes were proportionately
represented on the registers. Table 8 shows the racial distribution
of registered crippled children by States.
In chart 4 is shown the number of white and Negro crippled children
registered per 1,000 population of these races under 21 years of age for
all States in which more than 5 percent of the population under 21
years of age in 1930 was Negro. In a number of these States the
rate for crippled Negro children on the registers was less than twothirds of the rate for crippled white children. On the other hand
the rate for crippled Negro children on the registers in certain other
States exceeded the rate for crippled white children.


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35

D e v e lo p m e n t o f P ro g ra m , 1936—39
Table 8.— R a ce o f c r ip p le d c h ild r e n o n S ta te reg iste rs, b y S ta te ,
J u n e 30, 1938
R ace re p o rte d
T o ta l
n u m b er

S ta te 1

R ac e n o t
re p o rte d
(num ber)

P e rc e n t d is trib u tio n
N um ber
W h ite

T o ta l..

____

A labam a s-----------------

C alifo rn ia ___

—

----

D is tric t o f C o lu m b ia__

K a n sa s_______________

M a ssa c h u se tts________
M ic h ig a n ____________
M in n eso ta ._ ---------

N e b ra sk a _____________
N e v a d a ---- ------------------

N o rth C aro lin a _______
O k la h o m a ..

________

S o u th C aro lin a . ---------

W est V ir g in ia ------------

N egro

O th e r

146, 506

141, 205

91

7

4 ,3 4 6
156
704
655
2, 920
1, 163
280
192
1, 130
2, 309
860
884
862
2, 780
2, 781
3, 505
4, 617
7, 590
1, 350
L 637
1, 041
14, 225
7, 083
1, 693
1 , 816
1 , 355
L385
209
1, 174
1, 506
932
9, 346
14, 265
1 , 557
3’, 645
5, 860
254
4, 254
1, 668
2, 974
791
1, 550
985
994
5, 385
2, 056
3i 878
7,435
469

4, 229
156
704
655
2 ,1 3 7
1, 163
' 280
186
1,1 1 6
2, 309
860
884
862
2, 780
2, 604
3, 505
4, 581
7, 590
1,350
1, 637
6 , 971
12 , 128
6 , 445
1, 693
1 ,816
1 ,355
1,318
208
1, 174
1, 506
932
9, 223
13, 975
1, 557
3 ,1 3 9
5, 848
254
4, 254
1 , 668
2, 635
791
1, 546
’ 985
994
5, 385
2, 056
3, 857
7, 435
469

81
15
58

19

1

1
12
1
1
1

88
86

99
99
62
63
83
85
21
100

38
37
17
15
(»)

91
96
100

96
96

100

99
83
98
95
93
98
99
99
58

13

783
6

14
79
7

(»)
3
4

177

1

36

2

70
2, 097
638

14
1

3
.(»)

0)

(»)

38
4

<»)

1

(*)

4

(»)
(s)
(«)

67
5

1

6
0)

1

16

<«)
(»)

(»)

3

123
290
12

2

1
1

42

1
2

506

5
4
(*)

339

(*)

6

4
1

100

(i)

63
98
94

(*)

100

(*)

98

117
85
41

(>)

4

100

94
99

5,301

(»)

(«)

94
100

<*)

2

100
86

99
97
98
62
96
96
99
95

2

<*>

37
6

2

(*)
0)

21
2

* L o u isian a a n d T exas d id n o t re p o rt. Texas h a d n o t y e t established a register, an d L ouisiana was
n o t p a rtic ip a tin g in th e crippled ch ild ren ’s pro g ram u n d e r th e Social S ecu rity A ct.
i In clu d ed 397 children for w hom eligibility h a d n o t been d e term ined as of J u n e 30, 1938.
J Less th a n 0.5 o f 1 percen t.
i As o f S ep t. 30, 1938.


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Services fo r C rip p led C h ild ren

36

Chart 4.— Number of White and Negro Crippled Children on State Resisters, June 30,
193 8, per 1,000 Population of These Races Under 21 Years of A g e (1930 Census)
for Selected States1
NUMBER PER 1,000 POPULATION UNDER 21

0

1

2

3

4

9

6

7

6

»

10

II

I-------- 1---------1---------1---------1---------1---------1---------1---------1---------1---------1-------- 1
NORTH CAROLINA
DISTRICT OF COLUMBIA
KE NT U CK Y
OK LAHOMA

EM H SSP“

F LO RI DA

“

WEST VI RGINIA

i£52B2zzzzzzzz&

VIRG IN IA
ALABAMA

W B l259^™

SOUTH CA R O LI N A

m

MARY LAN D

BBSS-SS?1™
w

M IS S IS S I P P I

s s m

m

w arn w h i t e
V777\ NEGRO

DE LA W A R E
TENNESSEE
M IS SO U RI
NEW J E R S E Y
A R KA N SA S
GEORGIA

1 In clu d es all S ta te s in w hich m ore th a n 5 p e rc en t o f th e p o p u la tio n u n d e r 21 years o f age (1930)
was N egro.

D istribution by principal types of diagnosis.

The inclusion on the register of an overwhelming preponderance of
children with orthopedic or plastic conditions is evident from table 9.
Table 9.— N u m b e r o f crip p le d c h ild re n o n S ta te re g iste rs, b y ty p e o f
d ia g n o sis, J u n e 30, 1938
C hildren
D iagnosis
N u m b er

T o ta l___

________________ _____________________________

P e rc e n t

146, 506
140, 007

100

136, 081
3, 926

97
3

6 ,4 9 9

Approximately 97 percent of all children on State registers, for whom
there was a diagnosis by a licensed physician, had orthopedic or plastic
impairments resulting from congenital malformations such as cleft
palate, harelip, and clubfoot; from birth injuries; from cerebral palsy;
from infectious diseases such as poliomyelitis, osteomyelitis, tuber
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37

D e v e lo p m e n t o f P ro g ra m , 1936—39

culosis of bone or joint; from accidents, and so forth. Three percent
had other types of crippling conditions.
The figures in table 10 show the variations in the general types
of crippling conditions for which children were included on the
various State registers. Eleven States included orthopedic or plastic
conditions only, whereas in five States more than 10 percent of the
children registered were classified as having crippling conditions not of
an orthopedic or plastic nature.
Table 10.— N u m b e r o f crip p le d c h ild r e n o n S ta te reg isters, b y ty p e o f d ia g ­
n o sis a n d b y S ta te , J u n e 30, 1938
D iagnosis re p o rte d

S ta te i

T o ta l.

P e rc e n t d istrib u tio n

T o ta l
num ber

146, 506

N um ber

O rthopedic
o r plastic
conditions

140, 007

97

D iagnosis
n o t rep o rte d
(n u m b e r)

O th e r
crippling
conditions
6 ,4 9 9

103
4, 346
4 ,2 4 3
A lab am a 1__________
34
156
122
A lask a______________
100
704
704
A rizona_____________
60
97
595
A rk a n sa s____________
655
80
2, 920
C alifo rn ia___________
2, 920
100
C olorado____________
1 .163
1,1 6 3
3
97
280
277
C o n n ec tic u t_________
29
100
163
192
D e law a re ________ . . .
37
63
1 ,130
1 ,1 3 0
D is tric t o f C o lu m b ia.
98
2
2,301
2 ,3 0 9
F lo rid a _____________
3
97
806
860
G eo rg ia_____________
6
94
884
884
H a w a ii_____________
20
2
98
842
862
I d a h o _______________
268
100
2 ,512
2, 780
Illinois 4____________
100
2, 781
2, 781
In d ia n a _____________
99
3, 505
3, 505
Io w a _________ ______
99
4, 617
4, 617
K a n sa s _____________
100
7, 590
7, 590
K e n tu c k y ___________
12
97
1,3 3 8
1 ,350
M ain e ---------------------99
1,6 3 7
1 ,6 3 7
M a ry la n d __ . _______
2
,097
99
4, 944
7,041
M assa c h u se tts______
1, 502
99
12, 723
14, 225
M ich ig an ___________
641
92
6 ,4 4 2
7,083
M in n e s o ta __________
90
93
1, 603
1,693
M ississippi--------------1 ,8 1 6
95
1 ,8 1 6
M isso u ri-----------------99
1,355
1,355
M o n ta n a ----------------122
94
1,263
1,385
N e b ra sk a ___________
37
83
172
209
N e v a d a -------. ---------15
96
1 ,1 5 9
1 ,1 7 4
N ew H a m p sh ire ____
100
1, 506
1, 506
N ew J e rse y -------------91
932
932
N ew M ex ico________
127
100
9, 219
9, 346
N ew Y o r k . . -----------185
96
14, 080
14, 265
N o rth C aro lin a -------93
1,5 5 7
1 ,557
N o rth D a k o ta ---------95
3, 612
3, 645
O h io _______________ _
100
5, 860
5, 860
O k la h o m a __________
100
254
254
O reg o n --------------------59
95
4, 195
4, 254
P e n n sy lv an ia ----------248
94
1 ,420
1,668
R h o d e Is la n d _______
327
97
2 ,6 4 7
2, 974
S o u th C aro lin a -------89
791
791
S o u th D a k o ta ______
100
1, 550
1,5 5 0
T en n essee---------------96
864
985
U ta h .....................
100
994
994
V e rm o n t___________ '
100
5 ,3 8 5
5, 385
V irg in ia____________
99
2, 056
2 ,0 5 6
W a s h in g to n ..---------82
98
3 ,8 7 8
3, 796
W est V irg in ia ---------271
99
7
.1
6
4
7
,435
W isconsin---------------5
100
(3)
464
469
W y o m in g ----------------l L o u isian a a n d T exas d id n o t re p o rt. T ex as h a d n o t y e t established a register, a n d L ouisiana was
n o t p a rtic ip a tin g in th e crip p led ch ild ren ’s p ro g ram u n d e r th e Social S ecu rity A ct.
t In c lu d e d 397 ch ild ren for w hom eligibility h a d n o t b een d e te rm in e d a s o f J u n e 30, 1938.
i Less th a n 0.5 o f 1 p erp en d
♦ A? of S ep t. 30, 1938.
99
87

<8>

<3>


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38

Services fo r C rip p led C h ild ren

,

Classification of Crippling Conditions by Diagnosis 1939
The State crippled children’s agencies were asked to report the
diagnosis for all children on the State registers on December 31, 1939.
Table 11 and chart 5 show the diagnoses according to reports received
from 42 States, the District of Columbia, Alaska, and Hawaii. All
diagnoses were made by licensed physicians.
The study showed that 10 types of crippling conditions accounted
for 62 percent of the crippled children on the State registers. Polio­
myelitis, cerebral palsy, clubfoot, and osteomyelitis were given as the
diagnosis for more than two-fifths of the children (43 percent). The
other 6 of the 10 principal diagnoses—harelip or cleft palate, tuber­
culosis of the bones and joints, scoliosis, rickets, birth paralysis, and
burns—were recorded for approximately one-fifth of the children (19
percent). All other diagnoses accounted for the remaining two-fifths.
The classification “All other definite diagnoses,” which accounted
for 36 percent of the children, covers many diverse conditions, such as
congenital absence of parts, congenital dislocations of the hip, muscular
dystrophy, spina bifida, arthritis, neoplasms, un-united fractures, and
flatfoot, as well as cardiac disease, congenital cataract, diabetes, and
other nonorthopedic conditions. Individually each of these condi­
tions occurred infrequently, but combined they made up an important
proportion of the registration.
Table 11.— N u m b e r in sp ecific d ia g n o s tic c la ssifica tio n s, p e r c e n t d is ­
tr ib u tio n , a n d n u m b e r p e r 10,000 p o p u la tio n u n d e r 21 y e a rs; c r ip p le d
c h ild r e n o n S ta te re g iste rs, D ec. 31, 1939
C rippled children
N um ber per

D iagnostic classification 1

1 . Poliom yelitis _____
__
2 . C ereb ral p alsy _ _ _ _ _

3.
4.
5.
6.
7.
8.
9.
10 .
11.
12 .

_

_

__

P araly sis d u e to b irth in ju ry (exclusive o f cerebral p a lsy )___
C lu b fo o t_________
__
H arelip or cleft p a la te . ______________
Tuberculosis o f bones an d jo in ts .
O steo m y elitis. _ . . . .
Scoliosis___ __ ______
R ic k e ts ______ ________
B u r n s __
__ __ . . .
All o th e r definite diagnoses
Provisional diagnoses 2______ __ __

10,000 p o p u ­

N um ber

P e rc e n t

188, 579

100 .0

5 0 .0

36, 271
19,172
4, 532
13, 784
8, 232
7 ,196

19. 2
10 . 2
2 .4
7 .3
4 .4
3 .8
5 .9
3 .6
3 .0
2. 2
35. 7
2 .3

9. 6
5 .1
1. 2
3. 7
2. 2
1. 9
2 .9

1 1 ,1 1 2
6 , 746

5 ,607
4,161
67, 410
4, 356

la tio n u n d e r
21 years
(1930 census)

1 7 .9

* T h e n u m b ers recorded rep resen t children, n o t conditions; th erefo re o nly one diagnosis is recorded
here for each child, a n d th a t is th e p rim ary one.
3 Ite m 12 is reserved for th a t relativ ely sm all g roup o f cases a b o u t w hich th e re is: ( 1 ) U n c ertain ty
betw een diagnoses; ( 2) only a n indefinite diagnosis, su ch as “ q u estio n of------ ” or “ suspicious o f____ ”
available a t th e tim e o f th is re p o rt; (3) grave d o u b t a b o u t th e correctness o f th e diagnosis. T his
ite m is used o n ly w hen i t is im possible to m ak e a defin ite diagnosis.


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D e v e lo p m e n t o f P rogram , 1936—39

39

Chart 5.— Percentage Distribution of Crippled Children, by Diagnosis, Dec. 31, 1939
PERCENT OF TOTAL DIAGNOSES

0
1

8
I2
I6
20
24
28
32
36
---- 1--------- 1---------1--------- 1--------- 1--------- 1---------1--------- 1---------1

4

POLIOMYELITIS
CEREBRAL PALSY
CLUBFOOT
OSTEOMYELITIS
HARELIP OR C LEFT PALATE
TUBERCULOSIS OF BONES AND JOINTS
SCOLIOSIS
RICKETS
BIRTH P A R A LY S IS 1
BURNS
ALL OTHER DEFINITE DIAGNOSES
PROVISIONAL DIAGNOSES
1Paralysis due to birth injury (exclusive of cerebral palsy).

Services Rendered Crippled Children
The State crippled children’s agencies began making reports to the
Children’s Bureau on their activities on July 1, 1936, but the reports
for the first 6 months were fragmentary. For the calendar year 1937
reports were received from all the States, except Louisiana and Oregon,
and from Alaska, Hawaii, and the District of Columbia. Oregon
began reporting in 1938 and Louisiana figures are included for the
year 1939.
The apparent increases in the figures for 1939 as compared with
1938 shown in table 12 may be due to an increase in the number of
States reporting, to a real increase in the amount of service provided,
to a difference in the number of agencies and institutions included in
the reports, to a difference in the accuracy or completeness of report­
ing, to statistical errors due to variations in interpretations of terms,
or to other factors. Several of these factors related to the initiation
of a new reporting system will grow less significant as each quarterly
report is prepared. After due allowance is made for various fortuitous
factors which may have influenced the increase, the figures undoubtedly
can be accepted as showing a real increase in the amount of service
rendered.

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40

Services fo r C rip p led C h ild ren

From the standpoint of the numbers of crippled children served,
probably the most significant figures are the number of admissions of
crippled children'to clinic service for diagnosis or treatment, 88,581 in
1939, and the number of children under care in hospitals, 41,692 in
1939. The children admitted to other services received clinic service
or hospital care as well and, therefore, are counted in these figures.
The numbers of children under care at the close of 1939 are sig­
nificant in showing the number of crippled children under care outside
their own homes at a given time: 3,492 children in hospitals; 1,438 in
convalescent homes; and 591 in foster homes. The increases in the
last two figures as compared with 1938 undoubtedly reveal a substan­
tial advance in the provision of these types of care by the State
agencies. The State reports, at the present time, do not show the
number of children undergoing medical treatment in their own homes.
Table 12.

C rip p led c h ild r e n o n S ta te re g iste rs a n d services fo r crip p le d
c h ild re n , c a le n d a r y e a rs 1938 a n d 1939

[R eported b y official S ta te agencies ad m in isterin g S ta te plans u n d e r th e Social S ecurity A ct, title V,
p a r t 2]
N u m b e r re p o rte d 1
Ite m
1939
C rippled children on S ta te registers a t end o f y ear
Service« for crippled children:
Clinic service (diagnostic o r tre a tm e n t):
A dm issions_______
V isits__________
- - H o sp ital care:
C hildren u n d e r care d u rin g y ear 2
C hildren u n d e r care a t end o f y ear
D ay s care pro v id ed d u rin g y ear
C onvalescent-hom e care:
C h ild ren u n d e r care d u rin g y e a r »
C h ild ren u n d e r care a t end o f year
D a y s care p rovided d u rin g y ear
h o ster-h o m e care:
C h ild ren u n d e r care d u rin g y ear 1
C h ild ren u n d e r care a t end o f y ear
D a y s’ care pro v id ed d u rin g y ear
P u b lic-h ealth -n u rsin g service:
A dm issions____
F ield a n d office visits
P h y sic al-th e ra p y service:
A dm issions_____
F ield a n d office visits
M edical-social service: Admissions
V ocatio n al re h a b ilita tio n : C hildren referred for v o catio n al services

248, 627

1938
171, 564
79, 590
181, 206
43, 097
3, 330
1, 398, 086
5 ,938
1,028
371, 840
1,890
302

86 , 858

40, 847
177, 292

j

3, 659

9 ,373
78, 952
12 , 601
4 ,6 4 0

d u rin g 'th e year?F ° f chlldren u n d e r care a t beginning o f y ear a n d th o se a d m itte d or re a d m itte d to care
visits are fairly d ^ ^ d a b ^ a s ^ ^ ^ i ^ f c a r i o i T ^ f t h ^
incom plete; figuresion adm issions a nd
inconsistencies in th e m eth o d s used b v th e S tate*
o f service provided, b u t, on acco u n t of
com putin g av erag e v isits p er adm ission.
rep o rtin g , th ese figures should n o t be used for


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D e v e lo p m e n t o f P ro g ra m , 1936—39

41

The State reports are also significant in revealing the volume of
public-health-nursing, social, and physical-therapy service rendered as
services auxiliary to medical diagnosis and treatment. The increase
in these services in 1939 as compared with earlier years to a large
extent reflects the development of the aftercare program, one of the
major accomplishments of the State crippled children’s agencies
since the crippled children’s program under the Social Security Act
was started.
Lim itations of the Crippled Children’s Program
The low registration of crippled children in some of the States will
be overcome in part as the continuance of the program makes it
possible for the State agencies to attain a more complete coverage of
the States in finding crippled children and in providing for diagnosis
of the crippling conditions affecting them. Too, the total number
to be registered will increase if the coverage of the crippled children’s
program is extended, as is recommended in the national health
program, to provide services for physically handicapped children
other than those suffering from orthopedic and plastic conditions.
The development of the crippled children’s program in some States
and Territories was retarded by the inability of these jurisdictions to
match Federal grants dollar for dollar with State or local public
funds or funds made available for public use, as was required during
the first Zy¿ years of the program. (Chart 6.) The inclusion in the
Social Security Act Amendments of 1939 of a provision authorizing
the appropriation of an additional $1,000,000 each year for grants
to the States, based on the financial need of each State for assistance
in carrying out its State plan, will enable the Secretary of Labor, in
allotting funds to the States, to take into consideration the ability of
the States to finance the State share of the program. Allotments from
this additional fund, for which matching by State and local funds is not
required, will make more nearly equal in all States the opportunity
afforded crippled children to benefit from the Federal-State program.
In a considerable number of the States the rendering of service to
children whose condition has been diagnosed has been retarded either
because funds to pay for surgical and hospital care have been insuffi­
cient or because a sufficient number of hospital beds have not been
available. On May 15, 1939, 34 of 51 State crippled children’s agen­
cies reported that nearly 13,000 crippled children were awaiting hos­
pitalization because of lack of funds, 15 reported that more than 1,200
crippled children were waiting because of lack of hospital beds, and
7 reported that more than 400 were waiting for other reasons.


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42

S ervices fo r C rip p led C h ild ren

Chart 6. Percentages of A n n u al Federal Allotments of Funds for Services for Crippled
Children, M atched by States in the Fiscal Years 1937 and 1939, Social Security A c t ,
Section 512 (a)
1937
0
■

AR IZ O N A
C A LIFO R N IA
COLORAOO
DISTRICT OFCOLUMBIA
IDAH O
IL L IN O IS
IN D IA N A
IOWA
KENTUCKY
M AINE
M ARYLAND
MASSACHUSETTS
M IC H IG A N
M IN N E S O T A
M IS S O U R I
NEBRASKA
NEW J E R S E Y
NEW M E X I C O
NORTH C A R O LIN A
OHIO
OKLAHOMA
P E N N S Y L V A N IA
SO U T H DAKOTA
TENNESSEE
TEXAS
UTAH
V IR G IN IA
W ASHINGTON
W EST V I R G I N I A
WISCONSIN
WYOMING
FLO RIDA
KANSAS
MONTANA
SOUTH CARO LINA
ALABAMA
HA W AII
NE W YO RK
VERMONT
NORTH DAKOTA
M IS S IS S IP P I
RHOD E I S L A N D
ALASKA
NEW H A M P S H I R E
G EOR GIA
ARKANSAS
C O N N E C T IC U T
DELAWARE
LOUISIANA
NEVADA
OREGON

80
1

PE R C E N T
40
60
1
1

1939
80
I

100
I

0
I

m

80
I

PERCENT
40
60
60
100
I------------- 1------------- 1-------------1

_____________

B ars exten d in g to 100 p e rc en t on scale in d ic a te th a t S ta te s rep resen ted supplied m a k i n g funds in
th e a m o u n t o f 100 p e rc en t o r m o r e o f an n u al F e d e ra l allotm ents.

The States have gradually raised the maximum age for assistance
to crippled children in their eligibility requirements. By June 30,
1939, crippled children up to 21 years of age were accepted for care by
the State agencies of 45 States. Of these, 1 State had an age limit of
18 years and 3 States of 16 years for eligibility for care from State
funds, but Federal funds were being used in these States to extend
service to crippled children up to 21 years of age. One of the 45
States still gave preference to children under 16 years of age. For

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D e v e lo p m e n t o f P rogram , 1936-39

43

the remaining 6 States with plans in operation, the age limit was
18 years for 3 States, 17 years for 1 State, 16 years for 1 State, and
15 years for 1 State.
A majority of States require legal residence in the State as a pre­
requisite to the giving of care from State funds. Some State agencies
have made reciprocal agreements with other State agencies whereby
financial responsibility for the care of children is accepted until such
time as legal residence is acquired.
There are in this country large unmet needs of handicapped chil­
dren with many types of crippling other than orthopedic and plastic
impairments. For example, it is estimated that there are approxi­
mately 400,000 children suffering from rheumatic heart disease;
approximately 60,000 children with severe visual defects; and several
million school children with visual defects that require correction
with glasses. More than 1 ^ million children have defective hearing,
and more than two-thirds of all school children have dental defects.
In the report on a national health program made by the Technical
Committee on Medical Care, submitted to the President in 1938 by the
Interdepartmental Committee To Coordinate Health and Welfare
Activities, the Technical Committee recognized the progress made
under the crippled children’s provisions of the Social Security Act in
making available orthopedic and plastic surgical service, hospitaliza­
tion, and aftercare. The Committee called attention to the need for
further provision for children crippled or handicapped from heart
disease, diabetes, congenital syphilis, and other conditions that require
prolonged care to insure recovery or restoration leading to self-support.
The Committee also called attention to the numbers of children who
have defective vision due to refractive errors, impaired hearing, or
dental defects, and to the need for providing proper treatment to
prevent and to remedy serious impairment.15
Advances To Be Sought
During the initial period of Federal and State cooperation in
providing services for crippled children a Nation-wide organization
for this program was created, basic policies and procedures were de­
veloped, and large numbers of crippled children were given the
remedial care they needed.
The experience of the first 3 years made apparent the necessity for
further development of the program in the following directions.
Continued emphasis is needed in all phases of the program on
improvement of the quality of care, including (1) direction by
physicians for all State crippled children’s programs, preferably
15 P a r t o f th e increased fu n d s for g ra n ts to th e S ta te s for services for crippled children au th o rized
b y th e Social S ecu rity A ct A m endm ents o f 1939 (ap p ro v ed A ugust 10, 1939) will be used for services
for children suffering from h e a rt disease d u e to rh e u m a tic fever.
239021°— 41----- 4


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S ervices fo r C rip p led C h ild ren

44

by physicians who have had pediatric and public-health training
and experience; (2) development of techniques and procedures
for periodic review of quality of care; (3) medical supervision by
qualified pediatricians in clinics, hospitals, convalescent and
foster homes, and, where possible, the child’s own home; (4) im­
provement in the method of prescribing and supervising physicaltherapy services; (5) further training for professional personnel
on State and local staffs; and (6) instruction of local practicing
physicians in the early recognition and prevention of crippling
conditions.
More provisions should be made for service for types of
crippling other than orthopedic and plastic conditions and for
children of migratory families and minority groups.
Improvement in clinic service is needed to provide for reexami­
nation as well as initial diagnosis; more effective follow-up of rec­
ommendations for treatment; more effective coordination of
State and local services at diagnostic clinics; extension of the prin­
ciple of planned conferences of professional personnel on an indi­
vidual-case basis; and more attention to arrangement for parents
to discuss the child’s condition with the orthopedic surgeons or the
clinic physicians or other clinic personnel so that the parents will
understand what is needed for the child.
Improvement is needed in hospital and convalescent-home
standards, with particular reference to the provision of more ade­
quate medical supervision of crippled children in the hospital by
qualified pediatricians; facilities for the isolation of children on
admission to institutions and of those who develop contagious
diseases during their sojourn and for the prescription and super­
vision of physical-therapy services.
Universal adoption by the States of standard birth certificates
that include provisions for reporting birth injuries and congenital
abnormalities is needed. Provision should be made for the report­
ing of acute rheumatic fever by physicians and for more effective
use of public-health reports now required on meningitis, bone
tuberculosis, poliomyelitis, and other infectious diseases that lead
to crippling.
Studies of intake and discharge policies and court-commitment
procedures are needed; of standards for convalescent and foster
homes and sanatoria; of appliances; of the cost of hospital and
institutional care; of services provided for crippled children
by local health and welfare workers; and of the effect of low
standards of public assistance on services provided for crippled
children.

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D e v e lo p m e n t o f P zo£t& m , 1936—39

45

There is great need for further development of treatment services
of the proper kind and quality for children who can be treated while
living at home. To some extent it will be possible to develop more
clinic centers where medical supervision can be maintained. Physicaltherapy treatments can be given from such centers and community
nursing services can be called on for the supervision of the child at
home. In sparsely settled areas it probably will be necessary to
develop consultation service by orthopedic and other specialists to local
general practitioners of medicine and to provide some type of itinerant
physical-therapy service or instruction of local public-health nurses
and parents in physical-therapy techniques, as well as advisory
service to local child-welfare workers and public-health nurses on the
social and nursing phases of the home care of the crippled child.
These services so strengthened will also improve the quality of after­
care provided for children who have been hospitalized.
The present crippled children’s program has evolved a method for
bringing to families assistance in dealing with the physical handicaps of
children. As the community and the Nation recognize the needs of
these children, the program can be steadily expanded to prevent the
incidence of crippling conditions among children and to provide the
care and training necessary to mitigate their physical handicaps and
to equip them for self-dependent adult life.


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State Summaries of Progress, 1936-38
By June 30, 1938, most of the State agencies had had more than 2
years’ experience in administering their enlarged crippled children’s
programs, and their patterns of administration were established. The
following brief reports by State administrators reveal the character
of problems met during the initial period, 1936-38, and the methods
devised for rendering effective service.
ALABAMA
S ta te a g en c y: D e p a r tm e n t o f E d u c a tio n , D ivisio n o f V o c a tio n a l
E d u c a tio n .
During the fiscal year 1938 definite progress was made in the program for
crippled children. A larger number of crippled children was reported this year
than during any previous year. Undoubtedly a large number of people have
become conscious of the needs of the crippled child. An increased number of cases
was reported by physicians. A referral card was made for the use of the physician,
and it is desired that crippled children have this card on being admitted to a
clinic, although this procedure is not compulsory.
Twenty-one itinerant clinics were held— an increase over previous years— and
approximately 2,334 children had their crippling conditions diagnosed or received
follow-up care. The attitude toward clinics on the part of the medical profession
was one of cooperation, and a clinic was held with the hearty approval of the
county medical society in every center where a request was made. Such endorse­
ment is necessary before arrangements are made for a clinic. Clinics were better
organized and were held in such places as would facilitate the handling of a larger
number of crippled children than previously. A competent brace maker attended
every clinic for the purpose of fitting new braces for those children for whom
braces were recommended. X-ray facilities were available at every clinic center.
Lunches were provided by local groups at almost every itinerant clinic.
The permanent clinics, held weekly at each hospital center, made possible
frequent check-up of cases and were well attended. An increased number of beds
and some additional facilities were provided both in the hospitals and in the
convalescent homes.
Better follow-up care was provided by the State staff and the cooperating
agencies. When a child enters the hospital, a notice is mailed to each of the
cooperating agencies; when he leaves the hospital, a form which gives concise
information, including data on follow-up care, is mailed by the hospital to the
State service. A letter is then written by the State service to the county health
department, incorporating this information, and copies are mailed to the welfare
and education departments. A form card is supplied by the State service for
use by county health departments in reporting visits made to crippled children.
County welfare workers visit children and families in their territories to help them
make adjustments, to see that the child is following the doctor’s orders, and to
check on welfare responsibilities.
A filing plan for checking the date of return of children to the doctor was
put into effect in such a way that a very large percentage of children received the
proper follow-up care.
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The W. P. A. teaching project for crippled children has been enlarged to provide
the services of a sufficient number of teachers and teaching hours to enable children
in hospitals to keep up with their studies in the regular schools. Home teaching
has been carried on in the larger centers where a considerable number of children
live close enough together for one teacher to visit them.
During the year occupational therapy was provided by the Junior League of
Mobile for the children hospitalized in that city.
A survey was made of crippled children in every white and Negro school in the
State. The superintendents, principals, and teachers were highly cooperative in
this project.
The Alabama Society for Crippled Children cooperated actively with the State
crippled children’s service and the rehabilitation service. A county-wide com­
mittee has been organized by the society in every county in the State. A “Crippled
Children’s Week” was proclaimed by the Governor and was impressively observed
throughout the State. The cooperation of county health, welfare, and education
departments and of the county committees has been of distinct advantage to the
State service.
A plan of referring to the State rehabilitation service for vocational guidance
and training those children whose crippling conditions are not fully removed has
worked satisfactorily. A great deal of emphasis is being placed by the rehabilita­
tion service on the vocational-guidance program for these children, and they will
be given vocational training at the proper time.
Many crippled children with spastic conditions received the services of a spe­
cialist in a school for motor re-education established in Birmingham. A great
deal was accomplished for a limited number of children through this institution.
ALASKA
S ta te a g en c y: T e rrito ria l D e p a r tm e n t o f H e a lth , D ivisio n o f M a te r n a l
a n d C h ild H e a lth a n d C rip p led C h ild ren .
Three important features marked the progress of the crippled children’s program
in Alaska during the fiscal year 1938:
1. About 150 children were reported to the central office as handicapped by
some type of deformity. This is an increase over 1937 of about 100 children.
2. Administrative arrangements for transportation, hospital care, and follow-up
care were more efficiently organized.
3. There was an increase in the number of cases cared for (13 in 1938 as com­
pared with 8 in 1937).1
Reporting of the handicapped children unfortunately still depends largely on—
1. School teachers of both the Territorial and Government schools (Office of
Indian Affairs).
2. The Government nurses.
3. United States Commissioners.
The public-health nurses and the practicing physicians are on the alert for
locating children with such deformities, but the majority of patients live in isolated
districts where a case remains undiagnosed until the deformity is so evident that
it is recognized by the “village trader.” Little progress was made in obtaining
medical diagnosis for these cases reported from isolated interior districts. The
acting director of the Division of Maternal and Child Health and Crippled Chil­
dren was able, in her field work, to examine some of these patients in southeast
Alaska, but she could not reach many of the small villages in the west and north.
1AU children requiring surgical care are transported to Seattle, Wash.


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Throughout the Territory there is an ever-increasing knowledge of the care
offered under the crippled children’s program, and the reporting of children in
need of care has improved. It is most unfortunate that, because of a limited
budget, care can be offered to only a few children. The sense of futility in reporting
is somewhat lessened but is still in existence.
The administrative arrangements for transportation have gradually been made
more efficient. * The family often provided part of this cost. Free transportation
on Government boats is available only at irregular intervals and at irregular ports
of call, but is used whenever possible.
Definite contracts were made for payment for services of orthopedic surgeons
in the States. Reports from the Children’s Orthopedic Hospital in Seattle, Wash.,
on the progress of the child under treatment, as well as a summary of the case and
recommendations for aftercare, have been requested and are regularly received.
The Territorial public-health nurses and the Government nurses are instructed as
to these recommendations, and their reports on the home treatment of the dis­
charged cases have been requested.
ARIZONA
S ta te a g en c y: B o a rd o f S o c ia l S e c u r ity a n d P u b lic W elfa re, D ivisio n fo r
C rip p led C h ild ren .
The fiscal year ended June 30, 1938, was an outstanding year in the history of
the crippled children’s program in Arizona. During this year a substantial
increase in funds was provided by the State legislature, and the Pima County
board of supervisors made the necessary changes in the hospital already under
construction. This resulted in the provision of three attractive wards for crippled
children and a physical-therapy department whose facilities include a treatment
pool. The Division for Crippled Children was given technical supervision of this
department, and a physical-therapy technician from the State-agency staff has
been assigned to this program,
A convalescent home with a graduate nurse in charge has been established in
Phoenix, which is the largest treatment center. The home is a roomy, wellbuilt structure with ample, attractive grounds, in a very good location 7 miles
from the center of Phoenix. In addition to regular home care, services include a
certified teacher and a nurse to take the children to and from the hospital and
clinic. Handicraft and music are taught by special teachers. The children are
frequently guests of the local theater manager and are invited to practically all
special children’s parties planned by the local school, Sunday schools, and clubs.
The regular school bus calls for all who are able to attend school, and kindly
neighbors and friends take them to Sunday school in their respective churches.
Only children who are receiving active treatment and who live at a distance too
great to permit adequate care are placed in this convalescent home. Where home
conditions are such that placement of the child elsewhere is necessary, he is
referred to the Child Welfare Division for service.
The convalescent home in Tucson, which is really more like a “junior” hospital,
has a graduate nurse on duty both day and night. Almost all the children placed
there require bed care but do not need intensive hospital care.
As the cost of care in these homes is less than half the regular hospital charges,
it has been possible to care for many more children. These homes have been
made possible through cooperation with many local groups. Practically all the
furnishings have been provided by such groups.


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The Arizona Society for Crippled Children has set up a fund for the maintenance
of older crippled children who otherwise would not be able to take advantage
of higher education or vocational training. The National Youth Administration
also is assisting in the educational program.
Transportation for children to and from treatment centers and clinics, travel
expenses of teachers and of a nurse, numberless pairs of new shoes, clothing,
material for handicraft, books, musical instruments (including a piano), and
many other items have been provided by interested lay groups. These same
groups are also giving a great deal of service, thereby eliminating the need for
several paid employees.
Extension and improvement of the services rendered directly by the State
agency have been made possible through employment of a field consulting staff
consisting of an orthopedic nurse, a medical-social worker, and a physical thera­
pist.
Development of community interest and resources and the extension and
improvement of crippled children’s services as provided for in the annual plan
have been the outstanding activities during this fiscal year.
ARKANSAS
S ta te a g en c y: D e p a r tm e n t o f P u b lic W elfa re, C rip p led C h ild re n ’s
D ivision.
The Crippled Children’s Division of the State Department of Public Welfare was
organized on July 1, 1937. The first patient was accepted in the Little Rock
General Hospital on September 1, 1937. Since that time patients have been ac­
cepted regularly for treatment.
During the summer of 1937 there was an extensive epidemic of poliomyelitis in
the State. Realizing the necessity of early treatment, the Crippled Children’s
Division accepted all indigent children who had had the disease during the
epidemic. These patients were accepted on the recommendation of their family
physician or the county health officer and were not compelled to wait for a diag­
nostic clinic. Children up to 21 years of age were accepted.
At the beginning of the program only two hospitals were used. Since that time,
however, four others have been used. The doctors on the staff include three
orthopedic surgeons and one plastic surgeon in Little Rock, one orthopedic
surgeon in Pine Bluff, and a specialist in arthritis in Hot Springs. There are four
pediatricians on the regular staff. Consultants in other fields of medicine are
called when needed and are paid on a fee basis.
A policy was established whereby all cases must be seen at a diagnostic clinic by
an orthopedic surgeon before they can be placed on the waiting list. The only
exception to this ruling was emergency cases— children suffering from acute polio­
myelitis, acute osteomyelitis, or acute suppurative arthritis, and infants with
harelip or clubfoot.
The Crippled Children’s Division made arrangements with railroad, bus, ambu­
lance, and taxicab companies for transportation of patients at reduced rates. The
Division paid for transportation to and from the hospitals but did not pay trans­
portation to and from clinics. If the families were able to pay for this service,
they were requested to do so.
There is no State-owned brace shop in Arkansas. Two shops have been used
for braces. Representatives from these shops attend each clinic and, when
braces are all that is recommended for a child, measurements are taken at the
clinic under the direction of the examining surgeon. When the braces are ready,
the child is called in to be fitted and the brace is approved by the surgeon who
examined the child at the clinic. Artificial limbs are provided in the same manner.


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A convalescent home for white children up to 16 years of age was established
by a registered nurse in October 1937. This home, staffed entirely by trained
nurses, can take care of as many as 20 to 25 children.
A convalescent home for Negro children was used for a time, but this home could
not maintain the required standards and has been discontinued.
Three foster homes for white children were established through the cooperation
of the Child Welfare Division during 1938.
The Crippled Children’s Division had cared for 421 cases at the end of the fiscal
vear.
CALIFORNIA
S ta te a g en c y: D e p a r tm e n t o f P u b lic H e a lth , C rip p led C h ild re n s
S ervices.
As it now operates, the program of aid for crippled children in California is
carried out in two ways: (1) Direct services, such as diagnostic clinics, hospitaliza­
tion, and aftercare of crippled children, administered by Crippled Children’s
Services; and (2) indirect services, which are established where local county pro­
grams for crippled children can be supervised and expanded through the use of
additional funds.
These services are offered crippled children under the provisions of the Cali­
fornia Crippled Children’s Act of 1927, which defines a crippled child as a “physi­
cally handicapped child” and limits the application of the act to those under 18
years of age. However, children up to the age of 21 years are eligible for care
under the Federal social-security program.
In each county that gives services to crippled children within the county
jurisdiction and whose standards of care have been approved, the director of the
State Department of Public Health appointed a special agent who is responsible,
in a liaison capacity, for the administration of the services.
Some local units also appoint a professional advisory committee. This com­
mittee must approve the medical reports and recommendations for care of crippled
children before such reports are submitted to the director of the State Department
of Public Health for his approval. Where no local professional advisory committee
functions, the unit makes use of the State professional advisory committee.
The personnel working in local programs and under supervision of Crippled
Children’s Services includes 43 public-health nurses, 6 nurses in hospitals, 2 welfare
agents, 2 county physicians, 4 social workers, and 1 physical-therapy technician.
In those counties where the program is not administered directly by Crippled
Children’s Services its representatives visit and inspect facilities for locating and
caring for crippled children in order to maintain uniform standards of care through­
out the State. These visits and inspections are made at intervals of approximately
3 months.
Crippled Children’s Services also makes arrangements whenever possible to
provide facilities for the care of crippled children where adequate local staff is
lacking.
Besides the local units with which Crippled Children’s Services works in an
advisory capacity, there are other State departments and organizations with which
the services are developed cooperatively. These include the Division of ChildWelfare Services, State Department of Social Welfare; Bureau of Vocational
Rehabilitation, State Department of Education; service clubs; and women’s
organizations.
Among many accomplishments during the formative period were the comple­
tion of plans for a State register of crippled children and diagnostic clinics and the
selection of hospitalization centers. Fee schedules also were worked out for hospi­
talization charges and specialists’ charges for professional services, as well as charges


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for convalescent care, foster-home care, appliances, and other services. This
work was accomplished with the assistance of the members of the professional
advisory committee, other private physicians, and individuals in charge of
hospitals and convalescent homes.
In short, during this 2-year period, the ground work for the program was laid
by the chief of the Crippled Children’s Services, with the guidance and under the
supervision of the director of the State Department of Public Health and with the
assistance of professional and lay advisory committees and of public and private
agencies interested in furthering the crippled children’s program in the State.
Under the present plan Crippled Children’s Services is responsible for the
following activities:
1. The registration and filing of all known cases of crippled children under the
age of 21.
2. The examination of crippled children admitted to diagnostic clinics held in
counties throughout the State.
3. The classification, through public and private agencies, of those children
whose parents are unable to provide proper care either in whole or in part; of
those who may receive care through local agencies; and of those who require
hospitalization and surgical care under the provisions of this program.
4. Medical care, nursing, physical therapy, aftercare, and supervision for all
children requiring corrective measures.
5. Supervision of all local programs for the care of crippled children.
6. Formulation of a program for the prevention of deformities whenever
possible.
7. Formulation and supervision of an educational program for parents, pro­
fessional and lay groups, health officers, and other official agents.
8. Strengthening of existing organizations for the care of crippled children
throughout the State and use of new organizations or facilities whenever these
meet the required standards.
As a part of the plan to register and file names of all known cases of crippled
children, a State register was set up in the central office in San Francisco. This
register will give as much factual identifying information concerning the type of
handicap and the medical and social background as may be obtained from the
diagnostic clinics held by Crippled Children’s Services and from the Bureau of
Vital Statistics, Bureau of Child Hygiene, Bureau of Tuberculosis, public-health
and school nurses, private physicians, hospitals, educational agencies, lay groups,
interested individuals, and an interdepartmental system of reporting cases. The
register will make it possible to check on all cases of crippled children in the State,
whether they are in need of medical treatment or are under private or public
medical care. The central office will thus be a clearing agency for tracing and
verifying histories and records desired by all organizations working for crippled
children.
To make the records more complete and to have available exact information
concerning each crippled child cared for by Crippled Children’s Services,
photographs of each patient requiring treatment are taken when the diagnostic
clinic is held or when a specialist first examines a patient. As treatment pro­
gresses, subsequent photographs are taken to illustrate corrections accomplished
through orthopedic or plastic surgery or other types of care given crippled
children.
Diagnostic clinics are held in counties throughout the State when the number
of crippled children warrants the organization of such clinics. Usually the


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clinics are in communities far removed from hospitalization centers. They are
held at intervals of 6 months, if there are enough cases under treatment or super­
vision to warrant holding repeated clinics.
The personnel for the clinics includes an orthopedic specialist, a public-health
nurse, a medical-social worker, and a stenographer. The clinician may be
assisted by a plastic surgeon, an ophthalmologist, an orthodontist, a pediatrician,
or some other specialist, depending upon the types of cases to be examined. Lay
assistance is always available through the work of interested volunteers, who
materially assist in conducting the clinics.
Attendance at the clinics averages 43 patients. Additional clinicians are
appointed if the known or estimated number of patients to be admitted is more
than one clinician can adequately examine. Time is allowed during the hours
of the clinic to give parents an opportunity to discuss the recommendations
made by the specialists.
Much interest in these diagnostic clinics has been shown by private physicians.
They have brought some of their patients for diagnosis and often were so keenly
interested in the work of the clinicians that they remained to observe and dis­
cuss the treatment recommended. In this manner expert and up-to-date tech­
niques are made available to private physicians in the more rural communities.
After a clinic has been held, follow-up work is begun by the medical-social
worker in conjunction with health and welfare agencies and interested and
responsible persons in the community. This work consists chiefly of arranging
for the care recommended by orthopedic or other specialists, which includes
provision for treatment—hospitalization, surgery, or supervision; for braces or
other appliances; for appointments; and for transportation to and from medical
centers. When patients return to the community it is often necessary for the
field workers to arrange for home treatment and sometimes for the return of patients
to the hospital for further treatment.
Records of the medical findings and recommendations, made when the diag­
nostic clinics are held, as well as subsequent reports of medical care, progress of
the patient, and recommendations, are made in duplicate and are forwarded to
the county health officers and to the public-health or school nurses concerned
with the care of the crippled child.
COLORADO
S ta te a g en c y: D ivisio n o f P u b lic H e a lth , D ivisio n o f C rip p led C h ild ren .
The fiscal year 1938 was marked by an almost continuous state of emergency
in Colorado. The Division of Crippled Children was hampered continuously by
a lack of personnel. Qualified field personnel were not available, and clerical
service was hampered by changes and delays in appointments. At the same time
the Division had to face the most widespread epidemic of infantile paralysis that
the State has known, with hospital resources not developed to meet such an
emergency and community and local workers not yet fully familiar with the plan
of operation. In view of these handicaps it was gratifying to be able to make
progress and to meet the emergency as adequately as was done. Contact was
made directly with the 237 patients placed under treatment under the auspices
of the Division of Crippled Children, and the other cases were provided for by
other agencies and by private physicians.
Orthopedic surgeons carried an unusually heavy load during the year, and
hospitals made every effort to meet the need. Two hospitals added trained
physical-therapy technicians to their staffs, and three added materially to their


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equipment. Two of the hospitals have established model pediatric wards, and
two hospitals provided for special postgraduate work for their pediatric super­
visors.
With respect to relationships with public and lay agencies, foundations laid in
the first year of work were built upon slowly but actively. Generalized instruc­
tions concerning regulations and procedures, given largely by direct contact
during the first 10 months of operation (during which time the State was canvassed
and served by clinic areas), were crystallized in bulletin form and sent to medical,
nursing, welfare, educational, and some lay agencies, with a report of the first
year’s services. These written instructions were supplemented by individual
assistance given by the field staff, every opportunity being taken to foster coordina­
tion of the various services and to prepare foundations for future improvement
An increase in interest and participation on the part of public-health nurses and
welfare staffs has been noticed, which opens the way for further improvement in
these services.
Medical understanding and participation have shown marked and satisfactory
development. The State medical society has continued its interest, and an in­
creasing number of local physicians have expressed approval by direct word and
by referring more children for registration and for treatment. In two areas where
medical groups had been reluctant to join with the program, approval of the
program and desire to participate have been expressed. This advance means
that the service is now active in every part of the State.
CONNECTICUT
S ta te a g e n c y : D e p a r tm e n t o f H e a lth , B u r e a u o f C h ild H yg ie n e, D ivisio n
o f C rip p led C h ild ren .
The field organization of the crippled children’s program for Connecticut began
on September 1, 1937, with the appointment of a physician as chief of the Division
of Crippled Children. The first steps in organization were the selection of five
suitably located hospitals to serve as clinic centers and the appointment of a
qualified orthopedic surgeon to head each clinic. In choosing locations for the
diagnostic clinics, an effort was made to avoid duplication of already existing
facilities for the care of crippled children, and yet to make at least one State clinic
accessible to every part of the State.
The crippled children’s technical medical advisory committee of the Connecticut
Medical Society cooperated in the selection of orthopedic surgeons and of other
professional personnel for the program, such as plastic surgeons, pediatricians,
and urologists; in the designation of locations for the clinics; and in the establish­
ment of a schedule of fees and rates for services rendered to crippled children
under the State program. The fee schedule provided for medical and surgical
services to crippled children at a nominal professional charge, and the rate sched­
ule established remuneration for hospital services on a basis close to actual cost.
Arrangements were made also with private brace makers and shoemakers to fill
orders from the Division of Crippled Children, usually at substantial reductions
from customary charges.
Concurrently with steps taken in the organization of the State program, efforts
were made constantly to acquaint the public as well as the medical and nursing
professions with the objectives and policies of the program. Publicity of this
character was carried on through newspapers, weekly and monthly bulletins of
he State Department of Health, circular letters of information to doctors and
nurses, and addresses to professional and lay groups.
Actual services to crippled children were begun in February 1938, at which time
tw o of the diagnostic clinics opened; the remaining three clinics opened in March.

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Immediate advantage was taken by the public of the services offered. In Feb­
ruary, 41 children reported; in March, 80 additional children were seen at the
clinics; and in April, 89 more children came in search of help. During the next
2 months 104 additional children reported to the clinics, making a total of 314
cases examined during the first 5 months of operation of the program.
These patients were referred to the State clinics by licensed Connecticut physi­
cians and were brought in by public-health nurses, social workers, parents, and
sometimes by the physicians themselves. The great majority of the children
examined (nearly 5 out of every 6) were in need of some type of service offered by
the State program. The number of serious conditions is indicated to some extent
by the fact that more than a quarter (85) of the total number of children in need
of care were recommended for hospital treatment—usually an operation— by the
examining orthopedic surgeon. The average hospital stay was 22 days.
Children not in need of hospital treatment required physical therapy in a great
number of cases. It was originally planned to treat these children through the
facilities of institutions employing physical therapists, but the demand for physical
therapy has so far exceeded the available supply that it has been found necessary
to provide supplementary physical-therapy services through State-employed
technicians. At the close of the fiscal year two full-time physical therapists were
to be added to the staff of the Division of Crippled Children in the near future to
treat crippled children 1 or 2 days a week in each of the hospitals where the diag­
nostic clinics are held.
A medical-social worker was added to the program on April 1, 1938, and arrange­
ments were made with local and State agencies to provide various types of case­
work services: Aid in making home and family adjustments; transportation;
education; vocational training; and services to meet welfare and health needs in
general. A financial investigation is made in all cases, and children who are in­
eligible for aid under the State program for financial or other reasons are referred
to a resource qualified to handle the problem involved.
The State agency is especially indebted for the success of the program to family
doctors for referral of cases, to local nurses for discovery and follow-up of patients,
to the superintendents of the clinic hospitals for the wholehearted manner in which
they have given of their facilities arid their personnel, and to the generous and at
times enthusiastic cooperation given by communities throughout the State to
the work of the Division of Crippled Children.
DELAWARE
S ta te a g en c y: B o a rd o f H e a lth , Services fo r C rip p led C h ild ren .
A crippled children’s program was instituted by the State Board of Health on
October 15, 1937. A selected nurse had previously received special training in
Boston to qualify her for field supervision.
Her first step was to make contact with every physician in the county in which
the service was started. All physicians in this county have proved very coopera­
tive. Diagnostic clinics were opened at three points. Investigation was begun
of a list of some 400 names reported by the National Youth Administration and
other agencies. A register of crippled children was established.
By arrangement between the State Board of Health and the Nemours Founda­
tion, Services for Crippled Children is assuming responsibility for case finding,
diagnosis, aftercare in the home, and general field work. The Foundation under­
takes to pay the costs of treatment, up to $75 per case, for patients who, in the
judgment of the clinician, are in need of hospital care and medical or surgical
treatment.


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Prevention and early correction of injuries present at birth are now largely the
responsibility of the State generalized nursing program, through prenatal care and
inspection of the newborn infants at the time a copy of the birth certificate is given
to the mother. A leaflet on prevention of crippling from infantile paralysis, pre­
pared in cooperation with the Nemours Foundation, has been issued.
DISTRICT OF COLUMBIA
S ta te a g en c y: H e a lth D e p a r tm e n t o f th e D is tr ic t o f C o lu m b ia , B u re a u
o f M a te r n a l a n d C h ild W elfare.
The administration of services for crippled children in the District of Columbia
was transferred from the Board of Public Welfare to the Health Department on
July 1, 1937, and the administrative responsibility for this program was placed in
the Bureau of Maternal and Child Welfare.
The major features of the program, plans for which were worked out during the
year, are as follows: (1) The addition of a question on the birth record for report­
ing birth injuries and congenital abnormalities; (2) the utilization of the existing
child-hygiene centers and the school medical-inspection and nursing services for
locating crippled children and for screening examinations; (3) the establishment of
a diagnostic and ambulatory-treatment center at Gallinger Municipal Hospital and
the utilization of wards in Gallinger and the Children’s Tuberculosis Sanatorium at
Glenn Dale for children needing hospitalization, as well as of Children’s Hospital
and Emergency Hospital for hospital and clinic care; (4) the development of plans
to provide in suitable institutions outside the District long-time institutional care
of a kind not available in the District of Columbia; (5) arrangements for follow-up
in the home through the field nursing service wherever possible; (6) the develop­
ment of a medical-social service; (7) the extension of physical-therapy service in
the wards and clinic at Gallinger Municipal Hospital and in the crippled children’s
schools; and (8) the formulation of plans for coordinating activities for crippled
children in the District.
The major accomplishments during the year were associated with the concrete
working out of details of the plan and the initiation of a study of facilities and needs,
particularly in relation to the aftercare of crippled children who have been hos­
pitalized at public expense since July 1936. This study revealed marked inade­
quacy in aftercare and pointed clearly to a need for more adequate post-hospital
follow-up and additional clinic facilities. At the end of the fiscal year plans were
definitely under way for providing the needed facilities and personnel.
FLORIDA
S ta te a g en c y: C rip p led C h ild re n ’s C o m m is s io n .
The Crippled Children’s Commission felt that progress was made during 1938
in that more children were hospitalized, better services were rendered, and a more
complete program was developed.
A better spirit of cooperation was manifested between the Commission and the
social-welfare organizations in that all children discharged from hospitals and
convalescent homes were referred to the State Board of Welfare, which then under­
took to visit these children in their homes in an effort to make such improvement as
was possible in their surroundings. These children were also referred to the
nursing service of the State Board of Health, and the nurses in their respective
localities visited the children in their homes and rendered such professional
services as were possible. The nurses also saw that instructions given in regard
to particular cases were carried out.


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The public was informed of the work being done at the clinics and hospitals by
newspaper articles and talks by the surgeons and field nurses before civic clubs
and schools.
The field nurses made contact with the parents of former patients when a clinic
was to be held in a locality and also informed the public so that each out-patient
clinic was well attended. These clinics were held for diagnostic purposes only,
but X-ray photographs were taken and appliances and braces fitted when
necessary.
Former patients were seen at the clinics and the surgeon prescribed whatever
measures might be of benefit to the children without their returning to the hospital,
thereby oftentimes saving a trip to the hospital for the child. The field nurses
also kept in close contact with the children after they were returned to their homes
and noted and reported progress to the orthopedic surgeon.
The three convalescent homes used by the Commission were all improved in
many ways; they added to their personnel, enlarged the buildings, and rendered
more efficient service. Schools were maintained in each convalescent home in
order that the children might continue their schooling. These schools were main­
tained at no expense to the Commission. Many children were referred directly
from the hospitals to the director of vocational rehabilitation.
The State register is being revised and will be maintained in the office of the
Crippled Children’s Commission at Tallahassee.
Reciprocal agreements were made with the States of Georgia, Alabama, and
New Jersey, and excellent cooperation was established with patients moving to
these States from Florida. The Commission is eager to establish reciprocal
agreements with all States in this service.
GEORGIA
S ta te a g en c y: D e p a r tm e n t o f P u b lic W elfa re, C rip p led C h ild re n 's
D ivision.
Immediately after a skeleton State staff had been organized, a list of crippled
children, located through a W. P. A. survey made in 1937, was sent to each county
welfare department and plans were made for diagnostic clinics to be held in various
sections of the State.
Between the initiation of the program April 1, 1938, and the end of the fiscal
year, June 30, 1938, 25 clinics were held in the several congressional districts,
covering 156 of the 159 counties in the State. About 7 or 8 counties participated
in each clinic. Each participating county brought from 6 to 8 children for exami­
nation. At this series of clinics approximately 800 children were examined by the
orthopedic surgeons participating in the program.
On April 15 the first child was admitted for hospitalization, and thereafter until
July 1, 1938, hospitalization at various hospitals throughout the State was
authorized for 156 children from approximately 130 counties.
The nursing and social-service field personnel was not organized until the last
month of the fiscal year, but district headquarters were designated for the field
personnel so that their work could be actively undertaken at the beginning of the
new fiscal year. During the month of May three nurses were given advanced
orthopedic training and a “refresher” course in orthopedic work at the Scottish
Rite Hospital in Decatur. These nurses were later placed in the field to follow
up hospital cases returned to homes.
During the first 3 months of the program convalescent service was developed
in Atlanta, where a home was set up temporarily to take care of 8 patients. Later
a dwelling was secured which offered facilities for 20 convalescent patients. The
personnel of this home is under the direct supervision of a graduate nurse, with


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practical nurses and orderlies as assistants. The home is located within the city
limits of Atlanta and is easily accessible to the various hospitals and participating
orthopedic surgeons. Physical therapy is carried out in the convalescent home
by a trained physical therapist. Arrangements were being made in Augusta,
Savannah, and Macon to maintain children under convalescent status in the hos­
pitals, as it was found that there were not sufficient numbers of convalescent
children in these cities during the early part of the program to justify the main­
tenance of convalescent homes. This arrangement has worked out satisfactorily.
The possibility of opening a convalescent home in Columbus was being considered
at the close of the fiscal year.
Outstanding cooperation was received from the beginning of the program from
local and county officials, church and civic organizations, local physicians, and
interested individuals. A statement outlining the purposes, plans, and organiza­
tion of the crippled children’s program was sent to local newspapers throughout
the State. Daily newspaper articles were published concerning the clinics held
throughout the State, and a radio address was given by the State director outlining
the purposes of the program.
HAWAII
S ta te a gency: T e rrito ria l B o a rd o f H e a lth , D ivisio n o f S ervic es to
C rip p led C h ild re n .
During the fiscal year 1938 a broader interpretation was given to the definition
of a crippled child so as to include more types of crippling conditions. Eye cases
were accepted when surgery could be expected to improve vision. Children with
cleft palate and harelip were given orthodontic and other services, in order to
rehabilitate them more completely.
The administration of this division was delegated by the Territorial Commis­
sioner of Public Health to the deputy health officer, as director of services for
crippled children. Other professional personnel consists of two orthopedic nurses,
one of whom was a public-health-nurse trainee during the year at Columbia
University. Her position was temporarily filled by a public-health nurse. The
position of medical-social worker was included in the budget, but no qualified
person was available.
All specialists assisting in the program are paid on a case basis.
As the program developed, working policies and procedures were clarified and
planned with many cooperating agencies. In the official State agency a closer
working relationship in the administration of the nursing program was worked out
with the director of the Bureau of Public Health Nursing.
Conferences were held with the staff of Shriners’ Hospital for crippled children
in order that its program could be extended, improved, and assisted by this D ivi­
sion. Social investigations by the Territorial Board of Public Welfare were
thoroughly discussed and planned by the directors of these two agencies, and the
crippled children's program was explained to their workers. The program for
eye work was greatly assisted by a cooperative policy adopted by the Bureau of
Sight Conservation and the Territorial Board of Health.
A great deal of effort and time was expended with the hospitals utilized by the
official agency in this program in planning fee schedules, facilities, records, and
personnel. Meetings were held with the county and Territorial medical societies,
with the technical advisory committees, and with the Hawaii Dental Society to
discuss the program in detail and the need for their cooperation.
The Department of Public Instruction cooperated in the provision of special
educational facilities for crippled children. The special speech class sponsored
by both agencies and the special crippled children’s class in one local school in
Honolulu are excellent examples of the part the Department of Public Instruction


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plays in the education of crippled children. The Division of Vocational Rehabili­
tation of the Department of Public Instruction carried along special training and
rehabilitation of crippled children showing aptitude.
Other accomplishments of the year were the establishment of the diagnostic
clinic for crippled children in the building occupied by the Board of Health; the
establishment of a private convalescent home supervised by this official State
agency; the beginning of the enlarged special speech class for children with post­
operative harelip or cleft palate; the completion of plans for the generalization of
the public-health-nursing program for crippled children, applicable to all the
islands; and the numerous educational releases in local newspapers and in the
magazine, “The Crippled Child.” Informal talks were given by the director and
the orthopedic nurses. Office procedures, follow-up records, and statistics were
improved during the year.
IDAHO
S ta te a g en c y: D e p a r tm e n t o f P u b lic W elfa re, D ivisio n o f P u b lic H e a lth ,
B u re a u o f M a te r n a l a n d C h ild H e a lth a n d C rip p led C h ild ren .
The progress achieved in the crippled children’s program in Idaho during the
fiscal year 1938 was steady though not spectacular.
A gratifying aid to the crippled children’s program came with the extension
of full-time public-health supervision to five additional counties. This has
resulted in marked improvement for these counties in education of the public
regarding the crippled children’s program, in case finding, in clinic organization,
and in aftercare services by public-health nurses.
During the fiscal year a complete review and analysis of the previous expendi­
tures of funds available for the care of crippled children and the number of crippled
children treated resulted in changing payment of the orthopedic surgeon, the
plastic surgeon, and the pediatric consultant from a fee-schedule basis to a parttime salary basis. It was also agreed that the surgeons should provide necessary
assistants with the exception of the anesthetists. This change not only has
simplified accounting but has enabled the agency to arrange financially for the
treatment and hospitalization of all children eligible under this program, which
was not formerly the case.
During the latter part of the fiscal year the assistant director of the crippled
children’s program since its inception took a 6-month course in medical-social
work at the University of Chicago.
A State orthopedic advisory nurse was selected and sent to Simmons College,
Boston, for advanced training in orthopedic nursing. Upon her return she will
assist in (1) in-service education, (2) follow-up services, (3) advice to official and
nonofficial nursing agencies, and (4) diagnostic and follow-up conferences.
A well-qualified physical-therapy technician was added to the State staff to
provide physical therapy for crippled children in hospitals and foster homes and to
assist in the diagnostic and follow-up conferences.
The problem of supplying teachers for convalescent patients was met when
the W. P. A. Adult Education Department agreed to supply grade-school and
high-school teachers to visit the hospitals and foster homes and give this im­
portant service.
Through cooperation with the State child-welfare supervisor, standards for con­
valescent and foster homes were set up, and child-welfare consultants are working
with the Bureau of Maternal and Child Health and Crippled Children in locating,
investigating, and certifying homes used for care of crippled children under this
program.
239021°:—41----- 5


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ILLINOIS

S ta te a g en c y: D e p a r tm e n t o f P u b lic W elfa re, D ivisio n fo r H a n d ic a p p e d
C h ild ren .
The Division for Handicapped Children in the State Department of Public
Welfare was completely organized during the fiscal year 1938. The Surgical
Institute for Children, a division of the Research and Educational Hospitals of
the University of Illinois College of Medicine (a State hospital, operated by the
Department of Public Welfare), increased its bed capacity from 80 to 140 beds
during the fiscal year. The Division for Handicapped Children, located with the
general office of the Department of Public Welfare in Springfield, administers the
program for crippled children and supplies public-health nursing, social service,
and orthopedic field clinics in the State of Illinois, exclusive of Cook County.
Activities carried on during the year included a State-wide case-finding census
(completed in 43 counties and partially completed in 52 of the 102 counties of the
State) and orthopedic clinics for children handicapped by orthopedic and plastic
conditions.
Sixty clinics were held in 30 communities during the year. Of the total regis­
tration of 2,174 patients in the Division for Handicapped Children (as of June 30,
1938) 1,744 were seen in the clinics. Of the latter number, 783 were recommended
for hospital care. By the end of the fiscal year this recommendation had been
carried out for 357 (46 percent). The following appliances were furnished directly
to patients attending the clinics: 138 braces, 39 artificial limbs, 184 orthopedic
shoes and shoe corrections.
Progress was made in the early location of patients with conditions which lead
to crippling, through dissemination of an illustrated pamphlet with each birthregistration certificate (120,000 copies of this pamphlet were distributed). This
was made possible by a cooperative agreement with the Division of Vital Statistics
of the Illinois State Department of Public Health. A colored and perforated
front sheet was devised that will shortly be placed in each birth-certificate book in
order to arrange for direct reporting of congenital deformities to the Division for
Handicapped Children.
A State-wide follow-up of poliomyelitis cases from the 1936 and 1937 epidemics
was carried out by the field nurses and the district health officers of the Illinois
Department of Public Health. Every case of residual paralysis from polio­
myelitis in Illinois, exclusive of Cook County, from the 1936, 1937, and 1938
epidemics is being brought under care, the majority being under supervision of
orthopedic surgeons.
Respirators owned by private organizations throughout the State have been
counted and listed. Seven new respirators were purchased from the Governor’s
contingent fund, to be placed at the joint command of the Division for Handi­
capped Children and State hospitals of the Department of Public Welfare. This
last item completes a State-wide program for the specialized supervision of cases
of poliomyelitis.
INDIANA
S ta te a g en c y: D e p a r tm e n t o f P u b lic W elfa re, S ervices fo r C rip p led
C h ild re n .
During the fiscal year 1938 the crippled children’s program in the State of
Indiana began to function along the lines anticipated. Early in the fiscal year a
manual for the administration of services for crippled children was prepared,
including necessary forms to make possible the acceptance of crippled children for
services by county and State departments of public welfare.
As many crippled children in Indiana were receiving treatment under


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the county commitment system which has prevailed since 1921, arrangements
were made by the county departments with county judges having juvenile
jurisdiction to transfer many of these children to the supervision of the State
Department in order that a coordinated State plan of services for crippled children
might be developed.
In November 1937 the South Bend Hospital Center was first used by the State
agency, and a medical-social worker was placed on the staff of the hospital center.
At that time the two local orthopedic surgeons were appointed agents of the State
Department and began their work with crippled children in the northern area
of the State. Early in November a medical-social worker was added to the
staff of the James Whitcomb Riley Hospital. During the year a special project
concerned with the care and treatment of children suffering from cerebral birth
palsy was also initiated at the same hospital.
Early in the year 1938 blanks were distributed to physicians for the reporting
of children with congenital deformities, and arrangements were made with the
State Board of Health to incorporate such forms in regular booklets distributed by
the State Board of Health for the reporting of births.
In January 1938 the first orthopedic nurse was added to the State staff; by March
four nurses were on the State staff.
After a period of in-service training to become familiar with the program as
conducted by the State Department of Public Welfare, the nurses were sent into
the field April 1. Between April 1 and June 30 arrangements were made by the
nurses and the State staff for setting up and conducting 9 orthopedic consulta­
tion services at which more than 400 handicapped children were seen by ortho­
pedic consultants selected and approved by the State Department of Public
Welfare.
IOWA
S ta te a g en c y: B o a rd o f E d u c a tio n , C rip p led C h ild re n ’s S ervices.
Ten mobile clinics were held in Iowa during the fiscal year 1938. Patients were
drawn from 33 counties to attend these clinics. The area covered represents 21
percent of the population of the State. At these 10 clinics 1,243 patients under 21
years of age were seen, of whom 478 had received no previous treatment.
Approximately 50 physicians attended these clinics as observers, either all or
part of a day. Since these clinics were held, 10 to 12 percent of the patients
discovered have been committed to the university hospital for a program of
treatment. Nearly all these patients belong to thelow-income group. No figures
are available to show how many of the remaining patients sought treatment
elsewhere, as the disposition of the patient after a mobile clinic is decided by the
local physician who referred the case. Disposition is made on the basis of a letter
to the local physician from the orthopedic surgeon who examined the patient at the
mobile clinic. This letter contains the history, social data, physical findings,
X-ray readings, and indications for treatment. These letters are prepared in the
central office of the mobile clinic.
During the fiscal year a definite increase in interest and cooperation was shown by
the local physicians, other interested agencies, and individuals. More physicians
attended the clinics than during the previous year.
A pamphlet for the home care of spastic paralysis was prepared by the assistant
director. This pamphlet is given free to all individuals concerned with the care
of spastic patients.
The convalescent home in Iowa City, the maintenance of which is a part of the
State program, admitted 254 patients during the fiscal year. The length of time
spent at the home varied from 1 week to 9 months. The home has a capacity of
25 beds. Eighty-five percent of the patients in the convalescent home received

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physical therapy in some form. All patients except infants received occupational
therapy.
The patients cared for in the convalescent home were selected from those patients
discharged from the department of orthopedic surgery of the university hospital,
who continued to need observation for an indefinite period.
Occasionally physicians requested consultation in orthopedic cases. Such
consultation was usually rendered in the office of the physician by a member of the
orthopedic staff.
All handicapped children seen in the mobile clinics are reported to the State
Board of Education. Individual children physically unable to attend school and
therefore in need of a home tutor are reported, as are those needing transportation
to school. There is close cooperation between the crippled children’s administra­
tion and the State Department of Health, which reports to the mobile-clinic office
all congenital deformities reported to it on birth certificates.
Various members of the State staff appeared before professional and lay groups,
acquainting them with the State program. The two field nurses presented the
State program to visiting nurses’ associations throughout the State.
KANSAS
S ta te a g en c y: C rip p led C h ild re n C o m m issio n .
In 1931 the Kansas Legislature passed the crippled-children law creating the
Crippled Children Commission composed of five members appointed by the
Governor to serve for a period of 4 years without salary or compensation. It is
the duty of the Commission to approve or disapprove, at its discretion, hospitals,
convalescent homes, boarding homes, and charges for necessary supplies, treat­
ments, and operations; and to have general supervisory authority over the
administration of work for crippled children in the State.
Since the passage of the law the Commission has approved 19 hospitals in the
State for treatment of harelip, cleft palate, and congenital cataract, and for ortho­
pedic work. There are 11 orthopedic surgeons on the staffs of 15 of these hospitals;
also 1 plastic surgeon, 9 eye surgeons, and 4 surgeons with special proficiency in
the handling of harelip and cleft-palate cases.
In 1936 six public-health nurses and one field representative were employed and
engaged in case finding and follow-up services over the State.
During the fiscal year 1938, 15 diagnostic clinics were conducted in which 945
examinations of crippled children were made. There were 588 crippled children
who entered approved hospitals for the first time under the provisions of the
crippled-children law between July 1, 1937, and July 1, 1938. Of this number,
539 were diagnosed as having orthopedic conditions or deformities, 44 as having
harelip or cleft palate, and 5 as having congenital cataract. More than 1,100
children who had been committed to hospitals prior to July 1, 1937, returned
during the fiscal year for check-up or further treatment.
In order to insure the proper functioning of the crippled-children law, the
Commission endeavored to inform and interest the general public throügh com­
munity programs. During the fiscal year seven public dinner conferences were
held in various parts of the State in connection with clinics. Each of these was
arranged through the united efforts of the local chamber of commerce, service
clubs, and women’s clubs. Prominent citizens appeared on the program with
either the chairman of the Commission or its legal adviser. At each meeting the
State crippled children’s program was described, and the functioning of the crip­
pled-children law was explained. Open forums followed these talks, thus giving
the local people an opportunity to ask specific questions. Local people were
urged to enlist in the campaign for the eradication of crippling conditions.


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KENTUCKY

S ta te a g en c y: D e p a r tm e n t o f H e a lth , C rip p led C h ild re n C o m m issio n .
Fiscal y ear
ended J u n e
30, 1937

F iscal y ear
ended J u n e
30, 1938

1 ,080
534
546
1, 420
$156. 09
27
2 ,1 5 3

1,161
533
628
1, 792
$146. 78
24
1 ,930

562
2, 715

664
2, 594

E x a m in a tio n s a t p e rm a n e n t clinics (w eekly a n d

In crease ( + )
or
decrease ( —)
+81

-1

+82
+372
—$9. 31
-3
-2 2 3

+102
-121

The figures above, comparing the fiscal years 1937 and 1938, show that 81 more
patients were treated in 1938 than in 1937, but a more significant figure is the
372 more admissions and réadmissions to hospitals. Patients once admitted
for treatment must frequently be readmitted for varying periods of care. This
necessarily cuts down the number of new patients whose applications can be
approved. An increase occurred in the number of previously treated patients
admitted for further care. It is gratifying to note that the per capita cost of
treatment (for individual cases) was $146.78 in 1938 as compared with $156.09 in
1937, a decrease of $9.31.
Clinic examinations in 1938 showed a decrease of 121 as compared with 1937.
Although there was a decrease in the number examined at the itinerant clinics, an
increase of 102 occurred in the number examined in the weekly or monthly clinics.
It is the policy of the Crippled Children Commission to encourage the follow-up
of cases by regular examination in the permanent clinics.
The major features of the crippled children’s program in Kentucky are the
holding of diagnostic clinics in sections where they are considered to be most
needed, the hospitalization and treatment of as many cases as possible as soon
after examination as finances permit, and as consistent aftercare service as the
small staff can provide. Progress was made along all these lines during the fiscal
year. As usual the chief handicap is lack of funds to treat and follow up the
many cases on the waiting list.
LOUISIANA
N o te .— The first State plan for Louisiana, approved on March 24, 1939, was
administered by the Board of Health, Division of Maternal and Child Health.
The State agency now is the Department of Health, Division of Preventive
Medicine, Section of Crippled Children.
MAINE
S ta te a g en c y: D e p a r tm e n t o f H e a lth a n d W elfa re, B u r e a u o f H e a lth ,
D ivisio n o f Services fo r C rip p led C h ild ren .
The crippled children’s program as it operates in Maine can be divided roughly
into the following major activities: Location of patients, clinic service, hospitali­
zation, aftercare service, and education.
Patients are located by all available workers, such as public-health nurses,
social workers, and physicians. During 1938 the number of cases referred by
physicians showed a definite increase. Especially noteworthy was the increased
number of congenital deformities referred shortly after birth, and the fact that

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other types of crippling conditions were referred in the early stages rather than after
extreme difficulties have occurred. Most physicians refer the cases through the
public-health nurses.
During the year one new clinic center was established at Rumford. In that
community are two State field nurses, a town school nurse, and two workers of
the Bureau of Social Welfare and the town welfare office. All cooperate in the
interests of child-health and welfare services, which of course include services for
crippled children. A treatment center was established in the nurses’ office where
muscle training, massage, and baking could be carried out. The town furnished
all the equipment.
During the year 776 new cases were seen at clinics and 1,774 clinic visits were
made by approximately 1,200 individuals. Arrangements were made for a new
clinic at Rockland to be held at 3-month intervals.
At the clinic the director of the Division of Services for Crippled Children takes
a history of all new cases and gives a general physical examination, because the
Division considers that the child should be treated as an individual rather than as
a cripple. As the physical therapist, an orthopedic nurse, and a medical-social
worker are present at the clinic, most clinic recommendations are either completed
or well under way at one sitting.
There has been no marked change in the number of patients hospitalized or
in the type of care which they have received. An increased number of patients
are being treated at the Central Maine General Hospital largely because the
orthopedist at the hospital attends as consultant at the Lewiston, Rumford, and
Machias clinics.
Aftercare services are given by public-health nurses, social workers, physicaltherapy technicians, and a medical-social worker. Among the public-health
nurses are five nurses who have had some orthopedic training and are able to care
for a large number of cases. Their techniques involving physical therapy have
been supervised by both the orthopedic surgeon and the staff physical-therapy
technician. Whenever possible, patients are treated in the physical-therapy
departments of the hospitals in order to cut down the home services. Appliances
are purchased by the Division of Services for Crippled Children except for those
cases in which there is town or State financial responsibility and for the few cases
in which the family can pay for the appliances.
During the year there was a poliomyelitis epidemic involving 137 cases. Sixtyfive of these patients received home follow-up care given either by the staff
physical therapist or by the five specially trained orthopedic nurses. These cases
were under the medical supervision of the family doctors and one of the consultant
orthopedists. A great deal of time had to be spent in the homes by nurses, but
the results obtained were worth the time and effort, because 9 months after the
epidemic no preventable deformities due to the disease were noted, although
75 percent of the patients were paralyzed, and a large number of these still
showed weakness or paralysis.
The nutritionist of the Division of Maternal and Child Health gave 79 con­
sultations to the Division of Services for Crippled Children, some of them at
clinics and some of them after the clinic had made recommendations.
An effort is being made to increase the use of convalescent (boarding) home care
in order to reduce hospitalization and at the same time have the patient available
for close follow-up by the orthopedists.
Medical-social service increased in scope and value during the year. The Chil­
dren’s Hospital became interested in having a medical-social worker added to the
staff. This worker was to come to the program in 1939 and was to be paid jointly by


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the Children’s Hospital and the Division of Services for Crippled Children.
Community contacts have widened, and in particular there has been, a more
closely knit relationship between the Division of Services for Crippled Children
and the Pine Tree Society for Crippled Children.
Two educational activities were inaugurated during the year. A series of
talks was given before 3 county medical societies, with about 125 persons in
attendance and to 5 of the 6 normal-school groups in the State, to acquaint
future teachers with the program in the hope that more cases will be referred
by teachers.
MARYLAND
S ta te a g en c y: D e p a r tm e n t o f H e a lth , Service fo r C rip p led C h ild ren .
The development and organization of services for crippled children in Maryland
had its beginning about the year 1900 under the Baltimore Council of Jewish
Women. That organization found a lack of educational facilities, both academic
and vocational, inadequate medical care, and lack of public support. Its work
was continued until April 1927, when it proposed its own withdrawal to give way
to the new State-wide organization, the Maryland League for Crippled Children.
The League immediately organized clinics throughout the State. The first was
held in Allegany County in May 1927, in charge of Dr. C. E. Bennett, Professor
of Orthopedic Surgery, Johns Hopkins Medical School. During the first year
of the League’s activities, 5 clinics were held at which 170 children were examined.
The service was gradually extended, and, by 1936, 34 clinics were held with an
attendance of 485 children.
When additional funds were made available by the Federal Government under
the Social Security Act, the Board of State Aid and Charities was first designated
as the official State agency, and the program was extended to include the services
of seven physical therapists located at strategic points throughout the State, sup­
plemented by the services of three orthopedic nurses. In 1937, by an act of the
legislature, the services for crippled children were transferred to the State Depart­
ment of Health.
The plans submitted to the United States Children’s Bureau by theBoar d of
State Aid and Charities and the one submitted by the State Department of Health
incorporated the fundamental principles which have guided the Maryland League
for Crippled Children and its professional advisers in their program. As early as
1929, legislation was passed placing the responsibility for proper classification and
provision of educational and professional facilities in the State Department of
Health. The joint responsibility for the care of crippled children developed close
cooperation between the State Department of Health and the Maryland League
for Crippled Children. Under the new plan it was natural that the official State
agency and the League should continue to develop the program in cooperation.
With additional funds made available it has been possible for the official State
agency to increase the number of clinics throughout the State to approximately
60 per year. Services not previously provided include the services of an ortho­
pedic nurse and attendance of one of the physical therapists at each clinic.
Through cooperation with the county health officers, it is now possible to have
X-ray examinations made at all the clinics when such service is required. The
interval of time between recommendation and hospitalization has been consid­
erably shortened, and with the service of physical therapists in the communities
it has also been possible to shorten the period of hospitalization to some extent.
Transportation to and from the clinic continues to be one of the most perplexing
problems, as this phase of the program rests almost entirely on the volunteer
services of the American Legion, civic clubs, and interested citizens. In spite of


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the limitations in this type of service, however, no child recommended to clinic
service has gone unattended, as the orthopedic surgeon in charge of the clinic
as requently made home visits when it was im no ssib le fn r
n o fip rtf f n fort nt.
the general clinic.
In addition to the services of the regular orthopedic surgeons conducting the
clinic, provision has been made for the services of a specialist in the care of spastic
and similar conditions. Children who are examined at regular diagnostic clinics
and who are found to be suffering from cerebral palsy are referred to a special
diagnostic clinic conducted by this orthopedic specialist. If in his opinion there
is evidence that benefit can be derived from treatment, provisions are made when­
ever possible for the care and treatment of the child at the Children’s Rehabilita­
tion Institute, which specializes in the care and treatment of such conditions
With the discharge of patients from the State register because of recovery
reaching the age limit, or other reasons, it is expected that the number of children
dropped from the register and new cases admitted will maintain an equal balance
and assure an even flow of those admitted and those discharged
M A SSA C H U SET T S
S t a t e a g e n c y : D e p a r tm e n t o f P u b lic H e a lth , S e rv ic e s f o r C r ip p le d
C h ild re n .

The crippled children’s program in Massachusetts is centered about a system
of diagnostic clinics located in 10 clinic districts. A clinic is held monthly on a
regularly scheduled day in a well-equipped hospital in the central city of the
district. No matter where a crippled child lives, one of these monthly clinics is
easily accessible.
Clinics are staffed as follows: There are 10 clinic consultants, one for each distnct and each one is a recognized orthopedic surgeon. The clinic consultant is
in full professional charge of all 12 clinics held in his district during a year
The
State, super visor of clinics for crippled children attends each clinic and is in charge
of administrative details, leavi«»
__ ____..
..
..
*_

o two clinics. A medical-social worker (there are
She is responsible for the medical-social work in
two or three specified clinic districts.


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and the apparatus is fitted to the patient by the consultant as soon as it is pre­
pared. The important point is that once a patient is admitted to services for
crippled children, he is given actual, continuous follow-up services as long as he is
carried on the list of active patients; that is, until he is cured, leaves the State,
or refuses to accept what is offered.
A very important feature of the program is that it has the complete support
and cooperation of the medical profession. If after investigation by field workers,
it is found that the case is a suitable one for admission to the clinic any child
may attend, on the approval of a physician, for examination, diagnosis, and
prescription, but acceptance for care rests with a designated committee of the
district medical society. Of the 1,500 cases admitted to clinics so far, this
approval has never been withheld. Final decision, however, rests with the
State Commissioner of Public Health.
The program has progressed satisfactorily. At almost every clinic session one
to three new cases are seen. This has been accomplished through the coopera­
tion of the medical and nursing professions. Special emphasis is being placed
on locating and operating on plastic cases. Operations for strabismus are also
being done in increasing numbers.
MICHIGAN
S ta te a g e n c y : C rip p led C h ild re n C o m m issio n .
The Michigan Crippled Children Commission during the fiscal year 1938
hospitalized 885 more crippled children than in the preceding fiscal year. The
Commission believes that this increase was due primarily to successful coopera­
tion with other State and local agencies interested in the crippled child.
Several new county health districts were established in Michigan by the State
Department of Health during 1937—38. The personnel cooperated with the
Commission in locating, reporting, and following up crippled children.
During the fiscal year 3,683 court commitments for crippled children were
issued, in comparison with 2,381 in the previous year. This was due in part to
the necessity for issuing new orders under the new crippled children’s act and in
part to the fact that the cost of transporting the crippled child, since the beginning
of the fiscal year 1938, has been charged to the State instead of to the county.
The Commission, in cooperation with local service clubs and medical societies,
sponsored 5 diagnostic clinics during the fiscal year 1938, at which 307 crippled
children were examined. Among these, 69 new cases were discovered. These
diagnostic clinics have been very valuable both to the crippled child and to the
State, as the orthopedic examining surgeon made recommendations regarding
treatment and further care without making it necessary to transport each child
to the hospital. The Commission’s field nurse made a follow-up visit for each
child and instructed the parents in regard to treatment and the proper procedure
to follow in securing State assistance, if the family was unable to finance treat­
ment.
The local service clubs and physicians have become more familiar with the
work of the Commission. Three “refresher” courses for physicians were held
during the fiscal year, each one on the evening prior to the diagnostic clinic.
These courses have been helpful in bringing the local physicians and agencies in
contact with the activities of the Commission.
Every effort has been made to find the crippled child early. In following this
program much has been gained both for the crippled child and for the State
agency.
During 1938 two additional orthopedic centers and one hospital were fully
approved for the care of crippled children. Two additional orthopedic surgeons

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have been approved by the Commission. This step has aided materially in early
treatment and lower transportation costs for the crippled child.
The 1937 crippled children’s law made provision for the crippled child needing
custodial care. The Commission has taken advantage of this legislation in car­
ing for and making possible an educational program for some of these children
with the appropriation which was set aside for this purpose. The Commission
hopes to continue this work.
MINNESOTA
S ta te a g en c y: B o a rd o f C o n tro l, D ivisio n o f S ervic es fo r C rip p le d
C h ild re n . (N ow S ta te D e p a r tm e n t o f S o c ia l S e c u r ity , D ivisio n o f S o cia l
W elfa re, B u r e a u fo r C rip p led C h ild re n .)
Progress has been made in the hospitalization of crippled children in private
hospitals, which has helped to decrease the waiting lists of children approved for
entrance to public hospitals. Attention is thus given to crippling conditions at
an earlier date and the load at the public hospitals has been decreased.
An increase in the number of field clinics from 12 to 14 makes it possible for any
crippled child in any rural county in Minnesota to have access to a clinic at some
time during the year. There are two orthopedic surgeons at each clinic instead
of one, because the number of cases at each clinic has increased to between 50 and
100 and sometimes exceeds 100. By means of the field clinics many new cases
continue to be found soon after disability has occurred. Clinics are one of the
most important means of finding crippled children soon after deformities have
appeared.
The nursing service was of real benefit during the year and was the means of
finding many new cases and rediscovering old cases in need of care.
Two publichealth nurses were given training in physical therapy at Harvard and will be much
more valuable for the service. The field nurses have been in contact with a large
number of local physicians in rural communities and have explained the program
to them. Cooperation is thus established in a way which would not be possible
by letter or by the usual indirect educational methods. The field nurses have
embarked on a definite educational public-health campaign in the homes and in
the offices of public officials and local physicians.
In regard to public-health education, the director of the Division of Services
for Crippled Children, in cooperation with orthopedic surgeons, carried on several
“refresher” courses for local practitioners held in conjunction with the meetings
of the county medical societies. These courses have been of value to the local
physicians and have been a means of explaining the services of the Division to
general practitioners throughout the State.
The statistical and research aspect of the work made good progress. Several
special studies were made and the results are to be published. The Division
developed a new record system which will make the State register more valuable,
flexible, and accessible for special studies. Approximately 1,000 new cases were
added to the State register during the year. It was found that in Minnesota the
ratio of crippled children on July 1, 1938, was 8 per 1,000 persons under 21. Other
studies indicate that the rate in the near future will be in the neighborhood of 10.
It has been possible to increase the amount and quality of cooperation with other
agencies interested in the crippled child. Cooperative facilities for investigation
of cases in the counties and provisions for transportation and for additional social
service have been added at the field clinics, where five or six social workers are
usually needed because the cases come in so rapidly that the staff of two cannot
handle the load. Cooperation with the State Board of Health and its various
departments and the State Department of Education and its Division of Rehabili­
tation was expecially noteworthy. The problem of the complete care of crippled

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children is so complex that it would not be possible to give maximum care without
the cooperation of every agency working with the crippled child.
M ISSISSIPPI
S ta te a g en c y: B o a rd fo r V o c a tio n a l E d u c a tio n .
Perhaps the greatest progress made by the Mississippi crippled children’s
services has been in the financial field, as that has made possible the other things
which have been done. In the first days of the regular 1938 session, on the
recommendation of the Governor, the legislature made an emergency appro­
priation of $15,000; later in the session an appropriation of $50,000 was made for
the new biennium. In view of the fact that no appropriation whatever had been
made by the 1936 legislature, it is evident that strong sentiment had been created
in the State in favor of the work.
Much closer cooperation was worked out with the State and county health units,
and the organization of lay committees in 50 of the 82 counties of the State was a
decided step forward in informing the people of the State of the work, as well as in
the location and aftercare of crippled children.
The presence of two nurses on the field staff instead of one has meant a great
deal in securing the consent of the parents to have children treated and in the
aftercare and treatment of these children in their homes. The addition of two
nurses for clinic duty at the poliomyelitis clinic which operated 1 day a week after
January 1 meant much to the progress of the work as it has made it possible for
the field nurses to remain in the field for the entire week.
With the help of the Mississippi State Federation of Women’s Clubs, some
local business men in the city of Jackson, and one of the Jackson daily papers,
funds were raised for the purchase of two “ iron lungs.” Because of the asso­
ciation of the editor of the paper with the work of the crippled children’s services,
much publicity has been given to the program through his paper and associated
papers throughout the State.
Before there was a State appropriation the greatest problems were naturally
financial. Money had to be raised through donations from individuals and
organizations, not only for the regular program but for a poliomyelitis epidemic
that has lasted more than 2 years. As soon as the individuals or organizations
were informed of the need, these problems were for the most part quickly solved.
The program in Mississippi has expanded so rapidly that the greatest problem at
the end of the fiscal year was hospital space. The orthopedic surgeons, the pedi­
atrician, and consultants work together harmoniously and have the program very
much at heart. The hospitals cooperate to the limit of their capacity. The
problem of trained personnel is being met as rapidly as possible by having the
nurses go away for specialized training. The program is already outgrowing
financial bounds, so that once again the major problem is that of finance.
MISSOURI
S ta te a g en c y: U n iv e rsity o f M isso u ri, S ta te C rip p led C h ild r e n s
S ervices.
In summarizing the activities and progress of the State Crippled Children’s
Service in the fiscal year 1938 it can be stated briefly that the major change was
in perfecting the organization of the field nursing services. Until Federal funds
became available there was no field nursing service and only one central
hospital service.
During the year the State was divided into five districts, and a specially trained
orthopedic field nurse was placed in charge of each district. This service in
general takes care of the rural areas in each district and omits the counties and
areas immediately surrounding large cities.

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Three additional hospital centers were provided where hospitalization is carried
out under the direction and supervision of a properly qualified orthopedic surgeon.
With four hospital centers available, the transportation of children to hospital
centers for treatment has been materially improved, children going in general to
the closest center.
Convalescent care is supplied at one convalescent home only; the facilities of
this home were increased somewhat through the additional funds available.
There has been an increased spirit of cooperation during the year between the
State Crippled Children’s Service and other agencies working with crippled
children. Specifically, public-health units are being established, each of which
has been very cooperative in looking after cases in its particular counties and in
arranging for clinics, transportation, and the like.
The State Vocational Rehabilitation Service sends a representative to each of
the diagnostic clinics, so that patients examined at the clinic are referred directly
to that department when appropriate, and such investigation as is necessary is
made by its own representatives. Other patients referred to the rehabilitation
service by letter were visited promptly, and some attempt was made to plan
a joint program.
The major private organization interested in crippled children’s work, the
Missouri Society for Crippled Children, was helpful in arranging for care for
children and adults over the State age limit, thus permitting continued care of
patients who otherwise would not receive it because of age restrictions.
MONTANA
S ta te a g en c y: D e p a r tm e n t o f P u b lic W elfa re, S ervices fo r C rip p led
C h ild re n (n o w D ivisio n o f C rip p led C h ild ren ).
In 1937 the State Legislature abolished the State Orthopedic Commission and
transferred its responsibilities to the newly created State Department of Public
Welfare. The appropriation for crippled children’s services was increased to
$30,000.
On July 1, 1937, Services for Crippled Children became a functioning divi­
sion of the Department of Public Welfare. The legislative act (Session Laws of
1937, ch. 82) created in every county seat a county department of public welfare.
These departments were made the responsible agencies for the administration of
the State program. With the creation of the State Department of Public Welfare
and the county departments of public welfare, minimum qualifications for per­
sonnel were established (known as the merit system). These minimum qualifica­
tions apply to all State and county personnel. Salary schedules also were estab­
lished. Personnel qualifications in Services for Crippled Children are based
on qualification standards established by the national organizations in the respec­
tive fields and recommended by the United States Children’s Bureau Advisory
Committee on Services for Crippled Children.
The State Department of Public Welfare appointed a technical advisory com­
mittee. It also limited the orthopedic surgeons on the staff to those certified or
eligible for certification by the American Board of Orthopedic Surgery.
On July 1, 1937, there was only one registered physical therapist in Montana.
Two registered physical therapists have since been appointed, and a third is eligi­
ble for registration.
NEBRASKA
S ta te a g en c y: B o a rd o f C o n tro l, C h ild W elfa re D ivisio n .
Much was accomplished indirectly as well as directly in the development of the
crippled children’s program during the fiscal year 1938. The State-county
organization for case finding and investigation of economic need was greatly

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improved. The program of the State Orthopedic Hospital, which formerly
functioned as a combination hospital and convalescent institution, was consider­
ably strengthened. Convalescent homes were established outside the hospital,
the latter now being used only for hospital cases. The medical staff was expanded
to include two additional orthopedic surgeons as well as a pediatrician and a
pathologist. Laboratory and other facilities were greatly expanded. Medica
records were improved. A registered physical-therapy technician was added to
the staff. A medical-social-work department was established, social records
were kept for the first time, and a systematic follow-up program was inaugurated.
The out-patient service, which was formerly conducted only one morning a week
for all cases, was changed to provide for two orthopedic clinics and one pediatric
clinic a week. Medical staff meetings were initiated. The hospital was approved
by the American College of Surgeons during the year. Consultation service to
local physicians on orthopedic cases was also initiated.
. . ,
The progress in carrying out the provisions of the State plan for crippled
children was more marked in the first 2 years of the program than in 1938, when
progress consisted chiefly of improvement in administrative techniques an
strengthening of relationships with professional groups and with the county
dCAmong the indirect results of the crippled children’s program during the year
was a very marked increase in the interest shown by the medical profession and
the public generally in methods of meeting the problems presented by the p ysically handicapped child whose parents are financially unable to provide for him.
The medical profession generally accepted the program during the year and thinks
of it as an experiment in the area of medical care for the needy. The program
developed significant administrative techniques in this area, including standards
of care, personnel qualifications, eligibility, administrative organization, Statecounty relationships, payment for professional services, and cooperation and
coordination with medical, health, nursing, and welfare groups. Through the
work with crippled children the public and professional groups were made more
aware of the need for adequate medical and social service for children suffering
from nonorthopedic conditions. Interest has developed in meeting the special
need for training of children, with cerebral birth palsy, as well as in providing
educational opportunity for the home-bound child.
The cooperation of county welfare departments with the local medical societies
on crippled children’s cases has stimulated the development of local programs o
medical care. Local physicians without adequate facilities for medical investi­
gation and specialized treatment are looking to the State service for consultation,
medical service, and leadership in treatment for other than orthopedic conditions.
The social, psychiatric, and psychological study of children in need of these services
under the crippled children’s program has demonstrated the value of these special­
ized services for children suffering from nonorthopedic conditions.
NEVADA
S ta te a g en c y: B o a rd o f H e a lth , M a te r n a l a n d C h ild H e a lth D ivisio n .
(N ow D e p a r tm e n t o f H e a lth , D ivisio n o f M a te r n a l a n d C h ild H e a lth a n d
^ N ev v d a b e g l i operation of the crippled children’s program for the first time in
th TheCfirsytestep9was to make a State-wide survey to locate handicapped children
and classify them, separating those that might come under the crippled children s
program. About 300 children were located. The first half of the year was taken
for this part of the work.

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Itinerant diagnostic clinics were held in five centers chosen for their convenience
to the greatest number of children. Ninety-seven children attended these clinics
held by an orthopedic surgeon of Los Angeles, Calif. Seven patients were suffer­
ing from other crippling conditions such as harelip, cleft palate, and deafness. Of
the remaining 90 children the surgeon’s report shows that—
26 children are ready for hospitalization.
5 children will need surgical care in years to come.
8 children need orthopedic direction and consultant care of pediatrists,
neurologists, and so forth.
14 children need no active treatment at present.
23 children would benefit from orthopedic nursing and physica 1therapy.
7 children cannot be benefited by medical or surgical care, but vocational
training might fit them to be s e l f - s u s t a i n i n g.
7 children are hopelessly handicapped.
Some of the children needing care have been able through their own resources
or through other means to get the necessary treatment.
Two children have been fitted with braces and one was hospitalized. More
than this could not be done with the funds available.
NEW HAMPSHIRE
S ta te a g e n c y : B o a rd o f H e a lth , D ivisio n o f M a te r n a l a n d C h ild H e a lth
a n d C rip p led C h ild re n ’s Services.
Progress in crippled children’s services in this State was made chiefly through
contacts of the nurse-physiotherapist. Case finding was made possible through
direct and indirect contact with known cases; birth palsies were picked up at the
time of birth or soon after through contacts with known cases in home visits by
nurses. Private physicians cooperated by reporting all known crippling condi­
tions early, and public and private agencies also cooperated in case finding.
Much more orthopedic and plastic surgery was done in 1938 than formerly,
especially in cases of cleft palate and harelip.
More cases were admitted to hospitals than in former years. A neurologist who
took interest in the cases gave volunteer service.
The work in clinics was expanded through more complete follow-up work.
This was made possible chiefly by cooperation with district nursing agencies,
private agencies, and public-welfare agencies.
Nursing service for crippled children was expanded, all State nurses doing
follow-up work and giving care in their own districts.
During the year two nurses were given stipends for a special 7 weeks’ course in
physical therapy, so that follow-up treatment may be of better quality.
Physical therapy was extended into the home and into the hospital clinics,
thereby reaching more of the patients and increasing the amount of surgical
treatment.
NEW JERSEY
S ta te a g e n c y : C rip p led C h ild re n ’s C o m m issio n .
One of the major features of the program of the Crippled Children’s Commis­
sion which showed marked progress during the fiscal year 1938 was the locating
of crippled children. As part of the survey of nursing and health organizations of
the State, the Commission’s nurses stressed the importance of locating and report­
ing all crippled children. Active cooperation was enlisted from all the organ i c tions with which contact was established, with the result that 2 months after the
completion of the survey the total number of monthly referrals of crippled children


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had increased approximately 17 percent and the number of individual agencies
reporting these children had increased approximately 28 percent.
In the spring of 1938 the Commission wrote an article entitled “ How the School
Nurse Can Cooperate with the Crippled Children’s Commission,” which was
published in the School Nurses’ Bulletin. This article stressed the importance of
reporting all crippled children located by the school nurses, with the result that
a number of cases have been referred to the Commission by these nurses.
Another step in progress was the addition of 6 hospitals to the 38 used by the
Commission for the care of crippled children. These 6 hospitals are located in the
heavily populated counties— 2 in Essex, 2 in Passaic, and 1 each in Hudson and
Camden. The Commission finds that with the added facilities made available
by the use of these hospitals there are no waiting lists of crippled children in
need of hospitalization or clinic care in the State of New Jersey.
The procedure inaugurated by the Commission in connection with all new
poliomyelitis cases is worthy of note. It is mandatory in New Jersey for physi­
cians to report all new poliomyelitis cases to the State Department of Health.
This department forwards a copy of these reports to the Commission. Imme­
diately upon receipt of such a report a letter is written to the physician, who is
offered the aid of the Commission in the purchase of appliances and in the provi­
sion of hospitalization and necessary convalescent care. At stated intervals
follow-up calls are made by the Commission’s nurses to insure that every child is
receiving proper care and attention, with the result that every poliomyelitis case
reported to the Commission during the fiscal year received or is now receiving the
care necessary for physical rehabilitation.
In connection with the aftercare of such cases the Commission sponsored the
erection of a new therapeutic pool and the purchase of modern physical-therapy
equipment at the Betty Bacharach Home in Atlantic City, thus making available
to the poliomyelitis victims of New Jersey the most modern methods of aftercare,
second only to Warm Springs, Georgia.
The use of the discharge report by the hospitals, on which is recorded the date
the child is to return for re-examination or clinic treatment and the type of aftercare service prescribed by the orthopedic surgeon, have enabled the Commission
to set up a definite procedure for follow-up or aftercare treatments.
The progress made by the cerebral-palsy experimental unit at Babbitt Hospital
is noteworthy. During the fiscal year the number of boys at the hospital increased
from 10 at the beginning of the year to the full quota of 21. Without exception
every child at the hospital responded to treatment. This is shown in improved
muscular coordination and is reflected in increased social confidence.
During the year Dr. Phelps wrote an article on cerebral palsy and later addressed
the Academy of Medicine of Northern New Jersey on “ Cerebral Palsy and
Poliomyelitis as They Concern the Family Doctor, the Orthopedist, and the
Neurologist.” These papers were printed in the journal of the Medical Society
of New Jersey and reprinted in pamphlet form. Both pamphlets were mailed to
physicians throughout the State. The letter of transmittal to the physicians
urged that they report to the Commission all cases of cerebral palsy with which
they come in contact. The results are indicated by the fact that at the monthly
cerebral-palsy clinics almost twice as many children per clinic were being exam­
ined at the end of the fiscal year as at the beginning of the year. As of June 30
1938, 227 children had been examined in these clinics. The data collected indi­
cate that in New Jersey cerebral palsy is one of the most serious forms of crippling
in respect both to the number of children affected and to the severity of the
handicaps resulting from it.


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NEW MEXICO

S ta te a g en c y: D e p a r tm e n t o f P u b lic W elfare, D ivisio n o f C rip p led
C h ild re n ’s Services.
During the fiscal year limited progress was made in carrying out the State
crippled children’s plan. There was further development of case location through
the health department, schools, civic clubs, local county committees, and local
welfare offices.
The Division of Crippled Children’s Services worked out with the Carrie
Tingley Hospital, which was completed during the year, a cooperative plan
whereby the Division took responsibility for the admission and discharge of all
patients other than private. This plan made it possible to hospitalize a large
number of children and greatly increased the responsibilities of the Division.
Itinerant clinics were practically abandoned during the year, as weekly clinics
at Carrie Tingley Hospital took their place. However, at the end of the year a
plan was made whereby the Division of Crippled Children’s Services and the
Carrie Tingley Hospital staff were to conduct a monthly clinic in each of four
clinic districts throughout the State. This made it possible to give more services
to children in communities near their own homes. This plan also revived the
interest of local communities by bringing the program back to them.
There was no development of foster or convalescent homes. The only foster
homes used in the State were those utilized for overnight stops for children en
route to and from the hospital. A convalescent home was maintained for a few
months in connection with an out-patient service which the State Department of
Public Welfare sponsored in Hot Springs, where Carrie Tingley Hospital is located.
Children were retained in the convalescent home for physical therapy, to await
braces, and when other situations warranted such care. The service did not seem
practical, and consequently the out-patient service and the convalescent home
were discontinued at the end of the fiscal year.
There was little development in aftercare services, as more emphasis was placed
upon preparing children for treatment rather than upon the necessary aftercare
program. A cooperative plan with the State Department of Public Health was
fostered whereby the public-health nurses gave as much aftercare as possible to
children upon discharge from the hospital.
The need for a technical advisory committee is recognized, but such a committee
has not yet been organized. The State advisory committee on crippled children’s
services did not function as a group during the year, but the Division was quite
consistently in touch with individual members.
NEW YORK
S ta te a g en c y: D e p a r tm e n t o f H e a lth , D ivisio n o f O rth o p e d ics.
The program for the rehabilitation of crippled children in New York State has
been in force since the epidemic of 1916. Since that time certain procedures have
grown up and policies have been established.
The program includes: (1) Diagnosis at State clinics, permanent or itinerant, by
orthopedic surgeons on the State staff; (2) hospitalization at the New York State
Reconstruction Home at West Haverstraw and at more than 50 hospitals located
in various parts of the State; (3) aftercare in convalescent homes or in the child’s
own home, and (4) a corps of State orthopedic public-health nurses in districts
who arrange for clinics and for the care recommended by the surgeon after diag­
nosis, at the time of discharge from the hospital or convalescent home, and during
the period after the child’s return to his own home.
Funds for this work have been provided since 1927 by the legislature and
local fiscal authorities. Federal funds have been used to supplement the State


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program in providing additional nurses and additional office staff for routine
clerical work.
The only new services undertaken with Federal funds have been those of a
statistician and a medical-social worker added to the staff. The statistical work
has been most useful in bringing to light interesting facts and figures from the
mass of data gathered since 1916. It is hoped that it will soon be possible to make
deductions from the statistical data that may have a bearing upon the direction
of the work.
The addition of a medical-social worker to the staff has been of value in making
possible a better tie-in with the various social groups and organizations throughout
the State doing related work. She has served to interpret to the nursing field staff
many of the social problems resulting from handicap which affect the patient’s
ability to profit from medical care.
The great need for a worthwhile plan of education of the general public in mat­
ters relating to handicapped children is generally recognized. Early discovery
has been one of the great problems. A program to acquaint the general public
with the details of this phase alone of the handicapped children’s program would
be an immense piece of work in itself in view of the size and population of New
York State. A series of lectures and demonstrations has been developed to
acquaint the nursing groups with early signs and symptoms of these conditions.
This, however, is only a beginning; if worthwhile results are to be obtained a reg­
ular program must be established as part of the general education of those who
are in closest contact with the younger element of the population.
There is need also of a program to afford some aid to the large number of children
suffering from cerebral palsy that have already been located.
NORTH CAROLINA
S ta te a g e n c y : B o a rd o f H e a lth , D ivisio n fo r C rip p led C h ild re n .
The North Carolina State Board of Health has completed the second year’s
experience in the direction of a coordinated plan of services for crippled children.
The State agency believes that this period has demonstrated again the wisdom of
the original features of the plan and is gratified at the record of achievement— a
marked advance in contrast to periods preceding the enactment of the Federal
Social Security Act with its provision for grants-in-aid to the States for extending
and improving services for crippled children.
The essential features of the plan provide the following services: (1) Location of
crippled children and registration of those eligible for classification under the
definition provided in the plan; (2) specialized diagnostic services; (3) specialized
treatment and care; (4) field supervisory and follow-up services; (5) engendering
and coordination of activities of public local agencies and lay organizations in
endeavors for crippled children; and (6) engendering of general interest and
education of the public in the needs of crippled children.
The registration of crippled children showed considerable progress in the fiscal
year 1938. It will require time, however, to collect the minimum information
essential to the standards suggested for registration. On every hand interest and
cooperation have been manifested in referrals by both public and private groups.
Clinic records indicate that approximately 23 percent of admissions for the year
have been new cases. The register includes approximately 13,000 of an estimated
20,000 eligibles.
The State clinics, numbering 18, were conducted at strategic geographic points
monthly or more frequently if such a need was indicated by attendance. These
provide facilities and services of specialized personnel for expert diagnosis, classi­
fication, and treatment. There were 9,782 admissions to these clinics within the
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period, an average monthly admission for each clinic of 45 children. The length
of the sessions ranged from a half day to a full day, as attendance indicated from
time to time. The reported treatment procedures in the clinics were as follows:
1,341 dressings, 692 casts, 398 corrective shoes, 314 exercises, 199 braces, 146
diets, 102 massages, and 84 proprietary bandages. These reports were not
complete. Hospital care was arranged for 1,606 children.
Seventeen selected general hospitals gave care to 1,044 children, representing
approximately 65 percent of the hospital load. The remaining 35 percent, or
562 children, received care at the State Orthopedic Hospital. These admissions
represent 80,255 bed days of care.
No convalescent care was furnished by the State agency in institutions as such,
although some of the care given at the State hospital might not have been necessary
had there been provision for convalescent care. This is also true in a more limited
way of the general hospitals.
The State has only recently undertaken care of crippled children in boarding
homes. Insufficient time has elapsed since this type of care was begun to make an
evaluation. Suffice it to say that such a plan appears feasible for a State with a
widely scattered rural population.
The activities of the field staff have been of unusual value in developing the
whole plan of services, in coordinating local services, and in engendering increased
interest on the part of local groups. These activities are reflected in the following
figures: Children admitted to field services, 3,122; field and office visits, 6,383;
conferences with surgeons, 288; conferences with health officials, 447; conferences
with welfare officials, 477; other individual conferences, 858.
The activities of the State staff in specific educational discussions included 3
radio addresses over 5 local broadcasting systems and 29 other talks and addresses
to audiences totaling 1,471.
NORTH DAKOTA
S ta te a g en c y: P u b lic W elfa re B oard, D ivisio n o f C h ild W elfa re.
The allocation of Federal funds to North Dakota for services to crippled children
in November 1936 made possible for the first time the development of State serv­
ices for the physical restoration and social readjustment of physically handicapped
children. The Public Welfare Board of North Dakota established a Division of
Child Welfare to administer child-welfare services and crippled children’s services,
and, with the agreement of the Board of Administration, the powers delegated to
it by child-welfare laws of 1923. This administrative structure has resulted in
an integration of crippled children’s services with county and State welfare, publicassistance, and social-welfare programs. Through the coordinated field staff
supervising all public-assistance and welfare programs administered by the county
welfare boards improvement has been made in local case-work services for crippled
children and in the interpretation of policies adopted by the State agency in
administering services to crippled children.
The administrative procedures established and activities planned in the fiscal
year 1937 were followed with slight modifications during the next year. Realizing
that the annual budget of $23,556 for 1937 was insufficient to meet the medical
and social needs of the crippled children eligible for services, the Public Welfare
Board allocated $50,000 for 1938 to match the Federal funds for services for
crippled children. These additional funds made it possible to extend treatment
and medical care to 633 children, as compared with 116 children receiving medical
treatment during the fiscal year 1937.
The maximum age limit for assistance to crippled children was changed from
18 to 21 years. Congenital strabismus needing surgery for correction was added
to the types of crippling conditions to be accepted for medical treatment.

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A total of 1,077 physically handicapped children were examined at the 11
itinerant diagnostic clinics conducted during the year. Two of these clinics
were entirely new public services in their areas; in 9 centers similar clinics had
been held the preceding year. The attendance at these clinics showed that
the public had a better understanding of the purpose of these diagnostic clinics,
as fewer children attended whose physical defects were nonorthopedic. Because
of the smaller attendance the orthopedic surgeons and physical-therapy technicians
were able to spend more time with each patient and to explain to parents, nurses,
and social workers follow-up care and services. A representative from an arti­
ficial-appliance company was present at all clinics to take measurements for braces
and to check the performance of appliances purchased by the State agency during
the year.
Local case-work services were increased for locating and giving follow-up services
to crippled children. Public-health-nursing services for crippled children and
for the teaching of mothers to give treatments and convalescent care recom­
mended by physicians were also increased during the year.
During August 1937 and June 1938 the North Dakota Anti-Tuberculosis Asso­
ciation cooperated with the Division of Child Welfare at Camp Grassick, the
Association’s 12-year-old health-education project, stressing value of rest, food,
and health-habit training, plus balanced activity and a general rehabilitation
program for children of low vitality who were free from communicable disease.
Camp Grassick enlarged its physical-education program to include physicaltherapy and additional occupational-therapy services under the supervision of
the orthopedic surgeons. A physical therapist was provided throughout the
season by the Public Welfare Board. A physical-therapy department made avail­
able treatment tables, a whirlpool bath, sun lamps, large mirrors, games, and.
exercise apparatus. Parents of crippled children attending were urged to visit
the camp frequently to be instructed in the treatments and exercises which should
be carried on with each child in the home. Explicit instructions for treatments
to be carried on at home were written out for each child by the physical therapist
for the use of parents, public-health nurses, child-welfare workers, and social
workers in directing the child in the physical therapy necessary in his physical
restoration. In a rural State, where the traveling expenses of a physical therapist
would be exorbitant, the facilities of Camp Grassick have made it possible to
have a center where physical-therapy services could be extended to crippled
children.
A number of children whose cleft palates had been repaired and who had
speech impediments were given speech training as part of their postoperative
treatment.
Arrangements were completed in the latter part of June for a medical-social
consultant on the State staff beginning July 1938.
OHIO
S ta te a g en c y: D e p a r tm e n t o f P u b lic W elfare, D ivisio n o f P u b lic A s s is t­
a n ce, B u re a u o f C h a ritie s, C rip p led C hildren*s B u re a u . (N o w D e p a rt­
m e n t o f P u b lic W elfa re, D ivisio n o f P u b lic A ssis ta n c e , S ervices fo r
C rip p led C h ild re n .)
During the fiscal year 1938 effort was centered on finding the crippled child,
giving much attention to the school enumeration. Though this is still not satis­
factory, a large number of children have been placed under treatment who were
located through this means. Other children were located through birth cer­
tificates. Families and private physicians are becoming more interested in re­
porting crippled children.

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In each of the counties the social workers in the programs for aid to dependent
children and child-welfare services and in the juvenile court were very helpful
in keeping the State agency informed of crippled children under their care.
A majority of the children, however, were reported through the diagnostic clinics.
These clinics are organized by the State orthopedic nurses in connection with
or in cooperation with the local health departments and agencies interested in
children’s work. The State Department of Health and the State Department of
Education, as well as the Ohio Society for Crippled Children, are represented at
these clinics. Furthermore, a special invitation is extended to all physicians in
the community. The permanent clinics have been sending in reports on all
children examined, and the number of children has increased. It is interesting
to note that this department took care of a greater number of crippled children
in 1938 than ever before.
The institutes for the public-health nurses conducted by the State Depart­
ment of Health have been most beneficial. Nurses from several counties are
usually invited to these institutes and a representative of this department attends.
Conferences with the State orthopedic nurses are held at each meeting.
The institutes conducted by the Division of Public Assistance were attended by
a representative from the Crippled Children’s Bureau, and crippled children’s
work has been stressed. These institutes cover several counties.
Owing to the installation of new equipment in several of the hospitals more
specialized and modern treatment can be given. There were decided improve­
ments in several of the convalescent homes within the year, and a new convalescent
home was dedicated.
A physical therapist was placed in each of the special schools for crippled
children throughout the State, and new equipment was installed for the physicaltherapy department in several of the schools.
Of the 45 orthopedic surgeons on the State agency’s approved list, 37 have been
certified by the American Board of Orthopedic Surgery. All hospitals are ap­
proved by the American Medical Association or by the American College of
Surgeons.
A greater number than formerly of older children are being rehabilitated under
the supervision of the rehabilitation bureau.
There are undoubtedly crippled children who have never been reported to any
agency, but more and more children are being reported and are under treatment.
Children from all 88 counties in the State are under treatment.
OKLAHOMA
S ta te a g en c y: C o m m is s io n fo r C rip p led C h ild ren .
Someone has said that the function of education is to teach the individual to do
better that which he would do anyway. The Oklahoma program for the care of
crippled children did not have many innovations or changes during the fiscal year
1938, but there were many distinct improvements in the various phases of the
work. Possibly we are becoming educated in that we are doing better the things
we have been doing for several years.
The number of diagnostic clinics held showed no increase over the previous
year but the follow-up was far more definite and fewer cases were lost. More and
more the diagnostic clinics are becoming check-up clinics rather than discovery
clinics. It is felt that the diagnostic clinics are valuable and will always remain
so in arousing and sustaining public interest.
The foster-home or boarding-home program was expanded and perfected. Defi­
nite standards were established. Distinction has been made among types of
homes and types of cases. The fact that a major part of the orthopedic and

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plastic work is done in Oklahoma City gives opportunity for an almost unlimited
development of the boarding-home program, if finances become available.
The establishment of a closer working relationship between the social-service
department of the Oklahoma Hospital for Crippled Children and the field nurses
has done much to avoid unnecessary trips and confusion. Arrangements have
been made so that a copy of each letter written by the medical-social worker in
respect to a patient goes directly to the field nurse of the district. These letters
are of special help with the patients living long distances from the hospital.
There is always a tendency for any hospital to serve its immediate locality or
neighborhood most intensively. The development of flexible arrangements for
transportation has done much to remove the distance handicap, however. Bus
companies and railroads advance transportation on order by the judge or the
hospital. The charge for transportation at a rate of 1 cent per mile is filed
against the respective county or commission. Thus there is seldom a legitimate
excuse for the patient’s not returning to the hospital or out-patient department
when directed to do so.
The working relationships with the public-health units and with the welfare
directors, especially the child-welfare directors, have improved through under­
standing and through working together.
During the year Oklahoma experienced one of the worst epidemics of acute
poliomyelitis in its history. The greatest incidence of the disease occurred in
the south central section of the State, where in some counties the incidence ex­
ceeded 40 per 100,000 population. The case rate for the entire State during the
calendar year 1937 was 18.1 per 100,000 population. During the first 6 months
of the fiscal year 1938, there were more than 300 cases of poliomyelitis on the
Commission’s active follow-up list. These children were seen at monthly itinerant
and permanent clinics by orthopedists who made recommendations regarding
their needs for further medical and nursing supervision, foster-home care, appli­
ances, and so forth.
OREGON
S ta te a g en c y: S ta te R e lie f C o m m itte e , C rip p led C h ild re n ’s D ivisio n .
(N ow S ta te P u b lic W elfa re C o m m is s io n , Services fo r C rip p led C hildren.')
The Oregon crippled children’s program as provided by State and Federal law
began active operation January 20, 1938, under the Crippled Children’s Division
of the State Relief Committee of Oregon. In the past the State of Oregon was
served only by the Shriners’ Hospital, which cared for cripples up to 14 years of
age. Individuals above this age limit were occasionally cared for through unor­
ganized efforts.
The Oregon crippled children’s program labored in its first months of existence
to inform those interested in crippled children’s services of the objectives of the
State program.
Four hospitals and seven orthopedic surgeons were selected to provide service
under the program.
Three public-health nurses were employed, one of whom had completed ad­
vanced orthopedic-nursing training before affiliation with the office, one of whom
obtained training during the fiscal year, and one for whom such training was
planned for in 1939. A physician with orthopedic training was employed as
assistant director.
The Oregon State register of crippled children was established and 218 chil­
dren were enrolled. The names of approximately 500 crippled children were
referred by the State Board of Health as candidates for benefits of the program.
During the 5}£ months of operation of the program 6 itinerant field diagnostic
clinics were conducted. In these clinics approximately 225 crippled children

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were examined by orthopedic surgeons. The surgeon’s recommendations were
referred to the physician sending the child to the clinic. All children financially
unable to meet the expense of the treatment recommended were declared eligible
for care at the expense of the Crippled Children’s Division of the State Relief
Committee. Individual family-budget studies were made by social workers of
the county relief committees, who at the same time determined the child’s
social need.
Oral agreements with the Vocational Rehabilitation Service, Child Guidance
Clinic, State Board of Health, State Department of Education, and the Shriners’
Hospital were established as preliminary moves to written understandings.
A technical medical advisory committee was formed to assist the medical
director. This committee had three meetings.
Hospitalization of orthopedic cripples was started on a small scale during the
last 2 months of the fiscal year.
Preliminary arrangements were made for care during 1939 of cleft-palate,
harelip, and burn-contracture cases.
Finally, the procedures and general ground work of a foster-home service
adjacent to the treatment center were formulated.
PENNSYLVANIA
S ta te a g e n c y : D e p a r tm e n t o f H e a lth , C rip p led C h ild re n ’s Service.
The following is a summary of the plan which has been carried out for crippled
children during the fiscal year 1938.
The Commonwealth of Pennsylvania was divided into 13 districts, each district
comprising 3 or more counties, depending on the population. Each district was
placed in charge of a competent and qualified orthopedic surgeon, who was
accredited or eligible to be accredited by the American Board of Orthopedic
Surgery. Surgeons were also chosen by virtue of their connection with a uni­
versity or a medical college, or by their reputation as being outstanding in their
specialty.
Each surgeon was paid on a part-time salary basis for holding four clinics
during the fiscal year in his assigned territory and for doing the necessary opera­
tive work upon the crippled children examined at the diagnostic clinic.
Hospitals used by the individual surgeons were selected by the surgeons them­
selves with the restriction that the hospitals used for State cases must be approved
by the American College of Surgeons.
Appliances recommended by the surgeons for deforming conditions diagnosed
in their clinics were paid for by the Department at a fair rate as billed by each
individual brace maker. Plaster-of-paris casts and X-rays prescribed at the time
of the clinic for a patient for whom hospitalization is unnecessary were paid for
by the Department at the regular charge for such services. Physical-therapy
treatments or medications necessary for improving the orthopedic condition of
patients were also paid for at the prevailing rate.
All long-term patients are referred to the State Hospital for Crippled Children
at Elizabethtown.
The program for convalescent and foster-home care is directed by a qualified
medical-social worker who places children following the termination of their
operative or physical correction in a convalescent or foster home, provided such
care is considered beneficial or necessary for the patient. The medical-social
worker investigates all patients recommended for such care by the surgeon and
maintains at all times an efficient investigation and check-up of convalescent
and foster homes used in the care of these patients. The Department does not


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stop at the physical correction of the patient but attempts to bring about a social
readjustment as well.
In many instances children who were over the age limit for care under the
program and who were eligible were referred for rehabilitation to the Bureau of
Rehabilitation in the Department of Labor and Industry.
The problem of care of those patients over 16 years of age deserves considera­
tion. Exceptions have been made in the past, and patients have been cared for
by the Department up to the age of 21 years, when it was felt that operative work
or appliances would be of great benefit in enabling them to make a livelihood
and when it was £nown definitely that the patient was otherwise unable to secure
this treatment.
RHODE ISLAND
S ta te a g en c y: D e p a r tm e n t o f P u b lic H e a lth , C rip p led C h ild re n ’s
D ivision.
During the fiscal year 1938 approximately 161 children under the age of 21 were
either located by or referred to the Crippled Children’s Division, making a total
of 1,668 crippled children on the register. They were immediately investigated
by the Division’s medical-social worker to determine their eligibility with reference
to mental condition and economic status. Those meeting the requirements estab­
lished by the State agency were accepted for care.
Forty-five diagnostic clinics were held, at which 307 children were examined
and recommended for treatment. One hundred and seventy-five were hospital­
ized for operative treatment and 64 were furnished with surgical shoes, braces,
lifts, supports, splints, crutches, or the like. Other children were recommended
for pool treatments and physical-therapy treatments in hospital clinics and at their
homes. It was possible for the Division to take its own X-ray photographs
through use of the facilities of the Division of Industrial Hygiene of the State
Department of Public Health.
When necessary, consultation services were rendered by pediatricians and neu­
rologists. From October to June 4, classes a week were held at the Providence
Boys’ Club pools and 2 classes a week at the Pawtucket Boys’ Club pool. At
these classes, each of which had an average attendance of 15 children, water
treatment and physical-therapy treatment were administered by the Division’s
physical-therapy technicians.
During the summer months a camp for crippled children was conducted at
Lakeside under the supervision of the Crippled Children’s Division. A total of
110 children enjoyed fresh air, sunshine, and good food. Water treatment and
massage were given 6 days a week by the physical therapists. Weather per­
mitting, the children went in bathing every day, 2 life guards being in charge
while the children were in the water.
Seventeen children, 16 years of age and over, were referred to the Division of
Rehabilitation of the Department of Education and the Bureau for the Handi­
capped.
SOUTH CAROLINA
S ta te a g en c y: B o a rd o f H e a lth , D ivision o f C rip p led C h ild ren .
The major objectives of the program for crippled children in South Carolina
are as follows:
1. Opportunity for care should be equally available to crippled children of rural
and urban areas, without regard to race.
2. All efforts in behalf of crippled children should be directed primarily toward
the prevention, correction, or minimizing of disability.
3. Children with physical disabilities should be given the opportunity to ob­
tain, as far as possible, an uninterrupted and adequate education.

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The services of five recognized orthopedic surgeons were secured to hold weekly
clinics in the five orthopedic districts. Adequate assistance in the way of interns
trained nurses is given in each district, and thus a more satisfactory clinic
program has been developed.
The American Legion is responsible for transporting all children of veterans
to clinics and to hospitals.
Cases are being reported with much more adequate information during this
year by the county school-attendance teachers. Therefore, many more rural
crippled children are being reached and helped.
The foster homes have filled an important gap in the program. Children in
these homes are provided an opportunity not only for physical improvement,
but also for training in personal hygiene, for happier and more sanitary home
living, and for a certain amount of academic education. The cost of this care is
$1.50 per child per day.
Many crippled children who are found to be suffering also from malnutrition
are sent to the foster homes. Some must go before an operation so that they may
be able to respond better to the treatment.
The average gain in weight per child in foster homes in the past 3 months has
been about 7 pounds. A pediatrician, member of the technical advisory commit­
tee, has prepared lists of diets which the foster mothers have used in feeding the
children of different ages in their homes. He has also offered further assistance in
special cases.
An orthopedic consultant nurse is receiving training in orthopedic nursing at
Boston, and will instruct the county nurses in the proper follow-up care of crippled
children in their homes.
The local groups have made it possible to avoid neglect of any phase of the pro­
gram by providing needed clothing in some cases; educational toys, books, special
teaching service, and the like for others; hot lunches for crippled children at schools
and clinics; rolling chairs; tricycles; and for one child a typewriter for use in exer­
cising her fingers.
A marked improvement may be seen in reporting crippled children to the State
agency; in having clinics better organized (certain counties have a designated
number of crippled children attend diagnostic or operative clinics weekly, thus
maintaining clinics more nearly uniform in size); in having regular and wellpublicized dates for holding diagnostic clinics; in securing proper and more nearly
adequate cooperation from lay groups; in providing the majority of the patients
with the advantages of public-school education (the latter problem has been
handled by local lay groups and individuals); and in seeing that families of these
handicapped children have access to welfare workers who may help with their
social problems.
The Rotary Club, Kiwanis Club, the Masons, Federated Clubs, parentteacher associations, and some of the county societies for crippled children rend­
ered valuable assistance in carrying on aid to the crippled children in their homes
and in transporting crippled children to school in some sections of the State.
The State Highway Department and the State Department of Education co­
operated in a prevention program by placing the book “ Man and the Motor Car”
*n
high schools of the State and urging the organization of school safety patrols
in all elementary and high schools. The State Congress of Parents and Teachers
further cooperated by offering prizes to high schools and elementary schools for
the best essays submitted on this book and for the best posters portraying the
schoolboy patrol.
The State Division of Crippled Children believes that with an intensive study
of the subject of highway, home, and farm accidents on the part of the young boys


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and girls, the number of accidents will be greatly lessened and many of the worst
deformities will ultimately be prevented.
The annual report shows 2,319 cases of children reported to the Division since
February 1935 and diagnosed by the orthopedic surgeons as having conditions in
need of correction.
Reports from other sources show that in addition to this number there are 4,312
crippled children in South Carolina who are private cases and 1,500 crippled chil­
dren who are Shrine cases. The known cases in the State thus total 8,131.
A State register including the name of every crippled child in the State whose
condition has been so diagnosed by a licensed physician and who has been reported
to the Division is now being kept in the office of the Division.
SOUTH DAKOTA
S ta te a g en c y: B o a rd o f H e a lth , D ivisio n o f C rip p led C h ild ren .
The Division of Crippled Children concerns itself with locating crippled children
and investigating them so that their eligibility may be established. The investi­
gations are carried on by field nurses, child-welfare workers, and in certain in­
stances by public-health officials in various county or district units. When
eligibility has been established, crippled children are entitled to attend diagnostic
clinics held at several points within the State. Clinical reports and requests for
service are made by the orthopedic surgeon at that time. Children are then
hospitalized when the hospital case loads are such that more patients may be
cared for. Follow-up service is provided by nurses acting under the orthopedist’s
direction and is rendered either in field clinics or, in an emergency, at the hospital
center.
Agreements were made during the fiscal year 1938 whereby the Division of
Crippled Children received the cooperative aid of the social workers employed
by the Department of Social Security, Division of Child Welfare. The two hos­
pital centers within the State developed plans whereby qualified physical therapists
could be added to their staffs. Limited hospital and surgical authorizations were
made, thus creating better estimates of obligated funds. - An organized system of
clinics throughout the State rendered service to both old and new cases and served
as an adequate method of eliminating cases outside the scope of the program, which
formerly required transportation and services incidental to visits at hospital
centers.
TENNESSEE
S ta te a g en c y: D e p a r tm e n t o f P u b lic H e a lth , S ervices fo r C rip p led
C h ild ren .
There have been many ups and downs in the administration of the crippled
children’s program since July 1, 1937. New policies have been inaugurated, new
forms adopted, and, in fact, a new program has been set up which is being inte­
grated as rapidly as possible with the program of the Department of Public Health.
For 3 months after July 1, 1937, only emergency cases were accepted and the
collection of delinquent county accounts was emphasized.
Because of time spent in the formation, adoption, and inauguration of the new
program, the actual number of crippled children handled during the fiscal year
1938 was not so large as that for the preceding fiscal year.
During the year two lay field representatives were replaced by regional nurses.
One of these had experience and training in orthopedic nursing, and the other had
a special course in orthopedic nursing and was to return to the field October 1, 1938.
Clinics— monthly and itinerant— were in operation at the end of the year, and
the State agency is looking forward to better days.


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TEXAS

S ta te a g en c y: D e p a r tm e n t o f E d u c a tio n , C rip p led C h ild r e n s D ivisio n .
The progress made by the official State agency during the fiscal year 1938 might
be summarized as follows: A form was adopted which, when adequately filled
out, will give a social history of the crippled child. The standards of hospitals
used by the State agency were raised; only those approved by the American Col.
lege of Surgeons in the State will be used. A technical advisory board was
appointed. Members of this board will be called in for consultation upon many
of the technical problems confronting the director of the State agency. The
Tom Hughes Crippled Children's School of Port Arthur was established. At
the suggestion of the director of the State agency, the maximum age of crippled
children admitted to the State Hospital in Galveston was raised from 12 to 14
years in October of 1937, the year the State register was started. A plan for
selecting, licensing, and supervising foster homes was made with the Division of
Child Welfare, and, finally, a most satisfactory cooperative program has been
worked out with all agencies interested in the general welfare of children.
UTAH
S ta te a g en c y: B o a rd o f H e a lth , C rip p led C h ild re n 9s Service.
The Crippled Children’s Service of Utah established within the fiscal year 1938
medical-social service for all crippled children cared for under the State program.
The medical-social worker was added to the staff in February 1938. She acts as
the coordinator between the Cripped Children’s Service, the State Department of
Public Assistance, and the Division of Child-Welfare Services. She interprets
to the local workers throughout the State the medical needs of children in relation
to social adjustments.
A trained physical therapist was added to the crippled children’s staff and is
permanently located in a center established for this purpose in Salt Lake City.
The physical therapist carries out the recommendations and orders given to her by
the physicians attending crippled children’s cases and also interprets the special
instructions for treatment recommended by the physicians to the parents and
guardians of the crippled children. A second center was established in Ogden,
so that the physical therapist may check on patients who have been given previous
treatment. These two centers are located in counties that contain one-third of
the population of the State.
Excellent cooperation has been established between the boards of education and
the Crippled Children’s Service regarding the transfer of children who are of school
age when it is necessary to make arrangements for them to attend school in other
counties.
Many changes were made in record keeping, especially in revising the system for
setting up the State register.
Intake and discharge services for children under care were set up on a much more
adequate basis. All crippled children admitted to the service must be immunized
for diphtheria and vaccinated for smallpox must and have a nose and throat culture
taken. A complete examination by a physician must be made before hospitali­
zation is authorized.
Physicians are to notify the Crippled Children’s Service 3 days in advance
when a child is to be discharged from a hospital. A time limit on all hospital cases
has become mandatory, the maximum period being 3 months, but hospitalization
may be extended upon authorization of the State agency.
At the end of the year the Crippled Children’s Service was planning a program
on prevention in which the State medical profession was cooperating. Together
they were to set up an educational program for physicians and all interested
agencies participating in work relative to prevention of crippling deformities.

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VERMONT
S ta te a g en c y: D e p a r tm e n t o f P u b lic H e a lth , C rip p led C h ild re n ’s
D ivision.
The Crippled Children’s Division is an outgrowth of the infantile-paralysis
aftercare division which was organized in 1914 following the most severe epidemic
that the State has experienced. Although the work was supported privately
during the first 19 years and by State funds after that period, the work since its
beginning has been carried on as a part of the program of the State Department of
Public Health.
This long experience, uninterrupted except for a few months during the World
War, served to build up a program that was readily adaptable to the broader service
possible with the use of Federal funds. When these additional funds became
available, the program was enlarged to include all types of crippling conditions
instead of infantile-paralysis cases only. Previous to that time children with all
types of orthopedic defects were admitted to the clinics for diagnosis and advice,
but if the treatment necessitated an expenditure of funds for braces, hospitaliza­
tion, or the like, the necessary funds had to be obtained elsewhere.
The major features of the present program are:
1. Locating of crippled children (accomplished mostly through referrals by phy­
sicians, public-health nurses, social agencies, interested individuals, and self­
application).
2. Follow-up care of patients with acute infantile paralysis in their homes in
conjunction with the physician in charge of the case.
3. Diagnostic and follow-up clinics.
4. Surgical care.
5. Postoperative follow-up care.
6. Supplying of apparatus when necessary.
7. Social study and treatment when indicated.
8. Cooperation with the Vocational Rehabilitation Division of the State D e­
partment of Education and other agencies providing various types of services
which are necessary and helpful in carrying out the program.
9. Occupational therapy for special cases.
Enlargement of the staff to include another part-time orthopedic surgeon, an
additional nurse-physiotherapist, a medical-social worker, and another secretary
has made possible an extension of the services available to crippled children.
During the fiscal year 1938 an increase occurred in clinic attendance, although
the number of State clinics did not increase.
Clinic facilities have improved since the appointment of a professor of ortho­
pedic surgery at the Medical College of the University of Vermont. Six diag­
nostic and six surgical clinics are held at the Mary Fletcher Hospital during the
school year.
More muscle transplantations and surgical work for correction of deformities
to eliminate the use of braces have been carried out during the past year.
The organization of the Vocational Rehabilitation Division has been a great
help to the program. Patients under the care of the Division have felt that there
is a better-defined goal to strive for, knowing that there is a possibility of vocational
training if they cooperate in trying to lessen their physical handicaps. Close
cooperation exists between the rehabilitation director and the Crippled Children’s
Division. There is continual interchange of referrals and of medical and social
information.


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VIRGINIA

S ta te a g en c y: D e p a r tm e n t o f H e a lth , C rip p led C h ild re n ’s B u re a u .
Every possible private and official agency operating in the State has been utilized
to locate crippled children. At the close of the fiscal year 1938, 47 Virginia coun­
ties had full-time medically directed health services and 12 counties had nursing
service. In those 59 counties the responsibility for work with crippled children
had been placed on the local health workers, and excellent cooperation had been
developed. They not only search for and find crippled children but they also
arrange for and do preliminary visiting for the clinics. They also arrange for
and operate the clinics and do the follow-up work. A complete report of each
hospital discharge is forwarded to these workers and they make the necessary
follow-up visits to see that the aftercare recommended by the orthopedic surgeon
is carried out. A copy of each hospital-discharge record is also sent to the family
physician. Local workers also arrange transportation of children to and from the
hospitals.
In the remaining 41 counties not covered by health workers, all work pertaining
to crippled children’s clinics and hospital discharges was carried out by the 3
orthopedic nurses attached to the State Department of Health. In addition to
these duties they act as instructors to the other public-health nurses throughout
the State.
Each county in the State has a county department of public welfare with a
trained social worker in charge. These county departments have been very
cooperative and have been of great assistance to the Crippled Children’s Bureau
in locating and helping to care for and transport crippled children.
The State Board of Education through the Division of Rehabilitation has
cooperated closely in the program, and through it a State-wide school survey was
conducted. Many unreported cases were brought to light through this survey.
The Bureau of Communicable Diseases in the State Department of Health has
been very cooperative in reporting promptly all cases of infantile paralysis.
This has enabled the Crippled Children’s Bureau to give early orthopedic con­
sultation and in many cases prompt hospitalization during the acute or sub­
acute stages of the disease.
The 16 orthopedic surgeons comprising the State Orthopedic Society are
affiliated in the Bureau’s clinic service. As of June 30, 1938, there were 43
permanent and 2 itinerant clinics. Clinic attendance during the year was 3,884.
Clinic rooms, equipment, and technique have gradually been improved. Effort
has been made to place these clinics on a consultation basis, and the family phy­
sicians of all patients were encouraged to attend the clinics and discuss with the
clinic surgeon the findings and recommendations relating to their patients.
Beds for 115 white and 35 Negro patients are available in the 2 State-owned
general hospitals located at Richmond and Charlottesville for the treatment of
orthopedic and plastic cases. Ten beds are available at Jefferson Hospital in
Roanoke.
WASHINGTON
S ta te a g en c y: D e p a r tm e n t o f S o c ia l S e c u r ity , D ivisio n fo r C h ild ren .
At the beginning of the fiscal year 1938 the crippled children’s program of
the State Department of Social Security was decentralized and was developed
m the four hospital centers in Seattle, Tacoma, Bellingham, and Spokane, with
a full-time medical-social worker in charge at each center. Her duties toward
crippled children between 14 and 21 years of age who are to receive care under
the program include (1) responsibility for planning of clinics, (2) distribution of


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clinic reports to the agencies concerned, (3) social investigation and determina­
tion of eligibility of children referred from the county where the center is located,
and (4) supervision of referral to the children’s workers in the surrounding
counties. Final authorization for beginning treatment and payment for services
rendered are still controlled in the State office. This decentralization has made
possible closer contacts with the children’s workers of the counties sending chil­
dren to each of the centers, as well as more nearly adequate aftercare services
for the children. The orthopedic staff surgeons can interpret their medical
findings and recommendations directly to the medical-social worker so that
she can then give more concise information to the children’s workers and the
county public-health nurses, who give public-health-nursing supervision in the
homes.
The most noticeable progress in the program is the increase in the number of
children seen through clinics and referred for care to the crippled children’s
program. Because 4 private orthopedic units in Washington have given excel­
lent medical care to children from birth to 14 years of age, it was thought
that within a 2-year period most of the children from 14 to 21 years of age—
the age group cared for in this State under the crippled children’s program—
who were in need of orthopedic care would be located and treated under the
State program. It was found, however, in 1938, that 785 children were examined
in the State clinics as compared with a total of 660 in the 1936 clinics. An
average of 130 children received care each month during 1938, whereas only 85
children per month received care in 1937. This increase in the number of crip­
pled children located may be attributed largely to the fact that there are now
public-health nurses in all counties of the State and child-welfare workers in
each county welfare department. Coupled with these causes is the routine
establishment of referrals, from the private orthopedic units, of children who
have reached their fourteenth birthday and are in need of continued orthopedic
service.
The medical service given in the clinics has been improved through the addition
of a pediatrician to each clinic staff. A psychologist has been added to the State
staff of the Division for Children. His services have likewise been made available
at the diagnostic clinics.
In Seattle the Swedish Hospital, a privately owned hospital, built an entirely
new wing for crippled children, consisting of 30 beds and complete physicaltherapy equipment, including a large pool, a classroom, and an office for the med­
ical-social worker. Much in the way of education and handicraft has been made
possible through this hospital unit. The medical-social worker has been able to
work with many local groups in behalf of these children. The Rotary Club has
provided transportation to and from the hospital, the auxiliary of the Veterans
of Foreign Wars has provided handicraft materials, the city school board has sent
a full-time teacher to the unit and the foster homes, and the Works Progress
Administration has provided a full-time handicraft instructor.
Similar programs are found in each of the other hospital centers.
During 1938, with medical-social workers in the 4 centers, it was possible to
place children in foster convalescent homes when they needed out-patient physical
therapy or were in a cast, but were not in need of hospital care. Twelve foster
convalescent homes are in use in the hospital centers. Two of the homes are
operated by graduate nurses. Children needing changes of dressings or children
in casts are sent into these two homes; only ambulatory cases are sent to the other
foster homes.
During 1938, 142 children treated under the crippled children’s program were
referred for training to the Vocational Rehabilitation Division of the State


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Department of Education. For 23 of this number the training continued into the
fiscal year 1939. Six children placed in training late in 1936 have obtained private
employment as stenographers or watch repairers.
In 1934 a survey of physically handicapped children was made under the direc­
tion of the State Department of Health. Three hundred and thirty-four of the
children located in the survey have received some form of service through the
crippled children’s program. At each clinic additional cases found in the survey
are brought in. Three of the private orthopedic units are providing monthly
State registry cards for children under 14 years of age receiving orthopedic service.
WEST VIRGINIA
S ta te a g e n c y : D e p a r tm e n t o f P u b lic A ssista n c e , D ivisio n o f C rip p led
C h ild ren .
Provision for consultation services other than orthopedic has been made by
arranging to pay consultation fees for medical relief on the basis prescribed by
the Department of Public Assistance.
The educational program for the staff has been improved by school and
in-service training. In-service training has included State convention programs,
lectures by State orthopedists, and conferences held by the nursing staff. Clinics
have been used as demonstration centers.
The method of locating crippled children has been improved through the coop­
eration of the county units in assisting in the location and reporting of crippled
children. The method of having the county units clear the cases has proved most
satisfactory, as it has centralized the intake service.
The permanent register book in each clinic has provided additional detailed
information. Index clinic cards are now used in all clinics. The information on
these cards is available in cases where there is any question as to status and assign­
ment to clinic orthopedist and hospital. This has given invaluable assistance, as
the State workers and nurses are not familiar with the cases in all districts.
The organization of clinic service has been improved. The use of clinic orders
and turning over the arrangements for transportation to the county units of the
Department of Public Assistance has eliminated duplication and unnecessary
work. A standard procedure is used in all clinics.
Hospitalization services have been much improved by the addition of more
bed space, the employment of trained nursing supervisors, and the provision
made in some hospitals for physical therapy for State cases.
A case summary giving complete social history and financial standing must be
furnished for every case submitted to the Department for authorization.
Convalescent-home care has been improved by the addition of two new build­
ings at two of the convalescent homes. All members of the nursing staff are
qualified, and each supervisor is a graduate nurse.
Foster-home care has been more closely supervised by the medical-social worker
and the nursing supervisor.
The educational and vocational program has been so organized as to give better
service to a larger number of children.
An attempt has been made to coordinate the activities of the county depart­
ments of public assistance, the Division of Child-Welfare Services, and the Division
of Crippled Children. A graduate registered nurse qualified in orthopedic
nursing, with public-health experience, is supervisor of nursing.
A State physical-therapy technician has been added and a definite plan for
services has been worked out.
A medical-social worker was also added to the staff during 1938.


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WISCONSIN
S ta te a g en c y: I n te r d e p a r tm e n ta l C o m m itte e o n S ervices fo r C rip p led
C h ild re n , C rip p led C h ild re n ’s D ivision, S ta te D e p a r tm e n t o f P u b lic
I n s tr u c tio n . (N ow S ta te D e p a r tm e n t o f P u b lic I n s tr u c tio n , B u r e a u fo r
H a n d ic a p p e d C h ild re n , C rip p led C h ild re n ’s D iv isio n .)
The Crippled Children’s Division, functioning as part of the State Department
of Public Instruction under the Interdepartmental Committee on Services for
Crippled Children, has combined, under the supervision of one State agency, a
concurrent program for the physical restoration and the education of crippled
children. In order to provide centers for carrying on this combined program,
orthopedic schools have been established in 11 cities in the State; one of these
schools was established during the fiscal year 1938.
During the year 891 children were served by the orthopedic schools, an increase
of 99 over the preceding year. These schools serve a twofold purpose: (1) To
provide special building facilities for the children who are too handicapped to
attend a regular school, and (2) to provide facilities for physical therapy and
supervision for children for whom medical recommendation has been made for
such care. All children come to the orthopedic schools with medical recom­
mendations. Those for whom treatment has been recommended are served by
the physical-therapy departments of the schools until their physician feels they
have obtained maximum improvement from such care. If these children are able
to attend their regular school with safety and comfort, they do so. If they cannot,
they remain in the academic classes of the orthopedic school until they complete
the elementary grades.
Children dismissed from the orthopedic schools, however, remain under the
active supervision of the Crippled Children’s Division until their disability is
corrected or until they reach the age of 21. This Division also has supervision
of the educational program for all crippled children during the elementary and
high-school period whether they are under supervision of orthopedic schools,
hospital classes, or regular schools.
To supplement the educational facilities available in the public-school system,
the Crippled Children’s Division has established academic classes in three
children’s hospitals in this State, so that children who are confined to these
hospitals for long-time orthopedic care may continue their academic education.
It was found necessary this past year to expand certain phases of the program
to meet the emergency resulting from the large number of poliomyelitis cases in
two sections of the State. One of these sections was the city and county of
Milwaukee and the other the territory surrounding the city of Eau Claire. The
Crippled Children’s Division, with the approval and cooperation of the Eau
Claire County Medical Society and the councilor to the Wisconsin State Medical
Society from that section of the State, established a convalescent center in a
hospital in Eau Claire. Arrangements were made for the hospitalization of 14
children. Physical therapy was provided by a member of the field staff of the
Crippled Children’s Division. The county medical society invited an orthopedic
specialist to come to Eau Claire at periodic intervals for examination and care of
patients. A local pediatrician was designated by the county society to provide
the necessary general medical supervision. Academic instruction was provided
during the several months that this convalescent-care program was continued in
the hospital, until the children could be transferred to the orthopedic school.
They were then placed in various private homes and were transported each day
to the orthopedic school where the physical-therapy care was continued.


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During the summer months the physical-therapy service was continued at the
orthopedic schools located in Eau Claire, Kenosha, Madison, Milwaukee, and
West Allis to provide care for recent cases of poliomyelitis during the summer
period when the orthopedic schools are usually closed.
During the past fiscal year public-health-nursing service was established or
renewed in a number of counties. For those counties the Crippled Children’s
Division furnished detailed information regarding crippled children residing in
those areas, including a summary of the last medical recommendation which had
been made for each child.
There has been an increasing interrelationship between the work carried on by
the Crippled Children’s Division and public-health services throughout the State.
WYOMING
S ta te a g en c y: B o a rd o f H e a lth , D ivisio n fo r C rip p led C h ild re n .
The major features of the Wyoming program for crippled children are:
1. The finding of crippled children.
2. The maintenance of a State register of all crippled children.
3. The provision of diagnostic facilities for orthopedic and plastic cases.
4. Provision of facilities for the correction of orthopedic and plastic defects, if
the parents are unable to afford all or part of the cost of such care.
5. Provision of aftercare services on a State-wide basis for children who have
been operated on, who have been given braces, or for whom physical therapy has
been prescribed.
6. Cooperation, especially with the education and welfare departments, in
working out plans for the general welfare of the crippled child.
Progress during the fiscal year 1938 was made in connection with each of these
features as follows:
1. Case finding was improved through—
(a) Referral of others by satisfied patients.
(b) Improved publicity in relation to orthopedic conferences.
(c) Increased referrals from local physicians as a result of better under­
standing and cooperation.
(d) Increased referrals from Shrine and other service clubs.
2. A card was devised for the State register listing only those items requested
on the memorandum issued by the United States Children’s Bureau on April 5,
1938.
When a child’s name is placed on the State register, or has been reported foi
registration but his eligibility has not been determined, a card is filed in the county
file and a referral card is placed in the general file in which are listed all children
who have ever been referred to the Division for Crippled Children. At the end
of each quarter the director and assistant director go over all the cards in the
county file, making such changes as are needed.
3. Diagnostic clinics were held in 10 towns (5 clinic districts). Each was
conducted by an orthopedic surgeon who is a diplomate of the American Board of
Orthopedic Surgery. General examinations were usually made by the local
county health officer. Assistance was given by the director and assistant director
of the State Division for Crippled Children, by one or more of the public-health
nurses working under the Division of Maternal and Child Health, and by local
volunteers.
When cases were reported to be needing immediate orthopedic examination,
provision was made for such an examination in the office of the nearest orthopedic
surgeon.


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4. Financial aid was offered both to charity and to part-pay cases. When
necessary, transportation was furnished. Some plastic as well as orthopedic cases
were cared for this year. Sufficient funds were available to offer aid to all cases
coming within the State definition of a crippled child. Hospitalization was
provided for all patients needing it.
5. Aftercare services were improved through
(a) An increase in the number of home visits.
(2>) Improved follow-up in those counties where local nurses were working,
as a result of the revision in the form used and of individual instruction given
to public-health nurses.
6. The head of the Division of Vocational Rehabilitation was invited to all
orthopedic conferences. Following conferences cases needing either vocational
rehabilitation or special education in the home were discussed with the proper
persons in the education department, who, in turn, brought to the Division for
Crippled Children problems related to handicapped children referred to them from
other sources.

2 3 9 0 2 1 °— 41

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Appendix.—Text of the Sections of the Social Security
Act Relating to Grants to States for Services for
Crippled Children, as Amended by the Social Se­
curity Act Amendments of 19391
[Original law printed in roman; new law printed in ita lics\

Title V —GRANTS TO STATES FOR MATERNAL AND CHILD
WELFARE
*

*

*

*

*

*

4

Part 2 — SERVICES FOR CRIPPLED CHILDREN
A P P R O P R IA T IO N

Sec. 511. For the purpose of enabling each State to extend and improve (es­
pecially in rural areas and in areas suffering from severe economic distress), as
far as practicable under the conditions in such State, services for locating crippled
children, and for providing medical, surgical, corrective, and other services and
care, and facilities for diagnosis, hospitalization, and aftercare, for children who
are crippled or who are suffering from conditions which lead to crippling, there is
hereby authorized to be appropriated for each fiscal year, beginning with the fiscal
year ending June 30, 1936, the sum of $3,870,000.2 The sums made available
under this section shall be used for making payments to States which have sub­
mitted, and had approved by the Chief of the Children’s Bureau, State plans for
such services.
A L L O T M E N T S TO S T A T E S

Sec. 512. (a) Out of the sums appropriated pursuant to section 511 for each
fiscal year the Secretary of Labor shall allot to each State $20,000, and $1,830,000*
to the States according to the need of each State as determined by him after taking
into consideration the number of crippled children in such State in need of the
services referred to in section 511 and the cost of furnishing such services to them.
(b) O u t o f th e s u m s a p p ro p ria te d p u r s u a n t to se c tio n 511 fo r ea ch fisca l
y e a r th e S e c re ta ry o f L a bor s h a ll a llo t to th e S ta te s $1,000,000 (in a d d itio n
to th e a llo tm e n ts m a d e u n d e r s u b s e c tio n (a)), a cc o rd in g to th e fin a n c ia l
n e e d o f ea ch S ta te fo r a ssista n c e in ca rryin g o u t its S ta te p la n , as d e te r ­
m in e d b y h i m a fte r ta k in g in to c o n s id e ra tio n th e n u m b e r o f c r ip p le d
c h ild r e n in s u c h S ta te in n e e d o f th e services re fe rre d to in se c tio n 511 a n d
th e c o s t o f fu r n is h in g s u c h services to th e m .*
(c) The amount of any allotment to a State under subsection (a) for any fiscal
year remaining unpaid to such State at the end of such fiscal year shall be avail­
able for payment to such State under section 514 until the end of the second suc­
ceeding fiscal year. No payment to a State under section 514 shall be made out
of its allotment for any fiscal year until its allotment for the preceding fiscal year
has been exhausted or has ceased to be available.

149 S ta t. 629; 53 S ta t. 1360.
3$2,850,000 in th e law as e n acted in 1935.
3 “ T h e rem ain d er” [$1,830,000] in th e law a s e n ac te d in 1935.
4T his section was ad d ed b y th e a m en d m en ts o f 1939.
92

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APPRO V A L O F ST A T E PL A N S

Sec. 513. (a) A State plan for services for crippled children must (1) provide
for financial participation by the State; (2) provide for the administration of the
plan by a State agency or the supervision of the administration of the plan by a
State agency; (3) provide such methods of administration ( in c lu d in g a fte r
J a n u a r y 1, 1940, m e th o d s r e la tin g to th e e s ta b lis h m e n t a n d m a in te n a n c e
o f p e r s o n n e l sta n d a r d s o n a m e r it basis, e x c e p t t h a t th e B o a r d 6 s h a ll ex er­
cise n o a u th o r i ty w ith re sp e c t to th e se le c tio n , te n u r e o f o ffice, a n d c o m ­
p e n s a tio n o f a n y in d iv id u a l e m p lo y e d in a cco rd a n ce w ith s u c h m e th o d s ) 6
as are necessary for the p ro p e r a n d 7 efficient operation of the plan; (4) provide
that the State agency will make such reports, in such form and containing such
information, as the Secretary of Labor may from time to time require, and comply
with such provisions as he may from time to time find necessary to assure the
correctness and verification of such reports; (5) provide for carrying out the pur­
poses specified in section 511; and (6) provide for cooperation with medical, health,
nursing, and welfare groups and organizations and with any agency in such State
charged with administering State laws providing for vocational rehabilitation of
physically handicapped children.
(b) The Chief of the Children’s Bureau shall approve any plan which fulfills
the conditions specified in subsection (a) and shall thereupon notify the Secretary
of Labor and the State agency of his approval.
PA Y M E N T TO STA TES

Sec. 514. (a) From the sums appropriated therefor and the allotments avail­
able under section 512 (a), the Secretary of the Treasury shall pay to each State
which has an approved plan for services for crippled children, for each quarter,
beginning with the quarter commencing July 1, 1935, an amount, which shall be
used exclusively for carrying out the State plan, equal to one-half of the total sum
expended during such quarter for carrying out such plan.
(jb) The method of computing and paying such amounts shall be as follows:
(1) The Secretary of Labor shall, prior to the beginning of each quarter,
estimate the amount to be paid to the State for such quarter under the pro­
visions of subsection (a), such estimate to be based on (A) a report filed by the
State containing its estimate of the total sum to be expended in such quarter
in accordance with the provisions of such subsection and stating the amount
appropriated or made available by the State apd its political subdivisions for
such expenditures in such quarter, and if such amount is less than one-half of
the total sum of such estimated expenditures, the source or sources from which
the difference is expected to be derived, and (B) such investigation as he may
find necessary.
(2) The Secretary of Labor shall then certify the amount so estimated by
him to the Secretary of the Treasury, reduced or increased, as the case may
be, by any sum by which the Secretary of Labor finds that his estimate for
s T h is reference to “ th e B o a rd ” ap p ea rs to h a v e b een m ad e in a d v e rte n tly , a s u n ifo rm a m e n d m e n ts
to sev eral title s o f th e a c t w ere being considered b y th e C onference C o m m ittee o f th e tw o H ouses o f
C ongress. I t should b e co n stru ed as if it read, “ th e C hief o f th e C hildren’s B u re au .”
“ O th e r th a n those re la tin g to selection, te n u re o f office, a n d com pensation o f personnel” in th e
law as e n acted in 1935.
7 A dded b y th e a m e n d m en ts o f 1939.

8


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Services fo r C rip p led C h ild ren
any prior quarter was greater or less than the amount which should have
been paid to the State for such quarter, except to the extent that such sum
has been applied to make the amount certified for any prior quarter greater
or less than the amount estimated by the Secretary of Labor for such prior
quarter.
(3)
The Secretary of the Treasury shall thereupon, through the Division
of Disbursement of the Treasury Department and prior to audit or settle­
ment by the General Accounting Office, pay to the State, at the time or
times fixed by the Secretary of Labor, the amount so certified.

(c) T h e S e c re ta ry o f L a b o r s h a ll fr o m tim e to tim e c e r tify to th e S e c re ­
ta ry o f th e T rea su ry th e a m o u n ts to b e p a id to th e S ta te s fr o m th e
a llo t m e n t availa b le u n d e r se c tio n 512 (b), a n d th e S e c re ta ry o f th e T rea s­
u r y sh a ll, th r o u g h th e D ivisio n o f D is b u r s e m e n t o f th e T rea su ry D e p a rt­
m e n t , a n d p r io r to a u d it or s e ttle m e n t b y th e G en era l A c c o u n tin g O ffice,
m a k e p a y m e n ts o f s u c h a m o u n ts fr o m s u c h a llo tm e n ts a t th e tim e or
tim e s sp e cified b y th e S e c re ta ry o f Labor.*
O P E R A T IO N O F S T A T E P L A N S

Sec. 515. In the case of any State plan for services for crippled children which
has been approved by the Chief of the Children’s Bureau, if the Secretary of Labor,
after reasonable notice and opportunity for hearing to the State agency adminis­
tering or supervising the administration of such plan, finds that in the adminis­
tration of the plan there is a failure to comply substantially with any provision
required by section 513 to be included in the plan, he shall notify such State
agency that further payments will not be made to the State until he is satisfied
that there is no longer any such failure to comply. Until he is so satisfied he
shall make no further certification to the Secretary of the Treasury with respect
to such State.
*

*

*

*

*

*

*

Part 5.—ADM INISTRATION
Sec. 541. (a) There is hereby authorized to be appropriated for the fiscal year
ending June 30, 1936, the sum of $425,000,® for all necessary expenses of the Chil­
dren’s Bureau in administering the provisions of this title, except section 531.
(^0 The Children s Bureau shall make such studies and investigations as will
promote the efficient administration of this title, except section 531.
(c) The Secretary of Labor shall include in his annual report to Congress a full
account of the administration of this title, except section 531.
*

*

*

*

*

*

*

Title X I —GENERAL PROVISIONS
D E F IN IT IO N S

Section 1101. (a) When used in this act—
(1) The term “State” (except when used in sec. 531) includes Alaska, Hawaii,
and the District of Columbia, a n d w h e n u se d in title s V a n d V I o f s u c h a c t
( in c lu d in g sec. 531) in c lu d e s P u e rto R ic o .1*

8T his section was a d d ed b y th e am en d m en ts o f 1939
8T h e a m o u n t for each fiscal y ear is d eterm in ed b y F ed eral ap p ro p ria tio n acts,
if A dded b y th e a m en d m en ts o f 1939. T h e a m e n d m en t (show n in italics) becam e effective J a n ­
u a ry 1, 1940.


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95

(2) The term “United States” when used in a geographical sense means the
States, Alaska, Hawaii, and the District of Columbia.
*

*

*

*

*

*

*

(d)
Nothing in this act shall be construed as authorizing any Federal official,
agent, or representative, in carrying out any of the provisions of this act, to take
charge of any child over the objection of either of the parents of such child, or of
the person standing in loco parentis to such child.
R U L E S A N D R E G U L A T IO N S

Sec. 1102. The Secretary of the Treasury, the Secretary of Labor, and the
Social Security Board, respectively, shall make and publish such rules and regula­
tions, not inconsistent with this act, as may be necessary to the efficient adminis­
tration of the functions with which each is charged under this act.
S E P A R A B IL IT Y

Sec. 1103. If any provision of this act, or the application thereof to any person
or circumstance, is held invalid, the remainder of the act, and the application of
such provision to other persons or circumstances shall not be affected thereby.
R E S E R V A T IO N O F P O W E R

Sec. 1104. The right to alter, amend, or repeal any provision of this act is hereby
reserved to the Congress.
SH O R T T IT L E

Sec. 1105. This act may be cited as the “Social Security Act.”

O


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