jp (EmnmmuiJpaltli of iHaaaarhuaptta 
SPECIAL REPORT 
OF 
Services For Crippled Children 
DEPARTMENT OF PUBLIC HEALTH 
for the 
FIVE YEAR PERIOD 1936-1941 (bht fflnmm0timpalth of maaaadiaaatta 
SPECIAL REPORT 
OF 
SERVICES FOR CRIPPLED CHILDREN 
§ * M 
DEPARTMENT OF PUBLIC HEALTH 
FOR THE 
FIVE YEAR PERIOD 1936-1941 
PAUL J. JAKMAUH, M.D. 
Commissioner of Public Health 
Edward G. Huber, A.B., M.D., Dr.P.H. 
Assistant Director, Division of Administration 
Department of Public Health 
Chief of Orthopedic Unit 
Clinic Consultants 
Albert H. Brewster, A.B., M.D. 
William T. Green, A.M., M.D. 
Garry deN. Hough, Jr., B.S., M.D. 
Paul W. Hugenberger, A.M., M.D. 
Eugene A. McCarthy, A.B., M.D. 
Paul L. Norton, A.B., M.D. 
John W. O’Meara, A.B., M.D. 
Francis A. Slowick, A.B., M.D. 
George W. Van Gorder, A.B., M.D, 
Publication of this Document Approved by the Commission on Administration and Finance 
2m-3-42-9113 TABLE OF CONTENTS 
Page 
Introduction 1 
Service for Crippled Children under the Social Security Act 3 
The Federal Grant-in-Aid for Services for Crippled Children 3 
The Massachusetts Plan for Services for Crippled Children 4 
The Care of Cardiac Children 5 
Children with Strabismus 6 
Discussions with the Medical Profession 6 
Establishment of' Clinic Centers 7 
Publicity 8 
Locating Crippled Children 9 
State Register of Crippled Children 11 
Advisory Committees 11 
Staff Conferences 13 
Procedure for Admission to Clinic 13 
Administrative Procedures in the Orthopedic Unit 13 
Procedure at Clinic Sessions 14 
Physical Therapy 15 
After-care 16 
Pediatric Examinations 16 
Plastic Surgery 16 
Home Visits by Consultants 17 
Clinic Sessions 17 
Services for Crippled Children in State Health Districts 17 
Number of Children Admitted to Services for Crippled Children 18 
Years of Treatment Often Needed 19 
Clinic Attendance 21 
Many Patients Attend Clinics Often 21 
Age and Sex of Children Admitted to Services for Crippled Children 21 
The Orthopedic Unit does not Supplant the Work of Other Agencies 23 
Previous Medical and Surgical Care 24 
Reasons for Discontinuance of Treatment 25 
Admission Rates by Towns and Cities 26 
Recommendations of Clinic Consultants 27 
Referrals to Specialists 28 
Acceptance of Recommendations 28 
Classification of Crippling Conditions by Diagnosis 30 
Age of Crippled Children at Time of Admission to Service 32 
Crippling Conditions due to Prenatal Influences 33 
Crippling Conditions Resulting from Infection 34 
Crippling Conditions due to Trauma 34 
Admission to Hospitals 34 
Length of Hospitalization 37 
Care in Convalescent Homes 39 
Reasons for Discharge from Care 40 
Expenditures under th£ Federal Grant-in-Aid 41 INDEX OF TABLES 
Table 1. Location of Clinics and Number Conducted 7 
Page 
Table 2. Clinics for Crippled Children in 1941 9 
Table 3. New Cases Admitted to Clinics September 1 to August 31 of Year In- 
dicated 19 
Table 4. Patients under Active Care on September 1, 1941 in Respect to Year 
Admitted 19 
Table 5. Increase in Number of Patients under Active Care 19 
Table 6. Clinic Attendance September 1 to August 31 of Year Indicated 20 
Table 7. Number of Clinic Visits by Individuals During Four Years Ending 
September 1, 1940 22 
Table 8. Age and Sex of Patients at First Clinic Visit . 22 
Table 9. Medical or Surgical Treatment Previous to Attending State Clinic for 
Crippled Children 24 
Table 10. Reason for Discontinuing Treatment Previous to Attending Clinic for 
Crippled Children 26 
Table 11. Recommendations of Clinic Consultant for Patients Admitted to Clinics 
to August 31, 1940 27 
Table 12. Consultation Visits for Diagnosis or Treatment as Referred by Clinic 
Consultants 28 
Table 13. Number of Patients Referred by Clinic Consultants to Other Specialists 29 
Table 14. Acceptance of Recommendations of Clinic Consultant at Clinic for 
Crippled Children 29 
Table 15. Diagnoses of Children Admitted to Services for Crippled Children 30 
Table 16. Crippling Conditions Found in Clinics; Per cent of Total, in Each Clinic 31 
Table 17. Age on Admission to Clinic 32 
Table 18. Age and Sex of Children Admitted because of Certain Conditions Due 
to Prenatal Influences 33 
Table 19. Age and Sex of Children Admitted because of Certain Conditions due 
to Infections 34 
Table 20. Age and Sex of Children Admitted because of Certain Conditions due 
to Trauma or Physical Agents 34 
Table 21. Age and Sex of Children Admitted because of Crippling Conditions 
due to Miscellaneous Causes 35 
Table 22. Proportion of Children in Respective Clinics Requiring Surgical Treat- 
ment (including Lakeville) 35 
Table 23. Multiple Admissions of Patients to Hospital, including Lakeville 36 
Table 24. Hospitals to which Twenty or More Patients Each Were Admitted 37 
Table 25. Days Spent in Hospital by Patients from Respective Clinics 38 
Table 26. Number of Admissions to Hospital of Children Hospitalized (exclusive 
of Lakeville) 39 
Table 27. Reason for Discharge from Active Care Prior to September 1, 1940 41 
Table 28. Condition of Patient September 1, 1940, or at Time of Discharge from 
Care 42 
Table 29. Expenditures by the Orthopedic Unit of the Federal Grant-in-Aid for 
Services for Crippled Children by Federal Fiscal Years 42 
INDEX TO FIGURES 
Figure 1. Map Showing Location of Clinic Centers 6a 
Figure 2. Number of Children under Active Care at Intervals of One Year 18a 
Figure 3. Age at Admission to Services for Crippled Children 30a 
Figure 4. Number of Crippled Children per Thousand of Population under 
Twenty-one Years of Age Admitted to Clinic 38a SERVICES FOR CRIPPLED CHILDREN IN MASSACHUSETTS 
1 
In November 1925 Massachusetts instituted its first extensive public provision 
of medical and surgical care for crippled children by authorizing the Department 
of Public Health to admit patients suffering from extra-pulmonary tuberculosis 
to its Lakeville State Sanatorium. 
For several years before 1925 the necessity for public hospital facilities for 
the medical and surgical care of patients afflicted with extra-pulmonary tuber- 
culosis had been becoming increasingly evident. Since 1898 sanatorium beds 
had been provided for the victims of pulmonary tuberculosis and during the 
first decade of this service four state sanatoria, with one thousand beds in all, 
had been established. During the next ten years six counties and some ten 
cities had built their own sanatoria. With the subsequent decline in the mortality 
rate from pulmonary tuberculosis, it appeared by 1920 that enough beds for 
pulmonary tuberculosis in Massachusetts were then available. Since the mortality 
rate for extra-pulmonary tuberculosis had not decreased so rapidly as had the 
rate for the pulmonary form of the disease and because the general hospitals 
were unable to furnish the necessary facilities for the treatment of this type of 
patient, it seemed logical to convert one of the sanatoria so that it could be used 
for the care of patients with bone and joint tuberculosis. The Department of 
Public Health accordingly recommended to the General Court that the Lakeville 
State Sanatorium be remodeled for this purpose. A law authorizing this was 
enacted in 1924 and the first patient was admitted the following year. By the 
end of 1926 the entire two hundred beds at this sanatorium were available for 
the care and treatment not only of children but of men and women suffering 
from extra-pulmonary tuberculosis. 
Eighteen years before the Lakeville State Sanatorium was thus opened to 
patients with extra-pulmonary tuberculosis, the Department of Public Welfare 
had established the Massachusetts Hospital School with the avowed purpose of 
rehabilitating children whose wage-earning capacity was threatened or impaired 
by defects, lesions, or diseases of their bones, joints or motor apparatus. This 
was the first official act in the Commonwealth to aid the handicapped child. 
The Massachusetts Hospital School is described in its annual reports as being 
a school with hospital facilities so the emphasis has always been on education 
rather than on medical and surgical care. There are many reasons why the 
education of the handicapped child is important. In the first place, treatment 
for a crippling condition extends over a long period of time and education 
should not be neglected during this period. Furthermore, children who have 
received all the benefits of medical and surgical care must also receive academic 
and vocational training if they are to become self-respecting, self-supporting 
citizens. 
The establishment of the Lakeville State Sanatorium as a hospital with school 
facilities for the care of children (and adults) suffering from extra-pulmonary 
tuberculosis was recognition, even though belated, that it is illogical to educate 
a crippled child until provisions have been made for ample medical and surgical 
care. Educational facilities in addition to medical and surgical care were there- 2 
fore provided at the Lakeville State Sanatorium so that children can be taught 
concurrently with their treatment. This is particularly important in bone and 
joint tuberculosis, the treatment of which is of very long duration. But the 
emphasis is on physical restoration, for school work, essential as it is, seldom 
exerts its maximum influence unless at the same time, or earlier, the crippling 
condition is removed or at least alleviated to the maximum extent. 
The next logical step in a state program for aiding crippled children was to 
provide for the teaching of handicapped children in their homes. Severely 
crippled children were being educated either at the Massachusetts Hospital 
School or at one of the privately conducted schools and many less handicapped 
children were attending the regular public schools. But there were other crippled 
children living at home who were not receiving any education at all because their 
crippling condition was so severe they could not go to school and because their 
parents preferred to keep them at home where they could care for them themselves 
rather than to send them to an institution. With this in mind the State Legis- 
lature in 1930 enacted a law requiring that "the school committee in a town 
where there are five or more children so crippled as to make attendance at a 
public school not feasible shall, and in any town where there are less than five 
such children may, employ a teacher or teachers who shall offer instruction to 
such children in their homes or wherever the school committee may arrange’’. 
During the decade after the establishment of the Lakeville State Sanatorium 
as a center for the treatment of extra-pulmonary tuberculosis (1925-1935) the 
decline in the mortality from this disease was even greater in proportion than 
had been the decline in the mortality from pulmonary tuberculosis during the 
preceding quarter century. The result was, again, vacant beds at Lakeville. The 
logical thing to do was to use those beds for the treatment of patients with 
some other disease. This the General Court authorized in 1936 on the recom- 
mendation of the Department of Public Health when it enacted a law providing 
for the admission to the Lakeville State Sanatorium of persons crippled by anterior 
poliomyelitis on the same terms as patients with extra-pulmonary tuberculosis. 
It was not difficult to secure this legislation, for public attention had been focused 
on infantile paralysis during the preceding year when one thousand three hundred 
ninety cases had been reported in the Commonwealth, an epidemic with a mor- 
bidity rate of thirty-two per one hundred thousand population. 
During the next few years the influx of patients with the residual paralysis 
of anterior poliomyelitis (infantile paralysis) kept the Lakeville State Sanatorium 
filled almost to capacity. But as had happened before, empty beds then began 
to appear due to the continued decline in the incidence of extra-pulmonary tuber- 
culosis and to the subsidence of infantile paralysis. The infantile paralysis 
epidemic of 1935 has fortunately not been repeated although the year 1937 saw 
more infantile paralysis reported than in any other of the six subsequent years, 
but even then only a fourth as many cases were reported as had been reported 
in 1935. In 1941 the Legislature again accepted the recommendation of the 
Department of Public Health and authorized the admission to the Lakeville 
State Sanatorium of persons suffering from spastic paralysis. One of the rural homes visited by the field staff. Before spastics are actually admitted to the Lakeville State Sanatorium there 
will be drawn up and submitted to the U. S. Children’s Bureau for approval a 
comprehensive plan which will provide primarily for a state-wide program for 
the medical and surgical care of the sufferers from this disease and secondarily 
for research into the problems of prevention and treatment of the condition. 
3 
Services for Crippled Children under the Social Security Act 
The enactment of the Social Security Act by the Congress in 1935 was followed 
by an enabling act of the Massachusetts General Court (Chapter 494, Acts of 
1935) which empowered the Department of Public Health to receive and ad- 
minister the Federal Grants-in-Aid authorized by Titles V, parts 1 and 2, and 
Title VI of the Social Security Act. The appropriation in that Act for Services 
for Crippled Children is expressly stated as being for the purpose of improving 
and extending existing services in rural areas and in areas of economic distress. 
The Department is in full accord with this policy, for orthopedic surgeons 
and private agencies had been actively engaged in helping all types of handi- 
capped children long before public services were inaugurated for children 
crippled by bone and joint tuberculosis. It is impossible to estimate the amount 
of this private work or to express its value in dollars and cents, nor is it possible 
without making a special study of the subject to attempt to enumerate the agencies 
and physicians who have aided crippled children in one way or another, with no 
thought of financial recompense. It is wholly certain that the Federal Grant-in- 
Aid for the medical and surgical care of crippled children would be entirely 
insufficient to supplant these services, even were the Department inclined to try 
to do more than to improve and extend existing services. The new funds are 
used only for individuals not reached by other existing services. Most of the 
private work done for crippled children in the State has been and still is, in the 
larger cities, particularly in the Boston Metropolitan Area and in Worcester. 
Consequently, it was logical for the Department of Public Health to concentrate 
its efforts on rural areas, in conformity with the policy expressed in the Social 
Security Act. 
Because of the fact that so many private agencies and individuals have long 
been engaged in helping the handicapped child, many persons believed and 
said that it was not worth while for the Department of Public Health to organize 
and operate an Orthopedic Unit for Services for Crippled Children. They 
insisted it would not be possible to find enough patients not already cared for to 
justify the expense of administering such a Unit. That these fears were un- 
justified is demonstrated by the accomplishments for two thousand children 
admitted to clinics, whose records are analyzed in this Report. 
The Federal Grant-in-Aid for Services for Crippled Children 
Title V, Part 2 of the Social Security Act authorized the annual appropriation 
for payment to the states of $2,850,000 for services for crippled children. In 
1939 Congress amended this Act by authorizing an additional appropriation of 
$ 1,000,000 to be allotted to the states according to the financial need of each 
state for assistance in carrying out its State Plan. These funds are allotted by the Secretary of Labor who devises a formula based on the several pertinent 
factors. 
4 
The basic reason for a federal grant-in-aid is that there are now so many 
new and improved governmental services for which there is a demand that 
local taxing resources have been outrun. Many of those who object to the 
principle of the grant-in-aid say that after all federal money thus granted is 
merely money obtained from all of us by taxation and then returned to us. This 
is, of course, true but state and local governments depend largely upon property 
taxes, which have reached the upper limit. The Federal Government, which has 
jurisdiction over the entire economic community, has access to forms of taxation 
which are not available to states. 
The grant-in-aid is probably the best device to aid the states in rendering 
services which would otherwise be impossible for any but the more wealthy 
states. It thus has the advantage of equalizing the services in the several states, 
for all formulae for the allotment of funds give the states with less financial 
resources considerably more in proportion than is allotted to the more fortunate 
ones. In effect, the backward states are granted much more than they pay in 
federal taxes, while those at the other extreme receive less. There have been 
objections from the latter states, but a Supreme Court decision has ruled that 
Congress may make any appropriation it wishes and that if a state objects it 
need not participate. Failure to participate is thus virtually a fine for the state, 
so there is no choice but to accept federal supervision in order to get the funds. 
Federal grants-in-aid are not new, for the first one was made in Lincoln’s 
administration. During the succeeding fifty years no federal restrictions what- 
ever were imposed as conditions. Those now in force have been added gradu- 
ally. First, reports were required of the states; then the audit, with inspectors; 
then the sanction; then plans; and finally federal approval of the plan as a 
prerequisite for the grant-in-aid. The result is that the Federal Government 
now has effective control over the states. Congress has the spending power and 
can thus easily transfer state affairs of national interest to federal control. 
In order to be successful, state administration of services made possible by 
a federal grant-in-aid depends on a relationship of mutual confidence between 
federal and state officials, for antagonism between these groups can ruin a pro- 
gram. The fundamental policy of the Federal Government should be to develop 
a strong and able state administration and then to relax federal supervision in 
proportion to the degree of excellence achieved by each State Administration. 
When the federal agency responsible for the administration of a grant-in-aid 
continues to supervise and control detailed aspects of administration after the 
state has demonstrated its ability and its honesty of purpose, the basic end of 
federal supervision will be defeated. 
The Massachusetts Plan for Services for Crippled Children 
In accordance with the conditions set forth in the Social Security Act, a Plan 
and Budget were submitted by the Department of Public Health to the Chil- 
dren’s Bureau of the United States Department of Labor. After the approval 5 
of the Plan and Budget by the Children’s Bureau, an Orthopedic Unit was 
organized in the Division of Administration of the Massachusetts Department of 
Public Health. The Plan embraced the establishment of permanent state-wide 
diagnostic clinic centers and the admission to clinic of any child living in the 
state whose crippling condition is included in the State definition of a crippled 
child, provided such admission is requested in writing by a physician licensed 
to practice medicine in the State. For administrative purposes the term "crippled 
children” was defined as including those children under twenty-one years of 
age who are suffering from poliomyelitis, bone and joint tuberculosis, congenital 
defects, arthritis, cardiac conditions and other similar conditions that may lead 
to, or have produced crippling and that may be treated advantageously. In- 
cluded also in the definition were children requiring plastic operations following 
burns and accidents, or with congenital defects, such as harelip, cleft palate and 
so forth. Not included were those children who are the victims of "acute” acci- 
dents, or who require operations for hernia or for the removal of tonsils and 
adenoids. It was expressly stated in the definition that mere custodial care 
would not be provided for any child whether of normal or of low mentality. 
The Care of Cardiac Children 
The original definition of a crippled child as given above included the phrase 
"cardiac condition” as a cause of crippling. It was soon realized that without 
a special plan of operation it would not be possible to accomplish anything in 
this field. A number of private agencies, seeing the above clause in the definition, 
assumed that chronic cardiac children for whom nothing could be done except 
to give custodial care could now be cared for at governmental expense. Sad as 
is the state of such children they can not be cared for under Services for Crippled 
Children, the chief purpose of which is medical and surgical care for patients 
who can be benefited. Accordingly, the phrase concerning cardiac children was 
removed from the definition. It is essential that public money should be spent 
only on patients who can be benefited by treatment. Sentimentality has no 
place in the administration of a program which has so definite a purpose; cus- 
todial care is therefore denied both to cardiac children and to mentally defective 
children. Children in the latter group are, however, not wholly barred from 
treatment; if they are sufficiently cooperative so that orthopedic surgery will 
make them ambulant and thus relieve some member of the family, treatment is 
justified. 
The subject of cardiac children was revived when in 1939 Congress appropri- 
ated funds for an acute rheumatic fever and heart disease program. Plans for 
such a program were promptly submitted to the Children’s Bureau by the Massa- 
chusetts Department of Public Health and approval obtained. In the full realiza- 
tion that any program for the care of sufferers from this disease could not possibly 
succeed without the active aid of the practicing physician, steps were immediately 
taken to secure the cooperation of the medical profession. It took some months 
to present this matter to the profession, and in the meantime, there were a few 
misunderstandings so the greater part of a year elapsed before the Department 6 
of Public Health was ready to proceed with the work. Meanwhile the Children’s 
Bureau had withdrawn its previous approval of the Plan pending acceptance by 
the Department of Public Health of certain additional stipulations which were 
recommended by the Children’s Bureau. No further progress has been made 
in effectuating this program in Massachusetts. 
Children with Strabismus 
Early in the clinic year 1938-39 the definition of a crippled child was amended 
to include children suffering from strabismus, provided an operation was found 
to be necessary. There was no provision for buying glasses except as required 
incidental to the operation. Children with this diagnosis were admitted to 
service in the same manner as orthopedic cases, but they were generally referred 
by local ophthalmologists. The procedure was to have these children examined 
at the Massachusetts Eye and Ear Infirmary (Massachusetts General Hospital) 
and if operative interference was recommended, to admit them to that hospital 
for operation. Fifty-nine patients were admitted to service and forty-six of 
them were admitted to the Massachusetts Eye and Ear Infirmary. 
But administrative difficulties were soon encountered. Patients referred by 
local ophthalmologists for operation were examined at the Massachusetts Eye 
and Ear Infirmary and occasionally as a result of that examination operation 
was not recommended. These patients returned home disgruntled and the local 
ophthalmologist was more than disgruntled. When on one occasion a local 
ophthalmologist referred a certain child for examination and the Massachusetts 
Eye and Ear Infirmary decided against the operation the local ophthalmologist 
was particularly disturbed because he was on the staff of the Massachusetts Eye 
and Ear Infirmary and would have accepted the child for operation had he been 
on service at the time. The Department of Public Health was not willing to 
have operations done locally, primarily because the question of selection of local 
ophthalmologists for operative work would have presented great difficulties and 
secondarily because the Department was unwilling to take a step toward the 
establishment of a fee schedule such as would have been necessary had this 
work been done locally. It therefore seemed better to drop strabismus from 
the definition of a crippled child. To cease doing this work was regretted by 
the Department, for the children who had been helped were the only ones in 
the entire program who were sufficiently appreciative to write to the Department 
to express their gratitude. 
Discussions with the Medical Profession 
The medical and surgical care of crippled children, being a problem in cura- 
tive rather than in preventive medicine, is a new departure in the public health 
field. It therefore closely concerns the members of the medical profession, who 
under our economic system are dependent upon their fees from patients for a 
living. The problem was accordingly discussed with large and small groups of 
members of the Massachusetts Medical Society in almost all of the eighteen 
constituent districts of the Society before any moves were made toward the 
establishment of clinics. Some slight opposition was encountered among the —— ft, *i Q» «UO 
COMMONWEALTH OF MASSACHUSETTS 
DEPARTMENT OF PUBLIC HEALTH 
PERMAKEffT CLIIIC COTTERS - SEPTEMBER 1, 1941 
Serriees for Crippled Children 
Hssssohusetts Department of Public Health 
Present Cllnlo Centers 
Porner Cllnlo Centers 7 
ultra-conservative and among those who feared an encroachment by the State 
into the field of local clinics, but when finally the Council of the Massachusetts 
Medical Society unanimously endorsed the plan and approved the methods 
taken by the Department of Public Health to secure the cooperation of the 
members of the medical profession it was felt that sufficient preparations had 
been made for the inauguration of the service. 
Establishment of Clinic Centers 
Eleven state-wide clinic centers were established during the last four months 
of 1936 (Table 1); three in the northeastern part of the state, three in the 
southeastern, two in the central part and three in the western counties (Figure 1). 
Only two changes in the location of clinic centers have since been found advisable, 
namely in the Connecticut Valley where there originally were two clinic centers, 
at Greenfield and at Springfield. It has been thought best to have but one clinic 
center in that region, more central than either of the other cities, namely, at 
Northampton. These ten clinic centers are all at hospitals which are adequately 
equipped with diagnostic facilities. The space allotted for clinic use is ample 
and no charge is made for this use, even by the Cape Cod Hospital and the 
Brockton Hospital, in which none of the state clinic patients have so far been 
hospitalized. 
TABLE 1 
LOCATION OF CLINICS AND NUMBER CONDUCTED 
NUMBER OF CLINICS CONDUCTED SEPTEMBER 1 TO 
CLINIC 
Date of First Clinic 
AUGUST 
31 OF 
YEARS INDICATED 
1936-37 1937-38 
1938-39 
1939-40 
1940-41 
TOTALS 
Pittsfield 
September 2, 193 6 
11 
12 
11 
11 
11 
56 
Greenfield 
September 25, 1936 
8* 
8 
Springfield 
October 2, 193 6 
11 
12 
10** 
33 
Haverhill 
October 7, 193 6 
10 
12 
11 
11 
11 
55 
Salem 
October 13, 1936 
10 
12 
11 
11 
9 
53 
Hyannis 
October 19, 193 6 
11 
12 
11 
11 
11 
56 
Lowell 
October 24, 1936 
10 
12 
11 
11 
14 
58 
Gardner 
October 30, 193 6 
10 
11 
11 
11 
11 
54 
November 6, 193 6 
10 
12 
11 
11 
11 
55 
Fall River 
November 23, 1936 
10 
11 
10 
11 
11 
53 
orcester 
December 18, 1936 
9 
12 
11 
11 
11 
54 
Northampton 
July 19, 1939 
1 
11 
11 
23 
total 
110 
118 
109 
110 
111 
558 
clinic discontinued June, 
1937 
**Springfield clinic changed July, 1939 to 
Northampton clinic 
It is the spirit of the Social Security Act that aid is primarily for those in rural 
areas, therefore there is no Clinic for Crippled Children in the Boston Metro- 
politan Area. To be sure, some of the clinics are held in large cities, but this is 
only because clinics must be held where the hospitals have adequate facilities. 
For example, although the City of Worcester is the site of one of the clinics, the 
patients seen at that clinic are from surrounding rural districts only. The ortho- 
pedic surgeons in the City of Worcester maintain sufficient clinics there so that 
every crippled individual may obtain all the help he needs without any aid from 
state or federal funds. 
Each Clinic Center for Crippled Children is under the professional direction 
of an orthopedic surgeon who was selected for that position because of his 
professional ability and who has been appointed Clinic Consultant in the De- partment of Public Health on a part-time basis at a nominal salary. The ortho- 
pedic surgeons now serving in that capacity are: 
8 
Clinic Consultant 
Pittsfield Frank A. Slowick 
Northampton Garry deN. Hough, Jr. 
Haverhill William T. Green 
Salem Paul W. Hugenberger 
Hyannis Paul L. Norton 
Lowell Albert H. Brewster 
Brockton George W. Van Gorder 
Fall River Eugene A. McCarthy 
Worcester John W. O’Meara 
Dr. Arthur T. Legg and Dr. Mark H. Rogers were clinic consultants for the 
Haverhill and Gardner Clinics respectively until their deaths. Dr. Harold C. 
Bean had charge of the Salem Clinic until he was ordered to active duty in the 
United States Navy. 
It has not yet been found necessary or even desirable to make any special con- 
certed effort to give general publicity to Services for Crippled Children. The 
program is well known to the physicians of the State many of whom heard what 
the Department of Public Health proposed to do for crippled children weeks 
before the first clinic center was established. The initial skepticism manifested 
by many of them has given way to hearty cooperation. They have found that 
the Department is sincere in its wish to cooperate with the practicing physician 
and that the professional work being done is of the highest type. Under these 
circumstances they are perfectly willing to refer suitable patients to the state 
clinics. As a matter of fact, more new cases have been located with the aid of 
the family physician than through any other agency. Each physician (as well 
as all other interested agencies) receives, early in June and in December of each 
year a schedule of clinic sessions for the next six months. (Table 2 is a copy 
of the post card which was sent them in June 1941). Each month the New 
England Journal of Medicine publishes the schedule of clinic sessions for the 
succeeding month. At one Annual Meeting of the Massachusetts Medical Society 
the exhibit space allotted to the Department of Public Health was used by Ser- 
vices for Crippled Children. The most important function of the Supervisor 
of Clinics for Crippled Children (a physician) is to visit physicians in order 
to discuss specific matters with them. This method of dealing with the medical 
profession has been very effective in preventing misunderstandings or correcting 
them before they have grown. Physicians who report crippled children are kept 
informed of the progress of their patients. Such information is not furnished 
indiscriminately. Inquiries concerning patients under care are ordinarily referred 
to the family physician unless those inquiring are participants in the State pro- 
gram or have demonstrated a cooperative interest in the work. This method of 
procedure maintains the interest of the family physician in the patient. Represen- 
tatives of interested agencies, welfare workers, nurses, etc., are all welcomed at 
Publicity 9 
TABLE 2 
THE COMMONWEALTH OF MASSACHUSETTS 
DEPARTMENT OF PUBLIC HEALTH 
CLINICS FOR CRIPPLED CHILDREN—1941 
Please Preserve for Reference 
JULY 
AUG. SEPT. 
OCT. 
NOV. 
DEC. 
Salem 
2.00 P.M. 
1st Mon. 
7 
8 
6 
3 
1 
Haverhill 
10.00 A M. 
1st Wed. 
2 
3 
1 
5 
3 
Lowell 
2.00 P.M. 
1st Fri. 
* 
It 5 
3 
7 
5 
Gardner 
1.00 P.M. 
2nd Tues. 
8 
9 
14 
4* 
9 
Brockton 
2.00 P.M. 
2nd Thurs 
10 
11 
9 
13 
11 
Pittsfield 
10.30 A.M. 
3rd Mon. 
21 
15 
2'0 
17 
15 
Northampton 
2.00 P.M. 
3rd Wed. 
16 
17 
15 
19 
17 
Worcester 
1.00 P.M. 
3rd Fri. 
18 
19 
17 
21 
19 
Fall River 
10.30 A.M. 
4th Mon. 
28 
22 
27 
24 
22 
Hyannis 
10.00 A.M. 
4th Tues. 
22 
23 
28 
25 
23 
*Day Changed. 
TNo clinics in 
August except in 
Lowell, 
the clinics, as well as practicing physicians. One certain physician has not missed 
attending any of the fifty-six sessions of the clinic center near his home, except 
once when he was ill. In this connection it is interesting to note that in his 
county an unusually high proportion of crippled children was admitted to clinic. 
The Chief of the Orthopedic Unit and the Supervisor of Clinics have given 
many talks on the subject of State Services for Crippled Children before lay and 
professional organizations. The purpose of such talks is double. The first 
objective is to inform citizens of what their State government is doing in the 
way of helping the crippled child; the second is to enlist their aid in locating 
crippled children. Possibly the Department learns of crippled children as an 
indirect result of these talks but, in any event, the number referred in this way 
is small compared to the number of those referred by physicians. 
The radio has been utilized as a means for disseminating information con- 
cerning the program. Eight fifteen minute periods have been allotted to the 
Orthopedic Unit annually. Three techniques have been used; the talk, the ques- 
tion and answer, and the discussion between two or more persons. The type 
which seemed most satisfactory was a discussion between the Chief of the Unit 
or the Supervisor of Clinics and a social worker or physiotherapist concerning 
the aid which had been given a specific patient. The child was present and 
had something to say at the end of the program. It is very difficult to estimate 
the value of such radio programs in terms of publicity. There was no fan mail 
except a letter from a kind lady whose heart had been touched by one little girl 
patient who spoke on the program. She sent a $5 check for the child, which 
was used for the purchase of clothing. 
Articles, six hundred words in length, were prepared in the Orthopedic Unit 
and appeared in state-wide newspapers several times annually. Longer descrip- 
tions of Services for Crippled Children have been published in the New England 
Medical Journal, the Massachusetts Health Journal, the Physiotherapy Review, 
and others. 
The local public health nurse is in an excellent position to be of great assist- 
ance in locating crippled children. She should be on the watch for deviations 
from normal and when she notes them she should call them to the attention of 
Locating Crippled Children 10 
the parents and the family physician. She has unexcelled opportunities to explain 
Services for Crippled Children to all those who are interested. A circular was 
sent to each public health nurse in the state in the early days of the program 
asking her aid. As a result, some of the most interesting and most needy of 
all the children admitted to service were brought to the attention of the Ortho- 
pedic Unit. The aid of local nurses should be developed and to that end it is 
hoped to be able to employ a chief consultant supervising nurse to be attached 
to the Orthopedic Unit for the purpose of securing closer cooperation with 
local nurses. The physiotherapists and social workers have established cordial 
relationships with local nurses whenever this was possible, but a supervising 
nurse whose duty is specifically in that field should have a great influence toward 
perfecting this relationship. 
Another method of locating crippled children is by means of reports from 
physicians in compliance with "An Act Providing for the Reporting of Con- 
genital Deformities and Other Crippling Conditions in Infants”. This Act, 
which became effective October 1, 1939, provided that within sixty days after 
the birth of any child born in the Commonwealth with visible congenital de- 
formities, or with any condition apparently acquired at birth which may lead to 
crippling, report shall be made to the Department of Public Health. This law 
has so far not resulted in finding any appreciable number of patients for admis- 
sion to Services for Crippled Children for those physicians who are sufficiently 
interested to make the report are likewise sufficiently interested to see that the 
child is placed under care. However, the names are placed on the Register and 
in the course of a very few years the children and their physicians will be visited; 
again. During the two years this law has been in effect about four hundred 
crippling conditions have been reported of which three-fourths are orthopedic. 
The annual census of physically handicapped children which is required by 
law is an important means of locating crippled children. At the beginning of 
each school year the superintendent of schools in each city and town receives a 
letter from the Commissioner of Education calling attention to the law and 
asking for reports. The State Department of Education receives these reports and 
refers crippled children to the Department of Public Welfare for investigation. 
These investigations are carried on from the office of the Supervisor of Social 
Service for Crippled Children in the Department of Public Welfare. All 
reports are reviewed and statements as to the diagnosis and treatment are verified 
whenever possible. Special investigations are made when there is evidence that the 
child may be in need of treatment or education, or both. Children not receiving 
treatment but needing it are referred to suitable clinics. The policy here is to ac- 
quaint the family with the existing facilities and, when they have selected the one 
of which they wish to avail themselves, to make the initial contact for them either 
by letter or personal interview. Since the establishment of Services for Crippled 
Children within the Department of Public Health children in need of these 
services are referred to the Orthopedic Unit. When the Unit was established 
in the Department of Public Health, the office of Supervisor of Social Service for 
Crippled Children in the Department of Public Welfare was moved to an ad- Showing a mother how to give her son a physical therapy treatment. joining room and has been there ever since. There has been a continuing ex- 
change of information on all new and old cases reported to either Department. 
A State Register of Crippled Children is kept in the central office of the Ortho- 
pedic Unit. This Register contains certain essential information concerning each 
child on the Register, the most important of which is a physician’s diagnosis. 
The State Register would ideally include the names of all the crippled children 
in the State whether under adequate care or neglected. The basis for the Massa- 
chusetts Register, when the Orthopedic Unit was established, was a survey of 
crippled children in the State made in 1931 by the Department of Public Wel- 
fare, and a subsequent annual census of crippled children between the ages of 
six and sixteen conducted by the Department of Public Welfare and the De- 
partment of Education. In this survey, six thousand one hundred forty-one 
crippled children were located, many of whom as well as many of those found 
since in the annual school census are now over twenty-one years of age and thus 
no longer eligible for inclusion on the Register. The Register now includes 
the names of six thousand four hundred sixty-one children. It is an un- 
doubted fact that there are many more crippled children in the Commonwealth 
than are listed on the Register. By consulting the records of hospitals and 
of clinics throughout the state it would be possible to add several thousands 
of names to the Register, but such a survey would take much time and clerical 
help, and would probably result in finding only those children who are receiving 
adequate care. In addition, it would most certainly arouse the suspicions of 
some that the Department might be planning to replace those services. 
State Register of Crippled Children 
The Orthopedic Unit has not, however, ignored the names on its Register. 
Each field worker was given all available information concerning the children 
listed on the Register whose homes are in her district. During the course of her 
work she visited the family physicians of these children to learn if the child 
Were well cared for or if aid were needed. Children were occasionally admitted 
to clinics as a result of these visits. Families who said they had no doctor 
were often ones where the aid of the Orthopedic Unit was needed. 
One of the first steps in the organization of the Orthopedic Unit was the 
selection and appointment of advisory committees. The General Advisory Com- 
mittee is made up of about a dozen representatives of the agencies interested in 
helping the handicapped child, including the Department of Public Welfare, 
the Department of Education, the Massachusetts Medical Society, the Hospital 
Council of Boston, as well as individual leaders in social service and in nursing, 
the professions most concerned. 
Advisory Committees 
The present membership of this Committee is as follows: 
E>r. Robert B. Osgood, 372 Marlboro Street, Boston 
Mr. Arthur B. Rotch, Commissioner of Public Welfare 
Mr. R. O. Small, Director of Division of Vocational Education, Department of 
Education Mr. Herbert A. Dallas, Supervisor of Rehabilitation, Department of Education 
Miss Edith I. Cox, Superintendent, Robert Breck Brigham Hospital 
Dr. Elmer S. Bagnall, Secretary, Committee on Public Relations, Massachusetts 
Medical Society, 8 Fenway, Boston 
Dr. Bronson Crothers, 300 Longwood Avenue, Boston 
Dr. John E. Fish, Superintendent, Massachusetts Hospital School, Canton 
Miss Emily D. Rice, Director of Social Service, Peter Bent Brigham Hospital, 
Boston 
Miss Dorothy J. Carter, Community Health Association, 137 Newbury Street, 
Boston 
Rev. Thomas J. Brennan, Superintendent, St. Elizabeth’s Hospital, Brighton 
Rev, Richard J. Quinlan, Diocesan Supervisor of Schools, 75 Union Park Street, 
Boston 
Dr. T. Duckett Jones, House of the Good Samaritan, 25 Binney Street, Boston 
The Technical Advisory Committee is made up of ten physicians, leaders in 
the medical profession, five of whom are orthopedic surgeons. On September 
1, 1941 this Committee was constituted as follows: 
12 
Technical Advisory Committee 
Dr. Robert B. Osgood 
Dr. Bronson Crothers 
Dr. Frank R. Ober 
Dr. W. Lloyd Aycock 
Dr. R. Nelson Hatt 
Dr. T. Duckett Jones 
Dr. Kenneth D. Blackfan* 
Dr. Conrad Wesselhoeft 
Dr. Lloyd T. Brown 
Dr. James Warren Sever 
All the original members of this Committee are still serving except Dr. Arthur 
T. Legg, whose untimely death removed one of the Department’s most trusted 
advisors, and Dr. Smith-Peterson, who resigned because he was unable to devote 
the necessary time to his duties as a member of the Committee. Drs. Osgood, 
Crothers and Jones are also members of the General Advisory Committee. Both 
Committees have been very helpful and much reliance is placed upon their recom- 
mendations which have always been adopted by the Department of Public Health. 
The Orthopedic Sub-Committee of the Technical Advisory Committee has 
rendered invaluable service. The members are: 
Dr. Robert B. Osgood 
Dr. R. Nelson Hatt 
Dr. Frank R. Ober 
Dr. James Warren Sever 
Dr. Lloyd T. Brown 
Each member of this Sub-Committee visits annually two of the clinic centers 
to review the work being done there. Each visit is made at the time of a 
regularly scheduled clinic session. This is regarded as a "special” clinic, al- 
though the regular routine of the clinic is followed. New cases are seen, 
check-up examinations are made as in any session, but an attempt is also made 
by the clinic consultant to demonstrate to the representative of the Technical 
Advisory Committee just what has been accomplished during the preceding year. 
Patients whose operative work has been completed, those who present special 
problems, and those for whom physiotherapy or apparatus has been provided, 
* Deceased 13 
as well as others, are brought to clinic. Report is made to the Chief of the 
Orthopedic Unit after each one of these clinic reviews. The annual schedule 
is so arranged that each sub-committee member visits all of the ten clinic 
centers during a five-year period. 
Both administrative and professional conferences are held periodically. The 
former are bimonthly in Boston, except during the summer months and are con- 
ducted by the Chief of the Orthopedic Unit with all field workers attending. 
Professional conferences are conducted in turn by the clinic consultants who 
demonstrate their most interesting patients to the accompaniment of lively dis- 
cussion. A short period is then devoted to administrative matters and dinner 
follows. The May conference has always been held at the Lakeville State Sana- 
torium and is attended by the members of the Orthopedic Sub-Committee of the 
Technical Advisory Committee as well as by the clinic consultants. Conferences 
have been held in Springfield, Worcester and Lowell, in addition to Boston, 
where the respective clinic consultants and the Peabody Home for Crippled 
Children were hosts. 
Staff Conferences 
In order to be admitted to a clinic it is only necessary for a crippled child to 
present an application signed by a physician licensed to practice medicine in the 
Commonwealth, preferably the family physician. A child thus admitted is given 
a thorough examination at the clinic following which a complete social study 
of the patient’s family is made by a public health social worker. If this social 
study indicates that the child is so situated economically that without state aid 
or without the aid of some charitable organization he would be unable to obtain 
all the medical and surgical attention he needs, he is accepted for care. The 
data obtained as a result of this social study of the patient’s family is referred 
to the chairman of a special committee of the District Medical Society for an 
expression of his opinion as to the child’s eligibility for public care. Every 
effort is made to insure that persons who are able to pay for all the necessary 
treatment and apparatus, and who should pay, are excluded from clinics. The 
final decision as to eligibility for admission to clinic rests with the Commissioner 
of Public Health. In the event that patients can pay for part of the services 
rendered arrangements are made for them to pay the hospital or the brace maker. 
Procedure for Admission to Clinic 
There are no stringent residence restrictions. Any child living in the State 
is eligible for admission. Any child coming to Massachusetts to live from any 
other state is not only eligible as soon as he arrives but is urged to continue 
treatment as soon as the Orthopedic Unit receives appropriate information. 
Administrative Procedures in the Orthopedic Unit 
The administrative responsibility for the efficient conduct of Services for 
Crippled Children rests with the Commissioner of Public Health. He has 
delegated authority to administer these services and to secure efficient operation 
to the Chief of the Orthopedic Unit in the Division of Administration. The 
Orthopedic Unit includes both a clerical and a field staff. The physician who is Supervisor of Clinics for Crippled Children attends all the clinics and exercises 
administrative supervision over the field staff. Assisting him in the operation 
of the clinics are six physical therapists and two medical social workers. The 
field work is divided among the field staff by clinic districts, as equally as pos- 
sible. Each of the six physical therapists is in administrative charge of one or of 
two clinic centers according to location or to the size of the clinic. Nursing help 
at clinic sessions is obtained from the hospitals where the clinics are held, on an 
hourly basis, according to need. 
14 
Procedure at Clinic Sessions 
The clinics are exclusively diagnostic. Two types of patients are seen, new 
cases and those who have previously had their first examination and who have 
returned for follow-up examinations. Any crippled child, upon written appli- 
cation of a licensed physician may be admitted to a clinic for examination but 
only those children are subsequently accepted for full care whose parents are 
unable to pay for the treatment which is deemed necessary. The decision whether 
to accept or reject applicants is based on information obtained by the public 
health social worker on the field staff when she visits the family at home. 
When a child comes to clinic, he is examined by the clinic consultant who is 
in full professional charge of his clinic. The consultant is assisted by the 
Supervisor of Clinics for Crippled Children, by a nurse, by the physical therapist 
who is in administrative charge of the clinic, and by a public health social 
worker. The clinic consultant dictates his findings and recommendations during 
the course of the examination. This is recorded in duplicate, in the central 
office of the Orthopedic Unit, and in the records of the physiotherapist who 
administers the clinic. The clinic consultant always states when next he wishes 
to see the patient and the physiotherapist makes a special record of this recom- 
mendation. Her notebook of clinic visits shows months in advance what patients 
are to attend succeeding clinics. She notifies the patients by post card when they 
are to come, unless the patient is one whose home she visits to give treatments. 
In this event, notifications are, of course, oral. 
As a result of his examination the clinic consultant makes certain recommenda- 
tions. If he desires to refer the patient to a specialist in some other field for a 
special examination and report, this is arranged at once. He may consider it 
advisable to admit the child to a hospital for an operation. If so, all that is 
needed is to obtain the consent of the parents; when this is obtained the patient 
is admitted to the hospital designated by the clinic consultant. No formal com- 
mitment is necessary and there are no waiting lists for admission to hospital 
because of lack of funds to care for a child. The consultant is in full charge 
of his patient while the latter is in hospital and either performs the operation 
himself or, if it is a minor one, designates his assistant, who is duly authorized 
by the Department of Public Health to act in this capacity under the direction 
of the clinic consultant. 
Many patients attending the clinics require braces or other apparatus; ample 
provision has been made to meet these needs. The clinic consultant prescribes The patients do not object to their treatments. 15 
and takes the necessary measurements, and the order is given to the brace maker. 
When the apparatus is delivered, it is fitted to the patient by the clinic consultant. 
The Supervisor of Clinics for Crippled Children takes the medical history of 
each child on a prescribed form on its first visit to a clinic center and makes a 
general physical examination. Photographing the patients is a matter of routine, 
to show defects and later to show the improvement. Motion pictures are also 
made when the gait or other motions are to be recorded. 
Each clinic session is attended by a representative of the Division of Vocational 
Rehabilitation of the Massachusetts Department of Education. This relationship 
has been found to be a valuable one, for it often is possible to be of much as- 
sistance to patients who are under care or who are nearing the point of maximum 
improvement, by helping them secure suitable employment. 
One of the public health social workers attends each clinic session. She 
utilizes this opportunity to interview the patients and their parents. Opportunity 
is afforded her for interview in private, but she goes to the patient’s home for 
the complete initial social study of the family. The worker has many oppor- 
tunities at clinic to discuss numerous minor matters with patients and their 
families. She has many responsibilities in connection with patients, not only in 
relation to Services for Crippled Children, but in connection with the utilization 
of community resources. There are so many welfare agencies in the Common- 
wealth that one of the most important duties of the public health social worker 
is to serve in a liaison capacity. Many problems arise in the matter of adjust- 
ments in the family, in the school and in the neighborhood. The social worker 
thus plays an important part in the after-care of the patient. 
Many patients seen at the clinic do not require operations; they may need no 
other treatment than physical therapy. In such cases the clinic consultant pre- 
scribes the treatment he wishes given and arrangements are then made for the 
physical therapist of that clinic district to visit the home periodically to carry 
°ut these recommendations. Where there are several patients in a community 
who require such treatment they are brought together if possible at some con- 
venient available center and are there given treatment, thus conserving the time 
°f the physical therapist. Such an arrangement is not often possible, for most 
of the patients live in rural regions at some distance from each other. To have 
$uch patients brought to a central point would require transportation and the 
time of some other member of the family. The mother would generally not be 
able to take the time to go with the child for treatment and thus one of the 
most important functions of the physical therapist, that of teaching the mother 
or an older sister what treatment to give and how to give it, would be lost. 
Physical Therapy 
Muscle examinations are also invariably made at the patient’s home. If a 
child who obviously will need such an examination makes application for ad- 
mission to clinic long enough in advance of the clinic session, the examination 
is made before the clinic session so that the consultant can see the report when 
he examines the child. After-Care 
16 
The after-care which is provided for patients under the care of the Orthopedic 
Unit may be classified as follows; 
a. Medical. Patients are brought back to clinic at intervals specified by the 
consultant, or at any time when the physical therapist or public health 
social worker who sees the patient at the home thinks it necessary. If the 
child is unable to attend the clinic, or to go to the consultant’s office, the 
consultant goes to the home. 
b. Physical Therapy. This treatment is almost always given in the home by 
the physical therapist. The mother or an older sister is taught how to 
do it, and thus is enabled to assist in the after-care. 
c. Social Service. This consists of helping patients make the trying adjust- 
ments to changed conditions after hospitalization, etc., and to aid in 
utilizing community resources. 
d. Public Health Nursing. This is done by local nurses whenever necessary. 
Both nurses and local welfare workers are given opportunities to be of 
direct service to patients. 
Pediatric Examinations 
Pediatric examinations are now given whenever indicated, but it is deemed 
preferable to have these examinations made in the pediatrician’s office, by ap- 
pointment. The ordinary clinic space provided in hospitals is not sufficient for 
both a pediatrician and an orthopedist to make complete separate examinations. 
The most important examinations at the clinic session are orthopedic. The clinic 
consultant needs for his patients two or three cubicles or examining rooms and 
a dressing room. If the pediatrician were trying to make his examination at 
the same time, each would hinder the other. 
Plastic Surgery 
Nor is there a plastic surgeon at any clinic session. Most plastic cases are 
not required to attend clinic sessions. They are sent directly to the plastic 
surgeon’s weekly clinic, which he himself conducts at the Cambridge Hospital. 
This clinic has no connection with the Orthopedic Unit except that children 
referred by that Unit are examined there. 
Children with cleft palate or harelip or both have been admitted to service 
ever since the program was initiated in 1936. Unfortunately, the progress of 
this part of the program has not been so satisfactory as has the orthopedic work. 
The difficulty has not been in the professional work, for that can not be sur- 
passed, but in, first, the lack of available hospital beds and, second, in the diffi- 
culty in getting the necessary orthodontic work done at a cost which is com- 
parable to that paid for other professional work. When its services are available 
the Harvard Dental School Clinic is of great assistance and the cases which 
have been completed as a result of that assistance show remarkably good results. 
The matter of availability of hospital beds has apparently now been settled, for 
the Cambridge Hospital will admit our patients. Dr. V. H. Kazanjian and 
Dr. Bradford Cannon conduct a weekly clinic at that hospital and all patients requiring plastic surgery are sent to this clinic and then admitted for operation. 
All future plastic work authorized by the Orthopedic Unit is to be done there. 
17 
Home Visits by Consultants 
Not infrequently it is necessary for the patient to be seen by the clinic con- 
sultant between clinic sessions. If the child is able to visit the physician’s office, 
an appointment is made by the physiotherapist. If not, the clinic consultant 
goes to the patient. Provision is also made for consultation visits by the clinic 
consultant at the request of the family physician to aid him in the treatment of 
paralytic subacute anterior poliomyelitis. Acute anterior poliomyelitis, being a 
reportable disease, the Division of Communicable Diseases of the Massachusetts 
Department of Public Health receives reports from physicians when cases occur. 
The information given on these reports is transmitted to the Orthopedic Unit 
and the reporting physician is then informed by letter that if he desires this 
consultation service he may have it. 
Clinic Sessions 
During the five years since the establishment of the first clinic center for 
crippled children at St. Luke’s Hospital in Pittsfield on September 2, 1936, five 
hundred fifty-eight clinic sessions have been held (Table 1). Clinic sessions 
were monthly at each clinic center until the summer of 1939 when it was decided 
that each member of both office and field staffs should take the major portion of 
his or her vacation during the month of August and that there should be no 
clinics during that month. This procedure so simplified clinic administration 
that it was adopted as a policy. 
Three of the clinic centers, those at Hyannis, Brockton and Worcester, have 
each had an unbroken series of all scheduled monthly sessions since the inaugura- 
tion of service. Ten scheduled clinic sessions at the other clinic centers have 
bad to be cancelled, in emergency, during the five-year period. 
It is interesting to note that in the Annual Report of the Secretary of Labor 
for the federal fiscal year ending June 30, 1940 the statement is made that during 
the federal fiscal year 1939 clinic sessions were held regularly in three hundred 
fifty-nine permanent clinic centers as part of the state program in the United 
States. No information is given as to how frequently clinic sessions were con- 
ducted at those centers. In that year there were in Massachusetts ten permanent 
clinic centers where one hundred nineteen monthly clinic sessions were con- 
ducted. In the entire country five hundred nineteen itinerant clinics were held 
during that period. Massachusetts does not conduct itinerant clinics, for the 
reason that efficient follow-up services are not readily provided without 
definite scheduled clinics. 
Services for Crippled Children in State Health Districts 
In Massachusetts the towns and cities are characteristically autonomous in 
governmental functions. Health work is no exception and, as a result, since 
roost of the three hundred and fifty-one towns and cities are small in population, 
local health work in such communities is generally limited and much reliance is placed on the State Department of Public Health. Unions of towns for health 
work have been attempted, but these are voluntary, unstable and not to be relied 
upon in the Jong run, although one union of ten towns and another of two 
towns are each now functioning as a health unit. The modified form of county 
health department is also in use in one county (on Cape Cod) and much can be 
said in favor of this type of organization. 
18 
The Commissioner of Public Health was authorized some years ago to 
divide the state into not more than eight health districts. This was done, but it 
is only recently that steps have been taken to perfect the organization of these 
districts to make each a complete health unit. These districts are administrative 
units under the direction of the Director of Local Health Administration, who is 
the Assistant to the Commissioner of the Department of Public Health. One 
district, the Worcester District, is now a fairly complete health unit. 
District organization of this kind has an important relationship to the ad- 
ministration of Services for Crippled Children. There are two clinic centers in 
the Worcester District. One physiotherapist and one public health social worker 
are assigned to these two clinic centers so their work is practically all in the 
Worcester District and they are members of the staff of the District Health 
Officer. These field workers are supervised administratively by the District Health 
Officer and receive only technical guidance from the Chief of the Orthopedic 
Unit. They have office space and clerical help in the District Health Office and 
are thus associated with other public health workers and are made to realize that 
they are in a health department and not lone workers in an independent activity. 
As district organization proceeds it is expected that the Orthopedic Unit will be 
relieved of many minor administrative duties and be able to pay more attention 
to technical guidance and to matters of policy. 
The flow of new patients to the clinics has been a fairly steady one (Table 3). 
The first two clinic years alone saw over five hundred new cases each year and 
over three hundred new patients were accepted during each of the next three 
years. The average number of new patients at each clinic session does not differ 
materially from the median number, statistical evidence that there is a steady 
accession of new patients normally distributed. There are not now and never 
have been waiting lists for admission to clinics or to service. Had the increment 
of new cases been more rapid, or more irregularly distributed, it is very likely 
that some of the clinic sessions would have been too crowded, with a resultant 
lack of efficiency. Experience has shown that not more than twenty-five or 
thirty patients can be satisfactorily examined at the ordinary half-day diagnostic 
clinic. 
Number of Children Admitted to Services for Crippled Clnldren 
Fifty-five patients were admitted from the Boston Metropolitan Area. There 
is no State Clinic in this area for the reason that ample voluntary facilities are 
available for the ordinary case. Patients are occasionally found in this area whose 
special requirements can not be met by existing facilities, for one reason or 
another. Such patients, after careful investigation, are accepted for care, but are NUMBER OF CHILDREN UNDER ACTIVE CARE AT INTERVALS OF ONE YEAR 
FIGURE 2 not required to attend one of the clinic sessions. An appointment is made for 
each such patient to be seen by one of the clinic consultants at his Boston office 
the examination is made and treatment prescribed. 
19 
New Cases Admitted to Clinics September 1 to August 31 of Year Indicated 
TABLE 3 
Average 
Median 
New Cases 
CLINIC 1936-37 1937-38 1938-39 1939-40 
1940-41 Total 
Per 
Per 
Clinic 
Clinic 
Brockton 54 
65 
54 
45 
47 
265 
4.8 
4. 
Pall River 40 
Gardner 69 
Haverhill 41 
Hyannis 46 
Lowell 49 
Pittsfield 3 5 
38 
25 
41 
42 
186 
3.5 
3. 
37 
19 
26 
13 
164 
3. 
2. 
29 
21 
30 
22 
143 
2.6 
2. 
36 
31 
24 
28 
165 
2.9 
3. 
51 
34 
48 
57 
239 
4.1 
3. 
36 
8 
29 
16 
124 
2.2 
1.5- 
61 
Worcester 49 
74 
21 
29 
17 
202 
3.8 
3. 
66 
36 
32 
39 
222 
4.1 
3. 
Connecticut Valley 115 
73 
53 
39 
47 
327 
5.1 
4.5 
Metropolitan Boston 
32 
13 
7 
52 
total 559 
505 
334 
*356 
•*335 ***2,089 
3.6 
3. 
‘Including 11 patients 
previously 
discharged 
but who 
were re 
-admitted 
to service. 
% including 14 patients 
**Including 25 patients 
previously 
discharged 
but who 
were re 
-admitted 
to service. 
previously discharged 
but who 
were re- 
admitted 
to service in 1939-41. 
TABLE 4 
Patients Under Active Care on September 1, 1941 in Respect to Year Admitted 
Number 
Discharged 
Still Under 
Per Cent 
Calendar Year 
Admitted 
Before 
Care 
Under Care 
9-1-41 
9-1-41 
9-1-41 
1936 
220 
176 
44 
20 
1937 
301 
356 
145 
29 
1938 
486 
324 
152 
33 
1939 
331 
173 
158 
48 
T, 1940 
332 
102 
230 
69 
Aug. 31, 1941 
219 
36 
183 
84 
total 
•2,089 
1,167 
922 
Including 23 patients previously discharged who were re-admitted to service in 
1939-41 
TABLE 5 
Increase in Number of Patients Under Active Care 
Sept. 1 to 
Admitted 
Under Active 
Aug. 31 of 
to 
Treatment 
Net 
Year 
Service 
Discharged 
on 8-31 of 
Increase 
Indicated 
Year Indicated 
1936-37 
559 
135 
1937-424 
1937-38 
505 
183 
1938-746 
322 
1938-39 
334 
226 
1939-854 
108 
1939-40 
•356 
311 
1940-899 
45 
1940-41 
*•335 
312 
1941-922 
23 
total 
2,089 
1,167 
Including 11 
patients previously discharged who were re- 
■admitted to service between 
9-1-39 and 
*8-31-40. 
including 14 
patients previously discharged who were re 
•admitted to service between 
9-1-40 and 
8-31-41. 
Years of Treatment Often Needed 
Of the two thousand eighty-nine admissions to service during the first five 
years of the State clinics, nine hundred twenty-two children were still under 
active care on August 31, 1941, of whom twenty-five were re-admissions of 
children previously discharged (Table 4). It is a well recognized fact that 
orthopedic treatment is necessarily long-continued, but it is a little startling to 
note that of the patients admitted during 1936 twenty per cent were still under treatment on September 1, 1941. This proportion increases as the period of 
treatment decreases so that eighty-four per cent of those admitted during the 
first eight months of 1941 were still on the active list on September 1, 1941. It 
must be remembered, in interpreting these figures, that a certain number of 
hopeless cases are brought to clinics by parents who are ever hopeful of getting 
aid. Such patients are, of course, not retained on the active list after the first or 
second clinic visit. In Table 7 it is shown that of the eight hundred fifty-five 
patients who had been discharged from service prior to September 1, 1940, five 
hundred sixty-six had made only one or two clinic visits each. These patients 
were discharged either because no treatment was possible, because they were not 
included in the definition of a crippled child, because they were referred to an- 
other clinic, or for some other similar reason (Table 27). If these patients had 
not been included in the figures in Column 2 of Table 4, the percentages in the 
last column would be larger for the base would represent only those patients who 
had actually been placed under treatment. 
20 
Apparently the number of patients under active care has reached its level. 
There is every indication that in the months to come unless an epidemic of acute 
anterior poliomyelitis comes and leaves a wake of residual paralysis the number 
of patients discharged will approximately equal the number of new cases ad- 
mitted, as was the case in the clinic year 1940 to 1941 when three hundred 
thirty-five were admitted and three hundred and twelve discharged (Table 5). 
TABLE 6 
Clinic Attendance September 1 to August 31 of Year Indicated 
Clinic* 
1936-37 
1937-38 
1938-39 
1939-40 
1940-41 
Total 
Attend- 
ance 
Median 
Attend- 
ance 
At Clinics 
Average 
Attend- 
ance 
At Clinic* 
Brockton 
107 
204 
196 
192 
195 
894 
16 
16 
Fall River 
104 
190 
183 
210 
221 
908 
17 
17 
Gardner 
120 
117 
110 
12'6 
125 
598 
10 
11 
Haverhill 
71 
117 
150 
195 
222 
755 
14 
14 
Hyannis 
128 
217 
207 
193 
243 
988 
17 
18 
Lowell 
98 
191 
235 
229 
327 
1080 
20 
19 
Pittsfield 
73 
148 
132 
130 
139 
622 
11 
11 
Salem 
136 
247 
175 
166 
124 
848 
16 
16 
Connecticut Valley 
202 
227 
258 
230 
234 
1151 
18 
18 
Worcester 
73 
200 
164 
184 
182 
803 
15 
15 
TOTAL 
1,112 
1,858 
1,810 
1,855 
2,012 
8,647 
16 
16 
Figure 2 demonstrates graphically the number of patients under active care 
on September 1 of successive years. This graph is not unlike the enumeration 
growth curve of a bacterial culture as discussed by Zinsser. All three phases 
are present; the lag phase, which is the period of time between the planting 
of the organism in the medium and the beginning of maximum multiplication 
rate; the logarithmic period, which is the period of maximum growth rate; 
and the stationary stage, which is a period in which bacteria are dying as fast as 
they are being formed. The analogy, even to phraseology, is complete in the lag 
phase and in the logarithmic period. In the stationary stage, if one changes the 
phraseology to read "a period in which patients are being discharged as fast as 
new patients are being admitted”, the analogy remains complete. It is to be 
hoped that changes in the "nutrient medium” of Services for Crippled Children can be prevented so that catabolic metabolism will not gain the ascendency and 
so that the period of senescence will be averted. 
21 
Clinic Attendance 
Clinic sessions are attended not only by new patients who present themselves 
with applications signed by their respective physicians, but by those who have 
attended a previous clinic session or sessions and who are returning for further 
observation, for adjustment of apparatus, for follow-up, for check-up or for any 
one or more of many other reasons. Total attendance has varied considerably 
among the ten clinic centers; it is summarized in Table 6. Two of the clinic 
centers, those at Pittsfield and Gardner, and especially the former, are well 
below the average in clinic attendance but, as shown in Table 22, the need of the 
Pittsfield Clinic patients for medical and surgical aid is greater, in proportion, 
than in any other clinic center. 
That the attendance at clinic sessions is kept at a reasonable figure is shown 
m the last two columns of Table 6. There is practically no difference between 
the median and the average attendance, which indicates that few clinic sessions 
have extremely low or extremely high attendance. The sessions are generally 
about three hours in length. Not infrequently four or even five hours are re- 
quired for careful examinations of the patients who attend. 
It is interesting to study the frequency of clinic visits by the patients although 
these figures are not final for more than half of the patients admitted were still 
°n the active list on September 1, 1940 and will attend many more sessions 
before they are discharged. Those who were discharged before September 1940 
made a fewer number of visits each, generally because it was evident that little, if 
anything, would be done for them. Table 7 shows that almost two-thirds of the 
discharged patients came to a clinic session only once or twice and that much 
kss than half of the active patients have so far been seen so infrequently as that. 
The majority of patients under active care on September 1, 1940 who had made 
°nly one or two clinic visits had been only recently admitted to clinic; during 
the course of their treatment these children will undoubtedly need further 
lamination. 
Many Patients Attend Clinics Often 
Age and Sex of Children Admitted to Services 
for Crippled Children 
A study of the age and sex of the crippled child at the time of first admission 
to clinic (Table 8) reveals the surprising fact that more children come to clinic 
tor the first time when they are in their sixteenth year than at any other age. If 
these adolescents came for help because of deformities which are the result of 
accidents or of infections, it might be possible to conclude that they had been 
mjured in their early teens, when children are on the streets more than when 
they are younger. But this is not the case, for the great majority of patients at 
this age have had their disabilities for several years. TABLE 7 
Number of Clinic Visits by Individuals During Four Years Ending 9-1-40 
22 
Number of 
Visits To 
Clinic 
Under 
Active Care 
9-1-40 
Discharged 
Before 
9-1-40 
Total 
Patients 
Total 
Visits 
0 
1 
22 
207 
29 
409 
51 
616 
616 
2 
125 
157 
282 
564 
3 
86 
77 
163 
489 
4 
82 
52 
134 
536 
5 
70 
34 
104 
520 
6 
63 
23 
86 
516 
7 
46 
15 
61 
427 
8 
38 
14 
52 
416 
9 
31 
10 
41 
369 
10 
24 
10 
34 
340 
11 
16 
5 
21 
231 
12 
17 
10 
27 
324 
13 
14 
5 
19 
247 
14 
13 
2 
15 
210 
15 
10 
1 
11 
165 
16 
9 
0 
9 
144 
17 
10 
2 
12 
204 
18 
3 
0 
3 
54 
19 
5 
0 
5 
95 
20 
3 
0 
3 
60 
21 
1 
0 
1 
21 
22 
1 
0 
1 
22 
24 
1 
0 
1 
24 
25 
2 
0 
2 
50 
Total 302 
899 
855 
1,754 
6,644 
Age and Sex of Patients at First Clinic Visit 
TABLE 8 
AGE* 
UNDER ACTIVE CARE 9-1-40 
DISCHARGED 
BEFORE 
9-1-40 
TOTAL 
M 
F 
T 
M 
F 
T 
M 
F 
T 
Under 1 
19 
9 
28 
6 
3 
9 
25 
12 
37 
1 
14 
15 
29 
13 
16 
29 
27 
31 
58 
2 
26 
13 
39 
17 
15 
32 
43 
28 
71 
3 
26 
19 
45 
1 1 
9 
20 
37 
28 
65 
4 
23 
15 
38 
21 
11 
32 
44 
26 
70 
5 
19 
17 
36 
16 
12 
28 
35 
29 
64 
6 
33 
15 
48 
14 
12 
26 
47 
27 
74 
7 
27 
24 
51 
18 
14 
32 
45 
38 
83 
8 
25 
24 
49 
20 
13 
33 
45 
37 
82 
9 
28 
16 
44 
20 
15 
35 
48 
31 
79 
10 
27 
19 
46 
28 
16 
44 
55 
35 
90 
11 
18 
19 
37 
26 
19 
45 
44 
38 
82 
12 
24 
22 
46 
26 
22 
48 
50 
44 
94 
13 
26 
29 
55 
23 
22 
45 
49 
51 
100 
14 
28 
35 
63 
28 
31 
59 
56 
66 
122 
15 
29 
35 
64 
30 
18 
48 
59 
53 
112 
16 
35 
37 
72 
31 
26 
57 
66 
63 
129 
17 
25 
24 
49 
28 
27 
55 
53 
51 
104 
18 
19 
12 
31 
24 
23 
47 
43 
35 
78 
19 
12 
13 
25 
32 
22 
54 
44 
35 
79 
20 
1 
1 
2 
17 
12 
29 
18 
13 
31 
21 
1 
1 
2 
14 
9 
23 
15 
10 
25 
Over 21 
12 
13 
25** 
12 
13 
25** 
TOTAL 
485 
414 
899 
475 
380 
855 
960 
794 1.754 
•Age determined by subtracting year of birth from year of first clinic attendance. 
♦ •These patients were merely seen in consultation and were not accepted for care. 
The reason for this can only be inferred. That the age of sixteen is the most 
popular one at which to go to a clinic for help is particularly true of boys. Girls 
come to clinic in gradually increasing numbers beginning at age thirteen, through 
ages fourteen, fifteen and sixteen. In fact, as many girls came to clinic for the 
first time at fourteen years of age as boys at sixteen years, although the sex ratio 
of children attending clinics is 1.23 boys to one girl. At ages thirteen to sixteen 
inclusive, two hundred thirty-three girls were admitted as compared with two A mother giving her daughter a physical therapy treatment under 
the watechjul eye of the physical therapist. hundred thirty boys at those ages. At all other ages there were seven hundred 
thirty boys to five hundred sixty-one girls. A possible conclusion is that many 
°f the patients at the adolescent age, both boys and girls, come on their own 
•nitiative when they begin to take an interest in themselves and in their ap- 
pearance. This change begins at a younger age in girls than in boys and reaches 
climax at age sixteen in both boys and girls. 
23 
The age group "over twenty-one” consists of two classes — those coming to 
chnic either before admission to or discharge from the Lakeville State Sanatorium 
and those applying for admission to clinic under some misapprehension about 
the age limit. Occasionally patients are examined in the State Clinics when they 
apply for admission to the Lakeville State Sanatorium in order to determine their 
Stability for admission there. Patients are also examined at the clinics after 
discharge from that institution in order to watch their progress. This is done 
ln cooperation with the Division of Tuberculosis of the State Department of 
Public Health. These patients, although thus occasionally admitted to a clinic 
for diagnostic service, are not given treatment by Services for Crippled Children. 
Patients whose medical and surgical treatment will obviously need to continue 
after they are twenty-one years of age are not accepted for care but no patient 
who reaches the age of twenty-one years before his treatment has been completed 
18 summarily dropped on the twenty-first anniversary of his birth if he needs a 
fittle more treatment. 
The Orthopedic Unit Does Not Supplant the Work of Other Agencies 
In carrying out its policy of improving and extending existing services for 
Cfippled children the Orthopedic Unit of the Massachusetts Department of 
Public Health does not knowingly supplant the work of any agency, either official 
0r voluntary. No patient is admitted to Service without a thorough investigation 
°f the previous medical and surgical care received. If the applicant proves to 
under the care of some physician, hospital or agency, or if he has been under 
such care within the previous year or two, the appropriate person is consulted 
and the patient admitted only when there is need for additional assistance and 
°f course after a full understanding with those concerned. If such a patient is 
denied care under Services for Crippled Children, it is because there is assurance 
hhat the existing facilities are ample for the needed care. 
*Phe medical profession of one of the largest cities in the State resisted the 
establishment of a clinic in their city until the true reason came to light so that 
fhe misunderstanding could be corrected. Local orthopedists in that city had for 
a number of years conducted orthopedic clinics for its citizens. They did not 
the State Department of Public Health to supplant these clinics and since 
nothing could be more foreign to the wishes of the Department than to replace 
this excellent work, it was not difficult to come to an agreement. A monthly 
cIinic is now held in that city, but no crippled children living within that city 
are admitted to clinic. When such a crippled child is found, the Chairman of 
appropriate committee of the District Medical Society of that city is given 
this information. He is then responsible that the child gets the care he needs. 24 
Medical or Surgical Treatment Previous to Attending State Clinic For 
Crippled Children 
TABLE 9 
Previous Medical or 
Surgical Care 
ACTIVE 
CLOSED 
TOTAL 
M 
F 
T 
M 
F 
T 
M 
F 
T 
Family Physician 
106 
96 
202 
112 
105 
217 
218 
201 
419 
Metropolitan Hospital 
100 
68 
168 
94 
56 
150 
194 
124 
318 
Local Hospital 
69 
68 
137 
66 
54 
120 
135 
1 2'2 
257 
State Hospital 
15 
8 
23 
7 
9 
16 
22 
17 
39 
Private Agency 
48 
43 
91 
67 
43 
110 
115 
86 
201 
Public Agency 
3 
1 
4 
8 
8 
16 
11 
9 
20 
No Treatment 
173 
154 
327 
93 
92 
185 
266 
246 
512 
Unknown 
31 
25 
56 
62 
40 
102 
93 
65 
158 
TOTAL 
545 
463 
1,008 
509 
407 
916 
1,054 
870 
1,924 
Previous Medical and Surgical Care 
Table 9 summarizes the previous medical and surgical care of the one thousand 
seven hundred fifty-four patients who were accepted for care before September 
1, 1940. Some of the children had had several types of previous care, hence the 
total in this table is greater than the number of patients. The largest single 
category is those who had had no treatment at all. This group numbered five 
hundred twelve children, almost a third of the total number of patients ad- 
mitted. That such a situation could and did exist in the Commonwealth of 
Massachusetts was somewhat disconcerting to those who had insisted, before 
the Orthopedic Unit was organized, that few neglected children would be found. 
In all justice to the medical profession it must be said that the reason these 
children had been neglected was not that physicians had refused to help them 
but that the parents had made no effort to get care for their children. The 
tendency in families of the lower economic strata is to hide the deformed child 
from others than members of the family and to become so accustomed to the 
sight of the crippling condition that all thought of making the necessary efforts 
to try to get the condition corrected disappears. This attitude of the parents 
might well be one reason why so many children first come to clinic in their 
adolescent years on their own initiative when they are becoming self-conscious. 
This negligence on the part of the parents is due to one or more of the following 
factors: the realization that treatment and apparatus are expensive; the fear of 
operative procedures; and the feeling that the crippling condition is so hopeless 
anyway that nothing can possibly be done to alleviate it. There are, of course, 
those who believe that a deformity has been bestowed by the Deity and there- 
fore should not be disturbed. On the other hand there are certain parents who 
will not believe a condition to be hopeless, no matter who had told them it is, 
and who go to every clinic and to every physician who can speak with authority 
in the vain hope of finding some one who will promise physical restoration. 
The next largest group in Table 9 includes those who had consulted theif 
family physicians. It must be borne in mind that of the one thousand seven 
hundred fifty-four children under discussion (those admitted during the first 
four years) only forty-five came from the Boston Metropolitan Area and that 
none came from the city of Worcester. It is a rural-dwelling group and undef 
such conditions the family physician’s help is largely limited to giving advitf Slnce he cannot afford to provide hospitalization or apparatus. The only hospitals 
ordinarily available to rural patients are the smaller ones and in them free beds 
are not numerous and clinics are few. The Orthopedic Unit makes particular 
offort to extend Services for Crippled Children into just such areas in order to 
care for these children. 
25 
Over three hundred of the children admitted to care had had previous treat- 
ment in some metropolitan hospital, and almost as many had been in a local 
hospital. Practically all of these children had had operative treatment, and this 
had nearly always been well done. The records of the children admitted to the 
clinic centers contain transcripts of their hospital records so that clinic con- 
sultants know just what the previous treatment was. There is one important 
point in this connection and that is that no matter how successful an operation, 
unless there is efficient after-care and follow-up, much of the beneficial effect 
of an excellent operation is lost. Many of the patients seen in the clinics who 
had had operative procedures some years before they were admitted to Services 
for Crippled Children but who had had no after-care demonstrate this fact 
perfectly. Over two hundred patients had received aid from a private or public 
agency, generally the former, but very few such agencies do more than to provide 
hospitalization or apparatus, or both. Practically none furnish follow-up services. 
Reasons for Discontinuance of Treatment 
No special efforts were made to ascertain just why the patient’s parents dis- 
continued whatever treatment the crippled child was getting before admission 
to Services for Crippled Children. Certain questions were asked of each family 
m order to obtain the data necessary for the State Register of Crippled Children 
as well as to obtain full information concerning the economic and social status 
°f the family in order to determine whether the family is a needy one or not. 
fn the course of this questioning an attempt is made to learn why previous treat- 
ment was discontinued. If this information is not readily forthcoming, the 
matter is not pressed. Table 10 summarizes the information obtained concern- 
Ing reasons for discontinuing treatment. The largest single category in this 
table, aside from those who had had no treatment to discontinue, is, unfortu- 
nately, the group which did not give any reason for discontinuing treatment. 
One can only conjecture what their reasons might have been. By coming to clinic 
they gave evidence that they at least were not unwilling to be helped. This group 
mcludes more than a third of the patients, but the other two-thirds who frankly 
gave their reasons furnish excellent food for thought. 
Two hundred and sixty-five admitted that they lacked sufficient funds for the 
necessary treatment. Crippled children frequently require hospitalization and 
mtpensive apparatus. No matter how willing the family physician may be to 
£lve advice and any assistance within his power, he can not be expected to 
provide facilities such as these. 
Nore than one hundred discontinued previous treatment because they had 
reached the age limit established by the agency under whose care they had 
een. Since patients are accepted at the clinic centers up to the age of twenty-one 26 
years this is an excellent way to fulfill one of the purposes of Services for 
Crippled Children to "extend existing services”. 
The parents of two hundred and sixty-seven patients stated they had been 
advised against further treatment or had been told no more treatment was pos- 
sible. About one-half the patients in this group were discharged from the 
active list soon after admission to clinics, thus corroborating this advice, but it 
was found possible to aid the others. 
Reason For Discontinuing Treatment Previous to Attending Clinic For 
Crippled Children 
TABLE 10 
REASON 
ACTIVE 
CLOSED 
TOTAL 
M 
F 
T 
M 
F 
T 
M 
F 
T 
No treatment to discontinue 
173 
154 
3 27 
93 
92 
185 
266 
246 
512 
Lack of funds 
86 
72 
158 
67 
40 
107 
153 
112 
265 
Unknown 
92 
85 
177 
136 
108 
244 
228 
193 
421 
Reached age limit 
35 
26 
61 
43 
23 
66 
78 
49 
127 
Advised against further treatment 
56 
41 
97 
67 
62 
129 
12) 
103 
226 
No treatment possible 
13 
7 
20 
15 
6 
21 
28 
13 
41 
Dissatisfaction 
5 
4 
9 
2 
3 
5 
7 
7 
14 
Lack of transportation 
7 
7 
14 
6 
4 
10 
13 
11 
24 
Uncooperative 
6 
6 
12 
9 
8 
17 
15 
14 
29 
Not discontinued 
21 
16 
37 
43 
35 
78 
64 
51 
115 
TOVAL 
494 
418 
912 
481 
381 
862 
975 
799 1.774 
In a surprisingly small number of patients the parents were dissatisfied with 
whatever treatment had been given them, which speaks very well for the quality 
of care in Massachusetts. It is well known that patients or their parents are often, 
for the flimsiest of reasons, dissatisfied with results in orthopedic cases. 
Only a very few stated that lack of transportation was the factor which neces- 
sitated discontinuing previous treatment. Presumably these particular ones lived 
in rural regions and thus were especially eligible for Services for Crippled Chil- 
dren. Arranging for transportation for patients is one of the functions of the 
field staff of Services for Crippled Children. The purpose in distributing the 
clinic centers so that they were state-wide was to bring clinic service near the 
homes of all possible patients. That this has been successful is shown by the 
fact that the problem of transportation is but a minor one in the Massachusetts 
program, except in connection with the transportation of patients from Nantucket 
and Martha’s Vineyard, two islands off Cape Cod. A local public health nurse 
there who is much interested in the program brings the patients to the Hyannis 
Clinic, takes them home and provides after-care under the direction of the clinic 
consultant. She is reimbursed for her travel expenses. 
In one hundred and fifteen cases after special arrangements had been made, the 
Orthopedic Unit took over the treatment and the responsibility. In general, this 
was done because the patient needed either an expensive apparatus or an opera- 
tion and was unable to pay. 
Admission Rates by Towns and Cities 
Although there are many cities and towns in rural areas from which no patients 
have been admitted to Services for Crippled Children, Figure 4 presents evidence 
that the populous eastern and northeastern parts of the Commonwealth are the 
ones from which fewest patients have been accepted for care. Most of the cities AGE AT ADMISSION TO SERVICES FOR CRIPPLED CHILDREN 
MALES 
FEMALES 
FIGURE 3 and towns in this area have either sent no crippled children at all to the clinic 
centers or they have sent less than two per thousand of children in the popula- 
tion under the age of twenty-one years. The explanation is, of course, that the 
crippled children in this region are being adequately cared for by other agencies 
and do not need State help. 
27 
It is conspicuous that most of the towns on Cape Cod have a five year ad- 
mission rate of five or more crippled children per thousand children in the 
population. This is also true of many of the other towns in the southeastern part 
of the State. In the western counties some of the towns have a similarly high 
cate but in many of them the population is so small that one crippled child 
more or less makes a large difference in the admission rate. The important de- 
duction from Figure 4 is that there are still many rural towns in which no 
crippled children have yet been located. 
Recommendations of Clinic Consultant For Patients Admitted to Clinics to 
TABLE 11 
August 31, 
1940 
RECOMMENDATION 
ACTIVE 
DISCHARGED 
TOTAL 
M 
F 
T 
M 
F 
T 
M 
F 
T 
Operation 
233 
170 
403 
143 
100 
243 
376 
270 
646 
physiotherapy 
246 
254 
500 
115 
95 
210 
361 
349 
710 
£pparatus 
284 
227 
511 
129 
96 
225 
413 
323 
736 
A-ray (diagnostic) 
200 
214 
414 
117 
112 
229 
317 
326 
643 
•Referred to other specialist 
39 
29 
68 
26 
17 
43 
65 
46 
111 
hospitalization (non-operative) 
42 
40 
82 
17 
16 
33 
59 
56 
115 
Return to previous clinic 
3 
14 
17 
3 
14 
17 
hot clinic case 
96 
86 
182 
96 
86 
182 
Convalescent home care 
16 
12 
28 
3 
3 
6 
19 
15 
34 
Special treatment, dietary or medicinal 16 
16 
32 
10 
8 
18 
26 
24 
50 
total 
1,076 
962 2,038 
659 
547 
1,206 
1,735 
1,509 3 
,244 
As a result of examination at the diagnostic clinics, certain recommendations 
V'ere made by clinic consultants (Table 11), usually more than one for each 
patient. There were three thousand two hundred forty-four such recommenda- 
tions for the one thousand seven hundred fifty-four patients. Over two thousand 
°f the recommendations were for physical therapy, for operation or for apparatus. 
Almost all patients who were admitted to hospital for operation or who were 
given an apparatus of some kind had physical therapy in addition. The six 
Physiotherapists who have charge of the six clinic districts in which the ten clinic 
centers are located are trained experts in this field. The Massachusetts program 
does not employ orthopedic nurses for this purpose unless they have had thorough 
Gaining in physical therapy. The viewpoint of the Orthopedic Unit is that 
Physical therapy is the most important part of the follow-up work, so the greatest 
need is for thoroughly trained physiotherapists. Orthopedic nursing is essential 
while the patient is in hospital; after discharge from hospital physiotherapy takes 
hrst place. During the five years under consideration, almost twenty-one thousand 
physiotherapy treatments have been given to the patients admitted to service. 
addition to giving treatments, physiotherapists have made over eleven 
thousand visits to nurses, physicians, welfare workers, etc., in connection with 
follow-up work. 
Recommendations of Clinic Consultants If continuous nursing service is needed during after-care, a suitable convalesent 
home is utilized. When occasional nursing help is needed, local nurses are 
often called upon. The Commonwealth of Massachusetts is well supplied locally 
with nurses who are employed both by private and by public agencies and who 
are eager, for the most part, to be of all possible assistance. 
28 
In Table 11, one hundred and thirteen patients are shown as having been 
referred to a specialist for consultation and report. The recommendations that 
this be done were made at clinic sessions. When, during hospitalization or 
follow-up work, the need arose for the services of some other specialist than the 
orthopedist, authority was granted by the Chief of the Orthopedic Unit, who 
designated the specialist and made the appointment. 
Referrals to Specialists 
Table 12 not only shows the number of children who have been referred to 
specialists, but also the number of children making multiple visits to the desig- 
nated specialist. This group of one hundred and eighty-seven children includes 
the patients from the Boston Metropolitan Area, all of whose visits to physicians 
are in this group. Also included in this group are a number of patients who 
were referred to specialists for consultation and report, and later for treatment. 
These children were rather unequally distributed among the clinic centers (Table 
13). The largest single group was, of course, that from Metropolitan Boston. 
Four clinic consultants referred a total of twenty-two cases; the other six asked 
for the remaining one hundred and twenty consultations. 
The recommendations of clinic consultants have been surprisingly well ac- 
cepted (Table 14). No special efforts were ever made to induce anyone to 
consent to operation. The risks and the possibility of unsatisfactory results, as 
Acceptance of Recommendations 
Consultation Visits For Diagnosis or Treatment as Referred by Clinic Consultants 
TABLE 12 
NUMBER 
OF VISITS 
MALE 
FEMALE 
TOTAL 
None 
837 
730 
1,567 
1 
66 
31 
97 
2 
31 
21 
52 
3 
11 
6 
17 
4 
5 
2 
7 
5 
2 
1 
3 
6 
1 
1 
7 
2 
2 
8 
1 
1 
10 
2 
2 
11 
1 
1 
12 
1 
1 
16 
1 
1 
18 
1 
1 
68 
1 
1 
171 
960 
794 
1,754 TABLE 13 
29 
Number of Patients Referred by Clinic Consultants to Other Specialists 
CLINIC 
MALE 
FEMALE 
TOTAL 
Brockton 
13 
11 
24 
Fall River 
3 
5 
8 
Gardner 
3 
2 
5 
Greenfield 
1 
1 
Haverhill 
10 
5 
15 
Hyannis 
2 
2 
Lowell 
6 
7 
13 
Metropolitan Boston* 
32 
13 
45 
Northampton 
2 
1 
Pittsfield 
4 
3 
7 
Salem 
8 
3 
11 
Springfield 
19 
5 
24 
Worcester 
21 
9 
30 
TOTAL 
123 
64 
187 
‘Metropolitan patients did not attend clinics. They were seen by several of the clinic consultants at 
their offices, or by other specialists, direct. 
TABLE 14 
Acceptance of Recommendations of Clinic Consultant at Clinic For 
Crippled Children 
HOW ACCEPTED 
ACTIVE 
CLOSED 
TOTAL 
m 
F 
T 
M 
F 
T 
M 
F 
T 
Fully 
446 
388 
834 
392 
319 
711 
838 
707 
1,545 
Partially 
32 
19 
51 
39 
30 
69 
71 
49 
120 
Refused 
7 
7 
14 
44 
31 
75 
51 
38 
89 
total 
485 
414 
899 
475 
380 
855 
960 
794 
1,754 
Well as the possible benefits to be derived from surgical interference, were 
explained to each patient’s family. On the other hand, a parent’s first refusal 
was rarely accepted as final, especially if the chances for improvement in that 
child’s condition were good. Final definite refusal on the part of the parent after 
the clinic consultant and several members of the field staff had repeatedly talked 
with them resulted ordinarily in the discharge of the patient from clinic. Seventy- 
five patients in this category are listed as closed cases as compared with fourteen 
who were still carried on the active list on September 1, 1940 in spite of refusal. 
Those fourteen are being "labored with” in the language of the revivalist. Any 
patient who has been dropped from the active list because of final refusal to 
accept the aid which has been offered may, of course, be readmitted at any 
time that the parent decides to accept aid. Occasionally, in flagrant cases, the 
Society for the Prevention of Cruelty to Children is called upon for aid, which is 
gladly given. A child should not be penalized for life because ignorant parents 
refuse to allow him to have his handicap overcome. 
It is remarkable that so comparatively few refused all aid. That there are not 
more in this group is a tribute to the clinic consultants and to the field workers, 
physiotherapists and social workers alike, who interpret the orthopedists’ recom- 
mendations to the families. Most of the refusals came early in the program; 
they are rare now for the clinics have achieved a well-earned reputation for 
obtaining satisfactory results. 
One cogent reason for this reputation lies in the continuity of the service the 
patients get, once they are accepted. They are examined by the clinic con- 
sultant, who is aided by the clinic supervisor, the physical therapist and the social worker. If physical therapy is prescribed, they see the same physical 
therapist again and again. The same social worker sees them repeatedly at their 
homes and in clinics. When they return to clinics they see the same consultant. 
If an apparatus is ordered, it is fitted by the consultant, who gives full instructions 
concerning its use and who adjusts it as need arises. The physical therapist 
checks on its use, makes any necessary adjustments if she can, or has the patient 
come to clinic for this service. If operation is recommended, the child is ad- 
mitted to hospital, but not merely turned over to a hospital staff. The clinic 
consultant performs the operation, the physical therapist and social worker visit 
the child during the stay in hospital, not to perform any duties necessarily, 
since the child is under hospital jurisdiction, but to show personal interest and 
to assist the child or the family. A very striking result of this careful, kindly 
follow-up care is the attitude of patients in the clinic sessions. A child on its 
first visit is often apprehensive and worried, and manifests its emotions by 
crying and by resisting the examination. On subsequent visits the contrast in 
the child’s demeanor is striking, except in the case of the permanently un- 
cooperative child, of whom there are fortunately not many. 
30 
The diagnoses of children admitted to service during the first five years are 
classified in Table 16. Over a third of all the diagnoses are included under the 
first classification of crippling conditions, those due to prenatal influences. The 
next largest classification, about a fourth of the total, includes the crippling 
conditions resulting from infection. Crippling conditions due to trauma, to 
disorders of metabolism, and to new growths make up still smaller groups. 
Those due to unknown or uncertain causes together with those which are not 
included in a classification which is basically orthopedic, make up the re- 
mainder. Some of the children, of course, had several crippling conditions each. 
In this study only the most important crippling condition in each child was 
recorded so the number of diagnoses is the same as the number of children 
admitted to service. 
Classification of Crippling Condition by Diagnosis 
TABLE 15 
I. CRIPPLING CONDITIONS DUE TO PRENATAL INFLUENCES 
Congenital absence of a part 
18 
Cerebral spastic paralysis 
188 
Cleft palate and/or harelip 
51 
Congenital deformity 
58 
Congenital dislocation 
32 
Obstetrical paralysis 
98 
Spina bifida 
20 
Clubfoot 
43 
Torticollis, congenital 
37 
Miscellaneous 
58 
Total 
603 
II. CRIPPLING CONDITIONS DUE TO INFECTIONS 
Arthritis 
64 
Osteomyelitis 
37 
Subacute anterior poliomyelitis 
24 
Residual paralysis of anterior poliomyelitis 
317 
Miscellaneous 
13 
Total 
455 
Diagnosis of Children Admitted to Services For Crippled Children A physical therapist visiting a home for a 
demonstration by the mother of the progress 
she has made. III. 
CRIPPLING CONDITIONS DUE TO TRAUMA OR PHYSICAL AGENTS 
Amputations due to accidents and to other causes 26 
Cicatrices and contractures due to bums and other trauma 56 
Miscellaneous 5 7 
Total 
139 
IV. 
DISORDERS OF METABOLISM, GROWTH OR NUTRITION 
Deformity due to rickets 
Bone changes, abnormal growth 
36 
X 
Total 
57 
V. 
CRIPPLING CONDITIONS DUE TO NEW GROWTHS 
Miscellaneous 
13 
Total 
13 
VI. 
CRIPPLING CONDITIONS DUE TO ALL OTHER CAUSES, INCLUDING 
UNKNOWN OR UNCERTAIN CAUSES 
Flat foot (Axed, postural and spastic) 70 
Progressive muscular dystrophy 24 
Scoliosis 180 
Legg-Perthes’ Disease 11 
Miscellaneous 22 
1 j 
1 
Total 
307 
VII. 
MISCELLANEOUS CONDITIONS 
Strabismus 
Mental diseases 
Neurological disorders 
No crippling condition within definition 
Miscellaneous 
Total 
59 
18 
31 
32 
20 
180 
TOTAL NUMBER OF PATIENTS ADMITTED TO SERVICE 
1,734 
31 
Crippling Conditions Found in Clinics; Per Cent of Total, in Each Clinic 
TABLE 16 
Clinic 
Per Cent 
Due to 
Prenatal 
Influences 
Per Cent 
Due to 
Infection 
Per Cent 
Due to 
Physical 
Agents 
Per Cent Per Cent Per Cent 
Due to Due to Due to 
Disorders of All Other Miscellaneous 
Metabolism Causes Conditions 
Brockton 
11.3 
9.7 
17.3 
3.6 
18.2 
13.1 
Fall River 
8.2 
7. 
10.8 
31. 
6.5 
5.4 
Gardner 
11.6 
7.2 
8.6 
5. 
5.9 
3.6 
Haverhill 
7.8 
8.8 
5. 
5.7 
4.8 
Hyannis 
5.8 
6.8 
6.5 
8.6 
11.1 
11.2 
Lowell 
9. 
12.6 
7.9 
19. 
10.1 
10.7 
Metropolitan Boston 
2. 
.6 
7.2 
.3 
11.3 
Pittsfield 
6. 
7.7 
3.6 
6.9 
5.4 
Salem 
11.6 
16.2 
7.2 
6.9 
6.9 
3.6 
Worcester 
17.1 
8.2 
7.2 
12.1 
8.2 
17.9 
Connecticut Valley 
14.6 
15.2 
18.7 
13.8 
20.7 
13. 
total 
100. 
100. 
100. 
100. 
100. 
100. 
The first question that might be asked is whether these crippling conditions 
were seen equally in the ten clinic centers or whether certain conditions were 
more common in one clinic center or another. Table 16 presents evidence that 
the distribution is a normal one, for each group of crippling conditions listed 
in Table 15 is fairly equally divided among the clinic centers. For instance, of 
the six hundred and three patients whose crippling conditions were due to 
prenatal influences (Column 2 of Table 16), Brockton had 11.3 per cent, 
Gardner 11.6 per cent, etc. Other crippling conditions are similarly analyzed 
in the other columns. In no instance, except Fall River (Column 5), is the 
deviation from the mean statistically significant and in this instance we are 
dealing with a much smaller number, there being only fifty-seven in this classi- 
fication (Table 15). Table 16 does not take into consideration the variation in 
the total number of children admitted to the respective clinic centers. Had the 
figures been thus weighted the distribution would be even better. For instance. Pittsfield, the smallest clinic center in point of admissions to service, had only six 
per cent of the patients whose crippling conditions were due to prenatal in- 
fluences (Column 2), while the Connecticut Valley clinic center, more than 
twice as large, had 14.6 per cent. The patients from the Boston Metropolitan 
Area are, for reasons heretofore given, not compared with the clinic centers. 
32 
Age of Crippled Children at Time of Admission to Service 
The age distribution of these classifications (Table 17) is interesting in two 
respects: first, because it differs so widely from the figures which are given in 
Table 6 in Children’s Bureau Publication No. 258. The figures in the latter 
table are for children on State Registers and not for those actually being cared 
for by Services for Crippled Children. The Massachusetts State Register figures 
which are included in the Children’s Bureau summary are incomplete in many 
TABLE 17 
AGE 
GROUP 
DUE TO 
0-4 
5-9 
10-14 
15-20 
21 
TOTAL 
Prenatal Influences 
147 
145 
162 
141 
8 
603 
Infections 
32 
65 
135 
194 
29 
455 
Trauma or Physical Agents 
9 
21 
44 
61 
4 
139 
Disorders of Metabolism, 
Growth or Nutrition 
37 
14 
3 
3 
57 
New Growths 
4 
4 
3 
2 
13 
Other Orthopedic Causes 
30 
77 
97 
100 
3 
307 
All Others 
37 
59 
47 
34 
3 
180 
TOTAL 
296 
385 
491 
535 
47 
1.754 
Age on Admission to Clinic 
respects and probably do not give a true picture of the age distribution of 
crippled children in the Commonwealth. In the Bureau publication it is shown 
that less than 0.5 per cent of the children on the Massachusetts Register are 
under one year of age and only 5.0 per cent between one and five years of age. 
Table 17, Column 1 shows that two hundred ninety-six, or 17 per cent of the 
children admitted for care were under five years of age at time of admission. 
The difference is not so great in the case of the next older group, five to nine, 
where Publication No. 258 lists 15 per cent on the Massachusetts Register, while 
the proportion of patients in that age group actually under care in Massachusetts 
is 22 per cent. The difference is discussed here because the Publication comments 
on Massachusetts being lowest in the proportion of crippled children under the 
age of ten. The reverse is, of course, the case for children from ten to twenty-one 
years of age. 
Table 17 is interesting for a second reason. When Table 8 was commented 
upon, attention was called to the fact that more sixteen year old children than 
any others were admitted to service. One expects crippling conditions due to 
infections, to trauma and to some other orthopedic causes to be found in 
increasing numbers the older the child, but one is somewhat surprised to note 
that this is also true, at least insofar as applying for admission to clinic is 
concerned, in crippling conditions due to prenatal influences. The age at which 
the patients in the last-named group come to clinic most frequently is ten to 
fourteen. As this classification (prenatal influence) is considerably the largest, it 
has much weight in defining the mode in the age distribution. However, Services for Crippled Children in the Department of Public Health had been in existence 
only four years when these figures were tabulated and many of these children, 
particularly those living in rural areas, had had no opportunity to get aid earlier in 
life. Studies in future years will probably show changes in age distribution since 
the trend is for those children whose crippling conditions are due to prenatal 
influences to come to clinic earlier in life. 
33 
A study of the crippling conditions due to prenatal influences (Table 18) 
reveals the fact that all but fifty-eight of the six hundred and three children 
included in this classification may be grouped under nine broad diagnoses. 
There is nothing noteworthy about the first group (congenital absence of a part) 
except the preponderance of males and the fact that two-thirds of them lacked 
a forearm or parts of it. In the second group there were one hundred eighty- 
eight children uniformly distributed among the clinic centers whose crippling 
condition was due to cerebral spastic paralysis. Slightly more than half of these 
children had been discharged from active care before September 1, 1940 because 
orthopedic surgery had nothing more to offer them. The new program for the 
relief of these sufferers, which the Department plans to institute, should be of 
great benefit to these unfortunates. The third group includes seven patients with 
harelip, twenty-eight with cleft palate and sixteen with both. The congenital 
deformities making up the fourth group were of all types. Twenty-nine of the 
congenital dislocations (fifth group) were of the hip, and of these, twenty were 
in girls and five were double dislocations. Five of the ten clinic centers had 
seventy-one of the ninety-eight patients with obstetrical paralysis who make up 
the sixth group but, even so, Salem was the only clinic which had a dis- 
proportionate number. That clinic had twenty such cases, eleven per cent of all 
patients admitted to that clinic center. Two-thirds of the ninety-eight cases were 
of the whole arm type. Thirty-five of the forty-three clubfoot cases (the seventh 
group) were boys and less than half of these patients came to clinic younger than 
the age of four years. One child had both clubfeet and clubhands. There is 
nothing noteworthy about the twenty cases of spina bifida and thirty-seven of 
torticollis which were admitted. 
Crippling Conditions Due to Prenatal Influences 
TABLE 18 
Age and Sex of Children Admitted 
Because of Certain Conditions Due to Prenatal Influences 
0-4 
5-9 
MALE 
10-14 15-20 
21 
0-4 
5-9 
FEMALE 
10-14 15-20 
21 
Total 
Congenital absence of a part 
1 
6 
4 
4 
1 
2 
18 
Cerebral spastic paralysis 
20 
19 
26 
38 
2 
13 
19 
24 
25 
2 
188 
Cleft palate and/or harelip 
18 
2 
9 
6 
9 
4 
3 
51 
Congenital deformity 
13 
9 
12 
3 
9 
7 
2 
3 
58 
Congenital dislocation 
2 
3 
2 
4 
7 
8 
6 
32 
Obstetrical paralysis 
6 
13 
17 
14 
2 
4 
14 
14 
13 
1 
98 
Spina bifida 
2 
3 
5 
3 
2 
2 
3 
20 
Clubfoot 
17 
7 
5 
6 
2 
3 
1 
2 
43 
Torticollis, congenital 
7 
7 
4 
3 
1 
2 
5 
6 
2 
37 
TOTALS 
86 
69 
82 
76 
5 
46 
62 
62 
54 
3 
545 
All others 
58 
TOTAL 
603 TABLE 19 
34 
Age and Sex of Children Admitted 
Because of Certain Conditions Due to Infections 
0-4 
5-9 
MALE 
10-14 15-20 
21 
0-4 
5-9 
FEMALE 
10-14 15-20 
21 
Total 
Arthritis all forms 
3 
6 
10 
14 
i 
1 
2 
11 
14 
2 
64 
Osteomyelitis 
1 
2 
9 
14 
1 
2 
3 
5 
37 
Acute anterior poliomyelitis 
4 
3 
5 
4 
1 
3 
1 
3 
24 
Chronic anterior poliomyelitis 
10 
31 
52 
78 
13 
11 
15 
38 
57 
12 
317 
TOTALS 
18 
42 
76 
no 
14 
14 
22 
53 
79 
14 
442 
All others 
13 
TOTAL 
455 
The acute anterior poliomyelitis cases enumerated in Table 19 are those for 
whom family physicians asked for consultations in order better to direct the 
after-care during the subacute stage. Half of the chronic poliomyelitis cases 
involved a leg or foot or both. Twenty-five of them were over twenty-one 
years of age and were seen either preliminary to admission to the Lakeville State 
Sanatorium, or afterwards as part of the follow-up care at the request of the 
Division of Tuberculosis of the Department of Public Health, which administers 
the State sanatoria. 
Crippling Conditions Resulting from Infection 
Artificial limbs were generally provided for the children listed in Table 20. 
Almost half of them are boys fifteen to twenty years of age and a large proportion 
of them are residents of the Boston Metropolitan Area. 
Crippling Conditions Due to Trauma 
In Table 21 are listed the chief miscellaneous causes for admission to service. 
That there should be so many cases of deformity due to rickets indicates that 
disorders of metabolism, of growth and of nutrition are not uncommon, especially 
since the fifty-six patients with this disease seen at the clinic were so severe that 
they were orthopedic cases. Eighteen of these patients, a figure which apparently 
is statistically significant, were seen in the Fall River clinic center. 
Admission to Hospitals 
Six hundred and thirty-three patients were admitted to hospital eight hundred 
and eighty-one times during the first four years (Table 22). Thus, over one-third 
of the patients admitted to service required surgical intervention, some of them 
several times. These figures are by no means final for these patients, for of the 
six hundred and thirty-three children hospitalized, four hundred and twenty-eight 
were still under active care on August 31, 1940 and many of them undoubtedly 
will have received further operative treatment before they are discharged. 
Age and Sex of Children Admitted 
Because of Certain Conditions Due to Trauma or Physical Agents 
TABLE 20 
0-4 
5-9 
MALE 
10-14 15-20 
21 
0-4 
5-9 
FEMALE 
15-20 
21 Total 
Amputations due to all causes 
1 
1 
5 
12 
2 
1 
4 
26 
Deformities contractures, 
cicatrices 
4 
9 
4 
10 
1 
1 
7 
12 
8 
56 
TOTALS 
5 
10 
9 
22 
3 
1 
7 
13 
12 
82 
All Others 
57 
TOTAL 
139 i 
iff 
o fi „ 
ill 
•J si 
nil 
»§« 
2? o < 
! » | 
- i ~ \ % 
I 2 5 8 s 
ills! TABLE 21 
35 
Age and Sex of Children Admitted 
Because of Crippling Conditions Due to Miscellaneous Causes 
0-4 
5-9 
MALE 
10-14 15-20 
21 
0-4 
5-9 
FEMALE 
10-14 15-20 
21 
Total 
Deformity due to rickets 
20 
7 
1 
18 
6 
3 
1 
56 
Flatfoot 
12 
17 
9 
8 
7 
5 
7 
5 
70 
Progressive muscular dystrophy 
1 
5 
10 
1 
1 
1 
3 
2 
24 
Scoliosis 
2 
24 
16 
21 
1 
15 
45 
53 
3 
180 
Legg-Perthes’ disease 
8 
1 
1 
1 
11 
Stabismus 
4 
16 
13 
5 
1 
1 
11 
5 
3 
59 
TOTALS 
39 
77 
49 
37 
1 
28 
39 
63 
64 
3 
400 
All others 
157 
TOTALS 
557 
Proportion of Children in Respective Clinics Requiring Surgical Treatment 
(including Lakeville) 
TABLE 22 
Patients 
Admitted to 
Care Through 
8-31-40 
Patients 
Hospitalized 
Up to 
8-31-40 
Total 
Numer of 
Admissions 
to Hospital 
Per Cent 
of 
Patients 
Hospitalized 
Brockton 
218 
62 
83 
28 
Fall River 
144 
55 
94 
38 
Gardner 
151 
45 
66 
30 
Haverhill 
121 
50 
65 
41 
Hyannis 
137 
42 
60 
31 
Lowell 
182 
75 
112 
41 
Connecticut Valley 
280 
86 
105 
31 
Pittsfield 
108 
62 
93 
57 
Salem 
185 
49 
64 
26 
Worcester 
183 
82 
109 
45 
Metropolitan Boston 
45 
25 
30 
55 
TOTAL 
1,754 
633 
881 
36 
The most interesting point brought out by Table 22 is the distribution of 
surgical cases among the clinic centers. Table 16 shows there was a fairly normal 
distribution of crippling conditions among the ten clinic centers, but this is not 
true of the distribution of children who received surgical treatment. The Pitts- 
field clinic center, much the smallest in the number of children admitted to 
service, with only one hundred and eight patients in four years, hospitalized 
fifty-seven per cent of them. Not only that, but these sixty-two patients were 
admitted to hospital ninety-three times. This appears to be statistically significant. 
Another striking feature of the hospitalization statistics for this clinic is that of 
the one hundred and eight patients admitted, sixty-nine had been discharged 
before August 31, 1940, leaving only thirty-nine still on the active list. Of the 
sixty-nine that had been discharged, thirty-two had never been hospitalized and 
the others (thirty-seven) had been hospitalized fifty-six times. Although these 
patients had been discharged from the active list comparatively soon after opera- 
tion, the field worker in that clinic district visits them for follow-up care 
whenever her itinerary takes her near enough. 
The Connecticut Valley clinic center, the largest in number of patients, 
hospitalized less than the average proportion. The three clinic centers next in 
size, each with a little over one hundred and eighty admissions, varied much in 
their respective hospitalization figures. Of these three, Worcester hospitalized 
forty-five per cent, Lowell forty-one per cent, and Salem was lowest of all the 
clinic centers with but twenty-five per cent hospitalized. The patients from the Boston Metropolitan Area are included in the table, but 
this group obviously is not comparable to clinic groups. The mere fact that a 
patient from this area was accepted generally meant that the treatment he required 
was extensive. 
36 
Four hundred and sixty-seven children had single admissions to hospital and 
of these over three hundred were still under active care on August 31, 1940. 
The children with multiple admissions numbered one hundred and fifty-seven, 
of whom over one hundred were still under active care on September 1, 1940 
with the probability of eventual further hospitalization (Table 23). The dis- 
tribution of multiple hospitalizations among the clinics shows nothing striking 
with one exception, Gardner, which has a relatively large proportion. 
The hospitals to which most of the children were admitted for operation by 
the respective clinic consultants are named in Table 24. This list includes only 
those hospitals which had twenty or more admissions each. There are twelve 
such hospitals besides the Lakeville State Sanatorium. Four of them in the 
Boston Metropolitan Area had two hundred and forty-seven admissions, over 
thirty-six per cent of the total. At first glance this might appear to be in- 
consistent with the established policy of working chiefly in rural areas. As a 
matter of fact, when crippled children are hospitalized a local hospital is used 
whenever possible so that parents may the more easily visit their children. Five 
of the clinic centers are in cities near or in which the respective clinic consultants 
reside. These cities have acceptable hospitals where the clinic consultants do all 
their other operative work and where they have full control over their patients 
and can see them daily, if necessary. In several of the other clinic centers a 
limited amount of local hospitalization is done, but since the respective clinic 
consultants in those clinics have their offices in Boston, it is necessary for them 
to have their most important cases brought to the Boston Metropolitan Area for 
operative treatment. Minor cases are cared for locally, with the aid of authorized 
assistants. Two hospitals, the Cape Cod Hospital and the Brockton Hospital, 
both of which house clinics for crippled children, have never been used for 
hospitalization; but in spite of that, they continue freely to furnish space and 
facilities for clinics. Altogether, including the hospitals grouped under ''mis- 
cellaneous” in Table 24, twenty-three hospitals have received patients from State 
clinics. In each instance the orthopedic patients so hospitalized were under the 
direct supervision of the clinic consultant in charge of the patient. 
TABLE 23 
Multiple Admissions of Patients to Hospital, Including Lakeville 
None 
Act. 
1 
Dis. 
2 
Act 
Dis. 
Act. 
3 
Dis. 
Act. 
4 
Dis. 
5 
Act. Dis. 
6 
Act. Dis. Total 
Brockton 
156 
30 
16 
10 
3 
i 
i 
1 
218 
Fall River 
89 
19 
14 
8 
2 
7 
1 
3 
1 
144 
Gardner 
106 
18 
12 
10 
1 
1 
1 
2 
151 
Haverhill 
71 
33 
8 
4 
1 
2 
2 
121 
Hyannis 
95 
22 
10 
5 
2 
3 
137 
Lowell 
107 
48 
6 
6 
4 
7 
1 
2 
1 182 
Pittsfield 
46 
19 
27 
2 
4 
2 
4 
2 
1 
1 
108 
Salem 
136 
29 
11 
4 
3 
2 
185 
Worcester 
101 
44 
18 
11 
2 
6 
1 
183 
Conn. Valley 
194 
42 
29 
8 
3 
3 
1 
280 
Met. Boston 
20 
5 
16 
1 
2 
1 
45 
TOTAL 
1,121 
309 
167 
69 
25 
31 
10 
15 
2 
3 1 
1 1,754 TABLE 24 
37 
Hospitals to Which Twenty or More Patients Each Were Admitted 
Under 
Active Care 
9-1-40 
Discharged 
Before 
9-1-40 
TOTAL 
Lakeville State Sanatorium 
74 
19 
93 
Massachusetts General Hospital, Boston 
44 
27 
71 
Children’s Hospital, Boston 
60 
6 
66 
Cambridge Hospital, Cambridge 
St. Luke’s Hospital, Pittsfield 
55 
9 
64 
18 
34 
52 
Worcester City Hospital, Worcester 
38 
12 
50 
Massachusetts Eye & Bar Infirmary, Boston 
11 
35 
St. John’s Hospital, Lowell 
37 
7 
44 
Wesson Memorial Hospital, Springfield 
25 
19 
44 
Henry Heywood Memorial Hospital, Gardner 
24 
11 
35 
Union Hospital, Fall River 
22 
11 
33 
Salem Hospital, Salem 
19 
12 
31 
Cooley Dickinson Hospital, Northampton 
17 
3 
20 
Miscellaneous 
25 
6 
31 
TOTAL 
469 
211 
680 
Admissions to two or more hospitals 
Admissions to two or more hospitals one of 
30 
2 
32 
which was Lakeville 
11 
4 
15 
Total Multiple Admissions 
41 
6 
47 
TOTAL CHILDREN HOSPITALIZED 
428 
205 
633 
Length of Hospitalization 
Table 25 summarizes a study of the length of hospitalization of five hundred 
and forty patients admitted seven hundred and eighty-eight times to hospitals. 
One notes in the second column that the total number of days spent in hospital 
by patients from the respective clinic centers varies enormously, from seven 
hundred and twenty-nine in the case of Salem to two thousand nine hundred and 
thirty-six in the case of Worcester. This wide variation is not significant in 
itself since several factors must be considered; nevertheless Salem, a clinic center 
high on the list in the total number of patients admitted, is lowest in days of 
hospitalization. The ninety-three admissions to the Lakeville State Sanatorium 
are not included in this table. 
In every clinic center the median number of days in hospital per patient 
hospitalized is less than the average number of days spent in hospital by each 
patient. This indicates that all clinic centers had their share of patients who 
required long or repeated hospitalizations. Two clinic centers (Fall River and 
Haverhill) are conspicuous in this respect because each shows a long hospitaliza- 
tion per patient, almost sixty days. Here again the Salem center is low, but three 
other centers are at about the same level. 
If, however, one takes multiple admissions into consideration and computes 
the average duration of each hospitalization, there is a different grouping of 
clinic centers. The average duration of each hospitalization is, of course, lower, 
varying from fifteen to forty with a general average of twenty-three days. The 
Hyannis Clinic has much the highest average; in fact, with its figure of forty it 
is the only one with an average stay in hospital per admission of more than 
thirty days. Three clinics are grouped near thirty, and the other five are between 
fifteen and twenty. TABLE 25 
38 
Days Spent in Hospital by Patients From Respective Clinics 
Days 
Spent 
in 
Hospital 
Patients 
Hospitalized 
Up to 
9-1-40 
Median 
Number of 
Days in 
Hospital 
Per Patient 
Average 
Number of 
Days in 
Hospital 
Per Patient 
Total 
Number of 
Admissions 
to Hospital 
Average 
Days in 
Hospital 
Per 
Admission 
Brockton 
1,460 
50 
16 
29.2 
71 
20.6 
hall Kiver 
2,416 
42 
40 
57.5 
81 
29.8 
Gardner 
928 
41 
12 
22.6 
62 
15. 
Haverhill 
1,573 
38 
28 
41.4 
53 
30. 
Hyannis 
2,029 
34 
21 
59.7 
52 
40. 
Lowell 
1,655 
68 
17 
24.3 
105 
16. 
Metropolitan Boston 
543 
24 
8 
22.6 
29 
19. 
Connecticut Valley 
1,807 
85 
16 
21.3 
104 
17.4 
Pittsfield 
2,411 
55 
29 
43.8 
86 
28. 
Salem 
729 
31 
9 
23.5 
46 
16. 
Worcester 
2,936 
72 
26 
40.8 
99 
30. 
TOTAL 
18,487 
540 
17 
34. 
788 
23. 
The reason for treating the ninety-three Lakeville admissions separately is 
obvious when one studies the figures. The ninety-three poliomyelitis patients 
transferred there had spent 19,409 days in that hospital by August 31, 1940 as 
compared with 18,487 days for the five hundred and forty clinic patients who had 
been admitted to the other hospitals (Table 25). As shown in Table 24, 
seventy-four of the ninety-three patients were still under care in the Lakeville 
State Sanatorium on September 1, 1940. The median number of days in hospital 
per patient at Lakeville up to August 31, 1940 was one hundred and thirty-eight 
as compared with seventeen in the other hospitals; the average was two hundred 
and nine days as compared with thirty-four. The policy of Services for Crippled 
Children is to send to Lakeville as many as possible of its patients who are 
paralyzed from anterior poliomyelitis and obviously the ones allocated for 
transfer to Lakeville are those requiring the most treatment. Patients with bone 
and joint tuberculosis are not accepted at the clinic centers but are admitted 
directly to Lakeville on application of the family physician. Table 15, it will 
be noted, included no tuberculosis among the crippling conditions found in 
patients accepted for care by the Orthopedic Unit. 
Table 26 summarizes admissions to other hospitals than the Lakeville State 
Sanatorium. In this table patients are recorded by sex as well as by their status 
(active or discharged) on September 1, 1940. The sex ratio of admissions to 
hospital is 1.28, not significantly greater than the ratio in the case of admis- 
sions to the clinics if one takes into account that of the ninety-three children 
transferred to the Lakeville State Sanatorium, sixty-one were boys and thirty- 
two were girls. This disparity was probably a matter of availability of 
beds in male or female wards at Lakeville. It was frequently not possible 
earlier in the program because of lack of beds to admit patients to Lakeville as 
soon as desired, hence many poliomyelitis cases were hospitalized elsewhere. 
One patient was hospitalized as many as six different times. Four patients 
were in hospital five times each and seventeen others were admitted four times 
each. One hundred and thirty-five had two or three admissions each. Fre- 
quently the interval between admissions was short, but parents were reassured TABLE 26 
39 
Number of Admissions to Hospitals of Children Hospitalized 
(exclusive of Lakeville) 
Number of 
Admissions 
to Hospital 
of 
Each Child 
Under 
Active 
Care 
9-1-40 
Discharged 
From Active 
Care Before 
9-1-40 
TOTAL 
Total 
Number of 
Hospital 
Admissions 
M 
F 
T 
M F 
T 
M 
F 
T 
TOTAL 
None 
240 
231 
471 
356 294 
650 
596 
525 1 
,121 
1 
131 
104 
235 
85 63 
148 
216 
167 
383 
383 
2 
45 
24 
69 
11 14 
25 
56 
38 
94 
188 
3 
15 
17 
32 
6 3 
9 
21 
20 
41 
123 
4 
5 
9 
14 
2 1 
3 
7 
10 
17 
68 
5 
2 
1 
3 
1 
1 
3 
1 
4 
20 
6 
1 
1 
1 
1 
6 
TOTAL 
438 
387 
825 
461 375 
836 
899 
762 1,661 
788 
when they could have their children at home occasionally, even for short periods. 
In addition, there was considerable saving in hospital costs, not a disadvantage 
when a budget is being stretched to do as much good to as many people as 
possible. 
Only thirty-five of the one thousand seven hundred and fifty-four children 
had to be admitted to convalescent homes during the first four years of Services 
for Crippled Children. Of these thirty-five, thirty were boys, one of whom 
was admitted twice. Such admissions were necessary because of the unsuitability 
of the homes of these children or because nursing care was needed. Ordinarily, 
with the aid of the after-care given by the members of the field staff and the 
local nurses who assist, patients’ homes are satisfactory for convalescence after 
hospitalization. The parents naturally have been pleased with this method of 
taking care of convalescent patients. Whenever it was necessary to provide 
convalescent care every effort was made to find a satisfactory place near the 
patient’s home but unfortunately a suitable home so located was not always 
available. 
Care in Convalescent Homes 
The most frequently used convalescent home is that maintained by the Chil- 
dren’s Hospital in Boston where twelve of the thirty-five patients given con- 
valescent care were provided for. Those twelve children had all been patients 
in the Children’s Hospital so there was no interruption in the continuity of their 
treatment during the period of transition from hospital to convalescent home. 
The others given convalescent care were equally distributed among thirteen 
convalescent homes and three foster homes. (Foster homes are grouped here 
with convalescent homes not with any idea that these terms are synonymous, but 
because this type of care is so rarely necessary that separate classification is not 
worthwhile.) One hospital outside the Boston Metropolitan Area, when the 
condition of the patient was such that hospital care was no longer needed and 
a nearby convalescent home was sought, asked to have the patient remain in 
hospital at the same cost that a convalescent home would have been. This 
occurred twice and was, of course, entirely satisfactory. 
The number of days spent in convalescent homes by the thirty-five patients 
was four thousand two hundred and forty-seven. The median length of stay 
per admission was eighty-three days; the average one hundred eighteen days. Children at these homes except those at the Children’s Hospital Convalescent 
Home are always under the active supervision of the members of the field 
staff of Services for Crippled Children. 
40 
Reasons for Discharge from Care 
The reasons for discharge from service of those children who had been 
admitted to clinics but who were removed from the active list before September 
1, 1940 are listed in Table 27. The largest group, one-fourth of those dis- 
charged, is made up of children whose crippling condition had been terminated. 
These children number about one-eighth of the total number admitted to 
service during the four year period. Taking into consideration the fact that 
the treatment of crippling conditions, including after-care, is long in duration 
and that the number of admissions on which this proportion is based represents 
admissions during the entire period of four years, this result seem commend- 
able. Too much praise can not be given the clinic consultants who are entirely 
responsible for the success of the program in removing or alleviating the 
crippling conditions of the patients who have been admitted to service. They 
have served faithfully, conscientiously, and wholeheartedly and the professional 
skill which they have demonstrated over and over again is entirely out of 
proportion to the nominal remuneration which they receive. The Department 
of Public Health is responsible for the administration of the program, but such 
has been a comparatively simple task. All the personnel assisting the Chief 
of the Orthopedic Unit, administrative as well as professional, have rendered 
services of the highest quality so that the task of the Chief of the Unit is 
a gratifying and pleasant one. 
For one hundred and fifty-nine of those discharged, no further treatment 
could be recommended. Though this decision was sometimes made at the 
time of the first clinic visit, it was more often made after some attempts to 
afford at least partial relief from the crippling condition even when it was 
obvious from the start that the basic condition was hopeless. 
One hundred and twenty-five patients were discharged because they were 
uncooperative. This includes the seventy-five classified in Table 14 as refusing 
to accept the recommendations of the clinic consultant. In the table, sixty-nine 
were classified as partially accepting the recommendations. Some of these 
had to be discharged later because of lack of cooperation, after a certain 
amount of work had been done for them. Experience has shown it to be a 
waste of time to try to help people who are indifferent or only slightly attentive 
at follow-up visits and who show no evidence of having tried to cooperate 
either by taking recommended exercises or by wearing the apparatus provided. 
Most people of this type, though appearing surprisingly often at clinics (one 
hundred and twenty-six out of one thousand seven hundred and fifty-four), are 
fortunately not a serious problem. Generally, they are persons of so low a 
mental level that the difficulties in transforming them into self-respecting, self- 
supporting individuals are insurmountable. 
Another large group in Table 27 includes those who, at their first clinic visit, were obviously not eligible for admission to Services for Crippled Children. 
These children were discharged after one or two visits, but they were not 
merely refused care and sent home. Once having been admitted to a clinic 
center a child is regarded as a responsibility and if Services for Crippled Children 
can not itself be of help the child is referred to another agency, if one exists, 
which can help. 
41 
TABLE 27 
REASON FOR DISCHARGE 
MALE 
FEMALE 
TOTAL 
Reached age of twenty-one 
40 
39 
79 
Uncooperative 
71 
55 
126 
No further treatment recommended 
102 
57 
159 
Crippling condition terminated 
102 
106 
208 
Not a clinic case 
78 
67 
145 
(Not included in definition of a crippled child) 
Admitted to state school 
15 
4 
19 
Referred to another clinic 
45 
34 
79 
Moved out of state 
15 
10 
25 
Deceased 
2 
7 
9 
Application rejected 
5 
1 
6 
TOTAL 
475 
380 
855 
Reason for Discharge From Active Care Prior to 9-1-40 
Seventy-nine patients reached the age of twenty-one and were then auto- 
matically dropped. A similar number were referred to another clinic, either 
because they were on the active list of the other clinic at the time of the first 
clinic visit or because, for one reason or another, the patient or his family 
preferred to be cared for by some other agency. The Department of Public 
Health has always been meticulously careful to avoid taking someone’s else 
patient, for the policy of the Department is to help only those who can not 
get help elsewhere. 
Only six patients who applied were refused admission to service. In each 
instance the estimate of the cost of the required treatment was low and investiga- 
tion showed that the parents were well able to provide the necessary care. 
Except in one case these applications were rejected by the Department of Public 
Health without even referring them to the Committee Chairman of the District 
Medical Society. 
Finally, in a statistical study of the results accomplished in four years of 
operation of Services for Crippled Children, one should make some estimate 
of what has been accomplished in terms of the condition of the patient him- 
self. Table 28 attempts to give expression to this judgment. Over half of 
those discharged were benefited and almost all of those still on the active list 
on September 1, 1940 had received improvement. The few who had not 
were generally recent admissions. At any rate, there is still hope for them 
or they would not be retained for active care. 
Expenditures under the Federal Grant-in-Aid 
Table 29 summarizes the expenditures of the Grant-in-Aid, under Part 2, 
Title V of the Social Security Act during the respective federal fiscal years 
since the program began. Matching funds, which each state must appropriate, 
are provided in Massachusetts mainly by the expenditures at the Lakeville State 
Sanatorium for the children hospitalized there. These are much greater than 
is necessary to obtain the greatest possible allotment from the Children’s Bureau. TABLE 28 
42 
CONDITION OF 
PATIENT 
ACTIVE 
CLOSED 
TOTAL 
M 
F 
T 
M F 
T 
M 
F 
T 
Improved 
Unimproved 
452 
33 
388 
26 
840 
59 
250 194 
225 186 
444 
411 
702 
258 
582 
212 
1,284 
470 
TOTAL 
485 
414 
899 
475 380 
855 
960 
794 
1,754 
Condition of Patient 9-1-40, or at Time of Discharge From Care 
1936 
1937 
1938 
1939 
1940 
1941 
TOTAL 
Salaries and fees 
Travel, purchase and maintenance of cars 
Hospital care 
Colanvescent care 
Appliances 
Other expenses 
2713.75 
222,315.98 
8,029.58 
9,771.93 
5,177.41 
784.04 
4,796.24 
241,029.64 
10,529.36 
14,346.34 
4,290.72 
2,505.71 
7,600.08 
244,097.34 
13,214.88 
2^2,094.40 
1,486.26 
3,517.32 
9,628.23 
246,091.92 
5,547.25 
26,881.15 
1,985.15 
3,166.83 
5,191.96 
248,690.27 
7,601.37 
27,084.91 
3,371.71 
3,858.61 
2,868.00 
2202,225.15 
44,922.44 
100,178.73 
16.311.25 
13,832.51 
30.798.26 
TOTAL 
2713.75 
250,875.18 
280,301.85 
294,038.43 
288,864.26 
293,474.87 
2408,268.34 
Expenditure by the Orthopedic Unit of the Federal Grant-in-Aid For Services For 
Crippled Children By Federal Fiscal Years 
TABLE 29 The physical therapist leaving a home after giving a treatment. The Department of Public Health pays a state-wide uniform rate of $3.50 
per day for hospitalization of crippled children. A $10.00 charge is permitted 
for the use of an operating room. Roentgenograms are paid for at the rate 
of $2.00 each. If there is no anesthetist on the hospital staff, a maximum fee 
of $10.00 is paid for this service. When plaster dressings are applied, the 
actual materials used are paid for. If expensive medication is prescribed, the 
Department pays this charge. Maintenance in convalescent homes is paid for 
at $1,00 to $2,00 per day according to the particular needs of the patient. 
43 
During the five years of Services for Crippled Children, nine hundred and 
sixty-two appliances have been purchased for the children admitted to care. 
These varied from minor shoe adjustments to artificial limbs. Some of these 
were paid for in part by the patient’s family or by a local welfare agency. 
Patients were encouraged to pay for minor appliances themselves, and they 
gladly did so when financially able. It is only for the neediest that the more 
inexpensive items are purchased by the Department. 
Besides the maintenance of the Central Office and the Field Staff of the 
Orthopedic Unit, funds made available by this Grant-in-Aid are used to im- 
prove and extend the work of the Lakeville State Sanatorium. The employment 
of a supervisor of physiotherapy, two physiotherapists and a bracemaker is 
included in this aid. An othopedic surgeon, whose consultation fees are paid 
by means of this Grant-in-Aid, visits the Sanatorium regularly to perform the 
orthopedic surgery required by the victims of the paralysis of anterior polio- 
myelitis. A roentgenologist also makes periodic visits. In addition to these 
personal services, funds obtained through this Grant-in-Aid have been used 
to equip an excellent brace shop and to purchase two respirators as well as 
other valuable apparatus used in the medical and surgical care of patients. 
It is quite evident from Figure 4 that there is continued need in Massa- 
chusetts for State Services for Crippled Children. On September 1, 1940 there 
were almost one hundred towns with a total population of 160,000 from which 
no crippled child had yet been admitted to a State clinic. The other towns 
outside the Boston Metropolitan Area have sent to the clinics an average of 4.5 
crippled children each per thousand of children in the population under the 
age of twenty-one. Seventy-eight of these towns have each, however, sent 
less than two per thousand. Many of the towns which have high admission 
rates have small populations so that the admission rates have large standard 
deviations. It is not at all likely that it will ever be possible to locate as many 
crippled children in need of aid in other parts of the Commonwealth as have 
been found in Dukes County (Martha’s Vineyard) and Barnstable County 
(Cape Cod), where respectively 8.5 and 10.9 crippled children per thousand 
of children in the population have been admitted to service. Nevertheless, it 
is reasonable to assume that there are crippled children who are in need of 
care in many of the rural towns from which no patients have yet been admitted, 
and the Orthopedic Unit of the Department of Public Health plans to make 
special efforts to locate them so that they may be offered whatever help they 
need.