excellent arrangement at Sea Breeze Hospital at Coney Island, N. Y., for outdoor teaching during about half the year. From early spring until late in the fall the school classes there are held in a tent with wooden floor and board walls about 3 feet high. The walls are completed above that height by screens and canvas which may be dropped in case of rain.

Outdoor classes v. open windows.-The importance of fresh air for crippled children, especially for those with bone tuberculosis, can not be overemphasized. But there are differences of opinion as to the best methods for obtaining the fresh air. At the meeting of the Federation of Associations for Cripples in New York City in April, 1913, there was a discussion of outdoor schoolrooms and schoolrooms where windows are kept open in winter, which brought out sharp differences of opinion as to whether or not cold temperatures have a bad effect upon the children's physical condition. Many of the physicians seemed to agree that cold in itself was never harmful if the children were warmly dressed and had plenty of good food. But many physicians advise a reasonable degree of warmth in schoolrooms, especially those used by crippled children who have bone tuberculosis, and advocate schoolrooms with plenty of window space rather than outdoor rooms where little or no heat is provided. Better progress is usually made educationally when the children are warm enough to avoid the need of heavy wraps and are able to use their hands for writing.

It must not be forgotten that the effect upon the children's health can not be foretold from a knowledge of the mere facilities for securing fresh air unless one knows also how those facilities are used. An apparently old-fashioned building may be well ventilated if the individual teachers see to it that windows are lowered from the top and raised from the bottom in sufficient measure to obtain a good supply of fresh air. On the other hand, a room with the most approved movable walls will not have good air if these be not removed during the school sessions. The Crippled Children's East Side Free School of New York is noteworthy among day schools because its windows are actually kept open throughout the year. The fresh air and the nourishing food which are desirable for all children have been discussed here because they are specially needed by crippled children. These children need also much special attention for their health which is not necessary for other children.

SURGICAL AND MEDICAL SUPERVISION.

Most of the crippled children attending public school classes for cripples are or should be under the supervision of an orthopedic surgeon; they should report frequently at the hospital dispensary, where their surgeon can examine them. The relation of the school

to the surgical and medical treatment of the crippled children varies widely in the different cities.

At one extreme, the Crippled Children's East Side Free School in New York, at the expense of a private organization, offers to the children taught by public-school teachers in that building practically all phases of surgical and medical care for their orthopedic difficulties except operations requiring an anesthetic. A visiting orthopedic surgeon holds weekly clinics at the school building, where an assistant surgeon and a trained nurse assist him in the adjustment of braces, application of plaster dressings, and other treatments. Under the supervision of a staff of nurse maids, all the children have baths at the school twice each week. There were 9,703 baths recorded for one school year, and 450 visits were paid to the homes of the children. Philadelphia.—At the other extreme, the public school classes in Philadelphia have no orthopedic surgeons of their own and no nurses with special orthopedic training. This does not mean that the children in the Philadelphia classes are less well looked after from a medical point of view than those in other public schools. The difference is simply one of organization. Philadelphia is noted for its many fine hospitals, and the schools cooperate with the social service departments in the various hospitals. The school nurse has general supervision of the cripples, as of other children, and a matron is provided in each school where there are cripples to superintend the serving of their lunches and to act as attendant for children who can not go from one room to another without some help.

In all the six cities with public school classes for cripples, the children are either inspected by an orthopedic surgeon at the school or urged to attend the hospital dispensaries. A nurse or matron is sometimes present in the classroom all the time that the children are there; in other schools a trained nurse with special knowledge of orthopedics gives part of her time to work at the school and part of her time to visiting the children in their homes. Special gymnastic exercises adapted to crippled children are given in most of the classes, sometimes by the class teachers and sometimes by special teachers of gymnastics. There are so many differences between the detailed. methods used in different cities that we shall state here briefly the system of medical supervision in each city.

New York.-The City of New York has had since 1907 a special supervising teacher assigned to the classes for cripples by the director of physical training for the public schools of the city. Under her supervision the grade teachers have learned to watch carefully the health of their pupils. The physical activities of every child in the special classes for cripples are limited carefully in accordance with the recommendations of special hospital record cards kept at the

school.' These cards were originated by the department of physical training of the public schools of New York in order that each child's orthopedic surgeon himself might state the disease, treatment, and physical care he desired for the child. The cards show the exact nature of the child's disease or deformity and indicate which physical exercises are regarded by the surgeon as desirable, and just what kinds of exercise the child in question must not undertake. The card index also shows whether or not the child should be allowed to climb stairs. These cards are renewed once each year for all pupils who are under hospital supervision and once each term for all cases of bone tuberculosis. They are also renewed after any long absence from school, after any change in a child's brace or cast, and after any surgical operation. Every effort is made to keep the child's record on these hospital cards up to date.

Except at the Crippled Children's East Side Free School, where, as stated before, orthopedic supervision is provided by a private organization, the New York schools do not attempt surgical or medical measures at the schools. It is the endeavor of the schools to cooperate as intelligently as possible with the large orthopedic hospitals in the city whose dispensaries provide adequate supervision for all crippled children. Visiting nurses from these hospitals are largely responsible for seeing to it that the children actually come to the dispensaries when ordered by their surgeons and that directions are carried out by the parents at home. The teachers in the schools have given valuable cooperation in securing the interest of the children and their parents in the child's treatment at the hospital. The Association for the Aid of Crippled Children, a private society, has for many years initiated movements in behalf of crippled children in New York, and has aided great numbers of individuals.

The New York teachers have not only cooperated with the surgeons in charge of children who were already under treatment when they entered the public schools, but they have also persuaded the parents of many children not under treatment to take them to orthopedic dispensaries. The report of the New York schools for 1915-16 states (p. 114) that in some classes for cripples only 10 to 20 per cent of the children were under treatment when the classes were organized. In the same classes there are now 90 to 95 per cent of the children under orthopedic treatment regularly at various clinics. When one class for cripples was organized in Brooklyn, only 15 per cent of the children were receiving medical attention. The superintendent reports (1914-15) that every child in the class is under medical supervision. This cooperation on the part of the teachers should receive special commendation when we remember that it has meant

See appendix, p. 49.

frequent visits on their part to the homes of the children and sometimes to the hospitals in order to arrange for the child's visits to the dispensary.

Within the last two years New York has undertaken the segregation of crippled children with bone tuberculosis into separate classes in all of the school buildings where there are several classes for cripples. Such classes have been organized thus far in six different public schools. These classes are located in large rooms with southern exposure and open window ventilation, with a temperature in winter kept between 50 and 60 degrees. In addition to hot lunches at noon, the children have special feeding, both in the morning and just before starting for their homes in the busses at the close of the school day. The formation of these classes has been followed by very beneficial results. A teacher in one of the classes kept careful records of the children's physical improvement. One month after the formation of the class every child except one had gained in weight. At the end of seven months all had gained in weight except two children. who needed hospital care.

Children are not admitted to the special classes for cripples in New York unless they can walk well enough to look after themselves. It is recognized that there are in a large city like New York many crippled children living at home who are not able to walk but who are mentally bright and would profit by instruction. The superintendent's report for 1915-16 recommends the appointment of special visiting teachers who will be assigned to the instruction of crippled children in their own homes. While awaiting the city's action, the Association of Public School Teachers for Cripples in New York is trying to meet the need by providing volunteer teachers and by appealing for contributions which will enable one or two teachers to give their entire time to the work.

Chicago. The schools for cripples in Chicago have always emphasized strongly the physical care of the children. This is especially true of the larger of the two schools, the Spalding School. The principal of this school states in her report for 1915-16:

The policy of the school is to take in all crippled children who apply, even though the deformity may be very slight, so that advice and assistance may be given parents in obtaining proper treatment. The first aim of the school is to improve the physical condition of the children. The actual school work gives place always to this.

The teachers in the school are required by the board of education to take a special course of study concerning the diseases, treatment, and care of crippled children, and a course in industrial work suited to cripples. They are able to cooperate intelligently with the special teachers who give curative gymnastics to the children.

For many years the children attended daily clinics at the adjoining Home for Destitute Crippled Children, an orthopedic hospital.

An important change has been made during the past year. The entire care of the physical condition of the children has been taken over by the new Municipal Tuberculosis Sanitarium of Chicago, which has enlarged its field in order to care for all the crippled children whether or not the cause of their condition is bone tuberculosis. The sanitarium furnishes to the school a nurse and medical supplies, arranges for operations and treatment, and takes the children. to clinics. Complete files are kept, in which there is a social and physical history of each child. At the Spalding School itself, the children have thorough physical examinations frequently, daily dressing of sinuses, massage and curative gymnastics, and baths for medical purposes. The board of education has recently installed dental equipment at a cost of $500 and the board of health gives the services of a dentist. An oculist from the board of health also visits the school.

Cleveland.-The children who attend the school for cripples in Cleveland were very carefully supervised until a year and a half ago by a visiting nurse with special orthopedic training who was furnished jointly by Lakeside Hospital and Rainbow Cottage, a country convalescent children's hospital. At present the school children are examined only by the regular school nurse, but the former system had some merits so striking that we mention it here, although it is not now in force. The orthopedic nurse represented three links in a chain which offered all kinds of service for crippled children except asylum care. The employment by the three organizations, the hospital, the convalescent hospital, and the public school, of the same nurse or nurses had the very great advantage of permitting the nurse to follow individual children through every period of their care. She usually met a child first at the hospital dispensary. She visited his home and urged the mother to follow out the doctor's orders and to revisit the dispensary at the time set by the doctor. Later, she watched the child's progress at hospital or convalescent hospital. After he was able to leave the institution she visited him at home and at school. She renewed dressings and adjusted braces at the school itself and kept so closely in touch with the child's condition that she was always ready to suggest further hospital treatment if that seemed necessary.

A teacher of physical culture, employed by the board of education, comes to the school three times a week. She gives massage to the paralysis cases and teaches the waitresses to assist her in this work; she also superintends special gymnastic exercises which are conducted by the teachers on days when she is not there.

Detroit.-In Detroit an orthopedic surgeon, appointed by the board of health, examines all children applying for admission to the classes for cripples, and visits the school at intervals to examine the