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

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

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

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

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

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

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

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

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

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