S occupational therapists we have ex

Aperimented with three outlets for the

products of our work. We have tried giving them away, which is exploiting the patient or the institution or both. We have tried selling them on the sympathy basis, which is exploiting the public under the guise of charity, and we have tried selling them at market value. Aside from the ethical and economic questions involved, the patient's reaction to either of the first two methods has been found unsatisfactory. We have, then, to work out the best method of marketing our product on a commercial basis. To recognize the problem as a commercial one and to solve it on business principles is to subtract the smallest possible amount of time and energy from the therapeutic work of the occupational aide.

The problem becomes especially interesting in tuberculosis sanatoria, where patients remain under treatment for long periods of time and where a wide variety of light occupations makes for the production of comparatively large quantities of articles. Here, also, we have the patient to whom even a slight earning power may mean just the freedom from worry which shall insure an adequately long stay at the Sanatorium and the utmost benefit during that stay. fact that a product is salable seems to have a distinct therapeutic value to the tuberculous patient; a value, however, which may be cancelled in many cases by the overstimulation of sales made directly by the patient to visitors, with the nearly certain accompaniment of order-taking.

The

Craft production in occupational therapy for the tuberculous falls naturally into two general types; novelties and uniques made by the patient requiring the stimulus of creative interest, and standardized articles made in quantity by the patient requiring a more sedative daily routine.

Do not the possible markets divide quite as naturally to meet these two classifications?

Many tuberculosis sanatoria find an annual sale at the County Fair, or for Christmas, a satisfactory outlet for craft products of occupational therapy departments. Such sales help to acquaint the local public with the advantages of sanatorium treatment, espeIcially where the sale is conducted by an influential civic organization whose members will "talk it up," and where the occupational aide is present at the sale to answer questions about the work.

Experience convinces the writer that these local sales are our logical market for articles

produced in very small quantities. Consider the selling as selling. Flan far in advance. What does the public need? What are its interests and fads: Its spending habits? If the community is small we shall be wise to select as occupational therapy projects, in the various crafts suitable to our patients, such articles as will not compete with those in the local shops. Advertise. Send announcements by mail or messenger. Use the sort of posters people will notice and remember, and do not get posters out at too early a date.

Fortunately, a therapeutic use of color in our projects gives us also the colors which attract buyers. Plan a definite proportion and placing of colors, especially if there is to be a window display. Rely upon a few large articles or masses of color to arrest the attention of passers-by; then upon the fitness and correct pricing of many smaller articles for the bulk of the sales. There is no permanent advantage in prices either under or over the market value.

The small commission shop might offer a market akin to these sales.

There has been some question as to the desirability of wholesale production in occupational therapy. Are the questioners sure that as trained craftsmen we have not assumed for the average patient an artistic creative temperament he does not possess? During several years of occupational therapy in tuberculosis sanatoria the writer has worked with many patients who seemed to re-act better to a repetition of one or two model projects than to the constant introduction of new projects.

Large shops, whether buying outright or taking our wares on commission, supply us with a market for the articles we can standardize and produce in quantity. As we perfect the organization of our workers, we may expect a number of small isolated sanatoria to co-operate in the securing and filling of wholesale orders.

This market, also, has its characteristic needs and tastes. Why not cater to them? The successful merchant is ready to say definitely what kind of baskets, toys or other craft objects are salable and at what prices. If we choose wisely, and avoid overestimating our producing ability-in short, if we prove ourselves a dependable source of supply, the merchant not only provides us with a permanent market for our product but offers us valuable advice and suggestions.

To align ourselves with the experience of business people is to solve our marketing problem efficiently whether it be in retail or wholesale form.

I

WAS very much interested in Dr. Emerson's class, and I think what I have to say will be a continuation and elaboration of some of the points which he has brought out in his address.

Before beginning with my subject I want to pay a tribute to the Sociological Section of the National Tuberculosis Association. Four weeks ago there was a little mother in Iowa who was taking care of three little children that had the "flu." The children soon became well again but the mother acquired the disease, which was followed by pulmonary tuberculosis. That little woman was an intelligent woman, she was a college woman; she sat down immediately and wrote to New York asking for literature on the subject of tuberculosis. In a few days the literature arrived, and in the same mail a nice long, personal letter from Miss Drake, the state nurse at Des Moines, showing the wonderful organization of the sociological work of the National Tuberculosis Association. To-day that mother is in a sanatorium and is doing well.

My point of view is not that of the sociologist primarily but that of the scientist. I am going to tell you just a little about the work of our nutrition classes, and then I am going to ask the question: How do normal children grow? We have heard a good deal about standards of growth for underweight children: how do children grow?

In the first place, we have a nutrition class at the University of Iowa for students. It has been our method to have the experts, the various specialists in the different departments of the University, meet that class and take up the special problems. The students take one course. Then we have the pediatrician and the professor of orthopedic surgery, the professor of nutrition, the dean of the dental college, all of the various specialists, come and give their contribution to the course.

We are interested in nutrition in Iowa. The boys and girls in the State of Iowa are taller and heavier on the average than the boys and girls of the United States. They are considerably taller and heavier than the boys and girls of New York State, for example.

*Read before the Sociological Section at the Eighteenth Annual Meeting of the National Tuberculosis Association, Washington, D. C., May 4-6, 1922. This paper was illustrated by lantern slides.

We are interested in tuberculosis. During the past year 8,000 examinations have been made in our laboratories for tuberculosis alone. So my point of view is essentially that of a scientist, who comes to you with an attempt to give some insight into the investigations we are making on the question of how children grow.

You might do a child a very grave injustice to tell him that he is underweight and underheight, unless you are pretty sure of your standards, and unless you are pretty sure of the heredity and the condition under which the child has been living. So we are interested in the normal child and the superior child physically and mentally. We are setting up standards of growth, both mentally and physically.

About twelve years ago I began to investigate the question of how children grow. Since then I have collected data on 2,500 children for a period of ten or twelve years, with some thirty to forty physical traits for each child, making in all about 1,500,000 physical measurements on a limited number (2500) of normal or near-normal and superior children. It is the results of this investigation that I wish to present here today. We demonstrate our problems as far as possible by means of the lantern slides.

(Slide) The first slide is the picture of a boy that we snapped about two years ago, a little boy that was supposed to be normal. He had been to the County Fair and the State Fair in Prize Baby Contests. He was a little heavy for his height. This little boy, since that time, has had tuberculosis, acquired through cow's milk. He has been sleeping out of doors and he is practically well to-day.

(Slide) The next picture gives an illustration of the measuring of the length of a baby. Dr. Emerson has emphasized to-day the relationship between the weight and the height. I am much more interested, to be perfectly frank, in the length of a child than I am in its weight. The weight of the child is one index; it is a sort of thermometer which helps the doctor to understand the present condition of the child. But if you

are to know the future development of the child, if you are to know how tall he should be at a later period and how much he should weigh at a later period, it is much more important to know the length of the child at birth or at some subsequent period

than it is to know simply its weight. We must know the length and the weight both, if we are going to take up the problem of nutrition. We must not only know the weight and the length, but we must also know the age and type of the child.

In the few minutes that I have at my disposal, I am going to try to outline to you briefly first how children grow physically; second, the differences in physiological age of children; third, differences in anatomical age of children; and in the fourth place, the development of breathing capacity or Socalled lung capacity, which has a direct bearing upon the great problem of how we shall eliminate tuberculosis.

This is a simple method of determining the height of this particular child. (Slide) This is a normal girl, a girl whose weight is relatively normal for her height. At the time this picture was taken, she was eleven years of age. She had the height and the weight of a fifteen year old child.

(Slide) Here we have some individual growth curves. The vertical direction indicates the height in inches and centimetres. We make all our measurements in centimetres; but the numbers here 55, and 59, and 62 refer to inches. The divisions along this line indicate the age-seven years, eight years, nine, ten, eleven, twelve, and so on, up to eighteen years. These are the individual growth curves of some girls. The measurements were made on nude children; they were made by specialists in physical measurements or anthropometry. The children have had directed play, physical training and medical inspection, and the individual curves represent the growth in height of a particular child. Number 1 is a tall girl who was 55 inches at eight and a half years of age; and she was tall at twelve years of age, at thirteen, fourteen, fifteen, and so on. She was a pupil at the University of Chicago. Number 11 is the individual growth curve of a short girl, who was very short at eight years of age, short at twelve, short at fifteen, short at eighteen.

Now there are a few basic principles of growth which stand out very distinctly when you look at these curves. The tall children remain tall; short children remain short as a rule. The curves have a railroad appearance. Tall girls complete their growth in stature as a rule at about fourteen and fifteen years

of age.

This girl (indicating) practically stopped growing after fourteen years of age and we now have her records until she is 23 years of age. Short girls continue their growth longer than tall girls. These short girls at fourteen and fifteen and sixteen years of age are still growing in stature.

The point is this: Tall girls begin their rapid adolescent acceleration at an early age -eleven, twelve, or thirteen; tall girls complete within a few centimetres their growth in stature about the time they are fourteen

or fifteen or sixteen. Short girls do not begin to have their adolescent acceleration until they are thirteen or fourteen years of age, and they continue to grow rapidly until ntteen, sixteen or seventeen years of age. The point is, then, that tall children grow differently from short children; and any scale that would measure children by the average of these two would do injustice to both.

If you average those curves, those groups of curves, you are averaging the growth of a child that has completed its growth with the increment of growth of a child that is at its maximum rate of growth. Consequently, we need different standards for tall children and for short children. Tall children begin their adolescent acceleration earlier and finish their growth sooner than short children.

These are the weight curves; you see the weights vary more than the height. However, Number 1 is also the heaviest girl, covering a period of ten years. Number 10 is the lightest girl.

When we look at the boys' curves (Slide) we see the same thing. The boy that is tall at seven will be tall at fourteen and sixteen and eighteen; and the boy that is short at seven as a rule will be short at fourteen, fifteen and sixteen, and so on. The taller boys have their period of adolescent acceleration earlier than the short boys. These boys have almost finished their period of rapid growth, while these other boys are right in the midst of it. Tall boys grow differently from short boys. These taller boys--and the taller girls -are physically older, physically more mature than the shorter, lighter boys and girls. They reach their adolescent periods earlier; they reach their period of adolescent acceleration earlier; they reach their period of final stature earlier.

There are several interesting things that could be discussed in regard to these individual growth curves, and so far as I know no one else has followed the same children, year after year, for periods of five, ten and twelve years. Consequently, these 2500 individual height curves which we have worked out have direct significance in the study of the problem of how children grow. These growth curves are nearly parallel. In other words, if we would match the growth curve of a child at seven with this series of curves, we could tell approximately how tall the child would be at fourteen.

It

Another method is to get the coefficient of correlation. Now, everybody is talking coefficients of correlation, and you no doubt know a great deal about the methods. simply means if there is a one to one relationship-if the tall boy who is tall at six is tall at fourteen, and the short boy who is short at six is short at fourteen, and this relationship holds true for all the cases-there would be a coefficient of plus one (+.1). If the reverse were true there would be a coefficient of minus one (-1). If we get the coefficient of correlation at the ages of seven and sixteen for a large group of children, we

find that coefficient of correlation is plus point eighty-five or eighty-six, (+.85 or +86), or even point ninety (+.90); that is, children who range high at seven years of age (or low), range high at seventeen years of age.

Therefore, if you knew the group and you knew how tall the child was at seven, you could prophesy with a considerable degree of accuracy how tall the child would be at sixteen or seventeen.

We could go still a little further and apply the mathematical formula of the method of regression. We find that if we get the height of a child at seven years of age we can tell you to within two or three centimetres, how tall that child will be at seventeen years of age, providing there are no accidents, or diseases that will seriously interfere with the child's growth. In other words, we have come to the point where we can prophesy in physical growth. If you will tell us how tall a child is at six years of age, or even how long a child is at birth, we can prophesy to a high degree of accuracy how tall that child will be at sixteen or seventeen or eighteen years of age. And this has a tremendous educational, nutritional and sociological value, because if the child is not growing at the prophesied rate, remedial measures may be taken to stimulate growth or to retard growth, whichever may be the necessary type of improvement desired.

This

(Slide) The National Child Health Council met a year and a half ago and proposed that we go into the question of physical growth and formulate standards of growth. I have been working on this problem since and you have here a tentative table. table is based upon the consecutive measurements of nude children. No child is included who did not have at least five years of measurements. No child is included who was outside a "normal zone," all had had medical inspection, all were measured by trained anthropometrists. No child was included who was defective or had any serious disease or handicaps. Consequently, we took a group of children that were supposed to be normal or near-normal and we worked out standards for height, weight and age. Take a child, for example, 57 inches tall. If he is ten years of age, he should weigh 76 pounds, if eleven, 78 pounds, if twelve, 79 pounds, and if thirteen, 82; that is, there is a gradual increase for weight with age, after a certain age, regardless of the height. So, to know the height alone is not quite sufficient. Surely to know the age alone is very insufficient.

(Slide) This is a sample of one of the Iowa boys who is a little overweight for his height, about one pound. He is taller than the average boy of his age-three yearsand he is heavier.

(Slide) This simply shows a little preschool laboratory that we have where we are studying children from two to four years of age. These children come from homes in Iowa City to the University every day for the half day. We are carrying on psy

chological and anthropometric experiments on them daily.

(Slide) Here you have an illustration of a girl who belongs to a superior group. She is taller than the average for her age. She is twelve years old. She has the height and the weight of a sixteen-year-old child. She is physically developed similar to a sixteenyear-old child. There will be another picture later which will show her a year earlier than this. She is socially at the age of a sixteen-year-old child. She is a normal type judged by her height and her weight and the relationship between these two is in accordance with her physiological age. (Slide) Here are some more individual growth curves. This is a tall girl (indicating); this is a short girl (indicating); the dots show the period of maturation, the period of first menstruation of the girls. The tall girls as a rule mature earlier than the short girls. These conditions are modified by temperature or climate, and to some extent by social conditions.

The point I am trying to make is that tall heavy girls are physiologically older than short light girls; they mature earlier; they reach the period of adolescent acceleration in growth earlier. They are physically older, they are socially older, as a rule.

(Slide) This picture shows the distribution for pubescence of boys. There is a wide range of individual differences in the development of both boys and girls during the adolescent period. These results come from near here. They show that some boys are pubescent at ten years of age, some at thirteen, some at fourteen, and there are boys sixteen years of age who are pre-pubescent. Some boys are pubescent at ten, others not pubescent until after sixteen. There is a wide range of individual differences. Some girls mature at ten, some at eleven, some at twelve, and others not until fifteen or sixteen and in a few instances seventeen years of age.

(Slide) The effect of maturing may be noted on growth. We selected all of the girls from the University of Chicago High School, the Horace Mann School, at Teachers College, and our Iowa University School -the girls that had matured at twelve years of age. Those that matured at twelve years of age were growing between twelve and thirteen years of age at the rate of 7 centimetres, on the average, per year; in two years they dropped down to about 1 centimetre a year. That is, early maturity was followed by cessation of growth in stature. Tall girls mature early and the cessation of growth appears soon after. Girls that mature late do not have their cessation in growth until after maturity in most cases. That is not always the case, however.

(Slide) Here are four children twelve years of age, chronologically. These children are all the same age chronologically. They have approximately the same I.Q., that is in intelligence they rate approximately the

same. Their I.Q.'s run from 132 upward, this girl having a little higher I.Q. than the others.

Physically, they are all of different ages. This boy is pre-pubescent. This boy is pubescent. This girl is about at the age of maturity and this girl is post-pubescent, that is, she has had her period of first menstruation; she is the oldest physically; and this one comes second, this one third, and this one fourth. Girls, as a rule, of course, are older than boys, physiologically speaking, from a year to a year and a half, on the av

erage.

This boy (indicating) is mentally alert and has the intelligence, the I.Q., equivalent to the others, generally speaking, but he is mentally young; he is in the eighth grade. This boy is in the ninth grade. This girl is in the tenth grade, and this one is in the eleventh grade. They are all chronologically the same age; they are all, as far as intelligence is concerned, about the same; physiologically, they are all of different ages; and pedagogically they are all in different grades.

Socially, they are all of different ages. It would be a crime to put this little boy up into the eleventh grade; and it would be just as much of a crime to put this girl back into the eighth grade.

So let me suggest one note of warning: We cannot afford to promote the children on their I.Q.'s alone as is being advocated in this country in a very broad fashion. We have to take into consideration the physiological age of the child; we have to take into consideration the social age of the child. One index of the physiological age and the social age is the height of the child and its weight.

(Slide) Another method of testing physiological age is to take an x-ray of the wrist. I now have 350 of these x-ray pictures. You have here the picture of a little child who was a year and a half of age-my little girl. She has two bones in her wrist. When she gets to be fourteen, she will have eight bones in her wrist, but at present she has two.

(Slide) The next picture shows one of my twins, five years old; this boy has four bones