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Full text of "Medical inspection of schools"

RUSSELL SAGE 
FOUNDATION 



MEDICAL INSPECTION 
OF SCHOOLS , 



BY 



T 



LUTHER HALSEY GULICK, M.D. 

AND 
LEONARD P. AYRES, PH.D. 



NEW YORK 

SURVEY ASSOCIATES, INC. 
MCM X I I I 



Copyright, 1913, by 
THE RUSSELL SAGE FOUNDATION 

Printed October, 1908 

Reprinted January, 1909 

Reprinted December, 1909 

Revised and reprinted, January, 1913 



PRESS OF WM. F. FELL CO. 
PHILADELPHIA 



PREFACE 

THIS volume is a revision of Medical Inspection of Schools, 
published by the Russell Sage Foundation in October, 
1 908. The first edition was exhausted within three months, 
and the volume was reprinted in January, 1909, and again in 
December of the same year. During the three and a half years 
that have elapsed since the first publication of the volume there 
has been a three-fold increase in the number of American cities 
having systems of medical inspection of schools. In rapidity 
and extent, this development has been unequalled by that of 
any other educational movement in America. 

During these few years physical examinations have become 
an integral part of all the more important systems of medical 
inspection. The school nurse, almost unknown four years ago, 
is now an important adjunct of the systems of scores of cities. 
Dental inspection, then in its infancy, is now being carried on in 
nearly 200 cities. At that time three states and the District 
of Columbia had legal provisions for medical inspection. Now 
the number has increased to 20. 

These conditions have resulted in an increasing demand for 
a revision of the original text, and this has led to the preparation 
of the present volume. While covering much of the matter treated 
in the original book, the text has been entirely re-written, and the 
description of methods and forms, as well as the quantitative 
material, brought down to date. Like its predecessor, this book 
aims 

(i) To be of practical use; (2) to be a reliable source of 
information as to what is now being done and how it is being 
done; (3) to be frank in its admission of problems and difficulties 
as yet unsolved; (4) to avoid all dogmatism, saving that involved 
in the statement of actual experience. 

L. H. G. 
L. P. A. 
New York, January, 1913 



258679 



* 




SIGNIFICANT FACTS 

' < T T T E endorse legislation providing for the medical inspec- 
\/\ / tion of schools, because extended and varied experi- 
V V ence has demonstrated that efficient medical inspec- 
tion betters health conditions among school children, safeguards 
them from disease, renders them healthier, happier and more vig- 
orous, and aims to insure for each child such physical and mental 
vitality as will best enable him to take full advantage of the 
free education offered by the state/' Extract from Resolutions 
Adopted by the Conference of State and Provincial Boards of 
Health, Los Angeles, June 3o-July i, 1911. 

Medical inspection is a movement national in scope in 
England, France, Germany, Norway, Sweden, Austria, Switzer- 
land, Belgium, Japan, Australia and Tasmania. It is found in 
the more important cities in Denmark, Russia, Bulgaria, Egypt, 
Canada, Mexico, the Argentine Republic, and Chili. In the 
United States regularly organized systems are in force in nearly 
one-half of the cities, while a beginning has been made in nearly 
three-fourths of them. 

Medical inspection of schools had its inception some eighty 
years ago, and during the past quarter of a century it has assumed 
the proportions of a world-wide movement. It is found in all the 
continents and the extent of its development in different countries 
is in some measure proportionate to their degree of educational 
enlightenment. 

Clear distinction must be made between medical inspection, 
solely for the detection of communicable disease, and physical 
examinations which aim to discover defects, diseases, and physical 
abnormalities. The former relates primarily to the immediate 
protection of the community, while the latter looks to securing 
and maintaining the health and vitality of the individual. 

Medical inspection for the detection of contagious diseases 
may well be a function of the board of health, for it aims at the 

vii 



MEDICAL INSPECTION OF SCHOOLS 

protection of the community. Physical examinations for the 
detection of non-contagious defects should be conducted by the 
educational authorities, or at least with their full cooperation, 
because they are made for educational purposes. The records 
of physical examinations must be constantly and intimately 
connected with school records and activities. They do not need 
to be connected with other work of the board of health. 

At the beginning of the year 1912, seven states had man- 
datory laws providing for medical inspection, 10 had permissive 
ones, and in two states and the District of Columbia, medical 
inspection was carried on under regulations promulgated by the 
state boards of health and having the force of laws. 

Professor William Osier, the distinguished English physician, 
is credited with saying in regard to the work of medical inspection 
in England, " If we are to have school inspection, let us have good 
men to do the work and let us pay them well. It will demand 
a special training and a careful technique/' 

The school nurse is the most important adjunct of medical 
inspection. She is the teacher of the parents, the pupils, the 
teachers, and the family, in applied practical hygiene. She is 
the most effective possible link between the school and the home. 

Dental inspection is rapidly becoming one of the most 
important branches of medical inspection. First in Germany, 
next in England, and more recently in the United States, dental 
inspection has been inaugurated and school dental clinics estab- 
lished. The work is now being carried on in nearly 200 American 
cities. 

In terms of financial expenditure, the cheapest sort of 
medical inspection consists of examinations conducted by teachers 
for the discovery of defects of vision and hearing. These involve 
only the added expense of the simple printed material required. 
Inspection by physicians for the detection of contagious diseases 
costs about 10 cents per child per year. Systems including both 
inspections for contagious diseases and examinations to detect 
physical defects cost on the average about 25 cents per child per 
year. Where school nurses are employed, the average per capita 

viii 



SIGNIFICANT FACTS 

rate is about 30 cents per child per year, and this may probably 
be regarded as a minimum cost for adequate and efficient work. 

In foreign countries complete physical examinations are 
usually conducted only two or three times in the course of the 
child's school career. In this country most cities attempt to 
conduct such examinations every year and frequently fall far short 
of accomplishing their aim. A conservative standard efficiently 
maintained is better than a high ideal that is never reached. 

In American cities having relatively efficient systems of 
medical inspection, the number of defective pupils receiving 
remedial treatment as a result of the examinations ranges from 
about 10 per cent to about 50 per cent. In England the work is 
more efficient and from 20 per cent to 70 per cent of the defective 
children receive remedial treatment from physicians, oculists, or 
dentists. 

Medical inspection is essential in country districts as well 
as in large cities, and in rich communities as well as in poor ones. 
The locality has yet to be discovered in which the medical inspec- 
tion of school children is unnecessary or undesirable. 



IX 



TABLE OF CONTENTS 

PAGE 

PREFACE v 

SIGNIFICANT FACTS vii 

LIST OF ILLUSTRATIONS xiii 

LIST OF TABLES xv 

LIST OF FORMS xix 

CHAPTER 

I. The Argument for Medical Inspection i 

II. History and Present Status 7 

III. Inspection for the Detection of Contagious Diseases . 21 

IV. Physical Examinations 35 

V. The School Nurse 62 

VI. Making Medical Inspection Effective . . . . 72 

VII. Results . 89 

VIII. Per Capita Costs and Salaries 101 

IX. Dental Inspection 114 

X. Controlling Authorities in American Municipalities . 143 

XI. Physical Defects and School Progress . . . .152 

XII. Legal Provisions 164 

APPENDICES 

I. Suggestions to Teachers and School Physicians Regard- 
ing Medical Inspection 183 

II. Annual Report for iQio/of the Chief Medical Officer 

of the British Board of Education . . . .197 

BIBLIOGRAPHY 203 

INDEX 209 



XI 



LIST OF ILLUSTRATIONS 

Photographs illustrating work in the New York schools are repro- 
duced by permission of the New York Child Welfare Committee. Those 
referring to Orange, N. J., Rochester, N. Y., and Toledo, O., are used by 
permission of the chief medical inspectors and school authorities of those 
cities. Grateful acknowledgment is made of their courtesy. 



FACING 
PAGE 



In the school of the future compulsory education will involve 
compulsory health Frontispiece 

Mouth breathing means adenoids; adenoids mean deadened 

intellects -4 

A throat culture in time may save nine weeks of diphtheria . 1 2 
Vaccination inspection in New York City 21 

Case of chicken-pox discovered in a class room in New York 

City . . 27 

Case of mumps discovered in a class room in New York City . 27 

No exclusion for ringworm when cases are treated by the nurse 
at school 30 

First aid for small ailments in Toledo, Ohio .... 30 

Listening for trouble. Testing heart and lungs in New York 
City 36 

Strong boys must have straight backs ... .41 

Looking for obstructed nasal breathing in a New York City 
school 41 

Vision tests by physician and nurse in Orange, N. J. . . 46 

Testing the hearing of five boys at one time in a New York 
City school. Not so good as one at a time, but sometimes 
necessary 53 

School nurse in action; first aid demonstration in Orange, 

N.J N ' ' ' 6? 

xiii 



LIST OF ILLUSTRATIONS 



FACING 
PAGE 



The school nurse is the most efficient link between the school 

and the home 67 

Team work between physician and nurse in Toledo, Ohio . 76 

The equipment of this Rochester dental clinic cost about $700 1 02 

Dental treatment costs less than the extra schooling bad teeth 

involve 102 

Too late for effective treatment 114 

Each missing upper tooth renders useless the corresponding 

lower tooth 114 

Every pupil in Rochester, N. Y., needing dental inspection 

receives it 120 

Toothbrush drill in New York City 120 

Persistently neglected teeth become mere putrescent stumps . 1 29 

Reason enough for retardation; enlarged tonsils mean lowered 

vitality 129 

Waiting for the school physician in Toledo, Ohio . . .148 
Throat inspection in the Orange, N.J., schools . . . .148 

About 10 per cent of the school children of our cities suffer 

from malnutrition 155 

Typical adenoid faces showing mouth breathing, flattened 

noses, and protruding eyes 1 70 



xiv 



LIST OF TABLES 

TABLE PAGE 

1. Cities of United States having medical inspection, by groups of 

states. 1911 15 

2. Cities of United States having systems of medical inspection in 

each year from 189410 1911 . . . . . . .16 

3. Cities of United States having systems of medical inspection, 

cities employing school physicians, and number of physicians 
employed, by groups of states. 1911 17 

4. Cities of United States having systems of medical inspection, 

cities employing school nurses, and number of nurses em- 
ployed, by groups of states. 1911 18 

5. Cities of United States having systems of medical inspection, and 

cities employing school dentists, by groups of states. 1911 . 19 

6. Status of medical inspection in 1,046 municipal school systems in 

the United States. 1911 20 

7. Exclusions for contagious diseases in four cities .... 32 

8. Exclusions for contagious diseases in four cities: 

Relative figures on the basis of i ,000 exclusions in each city . 33 

9. School membership, exclusions for contagious disease, and number 

of exclusions per thousand pupils enrolled, for eight cities . 33 

10. Cities of the United States having examinations for the detection 

of physical defects, by groups of states. 1911 . . .36 

11. Results of physical examinations of schoolchildren in nine cities . 38 

12. Results of physical examinations of school children in nine cities: 

Relative figures on basis of each 1,000 children examined in 
each city 38 

13. Results of physical examinations of school children, New York, 

N. Y., 191 1 40 

14. Enrollment in day schools and number and per cent of pupils ex- 

amined in nine cities 41 

15. Vision and hearing tests conducted by physicians and teachers 

in American cities, by groups of states. 1911 . . 51 

xv 



LIST OF TABLES 

TABLE PAGE 

1 6. Results of vision and hearing tests in Massachusetts, Connecticut, 

and Maine 52 

17. Results obtained by medical inspectors aided and not aided by 

school nurses. Eight schools, Philadelphia, 1910 ... 66 

1 8. Results obtained by medical inspectors aided and not aided by 

school nurses. Philadelphia, 1910 67 

19. Salaries of nurses in 1 06 American municipalities .... 70 

20. Physical defects reported by medical inspectors, and number and 

percent of these defects treated. New York City, 191 1 . 92 

21. Four classes of physical defects reported and number and per cent 

of these defects treated. Newark, N. J., 1910-1 1 ... 93 

22. Physical defects recommended for treatment and number and 

percent of these defects treated. Harrisburg, Pa., 1909-10 . 94 

23. Physical defects reported and number and per cent of these defects 

treated. Pasadena, Cal., 1909-10 94 

24. Defects reported, number referred to physicians, and per cent of 

these in which physician was consulted. Summit, N. J., 
1909-10 95 

25. Defects reported and the number and per cent of these defects 

treated, in four cities 96 

26. Cases of physical defects treated by private practitioners and by 

institutions, New York, 191 1 96 

27. Percentages of cases of defects of eyes and ears treated profes- 

sionally. Somerville, Mass., 1906-10 97 

28. Recommendations for treatment by medical inspectors and num- 

ber and per cent of treatments in 24 English areas. 1910 . 99 

29. Number and salaries of medical inspectors and school nurses, 

average school attendance, and total annual expenditure and 
expenditure per pupil in average attendance for salaries of 
medical inspectors and school nurses in 77 American cities of 
more than 8,000 population. 1911 104 

30. Annual salaries of physicians and nurses in all cities reporting . 1 08 

31. Results of dental inspection of 447 children, ages six to sixteen, 

Elmira, New York, 1910 115 

32. Cities of the United States having dental inspection and cities hav- 

ing dental inspection by dentists, by groups of states. 1911 122 

33. Dental inspection of school children in twelve German municipal 

districts. Year ending April, 191 1 126 

xvi 






LIST OF TABLES 

TABLE PAGE 

34. Administration of systems of medical inspection in cities of United 

States, by groups of states. 1911 145 

35. Per cent of children examined found defective, among 907 "ex- 

empt" and 687 " non-exempt " children, in Philadelphia, Penn. 1 52 

36. Physical defects among 3,587 exempt and 1,418 non-exempt 

children, in Philadelphia, Penn., 1908 153 

37. Defects of vision and hearing among 8, no normal and 2,020 

retarded children in Camden, N.J., 1906 . . . . . 154 

38. Physical defects and irregular attendance among 1,279 normal 

and 573 retarded children who failed of promotion in 
Camden, N.J., 1906 154 

39. Physical defects among 1,093 children promoted and 303 children 

not promoted in elementary schools, in Manchester, Con- 
necticut, 1910 155 

40. Physical defects among 449 retarded children, of whom 345 had 

been in the first grade two years, 86 three years, and 18 four 

or more years. Elmira, New York, 1909-10 . . . .156 

41. Per cent of dull, normal, and bright pupils suffering from each 

sort of defect. Ages ten to fourteen, inclusive. All grades. 
New York, 1908 158 

42. Average number of grades completed by pupils having no physical 

defects compared with number completed by those suffer- 
ing from different defects. Central tendency among 3,304 
children, ages ten to fourteen years, in grades one to eight. 
New York, 1908 159 

43. Extent to which children suffering from each sort of physical 

defect show slower progress than do children with no de- 
fects. New York, 1908 160 

44. Number of years required by defective and non-defective chil- 

dren to complete the eight grades. New York, 1908 . .161 

45. Principal features of state laws and regulations providing for 

medical inspection. 1911 166 



xvn 



LIST OF FORMS 



PAGE 



Exclusion card, Brockton, Massachusetts 22 

Monthly report of medical inspector, Brockton, Massachusetts . . 23 

Exclusion notice with detachable stub, Chicago 25 

Envelope daily report of medical inspector in which are forwarded to 

Board of Health copies of exclusion notices, Chicago . . 26 

Combined directions and prescription, Everett, Mass 28 

Report of sight and hearing tests to superintendents of schools, 

Massachusetts 48 

Snellen chart for testing eyesight 49 

Record of sight and hearing tests, Massachusetts 50 

Notice to parent or guardian of defect of eyes or ears, Massachusetts . 50 

Individual record card. Physical examinations, Chicago, 111. . . 54 

Individual record card. Physical examinations, Pasadena, Cal. . . 55 

Individual record card (Face, Physical Record). Berkeley, Cal. . 56 
Individual record card (Reverse, Scholarship Record). Berkeley, 

Cal 57 

Notice to parent or guardian, Massachusetts 73 

Post card notification form, Birmingham, Alabama .... 74 

Parent's consent blank, St. Louis, Missouri 75 

Notification of defects and of opportunities for consultation, Oakland, 

California 77 

Notification of defects and of opportunities for consultation, Pasa- 
dena, California 78 

Notification to parents of school physician's office hours ... 79 
Notification of nurse's call and of school physician's office hours, Oak- 
land, California 79 

Agreement between dentists and schools, Muskegon, Mich. . . .123 

Combined directions and prescription for tooth powder, Philadelphia . 128 
Individual dental record Card, Philadelphia (Face) . . . .135 
Individual dental record Card, Philadelphia (Reverse) . . . .136 

xix 



LIST OF FORMS 

PAGE 

Notice to parent, Philadelphia 137 

Certificate for free treatment, Philadelphia 138 

Appointment card, Philadelphia 139 

Principal's record, Philadelphia . 140 

Weekly report of dental inspector, Philadelphia 141 



xx 



CHAPTER I 
THE ARGUMENT FOR MEDICAL INSPECTION 



M 



EDICAL inspection is an extension of the activities of 
the school in which the educator and the physician join 
hands to insure for each child such conditions of health 
and vitality as will best enable him to take full advantage of 
the free education offered by the state. Its object is to better 
health conditions among school children, safeguard them from 
disease, and render them healthier, happier, and more vigorous. 
It is founded upon a recognition of the intimate relationship 
between the physical and mental conditions of the children, 
and the consequent dependence of education on health conditions. 

When Boston initiated medical inspection in America in 
1894, by dividing her schools into 50 districts and placing a 
physician in charge of each district, she did so in the hope that 
the new measure would curb the waves of contagious disease 
that repeatedly swept through the ranks of the children, leaving 
behind a record of suffering and death. The experiment was 
successful, and when other cities learned how Boston was solving 
the problem, they too began to employ school physicians and to 
organize systems of medical inspection. 

During the first years the spread of the movement was 
slow, only one or two cities taking it up each year; then these 
pioneers were followed by dozens of their sister cities, later by 
scores, and in the past few years by hundreds. 

This sudden recognition of the imperative necessity for 
safeguarding the physical welfare of school children grew out of 
the discovery that compulsory education under modern city con- 
ditions meant compulsory disease. 

With the great changes which have been coming over 
American life, former conditions have disappeared and undisturbed 
indifference to the physical welfare of our school children has 
become impossible. We have changed from an agricultural 



MEDICAL INSPECTION OF SCHOOLS 

people to a race of dwellers in towns and cities. The school 
year has changed from a three months' winter term to one of five 
hours per day for ten months during the year. The number of 
years of school life has greatly increased. We have passed com- 
pulsory education laws. Going to school has become not only 
\>the normal but the required occupation of all children for a 
considerable number of years. 

The results of these changed conditions on the health of 
children have become so marked as insistently to demand atten- 
tion. The parents, school authorities, and health authorities 
have been unable to avoid recognizing the fact that in the nature 
of the case the school has become the most certain center of 
. infection in the community. 

The state, to provide for its own protection, has decreed 
that all children must attend school, and has put in motion the 
all-powerful but undiscriminating agency of compulsory education, 
which gathers in the rich and the poor, the bright and the dull, 
the healthy and the sick. The object was to insure that these 
children should have sound minds. One of the unforeseen results 
was to insure that they should have unsound bodies. Medical 
inspection is the device created to remedy this condition. Its ob- 
ject is prevention and cure. 

Wherever established, the good results of medical inspection 
have been evident. Epidemics have been checked or avoided. 
Improvements have been noted in the cleanliness and neatness 
of the children. Teachers and parents have come to know that 
under the new system it is safe for children to continue in school 
in times of threatened or actual epidemic. 

But medical inspection does not stop here, nor has it limited 
its activities to the field outlined. Other problems have been 
insistently forcing themselves on the attention of school men; and 
they, knowing something of the wonderful advances made in the 
field of medicine, have turned for aid to the physicians. 

With the changes in the length of the school term, and the 
increase in the number of years of schooling demanded of the child, 
has come a great advance in the standards of the work required. 
When the standards were low, the work was not beyond the capac- 
ity of even the weaker children; but with close grading, fuller 

2 



ARGUMENT FOR MEDICAL INSPECTION 

courses, higher standards, and constantly more insistent demands 
for intellectual attainment, conditions have changed. Pupils 
have been unable to keep up with their classes. The terms " back- 
ward," "retarded," and "exceptional," as applied to school chil- 
dren, have been added to the vocabularies of school men. 

School men discovered that the drag-net of compulsory 
education was bringing into school hundreds of children who 
were unable to keep step with their companions, and because 
this interfered with the ordinary administration of our school 
systems they began to ask why the children were backward. 

The school physicians helped to find the answer when they 
showed that hundreds of these children were backward simply 
because of removable physical defects. And then came the 
next great forward step, the realization that children are not 
dullards through the will of an inscrutable Providence, but rather 
through the law of cause and effect. 

This led to an extension of the scope of medical inspection 
to include the physical examination of school children with the 
aim of discovering whether or not they were suffering from such 
defects as would handicap their educational progress and prevent 
them from receiving the full benefit of the free education furnished 
by the state. This work was in its infancy five years ago, but 
today more than 200 American cities have systems of physical 
examination of their school children. 

Surprising numbers of children have been found who, through 
defective eyesight, have been seriously handicapped in their 
school work. Many are found to have defective hearing. Other 
conditions are found which have a great and formerly unrecognized 
influence on the welfare, happiness, and mental vigor of the child. 
Attention has been directed to the real significance of adenoids 
and enlarged tonsils, of swollen glands and carious teeth. 

Communities are seeing the whole matter in a new light. 
Gradually they are beginning to ask, not whether they can afford 
to take steps to safeguard in schools the welfare of their children, 
but whether they can afford not to take such steps. The realiza- 
tion is dawning that it is unbusinesslike to count carefully the 
cost of the school physician, but to disregard the cost of death and 
disease, of wrecked hopes and dependent families. 

3 



MEDICAL INSPECTION OF SCHOOLS 

Teachers and parents are beginning to realize that the prob- 
lem of the pupil with defective eyesight may be quite as important 
to the community as that of the pupil who has some contagious 
disease. A child who is unable to see distinctly is placed in a 
school where physical defects are unrecognized and disregarded; 
headaches, eyestrain, and failure follow all his efforts at study. 
He cannot see the blackboards and charts; printed books are 
indistinct or are seen only with much effort, everything is blurred. 
Neither he nor his teacher knows what is the matter, but he soon 
finds it impossible to keep pace with his companions, and, becom- 
ing discouraged, he falls behind in the unequal race. 

In no better plight is the child suffering from enlarged 
tonsils and adenoids, which prevent proper nasal breathing and 
compel him to keep his mouth open in order to breathe. Perhaps 
one of his troubles is deafness. He is soon considered stupid. 
This impression is strengthened by his poor progress in school. 
Through no fault of his own he is doomed to failure. He neglects 
his studies, hates his school, leaves long before he has completed 
the course, and is well started on the road to an inefficient and 
despondent life. 

Public schools are a public trust. When the parent delivers 
his child to their care he has a right to insist that the child under 
the supervision of the school authorities shall be safe from harm 
and shall be handed back to him in at least as good condition as 
when it entered school. Even if the parent does not insist upon 
it, the child himself has a right to claim protection. The child 
has a claim upon the state and the state a claim upon the child 
which demands recognition. Education without health is useless. 
It would be better to sacrifice the education if, in order to attain 
it, the child must lay down his good health as a price. Education 
must comprehend the whole man and the whole man is built 
fundamentally on what he is physically. 

The objection that the state has no right to permit or require 
medical inspection of the children in the schools will not bear 
close scrutiny or logical analysis. The authority which has the 
right to compel attendance at school has the added duty of insist- 
ing that no harm shall come to those who go there. The Mass- 
achusetts law, with its mandatory " shall," is certainly preferable 

4 




Mouth breathing means adenoids; adenoids mean deadened intellects. 



ARGUMENT FOR MEDICAL INSPECTION 

to the Connecticut law, with its permissive "may." The exercise 
of the power to enforce school attendance is dangerous if it is 
not accompanied by the appreciation of the duty of seeing that 
the assembling of pupils brings to the individual no physical detri- 
ment. When the subject is considered both from the standpoint 
of the individual and from that of the state, the wonder is, not 
that medical inspection is now being practiced, but rather that 
it was not begun long ago. 

Nor is the state, in assuming the medical oversight of the 
pupils in the public schools, trespassing upon the domain of 
private rights and initiative. Under medical inspection what is 
done for the parent is to tell him of the needs of his child, of which 
he might otherwise have been in ignorance. It leaves to the 
parent the duty of meeting those needs. It leaves him with 
a larger responsibility than before. Whatever view be taken of 
the right of the state to enforce measures for the correction of 
defects discovered, the arguments for and against do not enter 
into the present discussion. It is difficult to find a logical basis 
for the argument that the state has not the right to inform the 
parents of defects present in the child, and to advise as to remedial 
measures which should be taken to remove them. 

The justification of the state in assuming the function of 
education and in making that education compulsory is to insure 
its own preservation and efficiency. Whether or not it is to be 
successful will depend on the intelligence of its individual members. 

But the well-being of a state is as much dependent upon the 
strength, health, and productive capacity of its members as it 
is upon their knowledge and intelligence. In order that it may 
insure the efficiency of its citizens, the state through its compulsory 
education enactments requires its youth to pursue certain studies 
which experience has proved necessary to secure that efficiency. 
Individual efficiency, however, rests not alone on education or 
intelligence, but is equally dependent on physical health and 
vigor. Hence, if the state may make mandatory training in 
intelligence, it may also command training to secure physical 
soundness and capacity. 

Much time may elapse before there will be put in practice 
in all schools the measures, now so successfully pursued in some, 

5 



MEDICAL INSPECTION OF SCHOOLS 

for conserving and developing the physical soundness of rising 
generations. But the movement is so intimately related to the 
future welfare of our country, and has so signally demon- 
strated its value, that it is destined to be universal and perma- 
nent. 

For nineteen centuries the educational world has held as 
the most perfect expression of its philosophy that half line of 
Juvenal in which he pleads for the sound mind in the sound body. 
It has remained for the first decade of the twentieth century to 
awake to a startled realization that Juvenal was wrong wrong 
because he bade us think that mind and body are separate, and 
separately to be provided for. 

Only now have we come to realize the error and to take 
steps to rectify it. Only in the last few years have we begun 
to see that, educationally at least, mind and body are inseparable, 
and that the sound mind and the sound body are inextricably 
related both causes and both effects. 

All these things mean that it is our splendid privilege to 
see and to be a part of a movement which is profoundly trans- 
forming our traditional ideas of education. They mean that our 
children and our children's children will be a better race of men 
and women than are we or than were our fathers. 

Not alone our unwillingness to be outdone in this public 
service by foreign nations, not alone our sense of practical fore- 
sight, but our inherent feeling of obligation toward our children 
and our recognition of this service as one of necessity for the 
national well-being, are forcing upon us the incorporation of this 
phase of public activity as an integral part of our public education. 

The human race will be a better race because of the lessons 
that have been taught us by the child having contagious disease, 
the backward child, and the physically defective child. Because 
of these lessons, the youth of the future will attend a school in 
which health will be contagious instead of disease, in which the 
playground will be as important as the book, and where pure 
water, pure air, and abundant sunshine will be rights, and not 
privileges. He will attend a school in which he will not have 
to be truant, tuberculous, delinquent, or defective, to get the 
best and fullest measure of education. 

6 



M 



CHAPTER II 
HISTORY AND PRESENT STATUS 

ED I GAL inspection of schools was first provided for some 
eighty years ago but it is only during the past quarter 
of a century that it has assumed the proportions of a 
world-wide movement. It is found in all the continents, and the 
extent of its development in different countries is in some measure 
proportionate to their degree of educational enlightenment. In 
the most important countries it has now become national in scope. 

FRANCE 

The earliest work in the field of medical inspection seems 
to have been done in France, where the law of 1833 and the 
royal ordinance of 1837 charged school authorities with the duty 
of providing for the sanitary conditions of school premises and 
supervising the health of the school children. A few years later, 
irT '[^42 and 1843, governmental decrees were promulgated in 
Paris, directing that all public schools should be regularly inspected 
by physicians. In spite of these early beginnings, however, 
it was not until 1879 that genuine medical inspection in the 
modern sense of the term was begun in France. In that year 
the general council of the Department of the Seine reorganized 
the medical service in the schools of Paris and passed an appropri- 
ation for the payment of salaries to the physicians. Eight years 
later medical and sanitary inspection were made obligatory in 
all French schools, public and private. 

At the present time the work is carried on in Paris by a 
force of 210 school physicians who are selected on the basis of 
competitive examination and each of whom has supervision of 
not more than 1,000 children. These physicians visit each school 
at least twice every month and make careful examinations of the 
sanitary conditions, paying special attention to lightirfg, ventila- 

7 



MEDICAL INSPECTION OF SCHOOLS 

tion, cleanliness, and water supply. Visits are made to each 
school room and a general inspection of the pupils conducted. 
Following this general inspection, individual examinations are 
conducted in the inspector's private room. The children examined 
are of three classes : first, those whom the physicians have selected 
as apparently needing special attention; second, those referred 
to them by teachers and parents; and third, those who have 
returned to school after absence because of illness or some unknown 
cause. 

The first object of the examinations referred to is to detect 
and exclude cases of contagious disease. In addition to these 
inspections each child, during the first months of his school life, 
is given a thorough physical examination, and a careful record of 
the findings, entered on an individual record sheet, follows the 
child through his subsequent school career. Every six months 
measurements of height and weight are made and the results 
entered on these record sheets, together with data of any illnesses 
suffered during the period, and the results of subsequent physical 
examinations. Parents are informed of any defect or disease 
discovered and urged to secure remedial treatment. 

In other cities of France the systems followed are modeled 
after that of Paris, but in general are less thorough, and in the 
smaller places are not infrequently restricted to inspections for 
the detection and exclusion of cases of contagious disease. 

GERMANY 

In Germany the city of Dresden began medical inspection 
in 1867, when tests of vision were instituted. The first genuine 
system of medical inspection, however, appears to have been 
inaugurated by Frankfort-on-the-Main, which appointed a school 
physician in 1889, an example which was soon followed by many 
other localities. 

In the city of Wiesbaden a plan was developed that was 
widely copied and became a model, not only throughout the 
empire but in other countries. The plan adopted by the physi- 
cian on his monthly visits to each school closely resembles that 
already described as being followed in Paris. General inspec- 
tions are first made of class rooms and school premises and these 

8 



HISTORY AND PRESENT STATUS 

are followed by individual examinations of pupils selected be- 
cause they are suspected of suffering from contagious diseases. 
Previous to entering, each child has been given a physical examina- 
tion, and this is repeated in the second, fourth, sixth, and eighth 
years of school life. On each of these occasions an examination 
of heart, lungs, throat, spine, skin, and the higher sense organs is 
made, and (in the case of boys) an examination for hernia. The 
findings are entered on a report blank which accompanies the child 
from grade to grade. Twice a year the teacher records the height 
and weight of individual pupils. Whenever it is deemed necessary, 
the school physician takes chest measurements. The records of 
children who seem to require the regular care of a physician are 
marked accordingly, and these children report at regular intervals 
to the school physician. It is the duty of the school physician 
to give advice to the teacher with reference to the child. Parents 
are notified of the results of the examinations. 

There is wide variation in the thoroughness of medical 
inspection in different parts of the empire. Thoroughly organized 
systems under state regulations exist only in Saxe-Meiningen and 
Hesse-Darmstadt where every school, both public and private, in 
the country as well as in the city, is provided with a state-appointed 
physician. In other states the school physicians are appointed 
by and work under the municipal Magistral, the local board of 
education, or the board of health. 

In the year 1908 some 400 towns and cities had systems of 
medical inspection of schools, employing about 1,600 physicians. 
There are three common plans of employing and remunerating 
these school physicians. Under the first form of organization the 
physician is employed on full time, is paid a salary ranging from 
$1,750 to $2,750 per annum, and has the right to a pension. 
Under the second plan, a salary of from $i 50 to $250 a year is paid 
for part time services, and work is usually carried on in addition 
to other public health services, for which separate payment is 
made. Under the third plan, payment is made on a per capita 
basis, according to the number of children inspected, and the 
scale of payment ranges from 6 to 16 cents per child per year, the 
average being about 12 cents. Payment is also sometimes made 
at the rate of from 60 cents to $i .00 for each class examined. 

9 



MEDICAL INSPECTION OF SCHOOLS 

As yet the movement for the employment of school nurses 
has not made great progress in Germany, Charlottenburg and 
Stuttgart being, in 1910, the only cities having nurses. On the 
other hand, notable progress has been made in the development 
of other movements closely allied to medical inspection, such as 
open air schools, school feeding, dental inspection, and the organi- 
zation of special classes for exceptional children. 

GREAT BRITAIN* 

In England and Wales the medical inspection of schools is 
carried on under the provisions of the Education Act of 1907 which 
is mandatory in nature. In Scotland the work is carried on under 
the Education Act of 1908 which confers on school boards the 
powers necessary for a universal system of medical inspection. In 
Ireland alone compulsory medical inspection does not exist. Such 
work as is carried on is in the main performed by the school in- 
spectors of the national board of education, who are not medical 
men. 

The object of medical inspection in Great Britain, as stated 
by the memorandum of the board of education, is "to secure 
ultimately for every child, normal or defective, conditions of life 
compatible with that full and effective development of its organic 
functions, its special senses, and its mental powers, which consti- 
tute a true education. "f 

While medical inspection in England has been universal and 
compulsory only since the passage of the Act of 1907, it has 
existed in London since 1891, when the first school physician was 
appointed. From that date up to the passage of the National Act 
the development of the movement was sporadic. The details 
of organization are in the main left in the hands of the local 
authorities, subject to the minimum requirements laid down by 
the memorandum of the board of education. These minimum 
provisions include the physical examination of each pupil at the 
time of his entrance to a public elementary school, and if possible 
three subsequent examinations, the first of which takes place 
during the third year of school life or about the seventh year of age, 

* For full discussion of the English law, and methods of enforcement, see 
p. 1 74 if. fSee p. 176- 

10 



HISTORY AND PRESENT STATUS 

the second during the sixth year of school life or about the tenth 
year of age, and the third at the time the child is about to leave 
school and go to work. 

England was the pioneer in the employment of school 
nurses, the first having been appointed in London as early as 1887. 
However, the first school nurses in the modern acceptation of the 
term were appointed in 1901 by the London school board, and their 
employment is now becoming general in other cities. 

OTHER COUNTRIES 

In Belgium medical inspection is the rule in the more impor- 
tant municipalities, and Brussels is credited with having estab- 
lished the first system of medical inspection in the full modern 
sense of the term in 1874, when school physicians were appointed 
and charged with the duty of inspecting every school three times 
a month. This system was remarkably successful from its incep- 
tion, was copied in other cities of Belgium, and served as a model 
for systems in Switzerland. Some of the earliest work of school 
dentists and oculists was done in Belgium. 

In Norway medical inspection has progressed steadily since 
1885, when some localities began to support regular school physi- 
cians. Permissive regulations were passed in 1889 and were 
followed two years later by mandatory ones. 

Sweden is probably the country where the term "school 
physician" was first used in its modern sense. As far back as 1868 
medical officers were attached to the staff of every public secondary 
school. Their duties and spheres of activity have been progres- 
sively extended, beginning first with the higher schools, and since 
1895 including the primary ones. 

In Denmark there is no regular system of medical inspection 
nor any legislation directly providing for it. Nevertheless, some 
work is carried on in the elementary and secondary schools of her 
larger towns and cities, Copenhagen having led the way in 1896. 

Russia has made provision for medical inspection since 1871 
but with a few exceptions it has not extended beyond the secondary 
and higher schools. 

Austria was the first country to enact effective legislation 
providing for medical inspection in the elementary schools, by a 

1 1 



MEDICAL INSPECTION OF SCHOOLS 

ministerial decree of 1873 which provided for the regular employ- 
ment of school physicians. In Hungary the office of school 
physician was established by the act of 1885. 

In Bulgaria organized work dates from 1904, while in 
Roumania adequate legislation has existed since 1899. 

In Switzerland the medical inspection of schools and school 
children is recommended, but not enforced, by the federal govern- 
ment. Nevertheless some 13 cantons now carry out the recom- 
mended inspection and thorough work is done by the school 
physicians of some cities. 

In Japan medical inspection has been compulsory and 
universal since 1898, only small towns and country districts being 
exempt. 

In Egypt, Cairo appointed the first school physician in 1882, 
and the system has been in force ever since. 

In Australia and Tasmania the work dates from 1906 and 
includes not only measures for the prevention of contagious 
diseases but physical examinations, together with much scientific 
study of results. This renders the reports from these countries 
unusually valuable. 

In America a number of countries besides the United States 
have more or less fully developed systems of medical inspection. 
In Canada, Montreal began in 1906 with the appointment of 50 
school physicians. , Halifax and Vancouver followed in 1907. In 
all of the provinces there is inspection; and in Ontario, Manitoba, 
and Alberta, it is provided for by law. 

In Mexico medical inspection dates from 1896, when the 
department of medical inspection and school hygiene was organized 
under the director general of elementary instruction and a few phy- 
sicians were appointed. Since that time there have been several 
reorganizations of the system, with constant extension. In the 
city of Mexico and its suburbs, it is now very complete and notably 
efficient. From the capital the work has spread until it is now 
fully organized in the state of Chihuahua, and partly so in Guana- 
juato and San Luis Potosi. 

In South America, the Argentine Republic and Chile began 
medical inspection in 1888 and in both countries the systems are 
thoroughly developed. 

12 




A throat culture in time may save nine weeks of diphtheria. 



HISTORY AND PRESENT STATUS 

DEVELOPMENT AND PRESENT STATUS IN THE UNITED STATES 

Boston was the first city in the United States to establish 
a regular system of medical inspection, starting in 1894 with a staff 
of 50 school physicians. The movement came as a result of a 
series of epidemics among the school children. Chicago began in 
1895. New York City followed in 1897 when the board of health 
appointed a corps of 134 medical inspectors for the public schools, 
and Philadelphia in 1898. In all these instances medical inspec- 
tion in its inception had as its sole object the reducing of the 
number of cases of contagious disease among the pupils. The 
movement rapidly spread from the greater cities to the smaller 
ones, the first step in many cases being taken by a local med- 
ical society offering to carry on the work for a limited time with- 
out expense to the municipality, in order to demonstrate its 
desirability. 

BEGINNINGS OF STATE LEGISLATION * 
So rapidly and convincingly did the movement establish 
itself that it was soon provided for by laws in the more progressive 
states. In 1899 the legislature of Connecticut passed a law provid- 
ing for the testing of vision in all the public schools of the state. 
New Jersey authorized boards of education to employ medical 
inspectors in 1903. In the following year Vermont enacted a law 
requiring the annual examination of the eyes, ears, and throats 
of school children. 

The first mandatory legislation providing for state-wide 
medical inspection in all public schools was passed by Massachu- 
setts in 1906.1 From these beginnings the movement spread 
rapidly until by 1912 seven states had passed mandatory laws, 10 
had passed permissive ones, and in two states and the District 
of Columbia medical inspection was carried on under regulations 
promulgated by the boards of health and having the force of law.f 
The fact that the Massachusetts statute, passed in 1906, is the 
oldest of the laws now in force, shows that the whole body of 
legislative enactments which crystallize the views, beliefs, and the 

* See also Chap. XII, Legal Provisions, p. 164 ff. 
f See pp. 164, 1 68, and 177. J See map, p. 165. 

'3 



MEDICAL INSPECTION OF SCHOOLS 

results of experience of educators and physicians, is of distinctly 
recent origin. 

PRESENT STATUS 

The best body of evidence as to the present status of medical 
inspection in American municipalities is furnished by the results 
of an investigation conducted by the Russell Sage Foundation 
during the school year 1910-11. This investigation gathered the 
facts on medical inspection and school hygiene from 1,046 school 
systems in 1,038 cities and towns, or nearly 90 per cent of the 
American municipalities which have regularly organized systems 
of public schools under superintendents. For the purpose of 
tabulating the results, the states of the union were divided into 
five groups, following the order adopted by the Bureau of the 
United States Census. These groups are as follows: 



Maine 

New Hampshire 

Vermont 



NORTH ATLANTIC DIVISION 

Massachusetts 
Rhode Island 
Connecticut 



New York 
New Jersey 
Pennsylvania 



Delaware 
Maryland 
District of Columbia 



SOUTH ATLANTIC DIVISION 

Virginia 
West Virginia 
North Carolina 



South Carolina 

Georgia 

Florida 



Kentucky 
Tennessee 
Alabama 



SOUTH CENTRAL DIVISION 



Mississippi 

Louisiana 

Texas 



Arkansas 
Oklahoma 



Ohio 
Indiana 
Illinois 
Michigan 



NORTH CENTRAL DIVISION 

Wisconsin 
Minnesota 
Iowa 
Missouri 



North Dakota 
South Dakota 
Nebraska 
Kansas 



Montana 
Wyoming 
Colorado 
New Mexico 



WESTERN DIVISION 

Arizona 
Utah 
Nevada 
Idaho 

14 



Washington 

Oregon 

California 



HISTORY AND PRESENT STATUS 



Forty-three per cent of the cities and towns which reported 
to the Foundation had regularly organized systems of medical 
inspection in their public schools. The number of municipalities 
reporting, the number having systems of medical inspection, and 
the per cent having such systems in each state group, are shown in 
the following table: 

TABLE I. CITIES OF UNITED STATES HAVING MEDICAL INSPECTION, 
BY GROUPS OF STATES. IQI I 







CITIES HAVING MEDICAL 


Division 


Cities 
reporting 


INSPECTION 










Number 


Per cent 


North Atlantic 


411 


236 


57 


South Atlantic 


74 


23 


3i 


South Central 


101 


35 


35 


North Central 


382 


109 


29 


Western 


70 


40 


57* 


United States 


1,038* 


443 


43 



a Representing 1,046 school systems. 

The percentage figures in the final column show that medical 
inspection has made the best progress in the North Atlantic and 
Western divisions, where 57 per cent of the cities had taken up the 
new work. In the two southern divisions the percentages are 31 
and 35, and the poorest showing is made by the North Central 
division, where only 29 per cent of the cities had medical inspec- 
tion systems. 

It has been stated that the first system of medical inspection 
was inaugurated by Boston in the year 1894. Ten years later, 
in 1904, 36 cities and towns had such systems. From this time on, 
the increase was exceedingly rapid until in 1911, as shown above, 
the number of municipalities which had systems of medical 
inspection had increased to nearly 450. Out of the 443 cities and 
towns reporting systems of medical inspection, 32 did not state 
the year in which work began. From the records of the 41 1 cities 

15 



MEDICAL INSPECTION OF SCHOOLS 

which gave this information a table has been compiled showing 
the total number of cities having medical inspection systems in 
each year since the pioneer work in Boston. 

TABLE 2. CITIES OF UNITED STATES HAVING SYSTEMS OF MEDICAL 
INSPECTION IN EACH YEAR FROM 1894 TO IQI I 



Year 


Cities having medical 
inspection 


1804 




1807 


E 


1898 


8 


1899 

1900 


9 
1 1 


IQOI 


17 


IQO2 


23 


IQO3 


28 


1904 
1905 
1906 


37 
55 
77 
in 
167 


IQOQ 


f* 

263 


IQIO 


4OO 


191 I ....... 


41 1 







The reason for the comparatively slight increase in the year 
1911 is that the data were gathered in the early spring, so that 
cities which adopted medical inspection later in the year were not 
included. 

The chart on page 17 represents graphically the number of 
cities having medical inspection each year since 1894, and shows 
how the growth of the movement, at first slow and gradual, has 
become in the later years increasingly rapid. 

SCHOOL PHYSICIANS 

The returns of the investigation show that 354 of the 443 
cities having systems of medical inspection, or about 80 per cent 
of them, employed school physicians, and that the total number 
of physicians employed was 1,415. More than half of these were 
in the North Atlantic states and more than half of the remaining 
number in the North Central states. Their distribution in the 
several divisions is shown in Table 3. 

16 



HISTORY AND PRESENT STATUS 



'10 



'11 



'O9 



'06 



'or 



7 0> 



Off 



04 



55300 



en dad] 

eon 



ZQ 



$Z 7? Mt 

DIAGRAM I. CITIES OF UNITED STATES HAVING SYSTEMS OF MEDICAL INSPEC- 
TION IN EACH YEAR FROM 1894 TO 1911. 



TABLE 3. CITIES OF UNITED STATES HAVING SYSTEMS OF MEDICAL 

INSPECTION, CITIES EMPLOYING SCHOOL PHYSICIANS, AND 

NUMBER OF PHYSICIANS EMPLOYED, BY GROUPS 

OF STATES. I9II 



Division 


Cities having 
systems of med- 
ical inspection 


Cities employ- 
ing school 
physicians 


Number of 
physicians 
employed 


North Atlantic .... 
South Atlantic .... 
South Central .... 
North Central .... 
Western 


236 
23 

35 
109 
40 


215 

14 

27 
70 
28 


852 
48 
4i 
417 
57 


United States .... 


443 


354 


i,4i5 



MEDICAL INSPECTION OF SCHOOLS 

SCHOOL NURSES 

The school nurse is now almost universally admitted to 
be one of the most necessary adjuncts of a well developed system 
of medical inspection. The total number employed in American 
cities in 1911 according to the returns of the same investigation 
was 415, of whom 375, or 90 per cent, were in the North Atlantic 
and North Central states. Their distribution in the different 
divisions was as follows: 



TABLE 4. CITIES OF UNITED STATES HAVING SYSTEMS OF MEDICAL 

INSPECTION, CITIES EMPLOYING SCHOOL NURSES, AND NUMBER 

OF NURSES EMPLOYED, BY GROUPS OF STATES. 191 I 



Division 


Cities having 
systems of med- 
ical inspection 


Cities employing 
school nurses 


Number of 
nurses employed 


North Atlantic 
South Atlantic 
South Central 
North Central 
Western 


236 
23 
35 
109 
40 


52 
5 

2 4 8 

13 


261 
ii 

5 
114 

24 


United States .... 


443 


102 


415 



DENTAL INSPECTION 

Increasing attention is being paid in American schools 
to the inspection of children's teeth, and the work is being more 
and more commonly carried on as a branch of medical inspection 
in a semi-independent way. In a number of the large cities the 
local dental associations have established clinics at which school 
children are given treatment either gratis or at small expense. 
In most of these cases dentists serve without remuneration, but 
in a few cities they have been added as regularly paid members of 
the corps of medical inspectors. Sixty-nine cities had dental 
inspection conducted by dentists in 1911, and of these, 54, or 78 
per cent, were in the North Atlantic and North Central states. 
Their distribution by divisions was: 

18 



HISTORY AND PRESENT STATUS 



TABLE 5. CITIES OF UNITED STATES HAVING SYSTEMS OF MEDICAL 

INSPECTION, AND CITIES EMPLOYING SCHOOL DENTISTS, BY 

GROUPS OF STATES. II I 



Division 


Cities having systems 
of medical inspection 


Cities employing 
school dentists 


North Atlantic 
South Atlantic 
South Central 
North Central 
Western . . 


236 
23 
35 
109 
40 


24 

3 
30 
4 


United States .... 


443 


69 



FOUR PRINCIPAL FEATURES OF MEDICAL INSPECTION 
Systems of medical inspection in different parts of the United 
States vary from simple and rudimentary ones to the more com- 
plex organizations designed to safeguard every phase of the child's 
physical life in the school. There are four principal features which 
constitute component parts of these different systems, and they 
are found in almost every possible combination. These features 



1. Medical inspection conducted by physicians for the detec- 
tion and exclusion of cases of contagious diseases; 

2. Examinations conducted by teachers for the detection of 
defects of vision and hearing; 

3. Examinations conducted by physicians for the detection of 
defects of vision and hearing; 

4. Complete physical examinations conducted by physicians. 

The figures showing how these different features are com- 
bined in the systems of medical inspection in this country reveal 
the relatively chaotic condition and lack of uniformity existing 
in this branch of educational work. These conditions are shown 
in Table 6. 

The data that have been reviewed show that 443 school 
systems out of the i ,046 which reported had regularly organized 
systems of medical inspection in 1911. But these data fall far 
short of doing justice to the situation in the United States. While 

19 



MEDICAL INSPECTION OF SCHOOLS 

it is true that only 443 systems, or about 42 per cent of all, had 
regularly organized work, 722 systems, or nearly 69 per cent, were 
carrying on some sort of medical inspection. 

TABLE 6. STATUS OF MEDICAL INSPECTION IN 1,046 MUNICIPAL 

SCHOOL SYSTEMS IN THE UNITED STATES. IQII. (THE x's 

INDICATE FEATURES INCLUDED.) 



Inspection for 
contagious 
disease 


Vision and 
bearing tests by 
teachers 


Vision and 
hearing tests by 
physicians 


Physical 
examinations 
by physicians 


Number of 
school systems 
having the fea- 
tures specified 




X 






277 


X 


X 






92 


X 




X 


X 


80 


X 


X 


X 


X 


65 


X 


X 




X 


52 


X 


X 


X 




43 


X 








37 


X 




X 




32 




X 


X 




16 






X 




ii 






X 


X 


7 




X 


X 


X 


4 


X 






X 


3 




X 




X 


3 


Total ............. 722 


Systems not having medical inspection of any kind . . . 324 



Grand total 1,046 

SUMMARY. Medical inspection is provided for by law in 
something less than half of the American states. Regularly 
organized systems of medical inspection are in force in something 
less than half of the American cities, while a beginning has been 
made in nearly three-fourths of them. About four-fifths of the 
443 cities having systems of medical inspection employ school phy- 
sicians, almost a quarter of them employ school nurses, and in 
about one city in seven school dentists are employed. 



20 



CHAPTER III 

INSPECTION FOR THE DETECTION OF 
CONTAGIOUS DISEASES 

NEARLY all American systems of medical inspection have had 
for their object at the time of their inception merely the 
detection of cases of contagious diseases in their early stages. 
To this simple aim have always soon after been added the detection 
and exclusion of parasitic diseases. 

In towns and small cities medical inspection of this sort is 
a comparatively elementary matter involving few difficulties in 
organization or administration. In such places the teacher who 
thinks she sees suspicious symptoms in one of her pupils, and fears 
they may portend the beginning of some illness, notifies the 
principal of her fears. He notifies the school physician by tele- 
phone or messenger and the physician comes to the school and 
examines the pupil, sending him home if necessary. In addition, 
provision is frequently made, as in the Massachusetts law, that 
the school authorities shall refer to the school physician for exami- 
nation and diagnosis every child returning to school after absence 
on account of illness or unknown cause. 



BLANKS AND FORMS 

Such simple systems as those outlined require little in the 
shape of blanks or forms. Notification cards or blanks are used 
for informing the parents of the exclusion of the child, and weekly 
or monthly reports are made out by the school physician stating 
how many children he has examined, how many he has excluded, 
and for what diseases, and what other diseases he has found which 
did not require exclusion. A good example of such an exclusion 
card is the one used in Brockton, Massachusetts. 

21 



MEDICAL INSPECTION OF SCHOOLS 
EXCLUSION CARD, BROCKTON, MASSACHUSETTS 



Commonwealth of Massachusetts. 



CONTAGIOUS DISEASE. 



NOTICE TO PARENT OR GUARDIAN. 
In accordance with Chapter 502 of the Acts of 1906, you 

are hereby notified that 

has been examined by me as School Physician, and found to 

have symptoms of 

This child is excluded from the schools until he brings a 
statement from a regular practitioner certifying his complete re- 
covery. 

School Physician. 

...190 



The monthly report of the medical inspector of the same city 
is also a good specimen of forms which have given satisfaction in 
simple systems, and which might well be adapted for use in any 
locality where the number of cases handled is comparatively small 
and the pupils are individually known to the school authorities 
so that it is easy to keep track of them. 

Large systems require somewhat more complicated organiza- 
tion and records. Efficiency and economy of labor demand that 
printed forms be provided wherever their use obviates the neces- 
sity for any considerable amount of writing. The same considera- 
tion demands that on these forms underlining or checking of printed 
words be used wherever possible, instead of the filling in of blank 
spaces. The object is to attain the desired results with a minimum 
of clerical work consistent with efficiency. This is particularly 
important when the clerical work is to be performed by a high- 
priced man, as in the case of a high-class physician. 

Let us consider a case where the school physician has 
examined a child and found him to have unmistakable symptoms 

22 



INSPECTION FOR CONTAGIOUS DISEASES 



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MEDICAL INSPECTION OF SCHOOLS 

of a contagious disease. It is necessary that the office system 
enable him to dispose of the case so as to notify fully every one con- 
cerned. This requires (i) an exclusion notice to be sent to the 
parents; (2) a record for the school authorities; (3) a record for 
the board of health; (4) a record for the physician himself. 

The record for the board of health and the exclusion notice 
require, in addition to the name of the child and the disease, the 
name and address of the parent. 

Under many systems these notices are made out on four 
separate cards or sheets, and often the work is still further increased 
by having a separate card for the record of exclusions from each 
room in the school. This makes it necessary to secure the appro- 
priate card before the record can be made. Under such conditions 
the physician spends five or six times as much time in making 
entries on different cards as he does in inspecting the child. 

A large part of this waste of time and money can be obviated 
by a carefully planned system of records. In the case in point, for 
example, the work can be greatly reduced by adopting a system 
similar to the one in use in Chicago. Instead of being furnished 
with supplies of cards for making the several records, each inspector 
is given a book similar in size and shape to an ordinary check book. 
The leaves of the book are alternately of light and heavy paper 
perforated for separation, and have stubs like the leaves of a 
check book. The thin leaves and stubs are printed as shown on 
page 25. 

The heavy sheet underneath this thin leaf is an exact dupli- 
cate, except that in the lower left hand corner instead of the 
words " Hand to pupil excluded" it has the words " Mail this card 
to Chief Medical Inspector same day pupil is excluded." Between 
the two leaves a sheet of copying carbon is inserted. 

When an exclusion case is found the method of procedure is 
simple. The inspector fills out the blank and its stub. The 
original blank is the exclusion notice and is taken home by the 
pupil. The stub is handed to the school authorities as their 
record of the case. The carbon copy on the heavy sheet is torn out 
to be sent to the board of health as their notification of the case, and 
the stub of the carbon copy is left in the book as the inspector's 
record. 

24 



INSPECTION FOR CONTAGIOUS DISEASES 





















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Readmitted . . . 



MEDICAL INSPECTION OF SCHOOLS 

. Under the system in use until recently in Chicago the in- 
spector enclosed all the carbon copies of the exclusion notices in an 
envelope and forwarded it to the board of health. This envelope, 
besides being the holder for the exclusion notices, was the daily 
report of the inspector. On its face were blanks to be filled out as 
follows : 

ENVELOPE DAILY REPORT OF MEDICAL INSPECTOR IN WHICH ARE 

FORWARDED TO BOARD OF HEALTH COPIES OF EXCLUSION 

NOTICES. CHICAGO 



CITY OF CHICAGO, DEPARTMENT OF HEALTH 



MEDICAL INSPECTION OF SCHOOLS 

Inspector's Daily Report of Number of Examinations and Exclusions 

I have this day examined pupils at 

(NUMBER) 

the School, made 

(NUMBER) 

cultures for bacterial examination, performed vacci- 

( NUMBER) 

nations, and excluded pupils from attendance 

(NUMBER) 

at school for reasons stated on the enclosed exclusion cards. 

Date 19 M.D. 

Medical Inspector 

(Place the exclusion cards in this holder, enclose whole in special envelope and 
mail to Chief Medical Inspector. Report must be made EVERY SCHOOL DAY 
whether inspection has or has not been made.) 



The saving effected by this system is plainly seen by compar- 
ing the number of forms necessary under the separate card 
method with the number required by the "check book and carbon 
copy" method: 

CHICAGO METHOD SEPARATE CARD METHOD 

1. Notice and stub i. Notice to parents 

2. Envelope daily report 2. Record for school 

3. Record for board of health 

4. Record for inspector 

5. Daily report 
26 





1 5 

o 



U 



INSPECTION FOR CONTAGIOUS DISEASES 

This system has been described at length because the 
principle underlying it is fundamental. If medical inspectors are 
to do efficient work they must not be overburdened with complex 
clerical work. The aim in every case must be the smallest possible 
number of original entries. 

One commendable time-saving device which has been 
adopted in some cities is that of having cards for different uses 
in different colors so that the medical inspector can put his hand 
on the card he wants without a moment's delay. Utica and 
Syracuse, New York, have adopted this plan. Thus, in Utica the 
physical record card is white; the notice to parents of physical 
defects, salmon colored; the exclusion card, buff; the card of 
directions for ridding the hair of vermin, printed in English, is pink ; 
in Italian, cherry color. The room record of pupils excluded and 
re-admitted is lavender. 

In a number of cities it has been found necessary to have 
some of the cards that go to parents printed in several different 
languages. 

One feature which nearly all American systems of medical 
inspection have in common is the plan of supplying printed 
directions for ridding the hair of vermin. One of the best of these 
is that followed in Everett, Massachusetts, where the pupil is not 
only instructed as to treatment, but is furnished with a druggist's 
prescription for the material required. This plan is adopted not 
only for cases of pediculosis (lice), but for other common com- 
plaints, such as impetigo contagiosa, ringworm, and scabies. The 
forms used are reproduced on pages 28 and 29. 



CO-OPERATION OF THE TEACHER 

Experience has demonstrated that the highest efficiency in 
medical inspection can be secured only through the constant 
co-operation of the teachers. In the matter of detecting cases of 
contagious disease, the best results are secured by a compromise 
between the system of relying entirely upon the teacher for detect- 
ing symptoms of disease and that of insisting that the physician 
alone shall make the inspection. It is the verdict of experience 
that three general propositions hold true: 

27 



MEDICAL INSPECTION OF SCHOOLS 
COMBINED DIRECTIONS AND PRESCRIPTION, EVERETT, MASS. 









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DIRECTIONSiSaturat 
petroleum. Keep it wet fo 
wash the whole head with 
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Then comb the hair with 
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and more thorough, have 
before beginning treatment 
ment keep away from the f 




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28 



INSPECTION FOR CONTAGIOUS DISEASES 



COMBINED DIRECTIONS AND PRESCRIPTION, EVERETT, MASS. 

tinued) 



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29 



MEDICAL INSPECTION OF SCHOOLS 

1. It is impracticable to have the physician inspect all 
the pupils every day. 

2. He should see them all sometimes. (In some 
systems such routine inspections of all pupils are made once 
in two weeks, in others once a month, and in still others 
once a term.) 

3. Where school nurses are employed the problem 
largely disappears, as the teacher and nurse together readily 
decide which pupils should go to the inspector. 

In localities where systems have been carefully worked out, 
teachers are provided with printed instructions as to the symptoms 
which they should notice and on account of which children should 
be referred to the school physicians. Probably the most carefully 
worked out set of such instructions is given in a pamphlet issued by 
the Massachusetts state board of education. This little book, 
which so well fills the need that it has been reprinted for use in 
many other localities as a good example of what such a manual 
should be, is reprinted in its entirety in this volume.* Under the 
heading "Some General Symptoms of Disease in Children which 
Teachers should Notice, and on Account of which the Children 
should be Referred to School Physician" it gives explanatory 
directions under each of the following headings: 

Emaciation Eruptions of any sort 

Pallor Cold in the head with running eyes 

Puifmess of the face Irritating discharge from the nose 

Shortness of breath Evidence of a sore throat 

Swellings in the neck Coughs 

General lassitude and other evi- Vomiting 

dences of sickness Frequent requests to go out 
Flushing of the face 

EXCLUSIONS 

In most cities examinations are made for the following 
diseases: scarlet fever, diphtheria, measles, small-pox, chicken-pox, 
tonsilitis, pediculosis, ringworm, impetigo contagiosa, trachoma, 
and other transmissible diseases of the skin, scalp, and eye. Tu- 

* See Appendix I, p. 183. 
30 




No exclusion for ringworm when cases are treated by the nurse at school. 







First aid for small ailments in Toledo, Ohio. 



INSPECTION FOR CONTAGIOUS DISEASES 

berculosis, when thought to be far enough advanced to be a menace 
to public health, is generally reported to the chief medical inspector 
before the pupil is excluded from school. 

In general, the procedure with respect to the more common 
contagious diseases is substantially as follows: 

Scarlet fever cases are not allowed to return to school until all des- 
quamation is completed and there is an entire absence of discharge from 
the ears, nose, throat, or suppurating glands, and the child and premises 
are disinfected. 

Diphtheria cases are excluded until two throat cultures made on 
two consecutive days show absence of the Klebs-Loeffler bacilli. Those 
exposed to diphtheria are excluded one week from last exposure. 

Measles cases are excluded for three weeks or longer if there is 
present bronchitis, inflammation of the throat or nose, or abscess of the ear. 
Those exposed to measles are excluded two weeks from the date of last 
exposure. 

Whooping cough cases are excluded until after spasmodic stage of 
the cough usually about eight weeks. Those exposed to whooping 
cough are excluded two weeks after the date of the last exposure. 

Mumps cases are excluded for ten days after all swelling has 
subsided. 

Chicken-pox cases are excluded until the scabs are all off and the 
skin smooth. 

Cases oj tonsilitis are excluded on clinical evidence alone and throat 
cultures are made for future diagnosis. 

In making throat examinations wooden tongue depressors are used 
to the exclusion of all other tongue depressors. Each tongue depressor 
is used only once and then burned. Aseptic methods are employed in all 
examinations. 

When children are excluded sufficient reasons are written 
briefly on an exclusion card which is sent to the parents. One 
copy is filed with the school authorities and one with the board of 
health. School physicians are forbidden to make any suggestions 
as to treatment and management of sick pupils. This rule is 
nearly universal and is made imperative. 

Children recovering from measles, whooping cough, mumps, 
chicken-pox, scarlet fever, diphtheria, and small-pox are not al- 
lowed to re-enter the school without a permit from the department 



MEDICAL INSPECTION OF SCHOOLS 



of health. If they have been taken sick with any of these infec- 
tious diseases in the school room, the pupils of the room are dis- 
missed and the room disinfected. 

In the accompanying tables figures are presented showing 
the number of exclusions for each of the more important diseases 
in four cities. In Table 7 the figures are the original data 
taken from the latest available reports. In Table 8 the 
figures are relative, showing the number of exclusions for each 
disease among each thousand children excluded. They indicate 
the variations which are encountered in this work. These varia- 
tions exist not only between cities but between different years in 
the same city, and are mostly due to the fluctuations caused by 
local epidemics. The commonest disorder, and the one causing 
the largest number of exclusions, is pediculosis. 

TABLE 7. EXCLUSIONS FOR CONTAGIOUS DISEASES IN FOUR CITIES 





EXCLUSIONS 


Cause of exclusion 












Chicago 


Detroit 


Newark 


New York 




1910 


1909-10 


1910-11 


1911 


Pediculosis . 


i455 


426 


925 


i,475 


Tonsilitis 


2,957 


170 


337 




Chicken-pox 


1,010 


90 


217 


1,347 


Mumps . 


1,128 


33 


135 


i,475 


Impetigo 


986 


520 




227 


Measles 


1,004 


84 


'167 


414 


Conjunctivitis 


672 






1,137 


Scabies . 


579 


254 


1*5 


215 


Diphtheria . 


708 


7 


28 


848 


Ringworm . 




116 


162 


138 


Whooping cough 


298 


108 


83 


329 


Scarlet fever 


579 


ig 


27 


198 


Other causes 


2,783 


948 


1,925 


35i 


Total 


14,653 


2,775 


4,121 


8,154 



Further data showing the great variations between cities 
in the matter of exclusions are presented in Table 9, which 
compares the number of exclusions with the total school mem- 
bership in eight cities. The figures for exclusions are taken 

32 



INSPECTION FOR CONTAGIOUS DISEASES 



TABLE 8. EXCLUSIONS FOR CONTAGIOUS DISEASES IN FOUR CITIES! 
RELATIVE FIGURES ON THE BASIS OF I ,OOO EXCLUSIONS IN EACH CITY 





EXCLUSIONS 


Cause of exclusion 


Chicago 


Detroit 


Newark 


New York 




1910 


1909-10 


1910-11 


1911 


Pediculosis 


99 


154 


224 


181 


Tonsilitis 


202 


61 


82 




Chicken-pox .... 


69 


32 


53 


165 


Mumps 


77 


12 


33 


181 


Impetigo 




I8 7 




28 


Measles 


68 


30 


41 


51 


Conjunctivitis .... 


46 




. 


140 


Scabies 


40 


92 


28 


26 


Diphtheria 


48 


2 


7 


104 


Ringworm 


34 


42 


39 


17 


Whooping cough .... 


20 


39 


20 


40 


Scarlet fever .... 


40 


7 


6 


24 


Other causes .... 


190 


342 


467 


43 


Total 


1,000 


1,000 


1,000 


1,000 



TABLE 9. SCHOOL MEMBERSHIP, EXCLUSIONS FOR CONTAGIOUS 

DISEASE, AND NUMBER OF EXCLUSIONS PER THOUSAND PUPILS 

ENROLLED, FOR EIGHT CITIES 







EXCLUSIONS FOR CONTAGIOUS 






DISEASE 


City and year 


School 
membership 




Number 


Number per 
thousand pupils 


Chicago, 1910 .... 


301,172 


14.653 


49 


Cincinnati, 1910 
Cleveland, 1908-09 . 


47.454 
69,764 


i, 606 
i,798 


11 


Detroit, 1909-10 


57.996 


2,775 


48 


Newark, 1909-10 


57.742 


4,955 


86 


New York, 1909-10 . 
Philadelphia, 1910 . 


744,148 
174,441 


8,884 
6,794 


12 

39 


Rochester, 1910 


26,664 


1,050 


39 



33 



MEDICAL INSPECTION OF SCHOOLS 

from the annual reports as indicated in the table, whereas the 
figures for school membership are those given in the report of the 
United States commissioner of education for the corresponding 
years, showing the total number of different pupils enrolled in the 
day schools. The figures in the third column show the num- 
ber of exclusions per thousand children enrolled. The significant 
feature is that exclusions range all the way from 12 per thousand 
in New York to 86 per thousand in Newark. 

SUMMARY. In order to render inspection for the detection 
of contagious disease effective, the most important feature to be 
striven after is the reduction of the machinery of administration 
in order that the school physicians may devote the largest possible 
amount of time and energy to actual inspection, and the smallest 
to merely clerical details. 

Experience demonstrates that it is impracticable to have the 
physicians inspect all the pupils every day, and it is equally clear 
that complete inspection should be made occasionally. 

Where the work is done successfully and adequately the num- 
ber of cases of contagious disease among the children is greatly 
reduced, and the necessity for closing schools because of epidemics 
is largely done away with. Exclusions on account of contagious 
disease during the school year vary from about one in 100 to one 
in 10 of the school membership. The lower figure is approached 
only when school nurses are a part of the permanent corps of the 
school medical department. 



CHAPTER IV 
PHYSICAL EXAMINATIONS 

THE theory on which physical examinations are based rests 
on a different foundation from that underlying medical 
inspection for the detection of contagious diseases. The 
latter is primarily a protective measure and looks mainly to the 
immediate safeguarding of the health of the community. The 
former aims at securing physical soundness and vitality and looks 
far into the future. 

Physical examinations have come into existence because of 
the mass of evidence showing conclusively that a large percentage 
of school children probably from one-tenth to one-fourth suffer 
from defective vision to the extent of requiring an oculist's care if 
they are to do their work properly, and if permanent injury to their 
eyes is to be avoided. 

These conclusions are based on examinations of hundreds of 
thousands of children in all parts of the world. There is little 
doubt as to the substantial accuracy of the results. More than 
this, a considerable percentage of school children are so seriously 
defective in hearing that their school work suffers severely. 
Most important of all, only a small minority of these defects of sight 
and hearing are discovered by teachers or known to them, to the parents, 
or to the children themselves. When children attempt to do their 
school work while suffering from these defects, among the results 
may be counted permanent injury to the eyes, severe injury to the 
nervous system due to eye strain, and depression and discourage- 
ment, owing to inability to hear and see clearly. 

Moreover, there are other defects, in particular those of nose, 
throat, and teeth, which are common among children and which 
have an important bearing upon their present health and future 
development. The importance of these defects is emphasized by 
the fact that, if discovered early enough, they may easily be 

35 



MEDICAL INSPECTION OF SCHOOLS 

remedied or modified, whereas neglect leads, almost without fail, 
to permanent impairment of physical condition. 

In America, comprehensive systems embracing thorough 
physical examinations of all pupils are still far from general. The 
investigation conducted by the Russell Sage Foundation in the 
spring of 1911 showed that while 443* cities reported systems of 
medical inspection, in only 214, or a little less than half, did the 
work include complete physical examinations conducted by school 
physicians. Moreover, the cities having physical examinations 
were mostly in the North Atlantic division, where the work is 
oldest and most highly developed.! 

The accompanying table presents figures showing the number 
of cities in each division which include in their medical inspection 
systems full physical examinations for the detection of defects. 
In this table the states are classified by divisions according to the 
basis adopted by the United States Census. 

TABLE 10. CITIES OF THE UNITED STATES HAVING EXAMINATIONS 
FOR THE DETECTION OF PHYSICAL DEFECTS, BY GROUPS OF STATES. 

II I 



Division 


Number of Cities 


North Atlantic 
South Atlantic 
South Central 
North Central 
Western 


135 

10 
12 
38 
19 


United States 


214 



When these figures are compared with those giving the entire 
number of cities which have systems of medical inspection,* 
they show that the cities having physical examinations are more 
than half of all in the North Atlantic states, less than half of all 
in the South Atlantic and Western ones, and only about one-third 
of those in the South Central and North Central groups. 

*Seep. 15. 

t Divisions adopted by the U. S. Census. See p. 14. 

3 6 




Listening for trouble. Testing heart and lungs in New York City. 



PHYSICAL EXAMINATIONS 

CONDUCT AND RESULTS OF EXAMINATIONS 

Examinations for the detection of physical defects are 
usually conducted after the school physician has made his regular 
morning inspection for the detection of contagious diseases. The 
examinations are made in the physician's special room, which 
should be at least 20 feet long in order to allow sufficient space for 
the vision tests. In the older school buildings, where special 
rooms are not provided, the hallways are frequently utilized as 
unsatisfactory substitutes. 

The children are brought into the room in groups of three or 
four, and in making the examination the physician usually begins 
at the child's head and proceeds downward over the body. The 
object of the examination is to detect such physical conditions as 
interfere with the child's health and vitality or militate against his 
receiving the full benefit of the education furnished by the state. 
This means that the examinations are purely practical in intent 
and hence they should avoid unnecessary refinement. For ex- 
ample, it is futile for the physician to record history as to height 
and weight unless some real end is to be attained from the study 
of these data. Again, it is generally useless to make records of 
physical defects so unimportant that, although their existence can 
be detected, they do not require attention from the physician, 
oculist, or dentist. 

The defects which are looked for, and which should be 
recorded, are defects of teeth, throat, eyes, nose, glands, ears, 
nutrition, lungs, heart, nervous system, and bodily structure. 

The records of physical examinations show that from one- 
half to two-thirds of all the children examined are suffering from 
physical defects sufficiently serious to require the attention of the 
physician, the oculist, and the dentist. The most important kinds 
of defects which go to make up these large totals are those of teeth, 
throat, eyes, and nose. Indeed, these four combined constitute 
more than four-fifths of all the defects found. Table n, on the 
following page, presents the data showing the results of physi- 
cal examinations among more than half a million children in 
nine American cities. The significance of these data is more 
clearly shown by referring to Table 12, which presents the same 

37 



MEDICAL INSPECTION OF SCHOOLS 



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PHYSICAL EXAMINATIONS 

material reduced to relative form so as to show the conditions 
among each thousand children examined in each of the cities. 

While the comparison is interesting and instructive, the 
tables do not give an entirely accurate comparative view of condi- 
tions existing among the school children of the different cities. 
School physicians have varying standards for recording the differ- 
ent defects. Moreover, there is lack of uniformity in nomen- 
clature. In the present case adenoids have been included with 
defective nasal breathing under nose defects, and hypertrophied 
tonsils have been included under throat defects. Again, figures 
for defects of vision and hearing are lacking for Boston, because 
in that city the examination for these defects is conducted 
by the teachers instead of by the physicians, and further 
blanks in the table are caused by the fact that New York, 
Pasadena, and St. Louis do not report cases of enlarged cervical 
glands. 

Bearing in mind these considerations, we are still safe in 
interpreting the table as showing that the school physicians find 
about 65 per cent of the children in our public schools to be suffering 
from physical defects serious enough to require attention; that the 
most common are those of teeth, throat, eyes, and nose; and that 
these four classes of defects combined constitute about 85 per cent 
of all those discovered. 

Under the caption "other defects" are included many 
abnormal physical conditions varying greatly in importance. 
Some idea of the variety and proportion of these latter may be 
gained from Table 13, which shows the number and per cent of 
physical defects found by the school physicians in the schools of 
New York during the calendar year 1911. 

The publication of tables similar to those given here has 
resulted in many misapprehensions on the part of the public 
and those specially interested in the public schools. It has been 
repeatedly stated that results of physical examinations proved that 
two-thirds or three-fourths of all our children are physically 
defective, and such statements have aroused much discussion 
and called forth some denials. The difficulty is one of words 
rather than of facts. To use the word "defective" as it has been 
used in these cases is to give it a new and somewhat strained 

39 



MEDICAL INSPECTION OF SCHOOLS 

meaning. What the figures really show is that a large proportion 
of the children are found to have defects serious enough to need 
recording and to require attention from a physician, dentist, or 
oculist. Nevertheless, the defect so recorded is frequently nothing 
more serious than one or more carious teeth. 



TABLE 13. RESULTS OF PHYSICAL EXAMINATIONS OF SCHOOL 
CHILDREN, NEW YORK, N. Y., IQI I 







Per cent of all 




Number 


children 






examined 


Children examined 


230,243 


100 


Needing treatment 


166,368 


72.3 


Having: 






Defective teeth .... 


135.843 


59.0 


Hypertrophied tonsils 


34.639 


15.0 


Defective nasal breathing 


27.319 


11.9 


Defective vision ... 


24,514 


10.6 


Malnutrition .... 


5.845 


2.5 


Cardiac disease .... 


1,661 


7 


Defective hearing ... 


1,491 


.6 


Orthopedic defects ... 


1,190 


5 


Chorea 


86 1 


4 


Pulmonary disease ... 


483 


.2 


Tuberculous lymph nodes 


418 


.2 


Defective palates ... 


85 





It must be remembered, too, in this connection that the 
perfect human animal is exceedingly rare. The figures do not 
mean that our schools are filled with physical wrecks. They do 
mean that the results of examinations prove beyond doubt the 
need for finding out the facts and taking steps to have the defects 
remedied. Experience with the publication of results of medical 
inspection demonstrates no less clearly the imperative need for 
moderation of statement in making the results public. 

FREQUENCY OF EXAMINATIONS 

American practice differs from that in vogue abroad in 
providing, as a rule, for the physical examination of each child 
annually instead of at less frequent intervals. In Germany a 

40 




f -g 

rt </> 










&D 
C 

o 

c/5 



PHYSICAL EXAMINATIONS 



child is examined upon his entrance into the public school, and re- 
examined in the third, fifth, and eighth school years. The memo- 
randum of the English board of education provides for four 
examinations during the child's school life, upon entrance, and ' 
re-examination in the third and sixth years and upon leaving. To 
the date of its last report in 1911, however, the board had required 
in its code of regulations for public elementary schools only two 
examinations, one of "entrants" and one of prospective "leavers,"/ 
although the known intention of the board ultimately to demand 
the inspection of a third intermediate group had been anticipated 
in 1910 by some hundred local authorities. In America the ideal of 
annual examinations, almost universally held, is even reflected in 
several of the state laws. 

Unfortunately, this ideal has far outrun accomplishment and 
in few instances has any American city succeeded in examining all 
of its children in any one year. In the accompanying table figures 
are presented showing the number of pupils enrolled in the day 
schools of nine cities and the number and per cent of children who 
received physical examinations in the same cities. 

TABLE 14. ENROLLMENT IN DAY SCHOOLS AND NUMBER AND PER 
CENT OF PUPILS EXAMINED IN NINE CITIES 



City and year of examination 


Pupils enrolled 
in day schools 
1909-10 


PUPILS EXAMINED FOR 
PHYSICAL DEFECTS 


Number 


Per cent 


Boston 1912 a 
Chicago 1910 . 
Cleveland 1910-11 
Newark 1910-11 
New York 191 1 
Oakland 1910-11 
Pasadena 1909-10 
Rochester 1910 
St. Louis 1910-11 


111,632 
301,172 
74,438 
57,742 
744,148 
1 6, 780 b 
5,622 
26,664 
87,931 


82,224 
120,301 
50,864 
24,310 
230,243 
16,015 
4,036 

15,157 
20,591 


73-7 
39-9 
68.3 
42.1 
30.9 

95-4 
71.8 
56.8 
23.4 



a Partial data. 



b Figures for 1908-09. 



The percentages given, though indicative in a rough way 
of the proportions of the field covered in the several cities, should 
not be taken too seriously. Thus, in view of the impossibility of 



MEDICAL INSPECTION OF SCHOOLS 

securing uniform figures in regard to enrollment for the years dur- 
ing which the examinations were made, it was found necessary to 
fall back on the report of the United States commissioner of 
education for 1909-10. The figures in the first column of the table, 
which were taken from this report, are unsatisfactory not only 
because they are of too early a date but because they include 
(presumably) the membership of high schools, which, so far as 
known, no one of the nine cities attempts to cover. 

The situation in the cities showing respectively the highest 
and the lowest percentages Oakland and St. Louis requires a 
word of special comment. The enrollment figures for Oakland are 
by exception for the year 1908-09, while those for children examined 
are for 1910-1 1, a fact which may in part explain the very high 
percentage of examinations in this city. A greater effort was 
made in Oakland than elsewhere, however, to examine every 
child in the primary and grammar grades, if we may judge from 
the following statement made by the director of health develop- 
ment and sanitation: 

"All pupils present were examined during the first term, and after 
the Christmas vacation the schools were gone over again to get the new 
scholars and those missed at the first examination. A few who were 
absent at both examinations, or who have entered since the last, are not 
recorded." 

In St. Louis the efforts of the department of school hygiene 
are chiefly concentrated on 19 schools in the more densely popu- 
lated quarters of the city, practically every pupil attending which 
is examined, while only a small number of children from other 
schools are inspected when specially referred by their teachers to 
the school physicians. 

In general, the figures indicate that five out of the nine cities 
examined more than half of their school children. Of Boston it 
should be said that the investigation was still in progress at the 
date when the figures given were reported, and that it was the 
intention to continue it till the entire school population was 
covered. The follow-up system in this city seems, however, to 
be less highly developed than that in New York and other cities 
which show a far lower percentage of children examined. 

42 



PHYSICAL EXAMINATIONS 

It should be remembered that in general these data represent 
unusually good conditions rather than typical ones. It would be 
difficult to find many other cities with equally good records of 
accomplishment. The lesson to be drawn from this situation is 
that municipalities should aim at an ideal that is possible of attain- 
ment. It would be far better to plan to examine each child once 
every second year and succeed in doing so than to attempt to do 
the entire work every year and fail. It would also be far bet- 
ter to examine children in alternate years and employ vigorous 
measures to secure correction of defects than to examine every 
year and merely notify parents of the need of treatment. 

TIME AND COST* 

Physical examinations of the sort commonly given in the 
better American systems require from three to ten minutes each, 
depending on the skill of the examiner, the thoroughness of the 
examinations, and the condition of the pupils. Perhaps a fair 
average is 10 examinations per hour. This will not be reached 
in the poverty-stricken sections of our great cities, where the 
children are invariably of a low average of physical condition, 
and will be exceeded in the more prosperous districts, where the 
children are much more nearly normal. 

Although 10 examinations per hour is a fair average on which 
to base calculations, it must be remembered that one examiner 
should not be expected to do this work much more than two or 
three hours per day. This means a limit of from 20 to 30 examina- 
tions per physician per day. From these figures an estimate of 
per capita cost may be reached. How much this will amount to 
will depend not only on the rate of remuneration of the physicians, 
but to a considerable degree on the character of clerical help 
afforded him for recording the results of his examinations. 

Probably the best plan, making for increased efficiency as 
well as economy, is to have the school nurse or the room teacher 
record the results of the examinations. In the latter case a sub- 
stitute must of course be placed in charge of the teacher's room 
during her absence. There is a distinct advantage in thus enlist- 
ing the active sympathy and assistance of the room teacher. 

* For full discussion of this subject see Chap. VIII, p. 101 ff. 

43 



MEDICAL INSPECTION OF SCHOOLS 



TESTS OF VISION AND HEARING 

There are some differences of opinion and practice as to the 
manner of conducting tests of vision and hearing. Probably in 
a majority of cities which conduct physical examinations these 
tests are made by the school physicians. There are many locali- 
ties, however, in which they are conducted by the class room 
teacher. The laws and regulations of 1 1 states provide for 
physical examinations, and in seven cases provision, either 
mandatory or permissive, is made for vision and hearing tests 
by teachers. 

There can be little doubt that this practice has grown 
to such large proportions mainly through the influence of the 
Massachusetts statute of 1906, which required each teacher to 
test the sight and hearing of her pupils at least once a year and 
to report the results. This statute is still in force. The policy 
of the Massachusetts legislators in making mandatory tests 
by teachers, rather than tests by specialists, has evoked many 
expressions of surprise and some of criticism. However, the 
record of the debates which took place before the passage of the 
law shows that these provisions were inserted on the recommenda- 
tion of the specialists themselves, who deemed that such tests 
were wholly within the capacity of the teacher. It was their 
opinion that the children, if examined by the teacher, would be 
subjected to less nervous strain than if tested by a stranger and 
would, therefore, respond to the tests in a more natural way. 
It is the intention of the Massachusetts law that a scientific 
examination by a specialist shall be made in any case where 
defects are apparently revealed by the teacher's test. 

During the hearings before the state committee on ways 
and means, when the Massachusetts medical inspection bill was 
being considered, a mass of evidence was presented by experts 
bearing upon the question as to whether or not such examinations 
could be successfully conducted by teachers. The high standing 
of the three gentlemen who subscribed to it makes the following 
opinion* particularly significant: 

* Massachusetts Civic League, Leaflet No. 7, p. 38. 
44 






PHYSICAL EXAMINATIONS 

It is the opinion of the undersigned, based upon professional experi- 
ence, that school teachers, with the aid of printed directions properly 
prepared, are, because of their acquaintance with the individual children 
under their charge and their consequent ability to communicate with 
them and to find out what is in their mind, more capable of making a 
satisfactory examination of the hearing of such children than a doctor 
other than a specialist called in for the purpose would be likely to be. 

(Signed) Clarence John Blake, M.D. 
D. Harold Walker, M.D. 
William F. Knowles, M.D. 

The same opinion was expressed by other experts in regard 
to eyesight. 

The methods used in Massachusetts have proved so satis- 
factory after several years of statewide use, that the rules for 
testing are here quoted in full as a guide for the conduct of such 
examinations. 

SIGHT AND HEARING TESTS IN MASSACHUSETTS 

Vision and hearing tests are made in accordance with the 
following directions prescribed by the state board of health. The 
materials for the tests are distributed to all teachers by the state 
authorities. 

COMMONWEALTH OF MASSACHUSETTS 

Chapter 502, Acts of 1906 

Directions for Testing Sight and Hearing 

(Prepared by State Board of Health) 

To TEST THE EYESIGHT 

Hang the Snellen test letters* in a good, clear light (side 
light preferred), on a level with the head. Place the child 20 
feet from the letters, one eye being covered with a card held 
firmly against the nose, without pressing on the covered eye, 
and have him read aloud, from left to right, the smallest 
letters he can see on the card. Make a record of the result. 
Children who have not learned their letters, obviously, can- 
not be given this eyesight test until after they have learned 
them. 

To RECORD THE ACUTENESS OF EYESIGHT 

There is a number over each line of test letters, which 

shows the distance in feet at which these letters should be read 

* See p. 49. 

45 



MEDICAL INSPECTION OF SCHOOLS 

by a normal eye. From top to bottom, the lines on the card 
are numbered respectively 50, 40, 30 and 20. At a distance 
of 20 feet the average normal eye should read the letters on the 
20 foot line, and if this is done correctly, or with a mistake of 
one or two letters, the vision may be noted as |, or normal. 
In this fraction the numerator is the distance in feet at which 
the letters are read, and the denominator is the number over 
the smallest line of letters read. If the smallest letters which 
can be read are on the 30 foot line, the vision will be noted as 
|; if the letters on the 40 foot line are the smallest that can be 
read, the record will be f; if the letters on the 50 foot line 
are the smallest that can be read, the record will be |. 

If the child cannot see the largest letters, the 50 foot 
line, have him approach slowly until a distance is found where 
they can be seen. If 5 feet is the greatest distance at which 
they can be read, the record will be -/^ ( T V of normal). 

Test the second eye, the first being covered with the 
card, and note the result, as before. With the second eye 
have the child read the letters from right to left, to avoid 
memorizing. To prevent reading from memory, a hole \]4 
inches square may be cut in a piece of cardboard, which may 
be held against the test letters, so as to show only one letter at 
a time, and may be moved about so as to show the letters in ir- 
regular order. A mistake of two letters on the 20 or the 30 foot 
lines, and of one letter on the 40 or 50 foot lines, may be allowed. 

Whenever it is found that the child has less than normal 
sight, f, in either eye, that the eyes or eyelids are habitually 
red and inflamed, or that there is a complaint of pain in the 
eyes or head after reading, the teacher will send a notice to 
the parent or guardian of the child, as required by law, that 
the child's eyes need medical attention. 

METHOD OF TESTING HEARING 

If it is possible, one person should make the examina- 
tions for an entire school, in order to insure an even method. 
The person selected should be one possessed of normal hearing, 
and preferably one who is acquainted with all the children, the 
announcement of an examination often tending to inspire fear. 
The examinations should be conducted in a room not 
less than 25 or 30 feet long, and situated in as quiet a place as 
possible. The floor should be marked off with parallel lines 







Vision tests by physician and nurse in Orange, N. J. 






PHYSICAL EXAMINATIONS 

one foot apart. The child should sit in a revolving chair on 
the first space. 

The examination should be made with the whispered or 
spoken voice; the child should repeat what he hears, and the 
distance at which words can be heard distinctly should be 
noted. 

The examiner should attempt to form standards by test- 
ing persons of normal hearing at normal distances. In a still 
room the standard whisper can be heard easily at 25 feet, the 
whisper of a low voice can be heard from 35 to 45 feet, and of 
a loud voice from 45 to 60 feet. 

The two ears should be tested separately. 

The test words should consist of numbers, i to 100, and 
short sentences. It is best that but one pupil at a time be 
allowed in the room, to avoid imitation. 

For the purpose of acquiring more definite information 
concerning the acuteness of hearing, one may have recourse to 
the 512 v. s. (vibrations per second) tuning fork and the 
Politzer acoumeter. 

For very young children a fair idea of the hearing may 
be obtained by picking out the backward or inattentive pupils, 
and those that seem to watch the teachers' lips, placing them 
with their backs to the examiner, and asking them to perform 
some unusual movement of the hand, or other act. 

The sight test card used is the familiar Snellen chart. A re- 
production of the form used by the Massachusetts authorities is 
shown on page 49. In 1910 "in view of the known variations 
in practice both in recording and in reporting, and in the hope 
that the tests may be made and reported uniformly" the state 
board of education issued the following supplementary directions, 
prepared by the board of health: 

1. The test will be made as early in the school year as possible, pref- 
erably in September. 

2. The tests will be made under the most favorable conditions, and 
as nearly as possible under the same conditions, preferably in well-lighted 
rooms, in the early part of the day. 

3. The testing will be done by the teacher of the class, and will 
be supervised by the principal to see that the conditions of the test are 
as uniform as possible for the different classes. 

47 



MEDICAL INSPECTION OF SCHOOLS 

4. Children wearing glasses will be tested with the glasses, and if 
found normal will be so recorded. 

5. Examine all children, but record as defective only those whose 
vision is 20/40 or less, in either eye. 

6. Report to the State Board of Education the whole number of 
children examined and the number found defective according to the stand- 
ard given in No. 5. 

The results of the examinations are recorded by the room 
teacher on double sheets, with spaces for recording the results 
of the examination of 50 pupils. A reproduction of the sheet 
heading is given on page 50. 

A report of the results for each school is forwarded to the 
superintendent by the teacher or principal. 

REPORT OF SIGHT AND HEARING TESTS TO SUPERINTENDENTS OF 
SCHOOLS, MASSACHUSETTS 



The Commonwealth of Massachusetts 

Chap. 502, Acts of 1906 



Report on Sight and Hearing Tests to Superintendent of Schools 



City 

or [ School, 

Town 



Number of pupils enrolled in the school 
' found defective in eyesight 
' found defective in hearing 
" of parents or guardians notified 



Teacher or Principal. 



In addition to these reports the teacher is required to notify 
the parent or guardian of each child found to have some trouble 
with the ears or eyes. Notification cards like the one repre- 
sented on page 50 are furnished by the state board of education. 



PHYSICAL EXAMINATIONS 



The methods described for making tests of vision and hearing 
in Massachusetts are typical of the best practice in other states. 
The practicability of having these tests made by teachers has been 
abundantly demonstrated by extensive experience, and in many 
localities this work has been the opening wedge for the establish- 
ment of complete systems of medical inspection. 

According to the investigation, tests of vision and hearing 
were in 1911 established features in the schools of 552 municipali- 
ties. Moreover, 349 of these cities had begun the work without 
legal requirement, for they are located in states which had not 
made legal provision for these tests. The distribution of the 552 
municipalities and of 258 others in which vision and hearing 
tests are made by physicians is as follows: 

TABLE 15. VISION AND HEARING TESTS CONDUCTED BY PHYSICIANS 
AND TEACHERS IN AMERICAN CITIES, BY GROUPS OF STATES. 

I9II 



Division 


Tests by physicians 


Tests by teachers 


North Atlantic .... 
South Atlantic .... 
South Central .... 
North Central .... 
Western 


125 

12 
23 

73 
25 


261 
29 
43 

37 


United States .... 


258 


552 



Data are available giving the results of vision and hearing, 
tests in Massachusetts for the years 1907-10 inclusive. Similar 
data for Connecticut and Maine for the years 1908 and 1911 
respectively are also matters of record. In brief summary form, 
results from these three states are as shown in Table 16. 

The figures for Massachusetts show a constant and somewhat 
rapid falling off in the percentage of children reported each year 
as having defective vision and hearing. Just what has caused this 
falling off is difficult to determine, and indeed, has not been 
satisfactorily explained by the educational authorities of the state. 
Whatever the cause may be, the more important lesson of the table 



MEDICAL INSPECTION OF SCHOOLS 



is that in all these states the examinations result in the discovery 
each year of many thousands of pupils with defective vision and 
hearing. This means that each year large numbers of these chil- 
dren receive treatment for defects which otherwise would in all 
probability have continued uncared for and would have con- 
stantly grown more serious. 

TABLE 1 6. RESULTS OF VISION AND HEARING TESTS IN MASSACHU- 
SETTS, CONNECTICUT, AND MAINE 







NUMBER 


OF PUPILS 


PER CENT 


OF PUPILS 


State and year 


Pupils 
examined 


Defective 


Defective 


Defective 


Defective 






in vision 


in hearing 


in vision 


in bearing 


Massachusetts 












1907 . 


432,464 


96,607 


27.387 


22.3 


6.3 


1908 . 


437.435 


81,158 


22,601 


18.6 


5-2 


1909 . 


441,463 


73.129 


20,167 


16.6 


4.6 


1910 


454,058 


71,902 


17.329 


15.8 


3.8 


Connecticut, 1908 . 


142,554 


12,217 




8.6 




Maine, 1911 . 


87,954 


11,145 


4,075 


12.7 


4.6 



RECORDS 

Individual records are a most important feature of a system 
of physical examinations. General information about the health 
of the pupils as a whole will not do; there must be a complete 
individual record for each child. The record card or blank must 
have spaces for entering the results of subsequent examinations 
as well as the initial one. If the work is to be of real practical 
value, there must be the closest connection between the records of 
the physical examinations and those of the class room. 

Three classes of forms are essential. In the first place, there 
must be a system for notifying the parent of the results of the 
physical examination of the child. Forms of this sort are con- 
sidered in Chapter VI entitled, Making Medical Inspection 
Effective.* In the second place, there is the individual record for 
each child. To be effective, this record must be an integral part 
of the child's educational accounting and must be always available, 

* See p. 72 ff . 
52 




>> 

u 



PHYSICAL EXAMINATIONS 

constantly kept up to date, and frequently referred to as an aid 
in reaching decisions affecting the child's welfare. It does no 
good to have a record on a card filed away in the principal's office 
or in the office of the board of health, to the effect that Willie 
is stone deaf in the right ear, if the teacher knows nothing of his 
defect and still has Willie seated in the back left-hand corner of the 
room. Moreover, the records must follow the child from room to 
room and, in case of transfer, from school to school, for otherwise 
much of the information obtained is soon rendered useless. 

These are some of the reasons why systems for conducting 
physical examinations constitute entirely different problems from 
systems of medical inspection which aim only at the detection of 
cases of contagious disease. The latter sort of work can quite 
satisfactorily be handled by representatives of the board of health, 
while systems for conducting physical examinations, if they are 
permanently to succeed, must have the active co-operation of the 
educational authorities. 

Few cities have developed record systems which satisfactorily 
fulfill the requirements outlined above. A fairly well devised card 
for keeping the individual record of physical examinations is that 
in use in the Chicago schools. It is reproduced on page 54. This 
card measures 4x6 inches and has spaces which provide for eight 
annual examinations. On the reverse side are spaces for "diag- 
nosis" and "treatment received" with dates. 

A somewhat more complete record is the one kept in the 
public schools of Pasadena, California. This card, shown on page 
55, has the added advantage of providing spaces for the recording 
of data by the teacher as well as by the physician. This feature 
insures the intimate interest of the class room teacher in the work 
and in the records. The reverse of the Pasadena card has spaces 
designed to record the dates of physical examinations, and the 
dates and results of visits made by the school nurse to the pupil's 
home. 

A still more complete record is called for by the card used in 
Berkeley, California, which provides on its face for the data of the 
physical examinations, and on its reverse has spaces for keeping 
the scholarship record. This card, face and reverse, is given on 
pages 56 and 57. 

53 



INDIVIDUAL RECORD CARD. PHYSICAL EXAMINATIONS, CHICAGO, ILL. 



DEPARTMENT OF HEALTH CITY OF CHICAGO 

NAME ADDRESS 


PHYSICAL RECORD 
SEX AGE BIRTHPLACE 


NATIONALITY OF FATHER MOTHER 


No. OF CHILDREN IN FAMILY His. OF MEASLES 


DIPH. PERTUSSIS PNEU. SCARLET FEVER 


SCHOOL VACCINATED? 


DATE IST EXAM. 19 


O PLACED IN SQUARE MEANS ABSENCE OF DEFECTS. X DENOTES DEFECTS 


i GRADE 


i 


2 


3 


4 


5 


6 


7 


8 


2 YEARS IN SCHOOL 


















3 REVACCINATION 


















4 DISEASES DURING YEAR 


















S DATEOFPHYS. EXAM. 


















6 HEIGHT 


















7 WEIGHT 


















8 NUTRITION 


















9 ANEMIA 


















10 ENLARGED GLANDS 


















it GOITRE 


















12 NERVOUS DISEASES 


















13 CARDIAC DISEASE 


















14 PULMONARY " 


















15 SKIN 


















16 DEFECT ORTHOPEDIC 


















17 RACHITIC TYPE 


















1 8 DEFECT OF VISION 


















19 OTHER DISEASES OF EYE 


















20 DEFECT OF HEARING 


















21 DISCHARGING EAR 


















DEFECT OF NASAL 
22 BREATHING 


















23 DEFECT OF PALATE 


















24 " " TEETH 


















25 HYPERTROPHIED TONSILS 


















26 ADENOIDS 


















27 MENTALITY 


















28 CONDUCT 


















29 EFFORT 


















30 PROFICIENCY 


















31 WASTREATM'T ADVISED 




























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PHYSICAL EXAMINATIONS 



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57 



MEDICAL INSPECTION OF SCHOOLS 

Reference has been made to the three types of records which 
must be kept: the first is the card of notification to the parents, 
the second is the individual physical record, the third is the blank 
on which the school physician periodically records the numbers and 
results of the physical examinations made by him. This third 
form is in nature a recapitulation of the individual records and 
must be designed so that the results of large numbers of individual 
records may be combined on it and presented in report form. 



RECORDS OF COMBINATIONS OF DEFECTS 

Reference to the tables which have been presented, giving 
the results of physical examinations,* shows that the total number 
of defects reported is considerably in excess of the number of 
defective children found. This is because one child frequently 
suffers from several sorts of defects. 

For example, the child who has seriously hypertrophied 
tonsils commonly suffers from adenoids, and when he has both of 
these defects to a marked degree, he almost certainly has in addi- 
tion seriously defective teeth. Plainly, the value of the records 
would be greatly enhanced if there were some method for recording 
not only the existence of separate defects, but the combinations 
in which they are found. Only through making and studying such 
records can trustworthy conclusions be formed as to the degree to 
which different defects are to be rated as both causes and effects 
of one another. 

The first requisite of a plan for recording combinations is 
that it be simple; and this means that it must be restricted to a few 
of the more important defects. The reason for this is that the 
number of possible combinations increases with enormous rapidity 
with each increase in the number of defects considered. Thus, if 
we are considering two defects, A and B, there are four possible 
combinations. First, the child may have neither defect; second, 
he may have A; third, he may have B; and in the fourth place, he 
may have both A and B. When we consider three defects, there 
are eight possible combinations; and when the number is increased 
to four, the combinations increase to 16. Proceeding at the same 
* See Tables 1 1 and 12, p. 38. 

58 



PHYSICAL EXAMINATIONS 

ratio, there are 32 possible combinations of five defects, and 64 
of six defects. 

These figures will suffice to support the statement that any 
plan for recording combinations of defects must provide for 
recording data pertaining only to the more important sorts of 
defectiveness. Fortunately, this is made possible by existing 
conditions. We have seen from the data presented that defects 
of teeth, eyes, throat, and nose constitute more than four-fifths 
of all the cases of physical defectiveness. 

The problem, then, is to develop a system for recording 
the combinations of these defects. This can be done simply and 
easily by making provision on the individual physical record card 
of each child for recording the presence of any of these defects 
or any combination of them by printing the four words Teeth, 
Throat, Eyes, Nose, at the four corners of a square as follows: 

Teeth Throat 



Eyes Nose 

If the examination shows that the child has defective 
teeth, the fact is recorded by drawing a line from the word 
"Teeth" to the dot in the middle of the square as follows: 

Teeth. Throat 

Eyes Nose 

In a similar way this device may be used to record any one 
of the 1 6 possible combinations of the four defects. These possible 
uses are the following: 

No Defect One Possible Combination 
Teeth Throat 






Eyes Nose 

59 



MEDICAL INSPECTION OF SCHOOLS 

One Defect Four Possible Combinations 
Teeth v Throat Teeth Throat 

Eyes Nose Eyes Nose 

Teeth Throat Teeth Throat 

Eyes Nose Eyes ^Nose 

Two Defects Six Possible Combinations 
Teeth. Throat Teeth .Throat 

Eyes Nose Eyes ^ 



Teeth ^Throat Teeth v Throat 



\ 



Eyes ' Nose Eyes ' N Nose 

Teeth Throat Teeth Throat 

Eyes Nose Eyes * ^Nose 

Three Defects Four Possible Combinations 
Teeth Throat Teeth Throat 

Eyes - ^Nose Eyes ^ Nose 

Teeth Throat Teeth .Throat 

Eyes * Nose Eyes ^ Nose 

Four Defects One Possible Combination 
Teeth Throat 

Eyes ' ^ Nose 
60 



PHYSICAL EXAMINATIONS 

If the recapitulation blank on which the medical inspector 
reports his work by schools for a term or year is furnished with 
spaces for recording these combinations, the data from the individ- 
ual cards can be rapidly and easily transferred. This makes it 
easy to bring together data for any part of the system for study 
and report. The scheme also has the advantage of showing 
automatically the number of pupils not defective and those 
suffering respectively from one, two, three, or four of these impor- 
tant defects. Moreover, by means of this scheme it is easy to 
discover the total number of cases of defective teeth, eyes, etc., 
both singly and in combinations. Most important of all, the plan 
furnishes valuable material for discovering causes and effects. 

SUMMARY. Physical examinations aim to insure for each 
child such physical and mental vitality as will best enable him to 
take full advantage of the free education offered by the state. 
There is a mass of convincing evidence showing that a large 
percentage of all school children suffer from remediable physical 
defects which can be prevented or cured if detected early in life. 

In the average city school system, about 65 per cent of the 
children have physical defects serious enough to warrant treatment 
by a physician, oculist, or dentist. Nearly 85 per cent of all these 
defects are those of teeth, throat, eyes, and nose. Complete 
examinations require from three to ten minutes per child. Eleven 
American states have laws providing for the physical examination 
of school children. 



61 



CHAPTER V 
THE SCHOOL NURSE 

THE value of the school nurse is the one feature of medical 
inspection of schools about which there is no division of 
opinion. Her services have abundantly demonstrated their 
utility, and her employment has quite passed the experimental 
stage. The introduction of the trained nurse into the service of 
education has been rapid, and few school innovations have met 
with such widespread support and unqualified approval. 

The reason for this is that the school nurse supplies the 
motive force which makes medical inspection effective. The 
school physician's discovery of defects and diseases is of little use 
if the result is only the entering of the fact on the record card or the 
exclusion of the child from school. The notice sent to parents 
telling of the child's condition and advising that the family physi- 
cian be consulted, represents wasted effort if the parents fail to 
realize the import of the notification or if there be no family 
physician to consult. The nurse converts these ineffective lost 
motions into efficient functioning by assisting the physician in his 
examinations, personally following up the cases to insure remedial 
action, and educating teachers, children, and parents in practical 
applied hygiene. 

HISTORY AND PRESENT STATUS 

School nursing had its inception in London in 1894 when the 
managers of a school in a very poor section asked a district nurse 
to visit the school to do what she could to promote the physical 
welfare of the children. This beginning was followed in 1898 by 
the formation of a volunteer "School Nurses' Society" with the 
object of supplying visiting nurses to elementary schools in four 

62 



K 5 . 




THE SCHOOL NURSE 

districts. Work was begun by the appointment of three nurses, 
each of whom had four schools under her care. 

These early experiments demonstrated so conclusively the 
value of the nurse's services that in 1904 the system was taken over 
by the city and supported by municipal funds. The number of 
nurses was greatly increased and the work rapidly spread to other 
towns and cities. 

From the work in London came the suggestion for a nursing 
staff in the schools of New York. Medical inspection had been 
begun in the schools of New York in 1897, and by 1902 the number 
of children excluded for infectious or contagious diseases had risen 
to alarming proportions. During the latter year there were 
nearly 18,000 such exclusions, and many schools were so depleted 
that almost half of their children were absent. This condition 
aroused serious protest on the part of parents and teachers. 

At this juncture Lillian D. Wald, head worker of the Henry 
Street Nurses' Settlement, called attention to the work of the 
school nurses in England and offered to lend the services of one 
of her staff for an experimental demonstration of one month. 
This first American school nurse was Lina L. Rogers. As in t 
England, so in America, it required only one demonstration to/ 
convince the public of the value of the school nurse. Her' 
services were so valuable that the educational authorities, the 
board of health, and the public were at once converted to the 
new idea, and the movement for the employment of nurses in 
connection with systems of medical inspection rapidly spread to 
other cities. By means of work in the schools and in the home 
minor ailments were promptly cared for, and the number of exclu- 
sions greatly reduced. 

According to the investigation conducted by the Russell 
Sage Foundation in 1911, there were at the beginning of that year 
415 school nurses employed in 102 municipalities in the United 
States, and 375 of these, or 90 per cent, were in the North Atlantic 
or North Central states. About one-quarter of the cities hav- 
ing systems of medical inspection employed school nurses, and 
the number is rapidly increasing. Again, there was a consid- 
erable number of cities where nurses were employed, but no physi- 
cians. 

63 



MEDICAL INSPECTION OF SCHOOLS 

THE NURSE IN AMERICAN SCHOOL SYSTEMS 

DUTIES 

The functions of the school nurse are most varied in different 
communities and include duties which range from the reporting 
of cases of truancy to diagnosing contagious diseases two extremes, 
neither of which properly falls within the purview of her work. 
In general her duties may be concisely summarized as follows: 

1. In the school: 

(a) Making routine examinations of children to detect those cases 
which should be referred to the school physician. 

(b) Assisting the physician in making physical examinations and 
recording results. 

(c) Acting in emergency cases such as caring for accidents, ban- 
daging cuts, removing splinters, caring for cases of fainting, convulsions, 
and the like. 

2. In the home: 

(a) Explaining to parents the significance of the notices sent by 
the school physicians concerning the condition of their children and aid- 
ing the parents in securing remedial action. 

(b) Instructing and educating parents in the practices of. applied 
hygiene. 

3. In the clinic: 

(a) Assisting the physicians in treatments and operations. 

(b) Leading the children to view the proceedings of the clinic as 
diverting experiences rather than terrifying ordeals. 

QUALIFICATIONS 

The history of school nursing shows its continual extension 
into wider and wider fields, and its constantly increasing demands 
for unusual qualifications on the part of the workers. In a techni- 
cal sense the work is not really nursing at all, but it calls for a 
skill and knowledge acquired only in the training schools for nurses, 
and demands in addition qualifications which can at present be 
secured only in the school of experience. 

It is a safe rule that no school nurse should be employed who 
is not a graduate of a training school of recognized high standing. 

64 



THE SCHOOL NURSE 

In addition, she should have had special experience with children, 
of the sort that she would gain through serving on the staff of a 
children's hospital. 

In judging the qualifications of candidates, success in dis-\ 
trict work should be given preference over length of experience./ 
The successful school nurse is, first of all, an intermediary between 
physicians, teachers, parents, and children. Permanent success 
requires tact above all other qualifications. No single phra; 
in our language adequately describes the qualification or abiliti 
referred to. It is that attribute which the Spaniards designat< 
as the "don de gentes," which, freely translated, means the ^gil 
of getting along with people/' 

Among other necessary qualifications may be mentioned 
activity, and ability to carry a large amount of work without 
worry. Any tendency to gossip should constitute sufficient cause 
for immediate disqualification. 

EFFECTIVENESS OF THE NURSE'S WORK 
Reference has been made to the value of the school nurse's 
work in reducing the number of exclusions on account of contagious 
and infectious diseases. How this operates in practice is shown by 
the experience of New York City before and after the organization 
of the corps of school nurses. In the system prevailing up to 1902 
all cases of contagious and infectious diseases were excluded by the 
physician. If this system had continued in force the number of 
exclusions in 1911 would have reached a grand total of 253,738. 
This number is so great in proportion to the total membership of 
the schools that had all these children been excluded the entire 
school system would have been seriously disorganized. The 
actual number of exclusions during 191 1 amounted to 8,154, or a 
little more than 3 per cent of the number of cases of contagious 
diseases. This means that in the experience of New York City, 
through the employment of school nurses exclusions from school 
had been reduced to something like one-thirtieth of their forme^ 
proportions. 

While a review of reports on medical inspection in American 
cities shows that superintendents and medical inspectors have 
abundantly endorsed the work of school nurses, it is only rarely 

5 6 5 



MEDICAL INSPECTION OF SCHOOLS 

that data are found giving any sort of measure of the value of their 
services. Almost the only direct comparison between results 
accomplished with and without the co-operation of the nurses 
comes from the city of Philadelphia. Data bearing on the problem 
were presented by Dr. Samuel W. Newmayer of that city in a paper 
entitled Evidence that the School Nurse Pays, printed in the 
proceedings of the Fifth Annual Congress of the American School 
Hygiene Association. 

The first set of data presented by Dr. Newmayer shows the 
number and per cent of recommendations acted upon in four 
schools where a nurse was at work as compared with the number 
acted upon in four other schools where the medical inspector was 
unaided by a nurse. This comparison is shown in Table 1 7. 



TABLE 17. RESULTS OBTAINED BY MEDICAL INSPECTORS AIDED AND 

NOT AIDED BY SCHOOL NURSES. EIGHT SCHOOLS, 

PHILADELPHIA, IQIO 



RESULTS WITH NURSE'S AID 


RESULTS WITHOUT NURSE'S AID 




*9 

| 


a 






K 


a 






** 









S 


S s 


8 




<3 




S 




53 


<3 S 


2 


School 


1 


s s 


li 
84 

<o 
k. 


School 


1 


1* 
h 

g ts 


H 

v. 




1 


O <3 


a. 




s 


2 Q 


tt. 




ftj 


Qtf 






04 


04 




A 


324 


262 


81 


E 


283 


83 


29 


B . . . 


445 


434 


98 


F . . . 


582 


152 


26 


C . . . 


320 


282 


88 


G . . . 


441 


94 


21 


D . . . 


264 


226 


86 


H . . . 


474 




'9 


Total . 


,353 


1,204 


89 


Total . 


1,780 


420 


24 



A comparison of the percentage figures shows that in the 
four schools where the inspector was aided by a nurse 89 per cent 
of the recommendations were acted upon, whereas in the four other 
schools, where the medical inspector worked alone, only 24 per 
cent of the recommendations resulted in action. 

Dr. Newmayer's second series of data contrasted two sets 

66 



THE SCHOOL NURSE 



of results with respect to four specified kinds of physical defects. 
The data are presented in Table 18. 

TABLE l8. RESULTS OBTAINED BY MEDICAL INSPECTORS AIDED AND 
NOT AIDED BY SCHOOL NURSES. PHILADELPHIA, 1910 



Defect 


RESULTS WITH NURSE'S 

AID 


RESULTS WITHOUT NURSE'S 

AID 


Number 
of cases 


Cases 
treated 


Per cent 
treated 


Number 
of cases 


Cases 
treated 


Per cent 
treated 


Vision .... 
Tonsils 
Adenoids 
Teeth .... 


441 
104 
62 
150 


355 
68 

45 
138 


80 
65 

73 
92 


272 
338 
36 
152 


r 
62 

5 
31 


26 
18 
14 

20 


Total 


757 


606 


80 


798 


1 68 


21 



A comparison of the figures in the percentage columns shows 
that where the inspector was aided by a nurse, 80 per cent of the j 
cases received treatment as contrasted with only 2 1 per cent where/ 
he was without such aid. The investigation covered the same 
period of time in the two cases and the defects existed among 704 
children in the school where the inspector was aided by a nurse, 
and among 75 1 children where he was not aided by a nurse. 

While the comparisons presented in the foregoing tables 
constitute an impressive argument in favor of utilizing the services 
of a school nurse to increase the effectiveness of medical inspection, 
they must not be accepted as giving a true measure of the value of 
such services. We must not interpret them as meaning as the 
figures would seem to show that medical inspection with a nurse 
is three or four times as effective as medical inspection without a 
nurse. In the case of the per cent shown in the first table we are 
not certain as to the character of the "results" reported, and in 
studying both comparisons it must be borne in mind that they 
represent reports of special studies made with the object of demon- 
strating the effectiveness of the nurse's work. Nevertheless, the 
comparisons are of value in showing that the effectiveness of medi- 
cal inspection is definitely and distinctly enhanced when the work 
of the school physician is supplemented by that of the school nurse. 

67 



MEDICAL INSPECTION OF SCHOOLS 

PROPORTION OF NURSES TO PUPILS 

Experience in New York, Philadelphia, and other large 
cities has shown that in the congested districts a nurse should be 
^provided for every 3,000 or 4,000 pupils. With this number of 
pupils the nurses can do effective and efficient home visiting as 
well as the work of routine inspection in the schools. In cities 
of from 20,000 to 30,000 inhabitants with a public school enroll- 
ment of 3,000 to 5,000 the services of one nurse will be found 
adequate, providing the schools are reasonably near together. 

It must be remembered in this connection that much depends 
on the social status of the children. The records of medical in- 
spection in great cities show that many sorts of physical defects 
vary in more or less direct proportion with the degree of poverty 
in the homes of the children. Among such defects are enlarged 
tonsils, defective nasal breathing, defective hearing, decayed 
teeth, skin diseases, vermin, and above all, malnutrition. In the 
poorer sections of cities and in quarters largely peopled with recent 
immigrants the prevalence of these conditions will require the 
appointment of more nurses if the work is to be done effectively. 
With conditions as they now exist in such sections of our greater 
cities, one nurse for each 2,000 children or even one for each 1,500 
is none too many. 

RULES FOR NURSES 

The following set of rules issued by the board of education 
of Newark, New Jersey, embodies most of the features that 
characterize the best practice in connection with the rules and 
instructions laid down for the guidance of school nurses. With 
such modifications as local conditions demand, they will be found 
satisfactory for use in most communities. 

Rule i. Nurses shall at all times be under the direction of the 
Supervisor of Medical Inspection. 

Rule 2. Applicants for the position of school nurse shall submit 
to an oral and written examination and also to a physical examination 
by the Supervisor of Medical Inspection. All applicants must hold a 
certificate of graduation from an approved training school for nurses, 
having a course of not less than two years. 

Rule 3. The salary of each nurse shall be for the first year, $720; 

68 



THE SCHOOL NURSE 

second year, $780; third year, $840; fourth year, $900, the maximum; 
in twelve monthly payments. In addition, each nurse shall be supplied 
with carfare at the expense of the Board of Education and an outfit, 
consisting of a bag and supplies for treating her cases. These supplies 
shall be obtained on order from the Department of Medical Inspection. 

Rule 4. Each nurse shall devote her entire time to the school 
work during the hours of service, which shall be from eight a. m. to 
twelve noon, and from one p. m. to five p. m. on all week days except 
Saturday, when the hours of service shall be from eight a. m. to twelve 
noon, and at other times if required by the Supervisor of Medical In- 
spection in special cases. Nurses shall report to the office of the Super- 
visor of Medical Inspection each morning at eight a. m. for instruction, 
and shall attend meetings with the Supervisor of Medical Inspection at 
his call. A daily report shall be made out by each nurse on forms sup- 
plied by the department and filed in the oifice of the Supervisor of Medical 
Inspection. Each nurse shall, on visiting a school, register her name, time 
of arrival and departure, in the attendance book in the principal's office. 

Rule 5. Nurses shall perform class room inspection once a month, 
or oftener if directed by the Supervisor of Medical Inspection. Nurses 
shall refer all cases of suspected disease or defect, except pediculosis, to 
the medical inspector for his opinion as to what shall be done. Where 
contagious disease is suspected, and the doctor is not in the school, the 
pupil shall be excluded. The name, age, address, and school of pupil 
shall be reported immediately to the office of the Supervisor of Medical 
Inspection. All other diseases and defects which are not contagious 
shall be brought to the notice of the medical inspector as soon as possible. 

Rule 6. The nurse shall have entire charge of all cases of pedicu- 
losis and uncleanliness. 

Rule 7. The diseases to be treated by the nurse are as follows: 
Ringworm, scabies, favus, impetigo, molluscum contagiosum, conjuncti- 
vitis, infected wounds, contusions and uncleanliness. No case of the 
above diseases shall be treated by a nurse without the diagnosis being 
confirmed by the medical inspector of the school which the pupil attends, 
and whenever possible, with the parents' consent. A record shall be kept 
of each pupil when placed under treatment by the nurse and the dates 
of subsequent treatments noted on forms supplied by the Board of Ed- 
ucation. 

Rule 8. It shall be the duty of the nurse to visit the homes in 
special cases, for the purpose of interviewing and instructing the parents 
or guardians. These visits shall be made before or after school hours 
and on Saturdays. 

69 



MEDICAL INSPECTION OF SCHOOLS 

Cases to be visited by the nurse at home are 

(a) Flagrant cases of pediculosis. The nurse shall show the 
mother how to treat the conditions and encourage persistence. 

(b) Excluded cases that do not return at the appointed time. 

(c) The nurse shall call at the homes of any children whose par- 
ents have refused or neglected to comply with the request of the medical 
inspector or have not given a satisfactory reason for not doing so. At 
this time the nurse shall urge upon the parent the need for treatment 
and, if necessary, demonstrate how it shall be done. 

Rule 9. Practical talks on personal hygiene and home hygiene 
shall be given by each nurse to the pupils at such times as the Supervisor 
of Medical Inspection shall specify, but not to interfere with the ordinary 
routine of the school. 

Rule 10. Each nurse shall receive one month's vacation during 
the interval between the closing of the school year in June, and the re- 
opening of the schools in September, the time of vacation to be designated 
and assigned by the Supervisor of Medical Inspection. 

Rule 1 1 . School nurses shall be appointed to serve for a term of 
one year, extending from February ist to January 3ist. In case a va- 
cancy occurs, same shall be filled for the unexpired term only. 

SALARIES 

The salaries of school nurses in American municipalities 
range from $500 to $1,500 per annum. The study made in 191 1 
showed that the salaries of nurses were distributed as shown in 
the following table : 

TABLE 19. SALARIES OF NURSES IN IO6 AMERICAN MUNICIPALITIES 



Salary 




Number of cities where nurses 
received salary indicated 


No salary . .... 

$2OI-$3OO . .... 

$40i-$5oo . .... 
$50i-$6oo . .... 
$6oi-$yoo . .... 
#70i-#8oo . .... 
$8oi-$9oo 




21 
2 

I 
21 

I? 
24 
I c 


$90i-$iooo 
$iooi-$i 500 
Fees according to service 




2 
2- 
I 


Total 




1 06 



70 



THE SCHOOL NURSE 

The table shows that there are more cities paying their 
school nurses from $70 1 to $800 per annum than there are paying any 
other salary, but the average salary would be about $700 per year. 
Where the nurses render services without cost to the municipality 
their salaries are paid by some other organization, and in the cases 
where the salary is between $200 and $300 the payment is made in 
return for only a part of the nurse's time. In some cases these 
salary figures represent remuneration for twelve months' service, 
and in other cases for only nine or ten months. 

It is a safe rule that no municipality should expect to secure 
the services of competent women of the right type for less than $75 
per month. In addition, provision should be made for increases 
based on satisfactory services and higher salaries for those doing 
supervisory work. 

SUMMARY. To sum up the case for the school nurse: She 
is the teacher of the parents, the pupils, the teachers, and the 
family in applied practical hygiene. Her work prevents loss of 
time on the part of the pupils and vastly reduces the number of 
exclusions for contagious diseases. She cures minor ailments in 
the school and clinic and furnishes efficient aid in emergencies. 
She gives practical demonstrations in the home of required treat- 
ments, often discovering there the source of the trouble, which, 
if undiscovered, would render useless the work of the medical 
inspector in the school. The school nurse is the most efficient 
possible link between the school and the home. Her work is 
immensely important in its direct results and far-reaching in its 
indirect influences. Among foreign populations she is a very potent 
force for Americanization. 



CHAPTER VI 
MAKING MEDICAL INSPECTION EFFECTIVE 

MEDICAL inspection came into being when educators 
awoke to a realizing sense of the intimate relationship 
existing between physical vigor and mental efficiency. 
Physical examinations have become the most important feature 
of medical inspection because of the great mass of data showing 
that a large proportion of all school children suffer from entirely 
remediable physical defects, the very existence of which was 
formerly unsuspected by the teachers, by the parents, and by the 
pupils themselves. 

The theory underlying the conduct of physical examinations, 
as we have noted, has been that it is the function of the school 
medical department to discover these defects and bring their 
existence to the attention of the parents. Wherever inspection 
has been carried on for any considerable time, experience has 
demonstrated that this procedure is not sufficient. After the first 
interest dies down, mere notification does not suffice to secure 
action on the part of any large proportion of the parents. In 
order that the work may be effective, the cases must be followed up, 
the parents convinced that some action is necessary, and the 
community educated up to a new standard of applied hygiene. 



SECURING PARENTS' CO-OPERATION 

NOTIFICATIONS OF PARENTS 

In the simplest systems of medical inspection, parents are 
notified of defects discovered by means of a simple card advising 
that the child be taken to a physician for treatment. A typical 
example of such a card is the one furnished by the state board of 
education of Massachusetts. 

72 



MAKING MEDICAL INSPECTION EFFECTIVE 
NOTICE TO PARENT OR GUARDIAN, MASSACHUSETTS 



Commonwealth of Massachusetts 



NOTICE TO PARENT OR GUARDIAN 

IN ACCORDANCE WITH CHAPTER 502 OF THE ACTS OF 1906 YOU 
ARE HEREBY NOTIFIED THAT 

HAS BEEN EXAMINED BY ME AS SCHOOL PHYSICIAN AND FOUND 
TO HAVE SYMPTOMS OF 

PLEASE SECURE COMPETENT MEDICAL ADVICE 
AT ONCE 

SCHOOL PHYSICIAN. 

....19 



When systems become more highly developed, it is found that 
the effectiveness of the work can be greatly enhanced by sending 
the notification on a return post card which serves the purpose of 
notifying the parent of the condition of his child, making a brief 
statement as to the importance of the case, and providing a con- 
venient means whereby the physician consulted can report back 
to the school authorities what action, if any, he has taken in the 
case. The post card form in use in Birmingham, Alabama, shown 
on page 74, fulfills these three objects admirably. 

SECURING PARENTS' CONSENT 

In many cities special forms are used on which parents give 
written consent to have their children treated at the school clinics 
or the hospitals working in co-operation with the educational 
authorities. A typical blank of this type is the form reproduced 
on page 75, which is in use in the public schools of St. Louis. 

PARENTS PRESENT AT EXAMINATIONS 

In England and in Germany special care is taken to have 
parents present during the examination of their children in order 

73 



MEDICAL INSPECTION OF SCHOOLS 

POST CARD NOTIFICATION FORM, BIRMINGHAM, ALABAMA 
Present this Card to Physician. Series C Form i 

BOARD OF EDUCATION 

BIRMINGHAM, ALA. 

School. Date 191.... 

M 

We have reason to believe that 

a pupil in the school, is in need of medical attention for 

We advise that you consult your 

family physician, or the Free Dispensary of the Hillman 
Hospital (open daily at 12:00 o'clock, noon). 

M. D. 

MEDICAL DIRECTOR. 



(OVER) 



TO TH F PHYSICIAN' In order to complete the record in this case, you 
' are requested to kindly state the result of your 

examination and to mail this card. Please do not write the name of the child, as this card 
is registered by number. 

The child presenting this card is found to suffer from 



Treatment has been instituted. 

Date M.D. 

No.... 



TO PARENTS: 

Experience has shown that a large percentage of school 
children suffer from eye-strain, throat or ear disease, or other 
preventable defects. These disorders can be greatly relieved 
or prevented, if recognized early, but if allowed to persist or 
grow worse, may seriously impair the child's general health 
and mental development. Mental backwardness may be 
traced frequently to physical defects. 

Such diseases may be readily recognized in the school 
room, and this recognition and prevention is the object of 
the Department of Medical Inspection in the schools. 
Respectfully, J. H. PHILLIPS, 

Superintendent. 

74 



MAKING MEDICAL INSPECTION EFFECTIVE 
PARENT'S CONSENT BLANK, ST. LOUIS, MISSOURI 



FORM II-Q 



ST. LOUIS PUBLIC SCHOOLS. 

DEPARTMENT OF HYGIENE. 



PARENT'S CONSENT BLANK. 

St. Louis, 

I desire and hereby authorize that my child 

be taken by the school nurse to 

the Free Medical Clinic or Free Hospital for whatever treat- 
ment, medicinal or surgical, the Doctors in charge find 
necessary to improve the health of the above named child. 
Respectfully, 



School Nurse Witness: 



that their sympathy and assistance may be enlisted and held. 
This purpose is expressed in the memorandum of the British 
board of education as follows: 

"Nor must the influence which the parent can exercise by ex- 
ample and precept be neglected. One of the objects of the new legisla- 
tion is to stimulate a sense of duty in matters affecting health in the 
homes of the people, to enlist the best services and interests of the parents, 

75 



MEDICAL INSPECTION OF SCHOOLS 

and to educate their sense of responsibility for the personal hygiene" of 
their children. The increased work undertaken by the state for the 
individual will mean that the parents have not to do less for themselves 
and their children, but more." 

In the attainment of this purpose, the English educational 
authorities almost invariably attempt to have either the parent 
or guardian of the child present during the first examination. 
In 1909 the percentage of parents attending inspections varied 
from 13 to 90 in different localities. In more than half of these 
localities the parents were present during more than 50 per cent of 
the examinations. 

Methods and results similar to those outlined are features 
of the German systems. Unfortunately, the plan has never been 
tried on any extensive scale in America and it is only recently 
that our educational authorities have begun to realize that true 
effectiveness in medical inspection is in a large measure dependent 
upon securing the active co-operation and interest of the parents. 

FOLLOW-UP VISITS 

In the chapter describing the work of the school nurse, 
reference has been made to the valuable services rendered by school 
nurses in following up cases and securing action.* Extended 
experience in many localities has demonstrated that by this 
method the percentage of pupils receiving remedial attention may 
be greatly increased and the effectiveness of the measures taken 
greatly enhanced. 

It is probably safe to hazard the generalization that after 
systems of physical examination have been in force for some years 
the percentage of children receiving remedial attention where no 
follow-up system is employed is apt to fall to about 15, and that 
where there is a follow-up system and school nurses are employed 
to visit the homes when necessary, this percentage can be held at 
about 75. 

OFFICE CONSULTATION 

In many of the more efficient American systems it has been 
found desirable for the school physician to arrange for regular 

* See Chap. V, p. 62. 
7 6 




Team work between physician and nurse in Toledo, Ohio. 



MAKING MEDICAL INSPECTION EFFECTIVE 



office hours during which he can be consulted by the parents of 
the children. These consultations are for the purpose of furnish- 
ing advice and not for the purpose of giving treatment. They are 
most effective in securing the sympathetic co-operation of the 
parents with the work and aims of the school medical department. 
The forms reproduced below and on page 78, which are used in 
the public schools of Oakland and Pasadena, California, are good 
examples of cards used to notify parents of the opportunity for 
consulting with the school physician. 

NOTIFICATION OF DEFECTS AND OF OPPORTUNITIES FOR CONSULTA- 
TION, OAKLAND, CALIFORNIA 



School : OFFICE OF 

I DEPT. OF HEALTH DEVELOPMENT AND SANITATION 
Q ra( j e OAKLAND SCHOOLS 

Pupil's Name Date 

To the Guardian or Parent of 

Parents' Names 

Dear Sir: 

; : A physical examination of this pupil seems to 

Address 

; show an abnormal condition of the 

Remarks Kindly take the child to your family physi- 

dan or specialist for advice and treatment so that 

i may he in better condition to continue 

i studies. 

The Director will be in his office, /fth floor of the 
" \ Central Bank Building, from 1:30 to 4:30 p. m., 
\ Mondays and Thursdays, to meet parents and pupils 
Date i for consultation, but not for treatment. 

Very respectfully, 
\ TAKE THIS TO THE PHYSICIAN N. K. FOSTER, Director. 



These cards serve the double purpose of notifying the parent 
of the defects discovered and telling him of the office hours of the 
school physician. 

In Berkeley, California, a card* is used to inform the parent 
of the physician's office hours and invite him to visit the office. 

In Oakland another formf is used to notify the parent that 

* See p. 79. t See p. 79. 

77 



MEDICAL INSPECTION OF SCHOOLS 

NOTIFICATION OF DEFECTS AND OF OPPORTUNITIES FOR CONSULTA- 
TION, PASADENA, CALIFORNIA 



NO. 

PASADENA PUBLIC SCHOOLS 
HEALTH DEPARTMENT 

^School Date 



On careful examination we find that 
needs attention on account of 



The Public Schools of Pasadena, through their health 
department, are looking carefully into the health condition 
of all the pupils who seem to need such attention. It is 
our desire that parents shall co-operate by seeing a physi- 
cian, dentist, or other specialist as the case may require, 
without delay. The child's health must be good or his work 
will suffer. The medical examiner gives no treatment, his 
duty is to advise only. He will be glad to meet parents 
for further consultation and advice, at the office of the City 
Superintendent on Mondays and Fridays from 4 to 5 o'clock, 
provided an engagement is made for that purpose. 

DR. R. C. OLMSTED, 

Medical Examiner 
(OVER) 

The parent will kindly indicate what can be done in this 
case and return this card, signed, at the earliest possible 
time. We wish to check up the return messages within a 
week, if possible. 

In cases where parents cannot pay the usual charges for 
medical or dental treatment, special arrangements will be 
made on consultation with the medical examiner. 

(INDICATE HERE WHAT CAN BE DONE) 

Signed 



PARENT OR GUARDIAN 



MAKING MEDICAL INSPECTION EFFECTIVE 

the school nurse has called at the home during the absence of the 
parent. This card includes an invitation to call at the office for 
consultation with the medical director. 

NOTIFICATION TO PARENTS OF SCHOOL PHYSICIAN'S OFFICE HOURS 



Health and Development Department 
Berkeley Schools 



I 



CARD TO PARENTS 
F you will bring 



to the office of the School Physician, in the High School 
Building, any Tuesday, Thursday or Friday afternoon be- 
tween 2:30 and 4 o'clock, he will be very glad to give you 
additional information, and to advise you about obtaining 
medical or dental attention. 

MEDICAL DIRECTOR OF SCHOOLS 



NOTIFICATION OF NURSE S CALL AND OF SCHOOL PHYSICIAN S OFFICE 
HOURS, OAKLAND, CALIFORNIA 






DEPARTMENT OF HEALTH DEVELOPMENT AND SANITATION 
OAKLAND PUBLIC SCHOOLS 

1358 Broadway, 191 . . 

The School Nurse failed to find you at home when she 

called to consult with you regarding the condition of 

who was examined and reported for 

We desire to work with the parents to 

better the health and strength of the children, and request 
that you either call in person or report to this office if any 
attention has been given the reported defect 

Very respectfully, 

N. K. FOSTER, Director 
Office Days 
Monday and Thursday, 1:30 to 4:30 p. m. 

. .Nurse. 



79 



MEDICAL INSPECTION OF SCHOOLS 

COMMUNITY EDUCATION THROUGH PRINTED BULLETINS 

Nearly all well developed systems have some form of printed 
bulletin for instructing parents as to the methods and aims of 
medical inspection, the importance of conditions found, and 
steps necessary to remedy them. Examples of such instructions 
with respect to the care of pediculosis are to be found in the 
chapter on contagious disease, while similar instructions in regard 
to certain phases of dental work will appear in the chapter on 
dental inspection. 

Quite the best series of such bulletins is that prepared by 
Dr. Ernest Bryant Hoag of California and widely used in the 
cities of that state. These bulletins are in the form of two-page 
leaflets measuring 3>x 5^ inches, which are designed for distribu- 
tion among parents and children. They give in condensed and 
effective form authoritative information concerning the impor- 
tance of the more common physical defects. Several of them 
are reproduced in Dr. Hoag's excellent little book The Health In- 
dex of Children. This method of public education is so effective 
and Dr. Hoag's Health Pamphlets are so admirably designed to 
serve their purpose that two of them are reproduced herewith. 
Another of the same series dealing with the teeth is reproduced 
in the chapter on dental inspection. 

HEALTH PAMPHLET NO. i 

by 
Dr. Ernest Bryant Hoag 

THE RESULTS OF NOSE, THROAT AND EAR TROUBLES IN 
CHILDREN 

An examination of school children shows that many of 
them suffer from nose, throat and ear troubles. Probably 
at least 25% of our children in the schools of the United States 
have such defects. Why this is so we do not know. 

Parents are very likely to be unfamiliar with these con- 
ditions. Often they do not know when their own children 
are afflicted in this way. It is the business of the School Med- 
ical Examiner, employed by the Boards of Education or 
Boards of Health, to discover children who need medical at- 
tention. 

80 



MAKING MEDICAL INSPECTION EFFECTIVE 

No child can do his best work in school if he is suffering 
from some nose, throat or ear trouble. The commonest con- 
ditions found in such children are enlarged diseased tonsils, 
adenoids and deafness. 

The tonsils are glands in the throat, one on each side of 
the root of the tongue. When they are in a healthy con- 
dition they are barely visible. They often become much in- 
flamed and sometimes there is pus present in them. They 
may obstruct breathing. 

Any child with diseased tonsils is likely to be sickly. 

Any child with diseased tonsils is likely to have many 
attacks of sore throat, or tonsilitis. 

Any child with diseased tonsils is very susceptible to 
contagious diseases. 

Any child with diseased tonsils Has A TENDENCY 
TOWARD CONSUMPTION. 

No child can be well or do his best work in school with 
diseased tonsils. 

Diseased tonsils should usually be removed and should al- 
ways be treated. The operation is not dangerous. It al- 
ways improves the child's health. 

Adenoids are soft spongy growths behind the soft pal- 
ate, between the nose and throat. A child with adenoids 
usually breathes with his mouth open. He cannot breathe 
well through his nose. Mouth breathing is not a habit. If a 
child breathes with his mouth open it is because there is some 
obstruction in the nose. 

Adenoids cause a child to sleep with his mouth open. 

Adenoids often cause a child to snore. 

Adenoids nearly always make the teeth come in crooked. 

CROOKED AND PROMINENT TEETH ARE 
NEARLY ALWAYS CAUSED BY ADENOIDS. 

Adenoids make a child take cold easily. 

Adenoids often give a child a stupid appearance. 

Adenoids often RESULT IN ACTUAL STUPIDITY, 
because the child cannot get enough air. 

Adenoids often cause ear ache and deafness with some- 
times a running ear. Catarrh, deafness, ear ache and dis- 
charge from the ear are more often due to some obstruction 
in the nose or throat than to anything else. 

Adenoids usually result in delicate health. 

6 8l 



MEDICAL INSPECTION OF SCHOOLS 

Adenoids MUST BE REMOVED if you expect a child to 
be healthy or mentally bright. 

It is an injustice to children to neglect caring for them 
when adenoids or diseased tonsils are present. It is very 
poor economy on the part of the parent to neglect the treat- 
ment of children so affected. Any child will grow up health- 
ier, happier, and more useful if these conditions are taken 
care of. 

HEALTH PAMPHLET NO. 2 

by 

Dr. Ernest Bryant Hoag 
THE RESULTS OF DEFECTIVE EYE-SIGHT 

Defects of eye-sight in school children are very common. 
Probably at least 20% of the children of our American schools 
suffer from such defects. 

These defects not only cause a great deal of trouble in 
the eyes themselves, but often produce many other serious 
results, which do not at first seem to be connected with the 
eyes. 

The proper treatment of children's eyes will nearly al- 
ways bring good results. In this way they will often be saved 
from life-long suffering. 

A child's education will not be worth much to him if he 
does not have good eye-sight. The ability to earn a living 
depends very largely upon good eye-sight. It is very poor 
economy to neglect to care for defects in the eyes of children, 
for sooner of later such children may become burdens upon 
some one. 

The common defects in the eyes of children are as follows : 

1. NEAR SIGHT 

This condition is very serious. It not only limits the 
child's range of vision and prevents his taking part in health 
giving sports and recreation, but it produces changes in the 
eyes which often result in practical blindness. 

2. FAR SIGHT 

This condition is more common than near sight. It 
results in eye strain and often causes squinting, red eyes, 
headache, nervousness, backwardness in studies, and some- 
times digestive disorders and poor health generally. 

82 



* 



MAKING MEDICAL INSPECTION EFFECTIVE 

3. ASTIGMATISM 

This is the most common of all eye defects. It results 
in blurred vision, headache, nervousness, and other kinds of 
discomfort. It may be associated with either near sight or 
far sight. 

4. CROSS EYES OR SQUINT 

This is often the result of FAR Sight. It is absolutely 
necessary to have this defect corrected. In children this can 
usually be done with glasses alone. If the trouble is not cured 
the vision of the crossed eye will become poorer and poorer 
UNTIL AT LAST THIS EYE BECOMES BLIND. 

5. INFLAMED OR RED EYES 

This condition is often caused by a defect in vision, 
but frequently it is due to INFECTION. That is, some- 
thing has gotten into the eyes and carried PUS-PRODUC- 
ING GERMS WITH IT. 

Serious eye disorders are sometimes "caught" from 
dirty towels, public bathing pools, dirty hands, or dust. 

Each child and grown person should use only his own 
towel. Red sore eyes ought never to be neglected. Remem- 
ber that many cases of sore eyes are contagious and that all 
such cases need the attention of a doctor. 

Peculiar postures, holding the head on one side, squint- 
ing, miscalling words and headache should always raise the 
suspicion of possible eye trouble. 

LEGAL COMPULSION 

Two of the states which have framed regulations or enacted 
laws on medical inspection have provided for compulsory action 
against parents who fail to act upon notification of disease or 
defect in their children. 

Colorado, in the law passed in 1 909, provided that 

" If the parents or guardian of such child [i.e., one found defective 
concerning whom notification of need of treatment has been sent] shall 
fail, neglect, or refuse to have such examination made and treatment be- 
gun within a reasonable time after such notice has been given, the said 
principal or superintendent shall notify the State Bureau of Child and An- 
imal Protection of the facts . . . ." 

83 



MEDICAL INSPECTION OF SCHOOLS 

The procedure regarding such cases is further elaborated in 
a circular letter of instructions to teachers and principals: 

"The Physician's Report is to be returned to the Teacher. If 
within a reasonable time the Physician's Report is not received by the 
Teacher or proves to be unsatisfactory; or where in lieu thereof the par- 
ent or guardian sends a written statement that he has not the necessary 
funds wherewith to pay the expenses of such examination and treatment 
the Teacher will send a Failure Notice (with such written statement if 
any) to the Principal or County Superintendent, recording same on the 
pupil's Teacher's Record Card. 

"The Principal or County Superintendent will record the Failure 
Notice on Pupil's Record Card and forward the Notice to the State Bu- 
reau of Child and Animal Protection, State House, Denver. 

"If a written statement of inability to pay accompanies a Failure 
Notice, the Principal or County Superintendent will at once 'cause such 
examination and treatment to be made by the County Physician of the 
District wherein said child resides'; who if unable to treat such child 
shall forthwith report such fact to the County Commissioners with his 
recommendation. If satisfactory results are not had within a reasonable 
time, the Failure Notice, written statement of inability to pay, statement 
of reference to County Physician, etc., with other information germaine 
to the case is to be forwarded by the Principal or County Superintendent 
to the State Bureau of Child and Animal Protection. 

"What constitutes a 'reasonable time' will be left to the judg- 
ment of the Teacher, under the advice and direction of the Principal or 
County Superintendent. If, after taking all the circumstances into con- 
sideration, doubt exists, refer the matter to the Bureau of Child and 
Animal Protection, with full particulars. 

"Whatever unpleasant or difficult duty may arise in the enforce- 
ment of the law for the examination and care of School Children, is laid 
by the law, not upon the Teacher, the Principal, the County Superin- 
tendent or the State Superintendent of Public Instruction, but upon the 
State Bureau of Child and Animal Protection. 

"Whenever the State Bureau of C. and A. P. receives a Failure 
Notice it will at once send its own notice to the Parent or Guardian re- 
questing compliance with the law, and will, at the same time notify the 
Teacher of that action. 

"In most cases a notice from the Bureau will be sufficient to in- 
duce prompt obedience to the law. If, however, they still 'fail, refuse or 
neglect,' the Teacher will send a second Failure Notice, marked 'No. 2,' 

8 4 



MAKING MEDICAL INSPECTION EFFECTIVE 

to the Principal or County Superintendent, who will forward it to the 
State Bureau of C. and A. P. at the State House, Denver. 

"When the Bureau of C. & A. P. receives a Failure Notice accom- 
panied by a written statement of inability to pay, etc., it will investigate 
and assist. 

"When the Bureau receives a second Failure Notice it will send 
an officer who will first consult with the Teacher, if possible with the 
Principal or County Superintendent, and acting under the direction of 
the Bureau will take charge of the case. " 

Regarding action under this law, the report of the Colorado 
State Superintendent of Public Instruction for 1909-10 has this 
to say : 

"Out of the 41,546 cases of defectiveness reported to the State 
Superintendent of Public Instruction as having been discovered, and pre- 
sumably reported to the parents of the children, 221 cases were reported 
by teachers to the State Bureau of Child and Animal Protection for 
failure of parents to have the medical examination indicated by the 
teachers' examination made. Whether this was the total number of 
cases which should have been reported we have no means of knowing. 
In the absence of further information it may be assumed that it does not 
depart far from the total which should have been referred. 

"With one exception the parents in all these cases were induced 
by letter or by the visit of our officer to do whatever the children's con- 
dition required. In the one case where it was necessary to bring the 
parents into court the child's throat was nearly closed by enlarged tonsils 
and his health seriously affected. At the trial the father was sentenced 
to thirty days' imprisonment." 

The New Jersey law, passed also in 1909, provides as follows: 

"If the cause for exclusion is such that it can be remedied, and 
the parent, guardian or other person having control of the child excluded 
as aforesaid shall fail or neglect within a reasonable time to have the 
cause for such exclusion removed, such parent, guardian or other person 
shall be proceeded against, and, upon conviction, be punishable as a dis- 
orderly person. " 

No record of action under this provision of the law has been 
found. Neither the report of the New Jersey Superintendent 
of Public Instruction for 1909-10 nor any of the 21 reports from 
county superintendents, or the 30 reports from city superintend- 

85 



MEDICAL INSPECTION OF SCHOOLS 

ents contained in the same volume, mentions this clause of the 
law, though most of them contain statements regarding medical 
inspection. One county superintendent writes: "The weakest 
place in the system seems to be lack of efficient remedy when 
defects are discovered of a nature not infectious or contagious/' 

In England many fines have been imposed (some under 
attendance by-laws, others under a clause of the children's act) 
upon parents who failed to cleanse or keep clean the bodies and 
heads of their children. Parents who neglected and ill-treated 
their children have also been imprisoned or fined, another clause 
of the children's act being invoked in their cases. In this latter 
group of cases are included those of children suffering from defec- 
tive eyesight, enlarged tonsils and adenoids, decayed teeth, and 
ulcerated mouths. Many such children were treated after the 
cases had been brought into court, with the result that proceedings 
against the parents were stopped. 



SCHOOL AND HOSPITAL CLINICS 

Wherever systems of medical inspection become highly 
developed and the authorities attempt to make the work effective, 
they are confronted with the problem of what to do to secure 
adequate treatment for children whose parents either cannot pay 
for it at all or can pay only a small fee. The services of the 
school nurse are effective in securing action on the part of many 
parents who would otherwise take no action whatever, but there 
always remain a considerable number of parents who are willing 
that their children should receive treatment but who are unable 
to meet any large expense involved. 

Thus the school nurse alone cannot meet the situation and 
some agency must be provided to cope with the problem. In 
most cases this agency is a hospital, more rarely a clinic established 
within the school itself. In either case it is generally true at the 
present time in American cities that facilities are inadequate to 
meet the need. 

In Great Britain the policy of the board of education since 
the adoption of the medical inspection law in 1907 has been to 
urge local school authorities to secure the utmost possible degree 

86 



MAKING MEDICAL INSPECTION EFFECTIVE 

of co-operation from existing hospitals and clinics. Where such 
institutions have been of high character, but limited in capacity 
by their small endowments, special government subsidies have in 
some instances been approved in order to permit the extension 
of their work to care for cases referred from the public schools. 

Nevertheless, these measures have frequently been found 
inadequate, and prior to 1911 school clinics for the treatment of 
skin and scalp diseases and in some instances for the care of 
defective teeth, eyes, ears, and throats, had been established in 
30 cities. 

Almost the only writer on medical inspection in America 
who has faced the problem of inadequate treatment squarely is 
Dr. George J. Holmes, supervisor of medical inspection in Newark, 
New Jersey, whose views are outlined in the following quotations 
from his article published in the Journal of the Medical Society 
of New Jersey, 1911. 

" I have suggested that free public school clinics be established to 
care for all diseases and defects common to school pupils. No pupil to 
be admitted unless attending a public school, presenting a printed slip 
showing that he or she has been referred for treatment by a medical in- 
spector, and that his or her home has been visited by a school nurse, find- 
ing such poverty that free treatment is necessary and right. 

"Were such a clinic established by the Board of Education and 
conducted by the supervisor of medical inspection and his assistants, 
both physicians and nurses, it would no longer be necessary for a pupil 
to leave school during session for treatment or examination. Pauperism 
would not be fostered. Such a clinic should be held from three to six 
p. m. daily, except Sundays. 

"Other benefits resulting from school clinics would be the creating 
of greater interest among the physicians and nurses of the department, 
in their being able to follow the cases and see the results. Greater op- 
portunity would be afforded both physicians and nurses to meet parents 
of the children afflicted, and opportunity for preaching and impressing 
the common facts relating to personal and home hygiene on the parents. 
Greater results would be obtained and better opportunity would be given 
the supervisor to observe the work of each member of the department." 

It is probable that few of the educational authorities in 
this country would be prepared to accept so radical a proposition 

8? 



MEDICAL INSPECTION OF SCHOOLS 

as that of Dr. Holmes. So far as is known, the only strictly 
school clinics conducted in the United States are the dental 
clinics in Rochester, Cincinnati, Muskegon, Philadelphia, and 
Elmira, and the eye clinic in Cleveland. The time is undoubt- 
edly at hand, however, when some solution to the pressing prob- 
lem created by needy children left untreated must be sought out 
and applied. Frank facing of the problem is needed if medical 
inspection is to fulfill the hopes of its friends. 

SUMMARY. Invitations to parents to be present at examina- 
tions of children, follow-up visits by nurses, arrangements for 
children to attend hospitals and clinics, the establishment of 
office hours when medical supervisors may be consulted by parents, 
and the education of the community through printed bulletins 
explaining the nature and importance of defects, are five measures 
of great value in rendering medical inspection effective. 

Mere notifications of defects, unsupplemented by such 
measures as the above, can never be expected to secure more than 
a small proportion of the treatments needed. The possibilities 
of increasing the effectiveness of medical inspection by legal 
measures to compel neglectful parents to take action have not 
yet been thoroughly tested in this country, but the working of 
Colorado's experiment along this line is worth study. 

The presence throughout the schools of the country of large 
numbers of children whose parents cannot afford to pay current 
rates for treatment creates a problem which is pressing for solution. 
The suggestion that dental and medical school clinics be estab- 
lished to deal with this class of cases will increasingly demand the 
attention of school authorities who are dissatisfied with the 
inadequate returns secured by present systems of medical inspec- 
tion. 



CHAPTER VII 
RESULTS 

DEFINITE information as to the actual results achieved by 
medical inspection for the detection and correction of 
physical defects is exceedingly meager. Superintendents 
and health officers frequently state in their annual reports that 
the response of parents to notifications is unsatisfactory, and urge 
the adoption of more effective follow-up methods. Where nurses 
have recently been installed, satisfaction is generally expressed 
and the statement made that a marked increase of co-operative 
action has resulted. Definite statistical evidence is, however, rarely 
offered with regard to any phase of the problem. 

The success of a system of medical inspection of schools is 
to be measured by the results achieved. The mere piling up of 
statistical data as to defects would be valueless unless action of 
some sort followed. In printed reports, the meaning attached to 
the word "results" is the crux of the whole matter. In most 
cases where any mention is made of results secured it takes the 
form of "treatments reported/' "attention given/' or "physician 
consulted/' Occasionally some detail is entered into, as the num- 
ber of pairs of glasses obtained or the number of operations per- 
formed. Very rarely a notation as to improvements following 
treatment is made. 

The type of report on results which a school physician 
makes is naturally determined by his conception of the function 
of his office. On the side of results, four possible functions may be 
formulated : 

1. To bring parents to the point of taking their children to a 
physician or dentist, clinic or hospital. 

2. To ascertain whether the consultation is a genuine one and 
whether appropriate treatment has been instituted. 

3. To ascertain, where no treatment or inadequate treatment only 

89 



MEDICAL INSPECTION OF SCHOOLS 

has been given, what is the reason for such failure (i. e. parental igno- 
rance, indifference, hostility or poverty, lack of clinical resources, etc.). 

4. To ascertain the ultimate results of treatment upon the child's 
physical health and mental development. 

The first function is inevitably the one first recognized, as 
it is undoubtedly the most important. The second function is 
almost forced upon the inspector where later contact with a child 
reported "under treatment" leads to the discovery that no 
effective measures to remedy bad conditions have been taken. 
It is especially important in large cities where unprincipled 
practitioners find it easy to connive with parents in a pretense 
of consultation. Yet assumption of the duties and responsi- 
bilities it implies is rare in American cities. The third function 
follows naturally upon the second and would call for but little 
additional work. 

The fourth function is as yet recognized by scarcely any 
American community. It can be developed to its fullest possible 
limits only where there is active and enthusiastic co-operation 
of teachers and principals with medical officers. Such following 
up of children as it requires is far more difficult in large cities than 
in small towns, since transfers from school to school mean re- 
examinations by different inspectors, in which case comparison 
of "before" and "after" conditions becomes unreliable. Records 
of re-inspections by physicians when sufficient time has elapsed 
after treatment so that definite results are discoverable, and records 
by teachers of their observations during extended periods are, 
however, essential features of any scheme for testing the value 
to the child and to the community of medical inspection. 

The report of a school physician who based his work on 
the assumption that all the above functions belonged to his 
office would be likely to contain several features not now generally 
found in such reports. Among them would probably be: 

A statement of the number of children enrolled, the number ex- 
amined, the number having specified defects and combinations of defects, 
and the number reported as having consulted a private physician or 
dentist, or as having been taken to a clinic or hospital for treatment. 

A statement of the number of these children found on investiga- 
tion, after a stated period following the reported consultation has elapsed, 

90 



RESULTS 

to have received adequate treatment, the kind of treatment being speci- 
fied. 

A statement of sources of treatment; that is, private physicians 
or dentists, specialists, clinics, hospitals, etc., with number of children 
treated by each. 

A statement of the number of children who failed to receive ef- 
fective treatment, classified to show causes of failure; that is, parental 
neglect or opposition, poverty, lack of adequate or accessible clinics, 
lack of intelligent co-operation by clinics and family physicians, etc. 

A statement of ultimate results on health and school standing pro- 
duced by specified kinds of treatment in children suffering from each sort 
of defect. 

Such a report would furnish a basis for the formulation of 
policies now generally lacking. If, for example, it revealed a 
large amount of parental neglect of serious conditions when 
adequate means of securing treatment for such conditions existed 
in the community, the need of a new type of educational activity 
directed toward the older generation would be made evident. If 
on the other hand there were revealed many cases where lack of 
facilities for medical, surgical, or dental treatment was the cause 
of unsatisfactory results, the problem of securing adequate facili- 
ties for treatment would be placed squarely before the educational 
and health authorities with its alternative of continued waste 
of public funds in ineffective inspection. 

RECORDS OF DEFECTS TREATED IN NEW YORK CITY 

New York occupies the first place in the discussion of this 
subject, both on account of the size of its problem and because the 
history of its endeavor to cope with that problem is an unusually 
long and instructive one. Treatments, as reported by the Division 
of Child Hygiene of the Department of Health for the year 191 1, 
include all cases where report of attention received was made by 
physicians. Instructions in mouth hygiene by nurses, said to have 
been given in all cases where defective teeth were discovered, are 
not included. The figures undoubtedly include many cases where 
treatment never went beyond the initial visit to a physician. 
Moreover, according to the director of the Division of Child 
Hygiene of the Department of Health, they include cases where 

91 



MEDICAL INSPECTION OF SCHOOLS 



physicians, without examination and for a fee of 25 cents, have 
furnished diagnoses agreeing with those of the medical inspectors 
on the slips brought them by the children. There is, however, no 
reason to suppose that the figures given are any less reliable than 
those reported from other cities. The data showing in detail the 
number and per cent of defects treated are presented in Table 20. 

TABLE 2O. PHYSICAL DEFECTS REPORTED BY MEDICAL INSPECTORS, 

AND NUMBER AND PER CENT OF THESE DEFECTS TREATED. 

NEW YORK CITY, 1 9! I 



Defect 








Cases 
reported 


Cases 
treated 


Per cent 
treated 


Vision .... 








24,5M 


16,633 


68 


Hearing .... 








1,491 


847 


57 


Nasal breathing . 








27,319 


22,839 


84 


Hypertrophied tonsils 








34,639 


22,647 


65 


Tuberculous lymph nodes 








418 


295 




Cardiac disease 








i, 66 1 


1,286 


77 


Pulmonary disease 












78 


Chorea .... 








86 1 


483 


56 


Orthopedic . 








1,190 


522 


44 


Malnutrition 








5.845 


3,632 


62 


Teeth .... 








135.843 


18,164 


13 


Palate .... 








85 


40 


47 


Total .... 








234,349 


87,765 


37 



In the case of four of the defects, further details are given 
as to the character of the remedial treatment. These details 
are as follows: 



Defective vision: 

Treated by supplying glasses . 
Receiving medical treatment . 

Defective nasal breathing: 

Receiving operative treatment 
Receiving medical treatment 

Hypertrop b ied tons Us : 

Receiving operative treatment 
Receiving medical treatment 

Defective teeth: 

Treated by extraction 
Treated by filling 



11,304 
5.329 

11,284 
1I >555 

9,808 
12,839 



7,373 
10,791 



It is interesting to note that the highest percentage of 
treatments was that reported in cases of defective nasal breath- 

92 






RESULTS 

ing where over 80 per cent were treated, more than 40 per cent by 
operation. In nearly all other classes of defects, upwards of 
50 per cent of cases were reported treated, but the very low per- 
centage of cases of defective teeth which received attention is 
in striking contrast, and evidently accounts for the fact that but 
37 per cent of all the defects needing attention received it. 

Lack of appreciation of the need of dental care, and lack of 
clinics where teeth can be put in order at a moderate cost, are 
doubtless alike reflected in the low percentages of extractions and 
fillings. 

REPORTS FROM OTHER CITIES 

In the report of medical inspection in the schools of Newark, 
New Jersey, occurs the following statement showing the definite 
action taken on defects of vision, hypertrophied tonsils, adenoids, 
and defective teeth; that is, provision of glasses, operations for 
tonsils and adenoids, and dental treatment. 

TABLE 21. FOUR CLASSES OF PHYSICAL DEFECTS REPORTED AND 
NUMBER AND PER CENT OF THESE DEFECTS TREATED. 
NEWARK, N. J., 



Defect 


Cases 
reported 


Cases 
treated 


Per cent 
treated 


Vision 
Tonsils 
Adenoids 
Teeth 


3,003 
4,588 
1,866 
7.124 


989 
416 
238 

772 


33 
9 
13 
ii 


Total 


16,581 


2,415 


15 



As the table shows, the percentage of defects receiving the 
specified remedial treatment was 15. The corresponding figures 
cited for New York City give a percentage of nearly 23. In the 
New York report the term "defective nasal breathing" is con- 
sidered equivalent to the term "adenoids" in the Newark one. 
In general, the figures make it appear that Newark is somewhat 
behind its larger neighbor in the treatment of eyes, ears, and 
throats, and about on a par in the treatment of defective teeth. 

Harrisburg, Pennsylvania, gives the following statement of 
reported treatments for the school year 1909-10: 

93 



MEDICAL INSPECTION OF SCHOOLS 



TABLE 22. PHYSICAL DEFECTS RECOMMENDED FOR TREATMENT 
AND NUMBER AND PER CENT OF THESE DEFECTS TREATED. 
HARRISBURG, PA., 



Defect 


Cases 

recommended 
for treatment 


Cases reported 
treated 


Per cent of 
recommended 
cases reported 
treated 


Malnutrition .... 


72 


24 


33 


Enlarged cervical glands 


17 


4 


24 


Chorea 


8 


4 


50 


Cardiac disease 


8 


3 


38 


Pulmonary disease . 


5 


4 


80 


Skin disease .... 


61 


30 


49 


Defective vision 


677 


268 


40 


Defective hearing 


'43 


51 


36 


Defective nasal breathing 


204 


83 


4i 


Defective teeth 


187 


48 


26 


Deformed palate 


8 


2 


25 


Hypertrophied tonsils 


805 


249 


3 


Adenoids ..... 


432 


>53 


35 


Total 


2,627 


923 


35 



The numbers here are small, in some cases so small that the 
percentages are hardly worth considering. In general, it would 
appear that from 20 to 40 per cent of cases needing treatment 
received it. 

In Pasadena, California, during the same year, the propor- 
tions of cases treated were not very different. The report of 
action taken is as follows: 

TABLE 23. PHYSICAL DEFECTS REPORTED AND NUMBER AND PER 
CENT OF THESE DEFECTS TREATED. PASADENA, CAL., 



Defect 


Cases reported 


Cases treated 


Per cent treated 


Eyes 
Ears 
Nose 
Throat 
Teeth 
Nutrition 
Nervous system 


685 
117 

202 
240 
1,230 

195 

4 8 


242 

21 
6 9 
91 

3 P 
64 

12 


35 

18 

? 

30 
33 
25 


Total 


2,717 


874 


32 



94 



RESULTS 



From Summit, New Jersey, comes a report of the numbers 
of cases discovered, the number referred to a physician, and the 
cases in which a physician was consulted. 

TABLE 24. DEFECTS REPORTED, NUMBER REFERRED TO PHYSI- 
CIANS, AND PER CENT OF THESE IN WHICH PHYSICIAN WAS 
CONSULTED. SUMMIT, N. J., 1909-10 











Per cent of 


Defect 


Cases 
reported 


Cases 
referred 
to phy- 
sician 


Cases in 
which 
physician 
was 
consulted 


cases refer- 
red to physi- 
cian in 

which phy- 
sician was 










consulted 


Defective vision . 


185 


132 


79 


60 


Defective hearing 


21 


10 


8 


80 


Hypertrophied tonsils 


124 


43 


12 


28 


Adenoids .... 


35 


18 


6 


33 


Defective teeth . 


383 


I 12 


44 


39 


Total 


748 


315 


149 


47 



The striking feature of this report is the large proportion 
of cases discovered which were not considered important enough 
to be referred for treatment. It is to be assumed that all cases 
regarded as needing treatment were referred. The percentage 
of eye and ear cases in which physicians were consulted, based upon 
the numbers referred, is much higher than in Harrisburg or Pasa- 
dena; but the number of cases under the. head of "hearing" is 
so small that discussion as to their disposition is hardly worth 
while. 

INTER-CITY COMPARISONS 

The foregoing data, cited from the reports of the different 
cities, give a general idea of the degree to which inspection for 
the detection of physical defects results in remedial treatment. 
It must be remembered that these data are gathered from cities 
where the problem has been given special attention and undoubt- 
edly reflect conditions distinctly better than the average. When 
the figures from four of the cities are brought together the result 
is as shown in the following table: 

95 



MEDICAL INSPECTION OF SCHOOLS 



TABLE 25. DEFECTS REPORTED AND THE NUMBER AND PER CENT 
OF THESE DEFECTS TREATED, IN FOUR CITIES 



City and year 


Dejects 
reported 


Defects 
treated 


Per cent 
treated 


New York City, 191 1 . 


234,349 


87,765 


37 


Pasadena, Gal., 1909-10 


2,717 


874 


32 


Harrisburg, Pa., 1909-10 . 


2,627 


923 


35 


Summit, N. J., 1909-10 


748 


149 


20 



Several other cities report the number of children given 
remedial treatment, rather than the number of defects remedied. 
These figures reduced to percentages for three cities are as follows : 



St. Louis, Mo., 1909-10 . 
Trenton, N. J., 1909 
Oakland, Gal., 1910-11 . 



24 per cent 
39 per cent 
52 per cent 



As has been noted, statements as to improvement resulting 
from treatment are rare. In Trenton, according to the report 
referred to above, 172 out of the 190 children treated were "im- 
proved/' Our ignorance as to kinds of defects included, nature 
of treatment, and standards by which improvement was judged, 
makes the statement of slight value. 

TREATMENT BY PHYSICIANS AND INSTITUTIONS 
Statements with regard to the agency from which treatment 
was obtained are made by two cities New York and St. Louis. 
Those for New York are as follows: 

TABLE 26. CASES OF PHYSICAL DEFECTS TREATED BY PRIVATE 
PRACTITIONERS AND BY INSTITUTIONS, NEW YORK, IQI I 



Defect 








Cases treated by 
private practitioners 


Cases treated by 
institutions 


Glasses . 
Operative 
Medical . 
Physical culture . 
Instructions . 
Extraction of teeth 
Filling teeth . 









5,530 
9,777 
20,604 

17 
836 

1,222 


5,666 
1 0,048 
10,684 
42 
341 
232 
151 


Total . 








37,986 


27,164 



96 



RESULTS 



The St. Louis report for 1910-11 states that during that 
school year the number of cases treated by family physicians or 
dentists was 825 as compared with 1,088 cases treated at free 
dispensaries or clinics. 



TREATMENT FOLLOWING EXAMINATIONS BY TEACHERS 

All the reports thus far cited have been of results following 
more or less complete physical examinations by physicians. 
Two Massachusetts cities, Lowell and Somerville, offer figures 
bearing on treatments resulting from teachers' examinations of 
sight and hearing. Lowell reports that of 922 cases of defective 
eyes and ears referred to parents in 1910, 349, or 37.8 per cent, 
were "professionally treated/' Somerville's percentages of "pro- 
fessionally treated" cases during five successive years are as 
follows : 



TABLE 27. PERCENTAGES OF CASES OF DEFECTS OF EYES AND EARS 
TREATED PROFESSIONALLY. SOMERVILLE, MASS., 1906-10 



Defect 


1906 


1907 


1908 


1909 


1910 


Eyes 


25.3 


14.3 


24.9 


13.4 


10.8 


Ears 


20.9 


12.5 


10.2 


12.3 


12.3 



It is evident that a larger proportion of cases received 
attention in the first year in Somerville than have ever been 
treated since. The result is the more difficult to explain, since 
the percentage of children examined who were found defective, 
both in eyes and ears, has steadily decreased from year to year. 

Comparison of the Somerville and Lowell percentages of eye 
and ear treatments with the data 'from other cities already cited 
reveals the fact that Lowell's results approximate those secured 
in Harrisburg and Pasadena, while Somerville's are far behind. 
This contrast may be due to the fact that Somerville is the only 
one of the group which does not employ a nurse or home visitor 
to follow up cases needing attention. 
7 97 



MEDICAL INSPECTION OF SCHOOLS 

The diverse reports made by the 10 cities mentioned in 
this chapter indicate that anything in the nature of a general 
conclusion as to the value of results achieved by medical inspec- 
tion for physical defects cannot be drawn. It is, however, safe 
to assume that scarcely any American city has yet succeeded in 
securing the benefits of genuine treatment for as many as half 
the children needing it. While a certain irreducible minimum of 
defectiveness must doubtless always remain uncorrected, it seems 
certain that this minimum has nowhere yet been reached. 

Doubtless continuing efforts for adjustment will result in the 
devising of new methods for meeting the need. One of the most 
practicable plans now being urged is that for the establishment 
of school dental clinics, which is discussed in another chapter.* 
The correction of all dental defects, which are everywhere the 
most common defects, would mean a long step in advance. The 
establishment of open air schools for tuberculous and anemic 
children is also a measure the effectiveness of which has been abun- 
dantly demonstrated in many cities both here and abroad. 

REPORTS OF TREATMENT IN ENGLISH COMMUNITIES 

Reports of treatment for physical defects are more common 
in England than in this country, but from the comments of the 
chief medical officer of the board of education it is evident that 
there is some uncertainty as to what is meant by the word 
"treatment." In his report for 1910 he states that more accurate 
description of results cannot be achieved " until the report on the 
results is based on actual re-examination by the medical officer." 
The medical officer should inform himself on four points: 

1. Whether treatment was obtained. 

2. The nature of the treatment, e. g., whether by medication, the 
provision of food, a visit to a convalescent home, or the performance of an 
operation. 

3. By what agency the treatment was obtained, e. g., by parent, 
nurse, charitable society, private practitioner, at the hospital, or through 
the Poor Law. 

4. The exact results of such treatment, or the causes, so far as can 
be ascertained, of failure to obtain treatment. 

*See Chap. IX, p. 114. 



RESULTS 



Reported treatments are tabulated in 24 areas, 12 of them 
counties, 12 of them boroughs or urban areas. The defects and 
diseases reported on are: defects of vision (including in some cases 
squint), defects of the external eye, of tonsils and adenoids, 
defective hearing, ear and skin diseases. Not all of these defects 
are, however, reported on from every area. Report is also made 
from some areas regarding " uncleanliness and vermin." The 
figures relative to these conditions are omitted in the accompany- 
ing summary: 

TABLE 28. RECOMMENDATIONS FOR TREATMENT BY MEDICAL 
INSPECTORS AND NUMBER AND PER CENT OF TREATMENTS IN 
24 ENGLISH AREAS. 





Cases 




Per cent of 


County areas 


recommended 


Cases treated 


recommended 




for treatment 




cases treated 


Anglesey 


374 


204 


54-5 


Devonshire 


2,5 2 5 


557 


22.1 


Ely, Isle of 


257 


144 


56.0 


Essex 


3>643 


i,735 


47.6 


Kent 


6,290 


2,502 


39-8 


Middlesex 


2,481 


1,169 


47.1 


Norfolk 1 


i,303 


692 


53- 1 


Nottinghamshire 


626 


284 


45-4 


Surrey 


i,4'7 


688 


48.6 


Sussex (West) 


505 


358 


70.9 


Worcestershire 


598 


419 


70.1 


Yorks (East Riding) .... 


312 


, 7 6 


56.4 


Total 


20,331 


8,928 


43-9 


Borough and Urban Areas 








Beckenham 


204 


52 


25.5 


Blackburn 


803 


458 


57.0 


Darlington 


608 


281 


46.2 


Derby, C. B 


334 


83 


24.9 


Leicester, C. B 


1,235 


639 


5i-7 


Lincoln, C. B 


J 33 


88 


06.2 


Middlesborough .... 


992 


545 


54-9 


Morley 


350 


73 


20.9 


Penge 


179 


38 


21.2 


Salisbury 


202 


119 


58.9 


South Shields 
Wolverhampton .... 


732 
322 


420 
148 


57-4 
46.0 


Total 


6,094 


2,944 


48.3 



99 



MEDICAL INSPECTION OF SCHOOLS 

It would appear that the English communities are con- 
siderably in advance of those of the United States, as exactly 
12 out of the 24 included in this summary report over half of 
their defects as treated, while but one American city was found 
which reported as high as 50 per cent of treatments. 

SUMMARY. American cities which offer statistical reports 
regarding defects treated are exceptional. Such reports as are 
offered show roughly from 1 1 per cent to 50 per cent of treatments, 
figured in some cases on a basis of number of defective children, 
in others on a basis of number of defects. 

Reports from England are far more numerous and show a 
higher range of percentages treated from 20 per cent to 70 per 
cent while the average for 24 areas is about 50 per cent. 

Definitions of what is meant by "treatment" are seldom 
given in either country, but such evidence as exists indicates 
that the figures published generally tend to overstate rather than 
to understate the proportion of cases genuinely treated. 



100 



CHAPTER VIII 
PER CAPITA COSTS AND SALARIES 

SINCE systems of medical inspection vary in scope from 
vision and hearing tests conducted by teachers to complete 
physical examinations conducted by physicians, and because 
the attendant expense may range anywhere from the slight cost 
of printed material supplied to teachers to high salaries paid 
physicians and nurses, it follows that generalizations concerning 
per capita costs must be somewhat indefinite. 

COST OF INSPECTION FOR CONTAGIOUS DISEASE 
The sort of medical inspection which has for its object the 
discovery of incipient cases of contagious disease and their exclu- 
sion from school, is in reality merely an extension of the work 
which has been done by boards of health. It is not inherently 
expensive in terms of time or money. In most cities the work is 
carried on by having the school physicians call each day, or two 
or three times a week, and inspect the children referred to them 
by the teachers as seeming to be in ill health, or who have returned 
to school after an unexplained absence. In most cases, the 
physician comes at stated times, without being notified. In 
some places the less efficient method is followed of having the 
principal notify the physician by telephone when he is wanted. 
The annual per capita cost for this sort of medical inspection 
averages about 13 cents. 

COST OF VISION AND HEARING TESTS GIVEN BY TEACHERS 

By far the least expensive of all systems are those consisting 
solely of examinations conducted by teachers for the detection 
of defects of vision and hearing. They are prescribed by state 
law or regulation in Massachusetts, Colorado, Indiana, Maine, 

101 



MEDICAL INSPECTION OF SCHOOLS 

Minnesota, Rhode Island, and Utah, and are conducted without 
legal enactment in many towns and cities of other states. 

The only expenses incurred in such examinations, in addition 
to the cost of the teacher's time, are for printed material consisting 
of directions, test cards, record blanks, notices to parents, etc. 
Even for a large number of children, the expense is low. The 
amount appropriated by the Massachusetts act is $800 per year, 
and of this appropriation only $592 was actually expended in 
1910-11. As there are approximately half a million children in 
the public schools of Massachusetts, this means an annual per 
capita expenditure of slightly more than one mill. 

In Connecticut, where tests of vision are conducted trien- 
nially, the total expense for the state is about $700 for each test, 
which means a per capita cost of nearly one-half cent. 

The time necessary to conduct these examinations is from 
three to five minutes per pupil. These figures show that both in 
time and in money, the necessary expenditure for conducting 
vision and hearing tests by teachers is slight. 

Such tests do not take the place of thorough examinations 
by competent trained experts. It cannot be gainsaid, however, 
that they are of great and real value, and it is to be doubted 
whether, in the whole range of educational endeavor, there can be 
discovered another field where so great returns for good are to be 
secured at so small an expenditure of time and money. 



SALARIES AND PER CAPITA COST FOR SALARIES 

The great variation in the amount and character of work 
done in different systems of medical inspection renders a discus- 
sion of salaries most difficult. This is because of the inherent 
difficulty in comparing the work done in one locality per unit 
of salary with that performed in another. An idea of the salaries 
paid to school physicians and nurses in American cities may be 
gained from Table 29.* This table presents conditions in 1911 
in 77 American cities of more than 8,000 population where the 
work was conducted under the auspices of the board of educa- 
tion. Data are taken from the investigation conducted by the 

*See p. 104 if. 
I O2 




The equipment of this Rochester dental clinic cost about $700. 




Dental treatment costs less than the extra schooling bad teeth involve. 



PER CAPITA COSTS AND SALARIES 

Russell Sage Foundation in the spring of 1911, and the figures 
for attendance are taken from the report of the United States 
Commissioner of Education for the year 1909-10. Data have 
been restricted to the cities where the work is conducted under 
the department of education, because it is frequently the case 
in systems under the board of health that part of the salary 
paid is in return for other sorts of inspection work conducted for 
the board of health. 

It will be noted that the per capita figures presented in the 
table refer only to expenditures for salaries of inspectors and 
nurses and do not take into account sums paid for printing, 
supplies, equipment, and so forth. Cities where the systems of 
medical inspection do not include examinations for physical 
defects are indicated. All other rates thus apply to relatively 
complete systems, including physical examinations as well as 
inspections for the detection of contagious disease. 

In the 52 cities where physical examinations are conducted, 
the average per capita rate is 24 cents, while in the other 25 cities 
it is slightly over 13 cents. Only six cities pay more than 50 cents 
per child for medical inspection, and of these, two are in California 
and four in New Jersey. Unfortunately, it is impossible from the 
data at hand to determine a minimum per capita rate for efficient 
medical inspection including adequate follow-up work. It is 
worthy of note, however, that among the 19 cities listed in this table 
employing school nurses the average per capita rate is 30 cents, 
and it is probable that this sum may fairly be regarded as a mini- 
mum for securing an adequate and efficient system. 

SALARIES OF SCHOOL PHYSICIANS AND NURSES 
Professor William Osier is credited with saying, as already 
quoted, in regard to the work of medical inspection in England : 
" If we are to have school inspection, let us have good men to do 
the work and let us pay them well. It will demand a special 
training and a careful technique/' It is certainly to be regretted 
that this point of view has not been more generally taken in Amer- 
ica. In this country the financial remuneration of school physi- 
cians and school nurses is almost invariably inadequate. The 
salaries paid range from nothing to $4,000 per annum. 

103 



MEDICAL INSPECTION OF SCHOOLS 



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104 



PER CAPITA COSTS AND SALARIES 





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MEDICAL INSPECTION OF SCHOOLS 



In many localities the local medical association conducts in- 
spection for a year or two without cost to the city in order to 
demonstrate its value. This is why the tabulated returns show 
that in a considerable number of cities the physicians and nurses 
receive no pay. It may also be a factor in bringing about the ex- 
tremely low salaries that are received after regular payment is 
given. 

The following table is made up from the study of condi- 
tions in 1,038 cities and shows the number reporting salaries in 
which the salaries of physicians and nurses fall within the limits 
named in each group. That is to say, the first line shows that 
there are 75 cities in which the physicians give their services and 
21 in which the school nurses do the same. The second line 
indicates that there are 47 cities in which the salaries paid to the 
physicians are between $i .00 and $100 per annum, and so on. 

TABLE 30. ANNUAL SALARIES OF PHYSICIANS AND NURSES IN ALL 
CITIES REPORTING 





Cities in which 


Cities in which 


Annual salary 


physicians receive 


nurses receive salary 




salary indicated 


indicated 


No salary 


75 


21 


$I-$IOO . 


47 




$IOI-$2OO . 


5 




$20 I -$300 . 


44 


2 


$30 I -$400 . 


25 




$40I-$500 . 


24 


I 


$ 5 oi-$6oo . . 


18 


21 


$60 I -$700 . 


2 


17 


$70I-$800 . 


12 


24 


$80 I -$900 . 


6 


15 


$901-^1,000 


13 


2 


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18 


2 


$i,50i-$2,500 


7 


. . 


$3,500-$4,ooo 


3 


. . 


Fees according to service 


19 


I 








Total 


363 


1 06 



The table shows that there are more cities paying their 
school physicians at the rate of between $100 and $200 per year 

1 08 



PER CAPITA COSTS AND SALARIES 

than there are paying salaries of any other amount. On the other 
hand, the average salary is somewhat higher than this. If com- 
puted on the basis of the table, without taking into account the 
number of physicians employed in each individual city, the average 
salary would fall within the group receiving from $201 to $300. 

Of course the sum of $200 per annum paid to school physi- 
cians is given in return for only a part of their time. Never- 
theless, it has come to be regarded as a somewhat standard rate 
of remuneration for school physicians all over America. There are 
cases where so little work is required that this amount may be 
considered adequate, but undoubtedly in most cases it represents 
either an undue degree of sacrifice on the part of the school 
physician or inadequate work. 

That the words of the eminent Oxford professor have been 
heeded in his own country seems evident from the salaries paid 
to the medical inspectors of schools in England. Almost without 
exception salaries are appreciably higher than those paid in America, 
and more liberal provision is made for clerk hire and for meet- 
ing incidental expenses. Indeed, the undoubted fact is that the 
whole movement has been placed on a higher plane in England 
than in the United States. Nevertheless, the situation in England 
with respect to remuneration for school medical work is still such 
as to call forth much criticism from the British medical societies. 
It appears that the dominant idea at the time that medical 
inspection was inaugurated under the board of education was that 
inspectors should be paid at the rate of from 25 to 60 cents for 
each child examined. However, no definite financial standard was 
established and much dissatisfaction has resulted. The British 
Medical Association recently took up the subject and attempted 
to formulate a standard which may be summarized as follows:* 

Payment to be based on time spent in school work (including 
advisory and supervisory work), not on number of children examined. 

Salary for part-time oificers: $250 per annum for one session per 
week, or $200 per annum in the case of inexperienced beginners. (Women 
to receive same salaries as men.) 

Not less than $2,500 per annum for experienced whole-time officers; 
young assistants, $1,250 to $1,500 per annum. 

* Hogarth, A. H.: Medical Inspection of Schools, p. 136. London, Henry 
Frowde, Oxford University Press, 1909. 

109 



MEDICAL INSPECTION OF SCHOOLS 

In many instances salaries are now paid on a scale equal 
to that indicated. Thus the town of Guilford, England, has 
appointed a chief medical officer at $3,000 to be increased to $4,000 
by equal increments, and four assistants at $1,250 each, besides 
an allowance of $200 to each physician for traveling expenses. 
Northampton has employed two inspectors at $1,500; Stafford 
has one at $1,515 and three at $1,250, with provision for increase 
to $1,500 and for payment of expenses and clerical assistance. 
It must be remarked in considering these English salaries that the 
amounts paid represent relatively greater incomes than do the 
same sums in America. Moreover, the English code provides for 
but three physical examinations in the course of the school life of 
the child, whereas the Massachusetts law, where the standard 
salary of the school physicians is $200 per year, requires that such 
a complete physical examination of each child be made every year. 



COST OF CLERICAL ASSISTANCE 

A feature of the financial administration of medical inspec- 
tion which has received adequate attention abroad, but which has 
been almost entirely neglected here, is that of furnishing medical 
inspectors with adequate clerical assistance. In the nature of 
the case, the work requires the making of a great many entries 
on individual record cards or sheets; and upon the thoroughness 
and system with which this is done depends to a large degree the 
eificacy of the work. Recent careful timing of work done by one 
of the most skilful examiners in the employ of the New York City 
board of health shows that it took him on the average about 
twelve minutes to make each physical examination. Half of 
this time was employed in conducting the examination itself and 
the other half was spent in the purely clerical work of entering 
results on the sheets. The very writing of the names of the 
pupils on their individual record cards and those of the parents on 
notification cards often consumes a great deal of time in some 
quarters of the city, and constitutes a class of work which ought 
not to be foisted upon a trained physician. Here are some 
names taken more or less at random from the school registers in a 
Polish section: 

no 



PER CAPITA COSTS AND SALARIES 

Rzemieszkievicz Klymezynski 

Zdrojewski Wrzesimski 

Gorzelanczyk Guleszecwicz 

When a physician is being paid at the rate of from $1.00 to $2.00 
per hour, it is certainly a most unbusinesslike and inefficient 
policy to require him to spend half of his time doing work which a 
clerk at $12 or $15 a week could perform equally well. The 
physician above mentioned said in answer to a query that he felt 
sure he could examine twice as many children in the given time 
if he had the help of a clerk, and that he would find the work much 
more agreeable. This is a matter which demands attention 
wherever systems of medical inspection are to be installed. It 
is at present one of the weak points of all American systems. 

EQUIPMENT 

FOR SCHOOL PHYSICIANS 

The following statements concerning the necessary equip- 
ment for school physicians and school nurses are taken from an 
article* published in 1911 by Dr. George J. Holmes, Supervisor of 
Medical Inspection of Newark, N. J. They are based upon ex- 
tended and successful experience. 

The school physician's room should be "well lighted, painted 
white or light colored, wood floor." It should contain the follow- 
ing equipment: 

One or two small, flat-top tables with a drawer, painted white 
enamel 

Chairs rather than benches 

Wash basin and running water 

Paper towels 

White enamel pail for waste materials 

Screen 

Window shades operated from below upward 

Wooden tongue depressors 

Eye charts (Snellen's and illiterate) 

Medical cabinet of wood, with lock and key for medical and surgi- 
cal supplies of nurses and physicians 
* Journal of the Medical Society of New Jersey, 1911 
III 



MEDICAL INSPECTION OF SCHOOLS 

File boxes and index for filing physical examination cards 
Absorbent cotton, bandages, alcohol, bichloride tablets, tincture 

of green soap, quart jar with screw top for bandages and 

dressings 
Full list of printed forms used by inspectors 

FOR SCHOOL NURSES 
The following is a list of supplies used by nurses in schools: 

Absorbent cotton, ^ Ib. pkg. Lysol 

Adhesive plaster, 2 in. by 10 yds. Sulphur ointment 

Alcohol, grain, 95 per cent Sweet oil 

Bandages, i in. by 10 yds., Linton Stearate of zinc (powder, in boxes) 

gauze White precipitate 

Bandages, 2 in. by 10 yds., Liriton Zinc ointment 

gauze Bottles, 4 oz., with corks 

Plain gauze, i yd. long, i yd. wide Ciliary forceps No. 1,628 

Argyrol, 5 per cent Clinical thermometers 

Bichloride tablets, 7^ gr. Ointment jars, 4 oz. 

Flexible collodion Tooth picks 

Iodine, tincture Full list of printed forms used 



SUMMARY. In summing up the problems of administration 
which relate to expense it can only be said that in this, as in all 
other branches of organized endeavor, cost varies with the extent 
and kind of work done. Examinations by teachers for the dis- 
covery of defects of vision and hearing involve only the added 
expense of the simple printed material required. Inspection by 
physicians for the detection of contagious diseases is inexpensive 
and of great value in its results. 

Systems of medical inspection which include careful physical 
examinations of all children cost the most and are by far the most 
valuable. From a social and economic point of view they are by 
far the cheapest in the better sense of the word, as they are the 
most far-reaching both in their immediate and in their indirect 
results. 

If, however, a system of medical inspection is to be efficient 
and effective for any considerable length of time, it is clear that 
adequate salaries must be paid to those in charge of the work. 

1 12 



PER CAPITA COSTS AND SALARIES 

Efficient work can not long be expected from volunteers, 
and perhaps even less will it be given by physicians who receive 
a bare pittance in return for their time and skill. Neither can 
it be expected that first class men will long be content to spend 
the greater part of their time in doing the purely clerical work 
of filling out blanks in duplicate and triplicate. 

Permanent efficiency will require skilled workers, careful 
administration, and adequate remuneration. 



CHAPTER IX 
DENTAL INSPECTION 

DR. WILLIAM OSLER is credited with saying, "If I were 
asked to say whether more physical deterioration was 
produced by alcohol or by defective teeth, I should say 
unhesitatingly, defective teeth/' The history of the movement for 
dental inspection of school children shows that during the past decade 
educators and hygienists all over the world have been awakening to 
a realization of the truth and significance of Dr. Osier's statement. 

Although the development of dental inspection both in 
America and abroad has come almost entirely within the past 
decade, the beginnings date back more than a quarter of a century. 
So far as is known the first free dental clinic in the world was 
established in Rochester, New York, more than twenty-five years 
ago. While this was not strictly a school clinic, work with children 
was done and the present movement might have had its inception 
there had not lack of support resulted in the closing of the clinic 
after some two years of existence. 

Fifteen years later dental work for school children was 
seriously started in Germany and was soon followed by similar 
work in England, in the United States, and to some extent in 
other countries. 

The movement owes its rapid development to the world- 
wide awakening to the importance of dental conditions and still 
more directly to the publication of the findings of school physicians 
employed in the work of medical inspection. These reports have 
shown with convincing consistency that a large proportion of 
all school children are suffering from decayed teeth. These 
results come from all civilized countries and reveal especially 
serious conditions in the poorer quarters of our great cities. 

Thus Unghavari reported* as a result of his studies of 
dental conditions among school children in Hungary that 87 per 

* Unghavari (Hungarian physician): A study in Scedegin. Referred to by 
W. H. Burnham in Hygiene of the Teeth, Pedagogical Seminary, September, 1906, 
P- 2 93- 

114 




Too late for effective treatment. 




Each missing upper tooth renders useless the corresponding lower tooth. 



DENTAL INSPECTION 

cent had diseased teeth. An extensive investigation in Prussia* 
showed that among almost 20,000 children in 19 cities, 95 per cent 
were afflicted with dental caries. Dr. Heniej examined school 
children in Norway and found 97 per cent with decayed teeth. 
Investigations conducted in Dunfermline, Scotland, J showed that 
96 per cent of the children needed dental attention. Among 
2,200 pupils in the public schools not a single child was found who 
had had dental care or whose teeth were filled or otherwise attended 
to. In America conditions are little if any better than abroad. 

The serious significance of dental conditions existing among 
school children in a typical American city may be appreciated by 
studying the record of the examination of 447 school children 
ranging in age from six to sixteen years in Elmira, New York. 
These children were examined by local dentists in I9io. The 
findings are given in Table 3 1 . 

TABLE 31. RESULTS OF DENTAL INSPECTION OF 447 CHILDREN, 
AGES SIX TO SIXTEEN, ELMIRA, NEW YORK, 1910 

No. of children examined 447 

No. of children with teeth in perfect condition . 22 

No. of cavities needing filling 2063 

No. of teeth and roots needing extraction . . 617 

No. of children needing teeth cleaned 425 

No. of children needing gums treated 18 

No. of children suffering with pus-discharging abscesses 15 

No. of children in need of surgical treatment for irregular teeth ... 60 

No. of teeth prematurely lost by extraction 315 

No. of children with malocclusion 9 

No. of children using tooth brush daily (condition of mouths did not verify 

this claim) 127 

No. of children who had been to a dentist (in most cases for extractions only) 100 

182 or 40 per cent of the children had fairly good masticating capacity. 

1 19 or 27 per cent of the children had three-fourths masticating capacity. 

106 or 24 per cent of the children had one-half masticating capacity. 
38 or 8 per cent of the children had one-fourth masticating capacity. 
2 children had no masticating capacity. 

* Investigation made by an association of dentists in the province of Schles- 
wig-Holstein. Zeitschrift fur Schulgesundheitspflege, No. 7, 1900. Referred to 
by W. H. Burnham, op. cit. 

t Dr. C. Henie (School physician in Hamar, Norway) : Untersuchungen 
iiber die Zahne der Volksschiiler zu Hamar in Norwegen. Zeitschrift fur Schulge- 
sundheitspflege, February, 1898, Vol. II, pp. 65-71. Referred toby W. H. Burn- 
ham, op. cit. 

t Second Annual Report on the Medical Inspection of School Children in 
Dunfermline, Scotland, 1907, pp. 12-14. 

Annual Report of Don C. Bliss, Superintendent of Schools, Elmira, N. Y., 
1909-10, p. 30 ff. 



MEDICAL INSPECTION OF SCHOOLS 

The importance of these conditions is emphasized by a mass 
of information showing with startling distinctness that as civiliza- 
tion advances human teeth tend to become less efficient and even 
to disappear. According to Dr. Rose* only about 2 per cent of 
the Eskimos have defective teeth, 3 to 10 per cent of the American 
Indians, 3 to 20 per cent of Malays, 40 per cent of Chinese, and 80 
to 96 per cent of Europeans and Americans. There is evidence 
showing that for centuries the lower face and jaws of civilized man 
have been deteriorating. An examination of 402 British soldiers! 
revealed the fact that only eight had a width of jaw equal to the 
average jaw width of the Roman soldier. The average American 
jaw has been found to be more than one-third of an inch narrower 
than that of the ancient Roman. These facts mean that we are 
here dealing with a problem in which we must do far more than 
merely let nature have her own way if we are to conserve normal 
healthy conditions. 

There is another mass of evidence tending to show in definite, 
quantitative terms the importance of good teeth among school 
children. In Chapter XI, on Physical Defects and School Prog- 
ress, are quoted data taken from an investigation in New York 
City which showed that, on the average, children having defective 
teeth take one-half a year longer to complete the elementary 
school course than do children not so afflicted. 

In the Nineteenth Century for July, 1899, Dr. Collinsf reports 
an investigation indicating that children with good teeth stand 
appreciably higher in scholarship and school promotion than do 
those having poor teeth. 

In 1901, Dr. Johnson conducted an investigation in the 
schools of Andover, Massachusetts,! which showed that in physi- 
cal development as indicated by weight, children with good teeth 
were on the average about half a year ahead of children with poor 

* Dr. Karl Rose, Die Zahnpflege in den Schulen. Zeitschrift fur Schulge- 
sundheitspflege, 1895, Vol. VIII, pp. 65-87. Referred to by W. H. Burnham, op. 
cit. 

f Examination of British and American Soldiers. Referred to by E. S. 
Talbot: Degeneracy, Its Causes, Signs and Results. Contemporary Science Series. 

J Collins, Dr. Edwin: The Teeth of the School Boy. Nineteenth Century, 
July, 1899, p. 84. 

Johnson, Dr. George E.: The Condition of the Teeth of School Children 
in Public Schools. Pedagogical Seminary, March, 1901, pp. 45-58. 

116 



DENTAL INSPECTION 

teeth. Again, Superintendent Verplanck of South Manchester, 
Connecticut, reported in 1910* that only 25 per cent of the children 
promoted at the end of the year had seriously defective teeth as 
compared with 38 per cent of the non-promoted children. 

While such statistical evidence is not abundant, the data 
which exist show consistently a relation between dental conditions 
and mental ability. 

DENTAL INSPECTION ABROAD 

GERMANY 

The first dental clinic for school children in Germany seems 
to have been established by Dr. Jessen in Strassburg in 1902. 
From its inception the work has had a marked success and has 
rapidly grown. At present Strassburg has a $60,000 building for 
a school dispensary. The children are examined upon their 
entrance into the public schools and twice a year thereafter until 
they reach the age of thirteen. The treatment furnished includes 
cleaning, fillings, and extractions. Parents able to pay are charged 
for the service, but the most necessitous cases are treated gratis 
and the deficit is made up by the municipality. The dentists 
are state officers receiving regular salaries and are not permitted 
to engage in private practice. One feature of the work is the 
supplying of tooth brushes to all patients. 

The work initiated in Strassburg rapidly spread to other 
German cities and served as a model in the organization of many 
of the new systems. Cologne established a dental clinic in 1908 
at an initial cost of $5,500. The school children are referred to the 
clinic by the teachers but they must secure the consent of their 
parents before being given dental treatment. The cost of main- 
tenance amounts to from $6,000 to $6,500 annually, this sum 
serving to meet the salary expense of one director on part time, 
two assistants on whole time, and two nurses on whole time. 

In the city of Hamburg work was begun in 1911 in connection 
with the dental clinic of the Municipal Insurance Committee. 
This clinic occupies twelve rooms and was designed to provide 

* Annual Report of Fred. A. Verplanck, Superintendent of Schools, South 
Manchester, Conn., 1910, p. 37. 



MEDICAL INSPECTION OF SCHOOLS 

dental attention for domestic servants receiving the benefits of 
compulsory industrial insurance. It was found that the force and 
equipment were so ample that other work could be undertaken 
and the clinic arranged to treat 40 school children per day. Its 
support is guaranteed by a municipal appropriation of $2,000 per 
year for the three years 1911-14. The children treated are 
referred to the clinic by the school physicians. 

In all, some 78 German cities and towns give some kind of 
dental treatment to school children. Of these 78 localities, 70 
are cities of more than 10,000 population. The fact that the 
remaining eight cities have populations of less than 10,000 indi- 
cates that in Germany they have begun to realize that dental 
inspection, like medical inspection, is no less important in the small 
towns and rural districts than it is in the great centers of popula- 
tion. In about 30 localities the authorities have come to regard 
dental treatment as a necessary accompaniment of education 
and have made it free and universal. In twelve localities a more 
conservative course is followed and free treatment is furnished poor 
children only. A still more conservative attitude is represented 
by the course followed in 26 cities where the parents make 
small annual payments for the treatment furnished their children. 
These annual contributions vary in amount from 12 to 50 cents 
per child. 

Of the 78 school dental clinics in the Empire 38 are municipal, 
three are attached to universities, three are in private hands, and 
the remaining 34 are conducted by dentists who give part-time 
service. The clinics vary in size from small ones of one or two 
rooms to those in Strassburg and Hamburg containing 10 and 12 
rooms respectively. 

There are three general plans of administration. In the 
first the dental clinic is maintained by the school authorities as 
an integral part of the educational system. In the second the 
clinics are supported by means of municipal grants to local dental 
associations. In the third, commonly adopted in smaller com- 
munities, arrangements are made with private dentists whereby 
school children needing treatment are sent to them on certain 
specified days. 

The dental clinic has passed the experimental stage in 

118 



DENTAL INSPECTION 

Germany. In no part of the public medical service have such 
valuable results been obtained through the expenditure of such 
small funds. The experience of many cities demonstrates that 
the health of the children has been markedly improved by dental 
treatment and that the work has been of genuine value in the 
campaign against tuberculosis and contagious disease. The 
number of children requiring treatment each year is steadily 
declining, and with the development of better conditions the num- 
ber of extractions is becoming constantly smaller. Moreover, 
both children and parents appreciate the value of the dental work 
and voluntarily apply for treatment instead of having to be urged 
to submit to it as was formerly the case. 

ENGLAND 

In England the first dental clinic was started in Cambridge 
in 1907 as a private venture. Two years later the work was taken 
over by the city. At the present time provisions for the dental 
treatment of school children are made in 16 cities. In three of 
these the clinic is connected with a public infirmary and sup- 
ported by municipal contribution. In 12 cities the dental clinics 
are supported by separate institutions, and in five of these cases 
the dentists are employed on whole time and in the other seven 
on part time. One city employs part-time dentists but does not 
support a clinic. 

Perhaps the most significant and interesting school dental 
work now being carried on in England is that conducted by the 
county of Somerset. In that county ten dentists are employed 
to care for the teeth of children in the villages and country districts 
as well as in the larger towns. They are paid at the rate of $7.50 
per six-hour day and are allowed to give their time in either 
whole or half days. They are allowed 12 cents for material for 
each child treated and are granted allowances to cover reasonable 
traveling expenses. Wherever possible the work is done in the 
private office of the dentist, and where this cannot be arranged 
the school authorities set aside a room for the purpose. The 
instruments and appliances are supplied by the dentists. 

Conditions among the English children have been found so 
serious that in general the object of the work is to prevent the 

119 



MEDICAL INSPECTION OF SCHOOLS 

progress of dental deterioration rather than to cure the already 
existing conditions. The problem is to administer a limited force 
and limited funds so as to do the greatest permanent good to the 
greatest possible number of children. The solution* has been 
found through beginning with the youngest children and, after 
once treating a child, assuming the responsibility for keeping 
its permanent teeth in good condition. This plan makes it 
possible to advance the age limit of caring for the children annually 
by one year, and in a few years will make it possible to include 
all, the oldest as well as the youngest. The basis of this plan is 
the proposition that it is better to clean and care for the teeth of 
nine children who have one decayed tooth apiece than it is to 
spend the same time caring for one child with nine decayed teeth. 
While this policy results in leaving many serious cases almost 
uncared for, it secures the maximum advantage for the minimum 
expenditure and will make it possible to cope with the entire 
problem within a few years. 

OTHER COUNTRIES 

Dental inspection is well under way in Wales and notably 
good work has been done in Scotland, especially in the town of 
Dunfermline. Dental clinics have been established for school 
children in several of the cities of Switzerland, Austria, and France, 
and the latest report from Russia tells of the establishment of 
nine dental clinics in the city of St. Petersburg. 



DENTAL INSPECTION IN THE UNITED STATES 

After the pioneer work carried on temporarily in Rochester, 
New York, a quarter of a century ago, the city again became a 
pioneer by establishing the first American school dental clinic 
in the modern sense of the term in 1905. This was made possible 
by the public spirited enterprise of Mr. Henry Lomb, who person- 
ally gave $600 and was instrumental in securing an equal amount 
from local merchants with which to purchase a $1,200 equipment. 
Premises for the clinic were supplied by the Public Health Asso- 
ciation and work was at first carried on two afternoons each week. 
A little later there was a re-organization which resulted in the 

120 




Every pupil in Rochester, N. Y., needing dental inspection receives it. 




Toothbrush drill in New York City. 



DENTAL INSPECTION 

employment of two dentists, one of whom was on duty each week- 
day from 2 to 5 p.m. These men were paid at the rate of $50 
a month. This expense was met by Mr. Lomb. Since that time 
two other clinics have been established in two of the public 
schools. 

In New York City there are 17 dental clinics. Fourteen 
of these are connected with general dispensaries or dental colleges 
and treat both adults and children ; the other three are independent 
and are exclusively for school children. 

In 1907 the Children's Aid Society of New York opened a 
clinic for the treatment of children enrolled in its schools. This 
clinic was so successful that another was established in 1909. The 
society meets the expense of equipment and maintenance, and 
members of local dental societies give their services. 

In January, 1910, through the generosity of Judge Peter 
T. Barlow and several of his friends, a free dental clinic was opened 
to care for New York City school children whose parents are too 
poor to pay for dental treatment. Two dentists are employed and 
are on duty every afternoon from Monday to Friday inclusive, 
and on Saturday mornings. The board of health supplies a nurse 
to assist the dentists and to instruct the children in the care of 
the teeth. 

In the year 1909, the work was begun in Cleveland, Ohio, 
and in Reading, Pennsylvania, and both cities have been leaders in 
demonstrating its value and contributing to its technique. 

From these early beginnings the movement for dental 
inspection spread rapidly over the United States until in 1911 
some 198 cities reported that such inspection was being carried 
on in their local schools. This does not mean, however, that the 
work has been in every case of the type under consideration. It 
frequently means only that the local medical inspector examines 
the children's teeth and advises them to secure dental treatment. 
However, dental inspection carried on by dentists was being con- 
ducted in 89 American cities at the close of the year 191 1. 

The number of cities in each division carrying on dental 
inspection and the number of cities where this work is done by 
dentists are shown in the following table: 

121 



MEDICAL INSPECTION OF SCHOOLS 



TABLE 32. CITIES OF THE UNITED STATES HAVING DENTAL INSPEC- 
TION AND CITIES HAVING DENTAL INSPECTION BY DENTISTS, 
BY GROUPS OF STATES. II I 



Division 


Cities having dental 
inspection 


Cities having dental 
inspection by dentists 


North Atlantic .... 
South Atlantic .... 
South Central .... 
North Central .... 
Western 


94 
15 

8 

59 

22 


3 8 
4 
39 


United States .... 


I 9 8 


89 



ADMINISTRATION 

In nearly all cases dental inspection in America has had its 
inception in volunteer work of the local dental association. This 
generally results in an arrangement whereby the association 
carries on demonstration work in the public schools. When the 
experimental stage is past the dental inspection in the public 
schools and the remedial work carried on through clinics are 
usually administered by the public school authorities and the 
dental association, acting in co-operation. 

A good example of this sort of co-operation is found in Read- 
ing, Pennsylvania, where the medical inspectors in the public schools 
examine the children and select those needing treatment. The 
local charity organization society investigates the home condi- 
tions of candidates for gratuitous treatment and the local dental 
society supports the clinic and contributes professional services. 

In New York City the clinics exclusively for school children 
are supported through the co-operation of the children's aid 
society, the dental societies, the board of health, and private 
individuals who have no connection with the public schools. 
In both Milwaukee, Wisconsin, and Ann Arbor, Michigan, a 
woman dental inspector is employed as a member of the staff of 
medical inspectors and recommends children for treatment, send- 
ing them either to clinics or to private dentists as their finan- 
cial condition makes advisable. 

122 



DENTAL INSPECTION 

The situation in Philadelphia is of particular interest because 
so far as is known that city is the only one which started dental 
inspection entirely through public funds. The work was begun 
by co-operative endeavor in which the municipality appropriated 
money for the establishment and equipment of a dental clinic 
for school children and the local dental societies carried on volun- 
teer demonstration work for nearly a year. The success of this 
experiment led to the appointment of eight dentists on half time 
at a salary of $700 per year each, and the establishment of a second 
clinic in one of the public schools. 

In Valparaiso, Indiana; Muskegon, Michigan; Cincinnati, 
Ohio; Elmira, New York; and in many other localities the work is 
carried on by arrangements between the public schools and the 
individual dentists in the locality. The case of Muskegon is 
particularly interesting because of the nature of the agreement 
entered into between the public schools and the dentists, and also 
because of the marked success attained. This agreement is shown by 
the accompanying reproduction of the blank used for the purpose. 

AGREEMENT BETWEEN DENTISTS AND SCHOOLS, MUSKEGON, MICH. 



To the Honorable, The Board of Education 
of the Public Schools of the City of 
Muskegon 

Gentlemen: 

I, the undersigned, am in favor of a Free Dental Clinic and agree 
to give at least one-half day of my time every three months, for a period of 
one year (from the date of the opening of the office), to the clinic estab- 
lished by the Board of Education in the Hackley School. 

My understanding is that the dates of assignment shall be by lot. 
I will take charge of the office on the dates assigned to me, or send a sub- 
stitute, provided I receive notice of the assignment two weeks before each 
date. 

Muskegon, Mich., 1911. 



Signature. 



In Boston plans are under way looking toward the es- 
tablishment of a free dental infirmary on a more extensive scale 
than any that exists elsewhere in the world. This will be made 

123 



MEDICAL INSPECTION OF SCHOOLS 

possible through the gift of Mr. Thomas A. Forsyth who under- 
took the work in the desire to establish a highly practical charity 
in memory of his brothers. Mr. Forsyth's gift amounts to about 
$500,000 and it is hoped that this sum will be increased by other 
donations to a total of something like $2,000,000. The object 
of the foundation will be to co-operate with the school authorities 
in extending popular education in dental hygiene and in furnishing 
dental services free to every child in the city from early childhood 
to the age of sixteen. Already a charter has been granted by 
the Massachusetts legislature and land purchased for the erec- 
tion of a building. The plan contemplates the most modern and 
complete equipment possible. 

LEGAL PROVISIONS 

Up to the present time New Jersey is the only state that has 
passed a legal enactment specifically providing for the public 
support of free dental clinics. This act was passed in March, 
1911, and is as follows : 

Be it enacted by the Senate and General Assembly of the State of 
New Jersey: 

i. Section one of an act of the Legislature of this State, entitled, 
"An Act to authorize cities of this State to make annual appropriations 
to incorporate dental associations of this State conducting and maintain- 
ing dental clinics in such cities for the free treatment of indigent persons," 
approved April ninth, one thousand nine hundred and ten, be amended so 
that the said section shall read as follows: 

1. Whenever any dental association regularly incorporated under 
the laws of this State shall maintain and conduct in any city of this State 
a dental clinic or clinics where indigent persons residents of such city may 
receive treatment and relief without charge or fee therefor, it shall be law- 
ful for the board or body having control of the finances of such city to 
appropriate and pay to such association, each year, such sum or sums, 
not exceeding in all the sum of five thousand dollars, as it shall deem advis- 
able, to be used and applied by such association only for the support, 
maintenance and equipment in such city of a dental clinic or clinics, for 
the free treatment of indigent persons, residents of such city and for no 
other purpose whatsoever. 

2. This act shall take effect immediately. 
Approved March 30, 1911. 

124 



DENTAL INSPECTION 

COST OF SUPPLIES AND EQUIPMENT 

Experience in the equipment of dental clinics shows that the 
cost of a complete, high grade equipment with one chair is approxi- 
mately $700. As the number of chairs increases, the cost per chair 
becomes somewhat less because all of the equipment does not have 
to be duplicated for every new chair installed. The common 
items of expense are about as follows: 

Chair $170 

Table 10 

Flush spittoon with water attachment .... 60 

Electric engine 140 

Electric heater and sterilizer 25 

Excavators 18 

Chisels 25 

Appliances for use with engine 75 

Miscellaneous hand instruments 50 

Initial supplies 127 

$700 

These figures are taken from the accounts of the Philadelphia 
clinic. They agree substantially with data from other cities. 

In New York City it has been found that the expense for 
establishing a clinic is about $750, and the annual maintenance costs 
about $250, not including payment for the services of the dentists. 
In one clinic of two chairs, where equipment and supplies, the 
expense of rent, salaries of two dentists and a nurse, etc., were met 
from clinic funds, the total expenses for one year were $4,631.31. 
Of this sum $1,129.61 was expended on permanent equipment; 
the remaining $3,501.70 represented the cost of maintenance. 

The directors of the Elmira clinic figure that with an annual 
appropriation of $400 they can meet the running expenses of the 
clinic, including supplies, laundry, and incidentals. 

In Muskegon, Michigan, an equipment with one chair 
cost $750 and in Rochester, New York, one with two chairs cost 
$1200. In Reading, Pennsylvania, a most excellent outfit with 
one chair was secured for about $600, but because of donations 
and specially reduced prices this represents a real value of more 
nearly $1000. 

PER CAPITA COST 

The best data as to per capita cost are drawn from the 
European experience. In Hamburg it is found that the average 

125 



MEDICAL INSPECTION OF SCHOOLS 



cost of treatment per child is about 26 cents. Of this amount 
14 cents is paid out of the municipal grant and the remaining 12 
cents is paid by the parents, or in necessitous cases by the Poor 
Law Committee. German experience in general shows a per capita 
cost for children treated varying from 20 cents to 47 cents. The ex- 
perience of 1 2 municipal districts is shown in the accompanying table. 

TABLE 33. DENTAL INSPECTION OF SCHOOL CHILDREN IN TWELVE 
GERMAN MUNICIPAL DISTRICTS. YEAR ENDING APRIL, IQI I 











ANNUAL COST 








Number 


Num- 
ber of 


Initial 


OF 
MAINTENANCE 


Number 

nf fhil 


Per 


Municipal district 


of school 


rooms 


capital 




OJ C/Jll- 

dren 


capita 








children 


in 
clinic 


outlay 


Salaries 


Ma- 
terial 


treated 


cost 


Berlin I . 


230,000 


6 


$1,944 


$2,736 


$486 


12,000 


$0.27 


Berlin II 




7 


2,586 


2,620 




13,132 


.20 


Charlottenburg 


24,000 


6 




3,353 




9,949 


34 


Cologne . 


69,293 


10 


3.475 


2,187 








Dortmund 


35,000 


7 


1,944 


2,430 


729 






Dinsburg 


34,000 


5 


1,166 


2,916 


1,215 


8^735 


47 


Schoneberg 


12,696 


4 


875 


,944 


340 


8,311 


.27 


Stuttgart 


20,000 


4 


2,187 


,604 




6,778 


.24 


Darmstadt 


9.057 


6 


1,458 


,312 


486 






Colmar . 


6,200 


3 


972 


,045 


170 


3,095 


39 


Mulhausen 


19,500 


3 




,312 


267 


3,610 


44 


Strassburg 


20,680 


10 




2,775 




7,094 


-39 



According to the English experience one dentist working five 
days a week may be expected to care for the teeth of a school 
population of from 3,000 to 4,000 children. In the county of 
Somerset an allowance of 12 cents per child is made for material. 

Reports from Rochester, New York, show that for 1910 the 
per capita cost for dental treatment was 57 cents. Of this sum 
1 1 cents was for material used. In 1911 there was a per capita 
increase of 12 cents. This increase was due to the fact that 
during 1910 most of the material had been given, while in 1911 
practically all of it was purchased from the clinic funds. 

According to the charter of the Elmira School Dental 
Infirmary no charges can be made for treatment. 

The Newark, New Jersey, clinic treats all school children 
free, but they can donate any sum they wish toward the support 
of the clinic. 

126 



DENTAL INSPECTION 

In Lynn, Massachusetts, the dental dispensary in connec- 
tion with a Neighborhood House makes a flat charge of 15 cents 
for cleaning, 10 cents for extractions, and 25 cents for each filling. 
In Winchester, Massachusetts, nine local dentists devote half a 
day a week to treating poor school children at a flat rate of 25 
cents per case. 

SALARIES 

In Strassburg, Germany, the dental clinic employs one 
director on part time, two assistants on whole time, and two 
nurses at an annual expenditure of $6,000 to $6,500. In England, 
as has been mentioned, the dentists in the county of Somerset are 
paid at the rate of $7.50 for each six-hour day. In Philadelphia 
the eight dentists employed are paid $700 a year for half-time 
services. In Rochester, New York, dentists working from two 
to five o'clock each afternoon are paid at the rate of $50 per month. 

The staff of the two Newark, New Jersey, clinics consists 
of one chief and four consulting dental surgeons, who give their 
services; four dentists, who are on half-time for six days a week, 
at an annual salary of $500 each; and two attendants on whole 
time at $520 each. In addition to this force several local dentists 
work without pay. 

Ann Arbor, Michigan, has a woman dental inspector who in- 
spects the children's teeth twice a year at an annual salary of $400. 

EDUCATION IN DENTAL HYGIENE 

One of the most valuable features of the work in dental 
inspection is the education of teachers, children, and parents in 
dental hygiene. Dentists have been wide awake to the importance 
of this feature and are carrying on, both abroad and in this coun- 
try, an active campaign, the keynote of which is prevention and 
conservation. Work is carried on by means of leaflets, illustrated 
lectures, magazine and newspaper articles, and dental exhibits. 
In New York the state board of health has four dentists on its 
staff of lecturers and these men give illustrated lectures to teachers 
and parents in cities and towns throughout the state. The 
Virginia state board of health in March, 1911, issued for general 
distribution a bulletin on Good Teeth and Bad: The Essentials 
of Oral Hygiene. 

127 






MEDICAL INSPECTION OF SCHOOLS 



In Valparaiso, Indiana, in 1911, local dentists made careful 
examinations of school children, and the results of their findings 
were made into tables and diagrams showing existing conditions. 
These were explained by one of the dentists at a teachers' meeting 
and the need for instruction on the care of the teeth was discussed. 
The result was the awakening of interest on the part of the teachers 
and the beginning of class-room instruction in dental hygiene. 
This was followed up by a dental exhibit shown in every school 
house of the city. Local cartoonists interested in the movement 
contributed drawings. 

In 1910, through the activity of the Rochester, New York, 
Dental Association a lecturer who knew how to interest children 
was secured. For two weeks he gave illustrated talks in the 
different school rooms on the teeth and their care. At the end 
of the second week a mass meeting of citizens addressed by men of 
national prominence was held. This resulted in general and 
active support of the movement. 

In Philadelphia every child receives a tooth brush and box 
of tooth powder when the work on its teeth is completed. Direc- 
tions for brushing the teeth and the formula of the powder are 
printed on the label of the box. The following is a reproduction 
of the label: 

COMBINED DIRECTIONS AND PRESCRIPTION FOR TOOTH POWDER, 

PHILADELPHIA 















DIRECTIONS 

Turn out about a teaspoonful of 
powder into the palm of one hand, 
touch the powder with the wet brush, 
and brush, (i) up and down the in- 
side of the lower front teeth, (2) the 
right, and (3) the left side of the lower 
back teeth, (4) inside of the upper 




PHILADELPHIA 
Department of Public Health and 
Charities 
BUREAU OF HEALTH 
DENTAL DISPENSARY 
Room 706, City Hall 






of the upper back teeth, (7) outsides 
of all teeth, upper and lower, brush- 
ing up and down. 
To clean each of these seven divi- 




TOOTH POWDER 

FORMULA 

Precipitated Chalk 95% 






in the powder in the hand. 
Brush the teeth at night and rinse 
the mouth night and morning with 
table salt dissolved in warm water. 




CastileSoap. 3% Oil of Birch.. i% 
Saccharin . . . Y& % Oil of Pepper- 
mint H% 

Compliments of the DENTAL CORPS 















128 




1 







DENTAL INSPECTION 

The Children's Aid Society of New York City sells tooth 
brushes for three cents apiece. A leaflet containing directions 
for the care and use of the teeth is distributed. 

This leaflet reads as follows : 

DIRECTIONS FOR THE CARE AND USE OF THE 

TEETH 

A clean mouth is essential to 
good health 

Clean teeth do not decay 
****** 

Prepared by the 

SCHOOL DENTAL CLINIC OF THE 
CHILDREN'S AID SOCIETY 

For. free distribution among the patients 
of the School Dental Dispensaries 

WHAT ARE YOUR TEETH FOR? 

To grind the food into fine particles, and mix it with the 

saliva. 
Food which is not thoroughly chewed causes indigestion 

and constipation. 

HOW LONG SHOULD THE TEETH LAST? 

Throughout life. 
HOW DO WE LOSE THEM? 

By decay and loosening. 
WHAT CAUSES TEETH TO LOOSEN? 

Deposits of tartar upon the teeth in contact with the gums, 
uncleanliness, and lack of use in chewing the food. 

WHAT CAUSES TEETH TO DECAY? 

Particles of food and candy sticking to them, lack of exer- 
cise in the thorough chewing of food, irregular teeth, 
also a poor physical condition. 

WHERE DOES THE FOOD LODGE? 

Between the teeth, in the crevices of the grinding surfaces, 
and along the margin of the gums. 

CAN DECAY BE PREVENTED? 

Yes, to a large extent. 
9 129 



MEDICAL INSPECTION OF SCHOOLS 

HOW CAN DECAY BE PREVENTED? 

By the thorough chewing of the food, by keeping the 
mouth clean through the careful use of the tooth brush 
with tooth powder or paste, and waxed silk, also by 
keeping up the general health. Such care will also pre- 
vent the teeth from loosening. 

HOW OFTEN SHOULD THE TEETH BE CLEANED? 
At least twice each day, before breakfast and at bed time. 
Better after each meal. Tooth powder or paste should 
be used morning and night. 

HOW SHOULD THE TEETH BE BRUSHED? 

In an up and down direction, allowing the brush to come 
well up over the gums in both jaws. This should be 
done on the outer surface of all the teeth. Then 
open the mouth and carefully brush the grinding sur- 
faces, special care being given to those in the back part 
of the mouth. Then by tilting the brush, cleanse the 
inner surfaces of the teeth again allowing the brush to 
come well up on to the gums. The tongue should also 
be extended from the mouth and brushed. 

ARE THE GUMS INJURED BY BRUSHING? 

No, if brushed in an up and down direction. They will be 
strengthened by such brushing and rendered less liable 
to disease. 

HOW OFTEN SHOULD THE TEETH BE EXAMINED 
BY A DENTIST? 
At least twice each year. 

WHAT IS THE PURPOSE OF THE DENTAL CLINIC 
OF THE CHILDREN'S AID SOCIETY? 
To provide free dental treatment to the children of the 

school. 

To teach them the care and use of the teeth. 
To help them to understand that a clean mouth is as 

important as a clean body. 

That food thoroughly chewed is more easily digested. 
That good digestion is the first essential to health. 
That well cared for teeth and a clean mouth help prevent 

tuberculosis. 
That cleanliness and fresh air are the best safeguards 

against disease. 

130 



DENTAL INSPECTION 

Waltham, Massachusetts, distributes a leaflet on the care of 
the teeth, addressed to the parents of the school children: 

THE TEETH AND THEIR CARE 

Waltham, Mass. 
To Parents: 

You are reminded of the necessity for early care of 
children's teeth. With such care, the teeth may be preserved 
throughout life. This will not only save much inconvenience 
and discomfort in later life, but it may enable the child in the 
meantime to live a more vigorous and hence a more successful 
life. 

The condition of the teeth has much to do with the gen- 
eral health. 

The following cautions, abbreviated from those issued 
to teachers and school physicians by the Massachusetts board 
of education, are commended to your attention: 

Unclean mouths promote the growth of disease germs, 
and cavities in the teeth are centers of infection. 

Irregularities of the teeth, especially those which make 
it impossible to close the teeth properly, thus leading to faulty 
digestion and faulty breathing, should receive careful treat- 
ment. 

The first permanent molars are perhaps the most impor- 
tant teeth in the mouth. They come at about the sixth year, 
immediately following the temporary teeth, and are the most 
frequently neglected because they are often mistaken for 
temporary teeth. 

It should be known that decay of the teeth is caused 
primarily by the fermentation of starchy foods and sugars, 
and that the greatest factor in preventing disease of the teeth 
is the removal of food particles by frequent brushing. Chil- 
dren should be prevented from eating crackers and candy 
between meals, and when possible the teeth should be cleaned 
after eating. Inspection of the teeth by a dentist should be 
made at least once or twice a year. 

Your attention is also called to the prevalence of mala- 
dies of the nose and throat. 

The health of a child and his ability to do his school work 
may be seriously impaired by the presence of adenoid growths. 
When a child shows obstruction of the nose by mouth breath- 



MEDICAL INSPECTION OF SCHOOLS 

ing, snoring, continual discharge, or recurrent ear trouble, 
adenoids should be suspected. 

Enlarged tonsils, recurrent tonsilitis, and enlargement 
of the glands in the neck also constitute a serious handicap 
to the child. Either condition must be remedied before he 
can have a fair chance in the world, and the earlier the better. 
The family physician should be consulted and the child given 
such treatment as he may advise. 
Waltham, Mass., 
January i, 1908 

In many California cities the school authorities distribute 
a series of health pamphlets prepared by Dr. Ernest Bryant Hoag.* 
In this series belongs the following on The Causes, Results, and 
Prevention of Poor Teeth. 

HEALTH PAMPHLET NO. 3 

by 

Dr. Ernest Bryant Hoag 
The Effects of Decayed Teeth 

It has been shown by examination of school children 
throughout the United States that from seven to eight out of 
every ten have decayed and defective teeth, needing the care of a 
dentist. 

The condition of the teeth has a very important bearing 
on the health of the child. By early attention not only much 
inconvenience, discomfort and greater expense in later life 
may be saved, but it will enable the child in the meantime to 
live a more vigorous life and be more healthy. 

Very often business men do not want in their employ 
people whose breath is offensive, whose teeth are decayed, 
blackened and unsightly. 

It is the best of economy on the part of the parent to 
have the teeth of the children examined once or twice a year 
by a dentist. If the cavities become large the expense of filling 
and the pain suffered will be greater, or the tooth will be lost. 
It is frequently thought that baby teeth may be neg- 
lected, that the cavities are of no importance. This is wrong. 
Digestive troubles and poor nutrition are frequently traced to 
the neglect. 

* For other pamphlets in this series, see pp. 80-82. 
132 



DENTAL INSPECTION 

Baby teeth can be filled with cement easily and with 
little pain. 

Neglect of baby teeth is often the cause of the coming 
in of irregular permanent teeth. 

Irregular teeth are unsightly. The irregularity often 
causes imperfect closure and inability to chew the food. 

Poor mastication of food in childhood is often the cause 
of serious stomach disorders. This means prolonged suffering 
and doctors' bills. 

Food which is not thoroughly chewed causes constipa- 
tion and indigestion. 

Decay of teeth can be prevented. 

An unclean mouth is an excellent place for the growth 
of disease germs. 

It is a fact that tuberculosis often gains entrance to the 
glands of the neck and so to the lungs through decayed places in 
the teeth. 

Abscesses of the jaw and glands of the neck come from 
decayed teeth. 

Bad conditions of nose, throat and ears are made worse 
by decay of teeth. 

Causes of Decay 

Small particles of food lodging along the gums, in cavi- 
ties and between the teeth ferment. The protecting enamel 
is dissolved by the substances formed by this fermentation. 
Cavities result. The gums are also liable to become dis- 
eased. 

The loosening of teeth and disease of the gums is, in 
nearly all cases, caused by collections of tartar. 

Tartar collects on the teeth of every person. It fre- 
quently collects along the teeth down under the gums where 
it can only be reached by the dentist's instrument. 

The Armenians are noted for their beautiful and perfect 
teeth. The children are taught to clean their teeth after any- 
thing being taken into the mouth, even an apple. 

If a child is taught to use a tooth brush in early life he 
will be apt to take proper care of the teeth throughout life. 
It is very important to establish cleanly habits. 

It is more important for children to brush the teeth than to 
wash the face. 

133 



MEDICAL INSPECTION OF SCHOOLS 

RECORD FORMS AND BLANKS 

The simplest systems of record keeping used in connection 
with dental inspection consist merely of small charts showing in 
outline a full upper and lower set of teeth. By marking these 
pictured teeth the medical inspector indicates which of the child's 
teeth are in need of attention. 

In a fully developed system of dental inspection including 
dental clinics and examinations of children in the schools by 
dentists, work is facilitated by using a set of nine or ten records 
each serving its own end. Perhaps the most satisfactory record 
system of this sort is that in use in connection with the dental 
clinics of Philadelphia. Because these records are so well adapted 
for the work they are designed to do it seems worth while to present 
the series in detail. 

The individual record card, the face and reverse of which 
appear on pages 135 and 136, measures 5x8 inches and is designed 
to record the salient data concerning the teeth of one child. 

After the child has been examined and a condition found 
which requires treatment, a notice, reproduced on page 137, is sent 
to the parent telling him what has been discovered and advising 
that the child be treated by a competent dentist. 

If the notification to the parent brings to light the fact that 
he desires to have his child receive dental attention but is unable 
to pay the cost, the dental inspector and the principal jointly 
issue a certificate, shown on page 138, authorizing the child to be 
treated at the dental dispensary. 

When the child visits the dispensary he is given a small 
appointment card see page 139 measuring 2^ x 3^ inches, on 
which are written the date and hour of his appointment and 
which contains spaces where the dentist indicates the dates on 
which he worked. One end served by this card is to insure that 
the same dentist shall carry the case through to a conclusion. 
Directions for brushing the teeth are on the reverse of the card. 
These are the same as those already reproduced on page 128 as 
part of the label on the tooth powder box. 



134 



INDIVIDUAL DENTAL RECORD CARD, PHILADELPHIA (Face) 



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INDIVIDUAL DENTAL RECORD CARD, PHILADELPHIA (Reverse) 











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DENTAL INSPECTION 
NOTICE TO PARENT, PHILADELPHIA 



Form 9 D. D. 



CITY OF PHILADELPHIA 
Department of Public Health and Charities 

BUREAU OF HEALTH 



DIVISION OF SCHOOL INSPECTION 

DENTAL DISPENSARY 
ROOM 706, CITY HALL 

PHILADELPHIA, 191 

Mr.. 



Dear 

This is to notify you that your child 

attending 

School, 

is in need of Dental treatment. 

progress in school is retarded by impairment of 

general health, resulting from decayed teeth. 

For the best interests of your child we strongly advise 
that teeth be treated at once by a competent dentist. 

For further information call at the school and consult 
the Principal. 



..INSPECTOR 



PRINCIPAL 

PLEASE BRING THIS NOTICE WITH YOU TO THE SCHOOL 



137 



MEDICAL INSPECTION OF SCHOOLS 
CERTIFICATE FOR FREE TREATMENT, PHILADELPHIA 

Form 6 D. D. 

CITY OF PHILADELPHIA 
DEPARTMENT OF PUBLIC HEALTH AND CHARITIES 

BUREAU OF HEALTH 



DIVISION OF SCHOOL INSPECTION 

DENTAL DISPENSARY 

ROOM 706. CITY HALL 

Philadelphia, 191 

THIS IS TO CERTIFY that 

age Residence 

School Section 

Grade is in need of dental treatment and the pa- 
rents are unable to pay for the same. 



INSPECTOR 



PRINCIPAL 



PRESENT THIS CERTIFICATE AT ROOM 706, CITY HALL. Office Houn: 
Monday to Friday, 9 A. M. to 4 P. M. Saturday. 9 A. M. to 12 Noon. 



138 



DENTAL INSPECTION 
APPOINTMENT CARD, PHILADELPHIA 



CITY OF PHILADELPHIA 
Department of Public Health and Charities 



BUREAU OF HEALTH 

DENTAL DISPENSARY: Room 706 City Hall. 
Branch Southwark School, 9th and Mifflin Sts. 



HAS AN APPOINTMENT FOR 



Monday at 

Tuesday at.... 

Wednesday at.... 

Thursday at.... 

Friday at.... 

Saturday at.... 

BRING THIS CARD WITH YOU 
Discharged .for Months 

SHOW THIS CARD TO YOUR TEACHER 



ATTEST 
WHEN PRESENT 



DIRECTIONS FOR BRUSHING THE 
TEETH 

Turn out about a teaspoonful of 
precipitated chalk into the palm of 
one hand, touch the chalk with the 
wet brush, and brush, (i) up and 
down the inside of the lower front 
teeth, (2) the right, and (3) the left 
side of the lower back teeth, (4) in- 
side of the upper front teeth, (5) 
right, and (6) left side of the upper 
back teeth, (7) outsides of all teeth, 
upper and lower, brushing up and 
down. 

To clean each of these seven di- 
visions, first wet the brush, then dip 
it in the powder in the hand. 

Brush the teeth at night and rinse 
the mouth night and morning with a 
teaspoonful of table salt dissolved in 
a tumbler of warm water. 



After the pupil has been treated at the dispensary an in- 
dividual record of the work done is made and filed. This is a 
card measuring 5x8 inches and its face is identical with that of 
the individual record card already reproduced. On the reverse 
are spaces for recording the date, the operation performed, and 
the name of the operator. 

The school's record of the work done takes the form of a 
card measuring 5x8 inches and is kept by the principal. On 
this card, seen on the following page, are spaces for recording the 
names of the pupils and the dental inspector together with the 
action taken by the parent, private dentist, or dispensary. 

The record of the work done by the individual dental 
inspectors takes the form of a card measuring 5x8 inches having 
spaces wherein the inspectors record each week the work done 
on each school day. This card is reproduced on page 141. 



139 



MEDICAL INSPECTION OF SCHOOLS 



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DENTAL DL 
ROOM 706, C 
Report from... 




MONDAY 


TUESDAY 


WEDNESDAY 


THURSDAY 


FRIDAY 


TOTALS 







141 



MEDICAL INSPECTION OF SCHOOLS 

For administration purposes the dental clinic keeps detailed 
monthly reports which are summaries of the individual reports 
received from the children and the schools. There are two princi- 
pal record forms which are sheets designed for use in loose leaf 
binders. The first of these has spaces for recapitulating the work 
during each day of the month. The column headings are: 
Day of Month Canals Pericementitis 

Daily Number of Dressed Alveolar Abscess 

Patients Filled Gingivitis 

Fillings Pulps Stomatitis 

Amalgam Pulpitis Cleansing 

Gutta Percha Capped Extractions 

Cement Devitalized Miscellaneous 

Copper Cement Extracted 

The second of the two recapitulation sheets has spaces 
for recording the work done each month by the individual inspec- 
tors. The column headings across the top of the sheet are: 

Inspectors, Schools Assigned, Visits Made, Pupils Examined, Treat- 
ment Recommended, Parents Notified, Parents Called on Principal, 
Treated by Private Dentist, Recommended by Dispensary, Treated at 
Dispensary, Treatment Secured, Remarks. 

SUMMARY. In summarizing the situation with respect to the 
dental inspection of school children the most salient fact is that the 
commonest of all physical defects among school children is decayed 
teeth. Cases of dental defectiveness are frequently greater in 
number than are all other sorts of physical defects combined. 
Moreover, it is probably true that there is no single ailment of school 
children which is directly or indirectly responsible for so great 
an amount of misery, disease, and mental and physical handicap. 

Within the past decade those having the greatest interest 
in the physical welfare of children have awakened to the existence 
of these conditions and vigorous steps have been taken to remedy 
them. First in Germany, next in England, and more recently 
in the United States dental inspection has been inaugurated and 
school dental clinics established. The means and methods 
developed have so conclusively demonstrated their usefulness 
that the movement is everywhere extending rapidly and steadily. 



142 



CHAPTER X 

CONTROLLING AUTHORITIES 
IN AMERICAN MUNICIPALITIES 

UNDER American systems of municipal government, the 
question as to whether medical inspection of schools is a 
proper function of the board of education or the board of 
health is bound to arise as soon as the organization of such a 
system is contemplated. The claims of both are certain to be 
warmly argued. 

On the side of the board of health is the argument that the 
machinery of government already existing for the conservation 
of the health of the community may properly be extended to 
include new activities, and that another branch of the government 
should not duplicate social machinery already existing. It is 
further argued that an important feature of the medical inspection 
of schools is the detection and segregation of cases of contagious 
disease. This is a protective measure relating to the safety of 
the whole community, and as such should remain a function of 
the board of health. 

The argument for keeping the work in the hands of the board 
of education is that the whole work, to be effective, must be 
closely related to school work and school records; that friction 
is inevitably produced when those in charge are in the employ of 
an outside body, neither responsible to nor perhaps in sympathy 
with those who have the schools in charge. This results in a loss 
of efficiency. 

The further claim is made, and substantiated by referring 
to records in many cities, that the exclusion of cases of contagious 
disease is after all a comparatively small part of the work of med- 
ical inspection. Thus in Newark, New Jersey, in 1909-10, the 
total exclusions amounted to 4,955 in a school membership of 

143 



MEDICAL INSPECTION OF SCHOOLS 

57,742, or about 8 per cent. In Cincinnati and Rochester in the 
same year the exclusions amounted to between 3 and 4 per cent, 
in Philadelphia and Spokane to 4 per cent of the membership. 
In the state of Massachusetts in 1907, towns and cities having an 
average attendance of 342,000 reported something more than 
1 5,000 exclusions during the year. Again the percentage is 4. It 
should be mentioned that in many cities cases of pediculosis form 
a very large proportion of the diseases listed as communicable. 
In New York City, where only the worst cases of this class are 
excluded, the total exclusions in 1909-10 amounted to little more 
than i per cent (8,884) f a tota l membership of 744, 148. 

These facts have a direct and important bearing on the 
question at issue. The data showing that the proportion of cases 
requiring exclusion on account of contagious disease does not 
exceed 4 per cent of the school membership indicate that the por- 
tion of the work falling within the purview of the department of 
health is specific and limited. On the other hand, the fact that 
all the children need medical and sanitary supervision with respect 
to exercises, suitable seats and desks, type, paper, suitable hours 
of study and recreation, drinking water, physical and mental 
defects, and the like, indicates that the portion of the work which 
legitimately forms a function of the educational authorities is 
general in nature and almost unlimited in scope. 

By far the most important evidence bearing on the problem 
is that drawn from the experience of American commonwealths 
and municipalities. Medical inspection laws, or regulations 
equivalent to laws, are now in force, as has been stated, in 19 states 
and the District of Columbia. It is most significant that in 17 
of these 20 cases the administration of the provisions is placed in 
the hands of the educational authorities. In one case administra- 
tion may be through either the department of health or the depart- 
ment of education, and in only two cases is it entirely in the hands 
of the health authorities. 

No less striking is the situation among American municipal 
systems. In the early days of medical inspection practically all 
systems were administered by local boards of health, but as 
experience has accumulated the tide has turned until at the present 
time only about one-quarter are under boards of health and in 

144 



CONTROLLING AUTHORITIES 

the remaining three-quarters the board of education is the con- 
trolling authority. 

In the investigation conducted in 1911, as has been stated, 
the facts concerning medical inspection were gathered for 1,046 
school systems in 1,038 cities and towns. Among these, 443 had 
systems of medical inspection. The following table shows how 
these systems were divided between the two forms of administra- 
tion. 



TABLE 34. ADMINISTRATION OF SYSTEMS OF MEDICAL INSPECTION 
IN CITIES OF UNITED STATES, BY GROUPS OF STATES. 19! I 



Division 


Cities having 
systems of 
medical 
inspection 


Cities having 
administra- 
tion by board 
of health 


Cities having 
administra- 
tion by board 
of education 


North Atlantic 
South Atlantic 
South Central 
North Central 
Western . 


236 
23 
35 
109 
40 


58 
7 

12 

21 

8 


78 

16 

23 
88 
32 


United States 


443 


1 06 


337 



A good idea of the feeling of those in charge of the work in 
localities where the question as to administration has been raised 
may be gained from reading some extracts, mostly taken from 
official reports made by executive officers. 

In his report for 1907 (pages 142-3), William H. Maxwell, 
city superintendent of schools of New York, says: 

" Dual responsibility in the school that of the board of education 
and that of the department of health always has resulted and always 
will result in confusion and inefficiency in the work effected. It is owing 
to this dual responsibility that the large annual appropriation made by the 
city for the physical examination of school children is to a great degree 
wasted. Efficient service will be obtained only when the board of educa- 
tion is made solely responsible for all the work that goes on in the schools. 

"The physicians employed by the board of health do not perform 
any of the functions which it is highly advisable should be performed by a 
truly educational department of hygiene, such as studying hygienic condi- 
10 145 



MEDICAL INSPECTION OF SCHOOLS 

tions in the schools and advising teachers regarding the pedagogical 
treatment of children in cases of fatigue and nervousness. 

"The nurses employed by the department of health have done good 
work in visiting the homes of sick children, in giving advice and assistance 
to mothers, and in looking after slight ailments in the school. The fact, 
however, that they are under the control of an outside organization is a 
constant hindrance to their work. It is another instance of the evil 
effects which arise from dual control or divided responsibility. I risk 
nothing in saying that the school nurses would do much more and better 
work if they were made responsible to the educational authorities." 

Dr. Thomas F. Harrington, of the department of hygiene, 
Boston, says * in speaking of the system of medical inspection by 
physicians in the employ of the department of health: 

"The greatest criticism against this system of inspection is that 
it lacks uniformity; that it excludes pupils, and does not provide any 
means of 'follow up' nor any guarantee that the child will receive medical 
care; that the duties of the inspector as an agent of the board of health 
bring him in contact with much contagion in the homes; and finally, that 
the dual duties and divided responsibility are not conducive to the best 
in the health and efficiency of school children." 

Speaking of the work of the school nurses, he says : * 

" It does not seem possible to conceive a more satisfactory arrange- 
ment, nor a more effective piece of school machinery, than nurses under 
school supervision. With a corps of medical inspectors under this same 
supervision, who would conduct a daily clinic in their respective school 
districts, there are no problems connected with the health and efficiencv 
of school children which could not be quietly, rationally, economically, 
and effectually solved. Until such an organization is perfected in part 
or in whole, little progress can result from the efforts to promote the health 
and efficiency of our school children." 

The superintendent of schools of Boston in his twenty- 
seventh annual report, July, 1907 (page 39), says in regard to 
the Massachusetts law making medical inspection compulsory: 

"In this connection it should be stated that while the school physi- 
cians were concerned solely with contagious diseases, they were properly 
to be controlled by the board of health. Under the new law, the work 
* School Hygiene, Sept., 1908, p. 21. 
146 



CONTROLLING AUTHORITIES 

of examining into any defect that interferes with the progress of the chil- 
dren in school is not in the main a question of public health. It is rather 
an educational question and is so directly allied to the work of the depart- 
ment of physical training that the school physician should be appointed 
by the school board and become a part of this department. The highest 
efficiency will be impossible until this action is taken." 

The superintendent of schools of Cleveland says in 
his report for 1907 (page 42), after making an able plea for the 
establishment in the schools of the city of a system of medical su- 
pervision : 

"While it has been suggested that the kind of service here treated 
should be performed by the board of health, it is the belief that medical 
supervision is peculiarly a function of the department of physical training 
and school hygiene, and that the board of health's relation to the schools 
should relate to the matter of communicable disease." 

In his report for 1907 (page 119), Dr. Poland, the superin- 
tendent of schools of Newark, New Jersey, states that the medical 
inspection as conducted by the board of health has been satisfac- 
tory, but adds that the only objection that can be raised against it 
relates to the executive control of the staff of medical inspectors. 
He says: 

"By additions to the staff, the number of medical inspectors now 
employed in the schools is 16. The direction and control of this large 
number requires some one who can give more time to it than is possible 
for the busy and overworked, but exceedingly efficient, health officer. It 
seems hardly fair to impose upon him in addition to his other duties the 
duty of overseeing daily the work of sixteen medical inspectors." 

Dr. Fred S. Shepherd, superintendent of schools of Asbury 
Park, New Jersey, says in his report for 1907: 

"Again, if the system is to work harmoniously, the medical in- 
spector should work under the direction of the superintendent of schools, 
as do the teachers. If the medical inspector should regard himself as not 
called upon to accept any suggestions whatsoever from the school officers 
of administration, such as superintendents or school principals, it is plain 
that friction might arise. In this connection toe should not overlook the 
fact that medical inspectors are human and have a few of the faults com- 

147 



MEDICAL INSPECTION OF SCHOOLS 

mon to humanity. It is possible for them, as it is for teachers and others 
higher in authority, to slight their duties or to perform them in an ineffi- 
cient and unsatisfactory manner. School boards are not able to pass 
judgment upon these inner workings of the system, and somebody should 
have the responsibility for holding even medical inspectors, if necessary, 
to the letter if not to the spirit of their obligations." 

It is to be noted that Superintendent Shepherd is speaking, 
not from the point of view of the theorist, but from that of one 
experienced in conducting a school system which has a successful 
system of medical inspection conducted by physicians appointed 
by the board of education. In describing the workings of this 
system in actual practice, Dr. Shepherd goes on to say: 

"It has been suggested in some quarters that medical inspection 
of school children should be one of the functions of the local board of 
health, in order to prevent clashing of authority. As boards of health 
are organized in our own state, however, I can see no likelihood of such 
cross purposes. I presume it does devolve upon local boards of health 
to inspect for sanitary purposes all public buildings, including the public 
schools. This, I judge, is also, or should be, one of the duties of the 
medical inspector. To have the public schools inspected intelligently 
by two such departments seems to me a good thing. What one might 
overlook, the other might see. Aside from this apparent overlapping 
of jurisdiction, I see little opportunity for any clashing of interest. On the 
contrary, it is possible for the very closest relations to be established 
between boards of health and the school medical authorities. How it 
might be in other cities of the state, I am not aware; but in the city of 
Asbury Park every case of contagious or infectious disease is reported 
immediately by the board of health to the school authorities, and vice 
versa." 

That the fears expressed by Dr. Shepherd are not groundless 
is shown by experience in cities where the dual system of control 
is in practice. 

Such an example comes to light in the city of Lawrence, 
Massachusetts. There medical inspection is, of course, con- 
ducted under the provisions of the state statute, which provides 
for the appointing of school physicians by either the school com- 
mittee or the board of health. In Lawrence the threatened con- 
flict occurred in August, 1907, when the board of health appointed 

148 




Waiting for the school physician in Toledo, Ohio. 




Throat inspection in the Orange, N. J., schools. 



CONTROLLING AUTHORITIES 

five physicians to inspect both public and private schools. By an 
order of the school committee the principals and teachers were 
forbidden to extend official recognition to any but Dr. Bannon, who 
had been appointed by the school committee in August, 1906, for 
a term of three years. This state of affairs continued for some 
time and the schools were under a double inspection, with much 
consequent unavoidable friction. 

One of the strongest arguments in favor of medical inspec- 
tion under the authority of boards of education undoubtedly is 
that efficiency demands that there shall be the closest co-operation 
between the medical and educational authorities. If the children 
are to be benefited, if diligent effort is to be made to correct the 
defects found, if the physical conditions brought to view are to be 
used for the guidance of the teacher in the class room, then certainly 
such intimate relationships are essential. 

It has been claimed that where inspection is conducted under 
the board of health this is difficult or impossible. Certainly an 
examination of the annual reports of some of the superintendents 
of schools in cities where it is so conducted would indicate that the 
educational authorities know little of the work that is being done, 
and so regard it as of slight importance as a guide in the class room. 
Examples of such an attitude as this are found in reports of the 
superintendents of schools of Haverhill and Springfield, Massachu- 
setts, for 1907. The superintendent of schools of Haverhill dis- 
poses in his report of the subject of medical inspection with the 
following brief remarks (pages 32-33) : 

"The school physicians have continued their work on the same basis 
as last year, under appointment from the board of health. I am permitted 
to make the following summary of such portions of their work as admit 
of classification. A large proportion, perhaps the largest portion of their 
work, is not such as can be shown in the form of statistics." 

Then follows a brief list of the diseases noted by the school 
physicians and of the statistics concerning vaccination. No details 
are given, nor is there any mention made even of the number of 
pupils examined. The report is confined to some 10 lines. Such 
comment certainly does not seem to indicate intimate knowledge 

149 



MEDICAL INSPECTION OF SCHOOLS 

of what is being done, or a close relationship between the work 
of the school physicians and that of the educational authorities. 

A similar condition seems to be revealed in Springfield, 
where the sole comment of the school board on the work of the 
physicians appointed by the board of health is (page 17), "So far 
as we can learn, the inspectors are fulfilling their requirements 
and parents generally follow the advice given/' 

In Massachusetts, medical inspectors are appointed in 
some of the cities by the boards of health and in others by the 
school committees. After watching the operation of the two 
systems for more than a year under the state law, Secretary 
George H. Martin of the state board of education writes:* 

"The movement now in progress, which has reached different 
stages in different countries, seems to be shaping itself so as to include as 
necessary features the following elements: 

"(i) Physicians. A sufficient number of trained physicians to 
carry on the necessary examinations and exercise the needed oversight of 
all the children in the public and private schools, these physicians to act 
under the direction of the local educational authority, but in co-operation 
with local health authorities. In the larger cities the physicians should 
act under the immediate direction of a chief medical officer, who should 
be a permanent member of the educational staff." 

SUMMARY. In summing up, then, we may conclude as a 
result of the evidence presented: 

1. The detection of contagious diseases in the schools, 
involving daily visits by physicians and the power of the law, is 
in the nature of an extension of the powers heretofore exercised 
by boards of health; and where medical inspection is to include 
nothing more than this work, systems may well be administered 
by boards of health, if care be taken to establish and maintain 
sufficiently close and friendly relations with the school officials. 

2. Those activities which have to do with the child's phy- 
sical condition and the hygiene of school work seating, exercise, 
hours of home study that is to say, all functions of the medical 
inspection of schools except those pertaining to contagious diseases, 

* Massachusetts State Board of Education, yist Annual Report, 1906-07, p. 123. 

150 



CONTROLLING AUTHORITIES 

are, in the nature of the case, an integral part of school interests 
and must not be divorced from them. Moreover, the records 
of the examination of school children for physical defects likely 
to interfere with proper growth and education must, if they are to 
serve their end, follow the child from grade to grade and from 
school to school, and each case must be followed up constantly; 
that is, they are an important part of the school records and 
must be so made and administered. 
In brief: 

(a) Medical inspection for the detection of contagious dis- 
eases may well be a function of the board of health. 

(b) Physical examinations for the detection of non-contagious 
defects should be conducted by the educational authorities, or 
at least with their full co-operation, because they are made for 
educational purposes. 

(c) The records of physical examinations must be constantly 
and intimately connected with school records and activities. 

(d) They do not need to be connected with other work of the 
board of health. 






CHAPTER XI 
PHYSICAL DEFECTS AND SCHOOL PROGRESS 

THE literature of the newer school hygiene contains many 
references to the close relation between physical defec- 
tiveness and school retardation. Unfortunately, however, 
few investigations have been conducted to find out just what 
relation exists between progress and the physical condition of the 
pupil, and the published reports of such investigations as have 
been carried on are meager and unsatisfactory. 

Six American studies bearing on the problem are sufficiently 
significant to warrant review. The first of these was an investiga- 
tion carried on by Dr. Walter S. Cornell and reported in the 
Psychological Clinic for January, 1908.* 

DEFECTS AMONG "EXEMPT" AND "NON-EXEMPT" CHILDREN 

In Philadelphia, where Dr. Cornell's work was done, the 
pupils were divided into so-called "exempt" children, those whose 
work had been so thoroughly satisfactory that they were advanced 
to higher grades without examination, and "non-exempt," those 
whose work was less satisfactory. Among 1,594 children in five 
schools who were given physical examinations, he found the follow- 
ing: 

TABLE 35. PER CENT OF CHILDREN EXAMINED FOUND DEFECTIVE, 
AMONG 907 "EXEMPT" AND 687 "NON-EXEMPT" CHILDREN, 

IN PHILADELPHIA, PENN. 





Exempt 
children 


Non-exempt 
children 


Number examined 
Per cent defective 


907 

28.8 


687 
38.1 



*CornelJ, Walter S., M.D.: The Relation of Physical to Mental Defect in 
School Children. Psychological Clinic, Jan. 15, 1908, pp. 231-234. 

152 



PHYSICAL DEFECTS AND SCHOOL PROGRESS 



Here the figures show that the percentage of defectives is 
much higher among the non-exempt than among the exempt 
children. We are given no details, however, as to defects found 
and so no data indicating which particular sort or sorts of defects 
caused the preponderance on the side of the non-exempt pupils. 
Some light, however, seems to be thrown on this problem by the 
results of an investigation conducted in 1908 by Dr. S. W. New- 
mayer in the schools of Philadelphia* and covering the examina- 
tions of 5,005 children, of whom 3,587 were exempt and 1,418 non- 
exempt. Defects were found among them as follows: 

TABLE 36. PHYSICAL DEFECTS AMONG 3,587 EXEMPT AND 1,418 
NON-EXEMPT CHILDREN, IN PHILADELPHIA, PENN., 



Defect 


CASES AMONG 


CASES PER 100 CHILDREN 

AMONG 


Exempt 
children 


Non-exempt 
children 


Exempt 
children 


Non-exempt 
children 


Defective vision 
Defective hearing 
Defects of nose . 
Defects of throat 
Orthopedic defects 
Mentally defective . 
Skin disease 
Miscellaneous . 


371 
49 
54 
'37 
25 
6 
918 
214 


171 
29 

21 

53 
25 
80 
423 

128 


10 

2 

4 

i 

26 
6 


12 
2 
2 

4 

2 

5 
30 
9 


Total . . . 


1.774 


930 


50 


66 



With two exceptions the defects are distributed between 
the two classes of children with surprising equality. 

The brighter pupils seem to be afflicted in about the same 
degree as their duller companions. The two exceptions occur in 
the cases of "mental defects" and "skin diseases," both of which 
are more frequent among the duller children. That the former 
should be more common is to be expected. That the non-exempt 
children should be found to suffer more commonly from skin 
diseases is probably a reflection of poorer home conditions rather 
than a cause of their lower school standings. 

* Report not in print. 
153 



MEDICAL INSPECTION OF SCHOOLS 



DEFECTS AMONG NORMAL AND OVER-AGE CHILDREN 
In 1906 Superintendent James E. Bryan of Camden con- 
ducted an extensive study* of the relation between school prog- 
ress and physical condition. In all, 10,130 children were given 
physical examinations. Of these children, 8, no were of normal 
age and 2,020 retarded. The results of the vision and hearing 
tests were as follows : 

TABLE 37. DEFECTS OF VISION AND HEARING AMONG 8,1 IO NORMAL 
AND 2,O2O RETARDED CHILDREN IN CAMDEN, N. J., 1906 





Children of 
normal age 


Retarded chil- 
dren 


Number examined 


8,no 


2,020 


Per cent having defective vision .... 
Per cent having defective hearing 


27 
4 


29 
6 



From these data one would hesitate to draw conclusions 
as to any relation between retardation and defective vision and 
would feel doubtful with regard to defective hearing. 

Among the children studied 1,852 had failed of promotion. 
These children were given still further examinations. Among 
them 1,279 were of normal age for their school grade and 573 were 
retarded. The results of the examinations were as follows: 

TABLE 38. PHYSICAL DEFECTS AND IRREGULAR ATTENDANCE AMONG 

1,279 NORMAL AND 573 RETARDED CHILDREN WHO FAILED OF 

PROMOTION IN CAMDEN, N.J., 1906 





Children of 


Retarded chil- 




normal age 


dren 


Number examined 


1,279 


573 


Per cent having defective vision .... 


51 


40 


Per cent having defective hearing 


14 


1 1 


Per cent having bad health 


21 


21 


Per cent attending irregularly .... 


3 


4 



*Annual Report of the Board of Education of the City of Camden, New 
Jersey, 1907, pp. 81-120. 

154 



PHYSICAL DEFECTS AND SCHOOL PROGRESS 



These data furnish still further surprises. The children of 
normal age actually show higher percentages of defective vision 
and hearing than do the retarded ones, and the significant feature 
disclosed seems to be that irregular attendance rather than 
physical defects is the important factor affecting school progress. 

DEFECTS AMONG PROMOTED AND NON-PROMOTED CHILDREN 

In his report for 1910 (page 37), Superintendent Verplanck 
of South Manchester, Connecticut, reports results of physical ex- 
aminations among 1,396 children, of whom 1,093 were promoted 
at the end of the year and 303 failed of promotion. The find- 
ings are as follows: 

TABLE 39. PHYSICAL DEFECTS AMONG 1, 093 CHILDREN PROMOTED 

AND 303 CHILDREN NOT PROMOTED IN ELEMENTARY SCHOOLS, 

IN MANCHESTER, CONNECTICUT, I9IO 



Defect 


CASES AMONG CHILDREN 


CASES PER 100 CHILDREN 
AMONG THOSE 


Promoted 


Not promoted 


Promoted 


Not promoted 


Teeth .... 
Throat .... 
Adenoids 
Eyes .... 
Other defects 


272 
156 
162 
41 
23 


116 

39 
61 


25 
'4 
15 
4 

2 


38 
13 

20 

3 
3 


Total .... 


654 


233 


60 


77 



These figures show that a greater percentage of the non- 
promoted than of the promoted pupils had adenoids and defective 
teeth. In the case of the other defects the difference in the 
figures is so slight as to be non-significant. 

DEFECTS AMONG RETARDED CHILDREN 
In his report for 1909-10 (page 28), Superintendent D. C. 
Bliss of Elmira, New York, reports the results of the physical 
examinations among 449 children who had been in the first grade 
of the Elmira schools for from two to seven years. The findings 
are presented in Table 40. 

155 



MEDICAL INSPECTION OF SCHOOLS 

TABLE 40. PHYSICAL DEFECTS AMONG 449 RETARDED CHILDREN, 

OF WHOM 345 HAD BEEN IN THE FIRST GRADE TWO YEARS, 86 

THREE YEARS, AND l8 FOUR OR MORE YEARS. ELMIRA, 

NEW YORK, I9O9-IO 



Defect 


CASES AMONG CHILDREN 


CASES PER 100 CHILDREN 
AMONG THOSE 


2 years 
in grade 


3 years 
in grade 


4 or 
more 
years in 
grade 


2 years 
in grade 


) years 
in grade 


4 or 

more 
years in 
grade 


Adenoids 
Hypertrophied tonsils 
Anemia 
Enlarged glands . 
Defective vision . 
Defective hearing 
Rachitis 


67 
141 

5 2 

77 
72 

17 
38 


18 
25 
15 
'9 

21 

3 
'9 


9 
9 

6 

5 
i 

4 


19 
4i 
15 

22 
21 

5 
I I 


21 
29 

>7 
22 

25 

3 

22 


50 
50 
28 

33 
28 
6 

22 


Total .... 


464 120 


39 


134 


139 


217 



A study of the figures of the last three columns shows in 
general an increase in the percentage of defects found as we pass 
from the pupils who had been in the first grade two years to those 
who had been there three years and to the most retarded group 
who had been there from four to seven years. This increase of 
defects with progressive retardation is particularly evident in the 
case of the pupils who had adenoids or were anemic. 



DEFECTS AND PROGRESS IN NEW YORK 
In a study of retardation in the New York public schools, 
conducted in 1908 by the Russell Sage Foundation, a careful 
tabulation was made of the records of the physical examinations 
of 7,608 children who had been examined by school physicians. 
When these records were tabulated the astonishing condition was 
brought to light that nearly 80 per cent of the children who were 
of normal age for their grades were found to have physical defects, 
while only about 75 per cent of the retarded children were defective. 
Another noteworthy point was that the percentage of defec- 
tive children in the lower grades was decidedly greater than in the 
upper grades. The discovery of these unlooked-for results led 

.56 






PHYSICAL DEFECTS AND SCHOOL PROGRESS 

to further study of the figures. The data were retabulated by 
ages, and the findings showed a marked and consistent falling 
off of children who had each sort of defect from the age of six 
up to the age of fifteen. Defective vision alone increased slowly 
but steadily with advancing age. 

Moreover, these decreases were not due to the falling out 
or leaving school of children suffering from defects. This might 
be put forward as an explanation if we had to do with children 
above the age of compulsory attendance, or if the characteristic 
decrease did not take place until the age of fourteen or fifteen; 
but such was not the case. The children were from six to fifteen 
years of age, and the marked decrease began with the seven, 
eight, nine, and ten-year-old children and continued steadily. 

Were further data not available, it would be difficult to 
explain the seeming anomaly that retarded children have fewer 
defects than do children of normal age; but the data showing the 
decrease of physical defects with increasing age are illuminating. 
It is evident that here age is the important factor. The impor- 
tance of this factor in all investigations into the influence of physical 
defects on school progress is evident. 

Whether the term " retarded/' referring to over-age children, 
is used to express a condition or an explanation, it will always 
follow from the definition itself that retarded children will be 
older than their fellow pupils in the same grades. In all cases it 
will always be true that the "backward" pupils will be the older 
pupils. Now, the older pupils are found to have fewer defects. 
This is true whether they are behind their grades or well up in 
their studies. Therefore, it is not surprising that we find 80 per 
cent of all children of normal age have physical defects more or less 
serious, while but 75 per cent of the retarded children are found to 
be defective. This does not mean that pupils with more physical 
defects are brighter mentally. It simply means that those who are 
above normal age are older, and that older pupils have fewer defects. 

In order to ascertain what correlation may exist between 
physical defects and school progress, the records of the children 
were retabulated, using age instead of grade as a basis, so that the 
findings should not be vitiated by the heterogeneous age composi- 
tion of the grades. 

157 



MEDICAL INSPECTION OF SCHOOLS 



The children were arbitrarily divided into dull, normal, 
and bright groups, using as a standard, age in grade. For instance, 
it was considered that the eleven-year-old child in the first grade 
may as a rule be safely classed as dull, whereas the ten-year-old 
child in the sixth or seventh grade may safely be considered bright. 
Using the age-in-grade criterion as a basis, the records of the ten, 
eleven, twelve, thirteen, and fourteen-year-old children were re- 
tabulated and assigned to the dull, normal, and bright classes. 
Results are shown in Table 4 1 . 

TABLE 41. PER CENT OF DULL, NORMAL, AND BRIGHT PUPILS 

SUFFERING FROM EACH SORT OF DEFECT. AGES TEN TO 

FOURTEEN, INCLUSIVE. ALL GRADES. NEW YORK, IQO8 



Defect 


Dull 


Normal 


Brigbt 


Enlarged glands 


20 


13 


6 




24 


25 


2Q 


Defective breathing 


15 


II 


9 


Defective teeth 


42 


40 


34 


Hypertrophied tonsils 


26 


'9 


12 


Adenoids 


15 


10 


6 



Here we have figures which demonstrate that there is a real 
relation between physical defectiveness and school progress. 
In each case, save that of vision, a larger per cent of the dull 
pupils is found to be defective than is the case among the normal 
pupils, and these again are more defective than the bright 
pupils. The fact that defective vision does not follow this same 
rule is somewhat difficult of explanation. There can be no ques- 
tion that seriously defective vision constitutes a real handicap 
to the progress of the child. On the other hand, it has long been 
a matter of common observation that the brightest and most 
studious pupils are often afflicted with defective eyesight. It may 
very well be that these two factors somewhat more than counter- 
balance each other. That is to say, while defective vision is 
undoubtedly a real handicap and is the cause of backwardness 
among some children, there are found in the same classes unusually 
bright children who have so injured their eyesight through undue 
strain and use that they too have very defective vision. This 

158 



PHYSICAL DEFECTS AND SCHOOL PROGRESS 

explanation cannot be put forward as conclusive for there are no 
data to substantiate it. It seems, however, a reasonable explana- 
tion and one which coincides with the known facts in the case. 



TABLE 42. AVERAGE NUMBER OF GRADES COMPLETED BY PUPILS 
HAVING NO PHYSICAL DEFECTS COMPARED WITH NUMBER COM- 
PLETED BY THOSE SUFFERING FROM DIFFERENT DEFECTS. CEN- 
TRAL TENDENCY AMONG 3,304 CHILDREN, AGES TEN TO FOURTEEN 
YEARS, IN GRADES ONE TO EIGHT. NEW YORK, 



Defect 


Average number 
of grades 
completed 


No defects ...... 


A QA 


Defective vision ........ 


A QA 


Defective teeth ........... 


A ()C 




A C8 




A KO 




4 24 


Enlarged glands . . . 


4 2O 







Scale of Grades 

2345 



No defects 4.94 grades 
Defective vision 4.94 grades 
Defective teeth 4.65 grades 
Defective breathing 4.58 grades 
Hypertrophied tonsils 4.50 grades 
Adenoids 4.24 grades 
Enlarged glands 4.20 grades 




159 



MEDICAL INSPECTION OF SCHOOLS 

The results shown in Table 41 (page 158) indicate that there 
is a distinct relation between progress and physical defects. 
They do not, however, show what the relation is in terms of any 
given units. They do not show how many more grades are 
completed by the non-defective than by the defective child. 
In order to arrive at such a measure new computations were made 
showing the average number of grades completed by the ten-year- 
old pupils, by the eleven-year-old pupils, and so on for each of the 
other ages. The central tendency of all of these sets of results was 
then computed. The findings are shown in Table 42 and the dia- 
gram which follows. 

The notable feature of the table is the fact that in every case, 
except that of defective vision, the children suffering from each 
sort of physical defect made less progress in their school work 
than did those not so handicapped. The seriousness of these 
handicaps in terms of percentages is shown in Table 43. 

TABLE 43. EXTENT TO WHICH CHILDREN SUFFERING FROM EACH 

SORT OF PHYSICAL DEFECT SHOW SLOWER PROGRESS THAN DO 

CHILDREN WITH NO DEFECTS. NEW YORK, 1 908 



Defect 


Per cent of loss 
in progress 


Defective vision ......... 


. 


Defective teeth 


6 


Defective breathing 
Hypertrophied tonsils 
Adenoids ............ 


7 

9 
14 


Enlarged glands 


15 












In this table the average loss of 9 per cent which appears 
in the last line is not the numerical average of the percentages 
of loss corresponding to the different sorts of defects, but the 
general loss of progress discovered among all the children having 
physical defects. In other words, the children suffering from 
physical defects made on the whole 9 per cent less progress than 
did those having no physical defects. 

160 



PHYSICAL DEFECTS AND SCHOOL PROGRESS 

In order to show more definitely in terms of school prog- 
ress just what these handicaps mean we may apply them to the 
cases of hypothetical non-defective and defective children. If 
we assume that the average child without physical defects of any 
kind will complete the eight grades in just eight years, how long 
will it take defective children to complete eight grades? The 
answer to this question may be found in Table 44 and the accom- 
panying diagram. 



TABLE 44. NUMBER OF YEARS REQUIRED BY DEFECTIVE AND NON- 
DEFECTIVE CHILDREN TO COMPLETE THE EIGHT GRADES. 
NEW YORK, 



Deject 


Years required 
to complete 
eight grades 


No defects 


So 


Defective vision ......... 


So 


Defective teeth 


8 <; 


Defective breathing 


86 


Hypertrophied tonsils 


87 


Adenoids 


91 


Enlarged glands 


Q 2 







Scale of Years 

34 567 89 



No defects 8 years 


1 1 1 I 1 1 1 1 






Defective vision 8 years 


1 1 1 1 1 1 1 1 






Defective teeth 8.5 years 


1 1 1 I 1 1 1 1 1 






Defective breathing 8.6 years 


1 1 1 1 1 1 1 1 1 






Hypertrophied tonsils 8.7 years 


1 1 1 1 1 1 1 1 1 






Adenoids 9.1 years 


1 1 1 1 1 1 1 1 It 






Enlarged glands 9.2 years 


I 1 I 1 1 1 1 1 II 


ii 


161 



v 



MEDICAL INSPECTION OF SCHOOLS 

If these figures are substantially significant for all New York 
City school children, their educational and economic import is 
great. According to the data, the child with seriously defective 
teeth requires half a year more than a non-defective child to com- 
plete the eight grades. About one-half of the children have 
seriously defective teeth. The handicap imposed by defective 
breathing means six-tenths of a year. About one child in seven 
has defective breathing. The child with hypertrophied tonsils 
takes about seven-tenths of a year more than he should. About 
one child in every four has hypertrophied tonsils. The extra 
time required by the child with adenoids is about one and one- 
tenth years. About one child in eight has adenoids. The pupil 
with enlarged glands requires one and two-tenths years extra. 
Nearly half of the children have enlarged glands. 

The sums of -money-spent annually by New York City for 
public education reach high into the millions. It would be a 
simple matter to compute how many dollars are wasted each year 
in the futile attempt to impart instruction to pupils whose mental 
faculties are dulled through remediable physical defects. Roughly 
speaking, about 60 per cent of all the children suffer from such 
defects. If, then, we should show that the instruction given 
these children suffers a loss in effectiveness of nearly 10 per cent 
because of remediable physical defects, it is evident that the direct 
financial bearing of the problem is of great significance. 

Such a computation, while it would undoubtedly prove 
interesting, is perhaps better left unmade because we do not 
know that the data discussed are either truly reliable or generally 
representative. They are based on a comparatively small number 
of cases in one city, in one year, and could similar data be se- 
cured for longer periods of time and in more localities it is 
not only possible but probable that they would show different 
results. 

The examination is important because it establishes the 
principle that, except in the case of vision, older children have 
fewer defects. It shows that when children who are badly 
retarded are compared with normal and very bright children in 
the same age groups, the children rated as "dull" are found to 
have higher percentages of each sort of defect than the normal 

162 






PHYSICAL DEFECTS AND SCHOOL PROGRESS 

and bright children. In this generalization defective vision must 
be excepted. 

Moreover, the investigation gives us quantitative measures 
of the retarding forces of the different kinds of defects. I n general, 
children suffering from physical defects are found to make about 
9 per cent less progress than children having no physical defects. 
The figures do not really show the retarding influence of each sort 
of defect separately for the reason that the same child is often 
suffering from several sorts of defects. 

Because of the reasons that have been mentioned, the 
figures may be accepted as having distinct value in revealing 
general tendencies, but must not be interpreted as showing with 
precision the relative retarding force of each separate sort of defect, 
or even of physical defectiveness in general. 

Before the attempt to draw detailed and final conclusions 
on this subject is made, a series of similar investigations covering 
large numbers of children in different cities should be conducted, 
and the results carefully analyzed and compared. Until some 
such program has been carried out, dogmatic statements making 
general application of partial results should be avoided, and the 
tentative character of all conclusions thus far formulated, clearly 
recognized. 



163 




164 






CHAPTER XII 
LEGAL PROVISIONS 

TH E first state law concerning the medical inspection of school 
children appears to have been passed by Connecticut in 
1899. It did not provide for the complete sort of inspec- 
tion now carried on in many cities and states, but only for the test- 
ing of eyesight by teachers every three years. Complete medical 
inspection, with examinations for the detection of physical defects, 
was first provided for by state enactment in the permissive law 
of New Jersey passed in 1903. This was followed by the manda- 
tory law of Massachusetts, in 1906, which has been several times 
amended and has served as the basis for a majority of the bills 
which have since been presented in other state legislatures. 

By the beginning of the year 1912, as has been stated, seven 
states had mandatory laws, 10 permissive ones, and in two states 
(Louisiana and Minnesota) and the District of Columbia medical 
inspection was carried on under regulations promulgated by the 
boards of health and having the force of law. The accompanying 
map shows graphically which states have mandatory laws, which 
permissive ones, and in which there are no laws at all. 

The past five years have furnished a large body of experience 
gained under varying conditions in widely separated localities. 
The lessons of this experience can be read in the substantial 
agreement of a majority of the laws in several salient features. 
This agreement is graphically shown by the tabular presentation of 
the principal features of the laws and regulations on page 166. 

On four points there is substantial agreement. The first 
is that the administration of the provisions of the law is placed in 
the hands of the school authorities. The second, third, and 
fourth are respectively the placing of inspection for contagious 
diseases, physical examination, and inspection of teachers, jani- 
tors, and buildings in the hands of school physicians. In seven 
cases provision is made for vision and hearing tests by teachers. 



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LEGAL PROVISIONS 

A clear idea of the principal provisions of the different laws 
may be gained from the following abstract: 

Abstract of Laws and Regulations Covering Medical Inspection 

1. CALIFORNIA 

Adopted 1909. Permissive. Applies where adopted 

Administered by school authorities 

Provides for health and development supervision of 

teachers and pupils 
Inspectors may be either physicians or educators 

2. COLORADO 

Adopted 1909. Mandatory. Applies to all public schools 

Administered by school authorities 

Teachers or principals test sight, hearing and breath- 
ing of all pupils annually 

School authorities report to parents mental, moral or 
physical defectiveness discovered 

Enforcement by State Bureau of Child and Animal Pro- 
tection 

3. CONNECTICUT 

Adopted 1907. Permissive. Applies where adopted 
Administered by school authorities 
Physicians inspect children for contagious diseases 
Physicians may examine teachers, janitors and school 

premises 

Physicians conduct sight, hearing and physical examina- 
tions annually 
Defects reported to parents 
School authorities may appoint school nurses 

4. DISTRICT OF COLUMBIA 

Regulations of health officer and board of education 
Adopted in present form in 1907. Mandatory. Ap- 
plies to all public schools 
Administered by health authorities 
Physicians examine for contagious diseases 
Physicians examine sanitary conditions of buildings 
Physicians may examine teachers and janitors 

5. INDIANA 

Adopted 1 91 1. Permissive. Applies where adopted 

Administered by school authorities 

Physicians inspect children for contagious diseases 

.67 



MEDICAL INSPECTION OF SCHOOLS 

Teachers may test sight and hearing annually 

Physicians conduct physical examinations 

Defects reported to parents 

Not more than 2,000 children for one physician 

Compensation of physician not less than $5.00 for each 

school month 

Physicians may examine teachers, janitors and buildings 
If parents are too poor to provide necessary medical 

treatment it shall be paid for from public funds 
Penalty of $5.00 to $50.00 for violation of provisions of 

act 

6. LOUISIANA 

Adopted 1911. Regulations of sanitary code of state 
board of health having force of law. Mandatory. 
Applies to all public schools 

Administered by school authorities 

Principal of each school makes monthly report on phy- 
sical condition of children and sanitary condition of 
buildings on blanks furnished by state board of health 

Principals and teachers exclude children suffering from 
contagious disease 

7. MAINE 

Adopted 1909. Permissive. Applies to cities and towns 

of less than 40,000 
Administered by school authorities 
Not more than 1,000 pupils to a physician 
Physicians inspect children for contagious diseases 
Physicians may examine teachers, janitors and buildings 
Tests of sight and hearing annually by teachers or 

physicians 

Physical examination annually by physicians 
Defects reported to parents 

8. MASSACHUSETTS 

Adopted 1906; amended 1910. Mandatory. Applies 

to all public schools 

Administered by school or health authorities 
Physicians inspect children for contagious diseases 
Physicians may examine teachers, janitors and buildings 
Tests of sight and hearing made by teachers annually 
Physicians make physical examinations of children 

annually 

1 68 



LEGAL PROVISIONS 

Defects reported to parents 

Normal schools train students in testing sight and 

hearing 
Physicians conduct examinations of minors applying for 

age and schooling certificates 
9. MINNESOTA 

Regulations of board of health having force of law 
Adopted 1910. Mandatory. Applies to all public 

schools 

Administered by health authorities 
Physicians examine for contagious diseases 
Physicians may inspect teachers, janitors, and buildings 
Physicians conduct physical examinations annually 
Defects reported to parents 
Teachers test sight and hearing annually 
Normal schools train pupils in testing sight and hearing 

10. NEW JERSEY 

Adopted 1909. Mandatory. Applies to all public 

schools 

Administered by school authorities 
Physicians examine for contagious diseases 
Physicians conduct physical examinations, including 

sight and hearing tests 
Defects reported to parents 
Physicians deliver hygiene lectures to teachers 
Parents and guardians may be proceeded against as dis- 
orderly persons for failure to remove any pathological 
condition which may cause a child's exclusion from 
school 

1 1. NEW YORK 

Adopted 1910. Permissive 

Authorizes school authorities to expend school funds for 
the support of medical inspection 

12. NORTH DAKOTA 

Adopted 191 1. Permissive. Applies where adopted 
Administered by school authorities 
Physicians conduct physical examinations annually 
Defects reported to parents 

Co-operates with board of health to curb contagious 
disease and to secure treatment for indigent children 



169 






MEDICAL INSPECTION OF SCHOOLS 

13. OHIO 

Adopted 1910. Permissive. Applies to cities 
Administered by school authorities, but powers may be 

delegated to health authorities 
Physicians inspect children and schools 
School nurses may be employed 

14. PENNSYLVANIA 

Adopted 1911. Mandatory in districts of first and 
second class. Permissive in districts of third and 
fourth class. Districts of first class are those of more 
than 500,000 population, second class from 30,000 to 
500,000, third class 5,000 to 30,000 and fourth class 
less than 5,000 

Administered by school authorities 

Physicians conduct complete physical examinations of 
children annually 

Physicians make sanitary inspection of school premises 
annually 

In districts of fourth class medical inspectors are ap- 
pointed by state commissioner of health 

Provision for employment of graduate nurses 

15. RHODE ISLAND 

Adopted 1911. Mandatory with permissive clause 
providing for employment of physicians 

Administered by school authorities 

Physicians, where employed, make annual examination 
of pupils, teachers, and janitors in public and private 
schools, and inspect buildings and surroundings 

Annual vision and hearing tests by physicians or teachers 

Defects reported to parents 

1 6. UTAH 

Adopted 1911. Mandatory. Applies to all public 

schools 

Administered by school authorities 
Teachers or physicians examine all children annually for 

defects of sight or hearing, defective teeth or mouth 

breathing 
Defects reported to parents 

17. VERMONT 

Adopted 1910. Permissive. Applies where adopted 
Administered by school authorities 

170 






LEGAL PROVISIONS 

Physicians inspect pupils as provided by rules of state 

board of health 
On request, physicians examine pupils of private schools 

18. VIRGINIA 

Adopted 1910. Permissive. Applies where adopted 
Administered by school authorities 
Authorizes school boards to support systems of medical 
inspection 

19. WASHINGTON 

Adopted 1 909. Permissive. Applies to cities of first class 

Administered by school authorities 

Authorizes school boards to appoint medical inspectors 

who shall report monthly on health conditions in 

each school 

20. WEST VIRGINIA 

Adopted 191 1. Mandatory in cities, permissive in coun- 
try districts 

Administered by school authorities 
Physicians inspect children for contagious diseases 
Physicians conduct physical examinations annually 
Physicians, on request of board, report on lighting, 

ventilation, etc. 
School nurses may be employed 



PROVISIONS NEW LAWS SHOULD INCLUDE 

A comparative study of the provisions of the different laws 
shows that with the added experience gained through knowledge 
of how the older measures have met the test of time, school 
physicians and educators have incorporated in some of the more 
recent measures features which are genuine improvements, and 
which should be provided for in bills for new medical inspection 
acts and for amendments of the old ones. The following are the 
features which it would seem ought to be included in bills for new 
medical inspection laws : 

i. A provision that the administration of the system of medical 
inspection shall be in the hands of the school authorities, but that they 
shall have the power to delegate their authority to the local health 
officials, and that in the treatment of cases of contagious diseases the 
school and health authorities shall co-operate. 

171 



MEDICAL INSPECTION OF SCHOOLS 

The principle here involved is that routine medica' inspec- 
tion and physical examinations are primarily established to insure 
the health and vitality of the individual child and are preferably 
conducted by the school authorities who are charged with his 
daily care. The curbing of epidemics of contagious disease is 
primarily for the protection of the community, and in this the 
health authorities have the right as well as the duty to intervene. 
Examples of such provisions as those suggested are to be found 
in the laws of North Dakota and Ohio. 

2. Provision for inspection by school physicians to detect and ex- 
clude cases of contagious disease. 

3. Provision for annual examinations of all children by school phy- 
sicians to detect any physical defects which may prevent the children 
from receiving the full benefit of their school work or which may re- 
quire that the work be modified to avoid injury to them. 

This second provision should include the requirement that 
parents be notified of any defects discovered. 

4. Provision that annual tests of vision and hearing shall be con- 
ducted by the teachers. 

This provision was adopted by Massachusetts on the advice 
of the specialists in these fields and its wisdom has been demon- 
strated by extensive experience in that state. 

5. Provision that the school physicians may conduct examina- 
tions of teachers and janitors and shall make regular inspections of the 
buildings, premises, and drinking water to insure their sanitary condition. 

6. Provision that pupils in normal schools shall receive training in 
conducting vision and hearing tests. 

This requirement is found in the Massachusetts law and the 
Minnesota regulations. 

7. Provision for the employment of school nurses. 

This is provided for in the laws of Connecticut, Ohio, 
Pennsylvania, and West Virginia. 

8. Provision for the enforcement of the law. 

Such provisions, not very well developed, are found in the 
laws of Colorado, Indiana, and New Jersey. The nature of the 

172 



LEGAL PROVISIONS 

provision must vary with local conditions. In states where muni- 
cipalities receive a large part of their school funds from the state, 
and where their school policies are consequently largely controlled 
through the state board of education, it seems clear that the 
enforcement of the law should be placed in the hands of that body. 

The most authoritative formulation of the features which 
should be included in acts providing for the medical inspection of 
schools is that embodied in a series of resolutions adopted by the 
state and provincial boards of health at their annual meeting 
held in Los Angeles, California, from June 30 to July i, 1911. 
T^ris body has for some years had a standing committee on medical 
inspection legislation and has devoted much time to the study of 
the problem; and each year, for the past three years, has made 
reports of progress at the annual conference. The resolutions 
adopted in 1911 are as follows: 

RESOLUTIONS ADOPTED BY THE CONFERENCE OF STATE AND PRO- 
VINCIAL BOARDS OF HEALTH, LOS ANGELES, JUNE 30- 
JULY I, 191 I 

We endorse legislation providing for the medical inspec- 
tion of schools, because extended and varied experience has 
demonstrated that efficient medical inspection betters health 
conditions among school children, safeguards them from 
disease, renders them healthier, happier and more vigorous, 
and aims to insure for each child such physical and mental 
vitality as will best enable him to take full advantage of the 
free education offered by the state. 

It is our judgment that every law providing for the med- 
ical inspection of schools should make provision for frequent in- 
spections of the children by duly qualified school physicians to 
detect and exclude cases of contagious disease. 

It should further provide for annual physical examina- 
tions of all the children by school physicians to detect any 
physical defects which may prevent the children from receiving 
the full benefit of their school work or which may require that 
the work be modified to avoid injury to the child. 

It should empower school physicians to conduct examina- 
tions of teachers and janitors and to make regular inspections 
of buildings, premises and drinking water to insure their sani- 
tary condition. 

'73 



MEDICAL INSPECTION OF SCHOOLS 

We endorse the school nurse as a most valuable ac iunct 
of medical inspection and believe that provision for the 
employment of school nurses should be included in each law. 



THE MASSACHUSETTS LAW AND THE ENGLISH ACT 

There are two medical inspection laws which are more 
important than any of the others as typifying the legislative 
enactments under which the views and beliefs and the results of 
experience of educators and physicians have been crystallized in 
Europe and America in the field of medical inspection of schools. 
These two laws are the English statute which became effective 
on January i, 1908, and that of the state of Massachusetts. 
This commonwealth, always foremost in pioneer and progressive 
legislation, placed upon its statute books in 1906 mandatory laws 
far more comprehensive in their provisions than the English laws. 
In view of the fact that these two laws have served as the basis 
for most of the bills which have since been presented in other 
state and national legislatures, it seems worth while to quote 
them in full here with some comment on their similarity and 
differences. 

THE ENGLISH LAW 

The English law, known legally as Section 1 3 of the Admin- 
istrative Provisions of the Education Act of 1907, in its entirety 
is as follows: 

"13. (i) The powers and duties of a local education 
authority under Part III of the Education Act, 1902, shall 
include: (a) Power to provide for children attending public 
elementary schools, vacation schools, vacation classes, play 
centers, etc. (b) The duty to provide for the medical inspec- 
tion of children immediately before or at the time of or as 
soon as possible after their admission to a public elementary 
school, and on such other occasions as the Board of Education 
direct, and the power to make such arrangements as may be 
sanctioned by the Board of Education for attending to the 
health and physical condition of the children educated in pub- 
lic elementary schools : Provided, that in any exercise of powers 
under this section the local education authority may encourage 

'74 



LEGAL PROVISIONS 

and assist the establishment or continuance of voluntary 
agencies, and associate with itself representatives of voluntary 
associations for the purpose. 

" (2) This section shall come into operation on the first 
day of January, nineteen hundred and eight." 

The English lawmakers are not quite so verbose and prolix 
in statute drafting as are their American contemporaries, and the 
interpretation and construction of this short act was compre- 
hensively treated by the Board of Education in a memorandum 
issued on November 22, 1907,* before the act became effective, 
for the guidance of the administrative officers charged with the 
execution of the statute. 

This course differs somewhat from the American system. 
In the United States, the construction and interpretation of 
statutes are left finally to the courts. This procedure is a lengthy 
and involved process. In view of the fact that the memorandum 
of the English education authorities referred to has the practical 
effect of a parliamentary enactment in the execution of the law, 
it may be well to quote from it somewhat extensively. 

In stating the scope and purpose of the act the memorandum 
uses the following words: 

"The Board desire therefore at the outset to emphasize that 
this new legislation aims not merely at a physical or anthropometric 
survey or at a record of defects disclosed by medical inspection, but at 
the physical improvement, and, as a natural corollary, the mental and 
moral improvement, of coming generations. The broad requirements 
of a healthy life are comparatively few and elementary, but they are 
essential, and should not be regarded as applicable only to the case of the 
rich. In point of fact, if rightly administered, the new enactment is 
economical in the best sense of the word. Its justification is not to be 
measured in terms of money but in the decrease of sickness and incapacity 
among children and in the ultimate decrease of inefficiency and poverty 
in after life arising from physical disabilities." 

A further statement which concludes the same section of the 
memorandum is as follows : 

* Board of Education of Great Britain. Memorandum on Medical Inspec- 
tion of Children in Public Elementary Schools, Circular 576. 

175 



MEDICAL INSPECTION OF SCHOOLS 

"It is founded on a recognition of the close connection which 
exists between the physical and mental condition of the children and the 
whole process of education. It recognizes the importance of a satis- 
factory environment, physical and educational, and, by bringing into 
greater prominence the effect of environment upon the personality of 
the individual child, seeks to secure ultimately for every child, normal 
or defective, conditions of life compatible with that full and effective 
development of its organic functions, its special senses and its mental 
powers which constitutes a true education." 

It will be observed that the burden of executing the pro- 
visions of the statute is specifically laid upon the education author- 
ities. This is a distinct departure from the established course 
heretofore pursued in matters relating to the public health. In 
the view of the English Board of Education, however, the 
present act is not intended to supersede the powers which have 
long been exercised by sanitary authorities under various public 
health acts, but is meant to serve rather as an amplification and 
a natural development of previous legislation. In order that 
friction between the education and health authorities may be 
avoided, if possible, the board of education in this memorandum 
advises a thorough and friendly co-operation with such authorities 
in the administration of the law. 

The second most noticeable feature about the act is that 
it makes medical inspection compulsory. Theretofore, medical 
inspection had been more or less in vogue in various localities 
under the supervision of the education authorities, sometimes in 
conjunction with the health authorities. The central authority 
for the execution of the law is the board of education. The 
instruments of the board are the local education authorities. In 
country areas this local authority is the county council. It is 
suggested in the memorandum that the county council instruct 
the county medical officer to advise the education committee 
and to supervise the new work. It is also suggested that the 
county medical officer have an assistant appointed by the county 
council, whose duty shall be the inspection provided for by the 
statute. 

In county boroughs the town council, which is at the same 
time the local authority for public health and the local education 

176 



LEGAL PROVISIONS 

authority, is counseled to instruct their medical officer of health 
to advise the education committee and assume responsibility for 
the new work. Where no school medical officer has been appointed, 
it is suggested that his appointment be made by the education 
authorities. Where there are already school medical officers it is 
suggested that they be retained if competent and sufficient for 
the new duties. 

Although there is no provision for school nurses in the act, 
the board of education advises that wherever practicable such 
nurses be employed. 

The board decided that not less than three inspections during 
the school life of a child would be necessary to secure the results 
desired. In certain areas, the board may from time to time 
require inspection at shorter intervals and of a more searching 
character. 

The inspection of the sanitation of school buildings, the 
prevention of the spread of contagious diseases, and the super- 
vision of the personal and home life of the child are also suggested. 

Finally, it should be observed that neither the act nor the 
memorandum contains any section whatever requiring that 
parents of school children found diseased or defective after such 
inspection shall be compelled to provide proper medical attention 
at the hands of their own physician or of the hospital authorities.* 
As a means of securing the co-operation of parents the memoran- 
dum recommends "that each local educational authority should 
encourage one or both of the parents of the child to be present 
at the first inspection, and to this end a notification should be 
sent to the parents as to the time and place at which it will take 
place." 

THE MASSACHUSETTS LAW 

Let us now consider for comparison with the English statute 
the first legislative enactment in the United States which made 
medical inspection mandatory. As this Massachusetts law was 
the initial legislative effort in America along this line, it seems 
worth while to quote it in extenso. Legally it is known as Chapter 

* See Chap. VI, p. 86, for information regarding compulsory action taken 
in England. 

12 I 



MEDICAL INSPECTION OF SCHOOLS 

502 of the Acts of 1906, and it became a law of the state of Mass- 
achusetts on the first day of September, 1906. It provides: 

APPOINTMENT OF SCHOOL PHYSICIANS, ETC. 

Section i. The school committee of every city and 
town in the Commonwealth shall appoint one or more school 
physicians, shall assign one to each public school within its 
city or town, and shall provide them with all proper facilities 
for the performance of their duties as prescribed in this act: 
provided, however, that in cities wherein the board of health 
is already maintaining or shall hereafter maintain substantially 
such medical inspection as this act requires, the board of 
health shall appoint and assign the school physician. 

EXAMINATION AND DIAGNOSIS TO BE MADE 

Section 2. Every school physician shall make a prompt 
examination and diagnosis of all children referred to him as 
hereinafter provided, and such further examination of teachers, 
janitors, and school buildings as in his opinion the protection 
of the health of the pupils may require. 

AUTHORITY OF SCHOOL COMMITTEES, ETC. 

Section 3. The school committee shall cause to be 
referred to a school physician for examination and diagnosis 
every child returning to school without a certificate from the 
board of health after absence on account of illness or from 
unknown cause; and every child in the schools under its 
jurisdiction who shows signs of being in ill health or of suffering 
from infectious or contagious disease, unless he is at once ex- 
cluded from school by the teacher; except that in the case of 
schools in remote and isolated situations the school commit- 
tee may make such other arrangements as may best carry out 
the purposes of this act. 

NOTICE TO BE SENT TO PARENT OR GUARDIAN 

Section .4. The school committee shall cause notice of 
the disease or defects, if any, from which any child is found 
to be suffering to be sent to his parent or guardian. Whenever 
a child shows symptoms of smallpox, scarlet fever, measles, 
chickenpox, tuberculosis, diphtheria or influenza, tonsilitis, 
whooping cough, mumps, scabies, or trachoma, he shall be 
sent home immediately, or as soon as safe and proper con- 

.78 



LEGAL PROVISIONS 

veyance can be found, and the board of health shall at once be 
notified. 

TESTS OF SIGHT AND HEARING AND EXAMINATION FOR DIS- 
ABILITY OR DEFECTS 

Section 5. The school committee of every city and 
town shall cause every child in the public schools to be sepa- 
rately and carefully tested and examined at least once in every 
school year to ascertain whether he is suffering from defective 
sight or hearing or from any other disability or defect tending 
to prevent his receiving the full benefit of his school work, or 
requiring a modification of the school work in order to pre- 
vent injury to the child or to secure the best educational re- 
sults. The tests of sight and hearing shall be made by teachers. 
The committee shall cause notice of any defect or disability re- 
quiring treatment to be sent to the parent or guardian of the 
child, and shall require a physical record of each child to be 
kept in such form as the state board of education shall pre- 
scribe. 

STATE BOARD OF HEALTH TO PRESCRIBE DIRECTIONS: STATE 
BOARD OF EDUCATION TO FURNISH RULES, ETC. 

Section 6. The state board of health shall prescribe the 
directions for tests of sight and hearing and the state board 
of education shall, after consultation with the state board 
of health, prescribe and furnish to school committees suitable 
rules of instruction, test cards, blanks, record books, and 
other useful appliances for carrying out the purposes of this 
act, and shall provide for pupils in the normal schools instruc- 
tion and practice in the best methods of testing the sight and 
hearing of children. The state board of education may 
expend during the year nineteen hundred and six a sum not 
greater than fifteen hundred dollars and annually thereafter a 
sum not greater than five hundred dollars* for the purpose of 
supplying the material required by this act. 

The English statute and the Massachusetts one are simi- 
lar in that both make medical inspection compulsory, both place 
the administration in the hands of the educational authorities, 
and that neither provides for procedure against neglectful par- 
ents of defective children. They prescribe different methods of 

* Eight hundred dollars now appropriated under Chapter 189, Acts of 1908. 

179 






MEDICAL INSPECTION OF SCHOOLS 

securing the co-operation of parents for the correction of defects, 
the Massachusetts law requiring that notices of the results of 
inspections be sent, while the English memorandum recommends 
the summoning of parents to be present at the inspections. In 
the English statute there is no express provision as to the 
frequency of physical examinations, but as has been stated, the 
memorandum of the board of education prescribes three examina- 
tions as necessary during the school life of the pupil. In the 
Massachusetts statute an examination of every pupil at least 
once in every year for defective sight or hearing and any other 
physical disabilities, is provided for. The sight and hearing tests 
are given by teachers, while the other examinations are conducted 
by physicians. 

These are the leading statutes ot Europe and America on 
this subject. At the close of 1912 the American statute will 
have been in effect for six years and the English statute for five. 
Both of these pieces of legislation may therefore be considered as 
having passed through the experimental stage. 



1 80 



APPENDICES 



APPENDIX I 

SUGGESTIONS TO TEACHERS AND SCHOOL PHYSI- 
CIANS REGARDING MEDICAL INSPECTION 

Issued by the Massachusetts Board of Education 

COMMONWEALTH OF MASSACHUSETTS 
STATE HOUSE, BOSTON, Jan. 23, 1907 

In order to render the medical inspection required by chapter 502, 
Acts of 1906, effective and uniform throughout the State, His Excel- 
lency Governor Guild appointed a committee to prepare a circular of 
advice to the school physicians of the State. 

This committee consisted of Dr. Henry P. Walcott, Dr. Charles 
Harrington and Dr. Julian A. Mead, representing the State Board of 
Health; Mrs. Ella Lyman Cabot, Mr. George I. Aldrich and Mr. George 
H. Martin, representing the Board of Education; and Dr. Robert W. 
Lovett, Dr. Harold Williams and Dr. W. H. Devine, representing the 
medical profession. 

A sub-committee of this body arranged for conferences with the 
heads of departments and others connected with the medical schools and 
hospitals in and about Boston, and with physicians who have had ex- 
perience in school inspection. These gentlemen have given freely of their 
time and thought, and have furnished to the committee the suggestions 
contained in this circular. 

These suggestions cover the ground included in the clause in section 
5 of the law: "The school committee of every city and town shall cause 
every child in the public schools to be separately and carefully tested 
and examined at least once in every school year, to ascertain whether 
he is suffering from defective sight or hearing, or from any other dis- 
ability or defect tending to prevent his receiving the full benefit of his 
school work, or requiring a modification of the school work in order to 
prevent injury to the child or to secure the best educational results." 

The Board of Education issues this circular in the assurance that 
it represents the highest professional authority in the specialties covered 
by the law, and commends it to the careful attention of all teachers, 
school physicians and other school officers. 



MEDICAL INSPECTION OF SCHOOLS 

The following are the subjects treated, with the names of the physi- 
cians who have contributed suggestions: 

1. Infectious Diseases. Dr. John H. McCollom. 

2. The Eye. Dr. Myles Standish, Dr. Henry B. Chandler, Dr. 
Charles H. Williams, Dr. David W. Wells. 

3. The Ear. Dr. Clarence J. Blake, Dr. D. Harold Walker. 

4. The Throat and Nose. Dr. Samuel W. Langmaid, Dr. Algernon 
Coolidge, Jr., Dr. Frederic C. Cobb, Dr. George B. Rice. 

5. The Skin. Dr. John T. Bowen, Dr. James S. Howe, Dr. George 
F. Harding, Dr. Charles J. White, Dr. C. Morton Smith, Dr. John L. 
Coffin. 

6. Diseases of Bones and Joints. Dr. Edward H. Bradford, Dr. 
Augustus Thorndike, Dr. Charles F. Painter, Dr. George H. Earl, Dr. 
Robert Soutter. 

7. Children's Diseases. Dr. Thomas M. Rotch, Dr. John L. 
Morse, Dr. John H. Moore, Dr. Robert W. Hastings, Dr. Edmund C. 
Stowell. 

8. The Teeth. Dr. Edward W. Branigan, Dr. George A. Bates, 
Dr. Eugene H. Smith, Dr. Samuel A. Hopkins. 

9. Nervous Diseases. Dr. James J. Putnam, Dr. George L. Walton, 
Dr. Morton Prince, Dr. William N. Bullard, Dr. Edward W. Taylor, 
Dr. John J. Thomas, Dr. Walter E. Fernald. 

10. School Hygiene. Dr. Henry J. Barnes. 

11. School Furniture. Dr. Frederick J. Cotton, Dr. R. Clipston 
Sturgis. 

12. School Inspectors. Dr. George S. C. Badger, Dr. H. Lincoln 
Chase, Dr. Harry M. Cutts. 

GEORGE H. MARTIN, 

Secretary. 

DISEASES 
INFECTIOUS DISEASES 

Diphtheria. It is a well-recognized fact that nasal diphtheria of a 
mild type without constitutional disturbance is one of the most impor- 
tant factors in causing the spread of the disease, and also that children 
very frequently have profuse discharges from the nose. It therefore 
follows that, in order properly to inspect the public schools, it is impor- 
tant that cultures should be taken from the nose in every case where 
there is a persistent discharge, particularly if there is any excoriation 
about the nostrils. 

The throat should be examined at varying intervals, depending 

184 



APPENDIX I 

upon the physical condition of the children. Any hoarseness or any thick- 
ness of the voice should cause an examination of the throat. If the tonsils 
are enlarged, if the mucous membrane is congested, if there is swelling of 
palate, a culture should be taken. These symptoms precede diphtheria. 

A child with positive cultures should be excluded from school until 
two consecutive negative cultures at an interval of forty-eight hours 
have been obtained. 

Scarlet Fever. If there is a sudden attack of vomiting, if there is 
any redness of the throat, if the child complains of headache, if there 
is an unexplained rise in temperature, the child should be isolated at 
once. Any desquamation (peeling of the skin) should be looked upon 
with suspicion. If there are any breaks at the finger tips, if on pressing 
the pulp of the finger there is a white line at the juncture of the nail 
with the pulp of the finger, particularly if this occurs in the majority 
of the finger tips, the child should be excluded from the school. 

A child who has had scarlet fever should not return to school until 
the process of desquamation has been entirely completed, and all dis- 
charge from the nose and ears has ceased. 

Measles. Running from the nose and slight intolerance of light 
may call for an examination of the mucous membrane of the mouth for 
Koplik's sign. Koplik's sign, so called, is the presence on the lining 
membrane of the mouth, near the molar teeth, of minute pearly white 
blisters, without any inflammation around them. There may be only 
two or three of these blisters, and they may easily escape detection if the 
patient is not carefully examined in a good light. These blisters are 
certain forerunners of an attack of measles. 

No child should return to school after an attack of measles until 
the desquamation is entirely completed, and the child has recovered 
from the intercurrent bronchitis. 

Mumps. Any swelling or tenderness in the region of the parotid 
glands (situated behind the angle of the jaw) should be looked upon 
with suspicion. It is important to notice any enlargement or swelling 
about Steno's duct (inside the mouth, opposite the second upper molar 
tooth), as this is a very frequent symptom of mumps. 

A child should be excluded from school until one week has elapsed 
after the disappearance of all swelling and tenderness in the region of 
the parotid glands. 

Wbooping-cougb. A persistent paroxysmal cough, frequently ac- 
companied with vomiting, no matter whether there is any distinct whoop 
or not, is indicative of whooping-cough. In cases of whooping-cough 
of long standing, even if there has been no distinct whoop, an ulcer on 

185 



MEDICAL INSPECTION OF SCHOOLS 

the band connecting the lower surface of the tongue with the floor of the 
mouth is found in a certain number of cases. If there is no distinct 
ulceration, there may be a marked congestion of the band. 

As long as there is any cough, the child who has had whooping- 
cough should be looked upon with suspicion. 

Varicella (Chicken Pox). A few black crusts scattered over the 
bodv are evidences of an attack of chicken pox . The crusting seen in 
impetigo must be differentiated from that of chicken pox.* 

No child should return to school until all crusts have disappeared 
from the body, particularly from the scalp, for in this region the crusts 
remain longer than elsewhere. 

THE EYES 
[Supplement to circular already issued f] 

There are certain children who show normal vision by the ordinary 
tests, yet whose parents should be notified to have the eyes examined. 
These are: (i) children who habitually hold the head too near the book 
(less than twelve to fourteen inches); (2) children who frequently com- 
plain of headaches, especially in the latter portion of school hours; (3) 
children in whom one eye deviates even temporarily from the normal 
position. 

It should be remembered that the following symptoms are at times 
indicative of trouble with the eyes: (i) habitual scowling, and wrinkling 
of the forehead when reading or writing; (2) twitching of the face; 
(3) inattention and slowness in book studies in a child otherwise bright. 

THE EARS 

See circular of directions f for testing hearing, already in hands of 
teachers. 

THE THROAT AND NOSE 

In all cases of acute illness the throat should be examined for the 
presence of the eruption of scarlet fever and measles and for the exuda- 
tion or membrane of tonsilitis and diphtheria, and a culture taken in 
any suspected case of the latter. 

The presence of discharge from the nose should be noted, and 
if it is thick and creamy, a culture should always be taken. In all cases 
of severe hoarseness, with difficult breathing, diphtheria should be sus- 

* See Diseases of the Skin. 

f See pp. 45-47 for this circular. 

1 86 



APPENDIX I 

pected. If the discharge from the nose is only from one nostril, a foreign 
body in the nose should be looked for. 

In cases of chronic nasal obstruction, as evinced by mouth-breath- 
ing, snoring, continual post-nasal catarrh or recurring ear trouble, the 
presence of an adenoid growth (third tonsil) should be suspected, and 
the child referred for special examination and treatment. As a rule, 
digital examination for adenoids should be made only by the operating 
surgeon. Obviously large tonsils, recurring tonsilitis and enlargement 
of the glands of the neck, suggest the advisability of referring the child 
to the family physician as to the propriety of removing the tonsils. 

Recurring nose-bleed should be referred for special treatment. 

In cases of eczema about the nostrils, a cause may be sought in 
pediculi capitis (head lice). 

In referring cases for treatment, school physicians, in addition to 
the diagnosis, should state the symptoms upon which the diagnosis is 
based, for the benefit of the family physician or specialist. 

DISEASES OF THE SKIN 

Scabies (the Itch). A contagious skin disease, due to an animal 
parasite which burrows in the skin, causing intense itching and scratch- 
ing. The disease usually begins upon the hands and arms, spreading 
over the whole body, but does not affect the face and scalp. Between 
the fingers, on the front of the wrist, at the bend of the elbows and near 
the arm-pits are favorite locations for the disease; but in persons of 
cleanly habits the disease may not show at all upon the hands, and its 
real nature is determined only after a most thorough and careful examina- 
tion. There is a great variation in the extent and severity of this disease, 
lack of personal care and cleanliness always favoring its development. 
Scratching soon brings about an infection of the skin with some of the 
pus-producing germs, and the disease is then accompanied by impetigo, 
or a pus infection of the skin. 

At the present time itch is very common and widespread, and, 
because of the great variation in its severity, mild cases have been mis- 
taken for hives, eczema, etc., the real condition not being recognized, 
and the disease spread in consequence. All children who are scratching 
or have an irritation upon the skin should be examined for scabies. 

It is very important that all infected members of a family be treated 
till cured, else the disease is passed back and forth from one to another. 
It is also important that all underclothing, bedding, towels, etc., things 
that come in contact with the body, be boiled when washed. 

All cases of scabies should be excluded from school until cured. 

.87 



MEDICAL INSPECTION OF SCHOOLS 

Pediculi Capitis (Head Lice). An extremely common accident 
among children, either from wearing each others' hats and caps, or hanging 
them on each others' pegs, or from combs and brushes. No person should 
be blamed for having lice, only for keeping them. 

The irritation caused by vermin in the scalp leads to scratching, 
which in turn causes an inflammation of the skin of the neck and scalp. 
The skin then easily becomes infected with some of the pus-producing 
germs, and large or small scabs and crusts are formed from the dried 
matter and blood. Along with this condition the glands back of the 
ears and in the neck become swollen, and may be very painful and tender. 

The condition of pediculosis is most easily detected by looking for 
the eggs (nits), which are always stuck onto the hair, and are not readily 
brushed off. The condition is best treated by killing the living parasites 
with crude petroleum, and then getting rid of the nits. With boys, 
this is easy, a close hair cut is all that is needed; with girls, by using 
a fine-toothed comb wet in alcohol or vinegar, which dissolves the attach- 
ment of the eggs to the hair. All combs and brushes must be carefully 
cleansed. 

Children with pediculosis should be excluded from school until their 
heads are clean. By chapter 383, Acts of 1906, parents who neglect 
or refuse to care for their children in this respect may be prosecuted 
under the compulsory attendance law. 

Ringworm. A vegetable parasitic disease of the skin and scalp. 
When it occurs upon the skin, it yields readily to treatment; but upon 
the scalp it is extremely chronic. Ringworm of the skin usually appears 
on the face, hands or arms, rarely upon the body, in varying sized 
more or less perfect circles. One or more, usually not widely separated, 
may be present at the same time. All ringed eruptions upon the skin 
should be examined for ringworm. 

When the disease attacks the scalp, the hairs fall or break off near 
the scalp, leaving dime to dollar sized areas nearly bald. The scalp in 
these areas is usually dry and somewhat scaly, but may be swollen and 
crusted. The disease spreads at the circumference of the area, and 
new areas arise from scratching, etc. 

Another disease, somewhat like ringworm of the scalp, is known as 
favus, a disease much more common in Europe than America. In 
this disease quite abundant crusts of a yellowish color are present where 
the process is active. The roots of the hair are killed, so that the loss 
of hair from this disease is permanent, a scar remaining when the condi- 
tion is cured. 



1 88 



APPENDIX I 

Care must be taken to see that all combs and brushes are thoroughly 
cleansed, and to prevent children wearing each others' hats, caps, etc. 

Children with ringworm should not be allowed to attend school. 

Impetigo. A disease characterized by few or many large or small 
flat or elevated pustules or festers upon the skin. The condition is often 
secondary to irritation or itching diseases of the skin (hives, lice, itch), 
and scratching starts up a pus infection. 

The disease most often appears upon the face, neck, and hands, 
less often upon the body and scalp. The size of the spots varies very 
much, and they often run together to form on the face large superficial 
sores, covered with thick, dirty, yellowish or brownish crusts. 

The disease is contagious, and often spread by towels and things 
handled. 

Children having impetigo should not be allowed to attend school 
until all sores are healed and the skin is smooth. 

DISEASES OF THE BONES AND JOINTS 

All noticeable lameness, whether sudden or continued, may indicate 
serious joint trouble, or may be due to improper shoes. These cases, 
as well as curvatures of the spine, as indicated by habitual faulty postures 
at the desk or in walking, should be referred for medical inspection. 

Spinal curvature should be suspected when one shoulder is habitu- 
ally raised or dropped, or when the child leans to the side, or shows per- 
sistent round shoulders. 

Complaints of persistent "growing pains" or "rheumatism" may 
be the earliest signs of serious disease of the joints. 

SOME GENERAL SYMPTOMS OF DISEASE IN CHILDREN WHICH TEACHER 
SHOULD NOTICE, AND ON ACCOUNT OF WHICH THE CHILDREN 
SHOULD BE REFERRED TO THE SCHOOL PHYSICIAN 

Emaciation. This is a manifestation of many chronic diseases, 
and may point especially to tuberculosis. 

Pallor. Pallor usually indicates anemia. Pallor in young girls 
usually means chlorosis, a form of anemia peculiar to girls at about 
the age of puberty. It is usually associated with shortness of breath; 
the general condition otherwise usually appears good. Pallor may 
also be a manifestation of disease of the kidneys; this is almost invariably 
the case if it is associated with puffmess of the face. 

Puffiness of the Face. This, especially if it is about the eyes, points 
to disease of the kidneys; it may, however, merely indicate nasal ob- 
struction. 



MEDICAL INSPECTION OF SCHOOLS 

Shortness of Breath. Shortness of breath usually indicates disease 
of the heart or lungs. If it is associated with blueness, the trouble is 
usually in the heart. If it is associated with cough, the trouble is more 
likely to be in the lungs. 

Swellings in the Neck. These may be due to mumps or enlarge- 
ment of the glands. The swelling of mumps comes on acutely, and is 
located just behind, just in front and below the ear. Swollen glands 
are situated lower in the neck, or about the angle of the jaw. They may 
come on either acutely or slowly. If acutely, they mean some acute 
condition in the throat. If slowly, they are most often tubercular. 
They may also be the result of irritation of the scalp or lice in the hair. 

General Lassitude, and Other Evidences of Sickness. These hardly 
need description, but may, of course, mean the presence or onset of any 
of the acute diseases. 

Flushing of the Face. This very often means fever, and on this 
account should be reported. 

Eruptions of any Sort. All eruptions should be called to the atten- 
tion of the physician. It is especially important to notice eruptions, 
because they may be the manifestations of some of the contagious diseases. 
The eruption of scarlet fever is of a bright scarlet color, and usually 
appears first on the neck and chest, spreading thence to the face. There 
is often a pale ring about the mouth in scarlet fever, which is very charac- 
teristic. There is usually a sore throat in connection with the eruption. 
The eruption of measles is a rose or purplish red, and is in blotches about 
the size of a pea. It appears first on the face, and is usually associated 
with running of the nose and eyes. The eruption of chicken pox appears 
first as small red pimples, which quickly become small blisters. 

A Cold in the Head, with Running Eyes. This should be noticed, 
because it may indicate the onset of measles. 

Irritating Discharge from the Nose. A thin, watery nasal discharge, 
which irritates the nostrils and the upper lip, should always be regarded 
with suspicion. It may mean nothing more than a cold in the head, 
but not infrequently indicates diphtheria. 

Evidences of Sore Throat. Evidences of sore throat, such as swelling 
of the neck and difficulty in swallowing, are of importance. They may 
mean nothing but tonsilitis, but are not infrequently manifestations 
of diphtheria or scarlet fever. 

Coughs. It is very important to notice whether children are cough- 
ing or not, and what is the character of the cough. In most cases, of 
course, the cough merely means a simple cold or slight bronchitis. A 
spasmodic cough, that is, a cough which occurs in paroxysms and is 

190 



APPENDIX I 

uncontrollable, very frequently indicates whooping-cough. A croupy 
cough, that is, a cough which is harsh and ringing, may indicate the 
disease diphtheria. A painful cough may indicate disease of the lungs, 
especially pleurisy or pneumonia. A long-continued cough may mean 
tuberculosis of the lungs. 

Vomiting. Vomiting usually, of course, merely means some di- 
gestive upset. It may, however, be the initial symptom of many of 
the acute diseases, and is therefore of considerable importance. 

Frequent Requests to go out. Teachers are too much inclined to 
think that frequent requests to go out merely indicate restlessness or 
perversity. They often, however, indicate trouble of some sort, which 
may be in the bowels, kidneys or bladder; therefore, they should always 
be reported to the physician. 

THE TEETH 

Unclean mouths promote the growth of disease germs, and cavities 
in the teeth are centers of infection. Pus from diseased teeth seriously 
interferes with digestion and poisons the system. It causes a lowering 
of vitality and renders mental effort difficult. Diseased teeth, tempo- 
rary as well as permanent, are frequently the cause of abscesses, and 
should be carefully watched and treated. 

Irregularities of the teeth, especially those which make it impossible 
to close the teeth properly, lead to faulty digestion, to mouth-breathing, 
and to other diseases and evils which an insufficient supply of oxygen 
produces. 

The first permanent molars are perhaps the most important teeth 
in the mouth, and are the most frequently neglected, because they are 
so often mistaken for temporary teeth. (It should be remembered 
that there are twenty temporary teeth, ten in each jaw, and that the 
teeth that come at about the sixth year immediately behind each last 
temporary tooth four in all are the first permanent molars.) 

The teacher should be on the lookout for pain or swelling in the face. 
When the child keeps the mouth constantly open, an examination of 
the teeth should be made. When symptoms of indigestion occur, or 
physical weakness or mental dullness is observed, the teeth should be 
inspected. It should be remembered that disease of the ears, disturb- 
ances of vision and swelling of the glands of the neck may be caused 
by diseased teeth. 

It should be known that decay of the teeth is caused primarily by 
the fermentation of starchy foods and sugars, and that the greatest 
factor in preventing dental caries is the removal of food particles by 

191 



MEDICAL INSPECTION OF SCHOOLS 

frequent brushing. Children should be prevented from eating crackers 
and candy between meals, and when possible the teeth should be cleaned 
after eating. Inspection of the teeth by a dentist should be made at 
least once in six months. 

NERVOUS TROUBLES AND MENTAL DEFECTS 

Teachers and medical inspectors of the schools should investigate 
children who show certain physical and mental symptoms. Especially 
should they take notice of the presence of these symptoms in a child 
who did not formerly show them. The most important of these are the 
following: 

I. Restlessness and inability to stand or sit quietly, in a previously 
quiet child, especially if to this is added irritability of temper and loss 
of self-control, as shown by crying for trifles, or inability to keep the 
attention fixed. 

There may also be present quick, twitching movements of the mus- 
cles of the trunk, face, and especially of the hands, fingers, arms or legs. 
If severe, these may cause the child to drop things, render its work awk- 
ward, or interfere with buttoning the clothes, writing or drawing. Such 
children are often scolded for being inattentive or careless. 

These symptoms are the slighter ones of chorea (St. Vitus' dance). 
With these should not be confounded other forms of twitching of mus- 
cles, such as the blinking of the eyelids, the slower twitching movements 
of the face or shoulders, or other parts of the body, often called habit 
spasms, which may be due to defects of vision, adenoid growths or other 
reflex causes. These latter cases do not usually need to be withdrawn 
from school work, though often requiring treatment; while the former 
class should be removed from school at once, both for the child's sake 
and to prevent an epidemic of imitative movements, such as sometimes 
occurs. 

1 1 . Another class of symptoms requiring investigation are repeated 
faintings, especially if the child's lips become blue; attacks, often only 
momentary, in which the child stares fixedly and does not reply to ques- 
tions, or in which he suddenly stops speaking or whatever he is doing, and 
is unaware of what is going on about him. These lapses of consciousness 
may be accompanied also by rolling up of the eyes, drooling, or unusual 
movements of the lips, and often appear like a "choking" attack. 

Sudden attacks of senseless movements of various sorts, such as 
twisting and pulling at the clothes or handkerchief, fumbling aimlessly 
at the desk, especially if there is no recollection afterwards of what was 
done, are often another expression of the same conditions. 

192 



APPENDIX I 

Such attacks, particularly if repeated at varying intervals, even 
when not accompanied by complete loss of consciousness, are frequently 
as characteristic of epilepsy as the severe convulsions. 

Epileptic convulsions usually involve the entire body in sharp 
jerking movements, with blueness of the face or lips, complete loss of 
consciousness, and are usually followed by a period of sleep or drowsi- 
ness, and are frequently accompanied by frothing at the mouth, biting 
of the tongue, and occasionally by wetting or soiling of the clothes. 

Another class of convulsions is the hysterical, which are often 
difficult to distinguish. The hysterical convulsion, however, differs from 
the epileptic in the following respects. The hysterical patient often shouts, 
cries or raves, not only previous to but frequently throughout the attack, 
and is often able to reply to questions during the convulsion. The 
epileptic gives a single cry, immediately followed by unconsciousness 
and the spasm. The movements in the hysterical convulsion are often 
accompanied by bowing of the body backward, and very frequently 
simulate intentional or voluntary movements, such as tearing the hair, 
pulling at the clothes, and such things; while the epileptic movements 
are characterized by their jerking or twitching character. The hysterical 
patient, also, in place of a convulsion, may strike an attitude, such as of 
fear or entreaty, often accompanied by raving or singing. This again 
may follow the convulsion, taking the place of, and strikingly contrasted 
with the almost invariable sleep of the epileptic, which is almost never 
seen in hysteria. Hysterical patients if they fall seldom injure them- 
selves by the fall, as epileptics frequently do. Biting the tongue almost 
invariably indicates an epileptic seizure, as does wetting or soiling the 
clothes when it occurs. 

Cases of epilepsy, whether mild or severe, require treatment, and 
advice as to whether they should be removed from school. Many cases do 
not require to be withdrawn from school, and are benefited by its discipline. 

III. Excessive nerve fatigue, which is shown by irritability or 
sleeplessness, may indicate a neurasthenic condition, that is, a threatened 
nervous breakdown. Such symptoms may be due to irregular habits, 
want of proper sleep, lack of suitable food, poor hygienic conditions, or 
simply from the child being pushed in school beyond its physical or 
mental capacity. 

Excessive fear or morbid ideas, bashfulness, undue sensitiveness, 
causeless fits of crying, morbid introspection and suspiciousness may 
also be symptoms of a neurasthenic condition, and call for investiga- 
tion, and for the teacher's sympathy and winning of the child's confi- 
dence, to prevent developments of a more serious nature. 

13 193 



MEDICAL INSPECTION OF SCHOOLS 

This nerve fatigue may result in a child being unable for the time 
being to keep up in its work in school. 

Forgetfulness, loss of interest in work and play, desire for solitude, 
untidiness in dress or person, and like changes of character, are some- 
times incidental to the period of puberty. 

IV. Mentally defective children in the public schools exhibit cer- 
tain common characteristics. The essential evidence of mental defect 
is that the child is persistently unable to profit by the ordinary methods 
of instruction, as shown by lack of progress or failure of promotion through 
lack of capacity. After one, two or three years in school, they are either 
not able to read at all, or they have a very small and scanty vocabulary. 
One of the most constant and striking peculiarities is the feebleness of the 
power of voluntary attention. The child is unable to fix his attention 
upon any exercise or subject for any length of time. The moment his 
teacher's direction is withdrawn, his attention ceases. 

These children are easily fatigued by mental effort, and lose interest 
quickly. They are not observant. They are often markedly back- 
ward in number work. They are especially backward in any school 
exercise requiring judgment and reasoning power. They may excel 
in memory exercises. They usually associate and play with children 
younger than themselves. They have weak will-power. They are 
easily influenced and led by their associates. These children may be 
dull and listless, or restless and excitable. They are often wilful and 
disobedient, and liable to attacks of stubbornness and bad temper. The 
typical "incorrigible" of the primary grades often is a mentally defective 
child of the excitable type. They are often destructive. They may be 
cruel to smaller children. They are often precocious sexually. They 
may have untidy personal habits. Certain cases with only slight intel- 
lectual defect show marked moral deficiency. 

The physical inferiority of these defective children is often plainly 
shown by the general appearance. There is generally some evidence 
of defect in the figure, face, attitudes or movements. They seldom 
show the physical grace and charm of normal childhood. The teeth are 
apt to be discolored and to decay early. 

It is a most delicate and painful task to tell a parent that his child 
is mentally deficient. This duty should be performed with the greatest 
tact, kindness and sympathy. It would be a great misfortune for the 
school physician and teacher, as well as for the child, to designate a 
pupil as feeble-minded who was only temporarily backward. 

Temporary backwardness in school work may be due to removable 
causes, such as defective vision, impaired hearing, adenoid growths in 

194 



APPENDIX I 

nose or throat, or as the result of unhappy home conditions, irregular 
habits, want of proper sleep, lack of suitable food, bad hygienic condi- 
tions, etc. Great care must always be used in order not to confound 
cases of permanent mental deficiency with cases of temporary back- 
wardness in school work, due to the causes mentioned above, or those 
described under the head of excessive nervous fatigue. 

In some cases, where the existence of mental defect is in doubt, 
accurate information is usually to be obtained in the early history of 
the child. The time of first "taking notice," the time of recognition 
of the mother, that of beginning to sit up, to creep, to stand, to walk 
and to talk should be learned. Marked delay in development in these 
respects is usually found in all pronounced cases of mental deficiency. 

It may be found useful to require teachers to refer at stated intervals 
to the medical inspectors for examination all children who, without 
obvious cause, such as absence or ill health, show themselves unable to 
keep up in their school work, who are unable to fix their attention, or 
are incorrigible, though it does not follow that all such cases have 
either physical or mental defects. 

SCHOOL HYGIENE 

The school physician should notice the ventilating, lighting and 
heating of the rooms, and the location of the source of water supply with 
reference to possible pollution. In case pollution of the water supply is 
suspected, application should be made to the State Board of Health 
for an examination of the water. The general cleanliness of the school- 
room is of importance, and the admission of sunlight when possible is 
desirable. 

The Closets. The school physician, accompanied by the janitor 
of the school, should inspect the toilet rooms, to see if the floors are clean 
and dry, that the bowls of the closets are properly emptied and kept 
clean. (If outhouses are used, a large supply of earth will aid in keeping 
the place in a sanitary condition.) A few simple directions as to the 
cleanliness of the room should be posted in the closets. 

Cups. The use of one drinking cup for a number of children is to 
be condemned, as tending to spread the infectious diseases from child to 
child. The so-called hygienic drinking fountain, now in more or less 
general use in progressive cities and towns, is to be recommended where 
running water is available. If there is no running water, each child 
should use his own cup. 



195 



MEDICAL INSPECTION OF SCHOOLS 

SCHOOL FURNITURE 

Any proper sort of school furniture should furnish a seat of such 
height that the feet will rest easily on the floor. It should have a desk 
high enough not to touch the knees. It should have a desk low enough 
for the arm to rest on comfortably without much raising of the elbow; 
not, however, so low that the scholar must bend down to write on it. 

The seat should be near enough so that the scholar may reach the 
desk to write on it without leaning forward more than a little, and without 
entirely losing the support of the backrest. The seat should not be so 
close as to press against the abdomen nor near enough to interfere with 
easy rising from the seat. This means a distance of ten and one-half 
to fourteen and one-half inches from the edge of the desk to the seat 
back; it also means that the seat must not project under the desk more 
than an inch at most. 

The seat should have a backrest that will support the "small of 
the back" properly, without having the scholar lean back excessively. 
Whether it also supports the rest of the back or not is of small conse- 
quence; support of the back carried up to the level of the shoulder blades 
is likely to do more harm than good. 

These are given as the minimum requirements. Whether or not 
regular adjustable furniture is in use, we should not be content with 
less than the accomplishment in one way or another of these primitive 
adjustments. More accurate adjustment is desirable, and less care in 
adjusting would be hard to justify, in the light of our present knowledge 
of the results of faulty attitude. 



196 



APPENDIX II 

ANNUAL REPORT FOR 1910 OF THE CHIEF MEDICAL 
OFFICER OF THE BRITISH BOARD OF EDUCATION 

The following pages reproduce the table of contents of the 
Annual Report of the Chief Medical Officer of the British Board of 
Education. This table is printed to show the range of subjects 
and topics treated in a thorough and comprehensive report of a 
system of medical inspection. The report from which this 
material is taken is probably the clearest, most thorough, and 
most complete report on medical inspection that has yet appeared. 
It may well serve as a model for medical officers reporting on work 
in American communities. 

CONTENTS 

Page 
I. The Administration of Medical Inspection by the Local Educational 

Authorities 3 

Requirements of the Code 4 

Schedule of Medical Inspection 1 1 

Organization of School Medical Service 12 

The School Medical Officer 14 

Qualifications of Medical Officers 17 

School Nurses 17 

Special Inquiries '. 18 

Closure of and Exclusion from School 20 

Medical Inspection of Secondary Schools 22 

II. The Physical Condition of School Children as revealed by Medical In- 
spection 24 

Malnutrition 26 

Uncleanliness 33 

Defective Vision 36 

Defective Hearing 45 

Adenoids, Enlarged Tonsils and Glands 49 

Ringworm 56 

Miscellaneous Conditions 62 

Addendum on Sanitation of School Premises 65 

197 



MEDICAL INSPECTION OF SCHOOLS 

Page 

III. Tuberculosis in School Children 69 

Findings as regards Tuberculosis from the Reports of School 

Medical Officers 71 

Existing Provision for the Treatment of Tuberculous Children .... 79 
Suggestions for the Treatment of Tuberculous Children by the 

Local Education Authority 85 

IV. The Proceeding known as " Following Up" 96 

The Part played by the School Doctor and Parent 97 

The Part played by the Teacher 98 

The School Nurse 100 

The School Attendance Officer 103 

Voluntary Agencies and Care Committees 108 

The Results of " Following Up" 108 

Addendum on the Employment of School Children 1 16 

V. Action taken by Local Education Authorities in respect to Medical 

Treatment 119 

Introduction 119 

The Kind of Treatment Necessary 119 

Treatment by Medical Practitioners 121 

Modes of Treatment Available 122 

1 . Treatment under special Acts of Parliament 123 

2. Treatment under the Poor Law (see Section VI) 123 

3. Treatment under Section 13 of the Education (Administra- 
tive Provisions) Act, 1907 123 

Existing Provision for Medical Treatment out of Public Funds .... 126 

Employment of School Nurses 126 

Provision of Spectacles 127 

Contributions to Hospitals 128 

The London County Council Hospital Scheme 132 

VI. Medical Treatment for School Children under the Poor Law 143 

VII. School Clinics 146 

The Inspection Clinic 146 

The Treatment Clinic 152 

Treatment Clinics now established 155 

VIII. Dental Diseases and Dental Treatment , 166 

Causation of Dental Caries 171 

Diet in Relation to Dental Disease 172 

The Use of the Toothbrush 1 73 

The Treatment of Dental Diseases 175 

School Dentistry in Germany 177 

Existing Arrangements for Dental Treatment in England and 

Wales 1 79 



, 9 8 



APPENDIX II 

(Page 
IX. The Special Schools for Blind, Deaf, Physically Defective and Epileptic 

Children 187 

Schools for the Blind 188 

Schools for the Deaf 193 

Schools for Physically Defective Children 201 

Schools for Epileptic Children 203 

X. Education of Feeble-minded Children 206 

Adoption of the Elementary Education (Defective and Epileptic 

Children) Act, 1899 208 

Classification of Mentally Defective Children 209 

Educational Provision for Mentally Abnormal Children 211 

The After-care of the Feeble-minded 214 

Conclusion 219 

X I . Open-air Education 22 1 

The Open-air Classroom 222 

Playground Classes 223 

Country Schools 225 

Open-air Schools 226 

Premises 226 

Classification of Children Admitted 227 

Cost of Open-air Schools 228 

Provision of Meals 229 

Time-Table 229 

Results 230 

Permanency of Results 23 1 

XII. The Teaching of Hygiene and Physical Training 233 

The Teaching of Hygiene in the Training Colleges 233 

The Teaching of Hygiene in Public Elementary Schools 236 

The Teaching of Infant Care and Management 238 

Physical Training 242 

In Training Colleges 242 

In Secondary Schools 243 

In Public Elementary Schools 243 

XIII. Provision of Meals 245 

Introductory 245 

Historical Note 246 

The Act of 1906 247 

Returns from Local Educational Authorities for 1910 249 

Selection of Children and Duties of School Medical Officer 252 

Provision of Meals during Holidays 254 

Conclusion 256 



199 



MEDICAL INSPECTION OF SCHOOLS 



APPENDICES 

Page 

A. List of Medical Officers, etc 259 

B. Prosecutions by Local Education Authorities 270 

C. Memorandum on the Teaching of Infant Care and Management in Public 

Elementary Schools (Circular 758) 277 

D. Memorandum on Physical Training in Secondary Schools (Circular 779) . . 289 

E. Syllabus of Hygiene 299 

F. The Training of Teachers of the Blind and the Deaf 302 

G. Statistical Tables Relating to the Provision of Meals 303 



2OO 



BIBLIOGRAPHY 



BIBLIOGRAPHY 

BOOKS 

ALLEN, WILLIAM H.: Civics and Health. New York, Ginn and Com- 
pany, 1909. 411 pp. $1.50. 

Contains chapters on physical welfare of school children, mouth- 
breathing, eye-strain, dental sanitation, and departments of school 
hygiene. 

AYRES, LEONARD P.: Medical Inspection Legislation. New York, 
Russell Sage Foundation, 191 1. 56 pp. 30 cents. 
Summary of legal status in United States. 

BERGER^TEIN, LEO: Schulhygiene. Second edition. Leipzig, B. G. 
Teubner, 1910. 

CORNELL, WALTER S.: Health and Medical Inspection of School Chil- 
dren. Philadelphia, F. A. Davis Company, 1912. 644 pp. 195 
illus. $3.50. 

The most comprehensive treatment yet published. Based on 
extended experience. Indispensable in the library of the school 
physician. 

CROWLEY, RALPH H.: Needs, Objects and Methods of the Medical In- 
spection of Primary Schools. London, J. and A. Churchill, 1907. 
24 pp. 

CROWLEY, RALPH H.: The Hygiene of School Life. London, Methuen 
and Co., 1910. 403 pp. 

Contains practical suggestions for dealing with problems confront- 
ing local boards of education, medical officers, and parents. Chap- 
ters on physical condition of school children, special groups, school 
feeding, baths, exercise, open-air schools, infectious disease, treat- 
ment and school buildings. 

DUFESTEL, Louis: Guide pratique du medicin-inspecteur des ecoles. 
Preface de M. le Dr. Le Gendre; avec 19 figures dans le texte. Paris, 
O. Dion et fils, 1910. 236 pp. 

203 



MEDICAL INSPECTION OF SCHOOLS 

HOAG, ERNEST B.: The Health Index of Children. San Francisco, 
Whitaker, Ray-Wiggin Co., 1910. i88pp. 80 cents. 

A manual designed to show teachers and parents how to detect 
physical defects in children and to suggest means for correcting such 
defects and maintaining health afterwards. 

HOGARTH, A. H.: Medical Inspection of Schools. London, Henry 
Frowde, Oxford University Press, 1909. 360 pp. 6s. 

KELYNACK, T. N.: Medical Examination of Schools and Scholars. 
London, P. S. King and Son, 1910. 434 pp. 

Compilation of articles on the different divisions of work and the 
status of the movement in different countries. Best general survey 
of the entire field. 

MACKENZIE, WM. LESLIE: The Health of the School Child. London, 
Methuen and Co., 1906. 2s. 6d. 

Lectures dealing with the hygiene of school life, normal growth 
during school ages, and medical inspection and supervision of school 
children. Gives details of methods of medical inspection in Wies- 
baden and Nuremburg. 

MACKENZIE, WM. LESLIE, AND MATTHEW, EDWIN: The Medical In- 
spection of School Children. Edinburgh and Glasgow, William 
Hodge and Co., 1904. 455 pp. los. 6d. net. 

The most extensive and thorough treatise. Technical rather 
than popular. 

SCHUBERT, PAUL: Das Schularztwesen in Deutschland. Bericht iiber 
die Ergebnisse einer Umfrage bei den grosseren Stadten des Deutschen 
Reiches. Hamburg und Leipzig, Verlag von Leopold Voss, 1905. 
1 66 pp. 

STEVEN, EDWARD M.: Medical Supervision in Schools. London, 
Bailliere, Tindall and Cox, 1910. 268 pp. 

A first hand description of the workings of the system in Great 
Britain, Canada, the United States, Germany, and Switzerland. 

WOOD, THOMAS D.: Health and Education. The Ninth Yearbook of 
the National Society for the Study of Education. Parti. Chicago, 
The University of Chicago Press, 1910. 113 pp. 

Chapters on health examinations, school sanitation, hygiene in- 
struction, and physical education. Intended for the use of teachers 
rather than the specialist in school hygiene or physical education. 

204 



BIBLIOGRAPHY 

REPORTS, AMERICAN 

BUREAU OF MUNICIPAL RESEARCH: A Bureau of Child Hygiene. Re- 
port of co-operative studies and experiments by the Department qf 
Health of New York City and the Bureau of Municipal Research. 
New York, Bureau of Municipal Research, 1908. 41 pp. 35 cents. 

Report on the Division of Child Hygiene, Department of Health 
(New York City), with constructive suggestions. New York City, 
Bureau of Municipal Research, 191 1. 66 pp. 

MASSACHUSETTS BOARD OF EDUCATION: Suggestions to Teachers and 
School Physicians Regarding Medical Inspection. Special pamphlet. 
Boston, 1907. 

Medical Inspection. By G. H. Martin. 72nd Annual Report, 1907- 
08, pp. 87-109. Boston, Public Document No. 3, 1909. 

Medical Inspection in the Public Schools of Massachusetts. -By 
G. H. Martin. 74th Annual Report, pp. 164-193. Boston, Public 
Document No. 2, 1911. 

NATIONAL SOCIETY FOR THE STUDY OF EDUCATION: The Nurse in 
Education. The Ninth Year-book, Part II. Chicago, The Uni- 
versity of Chicago Press, 1911. 76 pp. 

Chapters on The Educational Value of the Nurse in the Public 
School, by Isabel M. Stewart and M. Adelaide Nutting; and Profes- 
sional Training of Children's Nurses by Mary L. Read. 

RUSSELL SAGE FOUNDATION: What American Cities are Doing for 
the Health of School Children. Bulletin, Dept. of Child Hygiene, 
New York, 191 1. 24 pp. 15 cents. 
Summary of conditions in 1,032 American cities. 

REPORTS, FOREIGN 

BOARD OF EDUCATION (BRITISH): Annual Report for 1910 of the Chief 
Medical Officer. London, Wyman and Sons, Fetter Lane E. C. 
1911. 313 pp. 

BRADFORD (ENGLAND) EDUCATION COMMITTEE: Report of the School 
Medical Officer (Lewis William, M.D.) for year ending December 
31, 1909. 1910. 117 pp. 

DUNFERMLINE, SCOTLAND: Fourth Annual Report on the Medical In- 
spection of School Children in Dunfermline. By J. C. Bridge. Car- 
negie Institute, 1909. 

205 



MEDICAL INSPECTION OF SCHOOLS 

NEW SOUTH WALES: Department of Public Instruction. Report upon 
the Physical Condition of Children Attending Public Schools in 
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vision), based upon statistics obtained as a result of the introduction 
of a scheme of medical inspection of public school children, 1907-08, 
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lick, Government Printer, 1908. 66 pp. 

Report upon the Physical Condition of Children Attending Public 
Schools in New South Wales, based upon observations made in con- 
nection with the medical inspection of public school children, 1908-09, 
with anthropometric tables and diagrams. Sydney, Wm. A. Gul- 
lick, Government Printer, 1910. 35 pp. 

LONDON COUNTY COUNCIL: School Dentistry in Germany. Report 
of the Education Officer presented to the Education Committee, 
June 22, 1910. London, Southwood, Smith and Co., 1910. 10 pp. 
Report of the Medical Officer (Education) for twelve months end- 
ing Dec. 31, 1909. London, Southwood, Smith and Co., 1910. 96 pp. 

TASMANIA: Report on the Work of the Medical Branch. J. S. C. Elk- 
ington, M.D., Chief Health Officer. Hobart, John Vail, Government 
Printer, 1908. 15 pp. 

BIBLIOGRAPHIES 

TEACHERS COLLEGE, COLUMBIA UNIVERSITY: A Bibliography on Edu- 
cational Hygiene and Physical Education. By Dr. Thomas D. 
Wood and Mary Reesor. New York City, Teachers College, 1911. 
41 pp. 20 cents. 

UNITED STATES BUREAU OF EDUCATION: Bibliography of Child Study 
for the Years 1908-1909. By Louis N. Wilson. Washington, D. C., 
Bureau of Education Bulletin No. 11,1911. 84 pp. 

Bibliography of Education for 1909-10. Washington, D. C., 
Bureau of Education Bulletin No. 10, 191 1. 166 pp. 

Contains sections on ventilation and lighting, cleaning and dis- 
infecting of school rooms, school hygiene, medical inspection, con- 
tagious diseases, feeding of school children, open-air schools, eyes, 
ears, and teeth. 



206 



INDEX 



INDEX 



ADENOIDS: among children promoted 
and not promoted in South Man- 
chester, 155; among retarded 
children in Elmira, 156; and 
associated defects, 58; and school 
progress in New York, 158-162; 
classed with cases of defective 
breathing, 39; handicap in school 
work, 3, 4, 162; treated in English 
communities, 99 ; treated in Harris- 
burg, 94; treated in Newark, N. J., 
93; treated in Summit, N. J., 95 

ADMINISTRATION: of dental clinics in 
Germany, 118, in United States, 
122; of medical inspection in 
cities of the United States, 143-151 ; 
of medical inspection in England, 
176; placed in hands of school 
authorities by most state laws, 
164; provision regarding, which 
new laws should contain, 171 

AGE OF CHILDREN: the important 
factor in physical defects, 157, 162 

ALBERTA, Canada: medical inspection 
in, 12 

AMERICA : frequency of examinations in, 
41; salaries of school physicians 
and nurses in, compared with 
those in England, 103, 109, no. 
See also United States 

AMERICAN SCHOOL HYGIENE ASSOCIA- 
TION: data regarding nurses' work 
presented to, 66 

AMERICANS: teeth and jaws of, 116 

ANDOVER, Mass.: report on weight and 
teeth of school children in, 116 

ANEMIA: among retarded children in 
Elmira, 156 

ANEMIC CHILDREN: open air schools 
for, 98 

ANGLESEY, England: treatments in, 99 



ANN ARBOR, Michigan: woman denta 
inspector in, 122, 127 

ARGENTINE REPUBLIC: medical inspec- 
tion in, 12 

ATTENDANCE, SCHOOL: and retardation, 
154; authority to compel, carries 
with it duties, 4; figures taken 
from United States Commissioner 
of Education's report, 103; in 
cities of United States, 104-107 

AUSTRALIA AND TASMANIA: medical 
inspection in, 12 

AUSTRIA: dental clinics in, 120; medi- 
cal inspection in, 1 1 

AUTHORITIES CONTROLLING MEDICAL 
INSPECTION. See Medical Inspec- 
tion 

BACKWARD CHILD: lessons taught by, 
will make a better race, 6 

"BACKWARD CHILDREN": term added 
to vocabulary of school men, 3 

BACKWARD PUPILS. See Retarded 

BANNON, DR.: appointed by school 
committee of Lawrence, 149 

BARLOW, PETER T., and his friends: 
dental clinic given by, 121 

BECKENHAM, England: treatments in, 

99 
BELGIUM: medical inspection in, n 

BERKELEY, California: consultations 
with medical director in, 77, 79; 
record of physical examinations 
usedin, 53, 56, 57 

BERLIN: dental work in, 126 

BIRMINGHAM, Alabama: post card 
notification used in, 73, 74 

BLACKBURN, England: treatments in, 
99 



14 



209 



INDEX 



BLAKE, CLARENCE JOHN: opinion on 
teachers' ability to test hearing, 45 

BLISS, D. C.: study of defects among 
retarded children by, 155 

BOARD OF EDUCATION. See Education 
BOARDS OF HEALTH. See Health 

BODILY STRUCTURE: defects of, 37. See 
also Orthopedic Defects 

BOSTON: follow-up system not well 
developed in, 42; medical inspec- 
tion in, i, 13; number of pupils 
examined in 1912, 41, 42; plan for 
dental clinic in, 123; results of 
physical examinations in, 38, 39; 
superintendent of schools in, 
quoted, 146 

BREATHING, DEFECTIVE: among school 
children in New York, 40; and 
school progress in New York, 158- 
162; cases classed with adenoids, 
39; treated in Harrisburg, 94; 
treated in New York, 92 

BREATHING, NASAL: prevented by en- 
larged tonsils and adenoids, 4 

BRITISH BOARD OF EDUCATION: chief 
medical officer, quoted, 98; in- 
spections provided for by, 41; 
memorandum of, quoted, 10, 75, 
175,176 

BRITISH SOLDIERS: jaws of, compared 
with those of Roman soldiers, 116 

BROCKTON, Massachusetts: forms used 
in, 22, 23 

BRUSSELS: medical inspection in, n 

BRYAN, JAMES E.: study of school 
progress and physical condition by, 
154 

BUILDINGS, SCHOOL: inspection of, 
under state laws, 165; provision 
for inspection of, in new laws, 172 

BULGARIA: medical inspection in, 12 

BULLETINS ON PHYSICAL DEFECTS, 80, 
82, 129, 131, 132 

BUREAU OF CHILD AND ANIMAL PRO- 
TECTION, Colorado State, 83-85 



CAIRO: medical inspection in, 12 

CALIFORNIA: abstract of medical in- 
spection law, 167; and New Jersey 
cities lead in salaries to school 
physicians and nurses, 103; cities, 
health pamphlets used in, 80, 82, 
129,132 

CAMBRIDGE, England: dental clinic 
in, 119 

CAMDEN: study of retarded children 
in, 154 

CANADA: school physicians appointed 
in, 12 

CARDIAC DISEASE: among school chil- 
dren in New York, 40; treated in 
Harrisburg, Penn., 94; treated 
in New York, 92. See also Heart 

CENSUS BUREAU, UNITED STATES: 
grouping of states by, 14 

CHARITY ORGANIZATION SOCIETY of 
READING: investigates for dental 
clinic, 122 

CHARLOTTENBURG: school nurses in, 10; 
dental work in, 126 

CHEST MEASUREMENTS: taken in Wies- 
baden, 9 

CHICAGO: exclusions for contagious 
diseases in, 32, 33; medical in- 
spection in, 13; number of pupils 
examined in, 1910, 41; record of 
physical examinations used in, 53, 
54; records of contagious disease 
inspection used in, 24, 25, 26; re- 
sults of physical examinations, 38 

CHICKEN-POX: exclusions for, 30-33 
CHIHUAHUA: medical inspection in, 12 

CHILD AND ANIMAL PROTECTION, Col- 
orado State Bureau of, 83-85 

CHILD HYGIENE, DIVISION OF: of New 
York Department of Health, 91 

CHILD. SCHOOL: has right to claim 
protection, 4 

CHILDREN: defects and school progress, 
152-163; number per school nurse , 
68; older, have fewer defects, 
162; payments according to num- 
ber examined, in Germany, 9; pro- 
portions found defective, in cities 
of United States, 37-39; treated 



210 



INDEX 



CHILDREN (Continued)' 

for defects, in three cities of United 
States, 96. See also Pupils; De- 
fects 

CHILDREN'S AID SOCIETY, New York 
City: dental clinics of , 121; direc- 
tions issued by, 129; sells tooth 
brushes, 129 

CHILE: medical inspection in, 12 
CHINESE: teeth of, 116 

CHOREA: among school children in New 
York, 40; treated in Harrisburg, 
Pa., 94; treated in New York, 92 

CINCINNATI, Ohio: dental work in, 88, 
123; exclusions and school mem- 
bership in, 33 

CLERICAL ASSISTANCE to medical inspec- 
tors, no, in 

CLEVELAND, Ohio: dental clinic in, 121; 
exclusions and school membership 
in, 33; number of pupils examined 
in, 1910-11, 41; results of physical 
examinations in, 38; school clinic 
for eyes in, 88; superintendent of 
schools in, quoted, 147 

CLINIC, EYE: in Cleveland, 88 

CLINICS, DENTAL: cost of supplies and 
equipment for, 125; established by 
dental associations, 18; established 
in Rochester, N. Y., 114; in En- 
gland, 119, 120; in Germany, 117, 
118, 126; law regarding, in New 
Jersey, 1 24; per capita cost for treat- 
ment in, 125-127; plan for, in Bos- 
ton, 123; salaries of dentists in, 127 

CLINICS: parents' consent to treatment 
of children at, 73; school and 
hospital, 86-88; subsidies to, in 
England, 87 

COLLINS, EDWIN: scholarship and con- 
dition of teeth reported on by, 116 

COLMAR: dental work in, 126 

COLOGNE: dental clinic in, cost of, 117; 
dental work in, 126 

COLORADO: abstract of medical inspec- 
tion law, 167; compulsory action 
against parents in, 83-85; vision 
and hearing tests prescribed in, 101 



COMMISSIONER OF EDUCATION: figures 
from reports of, 42, 103 

COMPULSORY ACTION AGAINST PAR- 
ENTS: in England, 86; in United 
States, 83-86 

COMPULSORY EDUCATION and compul- 
sory disease, i, 2, 3 

CONJUNCTIVITIS: exclusions for, 32, 33 

CONNECTICUT: abstract of medical in- 
spection law, 167; medical inspec- 
tion legislation in, 4, 13, 164; 
vision tests, cost, 102; vision 
tests, results, 52 

CONSULTATIONS WITH SCHOOL PHYSI- 
CIANS: in cities of United States, 
76-79 

CONTAGIOUS DISEASES: cost of inspec- 
tion for, 101, 112; exclusions for, 
in cities of United States, 32, 33; 
exclusions for, in New York, 63, 65; 
exclusions for, reduced by school 
nurses' work, 63, 65; for which 
children are excluded from school, 
30, 31; inspection, a small part 
of medical inspection, 143, 144; 
inspection in Germany, 9; inspec- 
tion in Paris, 8; inspection in 
United States, 19, 20, 21-34; in- 
spection in Wiesbaden, 9; inspec- 
tion placed in physicians' hands by 
state laws, 164; instructions regard- 
ing symptoms of, 30; medical 
inspection due to, i, 13, 21; 
provision regarding, which new 
laws should contain, 172. See also 
Exclusions; Epidemics 

COPENHAGEN: medical inspection in, u 

CORNELL, WALTER S.: report on defec- 
tive children, 152 

COST: annual per capita for medical 
inspection, 102-110; clerical assist- 
ance, no-in; dental clinics in 
Germany, 117, 126; dental treat- 
ment, per capita, 125-127; inspec- 
tion for contagious disease, 101, 
112; physical examinations in 
United States, 43, 101-110; sup- 
plies and equipment for dental 
clinics, 125; vision and hearing 
tests by teachers, 101, 102, 112 



211 



INDEX 



DARLINGTON, Eng.: treatments in, 99 
DARMSTADT: dental work in, 126 

DEAFNESS: as a handicap in school 
work, 4. See also Hearing; Ear 

DEFECTIVE CHILD: lessons taught by, 
will result in a better race, 6 

DEFECTIVE CHILDREN. See Children: 
Pupils; Defects 

DEFECTS OF EYE AND EAR: treatments 
following discovery of, by teachers, 
97. See Eye; Ear; Vision; Hearing 

DEFECTS, PHYSICAL: and school prog- 
ress, 152-163; common among 
school children, 35, 37, 39; decrease 
with age, 157, 162; found among 
children in New York, 40; found 
among children in nine cities, 38; 
records of combinations of, 58-61; 
treated by private practitioners and 
institutions, New York, 96, St. 
Louis, 97; treated in England, 98- 
100 ; treated in Harrisburg, Penn., 
94; treated in Newark, N. J., 93; 
treated in New York City, 91, 92; 
treated in Pasadena, Cal., 94; treat- 
ments in American cities compared, 
95-97; treatments in United States 
and England compared, 100 

DENMARK: medical inspection in, n 

DENTAL ASSOCIATION, Rochester, N. Y. : 
secured lecturer for children, 1 28 

DENTAL ASSOCIATIONS: clinics estab- 
lished by, 1 8, 122 

DENTAL CLINICS. See Clinics 
DENTAL HYGIENE: education, 127-133 

DENTAL WORK FOR SCHOOL CHILDREN: 
in England and other countries, 
119-120; in Germany, 10, 117-119, 
126; in United States, 18, 19, 120- 
124 

DENTISTS, SCHOOL: early work of, in 
Belgium, u; employed in United 
States, 1 8, 19, 121, 122; salaries 
of, in Germany, England and 
United States, 127; state officers 
in Strassburg, 117 

DERBY, C. B., England: treatments 
in, 99 



DETROIT, Michigan: exclusions for 
. contagious diseases in, 32, 33 

DEVONSHIRE, Eng.: treatments in, 99 
DINSBERG: dental work in, 126 
DIPHTHERIA: exclusions for, 30-33 

DISEASE: unbusinesslike not to count 
cost of, 3. See also Contagious 
Diseases 

DISTRICT OF COLUMBIA: regulations on 
medical inspection in, 13, 144, 164, 
167 

DORTMUND: dental work in, 126 
DRESDEN: medical inspection in, 8 

DUNFERMLINE, Scotland: dental con- 
ditions among children in, 115; 
dental work in, 120 



EAR DISEASES: treated in English 
communities, 99 

EAR TROUBLES: health pamphlet on, 
80 

EARS, DEFECTIVE: found among chil- 
dren in different cities, 38; treated 
in English school clinics, 87; 
treated in Lowell and Somerville, 
Mass., 97; treated in Pasadena, 
94. See also Hearing 

EDUCATION: compulsory, and compul- 
sory disease, i, 2; without health 
useless, 4 

EDUCATION ACT OF 1907 for England 
and Wales, 10 

EDUCATION ACT OF 1908 in Scotland, 10 

EDUCATION AUTHORITIES: co-opera- 
tion needed in physical examina- 
tions, 53; execution of medical 
inspection law in England laid on, 
176 

EDUCATION, BOARDS OF: medical in- 
spection under, 143-150 

EDUCATION, ENGLISH BOARD OF: chief 
medical officer quoted, 98; inspec- 
tions provided for by, 41 ; memo- 
randum on medical inspection, 
quoted, 10, 75, 175, 176 

EDUCATION, MASSACHUSETTS BOARD OF: 
directions issued by, 45, 47 



212 



INDEX 



EDUCATION, UNITED STATES COMMIS- 
SIONER OF: enrollment figures 
from report of, 42; attendance 
figures taken from reports of, 103 

EGYPT: medical inspection in, 12 

ELMIRA, New York: dental conditions 
among school children in, 115; 
dental work in, 88, 123; no charges 
for treatment in dental infirmary, 
126; running expenses of dental 
clinics in, 125; study of defects 
among retarded children in, 155, 
156 

ELY, ISLE or: treatments in, 99 

ENFORCEMENT: provision for, which 
new laws should contain, 172. See 
also Compulsory Action 

ENGLAND: children per school dentist 
in, 126; dental work for school 
children in, 114, 119; fines imposed 
on parents of school children in, 
86; frequency of examinations re- 
quired by board of education in, 41 ; 
medical inspection in, 10; pioneer 
in employment of school nurses, 
ii ; presence of parents at ex- 
aminations of children in, 73, 75, 
76; salaries of school physicians in, 
109-110; treatments in, 98, 99, 100 

ENROLLMENT: and exclusions, in eight 
cities, 33; and physical examina- 
tions, in nine cities, 41; figures, 
from report of United States Com- 
missioner of Education, 34, 42 

EPIDEMICS: among school children in 
Boston, 13; checked by medical 
inspection, 2, 34. See also Con- 
tagious Diseases; Exclusions 

EQUIPMENT: and supplies for dental 
clinics, 125; school nurses, 112; 
school physicians, in 

ESKIMOS: teeth of, 116 

ESSEX, England: treatments in, 99 

EUROPEANS: teeth of, 116 

EVERETT, Massachusetts: directions 
and prescriptions used in, 27-29 

EXAMINATIONS, PHYSICAL: by physi- 
cians, in United States, 19, 20; 
cities conducting, by groups of 



EXAMINATIONS, PHYSICAL (Continued] 
states, 36; conduct of, 37; cost of, 
43, 101-110; forms needed in con- 
nection with, 52, 58; frequency of, 
40, 41 ; in Australia and Tasmania, 
12; in Great Britain, 10; in Paris, 
7; medical inspection extended to 
include, 3; need of, summarized, 
61; new laws should provide for, 
172; placed in hands of school 
physicians by state laws, 164; 
presence of parents at, 73, 75, 76; 
results of, in cities of United States, 
38,39; results of , in New York, 40; 
time required for, 43; theory and 
origin of, 35; Wiesbaden system, 9 

EXAMINATIONS, VISION AND HEARING. 
See Vision and Hearing Tests 

EXCEPTIONAL CHILDREN: special classes 
for, in Germany, 10; use of term, 3 

EXCLUSION NOTICES to parents, and 
their use, 21, 22, 24-27 

EXCLUSIONS: diseases for which chil- 
dren are excluded, 30, 31; in 
various cities of United States, 
32-34, 143, 144; in New York 
City, 63, 65; reduced by school 
nurses' work, 63 , 65 . See also Con- 
tagious Diseases; Epidemics 

EXEMPT AND NON-EXEMPT CHILDREN in 
Philadelphia: defectiveness among, 
152, 153 

EYE AND EAR EXAMINATIONS. See 
Vision and Hearing Tests 

EYE CLINIC: in Cleveland, 88 

EYES, DEFECTIVE: among children in 
different cities, 38; among chil- 
dren promoted and not promoted 
in South Manchester, 155; one 
of four commonest classes of de- 
fects, 37, 39; treated in English 
communities, 87, 99; treated in 
Lowell and Somerville, 97 ; treated 
in Pasadena, 94. See also Vision; 
Eyesight 

EYESIGHT: directions for testing in 
Massachusetts, 45, 47; health 
pamphlet regarding, 82; Snellen 
chart for testing, 49. See also 
Vision 



213 



INDEX 



FEEDING, SCHOOL: in Germany, 10 

FOLLOW-UP SYSTEM: not so well de- 
veloped in Boston as in New York, 
42 

FOLLOW-UP VISITS: by nurse, to secure 
action, 76 

FORMS: used in medical inspection. 
See Records; List of Forms, p. xix 

FORSYTH, THOMAS A. : gift of, to estab- 
lish dental clinic in Boston, 124 

FRANCE: dental clinics in, 120; medical 
inspection in, 7-8 

FRANKFORT-ON-THE-MAIN: medical in- 
spection in, 8 



GERMANY: dental work for school chil- 
dren in, 114, 117-118, 126; fre- 
quency of physical examinations, 
40, 41 ; medical inspection in, 8-10; 
presence of parents at examina- 
tions of children in, 73, 76; school 
nurses and movements allied to 
medical inspection in, 10 

GLANDS, ENLARGED: among children 
in different cities, 38; among re- 
tarded children in Elmira, 156; 
and school progress in New York, 
158-162; cities which do not re- 
port, 39; treated in Harrisburg, 
Perm., 94 

GLASSES: obtained by school children 
in Newark, N. J., 93; obtained by 
school children in New York, 92, 
96 

GRADES, SCHOOL: completed by chil- 
dren with and without defects, 
159, 160; years required to com- 
plete, by defective children, 161, 162 

GREAT BRITAIN: medical inspection in, 
10; co-operation between school 
authorities and hospitals in, 86, 
87. See also Englaiid; Education, 
English Board of; Legislation 

GUANAJUATO : medical inspection in, 1 2 

GUILFORD, ENGLAND: salaries of medi- 
cal officers in, no 



HALIFAX: medical inspection in, 12 



HAMBURG: dental work in, 117, 118; 

per capita cost of dental treatment, 

125 
HARRINGTON, THOMAS F.: quoted, 146 

HARRISBURG, Pennsylvania: physical 
defects treated in, 94 

HAVERKELL, Massachusetts: superin- 
tendent of schools, quoted, 149 

HEALTH AUTHORITIES: co-operation 
with, in medical inspection urged 
by English board of education, 176 

HEALTH, BAD: among normal and re- 
tarded children in Camden, 154 

HEALTH, BOARD OF: Massachusetts, 
directions prepared by, on sight 
and hearing tests, 45, 47; New 
York City, division of child hy- 
giene, 91 ; New York City, supplies 
nurse to dental clinic, 121; New 
York State, dentists employed by, 
to lecture, 127; Virginia, bulletin 
on teeth issued by, 127 

HEALTH, BOARDS OF: can conduct con- 
tagious disease examinations, 53; 
medical inspection under, 143-150; 
regulations of, on medical inspec- 
tion, 13; resolutions adopted at 
conference of, 1 73 ; salaries of medi- 
cal inspectors under, 103 

HEALTH PAMPHLETS: by Dr. Ernest B. 
Hoag, 80, 82, 132 

HEARING, DEFECTIVE: among exempt 
and non-exempt children in Phila- 
delphia, 153; among normal and 
retarded children in Camden, 154; 
among retarded children in Elmira, 
156; among school children in 
New York, 40; effect on school 
work, 35; treated in English com- 
munities, 99; treated in Harris- 
burg, 94; treated in New York, 92; 
treated in Summit, 95. See Ears, 
Defective 

HEARING TESTS: by teachers and phy- 
sicians in United States, 19, 20; 
directions for making, issued in 
Massachusetts, 46; made by phy- 
sicians and teachers in cities of 
United States, 51, 52; new laws 
should provide for, 172; opinions 
of specialists as to teachers' ability 



214 



INDEX 



HEARING TESTS (Continued) 

to make, 44, 45; provision for, in 
state laws, 165; section of Massa- 
chusetts law on, 179. See also 
Vision and Hearing Tests 

HEART: examination of, 9, 37. See 
Cardiac Disease 

HEIGHT AND WEIGHT: records futile, 
37; records in Paris, 8; records in 
Wiesbaden system, 9 

HENIE, DR. C.: dental conditions 
among school children in Norway 
found by, 115 

HERNIA: examination for, in Wiesba- 
den, 9 

HESSE-DARMSTADT: medical inspection 
in, 9 

HOAG, ERNEST BRYANT: author of 
Health Index of Children, 80; 
health pamphlets by, reproduced, 
80, 82, 132 

HOLMES, GEORGE J.: equipment for 
school physicians and nurses 
recommended by, 111,112; quoted, 
87 

HOSPITAL CLINICS, 86, 87 

HOSPITALS: parents' consent to treat- 
ment of children at, 73; subsidies 
to, in England, 87 

HUNGARY: dental conditions among 
school children in, 114; medical 
inspection in, 1 2 

HYGIENE, DENTAL: education in, 127- 
133 



IMPETIGO CONTAGIOSA: directions and 
prescription for, 27, 28; exclusions 
for, 30, 32, 33 

INDIANA: abstract of medical inspec- 
tion law in, 167 ; vision and hearing 
tests prescribed in, 101 

INDIANS, AMERICAN: teeth of, 116 

INFIRMARY, DENTAL: in Boston, For- 
syth gift to establish, 124. See 
also Clinics, Dental 



INSPECTION: for contagious disease, 
cost of, 101, 112; of teachers, jani- 
tors, and buildings under state 
laws, 164-165, 172; intervals at 
which to take place in England and 
the United States, 40, 41; mini- 
mum per capita cost for efficient, 
103 See also Medical Inspection 

INSPECTORS, MEDICAL: corps appointed 
in New York, 13; results obtained 
by, with and without aid of nurses, 
66, 67; salaries of, 102-110. See 
also Physicians, School 

INSTITUTIONS: treatments by, New 
York, 96; treatments by, St. Louis, 
97 

IRELAND: medical inspection in, 10 



JANITORS: inspection of, under state 
laws, 165, 172 

JAPAN: medical inspection compulsory 
and universal in, 1 2 

JAW, width of: among ancient and 
modern peoples, 116 

JESSEN, DR.: dental clinic established 
by, in Strassburg, 117 

JOHNSON, GEORGE F. : weight and con- 
dition of teeth reported on by, 116 

JUVENAL: on the sound mind in the 
sound body, 6 

KENT, England: treatments in, 99 

KNOWLES, WM. F.: opinion on teach- 
ers' ability to test hearing, 45 



LAWRENCE, Massachusetts: conflict 
between health and educational 
authorities in, 148 

LAWS: compulsory education, 2 

LAWS, MEDICAL INSPECTION: abstract 
of, in United States, 167-171; 
authorities with which administra- 
tion placed, 144; early, in United 
States, 13; history and present 
status of, 164; mandatory pref- 
erable to permissive, 4, 5 ; of Eng- 
land, quoted, 174; Massachu- 
setts, text of, 178; points on which 



215 



INDEX 



LAWS, MEDICAL INSPECTION (Con- 
tinued) 

there is substantial agreement 
among, 164, 165; principal fea- 
tures of, 1 66; provisions which 
should be included in, 171, 172; 
similarities between those of Eng- 
land and Massachusetts, 179, 180. 
See also names of states and coun- 
tries; Education Act; Legislation; 
Regulations 

LEGAL ACTION: against parents, 83-86 

LEGAL PROVISIONS: regarding dental 
clinics, 124. See also Legislation; 
Laws 

LEGISLATION, MEDICAL INSPECTION: 
endorsed by boards of health in 
conference, 173; in different coun- 
tries of Europe and the United 
States, 7-13. See Laws, Medical 
Inspection; Regulations; Education 
Act 

LEICESTER, England: treatments in, 99 
LINCOLN: England: treatments in, 99 

LOME, HENRY: gift by, to establish 
dental clinic in Rochester, 120, 121 

LONDON: medical inspection in, 10; 
school nurses in, n, 62 

Los ANGELES: resolutions adopted by 
boards of health in meeting at, 173 

LOUISIANA: medical inspection regula- 
tions in, 164, 168 

LOWELL, Massachusetts: treatments 
following examinations by teachers 
in, 97 

LUNGS: examined in medical inspection, 
9, 37. See also Pulmonary Dis- 
ease 

LYNN, Massachusetts: charges of dental 
dispensary in, 127 



MAINE: abstract of medical inspection 
law, 1 68; vision and hearing tests 
prescribed in, 101; vision and hear- 
ing tests, results, 52 

MAINTENANCE: cost of, for dental 
clinics in Germany, 126 

MALAYS: teeth of, 116 



MALNUTRITION: among school children 
in New York, 40; treated in Harris- 
burg, Penn., 94; treated in New 
York, 92. See also Nutrition 

MANCHESTER. See South Manchester 
MANITOBA: medical inspection in, 12 
MARTIN, GEORGE H.: quoted, 150 

MASSACHUSETTS: appointment of medi- 
cal inspectors in, 150; Board of 
Health, directions as to methods 
of testing vision and hearing, 
quoted, 45, 46, 47; forms used 
in connection with vision and 
hearing tests in, 48, 50; history of 
medical inspection legislation in, 
13; instructions regarding symp- 
toms of contagious diseases issued 
in, 30; methods, typical of practice 
in other states, 51; notice to 
parent used in, 72, 73; results of 
vision and hearing tests in, 51, 52; 
tests by teachers in, influence of, 
44, 101 

MASSACHUSETTS MEDICAL INSPECTION 
LAW: abstract of, 168; and Eng- 
lish Act, most important, 174; 
examinations required by, no; 
mandatory, 4, 164; provisions re- 
garding school children returning 
after illness, 21; similarities to 
English Act, 179, 180; text of, 178 

MAXWELL, WILLIAM H.: quoted, 145 
MEASLES: exclusions for, 30-33 

MEDICAL ASSOCIATION, BRITISH: salary 
standard for medical inspection 
established by, 109 

MEDICAL ASSOCIATIONS, LOCAL: con- 
duct medical inspection, 108 

MEDICAL INSPECTION: administration 
in cities of United States, 143-151; 
administration in England, 176; 
four features of, 19, 20; forms of 
records used in, 21-27, 48, 50, 52- 
58, _ 73~75> 77-79, 134-142; per 
capita cost for, 102-110; results 
should be stated with moderation, 
40; statistical statements of re- 
sults rare, 89; status of, in cities of 
United States, 15-20; treatments 
resulting from, 91-100. See also 
Examinations ; Contagious Diseases; 
names of countries and cities 



2l6 



INDEX 



MEDICAL INSPECTORS. See Physicians, 
School; Inspectors 

MEDICAL OFFICER, CHIEF: English 
Board of Education, quoted, 98 

MEDICAL SOCIETY OF NEW JERSEY: 
quotation from journal of, 87 

MEDICAL TREATMENTS: in New York, 
92, 96. See also Treatments; names 
of cities 

MEMORANDUM: English board of edu- 
cation, provisions of, 10, 41, 175, 
176 

MENTAL DEFECTS: among exempt and 
non-exempt children in Philadel- 
phia, 153 

MEXICO: medical inspection in, 12 

MIDDLESBOROUGH, England: treat- 
ments in, 99 

MIDDLESEX, England: treatments in, 
99 

MILWAUKEE, Wisconsin: woman den- 
tal inspector in, 122 

MINNESOTA: regulations on medical 
inspection in, 164, 169; vision and 
hearing tests prescribed in, 102 

MONTREAL: school physicians ap- 
pointed in, 12 

MORLEY, England: treatments in, 99 

MOUTH HYGIENE: instruction in, by 
nurses, 91 

MULHAUSEN: dental work in, 126 
MUMPS: exclusions for, 31-33 

MUNICIPAL INSURANCE COMMITTEE of 
Hamburg dental clinic, 117 

MUSKEGON, Michigan: cost of equip- 
ment for dental clinic in, 125; 
dental work in, 88, 123 

NASAL BREATHING: prevented by 
adenoids, 4. See Breathing, Defec- 
tive 

NERVOUS SYSTEM, defects of: looked 
for in medical inspection, 37; 
treated in Pasadena, 94. See also 
Chorea 

NEWARK, N. J.: children treated free 
in dental clinic, 126; exclusions 



NEWARK, N. J. (Continued) 

for contagious diseases in, 32, 33; 
four physical defects treated in, 
93; number of pupils examined in, 
1910-11, 41; results of physical 
examinations in, 38; rules for 
nurses in, 68; staff and salaries in 
dental clinics of, 127; supervisor 
of medical inspection in, quoted, 87 

NEW JERSEY: law regarding dental 
clinics in, 124; medical inspec- 
tion legislation in, 13, 164, 169; 
provision for compulsory action 
against parents in, 85 

NEW JERSEY AND CALIFORNIA: highest 
costs for salaries in cities of, 103 

NEWMAYER, SAMUEL W.: data pre- 
sented by, to prove effectiveness 
of nurses' work, 66, 67; investi- 
gation of defects among school 
children by, 153 

NEW YORK CITY: beginning of medical 
inspection in, 13; Children's Aid 
Society issues directions regarding 
teeth, 129, sells tooth brushes, 129; 
dental clinics, 121, 122, 125; ex- 
clusions for contagious diseases, 
32, 33; funds wasted in attempting 
education of defective children, 
162; number of pupils examined 
in 1911, 41 ; origin of school nursing, 
63; records of defects treated in, 
91, 92; reduction of exclusions 
after introduction of school nursing, 
63, 65 ; results of physical examina- 
tions in, 38, 40; study of retarda- 
tion in public schools of, 156-163; 
treatments by private practi- 
tioners and institutions in, 96 

NEW YORK STATE: abstract of medical 
inspection law, 169; board of 
health employs dentists to lecture, 
127 

Nineteenth Century : article in, referred 
to, 116 

NORFOLK, England: treatments in, 99 

NORMAL SCHOOLS: provision regarding, 
in new laws, 172 

NORTHAMPTON, England: salaries of 
medical inspectors in, no 



217 



INDEX 



NORTH DAKOTA: abstract of medical 
inspection law in, 169 

NORWAY: dental conditions among 
school children in, 115; medical 
inspection in, 1 1 

NOSE, DEFECTS or: among exempt and 
non-exempt children, 153; im- 
portance among school children, 
35; number of children having, in 
different cities, 38; one of four 
commonest classes of defects, 37, 
39; treated in Pasadena, 94. See 
also Breathing; Adenoids 

NOSE TROUBLES: health pamphlet on, 
80 

NOTICE of results of vision and hearing 
tests used in Massachusetts, 50 

NOTIFICATION TO PARENTS: form used 
for, 73; not always sufficient to se- 
cure action, 72, 88 

NOTTINGHAMSHIRE, England: treat- 
ments in, 99 

NURSES, SCHOOL: and school clinics, 87; 
average per capita cost for medical 
inspection in^cities employing, 103; 
cannot meet situation alone, 86; 
duties of, 64, 71; effectiveness of 
work of, 34, 65-67; employment of, 
advised by English board of edu- 
cation, 177; equipment for, 112; 
follow up visits to secure action, 76; 
in Germany, 10; in London, n; 
in United States, by groups of 
states, 18, 20; in United States, 
number employed, 63; instruc- 
tions in mouth hygiene given by, 
La New York, 91; proportion of 
children to, 68; provision for, in 
new laws, 172; qualifications of, 
64; record results of examination, 
43; rules for, in Newark, N. J., 68; 
salaries, 70, 71, 102-108; under 
school supervision, 146; work of, 
in contagious disease cases, 30; 
value of, unquestioned, 62 

NURSING, SCHOOL: history of, 62 

NUTRITION, DEFECTIVE: looked for in 
medical inspection, 37; treated in 
Pasadena, 94. See also Malnu- 
trition 



OAKLAND, California: consultations 
with director of health develop- 
ment in, 77, 79; number of pupils 
examined in, 1910-11, 41, 42; 
results of physical examinations 
in, 38; treatments of defective 
children in, 96 

OCULIST, SCHOOL: early work of, in 
Belgium, n 

OHIO: abstract of medical inspection 
law of, 170 

ONTARIO: medical inspection in, 12 

OPEN-AIR SCHOOLS: establishment of, 
desirable, 98; in Germany, 10 

OPERATIVE TREATMENTS: in Newark, 
93; in New York, 92, 96. See 
also Treatments; Defects 

ORTHOPEDIC DEFECTS: among exempt 
and non-exempt children in Phila- 
delphia, 153; among school chil- 
dren in New York, 40; treated in 
New York, 92 

OSLER, WILLIAM: quoted, viii, 103, 114 

OVER-AGE CHILDREN: defects among, 
compared with those among nor- 
mal, 154. See Retardation 



PALATES, DEFECTIVE: among school 
children in New York, 40; treated 
in New York, 92 

PALATES, DEFORMED : treated in Harris- 
burg, 94 

PARASITIC DISEASES: detection and 
exclusion of, 21 

PARENTS OF SCHOOL CHILDREN: com- 
pulsory action against, 83-86; 
English medical inspection act 
has no provision for compulsory 
action against, 177; imprisoned 
and fined in England, 86; instruc- 
tion by printed bulletins, 80; left 
with larger responsibility by medi- 
cal inspection, 5; means of securing 
co-operation of, 72-79, 177; new 
laws should provide for notification 
of, 172; notified in Paris, 8; noti- 
fied in Wiesbaden, 9; payments by, 
for dental treatment, in Germany, 
117, 118; poverty of, creates prob- 



218 



INDEX 



PARENTS OF SCHOOL CHILDREN (Con- 
tinued) 

lem, 86, 88; presence of, at ex- 
aminations, 73, 75, 76; right to 
insist that child in school shall be 
safe, 4 

PARIS: medical inspection in, 7, 8 

PASADENA, California: consultations 
with medical examiner in, 77, 78; 
number of pupils examined in, 
1909-10, 41; record of physical 
examinations used in, 53, 55; re- 
sults of physical examinations in, 
38; treatments in, 94 

PAYMENTS: for dental treatment, by 
parents in Germany, 117,118. See 
Salaries 

PEDICULOSIS: directions and prescrip- 
tion for, 27, 28; exclusions for, 
30-33 

PENCE, England: treatments in, 99 

PENNSYLVANIA: abstract of medical 
inspection law of, 170 

PENSIONS FOR SCHOOL PHYSICIANS, 9 

PER CAPITA COST: for dental treat- 
ment of school children, 125-127; 
for salaries of inspectors and nurses, 
102-107. See also Cost 

PHILADELPHIA: beginning of medical 
inspection in, 13; data on effective- 
ness of nurses' work in, 66, 67; 
defective exempt and non-exempt 
children in, 152, 153; dental work 
in, 88, 123; directions and prescrip- 
tion for tooth powder in, 128; ex- 
clusions and school membership 
in, 33; salaries of school dentists 
in, 127; supplies and equipment 
for dental clinic in, 125 

PHYSICAL CULTURE TREATMENTS IN 
NEW YORK, 96 

PHYSICAL EXAMINATIONS. See Ex- 
aminations 

PHYSICIANS, PRIVATE: treatments by, 
New York, 96; treatments by, 
St. Louis, 97 

PHYSICIANS, SCHOOL: and school 
clinics, 87; conduct of physical 
examinations by, 3.7; contagious 
disease work of, 21, 30; equipment 
for, in; examinations by, in 



PHYSICIANS, SCHOOL (Continued) 

cities of United States, 19, 20; 
four possible functions of, 89, 90; 
forbidden to make suggestions as 
to treatment, 31; have varying 
standards, 39; in Belgium, n; in 
Boston, 13; in Cairo, 12; in 
France, 7; in Hungary, 12; in 
London, 10; in Montreal, 12; in 
New York City, 13; in Sweden, n; 
in Switzerland, 12; in United 
States, 1 6, 17, 20; in Wiesbaden, 9; 
inspections placed in hands of, by 
state laws, 165; office consultations 
with, 76, 77, 78, 79; report of, 
features desirable in, 90; salaries 
in England, 109-110; salaries in 
Germany, 9; salaries in United 
States, 102-110; section of Massa- 
chusetts law on, 178; tests of 
vision and hearing made by, in 
cities of United States, 51; time 
taken by clerical work, 24, no, 
in, 113. See also Inspectors 

POLAND, DR.: quotation from, on 
medical inspection under board 
of health, 147 

PREMISES, SCHOOL: provision for in- 
spection of, in new laws, 172 

PROGRESS, SCHOOL: and physical de- 
fects, 152-163 

PROMOTED AND NON-PROMOTED CHIL- 
DREN: defects among, in South 
Manchester, 155 

PROMOTION: normal and retarded 
children who failed of, in Camden, 
154 

PROVISIONS which new medical inspec- 
tion laws should include, 171, 172 

PRUSSIA: dental conditions among 
school children in, 115 

Psychological Clinic: article in, 152 

PUBLIC HEALTH ASSOCIATION of Roch- 
ester: supplied premises for clinic, 
1 20 

PUBLIC SCHOOLS: a public trust, 4. See 
Buildings; Premises 

PULMONARY DISEASE: among school 
children in New York, 40; treated 
in Harrisburg, Penn., 94; treated 
in New York, 92. See also Lungs 



219 



INDEX 



PUPILS: enrolled and examined, in 
nine cities, 41; found defective in 
vision and hearing, 52; proportion 
of nurses to, 68. See also Children 



RACHITIS: among retarded children in 
Elmira, 156 

RATE, PER CAPITA: for efficient medical 
inspection, 103. See also Cost 

READING, Pennsylvania: dental clinics 
in, 121, 122, 125 

RECORDS, FORMS, AND BLANKS used in 
medical inspection, 21-27, 48, 50, 
52-58, 73-75, 77-79, 134-142. 
See List of Forms, p. xix 

RECORDS: individual, should follow 
children, 53; making entries on, 
consumes inspectors' time, 24, no, 
in, 113; of combinations of de- 
fects, 58-61; of physical examina- 
tions in Paris, 8; in Wiesbaden 
system, 9; of physical examina- 
tions, three essential classes of, 
52, 58; used in connection with 
vision and hearing tests in Massa- 
chusetts, 48, 50 

REGULATIONS: on medical inspection, 
states having, 164. See Laws 

REPORTS OF SCHOOL PHYSICIANS: 
features they might contain, 90, 
91; rarity of statistical statements 
of results in, 89 

REPORTS. See List of Forms, p. xix 

RESOLUTIONS: adopted at conference 
of boards of health, 173 

RESULTS OF MEDICAL INSPECTION: 
features desirable in reports on, 
90, 91; records of treatments, 91- 
100; should be stated with modera- 
tion, 40; statistics on, rare, 89 

RETARDATION AND DEFECTIVENESS : 
conclusions reached on, tentative, 
163; study in Camden, 154-155; 
study in Elmira, 155-156; study 
in New York, 156-163 

RETARDED CHILDREN. See Retarda- 
tion 



RHODE ISLAND: abstract of medical 
inspection law of, 170; vision and 
hearing tests prescribed in, 102 

RINGWORM: directions and prescrip- 
tion for, 27, 29; exclusions for, 
30, 32, 33 

ROCHESTER, New York: dental clinics 
in, 88, 114, 120; equipment of 
dental clinic in, 125; exclusions and 
school membership in, 33; lecturer 
to children secured by dental as- 
sociation in, 128; number of pupils 
examined in, 1910, 41; per capita 
cost for dental treatment in, 126; 
results of physical examinations in, 
38; salaries of school dentists in, 
127 

ROGERS, LINA L. : first school nurse in 
America, 63 

ROMAN SOLDIERS: jaws of, compared 
with those of British soldiers, 116 

ROSE, KARL: on teeth of different 
peoples, 116 

ROUMANIA: me.dical inspection in, 12 
RULES FOR NURSES: Newark, N. J., 68 

RUSSELL SAGE FOUNDATION: investiga- 
tion regarding medical inspection 
conducted by, 14, 36, 63, 103; 
study of retardation by, 156 

RUSSIA: dental clinics in, 120; medical 
inspection in, 1 1 



ST. Louis, Missouri: concentration of 
examinations on 19 schools in, 42; 
number of pupils examined in, 
1910-11, 41; parents' consent 
blank used in, 73, 75; results of 
physical examinations in, 38; treat- 
ments of defective children in, 96; 
treatments by family physicians 
and institutions in, 97 

ST. PETERSBURG: dental clinics in, 120 

SALARIES: and per capita cost, 102-110; 
of school dentists in clinics, 127; 
of school dentists in Somerset, 
England, 119; of school nurses in 
cities of United States, 70, 71, 
102-108; of school physicians in 
cities of United States, 102-109; 
of school physicians in England, 



22O 



INDEX 



SALARIES (Continued) 

109, no; of school physicians in 
Germany, 9 

SALISBURY, Eng. : treatments in, 99 
SANITARY INSPECTION: in France, 7 

SAN Luis PoTosf: medical inspection 
in, 12 

SAXE-MEININGEN: medical inspection 
in, 9 

SCABIES: directions and prescription 
for, 27, 29; exclusions for, 31-33 

SCALP, DISEASES OF: treated in English 
clinics, 87 

SCARLET FEVER: exclusions for, 30-33 
SCHONEBERG: dental work in, 126 

SCHOOL AUTHORITIES: administration 
of medical inspection by, 164 

SCHOOL CLINICS. See Clinics 
SCHOOL FEEDING: in Germany, 10 

SCHOOL MEMBERSHIP: and exclusions, 
in eight cities, 33. See also En- 
rollment 

SCHOOL NURSES' SOCIETY formed in 
London, 62 

SCHOOL PROGRESS: and physical de- 
fects, 152-163 

SCHOOLS: closing of, because of epi- 
demics, 34 

SCHOOLS, OPEN-AIR: establishment de- 
sirable, 98 

SCOTLAND: dental work in, 120; medi- 
cal inspection in, 10 

SENSE ORGANS: examined in Wies- 
baden, 9. See Eye; Ear; Nose; 
Sight; Hearing; Vision 

SHEPHERD, FRED S.: quoted, 147, 148 

SIGHT AND HEARING, DEFECTIVE: as 
handicaps in school work, 3, 4. 
See Ears; Eyes; Hearing; Vision 

SKIN: examined in Wiesbaden, 9 

SKIN DISEASES: among exempt and 
non-exempt children in Phila- 
delphia, 153; treated in English 
communities, 87, 99; treated in 
Harrisburg, Penn., 94. See also 
Impetigo; Ringworm; Scabies 



SMALL-POX: exclusions for, 30, 31 

SNELLEN CHART: used in Massa- 
chusetts, 47; reproduced, 49 

SOMERSET COUNTY: allowance for 
materials for dental work in, 126; 
rate of payment to school dentists 
in, 127; school dental work in, 119 

SOMERVILLE, Massachusetts: treat- 
ments following examinations by 
teachers in, 97 

SOUTH AMERICA: medical inspection 
in, 12 

SOUTH MANCHESTER, Connecticut: 
study of defective children in, 
155; teeth of school children in, 
117 , 

SOUTH SHIELDS, England: treatments 
in, 99 

SPINE: examined in Wiesbaden, 9. 
See Orthopedic Defects 

SPOKANE, Washington: exclusions in, 
144 

SPRINGFIELD, Massachusetts: superin- 
tendent of schools, quoted, 150 

STAFFORD, England: salaries of medical 
inspectors in, no 

STATE: duties and rights of, in medical 
inspection, 4, 5 

STATE REGULATIONS: in Germany, 9; 
in Norway, u. See Regulations; 
Laws 

STATISTICS: showing results of medical 
inspection rare, 89 

STRASSBURG: dental clinic in, 117, 118; 
salaries of school dentists in, 127; 
dental work in, 126 

STUTTGART: school nurses in, 10; dental 
work in, 126 

SUMMIT, New Jersey: defects treated 
in, 95 

SUPPLIES: and equipment for dental 
clinics, 125; for school nurses, 112 

SURREY, England: treatments in, 99 
SUSSEX: treatments in, 99 
SWEDEN: medical inspection in, u 



221 



INDEX 



SWITZERLAND: dental clinics in, 120; 
medical inspection in, n, 12 

SYMPTOMS OF DISEASE: which teachers 
should notice, 30 

SYRACUSE, New York: use of colored 
forms in, 27 



TASMANIA: medical inspection in, 12 

TEACHERS: duties of, in medical 
inspection in Colorado, 84, 85; 
examinations of, provision for, in 
state laws, 164, 172; opinions as 
to ability to test vision and hearing, 
44, 45; plan of having physical 
records made by, 43; practicability 
of tests by, demonstrated, 51; 
record height and weight, Wies- 
baden system, 9; treatments 
following examinations by, 97; 
work of, in detection of contagious 
disease, 21, 27, 30. See also 
Vision and Hearing Tests 

TEETH: directions for care of, issued 
by Children's Aid Society of New 
York, 129; leaflet on care of, 
issued in Waltham, Massachusetts, 
131; pamphlet on, by Dr. Hoag, 
132 

TEETH, DEFECTIVE: among children 
promoted and not promoted in 
South Manchester, 155; among 
different peoples, 116; among 
school children in different cities, 
38; among school children in 
different countries, 114, 115; among 
school children in New York, 40; 
and school progress in New York, 
158-162; early discovery of, im- 
portant, 35; extractions and fillings 
among school children in New 
York, 92, 96 ; handicap imposed by, 
in terms of retardation, 162; in 
children with adenoids and enlarged 
tonsils, 58; instruction in mouth 
hygiene by nurses in New York, 91 ; 
one of four commonest classes 
of defects, 37, 39; physical deter- 
ioration caused by, 114; treated in 
English school clinics, 87; treated 
in Newark, N. J., 93; treated in 
New York, 92; treated in Pasadena, 
Cal., 94; treated in Summit, N. J., 
95 



THROAT, DEFECTS OF: among children 
in different cities, 38; among 
exempt and non-exempt children, 
153; early discovery of important, 
35; one of four commonest classes 
of defects, 37, 39; treated in 
Pasadena, Cal., 94 

THROATS: examined in Wiesbaden, 9; 
treated in English school clinics, 87 

THROAT TROUBLES: health pamphlet 
on, 80 

TIME and cost of physical examinations, 
43 

TIME necessary for vision and hearing 
tests, 102 

TONSILITIS: exclusions for, 130-133 

TONSILS, HYPERTROPHIED: among re- 
tarded children in Elmira, 156; 
among New York school children, 
40; and associated defects, 58; 
and school progress in New York, 
158-162; handicap imposed by, 
in terms of retardation, 162; 
how classified, 39; treated in 
English communities, 99; treated 
in Harrisburg, 94; treated in 
Newark, N. J., 93; treated in New 
York, 92; treated in Summit, 95 

TOOTH BRUSHES: and powder given to 
children in Philadelphia dental 
clinic, 128; sold to children by 
Children's Aid Society of New 
York, 129; supplied to patients in 
Strassburg clinic, 117 

TRACHOMA: exclusions for, 30 

TREATMENT, DENTAL: in Strassburg 
clinic, 117 

TREATMENT OF CHILDREN: securing 
parents' consent to, 73 

TREATMENTS FOR PHYSICAL DEFECT: 
in cities of the United States, 91-98; 
in English communities, 98-100 

TRENTON, New Jersey: treatments of 
defective children in, 96 

TUBERCULOUS CHILDREN: open air 
schools for, 98 



222 



INDEX 



TUBERCULOUS LYMPH NODES: among 
school children in New York, 40; 
treated in New York, 92 



UNGHAVARI: studies in dental condi- 
tions, results of , 114 

UNITED STATES: administration of 
systems of medical inspection in, 
145; census bureau's grouping 
of states, 14; cities of, employing 
school dentists, 19; cities of, em- 
ploying school nurses, 18; cities of, 
employing school physicians, 17; 
cities of, having medical inspection, 
15, 16, 17; cities of, having exami- 
nations for physical defects, 36; 
dental work for school children in, 
114, 120-142; development and 
present status of medical inspec- 
tion in, 1911, 13-20; treatment 
of defects in, compared with that 
in England, 100 

UNITED STATES COMMISSIONER OF 
EDUCATION: figures from reports 
of, 34, 42, 103 

UTAH: abstract of medical inspection 
law of, 170; vision and hearing 
tests prescribed in, 102 

UTICA, New York: use of colored forms 
in, 27 



VALPARAISO, Indiana: dental work in, 
123, 128 

VANCOUVER: medical inspection in, 12 

VERMIN AND SKIN DISEASES: forms 
used in cases of, 27, 28, 29. See 
also Pediculosis 

VERMONT: abstract of medical inspec- 
tion law of, 170; medical inspec- 
tion legislation in, 13 

VERPLANCK, FRED. A.: report on teeth 
of school children by, 117; study 
of defective children by, 155 

VIRGINIA: abstract of medical inspec- 
tion law of, 171; State board of 
health, bulletin on teeth issued by, 
127 



VISION AND HEARING TESTS: by teach- 
ers, cost of, 101, 102, 112; by 
teachers, do not take place of 
thorough examination, 102; by 
physicians and teachers in cities 
of United States, 20, 51, 52; 
directions for making, issued by 
Massachusetts Board of Health, 
45-47; forms used in Massachu- 
setts, 48, 50; opinions of special- 
ists as to teachers' ability to make, 
44, 45; new laws should provide 
for, 172; provision for in state 
laws, 101, 165; results of, in Massa- 
chusetts, Connecticut, and Maine, 
52; section of Massachusetts law 
on, 179; time necessary to conduct, 
102; treatments following, in 
Lowell and Somerville, Mass., 97 

VISION, DEFECTIVE: among children 
in New York schools, 40; among 
exempt and non-exempt children 
in Philadelphia, 153; among nor- 
mal and retarded children in 
Camden, 154; among retarded chil- 
dren in Elmira, 156; and school 
progress in New York, 158-161, 163; 
effect of, on children, 35; increases 
with age, 157, 158; percentage of 
children suffering from, 35; treated 
in English communities, 99; treated 
in Harrisburg, Penn., 94; treated 
in Newark, N. J., 93, in New York, 
92; treated in Summit, 95. See 
also Eyes; Eyesight 

VISITS TO HOMES: made by nurses, 76 



WALD, LILLIAN D.: lent services of 
nurse for school work, 63 

WALES : dental inspection under way in , 
120; medical inspection in, 10 

WALKER, D. HAROLD: opinion on 
teachers' ability to test hearing, 45 

WALTHAM, Massachusetts: leaflet on 
care of teeth issued in, 131 

WASHINGTON: abstract of medical in- 
spection law of, 171 

WATER, DRINKING: provision for in- 
spection of, in new laws, 172 



223 



INDEX 



WEIGHT AND HEIGHT, RECORDS or: 
futile, 37; in Paris, 8; in Wiesbaden 
system, 9 

WEST VIRGINIA: abstract of medical 
inspection law of, 171 

WHOOPING GOUGH: exclusions for, 31- 
33 



WIESBADEN: 
8-9 



medical inspection in, 



WINCHESTER, Massachusetts: rates for 
dental treatment of school children 
in, 127 

WOLVERHAMPTON, 

ments in, 99 



WORCESTERSHIRE , 
ments in, 99 



England: treat- 
England: treat- 



YORKS (East Riding), England: treat- 
ments in, 99 



22 4 



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