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RUSSELL SAGE
FOUNDATION

MEDICAL INSPECTION
OF SCHOOLS

BY
LUTHER HALSEY GULICK, M.D.

AND
LEONARD P. AYRES, PH.D.

N E W Y O R K

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

SIGNIFICANT FACTS

* ' T II 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. Sh£ 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 . 2 1

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 1910 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 .63

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 . . 1 48

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 . .170

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 191 1 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 1 8

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
n. 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., 1911 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

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

2 1 . 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

per cent 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 . 108

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 . 1 28
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,
in 1842 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 lighting, 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. I74ff- t See 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 19064 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.J
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.
t See pp. 164, 168, and 177. I See map, p. 165.

13

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
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

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. II I

CITIES HAVING MEDICAL

Division

Cities
reporting

INSPECTION

Number

Per cent

North Atlantic

411

236

57

South Atlantic

74

23

3i

South Central

IOI

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 191 1, 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

E

1808

§

1800 .

IQOO

I I

IQOI

17

IQO2

23

IQO3

Is

IQO4

37

IQQC

||

•y7

1906

77
1 1 1

1008

167

IOOO

1U/

263

IOIO

400

IQI 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

'09

'06

'07

167 £6$

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. II I

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

1,415

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

28
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. 191 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

248

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
are:

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
bearing 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 h

aving medical ii

ispection 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 I II

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

a

J

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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
requite, 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

1

1 s

Z IT

Q S

Q>

'I I

Qu <

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

F

o

i

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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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IRECTIONS: Saturate the hair with
oleum. Keep it wet for three hours,
i the whole head with hot water and
sat this process on three successive
i comb the hair with a fine-toothed
vith vinegar. To make the treatment
more thorough, have the hair cut
re beginning treatment. While under
t keep away from the fire or a lighted

IMPETIGO CONTAGIOSA
IRECTIONS: Wash the affected
warm water and soap. Apply the
t morning and night until the diseaj
ppeared.

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INSPECTION FOR CONTAGIOUS DISEASES

COMBINED DIRECTIONS AND PRESCRIPTION, EVERETT, MASS.

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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

Puffiness 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 oftonsilitis 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 oft
health. School physicians are forbidden to make any suggestions^
as to treatment and management of sick pupils. This rule isi
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 i

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 .

M55

426

925

1,475

Tonsilitis

2,957

170

337

Chicken-pox

1,010

90

217

'.347

Mumps .

1,128

33

135

1,475

Impetigo

986

520

227

Measles

1,004

84

167

414

Conjunctivitis

672

1,137

Scabies .

579

254

i'5

215

Diphtheria .

708

7

28

848

Ringworm .

494

116

162

138

Whooping cough

298

108

83

329

Scarlet fever
Other causes

579
2,783

948

27
1,925

198
35'

Total

14,653

2,775

4,i2i

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

is.

Impetigo

67

I87

28

Measles

68

30

4i

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 ....

I90

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

City and year

School
membership

EXCLUSIONS FOR CONTAGIOUS

DISEASE

Number

Number per
thousand pupils

Chicago, 1910 ....
Cincinnati, 1910
Cleveland, 1908-09 .
Detroit, 1909-10
Newark, 1909-10
New York, 1909-10 .
Philadelphia, 1910 .
Rochester, 1910

301,172
47,454
69,764

57>996
57,742
744,148
174,441
26,664

14,653
i, 606

1,798
2,775
4,955

6i794
1,050

49

11
&

12

39
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.

34

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.

191 I

Division

Number of Cities

North Atlantic

135

South Atlantic

10

South Central

12

North Central

38

Western

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.

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

36

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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^ - v£> rrs ON - O "^00
0000 — o« — 00 uNt^Tj-

f

Z

*

vo os^r, rj.« «

ON

UN

Si

UJ

*

Q

X

£

. 00 O Q ~ rr^<^S. °^ ^

rrs

UN

X ^

u w

Q
X

R

; \o — «N o •* r^-oo M

UN

u

UJ

ON O m TJ- rr\ — «
— — rs

UN

J —

U

u.

_

« «

o

u

DO

1

C

VO 00 t^»CO r<N r<N ^" UN UN

rr»
O

§ s

u. X

o ^

0

06
UJ

-

1
C

VO <S r<NCNOOO ON^ft^
«S O ^00 UN UN UN ON t^

I

Z

1

SH^gHl

l/N

18

Z

1

*% £ rT ON ONOO Q"^- °

UN

*,

J^ ^^2 ^ m ^ ^ °°

*

5 K

i5

^"f""^rfN

*

'ri

*1

rs roOO res N O O — I"*

§

i u

^

&!

Q52522Q92

Q

-*• £*

r» O O •<$• O VO ^ UNVO

ON

f1^

X «

ooooooooo

o

U

"I «

— «

UN

X O

0

"

uo

s ?

I O

j.

o S

City and yet,

J'J J S S? 2 e •
UUZZOOu^c/5

"rt

a Partial data.

TABLE 12. — RESULTS
L

O -

<* 2 o\ S^^J 5\ - r S*
mUUZZO^c2c/)

2
<

38

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
Defective vision ....

27.3 '9
24.5>4

II.Q

10.6

Malnutrition

5.845

2-5

Cardiac disease

i, 66 1

•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

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 — 1911 ....
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
87,93 i

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 j
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 f§, 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
f§; 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 •& (^ 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 i^
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, i

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 J. School,

Town

19

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.

48

PHYSICAL EXAMINATIONS

SNELLEN CHART FOR TESTING EYESIGHT

(Printed on heavy white cardboard, size n x 14 inches)

Commonwealth of Massachusetts

CHAPTER 502, ACTS OF IQO6

SNELLEN'S TEST LETTERS FOR MEASURING THE ACUTENESS

OF VISION

50 FEET

T C L D

40 FEET

L O E D T

30 FEET

O T P E C L

20 FEET

P T O L D E C

4 49

MEDICAL INSPECTION OF SCHOOLS
RECORD OF SIGHT AND HEARING TESTS. MASSACHUSETTS

The Commonwealth of Massachusetts

CHAP. 502. ACTS OF 1906

RECORD OF SIGHT AND HEARING TESTS

19

City or Town School Class.

NAME.

[If notice it sent to parent or
guardian, star name.]

EXAMINATION OF
EYES.

HEARING.

REMARKS.

Whisper heard (distance
in feet).

Eyesight.

Right Eye.

Left Eye.

Right Ear.

Left Ear.

-

NOTICE TO PARENT OR GUARDIAN OF DEFECT OF EYES OR EARS,

MASSACHUSETTS

The Commonwealth of Massachusetts

NOTICE TO PARENT OR GUARDIAN
IN ACCORDANCE WITH CHAPTER 502 OF THE ACTS OF 1906 YOU
ARE HEREBY NOTIFIED THAT THE SCHOOL EXAMINATION OF
............................................................ SHOWS THAT THERE IS SOME TROU-

BLE WITH THE WHICH NEEDS COMPETENT MEDICAL AD-

VICE. PLEASE ATTEND TO THIS AT ONCE.

TEACHER

....19

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
182

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 bearing

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.'29

20,167

1 6.6

4-6

1910

454,058

71,902

I7»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 completed
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 x

V

I

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

5 DATEOFPHYS. EXAM.

6 HEIGHT

7 WEIGHT

8 NUTRITION

9 ANEMIA

10 ENLARGED GLANDS

ii GOITRE

12 NERVOUS DISEASES

13 CARDIAC DISEASE

14 PULMONARY "

15 SKIN

16 DEFECT ORTHOPAEDIC

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

54

PHYSICAL EXAMINATIONS

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MEDICAL INSPECTION OF SCHOOLS

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PHYSICAL EXAMINATIONS

INDIVIDUAL RECORD CARD. SCHOLARSHIP RECORD, BERKELEY, CAL. (REVERSE)

DEPARTMENT OF SCHOOL HYGIENE Scholarship Record

CITY SCHOOLS OF BERKELEY

PARENT'S OCCUPATION

Father's Nationality

Mother's Nationality

SECOND TERM

J, Q ii

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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 j
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 j
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 Dejects — Six Possible Combinations
Teeth. Throat Teeth .Throat

Eyes Nose Eyes Nose

Teeth ^Throat Teeth. Throat

Eyes * Nose Eyes

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

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
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.

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 phrase
in our language adequately describes the qualification or ability
referred to. It is that attribute which the Spaniards designate
as the "don de gentes," which, freely translated, means the "gift
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 former
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 65

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 17.

TABLE iy. — 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

S

1

i

S

School

mmendati

|!

1 §

School

mmendati

H
11

r cent acte
upon

1

r

£

1

1

£

A

324

262

81

E . . .

283

83

29

B

445

434

98

F . . .

582

26

G . . .

320

282

88

G . . .

441

94

21

D . . .

264

226

86

H . . .

474

19

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,

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

^

45
138

80
65
73
92

272

338
36
152

70
62

5
3'

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
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 A
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 office 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.

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 sliall 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 ii. 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 1911
showed that the salaries of nurses were distributed as shown in
the following table:

TABLE IQ. — SALARIES OF NURSES IN IC)6 AMERICAN MUNICIPALITIES

Salary

Number of cities where nurses
received salary indicated

No salary

21

$20 i -$300

2

$40i-$500

I

$50i-$6oo

.

21

$60 i -$700

,

«7

$7oi-$8oo

.

24

#8oi-$9oo

t

15

$9Oi-$iooo

2

$1001-$! 500

2

Fees according to service

1

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

M

EDICAL 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.

PRINCIPAL. (OVER)

TO TH R PH YSI C I AKI • 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.

Nov

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.
76

Team work between physician and nurse in Toledo, Ohio.

MAKING MEDICAL INSPECTION EFFECTIVE

N 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

: DEPT. OF HEALTH DEVELOPMENT AND SANITATION
/-> j 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 pbysi-

\ dan or specialist for advice and treatment so that

t j may be in better condition to continue

; studies.

The Director will be in his office, 4th floor of the
" i 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.

Teacher 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 form| 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

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

1 358 Broadway, igi . .

The School Nurse failed to find you at borne 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 ^A 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 1909, 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,'

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, 191 1.

" 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

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

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, 19! I

Defect

Cases
reported

Cases
treated

Per cent
treated

Vision

24,514

16,633

68

Hearing

1,491

847

57

Nasal breathing .
Hypertrophied tonsils

27,319
34,639

22,839
22,647

84
65

Tuberculous lymph nodes

418

295

7i

Cardiac disease

1, 66 1

1,286

77

Pulmonary disease

483

377

78

Chorea ....

86 1

483

56

Orthopedic .
Malnutrition

1,190
5,845

522
3,632

£

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

Hypertrophied tonsils:

Receiving operative treatment
Receiving medical treatment

Defective teeth:

Treated by extraction
Treated by filling

11,304
5,329

11,284

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., IQIO-II

Defect

Cases
reported

Cases
treated

Per cent
treated

Vision
Tonsils
Adenoids
Teeth

3,003
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

«7

4

24

Chorea . .

8

4

5°

Cardiac disease

8

3

38

Pulmonary disease .

5

4

80

Skin disease ....

61

30

49

Defective vision

677

268

40

Defective hearing .

143

51

36

Defective nasal breathing

204

83

Defective teeth

187

48

26

Deformed palate

8

2

25

Hypertrophied tonsils

805

249

Adenoids

432

153

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

'48

242

21
69
91

375
64

12

\l

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-

Cases in
which
physician
was

cases refer-
red to physi-
cian in
which phy~

sician

consulted

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

112

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

Defects
reported

Defects
treated

Per cent
treated

New York City, 1911 ....

234,349

87,765

37

Pasadena, Cal., 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, Cal., 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, 191 I

D

eject

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

'7
836

1,222

5,666
10,048
10,684
42

34i
232

151

Total . .

.

37,986

27,164

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.
98

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. IQIO

Cases

Per cent of

County areas

recommended

Cases treated

recommended

for treatment

cases treated

Anglesey

374

204

54-5

Devonshire

2,525

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

.

1,303

692

53-i

Nottinghamshire

626

284

45-4

Surrey .

i,4i7

688

48.6

Sussex (West)

505

358

70.9

Worcestershire

598

419

70.1

Yorks (East Riding)

312

,76

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

y~

5!-7

Lincoln, C. B.

'33

88

66.2

Middlesborough

992

545

54-9

Morley

350

73

20.9

Penge .

179

38

21.2

Salisbury .

202

119

58.9

South Shields

732

420

57-4

Wolverhampton

322

148

J-

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 1 3 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 ff.
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 2 5 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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107

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 i ,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
salary indicated

nurses receive salary
indicated

No salary

75

21

$ i — $ i oo

47

$IOI-$200

50

$20 I -$300

44

2

$30 I -$400

25

$4OI—$5OO

24

I

$5OI— $6OO

18

21

$60 I -$700 .

2

'7

$70I-$800 .

12

24

$80 I -$900 .

6

15

$901-$ i, ooo

13

2

$ i, ooi-$ i, 500

18

2

$1,501-^2,500

7

$3 , 500— $4,000

3

Fees according to service

19

1

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 officers: $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
efficacy 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, 191 1
I I I

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, J^ 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., Linton 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. 293.

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. Henief examined school
children in Norway and found 97 per cent with decayed teeth.
Investigations conducted in Dunfermline, Scotland,}: 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 fiir Schulge-
sundheitspflege, February, 1898, Vol. II, pp. 65-71. Referred toby W. H. Burn-
ham, op. cit.

J 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 soldiersf
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.

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

t 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.

117

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

1 20

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 1911.

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

30
8
4
39

United States ....

198

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

$7°°

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, \g\ I

ANNUAL COST

Municipal district

Number
of school
children

Num-
ber of
rooms
in
clinic

Initial
capital
outlay

OF
MAINTENANCE

Number
of chil-
dren
treated

Per

capita
cost

Salaries

Ma-
terial

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.ooo

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

Miilhausen

19.500

3

,312

267

3,6io

•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 1 5 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.

Castile Soap. 3% Oil of Birch.. i%
Saccharin . . . K % Oil of Pepper-
mint Yt%

Compliments of the DENTAL CORPS

128

"S

bO

-J -I

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.

'33

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 1 38, 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>4 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

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,36

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 Hour.:
Monday to Friday, 9 A. M. to 4 P. M. Saturday. 9 A. M. to 12 Noon.

.38

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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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) of a total 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. II I

Cities having

Cities having

Cities having

Division

systems of
medical

administra-
tion by board

administra-
tion by board

inspection

of health

of education

North Atlantic ....

236

58

178

South Atlantic ....

23

7

16

South Central ....

35

12

23

North Central ....

109

21

88

Western

40

8

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 we should not overlook the
fact that medical inspectors are human and have a few of the faults com-

H7

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, jist 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. — PERCENT 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

•Cornell, 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., 1908

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
137

2l

918
214

171
29

21

53

8

423
128

10

2

4

i

26
6

12
2
2

4

2

5
30

9

Total . . .

i>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

1 '

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 ....

5«

40

Per cent having defective hearing

'4

1 1

Per cent having bad health

21

21

Per cent attending irregularly ....

30

40

*Annual Report of the Board of Education of the City of Camden, New
Jersey, 1907, pp. 81-120.

154

o

c
u
u

I

o

I

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

CASES AMONG CHILDREN

CASES PER 100 CHILDREN
AMONG THOSE

Defect

Promoted

Not promoted

Promoted

Not promoted

Teeth ....

272

116

25

38

Throat ....

156

39

'4

»3

Adenoids

162

61

15

20

Eyes ....

41

9

4

3

Other defects

23

8

2

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,

CASES AMONG CHILDREN

CASES PER 100 CHILDREN

AMONG THOSE

Defect

4 or

4 or

2 years
in grade

? years
in grade

more
years in

2 years
in grade

; years
in grade

more
years in

grade

grade

Adenoids

67

18

9

'9

21

50

Hypertrophied tonsils

141

25

9

41

29

50

Anemia

52

15

5

15

17

28

Enlarged glands .

77

19

6

22

22

33

Defective vision .

72

21

5

21

25

28

Defective hearing

17

3

i

5

3

6

Rachitis

38

'9

4

I I

22

22'

Total ....

464

120

39

'34

139

2I7

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

156

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 41 .

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

Bright

Enlarged glands

20

'3

6

Defective vision

24

25

29

Defective breathing

15

ii

9

Defective teeth

42

40

34

Hypertrophied tonsils

26

19

12

Adenoids

'5

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

.58

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, 1908

Defect

Average number
of grades
completed

No defects

4 04

Defective vision ...........

4 Q4

Defective teeth

465

Defective breathing

4-58
4.150

Adenoids . .....

424

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

MEDICAL INSPECTION OF SCHOOLS

The results shown in Table 4 1 (page 1 58) 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, 1908

Defect Per cent of loss

J in progress

Defective vision .
Defective teeth
Defective breathing
Hypertrophied tonsils
Adenoids
Enlarged glands

6

7

9

14

'5

Average

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, 1908

Defect

Years required
to complete
eight grades

No defects

80

Defective vision .......

80

Defective teeth

8 <;

Defective breathing

8.6
87

Adenoids ...........

9i

Q 2

Scale of Years
0123456789

No defects — 8 years
Defective vision — 8 years
Defective teeth — 8.5 years
Defective breathing — 8.6 years
Hypertrophied tonsils — 8.7 years
Adenoids — 9.1 years

Enlarged glands — 9.2 years
ii

I

1 i i i i i t

1

1 1 i i i i i i

1

1 i i i i i 1 1

1

1 1

I

i i i i i i i i i

I

I I I I 1 1 1 II

1

1 1 1 1 1 1 1 1!

161

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.

.63

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.

.65

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TABLE 45. — PRINCIPAL FEATURES

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1 66

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 191 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

168

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

11. 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 medical 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.
This 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.

173

MEDICAL INSPECTION OF SCHOOLS

We endorse the school nurse as a most valuable adjunct
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 13 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

174

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

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

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-

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.

,83

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.

Wlooo-ping-cough . — 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

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.

V

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.

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 booing 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 puifmess 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.

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.... 179

I98

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 221

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 231

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

200

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.

BERGERSTEIN, 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. Part I. Chicago,
The University of Chicago Press, 1910. 1 13 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 of
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, 1911. 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
New South Wales (with special reference to height, weight, and
vision), based upon statistics obtained as a result of the introduction
of a scheme of medical inspection of public school children, 1907-08,
with anthropometric tables and diagrams. Sydney, Wm. A. Gul-
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. 1 1, 191 1. 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, n6

ANEMIA: among retarded children in
Elmira, 156

ANEMIC CHILDREN: open air schools
for, 98

ANGLESEY, England: treatments in, 99

ANN ARBOR, Michigan: woman dental
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
used in, 53, 56, 57

BERLIN: dental work in, 126

BIRMINGHAM, Alabama: post card
notification used in, 73, 74

BLACKBURN, England: treatments in,
99

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,
i?5, 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,
1 5 2- 1 63 ; 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, 1 2
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,
1 1 8, 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, 1 01, 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, n

CORNELL, WALTER S. : report on defec-
tive children, 152

COST: annual per capita for medical
inspection, 102-110; clerical assist-
ance, iio-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

21 I

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, n; employed in United
States, 18, 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 or: 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 OF: 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

2I3

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

FORSYTE, 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, 1 60; 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 England; 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

HAVERHILL, 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,

O7

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, Perm., 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 OAKLAND, California: consultations

inspection law in, 169

NORWAY: dental conditions among
school children in, 115; medical
inspection in, 1 1

NOSE, DEFECTS OF: 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, u;
in United States, by groups of
states, 18, 20; in United States,
number employed, 63; instruc-
tions in mouth hygiene given by,
in 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

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, u

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, n 8. 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, 1 23 ; 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, 37; contagious
disease work of, 21, 30; equipment
for, ii i ; 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, 16, 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: medical 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, n

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, 102-1 10;
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,

220

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, n. 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, n

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:
schools for, 98

open air

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 OF:
futile, 37; in Paris, 8; in Wiesbaden
system, 9

WEST VIRGINIA: abstract of medical
inspection law of, 171

WHOOPING COUGH: exclusions for, 31-
33

WIESBADEN: medical inspection in,
8-9

WINCHESTER, Massachusetts: rates for
dental treatment of school children
in, 127

WOLVERHAMPTON, England: treat-
ments in, 99

WORCESTERSHIRE, England: treat-
ments in, 99

YORKS (East Riding), England: treat-
ments in, 99

224

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