RUSSELL SAGE FOUNDATION MEDICAL INSPEC- TION OF SCHOOLS By LUTHER HALSEY GULICK.M. D. DIRECTOR OF PHYSICAL TRAINING, NEW YORK PUBLIC SCHOOLS AND LEONARD P. AYRES GENERAL SUPERINTENDENT OF SCHOOLS OF PORTO RICO, I906-I908 NEW YORK CHARITIES PUBLICATION COMMITTEE MCMVIII L ,T^ LIBaARV of CONGRESS Tv Copies Received OCT 27 1908 Copyria.'u Entry CLASS Ol, XXc. No COPY 3, Copyright, 1908, by The Russell Sage Foundation PRESS or WM. r. FELL COMPANY PHILADELPHIA Contents Introduction PAGE Significant Facts CHAPTER I Nature and Aims of Medical Inspection Protection of the community S Development of the individual 5 Our change from rural to urban life . " Population of foreign parentage in American cities 7 Changed conditions of work ° Changed conditions of play 9 CHAPTER II The Argument for Medical Inspection The attitude of educators towards the physical well-being of children . .12 The "lockstep" in physical matters ^3 Awakening interest in problems of backward children 14 Physical defects and school life ^5 Medical inspection does not entail trespass on personalliberty . . . .16. CHAPTER III Historical Rise of medical inspection in France 1° Rise of medical inspection in Belgium and Germany 19 The Wiesbaden plan ^9 Hungary, Austria, and Norway 20 Sweden, Roumania, Moscow, and Switzerland 21 The English Medical Inspection Act 21 La Medecine Scolaire ... 22 Chile, Argentine Republic, and Japan 23 New York City 24 State Laws of Connecticut, New Jersey, Vermont, and Massachusetts . . 25 Cities of the United States having medical inspection 26 CHAPTER IV Inspection for Detection of Contagious Diseases Exclusion cards ^9 Medical inspection in New York City 3° iii iv Contents PAGE Forms used in Providence, R. 1 40 A system of records for medical inspectors r 41 Combined directions and prescriptions 46 Contagious diseases for which pupils are excluded 48 Beneficial results of medical inspection 50 CHAPTER V The Work of the Teacher in Detecting Contagious Diseases Competence of teacher to detect symptoms of disease 52 Directions for referring pupils to school physician ••>.•• 55 Hygiene rules for pupils 57 Forms used by teacher to refer pupils to school physician . . . . -59 CHAPTER VI The School Nurse Opinions on the value of school nurses 66 The w^ork of school nurses in New York City 67 The work of school nurses in Philadelphia . 69 The work of school nurses in Boston 73 Forms used in connection with work of nurses 77 CHAPTER VII Physical Examinations for the Detection of Non-Contagious Defects The basis of the argument for conducting physical examinations ... 82 Results of vision and hearing tests in public schools 83 Physical examinations in New York City 86 Application of work of school physician to work of class room .... 89 Forms used in connection with physical examinations 94 Directions concerning the care of the teeth . . .98 Extent to which defects discovered are remedied loi CHAPTER VIII Vision and Hearing Tests by Teachers Ability of teachers to conduct vision and hearing tests 104 Sight and hearing tests in Massachusetts 107 Eye and ear examinations by New York State Department of Health . -113 Eyesight tests conducted by State Board of Education of Connecticut . . 120 Examinations of the State Board of Health of Utah 129 CHAPTER IX Administration Four classes of systems of medical inspection 137 Salaries of medical inspectors and number of pupils per inspector. . . -139 Salaries of school physicians in England 142 Salaries of nurses i44 Salaries of medical inspectors in Germany 144 The question of free eyeglasses 148 Contents v CHAPTER X Controlling Authorities PAGE Board of Health or Board of Education 15° Detection of contagious disease a function of the Board of Health . . . 158 Development of the individual a problem for the Board of Education . . 158 CHAPTER XI Legal Aspects of Medical Inspection The English law . ^59 The Massachusetts act ^^^ The New York law concerning children in public institutions . . . .166 The New Jersey statute ^7^ The Connecticut law ^7^ The Vermont law ^^^ CHAPTER XII Retardation and Physical Defects Medical inspection and financial economies 185 Retardation and part time ^^^ Class standing of children and physical defects 189 Causes of backwardness ^9° Physical defects and age in grade 192 Decrease of defects with age ^99 BIBILIOGRAPHY APPENDIX I "Suggestions to Teachers and School Physicians regarding Medical Inspec- tion," issued by the Massachusetts Board of Education ... .222 APPENDIX II A typical set of European blanks and forms (those used in Briinn, Austria) . 238 APPENDIX III Rules issued to medical inspectors of schools in Chicago, 111. ; Detroit, Mich. ; and Springfield, Mass 251 INDEX vi Contents Charts PAGE 1. Teeth chart, Northampton, Mass 97 2. Snellen's chart for testing eyesight, Massachusetts iii 3. Chart of letters for testing eyesight, Connecticut 122 4. Chart for testing focusing power, Connecticut 123 5. Chart of graduated figures, Connecticut 124 6. Chart of E's, Connecticut 125 Forms PAGE 1. Exclusion card, Brockton, Mass 30 2. Monthly report of medical inspector, Brockton, Mass 31 3. Postal card notice to principal. New York City 34 4. Exclusion card. New York City 35 5. Code card. New York Cit}^ 36 6. Index card. New York City 37 7. Inspector's daily report of exclusions, New York City 38 8. Inspector's daily report of exclusions; reverse; New York City ... 39 9. Exclusion notice, Chicago 42 10. Envelope daily report of medical inspection, Chicago 43 11. Combined directions and prescription, Everett, Mass 44 12. Combined directions and prescription, Everett, Mass 45 13. Rules for contagious diseases. Providence, R. 1 56 14. Printed rules distributed to pupils, Providence, R. 1 57 15. Teacher's request to inspector, Providence, R. 1 59 16. Card of request to inspector, Asbury Park, N. J 59 17. Request of teacher and statement by inspector, Washington, D. C. . .60 18. Duplicate of above 61 19. Statements of physician and teacher, Somerville, Mass 62 20. Card used by Dr. Newmayer in Philadelphia 63 21. Slip taken by pupils to inspector, Philadelphia 64 22. Card recommending pupil for treatment, Philadelphia 77 23. Weekly report of nurse, Philadelphia 78 24. Weekly report of nurse, Baltimore 79 25. Individual record card, New York City 84 26. Postal card notice to parents, New York City 86 27. Reverse of above card . . .86 28. Record card showing teacher's comments, Pasadena, Cal 90 29. Reverse of above card 91 30. Physical record card, Los Angeles, Cal 92 31. Reverse of above card 93 32. Physical record card, Utica, N. Y 94 33. Physical record card, Asbury Park, N. J. 95 34. Notification to parents, Somerville, Mass. . 96 35. Notification to parents, Ann Arbor, Mich 96 36. Report on eyesight and hearing tests to superintendent, Massachusetts . no 37. Record of sight and hearing tests, Massachusetts 112 38. Notice to parents or guardian by teacher, Massachusetts . . . -113 39. Notice to parents or guardian by school physician, Massachusetts . -113 40. Report of teacher, New York State 118 Contents vii PAGE 41. Report of teacher, New York State 119 42. Notice to parents, New York State 120 43. Teacher's report to parent or guardian, Connecticut 127 44. Teacher's report to State Board of Education of Connecticut . . .128 45. Report to State Board of Education of Connecticut 128 46. Card of warning to parents, Utah 130 47. Report by teacher, tltah 131 48. Report to State Board of Health, Utah 132 49. Teacher's report to principal, Ogden, Utah 133 50. Blank for excuse for absence, Ogden, Utah 134 APPENDIX II (Forms used in Briinn, Austria.) 51. Notice to parents 238 52. Notice to parents 239 53. Health report 240 54. Reverse of above report 241 55. Monthly and yearly report of findings 242 56. Monthly and yearly report of visits by school physicians .... 243 57. Physician's report 244 58. Memorandum blank of unhygienic conditions in school-houses . . . 244 59. Questions to parents or guardians 245 60. Individual health report 246 61. Reverse of above form 247 62. Notice to parents, dental 248 63. Reverse of above form 349 64. Notice to dentist 250 Tables PAGE 1. Table showing population of foreign parentage in various American cities 7 2. Table showing cities of the United States having some form of medical inspection 26 3. Contagious diseases for which pupils are excluded in five cities . . .48 4. Examinations and exclusions in five cities 49 5. Diseases and defects reported in Massachusetts 49 6. Exclusions in New York City public schools 68 7. Excludable diseases in New York City 68 8. Table showing work of trained nurses, Philadelphia 70 9. Table showing nurse's visits to homes, Philadelphia 71 10. Table showing results of vision and hearing tests 83 11. Physical examinations in New York City and Minneapolis . . . .87 12. Facts in regard to medical inspection in 17 cities 140 13. Expense of medical inspection, Springfield, Massachusetts .... 146 14. Expense of medical inspection, Montclair, New Jersey 146 15. Expense of medical inspection. East Sussex, England 147 16. Standing in studies of normal and defective children, Philadelphia . . 189 17. Defective children rated "exempt" and "non-exempt" in Philadelphia . 189 18. Bright and dull children having nose and throat defects, Philadelphia . 189 19. School standing of children having normal, fair, and bad vision, Phila- delphia 190 viii Contents PAGE 20. Reasons for excessive age of children, Camden, N. J 191 21. Distribution of pupils by grades and defects. New York City . . . 192 22. Distribution of pupils by ages and defects, New York City .... 193 23. Physically defective pupils by grades and groups, New York City . . 193 24. Average number of defects per child. New York City 194 25. Per cent, having each defect. New York City 195 26. Per cent, having each defect by ages, New York City 195 27. Per cent, defective by defects and grades. New York City .... 197 28. Defects per 100 children by grades. New York City 197 29. Defects per 100 children by ages. New York City 198 30. Per cent, having each defect by sexes. New York City 199 31. Defects per child by sexes, New York City 199 Introduction This volume is one of the by-products of the " Backward Children Investigation", a research supported by the Russell Sage Foundation for the purpose of studying so-called "retardation" among school children. The investigation was inaugurated in November, 1907. No small part of the study of the adaptability of the school and its grades to children has consisted of investigation into the effect of school life on the physical welfare of the child. In the course of this investiga- tion it has been found necessary to accumulate information as to what was being done for the health of children, from both the pedagogical and medical standpoints, in the chief cities and countries of the world. The information relative to medical inspection was so scattered, and the desire for reliable information on the topic so general, that it was decided that it would be wise to publish the available matter at once. This book aims primarily at results of a practical nature. We believe that it contains material of scientific value, but the form of presentation is intended to render it of service to all who are directly connected with, or interested in, the betterment and safeguarding of the health and vitality of the future citizens of America. The importance of steps looking toward the health of our public school children is indicated by the following facts: 1. The school is the only governmental department that directly assumes control of children's lives. 2. At least nine out of every ten of all American children are subject to this control; and 3. Such control is maintained (roughly speaking) during the critical years of from seven to fourteen. Because of the practical nature of our objects, there have been included in the bibliography titles of books, reports, and articles on X Introduction medical inspection, containing material not relevant, and hence not used or referred to, in our particular study. There seems to be a general impression in America that medical inspection is still experimental and on trial, and that we are leading in this important work. The reverse of both of these impressions is true. With Brussels having a systematic inspection since 1874 and Paris since 1884, scientific journals in France and Germany devoted exclusively to this subject, and the movement a national one in France, England, Belgium, Sweden, Switzerland, Bulgaria, Japan, and the Argentine Republic, it is evident that, save in details, the matter is a settled one, and that America is one of the last of the civilized nations to seriously consider these problems. This book aims, then, 1. 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 not yet solved, as well as in the portrayal of stubborn and hitherto unsuspected and apparently unreconcilable facts, such as are discussed in Chapter XII. 4. To avoid all dogmatism saving that involved in the statement of actual experience. L. H. G. L. P. A. New York, September, 1908 Significant Facts Medical Inspection "is founded on a recognition of the close connec- tion which exists between the physical and mental condition of the child- ren and the whole process of education." It " 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 constitute a true education." — {Ex- tract from Memorandum of British Board of Education.) Medical Inspection is a movement national in scope in England, France, Belgium, Sweden, Switzerland, Bulgaria, Japan, the Argentine Republic, and practically so in Germany. In the United States seventy cities outside of Massachusetts, and all the cities and towns of that state, have systems of medical inspection. Massachusetts has a compulsory medical inspection law. New Jersey has a permissive one, Vermont a law requiring the annual testing of the vision and hearing of all school children, and Connecticut one providing for such tests triennially. As a rule, the work of medical inspection is underpaid in America. In England such services are compensated at the rate of from $1500 to $4000 per annum, while in America $200 has, in many quarters, come to be regarded as a standard salary for the services of the school phy- sician. Systems themselves vary so widely in scope and thoroughness here in America as to range in annual per capita cost from half a cent to a dollar and twenty-two cents. 2 Medical Inspection of Schools Clear distinction must be made between medical inspection solely for the detection of communicable disease and that physical examination which aims to discover defects, diseases, and physical condition. The one relates primarily to the immediate protection of the community, while the other looks to securing and maintaining the health and vitality of the individual. Medical inspection for the detection of contagious diseases can be adequately performed at an annual cost of about fifteen cents per capita, while physical examinations similarly performed, and including the in- spection for the detection of communicable diseases, cost about fifty cents. Effective medical inspection for the detection of communicable diseases can only be conducted by the Department of Health, or at least with its active co-operation, because of the necessity for legal authority for protecting the community, not only during epidemics of contagious diseases, but also to prevent them. Effective physical examination can only be conducted by the Board of Education, or at least with its full co-operation, because it involves the following of the child from grade to grade and year to year. It involves the constant attention of the teacher with reference to seating the deaf where they can hear best, and those having poor vision where they can. see best, as well as constant co-operation with the parents. Physical examinations can be well made by an experienced school physician in from twelve to fifteen minutes per child. Vision and hear- ing tests demand from three to five minutes per child. The conduct of medical inspection is such a technical matter and is so different from the work done by the practising physician as to demand special training and experience. Investigations so far indicate clearly that physical defects of children decrease with age. That is, taking into consideration a sufficiently large number of cases, children of fourteen years of age show fewer de- fects than do those of thirteen years, and these, in turn, fewer than those Significant Facts 3 of twelve years. Hence older children have fewer defects in whatever grades they may be found, and so, from the very definition of the term, retarded children in any given grade have fewer defects than children of normal age in the same grade. This fact is in direct contradiction not only to the prevailing opinion, but also to the conclusions that have been emphasized in current professional discussion to the effect that children behind their grades were so because of the handicap imposed on them by physical defects. This important fact should not in any way lessen our endeavors to bring the aid of medical science to the ser- vice of the physically handicapped. It should rather give us renewed hope, for we find that the direct tendencies of normal growth make to- ward rather than away from those wholesome physical conditions that it is the aim of every physician and every educator to bring about. Physical defects are not equally significant either from the medical or from the pedagogical standpoint. It is unfair and tends toward mis- leading conclusions to include in the same classification pediculosis and defective vision, club-foot and defective hearing, adenoids and ring worm. Therefore the effects of each kind of defect should be separately studied — e. g., the effects of defective vision, hearing, adenoids, carious teeth, etc., upon school progress and upon health. CHAPTER I Nature and Aims of Medical Inspection Two great forces have been making in America toward medical inspection of schools; forces that have hitherto been mutually uncon- scious and wholly unrelated as to source, objects and methods. It seems inevitable that the aims and objects of medical inspection are only to be accomplished by the coalescing of these two forces — each contributing what the other has lacked. On the one hand is medical science operating to protect the com- munity through its boards of health, while on the other is educational science operating through the great school systems of the world and expressing itself through its more or less scientific departments of physical training. Speaking historically, medicine has labored to cure and at best prevent disease and deformity, while education has aimed at the intellectual equipment of the individual. Pathology is prominent in the one case and development in the other. That community protection has been a chief aim from the medical viewpoint is indicated by the facts that (i) The detection of contagious disease has been uniformly the obvious and initial activity, and (2) That the records are almost, if not entirely, those of disease or deformity. That growth has been the chief aim from the educational standpoint is shown by the facts that where this work has had any scientific basis, (i) Exercise, cleanliness, ventilation, the importance of suitable and adequate nutrition, sleep, etc., have been primary objects; and (2) Records of height, weight, chest, girth, etc., have constituted the primary elements recorded. The distinction between these two forces is a philosophic one. It would not be true, for example, that hygienic knowledge has been absent on the one hand or medical knowledge on the other. The best 5 6 Medical Inspection of Schools medical inspection has included matters of personal hygiene and the best physical training has been directed by those having medical equipment. Dr. John J. Cronin, of New York City, has made most wise, ex- tensive, able and best known medical inspection from the standpoint of education, acting as an agent of the Department of Health, while George W. Ehler, of Cleveland, has put into operation a most effective educational program from the standpoint of medicine. It is to the departments of physical training in our colleges and secondary schools that we have to look in the main for our most com- plete records of growth and development. Still the classic and monu- mental work of Bowditch in measuring and weighing Boston public school children, as well as the work of Porter in St. Louis, and Boas in Toronto and Worcester, must not be forgotten. The forces that are compelling these two movements to coalesce consist in certain changes in the constitution of society which must now be sketched briefly. These changes must be examined from two points of view : (i) From that of the welfare of the community as such. (2) From that of the personal activities and functions, both physio- logical and social, of the individual. Let us take first the changes affecting the welfare of the community as such, involving an enlarged conception of the duties and powers of the Department of Health. We have to go back in our American history but a trifle over a century to discover that we were a set of rural communities — the urban population (cities of 8000 and over) at that time constituting but 3.3 per cent, of the total population. Now we are an urban nation; 33 per cent, live in cities. This percentage includes wide territories and vast sections that were not at that time a part of our country. When we examine the progress of the older and more advanced states, the direction in which we are moving becomes still more evident. New York has an urban population of 72 per cent.; Massachusetts 91 per cent.; Ohio 48 per cent.; Illinois 54 per cent., while Rhode Island has 95 per cent. This moving of the population toward centers has rendered essential attention by the communities to the cleanliness of water supply, to sewerage, street cleaning, problems of Hght and air in dwellings, the isolation of cases of contagious diseases, the transportation of food Nature and Aims of Medical Inspection 7 and hence its preservation and guarantee of its purity, conditions and hours of labor and a thousand other matters which in a rural community were of importance to individual families only. Of great importance also is the change that has taken and is taking place in our racial stock. This is important because standards of living, of cleanliness, of freedom from vermin, are being brought in by recent immigrants which are not only different from those that obtained under early American conditions, but which are inimical to those higher standards of life that are essential to the individuals in a democracy that is to endure. That this is a real and large factor is shown by the following figures taken from the last census: Per Cent, of (3i^Y_ Foreign Parentage. Boston 71-6 Chicago 77-2 Cleveland 75-4 Milwaukee 82.7 New York 76-6 San Francisco 7°-4 It is true that the percentage of foreigners in these cities does not represent that in the country at large. But these are among our largest and most important American centers, and the traditions that uUimately establish themselves in these cities are altogether more important to the country at large than would be indicated by the mere percentage of the total population that these cities contain. Our school systems have developed enormously during this period —developed altogether faster than has the population. What schools there were, were widely separated, were carried on for but a small fraction of the year, and were attended by but an inconsiderable fraction of the children. That is, the schools as such did not present any special problem from the standpoint of community hygiene. Now the school year lasts for ten months, and in many cities vacation schools round out the calendar year. So the schools in their intimate commingling of children from practically all families for most, if not all of the year, afford by far the most extensive means for the spread of contagious diseases that exist. Thus the community through its health boards has been forced not only to protect itself from the spread of disease in many ways quite 8 Medical Inspection of Schools unnecessary in the earlier period, but has had to become (unconsciously even to itself) an agency for the establishment of American ideals. Boards of health have been compelled to lay forcible hands upon the school, time and again during epidemics, long before it became recog- nized that the school was permanently to be a possible focus and distri- butor of disease, and hence needed permanent and thorough medical inspection. Let us turn now to a consideration of those changes in the constitu- tion of society which have involved a readjustment of the physiological functions of the individual in his relation to the social organism. In the earlier period, and indeed during all of that portion of man's history which preceded the last century, the bulk of the world's work was done by human muscle. It is true that man has made great use of the horse, camel and a few other animals, that windmills and water wheels and sails have long performed incidental service; but the general fact remains that human muscles have built the pyramids, dug the canals, erected the houses, tilled the fields, gathered the harvests, made the cloth, fought the battles, carried the water, hewn the wood, as well as written the books for mankind. It is to be remembered in this connec- tion that it has not been a small fraction of the people that have been chiefly concerned in this muscular labor, but that most of the people have been so engaged for most of their years. We must not forget that even during the golden age of Greece — the age of Pericles — eight out of every ten of the people were slaves who labored. These conditions have changed. This is not a matter that concerns itself with the city as contrasted with the country, and hence is to be cured by reverting to country life. It has changed for most of the people for most of the years of their lives. It is not only in the city that one turns on the gas instead of chopping the kindHngs. The bulk of the world's work is done, not by human or even animal muscle, and not by vagrant winds. Man has harnessed the great powers of nature. He breaks his land with the gang plow, illuminates his night world with electricity, carries himself and his goods with elevators, automobiles, steam vessels, raihoad trains, sub- marines and in this century with flying machines. He no longer sows or reaps by hand; he makes his cloth and clothing, shoes, hats and even decorations by machines. Nature and Aims of Medical Inspection g This change is important most of all to children, for it involves the two chief agencies that have been responsible for their development into adults having strong vitality and clean morals. I refer to work and to play. The horrors of child labor are still with us, although sure to disap- pear, but the normal work with the parents, about and for the home has gone or is going. The all-round farm where a boy learned the rudiments of a dozen trades has been displaced by the specialized farm. The girls can no longer work with their mothers in carding the wool, making the gar- ments, managing the dairy or poultry. The small garden is disappear- ing save as a luxury, washing is better and more cheaply done outside the home, most of the cooking and "putting up" is done elsewhere. It is perhaps unnecessary to further illustrate the fact that that element through which the children have come into and partaken of the family labor, and so gradually have learned to carry on the world's work, has gone or is going. But — of even greater importance from the standpoint of this present discussion — that muscular work which strengthened the muscles, enlarged the chest, and aided in giving the power to live is largely gone. The other great source of muscular exercise and physical develop- ment which has been the heritage of all of the children of all of the world is play. This is being attacked from three sources, namely Time for play Space for play Traditions for play. School life has increased to cover six hours a day for ten months a year. The school has pressed its importance till "home work" takes from one to four hours of the rest of the day. Our children are busy most of the time. There is little time left for quiet play with dolls, wandering through the woods, or corresponding activities in which un- conscious growth occurs. We are already an urban country and are rapidly becoming more so. Not one city has been planned with the real object of human life in mind, that is, the rearing of healthy, happy children. Every other crop has been provided for but this one, and yet this one transcends them all 10 Medical Inspection of Schools even in financial value. Our cities are being built up without play- grounds. Millions and millions have been spent on the Island of Man- hattan to remedy this lack of forethought, but allowing a scant space of three yards square for each child, only one child in ten can be given play room south of Fourteenth Street in this city. This is one of the reasons for the prevalence of such games as craps. It takes but little space, is quiet, can be played with a varying number of players, is interesting, etc. In fact, it is an ideal game for city children, with a single reservation. It is bad for their morals and useless as a developer of muscle or physical stamina. The great games of the world that have been handed down from child to child for hundreds or even thousands of generations, preserved in the amber of child tradition, do not in the main suit modern city conditions. Children do not bring their play traditions with them. It would seem as if a dozen families from a dozen lands would form a little com- munity with a wealth of childlore and games, but such is not the case. They only play what they have in common, and these are the most elementary games suited only to the younger children. This condition with reference to the absence of adequate traditions carrying suitable plays applies to the country and village districts as much as it does to the cities. The play of our country children is about as inadequate as is that of our city children. This is not a matter of poverty. The exquisitely dressed children led by the hand along Riverside Drive, New York, in order that they may "get the air" are a more pathetic sight than are the equally healthy though dirty children one sees play- ing on the East Side. That these conditions are actually resulting in decreased power to live is shown by several extensive studies made in Great Britain during the past decade. We have massed here several groups of facts bearing more or less closely on the alterations of children's lives that have occurred or are occurring to show the situation that is back of the movement for physical training, playgrounds, etc., in departments of education. The state provides for the education of all citizens as a measure of self-protection. The facts given show that the state must also take cognizance of their physical welfare for the same reason. Health and education belong hand in hand. This means that the existing educa- Nature and Aims of Medical Inspection ii tional agencies must ally with themselves expert medical officers who shall see that the health of children is conserved through the schools. This cannot be an incidental activity of some department, but must outrank all others in power, as it does in importance. Medical inspection, then, aims at both the protection of thecommunity and furnishing the physical conditions under which wholesome life can develop. It involves in this comprehensive aim the functions of both the departments of health and of education. CHAPTER II The Argument for Medical Inspection Since the days of Juvenal, men have been quoting his much abused half-Kne, "A sound mind in a sound body"; and while making diligent provisions for schools in which "sound minds" were to be shaped, have felt that these schools needed little scrutiny as to their fitness for con- serving and developing "sound bodies". The famous Spanish voyager who lost his life in his futile search for the phantom fountain of youth was far from being the first or the last of the long line of seekers for a "cure-all" which should eradicate the ailments of old age and restore that buoyant health of youth which modern science is just beginning to teach us must be dihgently con- served from childhood, if it is to be enjoyed in after-Hfe. To say that we have during all this time lost sight of the true source of a healthy old age would be an extreme statement, but it is certainly true that educators in general have given but scanty and fleeting atten- tion to the problem of the physical well-being of their charges. All too often the same complacent and care-free attitude of mind has been shared by the parent. All children had to have the " common children's diseases" — and the sooner, the better. If Johnny breathes through his mouth — "He always did that. He will outgrow it." The child's cough is only "a slight cold." "He always turns his head to one side when he writes or reads. It's a habit he has got into. He has always been pale. It is nothing unusual." In cases of serious epidemics it has always been recognized that parents have the right to insist that the schools shall be safe places for them to send their children. This right has been recognized by the closing of the public schools during an epidemic; but despite the fact that it has long been recognized that the pubHc school serves as a center of exchange for contagious diseases which pass from pupil to pupil, The Argument for Medical Inspection 13 the occasional closing down and the rare fumigation have constituted the sum total of preventive measures, with the single exception of the commonly insisted on requirement of vaccination. Again, except in extreme cases, the school has taken little note of such defects of mind and body as might vitally affect the chances of success and happiness of the child, unless such defects were of the more directly alarming nature of contagious diseases. The "lockstep" has been the rule in physical matters, as in the realm of the course of study. All the children have been received on an equality and have been treated equally, no matter what their mental endowments or physical condition. The quick and the slow, the sound and the sick, have been grouped together; and he who could not keep his place in his studies has been as unquestioningly left behind as has he who through illness could not retain his place in the school. That such a course was poor business policy, based on the false assumption of a universal mental and physical equality which does not exist, has been pointed out times without number. As in all movements, the leaders have been far in advance of the rank and file; and in our own, as in other countries, the great majority of people have been too much engaged in their special interests to give heed to the great problems involved in the work of improving the educational and physical well- being of the young of the race. With the great changes which have been coming over American life, former conditions have disappeared and this undisturbed indifference has become impossible. We have changed from an agricultural 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 compulsory 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 to insistently demand attention. 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. From these conditions grew up medical inspection, for the purpose 14 Medical Inspection of Schools of detecting cases of contagious diseases and of segregating such cases for the protection of other children. Wherever estabhshed, 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 con- tinue 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 stand- ards were low, the work was not beyond the capacity of even the weaker children; but with close grading, fuller courses, higher standards, and constantly more insistent demands for intellectual attainment, this has changed. Pupils have been unable to keep up with their classes. The terms "backward," "retarded," "exceptional" as applied to school children have been added to the vocabularies of the school men. In- quiries have been instituted into the causes underlying the phenomena of backward and retarded children, of those who are unable to keep up with their classes, or those who seem to be different from their com- panions in their ability to do the work demanded. As a result of these inquiries, physical examinations have been conducted by the doctors connected with the schools. Surprising num- bers 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. Persistently, earnestly and quietly this work has been pushed to a successful experimental accomplishment, and as a result we have to-day medical inspection in its various forms — not only for the detection of The Argument for Medical Inspection 15 contagious disease, but also for discovering those physical defects which interfere with the child's ability to do his school work, or which, if neglected, will seriously affect his physical efficiency in after-life. The movement as a whole constitutes both a sign and a result of the gradual awakening which has developed into a wave of interest in matters that pertain to the health of school children that is now sweep- ing over the civilized world. 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 realization is dawning that it is unbusinesslike to count carefully the cost of the school doctor, but to disregard the cost of death and disease, of wrecked hopes and dependent families. Teachers and parents are commencing to realize that from their viewpoint and from that of the school physician the problem of the pupil with defective eyesight may be quite as important to the com- munity as that of the child who has some contagious disease. This child, placed in a school where physical defects are unrecognized and disregarded, is unable to see distinctly, and headaches, eye-strain, 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, becoming 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 strength- ened 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 super- vision of the school authorities shall be safe from harm and will at 1 6 Medical Inspection of Schools least be handed back to him in as good condition as he was at first. Not only has the parent the right to claim such protection, but even if he does not insist upon it, the child himself has a right to claim it. The child has a claim upon the state and the state a claim upon the child which demand recognition. In the words of Dr. WilHam H. Allen: "When the state for its own protection compels a child to go to school, it pledges itself not to injure itself by injuring the child." We are beginning to find out that many of our backward pupils are backward purely and simply because, through physical defects, they are unable to handle the work of the school program. What these defects are and the causes that lie behind them are things that we must know. If we do not know them, we must find them out and guard against them. 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 physi- cally. Children are not dullards or defectives by the will of an inscru- table Providence, but rather by the law of cause and effect. 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 nor logical analysis. The authority which has the right to compel attendance at school has the added duty of insisting that no harm shall come to those who go there. The Massachusetts law, with its mandatory " shall, " is certainly preferable to the New Jersey law, with its permissive "may." The exercise of the power to enforce school attendance would be dan- gerous if it were not accompanied with the appreciation of the duty of seeing that the assembling of pupils brings to the individual no physical detriment. 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 agitated, but rather that it was not long ago put into practice. 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. American systems do not, like the feeding of school children (already resorted to in France and in parts of England), lessen the respon- sibility of the parent or tend to weaken or supersede the home. Under medical inspection absolutely nothing is done for the parent but to tell The Argument for Medical Inspection 17 him of the needs of his child, of which he would otherwise have been in ignorance. It leaves it to the parent to meet 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 seems 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 must 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 preserva- tion and efficiency. Whether or not it is to be successful will depend on 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 brought to bear in all schools the measures, now so successfully pursued in some, for conserv- ing and developing the physical soundness of rising generations. But, nevertheless, the movement is so intimately related to the future welfare of oiu: country and is being pushed with so great energy and earnestness by its advocates that it is destined to be successful and permanent. Not alone our unwillingness to be outdone in this public service by foreign nations, not alone our sense of practical foresight, 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. CHAPTER III Historical A Sketch of the Rise, Development and Present Status of Medical Inspection at Home and Abroad Medical inspection of schools is a movement of recent growth, although it is by no means in its infancy and has long since passed its experimental stage. In France the law of June 28, 1833, charged the school committees of the cities and towns with the care of keeping the school houses clean, while a royal ordinance of December 22, 1837, made it the special duty of the female supervisors of maternal schools (kindergartens) to watch over the health of the little children. In Paris separate govern- mental decrees were issued. The decrees of 1842 and 1843 ordered that every public boys' and girls' school should be visited by a physician who was to inspect the localities and the general health of the school children. This arrangement, while praiseworthy in purpose, had the great drawback of not being supported by the annual budgets. Hence an appeal to the generosity of the medical fraternity was necessary. Many physicians offered their services and gave them gratuitously for years. In 1879 the General Council of the Department of the Seine voted to reorganize the medical service in the schools and passed an appro- priation for the payment of salaries to the physicians. The department was divided into 114 districts, of which 88 were within the city of Paris. A physician was placed in charge of the work in a district, and each district contained from 20 to 25 school rooms. In January, 1884, the service was again reorganized. Needed regulations were drawn up and the districts were changed so as to give each inspector from 15 to 20 school rooms. It is from this year — 1884 — that the present institu- tion of medical supervision of schools in Paris dates. Historical 19 The organization there has served as a model for similar arrange- ments in other French cities. Through the school law of 1886, as well as through ministerial decrees and orders dated 1887, medical and sanitary inspection has been made obligatory in all French schools, public and private. To the city of Havre belong the honor and credit of having the first free public dispensary for children. It was founded in 1875. Probably the first system of medical inspection in the full modern sense of the term was that inaugurated in Brussels in Belgium in 1874, when school physicians were appointed who were required to visit schools three times per month. So successful did the system prove that it was soon copied in Antwerp, Louvain, Liege, and other cities, and served as a model for systems in Switzerland. Moreover, in view of the favorable results in Brussels, dentists and oculists were likewise appointed to visit the pupils regularly. In Germany, Leipsic and Dresden were the first cities to have medical inspection. A beginning was made in Dresden in 1867, when three physicians, formerly teachers of physical training, were intrusted with the examination of children in cases of epidemic eye disease; but these were not fully equipped school physicians. Not until i88g was a system of true medical inspection established. The movement spread rapidly and was taken up by city after city. In Wiesbaden a system was developed providing for a careful and thorough physical examination of each child at the time of entering school, and for a re-examination in the third, fifth, and eighth years of the public school course. The system also provides for careful service for the detection of contagious diseases and for the inspection of school buildings and surroundings. In 1898 the Wiesbaden method of school inspection was generally adopted throughout Germany. Wiesbaden Plan of School Inspection With the introduction of the Wiesbaden method of school inspection began a new epoch in the development of the school systems of Ger- many. The chief characteristic of this method lies in a strong emphasis upon the hygiene of the school child, without in any way neglecting the hygiene of the school building. Medical inspection in the schools 20 Medical Inspection of Schools of Germany, which previous to the introduction of this plan had lagged, has since its adoption gained rapidly. Wiesbaden was the first German city to make a test examination of all pupils, whereby an unusually high percentage of defects was revealed, of which the pupil, the teacher, and the parents were wholly ignorant. It became apparent to the Wiesbaden authorities that a medical examination of at least all children entering school was of the utmost importance. The result of the trial examination led to the establishment of a system of regular examinations. The provisions of the Wiesbaden plan are: systematic examination of heart, lungs, throat, spine, skin, and the higher sense organs (and in the case of boys also examination for hernia). The findings are entered on a report blank, which accompanies the child from grade to grade in his school life. Twice a year the teacher records the height and weight of individual pupils. Wherever 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 accord- ingly, and these children report at regular intervals to the school physi- cian. A careful re-examination of all pupils must be made in their third, fifth, and eighth school years. It is the duty of the school physi- cian to give advice to the teacher with reference to the child. In cases of defects requiring medical attention, the parents of the child are notified. It is not the fimction of the school physician to give treat- ment. In Hungary the law of 1887 provided for school physicians to visit the institutions of learning. Their duties are: the hygienic supervision of school rooms, the detailed examination of all children entering school, and the giving of lectures in the schools with reference to hygiene. In Austria medical inspection of schools is an affair of the state. In the different crown lands it is under the Provincial Councilor of Education, in the school districts under the district school boards, and in the different communities under the local school boards. In Norway the instructions have been enforced since 1899, to the effect that with the consent of the local administration, a physician may inspect the health of school children; but by the decree of Septem- ber 24, 1891, this regulation was extended so that the health of pupils Historical 2i must be examined three times per year, — in May, August, and Decem- ber, — and the report drawn up in prescribed form by the board of teachers and physicians, who are to give special attention to the causes of absences from school, headache, and fatigue. Sweden is probably the country where the term "school physician" in the modern sense was first employed, though at first the duties of school physicians did not comprehend the work done by them at the present day. In 1863 they were only obliged to examine with reference to exemption from gymnastic exercises. In 1874 committees on health were given charge of the schools, especially with reference to ventilation, and since 1878 school physicians have been required to examine the health of children at the beginning of the term and to report the results. In Roumania, by the decree of April 5, 1899, special physicians are required, either themselves or in the persons of district physicians, to examine all school children at least once a year; to inspect buildings with reference to construction and equipment (heating, light, cleanliness, drinking-water, privies, etc.); to supervise all that touches in any way on the subject of health, and to submit propositions to the proper authori- ties for supplying existing wants and remedying evils. Moscow has had school physicians in her schools since 1888. It is the duty of these physicians to examine all the pupils once a year and to make reports on the "sanitary lists" of the children. Since 1895 six physicians have been in charge of health matters in the 72 elementary schools, and since 1888 two female physicians have been employed at the girls' high school. Besides their other functions, these physicians are required to vaccinate and revaccinate, to treat poor sick pupils free of charge, and to manage affairs in cases of epidemics. In Switzerland medical inspection has become a national movement, although governed by different regulations in the several cantons. In England the medical inspection act, which went into effect January 1, 1908, is national in its scope and applies to all the public elemen- tary schools. It is thorough in its provisions for a complete system of medical supervision. Its high purposes are expressed in a memoran- dum of the Board of Education, in the following words: "It is founded on a recognition of the close connection which exists between the physical and mental condition 22 Medical Inspection of Schools of the children, and the whole process of education. It recognizes the importance of a satisfactory 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 constitute a true education." For the purpose of putting into operation the provisions of this act, the county educational committees throughout England have been taking active steps in creating the necessary machinery and perfecting existing organizations of medical officers. Already there is a national Society of Medical Officers for Schools. In France such a society has long existed and has now reached a degree of strength and importance which has prompted it to begin the publication of a monthly entitled, "La Medecine Scolaire," the bulletin of the Society of Medical Inspectors of Schools. Volume I, No. i, appeared on February lo, 1908. The deep purpose which actuates the leaders of the movement in France is expressed in the introductory editorial of the first number of the magazine. The editorial is entitled, " Our Program," and begins as follows: "The purpose of protecting children and of assuring them their best physical and intellectual development has for several years been assuming an ever-increasing impor- tance. In this movement in favor of all that pertains to conserving the health of children — in the work which Prof. Pinard has called ' puericulture ' — France has taken an important part. Indeed, for France this has become a most important duty, because the study of these ques- tions has a higher importance in this country than in more favored countries, where the question of the increase of population does not constitute one of the vital problems of the day." After going on to describe the purposes of the Association of School Historical 23 Medical Inspectors, and after studying some of the important work done by the society in the past, the publication of the new journal is introduced with the words, " To-day the Society of Medical Inspectors of Schools wishes to complete its work by the publication of the journal, ^ La Medecine Scolaire.' " But Europe and America are not the only parts of the world that have been receiving the benefits of medical inspection. Since 1882 in Cairo, Egypt, a school physician has been employed at a salary of 12,000 francs, besides two assistants, each with a salary of 3600 francs, having the supervision of 5000 pupils. In Chile in 1888 the supervision of schools was intrusted to a Provin- cial Coimcil, including a physician as a member, and the supreme direction of sanitary affairs was given in charge of a superior board of public health, composed of seven members. School physicians in Chile are required to visit each school at least once a month, inspect the sanitary condition of buildings and surroundings, inform them- selves of the condition of health among the children, make note of their observations, and hand in a monthly report. In the Argentine Republic great interest in medical inspection has been manifested, and the system is credited with being one of the most complete and efl&cient in existence. It provides for the vaccina- tion of school children, examination of the sanitary condition of school buildings, the visiting of sick children in their homes, the prevention of contagious diseases, the delivering of regular scientific lectures, and the giving of free medical advice to the teachers as well as to the pupils. In Japan in 1898 the Minister of Education directed the nomination of salaried school physicians in all public schools. Frederick J. Haskin, writing of the work there in 1898, says: "The Japanese system of medical inspection extends all over the empire and reaches the most remote rural community. Thus the Japanese department of education is able to tell how many children are in school in the empire, how many are robust, medium, or weak, how many have defective eyesight, and what diseases are most prevalent at different ages of school life. The department can also tell how many children in school at the age of 24 Medical Inspection of Schools fifteen years were 150 cm. tall, how many weighed 40 kg., and how many had a chest measurement of 75 cm. They can also tell the averages of all these statistics and the percentages of robust boys or fat girls." In the United States the first regular system of medical inspection seems to have been in Boston in 1894. Before this, however, in New York in 1892, Dr. Cyrus Edson, then Sanitary Superintendent, appointed Dr. Moreau Morse, Medical Inspector of Schools. Dr. Morse was probably the first public medical school officer to be appointed in this country. In Boston the need of medical inspection of schools, for the purpose of detecting contagious and other diseases among the school children, was brought to the attention of the mayor and city council in 1892; and for this purpose an appropriation was then secured. A delay of several months was occasioned in securing the approval of the school committee, so that the plan did not finally go into operation until Novem- ber, 1894, when the Board of Health selected 50 physicians for this purpose, divided the city into 50 school districts, and began school inspection. In New York the Board of Health, at a meeting held March 16, 1897, appointed 134 medical inspectors for public schools. Dr. A. Blauvelt, formerly assistant chief of the Bureau of Contagious Diseases, was appointed chief inspector at an annual salary of $2500. Chicago in 1895 was divided into nine districts for the purpose of the inspection of schools. One medical inspector was assigned to each district, giving each inspector an oversight of more than 20 square miles. In Philadelphia the Bureau of Health passed the following resolu- tion on June 7, 1898: "Resolved that the medical inspector be directed to have the 15 assistant medical inspectors visit one public school each day in their respective districts, who shall inspect each school according to the methods now em- ployed in Boston, New York, and Chicago." Historical 25 Since its first inception in Boston, the movement for medical inspec- tion has rapidly spread in the United States, and in many states has developed from mere inspection for the detection of contagious diseases to systems embracing most thorough physical examinations. Fovir state laws have been passed. In 1899 the legislature of Connecticut passed a law providing for the testing of eyesight in all the pubHc schools of the State. Under this law the State Board of Edu- cation is required to furnish test-cards and blanks, and instructions for their use, to the school authorities. The superintendent, principal, or teacher in every school is required to test the eyesight of all the pupils during the fall term, and notify in writing the parent or guardian of every pupil who has any defect of vision, with a brief statement of each defect. New Jersey has a statute which went into effect in 1903. It autho- rizes boards of education to employ competent physicians as medical inspectors of schools. It also defines the duties of the medical inspector. The law is permissive and not mandatory in its provisions. Vermont followed in 1904, with a law requiring the examination of the eyes, ears, and throats of school children annually. In 1906 the legislature of Massachusetts passed a law providing for a system of medical inspection throughout the State. According to its provisions every town and city must establish and maintain a system of medical inspection with competent physicians for the detection of contagious diseases. Examinations are conducted annually by the physicians for the detection of non-contagious physical defects, and eyesight and hearing tests are made each year by the teachers. The law is mandatory, not permissive, in its provisions. Without authoritative and specific enactment, the State Boards of Health of New York, Utah, and California have conducted examinations of the eyesight and hearing of school children. At the present time — 1908 — there are in operation, so far as can be ascertained, systems of medical inspection in some form in the following 70 cities outside of Massachusetts. (As in this State medical inspection is obligatory under the state law, systems exist in practically every city.) 26 Medical Inspection of Schools CITIES OF THE UNITED STATES, OUTSIDE OF MASSACHUSETTS, HAVING SOME FORM OF MEDICAL INSPECTION OF SCHOOLS, JUNE, 1908 City. State. Controlling Authority. Albany New York Albany County Medical Society. Ann Arbor Michigan Board of Education. Asbury Park New Jersey Atlantic City New Jersey . . . Baltimore Maryland " " Health. Buffalo New York ' Camden New Jersey ' Chicago Illinois ' Cincinnati Ohio ' Cleveland Ohio ' Dallas Texas ' Dayton Ohio Detroit Michigan Des Moines Iowa Polk Co. Medical Association Elgin Illinois Board of Health. Education. Health. Education. Montgomery Co. Medical Society. Board of Health. Englewood New Jersey " EvansviUe Indiana " Fort Dodge Iowa " Fort Worth Texas Galveston Texas " Grand Rapids Michigan " Hackensack New Jersey " Harrisburg Pennsylvania. . Education. " Health. . . " " School Trustees. . . " " Education (Nurses only). . . " " Health. .Dr. C. S. Rebuck, and Visiting Nurse Association. Hartford Connecticut Board of Health. Hazelton Pennsylvania Board of Education Houston Texas Houston Association of Opticians and Aurists. Jersey City New Jersey B oard of Education (Nurses only) . Lansing Michigan Volunteer work Lincoln Nebraska Long Beach California Los Angeles California Boards of Education and Health. Milwaukee Wisconsin Milwaukee Medical Society. Minneapolis Minnesota Associated Charities and Women's Club. Montclair New Jersey Board of Health. Mount Holly New Jersey Newark New Jersey Boards of Health and Education. New Haven Connecticut Board of Health. Newport Rhode Island.; " " ' Historical 27 Cities of the United States, Outside of Massachusetts, Having Some Form of Medical Inspection of Schools, June, 1908 (Continued) City. State. Controlling Authority. New Orleans Louisiana Board of Education New York City New York " " Health. Norristown Pennsylvania Ogden Utah Orange New Jersey Board of Education Pasadena California " " " Passaic New Jersey " " " Paterson New Jersey " " " Philadelphia Pennsylvania " "Health Plainfield New Jersey " " " Port Chester New York Portland Oregon Providence Rhode Island Board of Health. Reading Pennsylvania Volunteer work Rochester New York Board of Health. Salt Lake City Utah " " San Antonio Texas " "Education. Schenectady New York Seattle Washington " "Health. Sioux City Iowa Volunteer work. St. Joseph Missouri St. Louis Missouri Superior Wisconsin Syracuse New York Board of Health. Union Hill New Jersey .... " " Education. Washington District of Columbia Board of Health. Waterbury Connecticut " " " Waverly Rhode Island Westchester Pennsylvania White Plains New York Board of Health. Wilmington Delaware " " Education Woonsocket Rhode Island " " " The work in Massachusetts includes 32 cities and 321 towns. At the beginning of the present year it was reported from Massachusetts that boards of health had begun the work in 22 cities and 47 towns and boards of education in 10 cities. No reports were received from the remaining towns. The foregoing brief account of the history of medical inspection and its present status serves to give an idea of the firm basis on which 28 Medical Inspection of Schools the movement rests in other comitries, and the prominent place accorded it in educational esteem. In America the movement has been some- what tardy in arriving, but its spread has been rapid, and now that it has passed the experimental stage, its permanency is assured. Statistics and observation have shown the great prevalence of con- tagious diseases among school children. Investigations have revealed the large percentage of children suffering from non-commimicable physical defects. Whether or not the home is responsible for a large part of the conditions and how far they are aggravated by the conditions of school life are questions of ultimate importance, but not calling for immediate solution. The important condition confronting American educators and social workers is that the school furnishes an unrivaled opportunity for detecting and checking diseases and defects among children. The problem of caring for those found to be defective or ill, and of preserving the health of those who are physically sound, is one of the utmost importance. Given the importance of the problem and the good examples set abroad, there can be no doubt that rapid additions will be made to the list of American cities having systems of medical inspection of schools, and that those systems themselves will rapidly become broader in scope and more thorough in method. CHAPTER IV Inspection for the Detection of Contagious Diseases Nearly all systems of medical inspection in America have had for their object at the time of their inception merely the detection in their early stages of cases of contagious diseases. To this simple aim has always been shortly added the detection and exclusion of parasitic diseases. Conducting examinations for the detection of physical defects is a further development of the work and is still far from general. In towns and small cities medical inspection for the detection of contagious diseases is a comparatively simple matter involving few difficuhies 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 telephone or messenger and the physician goes to the school and examines the pupil, sending him home if necessary. Of course such simple systems require little in the shape of blanks or forms. Notifica- tion cards or blanks are used for informing the parent 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 sample of such a simple exclusion card is the one in use in Brockton, Mass. (see p. 30). The monthly report of the medical inspector of the same city (see p. 31) is also a good sample of the forms found satisfactory in simple systems and which might well be adapted for use in any town where the number of cases handled is comparatively small and the pupils are individually known to the school authorities and it is easy to keep track of them. 29 30 Medical Inspection of Schools EXCLUSION CARD. BROCKTON, MASS. CoinTnonwcaltb of jVlasdachusetts* 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 hy me as School Physician, and found to have symptoms of This child is excluded from the schools until he brings a state- ment from a regular practitioner certifying his complete recovery. School Physician. 190 As systems increase in size or it is found desirable to make them more thorough, difficulties increase and a more complex organization is found necessary. Probably the most complete and thoroughly organized system in the United States is that of New York City. While many of its features would be found unnecessary in other places, some of them would prove applicable anywhere. It therefore seems worth while to describe it at some length and to give as well a brief summary of its development since 1897, when the work was begun. The following account is largely taken from the report of the Department of Health of New York for the year ending December 31, 1906. The report was pubhshed November 30, 1907. THE MEDICAL INSPECTION AND EXAMINATION OF SCHOOL CHILDREN HISTORY March, 1897: Appointment of one hundred and fifty Medical Inspectors, at a salary of $30.00 per month. Morning inspec- tion only required. September, 1902 : System elaborated to include morning inspection, MONTHLY REPORT OF MEDICAL INSPECTOR. BROCKTON, MASS. •5 ^ S ^ Q) ^ .§ § t e a' a S T s ^ "^ •SIJjJlLOB^ *sdqmuoj3Q tnoiSBluo^-uofg 1 •«mMK3 sno^»N ■t 3 OTOimUOQ.UOfJ •spiouspy 1 o i i 9AiiBjnddng "S I. ■BSmMIQ U.i|S <2 ■s|,!t, aj HH C/2 'V '$■ =S "^ PI *« 1— 1 3 ^ O a — 4^ d l>^ p Oh w a, 2i .■S o ^ a '5b g X3 cj .23 o lO • Cj M (U D:^ en O -o H t;^ 73 »r- o 3 HH li- a " * lJ-5 p oi M a Q i^ d. <1 rt H !§■ Cj *>^ t« a" •S )-i Ph cr 'u o 0^ 'Sh ^ 2 tn < a, 3 < SQ O bb H Ph^ c75 ^ C3 )H ^ 1 '6 Ol )-( c a .a c3 a, o c3 CO o '3 H :zi -O 3 hH o 1— 1 H U w a ■*-> a i a 1— 1 rt Q 1:^ bO 45 en nS ^ , O) fH cfl tf O) o !/2 H n3 CO o o , a M (N p =i g 0) 'O >.S a, 13 t^ -^r.-^ r3 u ^ ■ ■-i-i CI 4:1 cd en W 1— 1 H CD 13 4-) s a t2 O en bO p C/3 .a ^ o C/3 o U hi ^ - 03 <]4 > ^ «4H 1) W .4J 43 ^ Oh 3 ^ 8 a, rO m O Or Hi -1 a f, H u ;3 •P -ci T3 Q g s d ^ (^ I !i^ a w •-V -o u "to !>, 3 CI, (U ^ fl > C^ 00 Q W P 5 o X P4 CO H-l Pn » I— I w o CO < pq CO Oh bn i 3 Pi <1J Oh a ^ O u O 3 _r! ^ s s a^ ^ SeS^sSI^IsI o bp uj •-C3 -i « (J bD 3 *CU O O o S O Oh .J2 1 "Th o3 1 ■ ^ cS 3 3 'ri 1 3 & -^ s^ kT^ J3 s « a •- Inspection for Detection of Contagious Diseases 49 After much labor the following brief figures as to exclusions in five cities in 1907 have been gathered: EXAMINATIONS AND EXCLUSIONS IN FIVE CITIES Number Number Per Cent, of Those Examined. Excluded. Examined, Excluded. Brockton, Mass. (3 months) 3,208 347 10.8 Lawrence, Mass. (3 months) 1,424 139 9.8 Montclair, N. J 2,503* 242 9.7 Newark, N. J 21,299 2323 10.9 Springfield, Mass 8,759 ^°43 12.2 About the only conclusion to be drawn from this table is that under common practice in cities not employing school nurses about 10 per cent, of the children referred to the school physician will be found to be suffering from diseases serious enough in nature to warrant their exclu- sion. In Massachusetts schools of the State having an average member- ship of 343,000 reported during the school year 1906-07 children suffering from diseases or defects as follows : DISEASES AND DEFECTS REPORTED IN MASSACHUSETTS, 1906-07 Diphtheria 238 Scariet fever 313 Measles 637 Whooping-cough 973 Mumps 367 Chicken-pox 548 Influenza 276 Syphilis 36 Tuberculosis 115 Erysipelas 17 Adenoids 2,525 Other diseases of the oral and respiratory tract 5,103 Otitis 407 Other diseases of the ear 363 Conjunctivitis 779 Other diseases of the eye 2,159 Scabies i ,054 Pediculosis 7,691 Impetigo contagiosa 1,568 Ringworm 715 Other diseases of the skin 1,170 Chorea 105 Epilepsy 41 Deformities (spinal and extremities) 142 Total of diseases and defects 2 7,342 * Average attendance. 50 Medical Inspection of Schools Of course defects of vision and hearing are not included in the above table. However, even these incomplete figures show that the aggre- gate effect upon school attendance and school work is a subject for the most serious thought. That the whole matter of the relation of contagious diseases to the school life of children is one for serious thought has been convincingly demonstrated. There is a mass of evidence showing conclusively that the schools are a principal means of disseminating disease through- out the community. This evidence can be readily secured by any one. Pupils are very apt to attend schools during the earlier stages of diph- theria and during the late but peculiarly infectious stage of scarlet fever, thus spreading the disease throughout the community. Medical inspection greatly reduces this danger. It is the testimony of Dr. Samuel H. Durgin, Chairman of the Boston Board of Health, that since the system of the medical inspection of schools was introduced in Boston, diphtheria has fallen off about two-thirds and scarlet fever about five- sixths. In the case of diphtheria, antitoxin has of course played a leading part. In the case of scarlet fever the starting of the new infec- tious ward at the City Hospital has had an important effect. But in both cases, medical inspection in the schools has also been impor- tant, as shown by the fact that before the inspection began some diseases, such as diphtheria, for instance, were more common during the school term than during the vacation period, but that after the inspection was introduced, they were less common diuring the school term than during vacation. Again, extensive studies indicate that over 90 per cent, of the deaths from contagious diseases, such as diphtheria, scarlet fever, whooping- cough and measles, occur before the age of ten. Contrary to popular opinion, there is great mortality from measles when this occurs in the early stages of life, and among the children of the poorer classes. Extensive statistics collected in the city of Munich show that the mortality from this disease between the second and fifth year was 4.55 per cent., while from the sixth to the tenth year it was only .4 per cent. These figures would indicate that if an epidemic occurs in the kindergarten period the deaths are likely to be 45 in 1000, whereas if the epidemic can be postponed until the primary school period, only 4 in 1000 will die. Inspection for Detection of Contagious Diseases 51 In the face of such evidence as the above to argue for medical in- spection is to argue for the promotion of efficiency in our schools, the protection of the community and the preservation of the lives of its children. CHAPTER V The Work of the Teacher in Detecting Con- tagious Diseases There is considerable difference of opinion among physicians hav- ing charge of systems of medical inspection as to whether the medical inspector should visit the school room only when called on by the principal or teacher, or whether he himself should systematically inspect without such call. As the result of the non-agreement upon this point there is, of coiu"se, wide variation in practice in different localities. Expressed in its simplest terms, the problem really resolves itself into the question, — Is or is not the room teacher competent to detect symptoms of disease among her pupils ? Among the important opinions which may be cited in support of the contention that the room teacher is competent to detect such symp- toms are those of Dr. C. Koon, of Grand Rapids, Mich., Dr. Bert Not- tingham, of Lansing, Mich., and Superintendent of Schools E. C. Moore, of Los Angeles, Cal. Dr. Koon, in speaking of the Grand Rapids system, says: "We place the responsibility of sending pupils for inspection on the teachers. It is impossible to have 600 or more pupils examined every morning. It would dis- commode school work. We have the same rule as in Detroit. The teachers in each room simply ask if any pupils are feeling sick, and if so, they are sent to the principal's room. If any child is out of school for the day that child is sent to the principal's room and examined. That is the better way. The teacher knows all her pupils and knows easily whether any pupil is feeling sick by his actions." 52 Work of Teacher in Detecting Contagious Diseases 53 In speaking of the Lansing system, Dr. Bert Nottingham says: "The system is a combination of the Ann Arbor and Detroit systems. The teachers detect the cases of disease. We hold classes of instruction with teachers and show them how to detect these diseases. We have a specialist on eye, ear, nose and throat, who gives them information about detecting weaknesses. Also we have the specialist on eye, ear, nose and throat as one of the inspectors." In a similar tone. Superintendent E. C. Moore, of Los Angeles, Cal., says: "The best health officer is one who is present all the time and ever watchful for the welfare of the child. That ever-present health officer is the teacher." On the negative side of the question may be cited Dr. Thomas F. Harrington, Director of School Hygiene of Boston, and Dr. Elliott Kent Herdman, Medical Inspector of Schools, Ann Arbor, Mich. In an address delivered before the national meeting of the Department of Superintendence of the National Education Association, held at Washington, D. C, February 25-27, 1908, Dr. Harrington expressed the following opinion : " An important fact in the method of medical inspection under the Board of Health is that the detection of cases of contagious diseases among the children is done by the teacher and not by the medical inspector; if the latter con- firms the suspicion of the teacher, the child is excluded from school; if the inspector does not agree with the conclusions of the teacher, the child returns to his classroom. Non- agreement is very frequent, and it requires exceptional perseverance for a teacher to hazard the chagrin of a second mistake, yet disastrous consequences might result from such hesitation. In Boston diu-ing the year 1905, 21,111 children were referred to the medical inspectors; 9,241 were found free from any disease. In London 54 Medical Inspection of Schools between 20 and 30 per cent, of the cases submitted by the teachers were not suffering in any way." In a paper read before the Ninth General Conference of Health Officers in Michigan, Dr. Herdman said: "In some cities the inspectors are required merely to take the daily reports of the various teachers. I am satisfied from my own experience that this is not enough. A school teacher, however excellent, is no more able to detect disease in the school room than in the home, and detection is all important." " I go into the schoolroom and sit down to familiarize myself with the faces of the pupils. After a few times, they have become used to it and I can detect anything wrong, I think the doctor should go into the schoolroom at least once a week. The teachers simply cannot detect." Despite the radically contradictory nature of these opinions, the problem has been solved satisfactorily in many localities. The solu- tions are in the nature of compromises between the system of relying entirely on the teacher for detecting symptoms of disease and that of insisting that the doctor alone shall make the inspection. It is the verdict of experience that three general propositions hold true: First, it is impracticable to have the doctor inspect all the children every day. Second, 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. Third, where school nurses are employed the problem largely disappears, as the teacher and the 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 directions 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 that given in the pamphlet issued by the Mass- achusetts State Board of Education, containing suggestions of teachers Work of Teacher in Detecting Contagious Diseases 55 and school physicians regarding medical inspection. This little book so well fills the need that it has been reprinted for use in many other localities. It is such a good example of what such a manual should be that it has seemed well to reprint it in its entirety in this volume. It will be found as Appendix I. 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, Pallor, Puffin ess of the face, Shortness of breath, Swellings in the neck. General lassitude and other evidences of sickness, Flushing of the face. Eruptions of any sort. Cold in the head with running eyes, Irritating discharge from the nose, Evidence of a sore throat. Coughs, Vomiting, Frequent requests to go out. In the Annual Report of the Superintendent of Schools of Albany for 1907 is found a list of symptoms for which teachers are required to refer children to the inspector. The list is not very different from that used in Massachusetts. It is as follows: ALBANY LIST Unusual pallor. Unusual dullness or sleepiness. Red or discharging eyes, Reddened or discharging ears, Deafness, Discharge from the nose, Mouth-breathing, Enlarged glands in the neck, 56 Medical Inspection of Schools Swelling of neck at angle of jaw, All skin eruptions, Constant scratching of any part of the body, Children who maintain peculiar postures at the desk. Children showing defective vision of either or both eyes. Children returning to school with excuse alleging illness and without note from attending physician, Children returning to school or attending regularly and living at the same time in houses in which there is, or has recently been, illness, Children asking frequent permission to go to the toilet. Providence, R. I., Syracuse and White Plains, N. Y., also furnish the teachers with similar printed directions. Providence, however, goes farther than this. There each teacher is furnished with a slip of paper to be pasted in her roUbook, where it will always serve for ready reference and as a constant reminder. This slip contains the following rules : RULES FOR CONTAGIOUS DISEASES, PROVIDENCE, R. I. RULES FOR CONTAGIOUS DISEASES. The Teacher will please paste this in the register book. Children with the following diseases must be kept out of School: With chicken-pox until the crusts are all off. With mumps two weeks, and longer if the glands are tender. With whooping cough while the child whoops. With German measles for two weeks. With measles until two weeks from the beginning of the sickness. When there is measles in a farnily, children who have previously had it may be allowed in school. Those who have not had it must be excluded for two weeks from the beginning of the last case. Permits are not necessary for any of the above. The teacher can usually determine the duration of the sickness better than the medical inspector. All children living in houses where there is diphtheria, scarlet fever or small-pox must be excluded from school until they present a permit from the health department. Work of Teacher in Detecting Contagious Diseases 57 Moreover, each teacher is furnished with a supply of sheets of paper on which are printed in simple language rules to be observed by the pupils and which the teacher is expected to teach and enforce. A copy is given to each child. PRINTED RULES DISTRIBUTED TO ALL PUPILS IN PROVIDENCE, R. I. REMEMBER THESE THINGS. Do not spit if] you can help it. Never spit on a slate, floor, or sidewalk. Do not put the fingers into the mouth. Do not pick the nose or wipe the nose on the hand or sleeve. Do not wet the finger in the mouth when turning the leaves of books. Do not put pencils into the mouth or wet them with the lips. Do not put money into the mouth. Do not put pins into the mouth. Do not put anything into the mouth except food and drink. Do not swap apple cores, candy, chewing gum, half eaten food, whistles or bean blowers or anything that is put in the mouth. Never cough or sneeze in a person's face. Turn your face to one side. Keep your face and hands clean; wash the hands with soap and water before each meal. Another feature of the Providence system is that the principals are furnished by the Department of Health with printed lists of the famihes of the city in which scarlet fever or diphtheria has been reported, to the end that children living at locations named on the list may be excluded from school until permits for their return are furnished by the department. The city of Wilkesbarre, Pa., goes even farther than does Provi- dence, R. I., in the matter of giving each pupil a set of simple health rules. The scheme is rather novel. The school board has adopted six simple rules for promoting health. They are to be printed on the cover of every book used in the public schools. Here they are: 58 Medical Inspection of Schools 1. Fresh air and sunshine are necessary to good health. 2. Night air is as good as day air, and in cities where there is much dust, better. 3. Eat little fried food, pastry, candy, cake, and sugar. 4. Wash your hands before you eat. 5. Never lick your fingers when turning pages or when counting money. 6. Avoid spitting because it promotes consumption and other diseases. There are several plans by which the teacher refers to the school physician the children she believes to show symptoms of some illness. The simplest and perhaps the most common is for the teacher to send the children to the principal's or the school physician's room without any note as to what trouble she suspects or any particulars as to the case. There are good reasons why this system is not satisfactory. Some of them are well stated by Dr. S. W. Newmayer, of Philadelphia, in "A Practical System of Medical Inspection with Trained Nurses, Adapted for Public Schools of Large Cities." Dr. Newmayer says: "Each morning the teacher fills out for each pupil she desires examined by the inspector that part of the card above the dotted line. This may seem as though more clerical work is being shifted on the aheady overworked teacher. But a moment's reflection will prove it saves her time, trouble, and responsibility. Many of the younger pupils do not know their name, address, and number of classroom, much less why the teacher sent them to the doctor. This necessitates the return of the pupil to his class with a note requesting the desired information, :' which is eventually written on any scrap of paper, to again be copied by the doctor, and a third time by the nurse. I have heard teachers say, ' Who wishes to go to the doctor ? ' There are a few shiftless pupils who are only too ready to accept such an invitation to get out of the classroom. With the teacher answering the question, 'Why sent to medical inspector?' this imposition is avoided." Work of Teacher in Detecting Contagious Diseases 59 A good specimen of a very simple card from the teacher, requesting the inspector to examine a child, is that used in the Providence, R.I., schools. TEACHER'S REQUEST TO INSPECTOR, PROVIDENCE, R. I. Note to School Inspector. Name Residence School Please examine this pupil jar Teacher. When out of Blanks notify Health Department. A card providing for a fuller statement, and in many ways a better one, is in use in the schools of Asbury Park, N. J. It is a standard 4x6 inch filing card and has the advantage of insuring futiu-e ready reference when filed in a card index drawer. CARD OF REQUEST TO INSPECTOR, ASBURY PARK, N. J. ASBURY PARK PUBLIC SCHOOLS. DEPARTMENT OF MEDICAL INSPECTION. . nntft This card is to be ii when any pupil appe should then be sent Rence Age Class Any cases of sickness at home "i S ^ outb to be i he doc a n — bJO •a.s 0^ ythet 11. Thi tor's d ^•3 =0 S .a > i m W° 0^ .a ^ s a ir! d g P u ^ ^ 13 1 a 3 d U < 1 s 1 S ft a i fa g % 0^ 1 3 > - - - - 01 1 1 .a Old New Old New T C Monday .. Tuesday . . Wednesday Thursday . Friday Saturday . . - — - - - - - - - — - - - - - - — Totals Total numb er of c as ;s cure d.. ... CASES TREATED AT HOMES Date. Name. Address. Disease. CASES TAKEN TO DISPENSARY Date. Name. Disease. Date. Nurse. The School Nurse 79 A simpler form of weekly report on the nurse's work is in use in Baltimore. WEEKLY REPORT OF NURSE. BALTIMORE SCHOOL INSPECTION. NURSES' WEEKLY REPORT. No. of pupils inspected in school (Work with School Inspector not included) No. of pupils inspected at home No. of pupils treated in school No. of pupils treated at home Schools Visited Nos No. of Homes Visited DISEASES TREATED IN SCHOOLS: DISEASES TREATED IN HOMES: REVERSE OF BALTIMORE CARD Difficulties, if any, at homes: Difficulties, if any, in schools: Remarks: Date, Nurse. 8o Medical Inspection of Schools 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 furnishes efficient aid in emergencies. She gives practical demonstrations in the home of required treatments, often discovering there the soiurce of the trouble, which if undiscovered, would render useless the work of the medical inspector in the school. The school nurse is the most efl&cient possible link between the school and the home. Her work is immensely im- portant in its direct results and very far-reaching in its indirect in- fluences. Among foreign populations she is a very potent force for Americanization . CHAPTER VII Physical Examinations for the Detection of Non-Contagious Defects The whole theory on which physical examinations conducted for the detection of defects are based rests on a different foundation from that underlying medical inspection for contagious diseases. The latter is primarily a protective measure and looks mainly to the present safeguarding of the community. The former aims at securing physical soundness and strength, and looks far into the future. It has been brought into being by the great mass of evidence showing conclusively that a very large percentage of school children — probably from a quarter to a third of all of them — are defective in 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 prevented. These con- clusions are based upon examinations of hundreds of thousands of children in all parts of the world. There is no doubt as to the sub- stantial accuracy of the results. More than this, a considerable per cent. — probably about five — of school children are so seriously defective in hearing that their school work is badly interfered with. Most im- portant of all, only a small minority of these dejects of sight and hearing are discovered by teachers or are 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 great injury to the eyes, sometimes resulting in blindness, permanent injury to the nervous system owing to eye straining, and depression and discouragement owing to inability to hear and see clearly. But not only are eyesight and hearing important, there are many other defects far from rare among children and having an important bearing on their present health and future development which, if dis- covered early enough, may easily be remedied or modified. 6 8i 82 Medical Inspection of Schools The argument for the physical examination of school children is based on a recognition of the important bearing of the physical and mental condition of the children on the whole process of education. It recognizes the necessity of a favorable physical and educational environment, and by emphasizing the importance of the effect of sur- roundings upon the personality of the individual child seeks to seciu-e for each pupil such conditions of life as will secure a full and effective development of its bodily strength and mental power. In America comprehensive systems embracing thorough medical examinations of all pupils are still rare. The oldest such system in public schools is of comparatively recent origin. Partial examinations, however, have been made in many places and tests of eyesight and hear- ing are by no means rare. In the nature of the case there has been so great variation in the methods used in conducting these tests that the results found in different cities, where examinations have been conducted perhaps under radically different conditions, are not directly comparable with each other. Nevertheless an examination of the available data serves to emphasize the far-reaching importance of doing something to better existing conditions and to show that eyesight and hearing troubles are not confined to any one locality or to large cities only. In the table on page 83 are shown the results of different recently conducted eyesight and hearing tests. In examining this table one is at once struck by the variations between the figures in the column giving the percentages of defective vision for the several places. Thus, Bayonne reports only 7.7 per cent, defective, while the congested districts of Cleveland report 71.7 per cent. Of course, such variations as this at once suggest what is un- doubtedly the case, that the results are largely influenced by the methods employed by the examiners, and variations from this cause are apt to be even more important than those caused by the actual differences in existing conditions. Leaving out of account such extreme cases as those cited, it will be noticed that in a considerable part of the cases the children having defective vision are from 20 to 30 per cent, of the whole number examined. In the two examinations conducted in Cleveland in 1907, the per- centage of those having defective eyesight in the well-to-do district was 32.4, while in about the same number of cases in a congested dis- Physical Examinations for Non-Contagious Defects 83 trict it was 71.7. It is said that every endeavor was made to use just the same standards in the examinations in these two tests. Certainly this is interesting, and suggests the importance of conducting similar tests in other cities. RESULTS OF VISION AND HEARING TESTS CONDUCTED IN PUBLIC SCHOOLS p. .„_ Tii-vv Number Defective Per Defective Per rLACE. UATE. ExAMINED. VISION. CeNT. HEARING. CeNT. Bayonne, N. J 4,610 353 7.7 115 2.5 Camden, N. J 1906 10,028 2,757 27.7 412 4.1 Cleveland 1900 30,045 6,221 20.7 Cleveland, well-to-do dis- trict 1907 668 216 32.4 34 5.2 Cleveland, congested dis- trict 1907 616 437 71.7 II 1.8 Dunfermline 1907 1,526 255 17.0 4.0 Edinburgh 1904 1,330 574 43.2 162 12.2 Massachusetts 1907 402,937 99,609 22.3 27,387 6.3 Counties of Mass. except Suffolk 1907 19.9 5.8 Suffolk County (Boston, Chelsea, Revere, Win- throp) 1907 30.7 7.7 Milwaukee 1907 1,960 293 14.9 Minneapolis 25,696 8,166 30.0 Minneapolis 1908 710 170 23.9 55 7.7 New York City 1906 79,065 24,534 31.3 1,633 2.0 Pawtucket, R. 1 1901 4,663 517 11. i 200 4.3 Utica, N. Y 1897 6,113 667 10.9 406 6.6 Worcester, Mass ii,953 2,281 19. i 313 6.6 Another point which may be of significance is that in the state ex- aminations of Massachusetts the percentage of defective vision of the coimties of the state outside of Suffolk County was 19.9, while Suffolk Coimty, which is almost entirely the city of Boston, reports 30.7 per cent. In corroboration of the suggestion that defective vision is more prevalent in cities than in country districts are also the figures from Scotland, where the city of Edinburgh reports 43.2 per cent, defective, while the town of Dunfermline reports only 17.0. It is to be noted that a similar situation exists with regard to the mCIVIDUAL RECORD CARD, NEW YORK CITY < i -s H H "S ^ ^ '*:^ c Ph 5z; a 1 1 a> 01 ' o M - N N - > 1 a 1 1 1 a to 1 3 ■O Q IS 1 a 1 A 0. 1 1 Ml § 3 iz; o 1 1 a n § 1 5 1 •s 3 3 § t5 •5 a i 1 1 a «^ o 1 { o 1 CO 11 o 1 ei ii 2 a o 1 i 1 c c ■s 1 a i 1 St 1 10 C4 1 a 1 84 Physical Examinations for Non-Contagious Defects 85 figures for hearing from these same locahties. The counties of Mass- achusetts outside of Suffolk report 5.8 per cent, defective in hearing while Suffolk reports 7.7 per cent. Dunfermline reports 4 per cent., as contrasted with 12.2 per cent, from Edinburgh. In general, from 5 to 6 per cent, of children examined are found to have defective hearing. Turning our attention now from tests for vision and hearing to more comprehensive physical examinations, we are at once attracted to the situation in New York. Up to the spring of 1903 the whole attention of the medical inspectors in New York had been directed against in- fectious and contagious diseases. In March of that year the system was so elaborated as to continue with the former work and at the same time to include the complete physical examination of each child. Since that time there has been but little change in the list of defects examined for. Immediately after the morning inspection for conta- gious diseases has been concluded the inspector receives the children of a class in turn in a special room set aside for the purpose and examines them for sight, hearing and physical defects. The headings under which entries are made can be seen by referring to the reproduction of the individual record card in use in the New York schools. In every case where a defective condition is found to exist the parent of the child is notified by means of a printed postal card form. The postal cards used are of the "reply" form. The postal card informing the parent that his child has some physical defect has on it the direc- tions: " Take the child to your family physician for treatment and advice. Take this card with you to your family physician." Attached to this card is another which the family physician to whom the case is referred is asked to fill in, telling what action he has taken, and mail to the chief medical inspector. This system allows of following up the cases. If the reply card is received, the authorities know that action has been taken in regard to the case. If no reply is received, the case demands further attention. The results of the New York examinations have attracted wide- spread attention, and a large number of newspaper and magazine articles have been written about this work in New York. There has been much discussion as to whether the conditions found by the doctors in New York were typical of conditions existing in other cities or were 86 Medical Inspection of Schools POSTAL CARD NOTICE TO PARENTS, NEW YORK ** This Notice Does NOT Exclude This Child From School " DEPARTMENT OF HEALTH THE CITY OF NEW YORK 190 The parent or guardian of of attending P. S is hereby informed that a physical examination of this child seems to show an abnormal condition of the Remarks , Take this child to your family physician for treatment and advice. Take this card with you to the family physician. THOMAS DARLINGTON, M. D., Commissioner of Health. HERMANN M. BIGGS, M. D., General Medical Of&cer. REVERSE OF CARD TAKE THIS CARD TO YOUR PHYSICIAN The Physician in charge is requested to fill out and forward this postal after he has examined this child. I have this day examined of P. S and find the following condition: and advised as follows: Respectfully yours, Date Physical Examinations for Non-Contagious Defects 87 exceptional. Unfortunately not enough work of a similar nature has been done in other places to furnish data for answering these questions, and where the work has been done the results are not usually in such statistical form as to allow of comparison. Almost the only available figures are from Minneapolis and are for a small number of cases. Nevertheless it is interesting to compare these figures with those for New York for the year 1906. PHYSICAL EXAMINATIONS IN NEW YORK AND MINNEAPOLIS New York City, Minneapolis, 1906. Per Cent. 1908. Per Cent. Number examined 78,401 100. o 710 loo.o Bad nutrition 4,921 6.3 166 23.3 Anterior cervical glands 29,177 37.2 377 53.0 Posterior cervical glands 8,664 n-o Chorea 1,380 1.7 2 0.2 Cardiac disease 1,096 1,4 15 2.1 Pulmonary disease 757 .9 30 4.2 Skin disease 1,558 1.9 12 1.6 Deformity of spine 424 .5 ... ... Deformity of chest 261 .3 ... Deformity of extremities 550 .7 ... ... Defective vision 17,928 22.8 170 23.9 Defective hearing 869 i.i 55 7.7 Defective nasal breathing 11,314 i4-4 •-- Defective teeth 39>597 55-° 309 43-5 Defective palate 831 i.o 2 0.2 Hypertrophied tonsils 18,306 23.3 221 31. i Postnasal growth 9,438 12.0 91 12.8 Defective mentality 1,857 2.3 ... Where treatment was necessary... 56,259 71.7 462 65.1 On the whole the figures in the per cent, columns show substantial agreement. It is to be supposed that the great difference under the heading " Bad nutrition" (6.3 per cent, in New York and 23.3 in Minne- apolis) is due to a different standard rather than to any great difference in conditions. Under "Defective hearing," again, there is a striking difference, the New York figure being i.i, while that of Minneapolis is 7.7. As so low a percentage as that given for New York is very 88 Medical Inspection of Schools rarely found elsewhere, here again it must be concluded that the standard in New York must be less rigid than in other places. Perhaps the most interesting figures of all are those for "Where treatment was necessary." The percentages are 71.7 for New York and 65.1 for Minneapolis. This is a feature of interpreting the results of the work of physical examinations which has caused many misapprehensions. It has been stated again and again that the results of physical examinations in New York proved that two-thirds of all the school children were defec- tive, and such statements have aroused much discussion and called forth some denials. The trouble is one of words rather than facts. To use the word "defective" as it has been used in this way is to give it a new meaning. What the figures really show is that more than two- thirds of the children are found to have defects serious enough to record them and which call for attention from a physician, surgeon or dentist. Nevertheless the defects so recorded may be nothing more serious than a carious tooth. Judgment as to what constitutes a defect serious enough to warrant including the child in the class "defective" varies greatly in different places. Recently newspaper articles announced that examinations of school children in Sioux City showed that 80 per cent, were defective, while a little later they announced that only 18 per cent, were defective in Minneapolis. This latter figure represented the proportion the physi- cians in the latter city considered "seriously defective." Of course, it must be remembered in this connection that the perfect human animal is exceedingly rare. At a recent examination in Chicopee, Mass., out of 500 pupils examined only|one was reported as having perfect teeth, and this one was found to have spinal trouble, so that not a single pupil was reported as being perfectly sound physically. All this does not mean, however, that our schools are filled with physical wrecks. While the results of the examinations prove beyond doubt the need for finding out the facts and taking steps to have defects remedied, the need for moderation of statement in making public the results is no less apparent. In any system of medical inspection which includes the feature of physical examinations the matter of keeping records is of the greatest importance. To begin with, a good system of individual records is Physical Examinations for Non-Contagious Defects 89 imperative. This is a field of work where general information will not do. There must be a complete individual record for each child. This record card or blank must have on it spaces for recording the results of subsequent examinations as well as the initial one. If the results of the work are to be of real practical value, there must be the closest connection between the records of the physical examinations and the classroom work. It does no good to have a record on a card in the principal's room or in the ofiice of the board of health to the effect that Willie is stone deaf in the right ear, if the teacher knows nothing of the fact and still has Willie seated in the back left-hand corner of the room. It is also obvious that if the records do not follow the child from room to room, and school to school, in case of transfers, much of the work is soon rendered useless. These are some of the reasons why a system of medical inspection with physical examinations is an entirely different problem, from the point of view of the school administration, from a system for the detec- tion of contagious diseases only. Experience proves that the latter sort of work can be handled satis- factorily by boards of health. In the system having physical examina- tions as an important feature the educational authorities must in any event have an active participation in the work, and will probably succeed much better if they have it entirely in their own hands. The necessity for applying the information gained through the work of the school physician to the work of the classroom has been recog- nized in Los Angeles and some other cities by having the teacher's roll books so made that in case any child has a physical defect, the fact is entered in a space beside his name in the book. Pasadena, California, recognizes the importance that the teacher's intimate knowledge of the child and his habits has for the school physi- cian who is conducting physical examinations. In that city individual cards are used for recording the results of the physical examinations made by the school doctors, and on the reverse of the cards are blanks which the teacher fills in, indicating the points which her knowledge of the child leads her to believe require attention. Of course, the teacher fills in her side of the card first, and the physician uses the information as a guide and assistance in making the physical examinations. 90 Medical Inspection of Schools RECORD CARD, SHOWING TEACHER'S COMMENTS ON HABITS AND PECULIARITIES OF PUPIL. PASADENA, CAL. HEALTH DEPARTMENT, PASADENA PUBLIC SCHOOLS Date Pupil's Name Parent's Name Address I Posture 2 Nutrition 3 Color 4 Activity, mental 5 Activity, physical 6 Teeth: crooked, prominent, decayed 7 Mouth breather 8 Frequent absences 9 Bad behavior lO Inattention II Delinquency in studies 12 Squinting, or other eye symptoms 13 Deafness 14 Nasal voice 15 Frequent colds 16 Skin diseases or pimples 17 Twitching of eyes, face or any part 18 Offensive breath 19 Over development, physical 20 Under development, physical 21 Uncleanliness 22 Vicious personal habits 23 Signs of fever 24 Signs of any contagious disease 25 Cough The Teacher will please fill in the blanks at the top of this card, and check off the points which she thinks require attention. Physical Examinations for Non-Contagious Defects 91 REVERSE OF CARD, SHOWING BLANKS FILLED IN BY SCHOOL PHYSICL^ PHYSICAL EXAMINATION No. Heart Lungs Eyes Ears Nose Throat Teeth Contagious Disease Skin Disease Special Data Recommendations Results Medical Examiner. 92 Medical Inspection of Schools o o w < O o K O CO ^ w M u h:i m CO o W % 5 ;•? CO CO o ;z: I-) u H O o ;^ ° O td p^ p< Q bp Q h < MX P^ c3 o -ti > c in O O n m Q >^ cu O o o rt fn '13 o o o T3 PI w C^- d TD . c« .SI >. iH T3 PM rf b c3 f-l n .!=^ c^ Oh C/2 y=l c« bD O Gj ^ ao CU C^ rri "-^ "I c3 i=l 'Tl bO. -3 ^ ? 5- ^ I I rt o o Ph o s bC rt 55 "^ 6 O OJ pi rs 'C •■4:: r2 cr' S^ ?j S « n o o bO?H •t:) s <^ (U '5 cJ5 o o Ph H^^ bb2-M ^ I i>-4^ bb ?^ J^ -p. ^ o ^ og-^ O 2 . c^ rt rs 2 S 'O pi 'c3 O) •^ PI o .tJ p c^ ^ -^ > 5b o O Tj t/2 .,-1 >-, ^ rf o c3 2 1 ^ C/2 t_l ■£ .+-, o P-. U d (U O 'P ^ •3 .t; <« S c ^ M^ o .a O _ > .a ^ ^ FP I VM Sh 1— I O rn ^ O P^ PI I •2 § _! g^^ 2 Jij Ph o g o 'a, o ra b? C rf oS -a i>^ bO PI w ■S3 o o -^ .id CO o P < H^ -PI <^ Physical Examinations for Non-Contagious Defects 93 p h « < < ?; u < X m fil (ji « J w < > () M p< (/J >• X a. •S s TD •^ ^ '^ .ti ^ § ■♦J 1-1 9 a o > 8- Dh Ph (/3 a o a o u a> 4> ' bO O 3 C )-, .^^ .2 O « -Eh '-'-' a, ;3 W CJ &H (U a M O o, PLI < : a ii S S /^ 1) rt g Oh PU +3 O a> c3 a rt S S S^ o "C ti "J^ rA ,cl y G C^ O o o en O a o H U to w lU (U .9 o a B •3 ii ID a CIS m bo 5 O 2 H W >> 5 f4 d e ei a u rS m a 1 3 a c« A O 1 0) u o a a Vision and Hearing Tests by Teachers 113 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 for this purpose are furnished by the State Board. NOTICE TO PARENT OR GUARDIAN Commontpealtj) of JHasisiacijusiettsJ 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 trouble with the ^^' which needs competent medical advice. Please attend to this at once. Teacher 190 Commonttiealtf) of Jllasisiactjusietts; 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 symp- toms of PLEASE SECURE COMPETENT MEDICAL ADVICE AT ONCE. School Physician. 190 EYE AND EAR EXAMINATIONS AS CONDUCTED BY THE NEW YORK STATE DEPARTMENT OF HEALTH In the examinations conducted by the New York State Department of Health, the sight test cards are similar to the ones used in Massa- chusetts. As the instructions issued differ somewhat from those in use in the New England State, they are reproduced in full, together with the blank xised for notifying the parents of defects found and the head- ing of the blank used by each teacher for reporting the results of the examination in her room. 8 114 Medical Inspection of Schools TEACHERS' INSTRUCTIONS FOR THE EXAMINATION OF THE EYES AND EARS OF SCHOOL CHILDREN, NEW YORK STATE NEW YORK STATE DEPARTMENT OF HEALTH ALBANY Teachers' Instructions for the Examination of the Eyes and Ears of School Children I — Excep- tions 2-3 — General Directions 4 — Abnormal Conditions 5— Test for Normal Vision 6 — Testing Distant Vision 7 — Inability to Narae Letters EYES Children under 7 years need not be examined. Children wearing glasses should be tested with their glasses properly adjusted to their faces. Children should be examined singly and privately. Ascertain whether the child habitually suffers from inflamed lids or eyes or after study has weariness or pain in eyes or head or is suffering from squint (eyes crossed). Find whether the vision is normal by the large charts. Do not expose the charts except when they are in use, as familiarity leads to memorizing the letters. The chart should have a good side illumination and not be hung in range of a window which will dazzle the eyes. It should be on a level with the head and at a measured distance of 20 feet from the child, who should sit facing it. Examine each eye separately by holding a card or other screen close in front of one eye while the other is examined, but do not have the test made with one eye closed by pressvue or otherwise. Test the right eye first by having the letters named in order from the top downward. For the left eye have the letters named from right to left to avoid repetition from memory. Where the child cannot name the individual letters although able to read, the chart of figures may be used. It may also be used as a control test. If the child does not know figures or letters use the chart of inverted E's, Vision and Hearing Tests by Teachers 115 asking the child to tell by the movement of the hand the side on which there is an opening in the E's in the different lines, i. e., up, down, right or left. If it is suspected that the answers are being made 8— Memoriz- from memory a hole about one and one-half inches may ^°S be cut in a narrow strip of cardboard so as to allow only one or two letters to show through the hole, and by skipping around rapidly it is easy to break up the mem- orizing of the letters. The lines on the 3 large charts are numbered 200, 9 — Recording 100, 70, 50, 40, 30, 20. These indicate the distance the I>istant respective letters should be read by the normal eye. ^^^^°^ The record is made by a fraction, of which the numerator represents the distance of the chart from the child, and the denominator the lowest line he can correctly read. Thus if at 20 feet he reads the lowest line the vision is f ^ or normal. If he only reads the line above, the vision is f^ or I the normal. If he cannot read the largest letter he must go slowly toward the chart until he can. The distance he is from the chart when he can read the largest letter will be the numerator and 200 the denomi- nator. Thus, if he could not tell the letter until he is 10 feet from the chart his vision will be ^Y^ or yV the normal. The eyes should also be tested at the near point and 10 — Testing separately as with the large chart, the scholar being seated ^^^^ Vision with his back toward the light and with the small chart °^ Focusing Power well lighted. Begin at 18 inches and steadily bring the chart nearer and nearer while the scholar continues to read aloud. When he can read no further measure the distance from his eye to the chart. If the child has difficulty in reading the chart he can spell the words, and the test will be determined by his failure to pronounce the letters correctly. The fractions |^, |^, ^VV, etc., will record the dis- i"g"DiJtant' tant vision (20 feet) of each eye. Reads right eye — and Near inches up to — inches ; reads left eye — inches up to — Vision ii6 Medical Inspection of Schools inches will record the focusing power of each eye; as, R. E. = i6 up to 4 in.; L. E. = 15 up to 3 J in. I — Excep- tions 2 — Directions 3 — Abnormal Conditions 4 — Testing Hearing 5 — Recording Hearing EARS All children should be examined. Children should be examined singly and privately. Ascertain whether the child has frequent earaches, has pus or a foul odor proceeding from either ear, suffers from frequent "colds in the head," is subject to a con- stant catarrhal discharge from the nose or throat, or is a mouth-breather. Seat the child facing you near one end of a quiet room with the windows closed and begin the test of the hearing at a measured distance of 25 feet. The test is made by having the left ear tightly closed with the finger while you observe the ability of the child to repeat your moderate whispers of numbers between 21 and 99 inclusive, avoid- ing those with ciphers; as, 75, 55, 37, 22, etc. Test the left ear with the right tightly closed. Avoid having a wall behind you to act as a sounding board. The figures should have as nearly equal emphasis as possible, and the distance at which the child correctly repeats a series of 3 numbers gives his hearing distance for that ear. No further test is necessary if the child hears the numbers perfectly with each ear. If this test shows a slight defect of either ear, further tests may be made by observ- ing how the child hears the tick of an ordinary watch, which should be heard normally at a distance of not less than 3 feet. The hearing is recorded by a fraction of which the numerator represents the distance you are from the child and the denominator is 25. If he repeats the numbers correctly at 25 feet his hearing is ff or normal. If he only repeats the numbers correctly when you are at 20 feet it is ff or |- the normal, and at 1 2 feet |^, etc. Vision and Hearing Tests by Teachers 117 CARDS AND REPORTS These examinations should be made annually in i — Time October, and after the mid-winter examinations in the case of new pupils. All the charts should be kept without rolling or being 2— Charts folded, in a clean dark place to prevent the yellowing of the paper. Send at once a properly filled blank to the parent or 3 — Reports to guardian of all children whose vision is less than ff , in Parents or either eye. Do not fail to report cases where the vision Guardians is f ^, if the child is backward in school work, suffers ^^7® Con- from any abnormal condition of the lids, inflamed eyes, has a discharge from either eye or frequent headaches. Report all cases where the hearing with either ear ^ j.^ Con- falls below normal, or the child suffers from any of the ditions conditions mentioned under "Abnormal Conditions —Ears." Mail to the State Department of Health a report 4 Health giving the name and age of all children examined. Department Where the distant vision is f^, the focusing power 18 Reports inches up to 4 inches, and there are no abnormal condi- tions of the eye or lids, or headaches; and where the hearing is normal in each ear, without any other abnormal condition, leave the spaces opposite such names vacant. The vision and hearing are recorded in the proper spaces for each by fractions as explained above. All abnormal conditions of the eyes, lids, ears, nose, throat, and headaches are to be recorded by proper abbrevia- tions under the respective headings. This report must be filed with the Department within 10 days. EUGENE H. PORTER, M.D., Commissioner of Health Town. NEW YORK STATE BOARD OF HEALTH, REPORT OF TEACHER District No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 Name. Age. Distant Vision. (20 feet.) R. E. L. E Focusing Power. (Inches.) R. E. L. E Eyes. Inflam. Disch. Squint. LIDS. Inflam. Scaly. Swollen. Eyes. Pain. Fatigued after use. ii8 Schoo l. Head- ache. Daily Weekly. Grade. Hearing. R. E. L. E. Ear. Pain. Ear. Disch. Odor. Nose. Colds, Catarrh. Throat. Mouth- breather Cases Reported to Parents or Guard- ians. Gen. Health. Remarks. 119 120 Medical Inspection of Schools BLANK USED FOR NOTIFYING PARENTS, NEW YORK STATE Public School No 190 Mr. * eyes *son An examination of your daughter shows the to be defective ■' ° nose throat and below the standard required by the State Department of Health. This child cannot do satisfactory work in school until this defect is corrected. You should consult with your family physician or with the health officer of the village as to the choice of an eye or ear doctor whom you are advised to consult about the trouble. Teacher. * Strike out the words not required. EYESIGHT TESTS CONDUCTED BY THE STATE BOARD OF EDUCATION OF CONNECTICUT Eyesight tests are conducted by the State Board of Education of Connecticut under the provisions of Section 2251 of the general statute. This section reads as follows : The State Board of Education shall prepare or cause to be prepared suitable test cards and blanks to be used in testing the eyesight of the pupils in public schools, and shall furnish the same, together with all necessary instruc- tions for their use, free of expense, to every school in the state. The superintendent, principal, or teacher, in every school, during the fall term in the year 1904 and triennially thereafter, shall test the eyesight of all pupils under his charge according to the instructions fm-nished, and shall notify in writing the parent or guardian of every pupil who shall be found to have any defect of vision or Vision and Hearing Tests by Teachers I2i disease of the eyes, with a brief statement of such defect or disease, and shall make written report of all such cases to the State Board of Education. INSTRUCTIONS The following instructions, prepared by S. B. St. John, M.D., of Hartford, give a method of intelligently making the tests required by the law and also indicate the form of reports to parents and the State Board of Education: Separate Test for Each Eye In testing the eyesight with the large chart (I), each eye should be tested separately, the other eye being covered with a screen and both eyes being open. Light The chart should be hung in a good light, preferably a side illumination, and not in range with a window (which might dazzle the eyes of the child). Method Seat the child at a measured distance of 20 feet from the chart and cover one eye with a pasteboard screen. Have him pronounce aloud the letters, beginning at the top, and reading from left to right, and note the lowest line that he reads correctly. Repeat the test for the other eye, but have him reverse the order and read from right to left (or backwards), to avoid the danger of repeating from memory. Record To record the visual power thus obtained notice that the lines are numbered 200, 100, 70, 50, 40, 30, and 20. These numbers indicate the distances at which the respec- tive letters should be read by a normal eye. The record is made by a fraction, of which the numerator represents the distance from the child to the card and the denominator the lowest line he can correctly read. Thus if at 20 feet STATE OF CONNECTICUT, EYESIGHT TEST, CHART I (Printed on heavy white cardboard, size 9 x 20 inches.) 200 100 991 70 50 40 30 20 m 15 PRBOHKOF Vision and Hearing Tests by Teachers 123 he reads the lowest line the vision is |^ or i = normal. If he only reads the line above, the vision is f ^ or § normal. If he cannot read the largest letter at 20 feet, he must go slowly toward the card until he can read the largest letter. The distance from him to the card (as before) will be the numerator and 200 the denominator. Thus, if he could not tell the letter until he was 10 feet from the card his vision = ^\, or ^V of normal. TEST OF FOCUSING POWER STATE OF CONNECTICUT, EYESIGHT TEST, CHART II (Printed on heavy white cardboard, size 6x8 inches.) State of Connecticut EYESIGHT TEST Chart II w»s born at York on the first of March In the iixth year of the reign of King Charles the First. Prom the time when waa quite a young child, I had felt a great wish to spend my life at sea, and as I grew, so did this taste grow more and miore strong ; till at last I broke loose from my school and home, and found my way on foot to Hull, where I soon got a place on board a ship. When we had set sail but a few days, a squall of wind came on, and on the fifth night we sprang* l«ak. All hands were sent to the pumps, but we felt the ship groan in all her planks, and her beams quake from stem to stern; so that it was soon quite clear there was no hope for her. and that all we could do was to save our lives. The first tiling was to fire off guns, to show that we were in need of help, and at length a ship, which lay not far from us, sent a boat to our aid. But the sea was too rough for it to lie near our ship's side, so we threw out a rope, which the men in the boat •aught, and made fast'and by this means we all got in. Still, in so wild a sea it was in vain to try to get on board the ship which had sent out the men, or to use our oars in the boat, and all we could do was to let it drive to shore. In the space of half an hour our own ship struck on a rock and went down and we saw her no more. We made but slow way to tk« land, of which we caught sight now and then when the boat rose to the top of some high wave, and there we The chart (II) of fine type is for testing the focusing power. In normal eyes the focusing power varies with age. Up to lo years the normal eye will read up to 2^ inches; at 12, up to 2|; at 15, up to 3, and at 20, up to 3I. The focusing power may be affected by temporary conditions, and variations from the normal figures are important only when marked and constant. The eyes should be tested separately, as with the large chart, the scholar being seated with his back to- ward the Hght, but not so much as to shade the card. Begin at 12 inches and steadily but slowly bring the card CHART OF GRADUATED FIGURES, STATE OF CONNECTICUT, EYESIGHT TEST, CHART III (Printed on heavy white cardboard, size 9 x 20 inches.) 100 mm 70 40: fct QflRB^ K l-i 30 20 a 1; (m 15 623094538280 124 CHART OF E's, STATE OF CONNECTICUT, EYE- SIGHT TEST, CHART IV (Printed on heavy white cardboard, size 9 x 20 inches.) 200 100 70 50I1W 30 M Ed 20 m m E [a a E 15 BBS m w E m "5 126 Medical Inspection of Schools nearer while the scholar continues to read aloud; when his hesitancy shows that he is not seeing correctly, measure the distance from his eye to the card, and record "Reads up to inches with R. eye." Repeat this test for the other eye and then for both eyes. If it is uncertain whether the hesitancy in reading arises from indistinct seeing or inability to pronounce the word, ask the scholar to tell the instant when the letters begin to be confused and measure the distance then. The chart of graduated figures (III) is to be used in cases where the scholar knows figures and does not know letters. The chart covered with E's (IV) is for those who know neither letters nor figures. The teacher should stand by the chart and point out the different characters, asking which is the "open side," i. e., whether it opens up, down, right, or left. It is better to have the scholar indicate the open side by a gesture of the hand in the direction corre- sponding to that side. The details of the use of charts III and IV are the same otherwise as of that containing letters. Use of Charts The charts should not be hung in the schoolroom when not in use, as the scholars very readily memorize them, which vitiates the examination. If the teacher suspects that the answers are being made from memory, a hole about i^ inches square may be cut near the end of a narrow strip of cardboard, and this may be used to cover the lines, exposing only one or two letters at a time through the hole. By skipping around rapidly with this device it is easy to break up the memorizing trouble. Vision and Hearing Tests by Teachers 127 REPORTS The following are forms of reports : Teacher's Report to Parent or Guardian, Blank i. Eyesight test blank i REPORT TO PARENT OR GUARDIAN BY TEACHER Town District School 190 . . . To You are hereby notified that the examination of the eyes of [name] shows that they are — [Here describe the condition in simple terms, whether sore, discharging matter, watery, or of strained appearance. If none of these conditions exist, cancel this section.] The examination of the eyesight shows that it is defective in < u„^u \ eyes. The defect is such that in the Right eye the sight power is ^ [give fractional form as deter- mined by tests] of what it should be, while in the Left eye it is ^ You are advised to take to a physician as soon as possible to ascertain what is the trouble, whether it can be remedied, and whether < , > should continue to go to school. Teacher. 128 ■ Medical Inspection of Schools Teacher's Report to State Board of Education, Blank ii. Eyesight test blank ii REPORT TO STATE BOARD OF EDUCATION BY TEACHER Scholar Town District School 190 Name Age General condition of health General appearance of eyes [whether red, watery, or discharging material thicker than water], General appearance of eyelids [whether red, swollen, or covered with crusts], Results of Testing (at 20 feet with chart). Vision of right eye = Vision of left eye = Results of Testing (with small type). With right eye, nearest point at which the diamond type can be read is inches. With left eye inches. With both eyes reads up to inches Teacher. Report to State Board of Education, Blank ill. Eyesight test blank iii REPORT TO STATE BOARD OF EDUCATION BY SUPERINTENDENT, PRINCIPAL OR TEACHER School Town District School Department Number enrolled in school [schools] Number tested Number blanks sent to parents Remarks. Superintendent Date, Principal or Teacher Vision and Hearing Tests by Teachers 129 SUGGESTIONS Blank i should be sent to parents only when some defect of eyesight is discovered by the test. No blank is to be sent when the eyesight is normal. When blank i is sent to parents, blank ii should be sent to the State Board of Education. When the eyesight of all pupils in the school has been tested, superin- tendents, principals, or teachers are requested to send to the State Board of Education the general blank iii showing the whole number of scholars tested. For blanks or information address State Board of Education, Hartford. EXAMINATIONS OF THE STATE BOARD OF HEALTH OF UTAH In Utah, cards similar to those in use in Massachusetts and New York are furnished for the testing of eyesight. The instructions fvir- nished teachers, together with a reproduction of the report blank filled in by the principal of the school and forwarded to the State Board of Health, follow. Instructions for the Examination of School Chil- dren's Eyes and Ears, etc. (After the Method Proposed by Dr. Frank AUport, of Chicago, 111.) For Use of Principals, Teachers, etc. Do not expose the card except when in use, as familiarity with its face leads children to learn the letters "by heart." First grade children need not be examined. The examinations should be made privately and singly. Children already wearing glasses should be tested with such glasses properly adjusted on the face. Place the "Vision Chart for Schools" (Snellen's) on the wall in a good light ; do not allow the face of the card to be covered with glass. The line marked XX (20) should be seen at twenty feet, therefore place the pupil twenty feet from the card. Each eye should be examined separately. Hold a card over one eye while the other is being ex- 9 130 Medical Inspection of Schools amined. Do not press upon the covered eye, as the pressure might induce an incorrect examination. Have the pupil begin at the top of the test card and read down as far as he can, first with one eye and then with the other. Facts to Be Ascertained 1. Does the pupil habitually suffer from inflamed lids or eyes? 2. Does the pupil fail to read a majority of the letters in the number XX (20) line of the Snellen's Test Types with either eye ? 3. Do the eyes and head habitually grow weary and painful after study ? 4. Does the pupil appear to be "cross-eyed"? 5. Does the pupil complain of earache in either ear? 6. Does matter (pus) or a foul odor proceed from either ear? 7. Does the pupil fail to hear an ordinary voice at twenty feet in a quiet room? Each ear should be tested by having the pupil hold his hand over first one ear, and then the other. The pupil shoidd close his eyes dviring the test. 8. Is the pupil frequently subject to "colds in the head" and discharges from the nose and throat ? 9. Is the pupil an habitual "mouth breather"? If an afl&rmative answer is found to any of these ques- tions, the pupil should be given a printed card of warning to be handed to the parent, which should read something like this : Card of Warning to Parents After due consideration it is believed that your child has some Eye, Ear, Nose and Throat disease, for which your family physician or some specialist should be at once consulted. It is earnestly requested that this matter be not neglected. Respectfully, School. Vision and Hearing Tests by Teachers If only an eye disease is suspected, the words " ear, nose and throat" should be crossed off; if only an ear disease is s\ispected, the words "eye, nose and throat" should be crossed off; if it is only a nose and throat dis- ease, the words "eye and ear" should be crossed off. It will be observed that these cards are non-obligatory in their natiure. They do not require anything of the parent, who is at perfect liberty to take notice of the warning card or not, as he sees fit. They simply warn the parent that a probable disease exists, thus placing the responsibility upon the parent. Nevertheless, if parents neglect the warning thus conveyed, the teacher should, from time to time, en- deavor to convince such parents of the advisability of medical counsel. Teachers are urged to impress upon pupils and parents the necessity for consulting reputable physicians. These tests should be made annually at the begin- ning of the fall term, and should include all children above the first grade. Each teacher should examine all the children in his or her own room, and should report the results of such ex- aminations to the principal, such report to be signed by the examining teacher. The following simple form of report, to be filled out by the teacher and handed to the principal, is suggested and may be printed upon paper of any size and character that is deemed advisable by the local and school au- thorities, and should be distributed to the different room teachers : 131 No. Name of Pdpil. Do THE Tests Indicate an Eye, Ear, Nose or Throat Disease ? Answer " Yes " OR " No." If so, which ? Was the Pupil Given a Card of Warning? I 2 3 4 John Doe Robert Smith Mary Brown Edward Hart Yes ; eye Yes ; ear No Yes ; nose or throat Yes. Yes. No. Yes. 132 Medical Inspection of Schools Report to State Board of Health of Utah, of Eye, Ear and Throat Tests Report to State Board of Health of Eye, Ear and Throat Tests of Pupils in Public Schools Date Place Name or Number of School Grade of Pupils Name of Principal Name of Teacher Number of Pupils in room Number of Pupils tested Nmnber of Pupils wearing glasses Number of Pupils free from symptoms of eye, ear, nose and throat disease Number of Pupils suspected of having defective sight or eye disease in addition to those v^earing glasses Number of pupils suspected of having defective hearing or disease of ears Number of Pupils suspected of having disease of nose or throat Has notification been sent to parents in each case where defect is sus- pected ? Remarks by Teacher or Principal Note. — This report should be mailed to the State Board of Health promptly after tests have been made. Vision and Hearing Tests by Teachers 133 In the city of Ogden there are three more interesting blanks used in connection with these tests. The first is the report of the teacher to the principal. Teacher's Report to Principal, Ogden, Utah TEACHER'S REPORT TO PRINCIPAL. No. Name of Pupil. Do the tests indicate an Eye, Ear, Nose or Throat Disease ? Answer " Yes" or "No." If so, which? Was the Pupil given a Card of Warning? The results of examinations and tests are made known to parents by means of a card of warning: Card of Warning to Parents, Ogden, Utah CARD OF WARNING TO PARENTS. As a result of examination and tests made under instructions from the State Board of Health, it is believed that your child has some Eye, Ear, Nose and Throat disease, for which your family physician or some specialist should be at once consulted. It is earnestly requested that this matter be not neglected. Respectfully, Teacher Many serious consequences result from uncorrected defects of sight and hearing in school children, also from mouth breathing, which is usually caused either by an obstruction in the nose or by the pres- ence of adenoids. It is extremely important that defects of vision shall be corrected by properly fitted glasses and that any condition causing mouth breathing shall be promptly removed by proper treatment. 134 Medical Inspection of Schools The third blank in use in the Ogden schools is of special interest because it is almost, if not entirely, unique among the blanks used in American school systems. It is a blank on which the teacher requests from the parent an explanation of the absence from school of a pupil and on which the parent writes the excuse. On the reverse are printed the rules governing absence and tardiness. Teacher's Request upon Parent for Explanation of Absence of Pupil, Ogden, Utah Ogden Public Schools Ogden, Utah, ..„ 190 M -- - - Your— - has been absent from school as follows : for which a sufficient excuse should be given. Teacher (WRITE EXCUSE BELOW) Parent SEE OTHER SIDE Vision and Hearing Tests by Teachers 135 Rules Governing Absence and Tardiness 7. Pupils are required in all cases of absence to bring, on their return to school, an excuse in writing from their parents or guardians, assigning good and sufficient reasons for such absence. The only valid excuses for such absence are: (i) Sickness of the pupil; (2) Sickness or death of some member of the family requiring the presence of the pupil at home or making it impossible to send the pupil promptly; (3) Inclement weather, when sending the pupil would endanger his or her health. 8. Pupils must bring written excuse from parent or guardian for tardiness, unless the cause of same be known to the teacher. Two times tardy is equal to one-half day's absence. 9. For violation of any of the foregoing rules the principal may temporarily suspend a pupil from school and thereupon shall immediately inform the parent or guardian of the fact and the cause therefor, and also report the case to the Superintendent. On second sus- pension of such pupil for the same offense, he shall not be permitted to return without a special permit from the Board, The methods advocated by the State Boards of Health of Massa- chusetts, New York, and Utah, and the State Board of Education of Connecticut, by which teachers can test their pupils for defects of eyesight and hearing, have been described at length, because it is gen- erally recognized that with slight training teachers are competent to conduct such tests. It is even claimed that there is an advantage in having them made by teachers, because parents will not accept the diagnosis as authoritative and will consult specialists as to the alleged troubles found. There can be no doubt, too, that making such tests awakens teachers to a quickened interest in the bearing of physical defects on school progress, gives them a closer insight into the charac- 136 Medical Inspection of Schools teristics of their pupils, and stimulates them to further work in the field of child study. Where no form of medical inspection exists, such tests by teachers certainly constitute a useful and practical first step toward securing such a system. It is just as certain that work done by teachers does not and cannot render imnecessary the services of the trained medical expert. CHAPTER IX Administration For the purpose of discussing different phases of administration, there may be distinguished four different classes of systems of medical inspection, all of them in force in different parts of the United States. First : Examinations for the detection of physical defects conducted by teachers. Such examinations are generally limited to examinations of vision and hearing. Second: Examinations conducted by physicians for the detection of contagious diseases only. Third: Medical inspections conducted by physicians for the de- tection of contagious diseases, combined with physical examinations for the detection of physical defects. Fourth : Systems combining the features of examinations by teachers for defects of vision and hearing, and examinations by physicians for the detection of contagious diseases and non-contagious physical defects. Obviously, examinations of the first sort, that is, examinations conducted by teachers for the detection of defects of vision and hearing, are by far the least expensive. Such systems have been discussed at length in Chapter VIII. They are prescribed by state law in Massa- chusetts, Vermont, and Connecticut ; and have been or are being conducted without specific legal enactment in some other states, notably New York, California, and Utah. The only expenses incurred in conducting such examinations are for printed material, consisting of rules of instruction, test cards, record blanks, notification cards, etc. Even for a large number of children the expense is low. The Massachusetts statute has the following sen- tence in Section 6: " 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 the act." 137 138 Medical Inspection of Schools In Massachusetts all the material used by teachers for the tests is sup- plied by the State Board of Education to all teachers. There are slightly over half a million pupils enrolled in the public schools of Massachusetts. At an annual cost of five hundred dollars, this means that the tests cost approximately one-tenth of one cent per pupil. The time necessary to conduct them is from three to five minutes per pupil. Thus it will be seen that both in time and in money the necessary expenditure is slight. As has aheady been explained, such tests do not take the place of thorough examinations by competent, trained experts. That they are of great and real value, however, is not to be gainsaid ; and it is greatly to be doubted if 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. The second sort of medical inspection, that which has for its object to discover incipient cases of infectious diseases and by their removal from school to prevent the disease from becoming epidemic, is in reality merely an extension of the work which has been done by boards of health. It is, of course, not expensive. In most cities the doctors call every day or at least several times a week, and look over all 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. Chicago employs one hundred doctors under the Board of Health to do this work. The system was in vogue in New York for a number of years. Before the passage of the medical inspection law, many cities of Massachusetts had it. It is still the most common system in this country. Under this plan the method of sending for the doctor varies in different towns. Usually in cities he comes at stated times without being notified, knowing that he is sure to find some children waiting for him to examine. In some places the principal hangs out a card as for the ice man, and the doctor, making his daily rounds, notices it and stops. A common method is for the principal or superintendent to notify the doctor by telephone. The third system combines with the inspections for contagious diseases a purpose much more fundamental in its character and likely to be more far-reaching in its influence. This purpose finds expression in physical examinations to ascertain whether the pupil is suffering Administration 139 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 prevent injury to the child or to secure the best educational results. This system probably finds its highest exemplification in the schools of New York City. It is, of course, a much more expensive form of medical inspection than either of the other two systems described. It requires the employment of skilful physicians for considerable periods of time. It is a much more serious matter to make a fairly complete, even if somewhat superficial, physical examination of a child than merely to decide whether or not a child shows symptoms of some conta- gious disease. With a like expenditiu-e of time, it is impossible for a doctor to look out for as large a number of children tmder this system as under the preceding one. Of the worth of the complete physical examination there can be no doubt. The only disadvantage which can be alleged against the system is that it often results in divorcing the work of the medical examiners from the interests of the teachers and the school authorities. This is mainly a difficulty of administration, rather than inherent in the system, and can largely be overcome. The foiirth system, that of having teachers examine for vision and hearing, and physicians for contagious diseases and physical defects, is the one prescribed by the Massachusetts law. It is also in use in some places outside of that state, notably in the city of Los Angeles, California. It has the advantage of enlisting the interest and cooperation of the teachers, while utilizing the trained knowledge of the physician. SALARIES OF MEDICAL INSPECTORS AND THE NUMBER OF PUPILS PER INSPECTOR The foregoing description of the different systems of medical in- spection has been necessary in order to discuss the question of salaries, on account of the great variation in different localities as to the work performed and the remuneration received. The following table gives the facts in regard to the number of inspectors, salaries, number of children per inspector, and per capita cost for salaries for seventeen cities: 140 Medical Inspection of Schools FACTS IN REGARD TO MEDICAL INSPECTION IN SEVENTEEN CITIES City. State. Average Attend- ance. Medical Inspectors. Children Per Inspector Salaries OF In- spectors. Total op Salaries. Per Capita Cost foe Salaries Only. Boston .Mass.. . 86,839 80 1085 $200 $16,000 $.184 Brockton. . .Mass. . . 7,781 7 iiii 200 1,400 .179 Camden . . .N.J... - 9,718 I 9718 2400 2,400 .247 Chelsea . . . . Mass. . - 6,047 3 2015 200 600 .099 Detroit ... .Mich. . • 37,757 27 1398 250 6,750 .178 Lawrence . .Mass. . • 7,530 I 7447 1500 1,500 .201 Montclair . .N.J... • 2,503 4 625 305 1,220 .487 Newark.. . .N.J... . .38,562 16 2410 400 6,400 .165 New Haven Conn. . - 18,135 5 3627 240 1,200 .066 New York. .N. Y. . .523,084 166 3151 1200 ' I at 199,200 .380 Paterson . . .N.J... - 15.238 3 5168 ■ 1500 sat ■ 1200 - I at 1 3,900 .251 Seattle .Wash.. • 16,174 II 1470 • 1200 10 at 600 ■ 7,200 •445 Somerville. .Mass. . . 11,166 7 1581 200 1,400 .126 Springfield. . Mass. . . 10,605 II 964 250 2,750 •259 Woonsocket R. I. . . . 2,862 6 477 5° 300 .104 Worcester . .Mass. . - 18,273 IS 1218 200 3,000 .164 A number of considerations are necessary to the understanding of the table. In the first place, the expense for salaries of inspectors is not the whole expense for medical inspection. In all of the cities ex- penditures for printing and incidentals are necessary, and in Boston and New York there is the very considerable added expense for paying large corps of trained nurses. It is further to be remembered that the inspectors in New York receive their salaries at $100 per month in return for their services as district physicians of the Board of Health and that their duties as school physicians constitute only a part of their work. Again, in cities where a considerable number of inspectors is employed, they are under the supervision of chief inspectors who receive higher salaries. These salaries do not appear in the table. Still another consideration is that in most of these cities the doctors conduct Administration 141 examinations for the detection of contagious diseases only, while in a few they make the much more exacting physical examinations and consequently fewer of them. In short, conditions vary so that they are not comparable on a basis of equaHty in any two cities. Bearing the above considerations in mind, a study of the table becomes possible. The number of children per inspector varies from 477 in Woonsocket, R. I., to more than twenty times that number, or 9,718, in Camden, N. J.; but the Woonsocket inspectors receive an annual remuneration of $50 per year apiece, while the inspector in Camden receives $2,400. These two cities also mark the extremes in the size of salary paid. ^In the matter of the per capita cost for salaries, how- ever. New Haven, Conn., stands at the foot of the list, with an expendi- ture of 6.6 cents for each pupil, and Montclair, N. J., at the head with one of 48.7 cents per pupil. Of course, many cities having systems of medical inspection do not appear in the table, and some of them represent still greater extremes. In many places the work is carried on by volunteer workers without remuneration. The towns of Shelburne and Littleton, Mass., pay their school physicians $25 per year. The committee appointed by the School Board of Harrisburg, Pa., to investigate and report on medical inspection reported in April, 1908, that twenty-four cities replied to their questions as to the per capita cost of medical inspection. The answers ranged from $.005^ to $1.22. These facts and considerations lead to the conclusion that there has not yet been adopted in this country any recognized basis for the equitable remuneration of the services of the school physician. One thing seems certain — that the almost universal tendency is to so under- pay this work as to give the whole movement an appearance of trivi- ality and fail to attract competent and experienced men of the medical profession. There can be no doubt of the validity of the opinion expressed by Professor Osier in speaking of the work of medical inspec- tion 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 America. That the words of the eminent Oxford professor were heeded in his own country seems evident from the salaries paid to the medical 142 Medical Inspection of Schools inspectors of schools in England. Almost without exception the ten- dency is to pay much higher salaries than in America and to make much more liberal provision for clerk hire and for meeting incidental expenses. Apparently by common consent the whole movement has been placed upon a higher plane than in the United States. The English law has but recently been put into operation, and the English newspapers have contained many accounts of the meetings of coimty councils where the new organizations were discvissed and salaries decided upon. It is both interesting and instructive to note the results of some of these meetings. In Northampton two inspectors have been appointed at salaries of $1500 apiece per year. In North Cumberland County it is estimated that there are 11,500 children to be examined. To do this work, two medical inspectors — one a man and the other a woman — have been appointed. They receive $1200 apiece, besides travelling expenses, and a clerk has been appointed to do the clerical work. ' An amendment introduced for the purpose of paying the woman doctor less than the man was defeated. The County of Guildford has employed a chief medical officer at $3000, to be increased by annual increments to $4000, and four assistants who are to receive $1 250 each. Each of these officials receives in addition $200 for travelUng expenses. Stafford employs a senior medical officer at $1515 and three jimior women inspectors at $1250, to be increased by annual increments to $1500. These officers also receive $2.00 for subsistence for each night they are forced to spend away from home. They are also supplied with a clerk who receives $405. In the West Riding District it is estimated that there are 50,000 children to be examined. The total cost of this work has been calculated at $25,000. Of this sum, $17,500 is to be devoted to salaries, $4000 to expenses, and $1000 to equipment. Many advertise- ments have appeared in The Lancet of young surgeons with some experience in children's hospitals who are willing to imdertake the work at salaries ranging from $1250 to $4500 per year. It is to be remarked, too, in considering these English salaries that the amoimts paid represent relatively greater salaries than would the same sums in America. The English law also requires but three ex- aminations in the course of the school life of the child, whereas the statute of Massachusetts, where the standard salary of a school physician Administration 143 is $200 per year, requires that such a complete physical examination of each child be made every year. In view of the differences of the v^ork locally and the great variations of the conditions under which medical inspectors work in different localities, it is impossible to lay down any rule as to the proper number of pupils for each inspector. Assignments of schools to inspectors should be governed by the consideration of such local conditions as the distances separating schools, the size of the schools, the age of the children, and whether or not the work presents special difficulties, such as, for instance, foreign race and nationality of the children. Moreover, it is evident that the greater the number of children for each inspector, the less intimate will be the knowledge he has of the individual children. Where examinations are conducted for the de- tection of contagious diseases only and doctors examine only those children referred to them by the teachers as being suspicious cases, it is pretty generally the opinion that the proper number is two, three, or even four thousand children per doctor, depending largely on the distances to be travelled to reach the schools. In school systems where school physicians conduct formal physical examinations, besides in- specting for the detection of contagious diseases, it is not uncommon to have them work three hours each forenoon, from nine to twelve. Under these circumstances they receive, of coiuse, much higher remuner- ation than under the system just mentioned, and can attend to fewer pupils. Dr. John J. Cronin, Assistant Chief Medical Inspector of the New York City Board of Health, is of the opinion that under these circumstances there should be one medical inspector and one nurse for each two thousand pupils. Where the doctors make physical examinations, the fact that each examination requires from twelve to fifteen minutes on the average must be used as a basis for deciding on an equitable remuneration, according to the local rates of remuneration. In smaller places where the doctors visit the schools only upon the request of the principal or superintendent, it is sometimes customary to pay them at the local rate per visit, considering the whole school as one patient. New York pays its nurses $75 per month and employs them for twelve months in the year. Boston pays the supervising nurse $924 for the first year, which is increased by an annual increment of $48 144 Medical Inspection of Schools to a maximum of $iii6. The assistant nurses receive $648 per year and an annual increase of $48 \mtil the maximum of $840 is reached. New Haven pays its nurse $600 per year. In both England and Germany arrangements are often made in regard to payments for medical inspection which might well be studied with a view to their introduction in America. In England it is not imcommon to pay according to the work done, rather than to decide on any fixed amount. Thus physicians in Derbyshire submitted an estimate to the County Council for conducting physical examination of pupils at the rate of 2 s. 10 d. per head; in Worcestershire the price agreed upon was i s. 8 d. per head. In the County of Somerset the physicians receive i s. 3 d. for each pupil in the rural districts and i s. in the urban districts. In the North Riding and Yorkshire Districts the arrangement is that the medical officer shall receive i s. per child for physical examinations, with the addition of £1 a school in rural districts. In "The Medical Inspection of Schools in Germany" {'' Das Schul- artzwesen in Deutschland"), Dr. Paul Schubert has the following to say regarding the salaries of school physicians : "As to the salaries of school physicians there are two methods — a fixed salary and payment according to work done. In many cities there is a combination of the two systems, that is, a certain addition is made to the fixed salary. For instance, in Wiesbaden the fixed salary of the school physician is 600 marks and a special remuneration is made for the examination of all children in their first, third, fifth, and eighth years of school life. In Leipzig the fixed salary is 300 to 500 marks, according to the size of the district, and an additional sum of 200 marks is paid for the examination of pupils entering school. In Aix-la-Chapelle each school physician receives out of the total appropriation of 6000 marks a fixed salary of 500 marks; the remainder is divided among the physicians at the end of the year, according to the number of children that each physician has examined." " In Mannheim the system of medical inspection is upon an altogether different basis. There one school physician Administration 145 is in general charge (precluding private practice) with a salary of 10,000 marks. We await results of this arrange- ment." A feature of the financial administration of medical inspection 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 it 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. Almost exactly 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 postal 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 on to a trained physician. Here are some names taken more or less at random from the school registers in a Polish section : Rzemieszkievicz, Klymezynski, Zdrojewski, Wrzesimski, Gorzelanczyk, Guleszecwicz. When a doctor is being paid at the rate of from one dollar to two dollars per hour, it is certainly a most unbiisinesslike and inefficient policy to require him to spend half of his time doing work which a clerk at twelve or fifteen dollars a week could perform equally well. The doctor in question 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. It is very difficult to gather reliable information as to the general 146 Medical Inspection of Schools expenses of medical inspection outside of the matter of salaries in Ameri- can cities. Apparently in most places no careful account has been kept. The expenses for printing, incidentals, etc., in connection with medical inspection have simply been included with the general expenses of the board of health or board of education. In only a few cases is informa- tion available. In Springfield, Mass., the average attendance of the public schools is 10,605. The expenses for medical inspection for the year 1907 were as follows : MEDICAL INSPECTION OF SCHOOLS, SPRINGFIELD, MASS. Receipts. By appropriation $2000.00 Expenditures. Salaries of inspectors $1970.00 Printing 25.15 Postage 4-00 Total payments 1999.15 To contingent account .85 $2000.00 Montclair, N. J., has an average attendance in its public schools of 2,503. The following is an account of the expenses for the medical inspection for the school year ending December 31, 1907: MEDICAL INSPECTION OF SCHOOLS, MONTCLAIR, N. J. Receipts. On hand Jan. i, 1907 $1018.60 Appropriated by Town Council 1750.00 ; $2768.60 Expenditures. Salary of inspectors, Jan. i to Jxily i , 1907 . 990.00 Salary of inspectors, July i to Dec. 31,1907 660.00 1650.00 Supplies Jan. i to July i, 1907 21.20 Supplies July i to Dec. 31, 1907 47-93 69.13 $1719.13 Balance on hand Jan. i, 1908, to carry till July i, 1908 io49-47 $2768.60 Administration 147 In decided contrast to these meagre appropriations, and showing that the EngUsh policy is as much more adequate than the American in the matter of appropriations for incidentals as in that of salaries, is the estimate of cost of medical inspection at East Sussex, England. The district contains 176 schools and approximately 26,000 pupils, of whom 21 per cent., or 5,460, are to be examined the first year. The following is a financial estimate of the subcommittee of the East Sussex Education Committee: MEDICAL INSPECTION OF SCHOOLS, EAST SUSSEX, ENGLAND Salaries and travelling expenses $3547.80 176 weighing machines at $6.06 each 1066.56 176 height measuring standards at 84 cents each 147-84 360 copies Snellen's test at $2.40 per doz 72.00 176 screens at $2.40 each 422.40 15,000 cards at $4.86 per thousand 73-9o 240 card cabinets 437-40 15,000 notices to parents at $2.43 per thousand 36.4S Sundries 607.50 Total for appliances and incidentals $2864.05 Total cost for first year $641 1.85 There are many other minor questions of administration which present themselves for discussion. Some of these are: Is it better to have medical inspectors devote their entire time to the work, or is it preferable that they give only part of their time and have outside prac- tice? Should the doctor be allowed to prescribe for children? What should be done in the case of parents too poor or too indifferent to take measures recommended by the physicians ? If, for instance, the child has defective vision and glasses are needed, who is to ftirnish them if the parents fail to do so? It is difficult to answer these questions because in many, if not most, cases the answer depends on local conditions. It is the general opinion of the best authorities that medical inspectors should not devote their whole time to the school work. The work is exceedingly monoto- nous, and if the doctor is prohibited from having an outside practice 148 Medical Inspection of Schools opportunities for increasing his skill and enlarging his experience are to a great extent cut off. To the question as to whether a doctor should prescribe for children, the answer must be made that under no conditions should he lay himself open to the charge that he is using his official position for the purpose of enlarging his private practice. This is the basis for the almost invariable rule that except in cases of emergency the school doctor shall not prescribe. It has been suggested that in cities of small size and in towns there should be employed one man, a physician, thoroughly trained in the science of modern preventive medicine, who should fill the offices of school medical inspector, director of physical training in the public schools, and director of physical training in the playgrovmds during the summer months. By such an arrangement a salary could be paid that would attract the best men, without undue burden on the tax- payers, even in comparatively small places. The problem of furnishing free eyeglasses for indigent pupils has been widely discussed. As far back as 1901 the city of Cleveland gave away 400 pairs to pupils needing them and whose parents claimed to be unable to meet the necessary expense. In a number of cities first class opticians have made offers to furnish glasses at a uniform price of $1 a pair to school children. A case in point is Lowell, Mass. In Philadelphia there is a city ophthalmologist who prescribes for children found to have defective vision, and then glasses are furnished through his office at the cost price of eighty-five cents a pair. In most places where the matter has been carefully studied it is found that careful follow-up work on the part of the school authorities will result in nearly all of the cases being taken care of by the parents of the children, and in the cases of families genuinely unable to meet the expense it has always been possible to arrange with charitable organizations to furnish the glasses. The percentage of cases where this has been found necessary or desirable is exceedingly small. 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. Examina- tions by teachers for the discovery of defects of vision and hearing involve only the added expense of the simple printed material required. Administration 149 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 ex- aminations of all children cost the most and are by far the most valuable. From a social and economic viewpoint 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. 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 most of their time in doing the purely clerical work of filling out blanks in duplicate and triplicate. Permanent efiiciency will require skilled workers, careful adminis- tration and adequate remuneration. CHAPTER X Controlling Authorities 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. Both sides of the question 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 segrega- tion of cases of contagious disease. This is a protective measvire re- lating to the safety of the whole community, and as such should remain a function of the board of health. On the side of the argument for keeping the work in the hands of the board of education it is claimed that the whole work, to be effective, must be so closely related to school work and school records that friction inevitably results when those in charge are in the employ of an outside body, neither responsible to nor perhaps in sympathy with those having schools in charge. This results in a loss of efficiency. The further claim is made, and substantiated by referring to records of work done in many cities, that the exclusion of cases of contagious disease is after all a comparatively small part of the work of medical inspection, even where the work is confined to the examination for the detection of cases of contagious disease and physical examinations are not made. Thus in Haverhill, Mass., in 1907 the total exclusions amounted to 222 in a school membership of 5230, or about 4 per cent. In Newark, N. J., in the same year the exclusions were 1579 in a school 150 Controlling Authorities 151 membership of 38,562, or again 4 per cent. In the State of Massa- chusetts in 1907, towns and cities having an average attendance of 342,000 reported something more than 15,000 exclusions during the year. Again the percentage is 4. In all of these cases a large proportion — in fact nearly half of the exclusions — are on account of one cause, pedicu- losis (lice). In cities where school nurses are employed, these cases are not excluded and thus the number of exclusions is greatly cut down. In New York in 1906 the exclusions amounted to 11,101 among a school membership of 505,000, or only 2 per cent. 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, Dr. William H. Maxwell, City Superinten- dent 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 Education 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 advisa- ble should be performed by a truly educational department of hygiene, such as studying hygienic conditions 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 tmder the control of an outside organization is a 152 Medical Inspection of Schools 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 guar- antee 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." In speaking of the work of the school nurses, he says: " It does not seem possible to conceive a more satisfac- tory arrangement, 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 efficiency 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, says in regard to the Massachusetts law making medical inspection compulsory : Controlling Authorities 153 "In this connection it should be stated that while the school physicians were concerned solely with contagious diseases, they were properly to be controlled by the Board of Health. Under the new law, the work of examining into any defect that interferes with the progress of the children 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 Department of Physical Training that the school physicians 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, after making an able plea for the establishment in the schools of the city of a system of medical supervision: "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, the Superintendent of Schools of Newark, N. J., says that the medical inspection as conducted by the Board of Health has been satisfactory, 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 in- spectors 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 154 Medical Inspection of Schools his other duties the duty of overseeing daily the work of sixteen medical inspectors. Dr. Fred S. Shepherd, Superintendent of Schools of Asbury Park, N. J., says: "Again, if the system is to work harmoniously, the medical inspector shoidd 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 common 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 inefficient and un- satisfactory 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 with the workings of a school system, having a successful system of medical inspection under physicians appointed by the Board of Education. In telling of 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 piurposes. I presume it does devolve upon local boards of health to inspect for sanitary purposes all public build- Controlling Authorities 155 ings, 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 ap- parent overlapping of jurisdiction, I see little opportunity for any clashing of interest. On the contrary, it is possi- ble for the very closest relations to be established between boards of health and the school medical au- thorities. 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 imaginary 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, Mass. There medical inspection is, of course, conducted xmder the provisions of the State statute, which provides for the appointing of school physi- cians by either the school committee or the board of health. In Lawrence the threatened conflict came to a head in August, 1907, when the Board of Health appointed 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 was appointed by the School Committee in August, 1906, for a term of three years. This continues and the schools are under a double inspection, with much consequent unavoidable friction. One of the strongest arguments in favor of medical inspection under the authority of boards of education is that the efficiency of the work demands that there shall be the closest cooperation between the medical and the educational authorities. If the results of the work are to be profitable, if diligent effort is to be made to correct the defects fovmd, 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 relation- ships are essential. 156 Medical Inspection of Schools It has been claimed that where the work is done by the board of health this is dij6&cult or impossible. Certainly an examination of the annual reports of some of the superintendents of cities where the medical inspection is conducted by the board of health would seem to 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 work of the class. Examples of such an attitude as this are foimd in reports of the Superintendents of Schools of Haverhill and Springfield, Mass., for 1907. The Superintendent of Schools of Haverhill, Mass., disposes in his report of the work of medical inspection with the following brief remarks : "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 classi- fication. 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 ten lines. Such comment certainly does not seem to indicate intimate knowledge of the work being done or any intimate relationship between the work of the school physicians and that of the educational authorities. A similar condition seems to be revealed in Springfield, Mass., where the sole comment of the School Board on the work of the physi- cians appointed by the Board of Health is, "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: Controlling Authorities 157 "The movement now in progress, which has reached different stages in different countries, seems to be shap- ing itself so as to include as necessary features the follow- ing 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 coopera- tion 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." In Chapter I we have already traced the two sources of the move- ment that is leading to the medical care of school children; one develop- ing from the standpoint of existing and recognized functions of the Department of Health, and the other from a less well defined or con- scious relation of departments of education to the welfare of school children. The relation between these two functions is not an easily defined one. The fact that from a number of cities the percentage of cases needing exclusion is not over 4 per cent., while the number of children needing care with reference to defects, exercise, suitable seats and desks, type, paper, suitable hours of study, and the like, include all the children, shows that one is specific and limited, the other general and almost unlimited in its scope. It is natural that those who have approached the problem from the standpoint of contagious disease or pathology are prone to regard the whole work as belonging as a natural function to the department of health. It is equally natural that those who are accustomed to look at growth and development as the ultimate object should fail to recognize the fundamental obligation supported by legal powers possessed by the boards of health with reference to community protection. This legal power and obligation cannot easily be transferred to any other city department, and should not be, even if it could. In summing up, then, we may conclude as a result of the evidence presented : 158 Medical Inspection of Schools I. The detection of contagious diseases in the schools, involving daily visits 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. II. Those activities which have to do with the child's physical condition as related to his 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— rare in the natiu^e of the case an integral part of school interests and must not be divorced from them. Moreover, the records of the examinations 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 diseases may well be a fimction 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 cooperation, 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 Legal Aspects of Medical Inspection On Friday, April 17, 1908, Mr. Almuth C. Vandiver, counsel for the Medical Society of the County of New York, read a paper on " Statu- tory Enactments relating to the Medical and Sanitary Inspection of Schools" before the Second Congress of the American School Hygiene Association, then in session at Atlantic City. Most of the facts pre- sented in the following chapter have been through the courtesy of Mr. Vandiver taken from his paper. There are few legislative enactments under which the views and beliefs, and results of experience, of educators and physicians have been crystallized in Europe and America in the field of medical inspection of schools. There are but two important statutes. The English statute, which became a law 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 a manda- tory medical inspection law far more comprehensive in its provisions than the English law. The English law, known legally as " Section 13 of the Administrative 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 attend- ing public elementary schools, vacation schools, vacation classes, play centers, etc. (b) The duty to provide for the medical inspection 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 IS9 l6o Medical Inspection of Schools Education for attending to the health and physical condi- tion of the children educated in public elementary schools: Provided, that in any exercise of powers under this section the local education authority may encourage 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 comprehensively 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 is left finally to the courts. This procedure is a lengthy and involved practice. In view of the fact that the memorandum 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. It will be observed that the burden of executing the provisions of the statute is specifically laid upon the education authorities. This is a distinct departure from the established course heretofore pursued in matters relating to the public health. In the view, however, of the London Board of Education 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 develop- ment 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 cooperation 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 Legal Aspects of Medical Inspection i6i 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 board's instruments are the local education authorities. In country areas this authority is the county council. It is suggested in the memorandum that the county council confer with and cooperate with the co\mty medical ofl&cer. 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 both the local authority for public health, and also the local education authority, is counselled to instruct their medical officer of health to advise the education committee. Where no medical officer has been appointed, it is suggested that his appointment be made by the educa- tion authorities. Where there is already a school medical officer, it is suggested that his appointment remain undisturbed. Although there is no provision for school nurses in the act, the Board of Education advised that wherever practicable such nurses be employed. The Board decided that not less than three inspections during the school life of a child will 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 supervision of the personal and home life of the child are also suggested. Finally, it should be observed that there is in the act no section whatever providing that parents of school children, found diseased or defective after such inspection, shall provide proper medical attention at the hands of their own physician or of the hospital authorities. "Every authority which has so far undertaken medical inspection," says Dr. Hackworth Stuart, commenting upon the new law, "has ex- perienced great difficulty in overcoming parental indifference and neglect in very many defective cases. In some cases it is at present impossible to persuade the parents to act on the notification made after the visits of inspection. Legal proceedings against the parents for neglect would not prove a very helpful custom for general adoption." Dr. Stuart suggests that inspection would become more fruitful in 1 62 Medical Inspection of Schools its results if the education authorities were empowered to secure treat- ment of cases where recommendations of the inspectors are repeatedly neglected and to recover the costs from the parents. In this view it is difficult to coincide so far as the United States are concerned. In this country a penal provision seems essential for the proper execution of any law imposing a duty upon the people or any part of them. Prior to the adoption of the EngUsh statute, the education authorities in various localities carried on a system of notification to parents of defects found to exist in their children by school medical inspectors. In these notifications, the parents were advised to secure medical atten- tion without delay, and explanations for the necessity of such action were included, but there was no legal authority existent to compel the parents to secure such medical attention if the same was neglected. It was found by the school authorities in Hanley that the segregation of defective pupils during school hours and during play-time had a more satisfactory effect upon the parents than any other method adopted. Let us now consider for a comparison with the English statute the only legislative enactment existing in the United States making medical inspection mandatory. As it 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 502 of the Acts of 1906, and became a law of the State of Massachusetts on the ist day of September, 1906. It provides: 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 in- spection as this act requires, the board of health shall appoint and assign the school physician. Section 2. Every school physician shall make a prompt examination and diagnosis of all children referred to him Legal Aspects of Medical Inspection 163 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. Section 3. The school committee shall cause to be referred to a school physician for examination and diag- nosis every child returning to school w^ithout 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 excluded from school by the teacher; except that in the case of schools in remote and isolated situations the school committee may make such other arrangements as may best carry out the pur- poses of this act. 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, tonsillitis, whooping cough, mumps, scabies, or trachoma, he shall be sent home immediately, or as soon as safe and proper conveyance can be found, and the board of health shall at once be notified. Section 5. 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 suf- fering 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 modifica- tion of the school work in order to prevent injury to the child or to secure the best educational results. The tests of sight and hearing shall be made by teachers. The committee shall cause notice of any defect or disability requiring treatment to be sent to the parent or guardian of the child, and shall require a physical record of each 164 Medical Inspection of Schools child to be kept in such form as the state board of educa- tion shall prescribe. 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 instruction and practice in the best methods of testing the sight and hearing of children. The state board of education may expend diir- ing 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 pur- pose of supplying the material required by this act. Section 7. The expense which a city or town may incur by virtue of the authority herein vested in the school com- mittee or board of health, as the case may be, shall not ex- ceed the amount appropriated for that'purpose in cities by the city council and in towns by a town meeting. The appropriation shall precede any expenditure or any in- debtedness which may be incurred under this act, and the sum appropriated shall be deemed a sufficient appropria- tion in the municipality where it is made. Such appropria- tion need not specify to what section of the act it shall apply, and may be voted as a total appropriation to be applied in carrying out the purposes of the act. (Repealed in 1908.) Section 8. This act shall take effect on the first day of September in the year nineteen hundred and six. (Ap- proved June 20, 1906.) It will be noted that the provisions of section 7 enabled any city coun- cil or town meeting to render ineffective the whole medical inspection law, by refusing to grant a proper appropriation therefor. A few cities and towns availed themselves of this opportunity, and in order to avoid this possibiUty the legislature of 1908 repealed the section. Legal Aspects of Medical Inspection 165 Observe that the English statute and the Massachusetts statute each make medical inspection compulsory. Neither includes a penal provision providing for procedure against neglectful parents of defective children. In these two essentials, the acts are similar. In the English act, the education authorities are charged with the administration of the law. In Massachusetts, the school authorities in every city or town appoint medical examiners, except in cities where the board of health is already maintaining or shall hereafter maintain such medical inspection as the act requires. In this latter class the board of health appoints. In the Massachusetts statute, an examination of each pupil is pro- vided at least once in every school year for defective sight or hearing, or any other disability. The tests are given by the teachers, but the board of health prescribes the directions for tests. Notices of defects must be sent to the parents. In the English statute, there is no expressed provision for the number of medical examinations, but as has hereinbefore been stated, the London Board of Education has prescribed three examinations during a school life as necessary. These are the leading statutes in Europe and America upon this sub- ject. The American statute has been in effect for less than two years, the English statute a little over one-half year. Neither, therefore, can be considered as yet away from the experimental stage of legislation. Let us now consider the work of medical inspection done without specific mandatory legislative enactment, and done under the existing permissive provisions of the Public Health Laws of the State of New York, in the most populous city of America. New York state has no specific statute making medical inspection compulsory. Such inspection is conducted in the city of New York by the Department of Health under the general authority of the PubHc Health Laws, authorizing local health boards to guard against the intro- duction of contagious and infectious diseases by the exercise of proper and vigilant medical inspection, and the control of all persons and things arriving in the municipality from infected places, or which from any cause are liable to communicate contagion. This statute is Section 24 of Arti- cle 2 of Chapter 661 of the Laws of 1893 and amendments thereto. 1 66 Medical Inspection of Schools Section 210 of Article 12 of the same statute makes the vaccination of school children compulsory. To show the attitude of the people of New York, it may be said that the enforcement of this section was bitterly contested to the Court of Final Appeal, where its constitutionality was affirmed in October, 1901. Although no legislative enactment yet appears upon the statute books of New York in regard to compulsory medical inspection of school chil- dren, more consideration has been displayed in section 213 of Article 12 of the same law, in regard to the examination and quarantine of children admitted to institutions for orphans, destitute or vagrant children, or juvenile delinquents. This section provides : "Every institution in this state, incorporated for the express purpose of receiving or caring for orphan, vagrant or destitute children or juvenile delinquents, except hos- pitals, shall have attached thereto a regular physician of its selection duly licensed under the laws of the state and in good professional standing, whose name and address shall be kept posted conspicuously within such institution near its main entrance. The words 'juvenile delin- quents' here used shall include all children whose com- mitment to an institution is authorized by the penal code. The officers of every such institution upon receiving a child therein, by commitment or otherwise, shall, before ad- mitting it to contact with the other inmates, cause it to be examined by such physician, and a written certificate to be given by him, stating whether the child has diphtheria, scarlet fever, measles, whooping cough or any other con- tagious or infectious disease, especially of the eyes and skin, which might be commimicated to other inmates and speci- fying the physical and mental condition of the child, the presence of any indication of hereditary or other consti- tutional disease, and any deformity or abnormal condition found upon the examination to exist. No child shall be so admitted until such certificate shall have been furnished, which shall be filed with the commitment or other papers Legal Aspects of Medical Inspection 167 on record in the case, by the officers of the institution, who shall, on receiving such child, place it in strict quarantine thereafter from the other inmates, vintil discharged from such quarantine by such physician, who shall thereupon indorse upon the certificate the length of quarantine and the date of discharge therefrom." " Section 214. Monthly examination of inmates and reports. — Such physician shall at least once a month thoroughly examine and inspect the entire institution, and report in writing, in such form as may be approved by the state department of health, to the board of managers or directors of the institution, and to the local board of the district or place where the institution is situated, its condi- dition, especially as to its plumbing, sinks, water-closets, urinals, privies, dormitories, the physical condition of the children, the existence of any contagious or infectious disease, particularly of the eyes or skin, their food, clothing and cleanliness, and whether the officers of the institution have provided proper and sufficient nurses, orderlies, and other attendants of proper capacity to attend to such chil- dren, to secure to them due and proper care and attention as to their personal cleanliness and health, with such reconomendations for the improvement thereof as he may deem proper. Such boards of health shall immediately investigate any complaint against the management of the institution or of the existence of anything therein danger- ous to life or health, and, if proven to be well founded shall cause the evil to be remedied without delay." The penal provisions of the Health Law in regard to violations thereof provide : "Section 397. Wilful violation of Health Laws. — i. A person who wilfully violates or refuses or omits to comply with any lawful order or regulation prescribed by any local board of health or local health officer, is guilty of a misdemeanor. *' 2. A person who wilfully violates any provision of the 1 68 Medical Inspection of Schools health laws, or any regulation lawfully made or established by any public ofi&cer or board under authority of the health laws the punishment for violating which is not otherwise prescribed by those laws, or by this code, is punishable by imprisonment not exceeding one year, or by a fine not exceeding two thousand dollars or by both." The Public Health Laws of the State of New York are sufl&ciently broad and comprehensive in their general authorizing provisions to warrant the establishment and maintenance by the health authorities of an adequate system of medical inspection of school children. Hearty cooperation on the part of the education authorities is essential, how- ever, to make the work effective. In 1892, medical inspection in the parochial schools of Philadelphia was established and was soon discontinued on accoimt of much opposi- tion thereto. In 1890, Boston ordered such medical inspection, but did not enforce it until 1894. In 1895, Chicago followed suit. The principle upon which medical inspection of schools was estab- lished in these cities, and in fact the principle upon which medical inspection has proceeded in all of the states in the Union, has been the prevention and elimination of infectious and contagious diseases, and not upon the high intellectual plane upon which the Board of Educa- tion of London in the memorandum before referred to have placed the reasons for the enactment of their legislation in the following words : " The Board desires, 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 improve- ment, 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 Legal Aspects of Medical Inspection 169 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." In 1897, ^5° physicians were appointed by the Department of Health of New York to inspect schools. In 1907, there were 166, together with 50 trained nurses, at work. From 1897 to 1902, the efforts of these physicians were directed to excluding children with infectious and contagious diseases. In 1902, each child was personally examined once a week. In 1905, the examination of each child thoroughly to ascertain the existence of any contagious affection was instituted. No child was treated whose parents were able to employ physicians. The fundamental principles in force at that time were: 1. Repeated and systematic inspection of all school children for the purpose of early recognition of contagious diseases. 2. Exclusion from school attendance of all children affected with an acute contagious disease. 3. Subsequent control of case with isolation of patient and disinfec- tion of the living apartment after termination of illness. 4. Control and enforced treatment of minor contagious ailments with the purpose of diminishing the number of children excluded from school attendance. 5. Knowledge of unreported cases of contagious diseases. 6. Complete physical examination of each school child with reference to the existence of any physical or mental abnormality. The working officers consisted of a chief medical inspector, a corps of physician inspectors, a supervising nurse, and a corps of trained nurses. In the English statute there is no provision for the employment of school nvu*ses, but such employment is recommended wherever feasible. It seems to be the general opinion of hygienic experts that admirable results in the furtherance of medical inspection, especially in the home treatment of defective children, have been obtained by the employment of school nurses. Under the regulations of the New York Health Department, each 1 70 Medical Inspection of Schools physician inspector visited a group of schools before ten in the morning and examined: 1. All children isolated by the teachers suspected of contagious diseases. 2. All children who had been absent from school for any reason. 3. All affected children neglecting treatment. 4. All cases referred by the school nurse for diagnosis. Upon diagnosis of contagious disease, the child was sent home and could not return to the school except on the certificate of the Depart- ment of Health as to the termination of the disease. Children suffering from skin diseases were ordered to go to their family physician, or to dispensaries, or to the school nurse for treatment. The nurses were assigned to schools in crowded tenement districts, and treated such pupils as were sent to them by the medical inspectors. Routine weekly inspections were also made by the nurse. All doubtful cases were referred for diagnosis. In 1905, the nurses treated 976,092 cases. Two dispensaries and one hospital for trachoma were established. Absentees were visited by the physicians and by the nurses. The Superintendent of Schools of New York in his annual report for 1907, has recommended legislation establishing a Department of Hygiene, to be placed under the sole and exclusive jurisdiction of the education authorities as the most important and necessary work to be accomplished at the present time by the Board of Education. Here is food for expert thought. Specific, compulsory legislation authorizing the education authori- ties in the city of New York to conduct medical inspection is suggested by the chief executive officer of the city schools, in the greatest city in the country. Dual responsibility is deprecated. On the side of the sole jmrisdiction of the education authorities stands the English statute. The tendency of the Massachusetts statute is to put the jurisdiction in the education authorities. In the latter, however, there is co- ordinate reference to the health authorities. It will be interesting to observe the measure presented for enactment in the state of New York, after due and proper discussion on the subject from all points of view. Legal Aspects of Medical Inspection 171 None of the other states of the Union have specific statutes making medical inspection mandatory. New Jersey has a statute making medical inspection permissible. This statute went into effect on October 19, 1903. It is Section 229 of Article 27 of the School Laws, and is as follows: "Medical Inspector. Duties. — 229. Every Board of Education may employ a competent physician to be known as the medical inspector, fix his salary and define his duties. Said medical inspector shall visit the schools in the district in which he shall be employed at stated times to be determined by the board of education, and diuring such visits shall examine every pupil referred to him by a teacher. He shall at least once during each school year examine every pupil to learn whether any physical defect exists, and keep a record from year to year of the growth and development of such pupil, which record shall be the property of the board of education and shall be delivered by said medical inspector to his successor in ofiice. Said inspector shall lecture before the teachers at such times as may be designated by the board of education, instructing them concerning the methods employed to detect the first signs of communicable disease and the recognized measures for the promotion of health and pre- vention of disease. The board of education may appoint more than one medical inspector." Vaccination is compulsory under the same statute, as it is in most states. The superintendent of the city schools of Newark is authority for the statement that there has been medical inspection in Newark for seven years last past. The weak point in the New Jersey law, in his opinion, consists in the lack of authority vested in the Board of Health or in the Board of Education to compel parents to give suitable treatment to those children excluded from school because of physical defects needing surgical treat- ment, etc. 172 Medical Inspection of Schools He also says : " It is the purpose of the Board of Education of this city to take over the full control of medical inspection of pupils combined with the approval of the Board of Health, which until now has shared responsibility. There are several important reasons with us why it is desirable that the Board of Education should have the sole responsibility in the matter of medical inspection and treatment of school pupils." In Newark medical inspectors are by Section II of the Board of Education instructions at all times under the immediate direction and control of the Board of Health in all matters pertaining to the per- formance of their duties. They are required to make a daily report to the Board of Health. The matter of more thorough inspection is now under consideration in New Jersey. In the belief that the legal status of medical inspection in the more progressive states of the Union, and the lack of the same in other states, might be interesting and perhaps helpful, an attempt has been made to collate the information relating thereto furnished by the health and education authorities of the various state governments. In Maryland there is no statutory requirement for individual inspec- tion and medical treatment of school children. In Baltimore there is medical inspection under the city ordinances. Section 5 of Article 43 of the Code of Public Health Laws of Mary- land provides, in reference to the duties of the Secretary of the State Board of Health, that "He shall when requested by local boards visit their respective districts, cities or villages, investigate the cause of any existing disease, and shall from time to time and whenever directed by the Governor or legislature make special inspections of public hospitals, asylums, prisons and other institutions, and shall when required by the Governor or other proper authorities advise in regard to the location, drainage, water supply and ventilation of any public institution " Section 22, same article, provides that "the board of County Com- missioners in the several coimties in this State shall ex officio constitute a Legal Aspects of Medical Inspection 173 local board of health for their respective counties and shall have and exercise all the duties of a board of health as provided in this article. The general authority to make such inspections under the Public Health Laws is given to the state and local boards of health. The secretary of the State Board of Health does not believe it ex- pedient to provide special legislation for the purpose of sanitary inspec- tion of schools if the general statutes give the necessary power. He is also of the opinion that individual attention to the health of school children is best provided for by local ordinances or regulations. In Pennsylvania there is no legislation relative to medical and sani- tary inspection of public schools. In the rural districts the State Department of Health has considered that, in its duty to protect the health of the public generally, it should make sanitary inspections, inasmuch as this matter appeared to be entirely neglected. In Philadelphia the local Board of Education has taken up the matter with the assistance of the local Board of Health. In Philadelphia school nursing has also received some attention, but so far as the action of the State Legislature is concerned, nothing has been done. The view of the Assistant Commissioner of Health in Pennsylvania is that sanitary inspection, referring to construction, location, etc., is a proper function of the Board of Education, and that the medical inspection, which involves the examination of pupils by physicians, should be undertaken by the Board of Health. The chief of the Bureau of Health of the city of Philadelphia says that the work in Philadelphia was the outcome of an agreement between the Bureau of Health and the Board of Education, and approved by City Councils, who furnished the means for the conduct of the work. In so far as the treatment of children found in the schools suffering from disease is concerned, the great majority of them are looked after by their parents. Those who cannot be looked after by their parents, are attended by the district physician or by some one or another of the hospitals in the city. Children having defective vision, who are in such destitute circum- stances that their parents cannot provide necessary relief, are relieved by this Bureau at the city's expense. 174 Medical Inspection of Schools The Bureau has an expert ophthalmologist making examinations, and money is provided for the piirchase of glasses. The chief is an advocate of school inspection. He believes it is only partially successful. He thinks it is imsatisfactory, that continuously, in the schools of their city, children are foimd who should be imder the care of specialists ; some of them requiring orthopedic corrections, some of them mentally enfeebled, and some epileptic, and others suffering from similar afflic- tions. These cases cannot be properly looked after by the means at the Biureau's disposal. He suggests special schools for children who are abnormal in any particular. The Bureau has no difficulty with children who are acutely sick. If their parents pay no attention to their condition, it is within the power of the Bureau to convey them to one or another of the hospitals under the Bureau's control. In Illinois there is no specific legislation relative to sanitary and medical inspection of public schools. The local boards of health throughout the state are legally em- powered to inaugurate and carry on such inspections. There is no law legalizing inspection of pupils in schools. Chicago has city ordinances under which sanitary inspection of school buildings is carried out. Also medical inspection of school pupils for the purpose of keeping out infectious diseases. There is no examination for physical or mental defects at present. The law does not authorize such. The medical inspector of the Department of Health, however, states that the Depart- ment of Health expects to try making such examinations and to endeavor to show results which wiU justify making laws legalizing such work. In the District of Columbia there is medical inspection imder rules formulated by the health officer in 1903, and approved by the Board of Education, in accordance with an act making appropriations to provide for the expenses of the government of the District of Coliunbia. They were amended in 1907. These rules have the full legal force and effect of law. In regard to inspection, the health officer says : " School nursing has not yet been provided in this Dis- trict, but the Commissioners have recommended that an Legal Aspects of Medical Inspection 175 appropriation be made for the services of two nvirses to operate in connection with the medical inspectors of schools. The only present means of enforcing the parental obligation to provide treatment for school children after exclusion from school is through the truancy act. If a child is excluded and a parent does not adopt such meas- ures as may be necessary to permit it to return to school, it might, if the measures to be adopted are reasonable and within the reach of the parent, be possible to compel action by the parent by prosecution for failing to send the child to school. This procedure has, however, not yet been tried in court, although the possibility of it has been a weapon effectually used in certain cases. " In my judgment, it is quite as important for the state to look after the physical welfare of its children as it is for it to provide for their mental training, and I feel that justi- fication could be found in the laws of most jurisdictions for every proper means toward that end; not necessarily existing statutes or regulations, but, if not, then warrant in the constitution, federal and state, for the enactment of such statutes and the promulgation of such regulations. The supreme authority which the state may exercise with respect to the physical welfare of pupils in attendance on public schools is shown, I beUeve, by the general trend of decisions in cases in which vaccination has been required as a condition precedent to school attendance." The regulations governing the medical inspection of pubHc schools in the District of Columbia provide for an examination by the teacher, and if any indications of defects or disease are discovered by her lay mind, the medical inspector must be summoned. The medical inspector is required also to make perfunctory routine visits to the schools. No physical examination of the pupils of any entire room or building is to be imdertaken except so far as may be necessary for the detection of communicative diseases and defects of sight and hearing, without the consent of the Board of Education. 176 Medical Inspection of Schools California. — There is but one law on the statute books of this State for medical attention to be bestowed upon public schools children. Many years ago a special act providing that no Board of School Trustees or Boards of Education shall permit any child to attend the public school who fails to show satisfactory evidence of vaccination, was enacted. The law met with much opposition. At each session of the Legislature its repeal is attempted. At Berkeley (site of State Uni- versity) the an ti- vaccinationists operate a school for their own children at their own expense. This information is from R. H. Webster, Deputy Superintendent of the Schools of San Francisco. Mr. Webster thinks there should be systematized medical inspection of children attending the public schools, and further that necessary treatment be provided in case that the parent or guardian of a child is in indigent circumstances. The matter is being considered in some cities, notably Los Angeles. A bill will be introduced into the next Legislature. Colorado. — There are no laws relative to medical and sanitary inspection of schools by boards of health. General statutes creating the state and local boards of health give necessary power. The local health officers of the various towns and coimties maintain supervision over the schools in their districts for the prevention of con- tagious and infectious diseases. The Health Department at Denver arranges for an examination of the pupils in the various schools at stated times. The Health Board of the state has insufficient fimds to go into the work as thoroughly as they should. Connecticut. — ^The Legislature of Connecticut, in 1899, passed a law providing for the testing of eyesight in all the public schools of the state. Under the law, the State Board of Education is required to fiu-nish test cards and blanks and instructions for their use to the school authorities. The superintendent, principal, or teacher in every school is required to test the eyesight of all the pupils during the fall term and notify in writing the parent or guardian of every pupU who has any defect of vision, with a brief statement of each defect. The tests are made triennially. The boards of education and school committees Legal Aspects of Medical Inspection 177 in the several towns of the state, under the authority granted in the general statutes, may appoint physicians to act as school inspectors. Florida. — There are no statutes looking to the protection of school children either in the construction of school houses or in the examina- tion of the pupils. In 1907, an effort was made by the State Board of Health to obtain some general legislation in regard to health and sanitary matters, but, in the language of the secretary, who is the State Health Officer: "A difficulty exists always in trying to acquire legislation of this kind which has no political significance or interest to the politicians, and the failure of the State Board of Health to better the sanitary and health condition of the people in this direction through legislative enactment was due altogether to these causes, and not to any interest or efforts on the part of the Board to effect the same." Georgia. — No legislation. The secretary of the Health Board says : "The matter of public hygiene has been given practic- ally no consideration in this part of the country as yet, though I trust that in the future it will receive more atten- tion. There is no question of the fact that there is great need of such legislation, but I see very little hope of any- thing being done in that line in the near future in this state." Idaho. — The State Board of Health was organized in 1907. There is a local board of health in each cotmty, consisting of the county physi- cian and the county commissioners. The State Board requires the inspection of public school houses as to their sanitary condition twice a year. There is no law covering the inspection of school children. Indiana. — The secretary of the State Board of Health tells Indiana's story in the following words : "Your letter received asking information concerning Indiana's Statutes which refer to the medical inspection of school children. There is not a single statute relative to this subject in Indiana. We simply let our defective and 178 Medical Inspection of Schools sick children die, and all pleas heretofore made to our legislatvire have been rejected. We hope some day that Indiana will rise above this barbarism by the people send- ing men to the legislature who are intelligent and pro- gressive enough to take hold of this great and important subject. " We are sorry that Indiana cannot make a better report. Indianapolis, at one time, had medical school inspection, but just now, there is a quarrel between the City Council and the school board, as to who shall pay the bill, and nothing is being done. Between looking after the health of our children and having the pleasure of a quarrel among politicians, we know which way it will go." Indiana boards of health, however, may make medical inspection of schools under the general statutes. Kansas. — No legislation requiring medical and sanitary inspection of schools by boards of education. In igo6, the State Board of Health made a rule requiring a critical sanitary inspection by county health officers of every public school building in their jiurisdiction, and during the summer vacation requiring that each school house be thoroughly and efficiently fumigated before the fall term of school began. This rule has been quite generally and effectively put into execution during the past two years, and many unsanitary and unwholesome conditions found and rectified. The Board of Health considers that there is much need for special legislation along these lines. In 1907 a bill providing for medical inspection was defeated. Kentucky. — No provision has been made by the state or city for medical and sanitary inspection of public schools. At the last meeting of the Legislature a bill was introduced providing for medical inspection in cities of the first, second and third classes. This biU failed of passage in the rush of business at the end of the session. Michigan. — No specific laws relating to the medical and sanitary inspection of schools. No obligation upon the parents or mimicipality to provide treatment when a child having some contagious disease that is dangerous to public health has been excluded from school. Legal Aspects of Medical Inspection 179 Detroit and one or two other cities have inaugurated medical inspec- tion of schools, and the results are most satisfactory. The secretary of the Board of Health believes that there should be not only medical inspection of the pupils, but a general supervision of buildings and grounds, toilets, heating, ventilating, and all the conditions under which a child is obliged to acquire an education. A general revision of the health laws at the next session of the Legis- latiure is being advocated. The schools of Detroit are inspected daily by physicians appointed by the Board of Health. There are 27 inspectors, each receiving a salary of $250 per year. The physicians do not prescribe. Minnesota. — The State Board of Health advises that medical inspec- tion is to be made throughout the state wherever possible, but under the present laws school inspection cannot be insisted upon. For some years, the Health Board has tried to secure the examination of the eyes and ears of school children throughout the state. In the smaller places, the Board has met with liberal support, but the larger cities, Minneapolis and St. Paul, have not yet fallen into line in this work. Minneapolis, during the winter of 1907 and 1908, has endeavored to introduce school inspection. Medical inspection, except in an experimental way, has not been carried on. There is no legislation, except that cities are permitted to introduce medical inspection if they see fit. The Health Commissioner is in sympathy with medical inspection carried on primarily as an aid to departments of health in the early detection of all kinds of contagious diseases. He thinks that if this should be pursued to the extent of employment of school nurses, it would prove pernicious. Nebraska. — No special laws. "Nebraska," says the health inspector of the state, "being yoimg and but lightly populated, and having abundance of pure air, does not, perhaps, stand so much in need of such laws as you of the east, with your dense population overcrowded cities, and smoky and noxious atmosphere." New Hampshire. — No legislation requiring medical inspection or providing treatment after inspection. No legalized system of sanitary inspection. i8o Medical Inspection of Schools Sanitary inspections of school buildings are occasionally made by local boards of health, more particularly upon complaint of parents, teachers, or school boards. The views of the secretary of the State Board of Health are that medical inspection of school children ought to be made everywhere, and that legal responsibility for the treatment of such as require it should be placed upon parents, if able, and otherwise, on the municipality. Ohio. — The present statutes permit boards of health to establish systems of medical inspection for the prevention of communicable diseases, and also permit such boards to make an inspection of school buildings twice a year for the purpose of determining conditions of lighting, ventilation, etc. There is nothing mandatory in this legislation and it is not likely that anything concerning this matter will be enacted during the present session of the Legislature, The feeling of the Board of Education is that boards of education should be empowered to make medical examinations of all school children and that there should be power conferred enabling the Board to require parents to do whatever is foimd necessary following such examinations. At the present time, the Board invokes the Juvenile Court in all matters coming to oiur attention. They are enabled on the charge of "neglect of children" to bring most parents to time in these matters. Oklahoma. — No laws at present. The first State Legislature now in session. Oregon. — No legislation in regard to medical and sanitary inspection of schools, other than that given city, county, and state boards of health in the state health laws. The State Board of Health has been in existence but five years. In the city of Portland there is a system of medical inspection, the inspection being given by various doctors throughout the city gratuitously. No legalized system or school nursing. The state health officer believes that every school should have thoroughly competent and well paid physicians to make regular examina- tions of all school children, as well as to give instructions to teachers relative to school sanitation, school hygiene, and the general health of the children. He also believes that this system should be carried into the country school districts. Legal Aspects of Medical Inspection i8i Rhode Island. — No legislation. Some inspection in Providence and Newport. Texas. — Sanitation of school buildings is required. No other laws. Local school boards have been interested in eye inspection, and specialists have been persuaded to make these examinations without charge. The same has been done with the ear, nose, and throat troubles. Texas is behind in these matters, but shows willingness to catch up. Utah. — Legislation expected at the next session of the Legislature. The State Board of Health has provided for the testing of the eyes of school children, and also examination as to the presence of defective hearing and of mouth breathing, the said test to be made by the teacher, and upon the discovery of any of the defects described, reporting the fact to the parents with recommendation that the child shall be examined by a competent specialist. The State Board of Health is also preparing rules making it the duty of teachers to report unsanitary or unhygienic conditions in the schools, including improper construction, and to use vigilance in the detection of symptoms of contagious disease among the pupils and the immediate exclusion of any pupil suspected of being so affected. The secretary thinks it should be the duty of all parents to provide for a competent physical examination of children before permitting them to enter school, the said examination to determine the presence of any defect requiring correction. He also thinks that the state should insist that the correction should be furnished by the parent. The last Legislature passed a law requiring the introduction in the public schools and in the normal schools of a course of instruction on the subject of preventable disease and preventive methods. Vermont. — No special legislation, except requirements as to ven- tilation, light, and general sanitary conditions in school buildings. Also a law requiring the examination of the eyes, ears, and throats of school children annually, enacted in 1904. The secretary of the State Board of Health says that it is very difficult to formulate a law in a rural state like Vermont, where, outside of a few large towns, the schools are small and widely scattered. South Carolina. — No legislation, aside from general statutes. The State Board of Inspectors, the public schools, and the State iSz Medical Inspection of Schools Board of Health are now inaugurating a system to protect the eyes and ears of school children. Washington. — No general laws. In the larger cities the matter is more or less covered by city ordin- ances and board of health regulations. Wisconsin. — Very little definite legislation regarding school inspec- tion. The State Board of Health is empowered under the general law to make observations and enforce proper sanitary care of school houses. The State Board of Health has endeavored through inspectors to see that the school houses were properly heated, ventilated, and lighted. No provision has been made for treatment of school children after such inspection. No legalized system of school musing or legislation on subjects kindred thereto. The Board is endeavoring to formulate methods in regard to the testing of eyes, ears, nose, and throat of school children. This question will probably be considered at the 1909 session of the State Legislature. In the following states there are no laws, aside from the general statutes, upon the subjects referred to: Louisiana Montana Maine Nevada Mississippi North Dakota Missouri South Dakota In the following states inquiries regarding medical inspection were unanswered : Alabama North Carolina Arizona Tennessee Arkansas Virginia Delaware West Virginia Iowa Wyoming New Mexico Legal Aspects of Medical Inspection 183 From the legal domain the suggestions prompted by the foregoing study are the following: Those having a part in the future of medical inspection should exert themselves to the utmost to secure so far as possible vmiformity in statutory provision. Legislation should provide that medical inspection shall be com- pulsory. That local conditions determine whether the onus of executing the law be upon the health or the education authorities. Insert a penal provision compelling parents or guardians to provide proper medical attention upon the order of the medical examiner. Most essential of all — insure the law's enforcement. CHAPTER XII Retardation and Physical Defects EDUCATIONAL ECONOMIES EFFECTED THROUGH MEDICAL SUPERVISION The memorandum of the British Board of Education on "Medical Inspection of Children in Public Elementary Schools," states in a few- brief words the fundamental basis upon which medical inspection rests. Of the recent English law it says : "It (the law of 1908) 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 satisfactory environment, physical and educational, and by bringing into greater prominence the effect of environment upon the personality of the individual child, seeks to secure ulti- mately 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 constitute a true education." That there must exist a close relation between mental and physical conditions no one will deny, but how important the relation is when measured in terms of its effect on the educational progress of school children, and whether indeed such measurement in quantitative terms is possible, are problems which have been seldom studied, and if at all, in the most casual fashion. With some notable exceptions, those who have occupied themselves with these matters have assumed that there exists a correlation between school progress and physical defects so marked and so direct that could we but correct and prevent bodily unsovmdness among the pupils of our Retardation and Physical Defects 185 schools, we should thereby at once do away with "backwardness" and "retardation." As a corollary to this hoped for disappearance of retardation not a few school men have argued that great financial economies would be effected and such evils as crowded rooms and "half time" schools rendered unnecessary. In some places this view has led to earnest argument in favor of the estabhshment of systems of medical inspection, and the plea has been made that the expense involved would be more than made up by the direct financial saving effected. An example is found in the latest annual report of the city superintendent of schools of one of the large New England cities. He pleads his case as follows: "Many children lose promotion and are compelled to repeat their work. Now, it costs the city in round num- bers $230,000 to educate its public school children. The average attendance is in the neighborhood of 93 per cent. — a loss of 7 per cent, on account of absence. Seven per cent, of $230,000, or more than $16,000, represents the annual waste caused by absence of children from school. If by a system of medical inspection this per cent, of attendance can be lifted only i per cent., it would amount to a saving of $1,600, or all that it would cost to secure good inspection for a city like ours." In other words, the superintendent argues that if every day 94 children can be induced to attend school where now only 93 are present, a financial saving will result amounting to some $1,600. The fallacy of this argument is, of course, evident; but it is nevertheless one which has found enthusiastic support in many places and which has been widely used by the advocates of medical inspection. The contention that a successful system of medical inspection would go far toward eliminating the evil of " half time," because it would reduce the amount of retardation or backwardness in our school systems, rests on an equally mistaken basis. Nevertheless, this argument, too, has been eloquently stated and actively urged in many quarters. A district superintendent of one of our largest cities, an eminent and able educator, stated the argument but a few months ago in a discussion of retardation in different cities. He says: i86 Medical Inspection of Schools " Boston is now able to make the proud boast that she has a seat in school for every child able to attend. This condition may in part be due to the smaller percentage of retardation. Were the stream of children through the grades less rapid, perhaps she would have thousands and tens of thousands upon ' part time,' while empty benches yawn for occupancy in the highest grades. Damming the stream of children passing through the grades of our schools defeats the purpose of oiu: public educational sys- tem and causes a wasteful expenditure of public funds." And again: " The child that takes ten years to complete an eight year coiurse costs the state 25 per cent, more than the one that goes through on time." Here again the problem of retardation is brought into relation to the problems of accommodation and cost. Inasmuch as a principal argu- ment of the advocates of medical inspection is that physical defects con- stitute a potent force for causing retardation, these claims are of the greatest interest in the present discussion. The first contention in the above quotation is that if the progress of the children through the grades in the city referred to were less rapid than it is, there would as a conse- quence be thousands or tens of thousands of pupils upon "part time." At first sight this seems a perfectly sound contention; but the fact of the matter is that the children who do not progress through the school grades at the normal rate, and hence find themselves at the age of say foiurteen in the fifth or sixth grade instead of the eighth, do not as a rule continue two or three more years in order to finish, but instead drop out without completing the comrse. That is to say, a city must have enough seats to accommodate all of its children between the ages of say seven and fourteen years. It makes little difference in this particular problem what progress the children make: the necessity for accommodation remains the same, whether all of them complete the eight grades, or only a small percentage do so. Under all circumstances they will require the same number of seats. Looking at it from the standpoint of expenditure, it is Retardation and Physical Defects 187 just as plain that it will cost fully as much to teach them, whether they are well along in their grades and studies, or far behind. The specific case mentioned of the child who takes ten years to com- plete the eight year covu-se sounds convincing, and the argument is indeed valid when this actually happens. The trouble is, however, that the case mentioned does not represent the average or even a common case. In practice the child — and he is typical of a far larger number than the general public commonly supposes — does not take ten years to finish an eight year course. He simply drops out without finishing. In stating these aspects of the problem it is not at all our purpose to minimize the evils of retardation or to deprecate the benefits to be gained through medical inspection; but cost and overcrowding are not evils of retardation. Financial economies are not directly effected through medical inspection, and "part time" is not related to the problem. " A penny saved is a penny earned " only when the saving is direct. In the case of medical inspection the economies effected are the indirect ones of securing greater educational returns for the expenditure of public funds expended to support the schools, and the still more indirect saving effected by bringing about conditions which will render the future citizens of the state more efficient. The fact that many of the children of the pubUc schools never reach the eighth grade and, therefore, do not obtain the eight years' education which the common school system provides, long known to educators, has of recent years received considerable attention through efforts to measvu-e the extent of this tendency and to discover, if possible, its under- lying causes. These efforts have been more or less scattered, but the appearance of such discussions in different parts of the country indicates a growing feeling among educators that these aspects of our school administration deserve more attention than they have hitherto received. From the standpoint of a comprehensive study of the problem of retar- dation it is quite true that the literature of the subject is still in its infancy, but there have been contributions to it in various quarters which have thrown considerable light upon the subject in its various aspects. To a considerable extent the treatment of the subject has been statis- tical, and one might say more or less unconscious of the large problems which are involved in it. It appears in this form in the reports of vari- ous school systems which print tables showing the number of pupils i88 Medical Inspection of Schools of each age in the several grades, indicating most clearly that the popula- tion of a grade is not homogeneous, but is composed of many elements. A few facts gathered from various cities were published in the report of the U. S. Commissioner of Education for 1903-04. This, again, is one of the factors which receives consideration in Dr. Edward L. Thorn- dike's publication on "The Elimination of Pupils from School," pub- lished by the U. S. Bureau of Education as Bulletin No. 4, 1907. The tentative considerations foimd in the report of the Commissioner of Education of the State of New York for 1908, in connection with his discussion of industrial education, will receive further elaboration in the report now in preparation. Perhaps the most useful source of informa- tion is the "Psychological Clinic," founded by Dr. Lightner Witmer, of the University of Pennsylvania, now in its second volume. It not only contains individual studies of abnormal children, but also several im- portant essays on the extent, not only of abnormality, but also of that lesser degree of mal-adjustment to which the term "retardation" is applied in various school systems. Attention is especially called to studies of conditions in Wilmington and Camden by the superintendents of schools in each of these cities, and to more comprehensive articles on "The Retardation of the Pupils of Five City School Systems," by Dr. O. P. Cornman; and "Some Further Considerations upon the Retarda- tion of the Pupils of Five City School Systems," by Dr. R. P. Falkner, in which the conclusions of Dr. Cornman are in part corrected and in large measure expanded. In all of the foregoing no doubt has been cast upon the validity of the basal argument that physical defects have a great and important influence on school progress. Public discussion has brought this matter into great prominence dm'ing recent years. The physical examinations that have been made have demonstrated that many children have not the healthy bodies that we have been taught to believe are the necessary accompaniments of sound minds. It is certainly disquieting to read that two-thirds of the school children of New York City have physical defects, and the inference has frequently been drawn that we have in this fact the explanation of backwardness in our schools. To be exact, we have one cause, not the cause. Among other factors must be reckoned, for example, late entrance, irregular attendance, mental dullness, transfers, ignorance of the English language, the "lockstep" in promotions. Retardation and Physical Defects 189 To what extent do physical defects cause backwardness? We do not know. We do know that we have here a fruitful field for investiga- tion. Such limited studies as have so far been made to ascertain the quantitative relationship between physical defects and backwardness have shown a much smaller causal relation than has been assumed and proclaimed by those advocating the physical examination of school children. Some of the best work that has been done on this problem is that of Dr. Walter S. Cornell, of the Medical Department of the Uni- versity of Pennsylvania. The results of some of his investigations were published in an article in the "Psychological Clinic" of January 15, 1908. Among 219 children of both sexes from six to twelve years old in one school in Philadelphia, he found the following results : Average Per Cent. IN Studies. Normal children 75 Average children 74 General defectives 72.6 Children having adenoids and enlarged tonsils 72 In another investigation the children of five schools were examined for physical defects. They were divided into so-called "exempt" children, or those whose work had been so thoroughly satisfactory that they were advanced to higher grades without examination, and "non- exempt," or those whose work was less satisfactory. The following were the results : Exempt. Non-Exempt. Children examined 907 687 Per cent, defective 28.8 38.1 Still another examination was conducted in one school to determine, if possible, the degree of harmful influence of defects of the nose and throat. The results follow : Bright Dull Dullest Children. Children. Children. Nimaber examined 89 32 29 Having nose or throat defects. .10 9 9 Percent ii.i 28.1 31 In an article published in the New York Medical Journal of June i, 1907, Dr. Cornell gives some results of a study of the effect of eyestrain iQO Medical Inspection of Schools on school progress. In this investigation the relationship of poor vision to scholarship was studied in 219 children. The results are expressed in the percentages obtained by the children in arithmetic, geography, and spelling. Children With: Arithme- Geography. Spelling. Average. TIC. Normal vision 79 69 76 75 — Fair vision 70 71 77 73 + Bad vision 66 70 71 69 It is, of course, to be noted that these investigations were conducted with a comparatively small number of cases. Moreover, the results ob- tained above represent only a very small part of the careful and pains- taking studies conducted by Dr. Cornell. The conclusion that he draws from his studies is that the educational result in our public schools suffers a discount of about 6 per cent, in the case of the physically defective children, as well as a waste of time rightfully belonging to the normal children. Diuring the school years 1904-5 and 1905-6 very extensive investiga- tions have been conducted in the city of Camden, N. J., by Superintendent of Schools James E. Bryan. The results are reported at length in the annual report of the Board of Education of the city of Camden, N. J., for the year ending June 30, 1906. In all, 10,130 children of both sexes were examined. From these were selected 2,020 children of excessive age for their respective grades, counting as of excessive age those who were at least one year more behind their grades than the standards commonly used in similar discussions. A careful attempt was made to classify the causes for the backwardness of these 2,020 pupils in their school studies. The causes assigned in the classification were: 1. Age upon starting in school, 2. Absence, 3. Slowness, 4. Dullness, 5. Health, 6. Physical defects other than sight and hearing, 7. Mental weakness. Under these seven reasons for excessive age the 2,020 children were distributed as is shown in the following table: Retardation and Physical Defects Excessive age due to: 191 Defects Number Ex- amined. Age Upon Starting. Absence. Slow- ness. Dull- ness. Health. Other than Sight and Hearing. Mental Weak- ness. Per Cent. Per Cent. Per Cent. Per Cent. Pel Cent. Per Cent. Per Cent. Boys . . . 1081 20.2 29.4 19.8 12. 1 7-4 3-6 4.6 Girls... 939 22.4 27-5 22.4 II.9 12. 1 4.4 2.6 Total 2020 21.2 28.5 21 12 9.6 3-9 3-7 Whether the causes assigned have sufficient definiteness, or whether the underlying assumption that in each case there is a single cause be correct, need not be considered here. For the purposes of the present discussion, two points in regard to this table are significant: First, that the results of the Camden investigation decidedly support the con- tention that physical defects constitute a cause, but not the cause of retardation; secondly, that the bearing of physical defectiveness on school backwardness does not appear to be very great. Under the caption "Health" it appears that bad health was assigned as a reason for backwardness in 7.4 per cent, of the cases of the boys and in 12.1 per cent, of those of the girls. Physical defects other than sight and hearing were assigned as reasons for excessive age in 3.6 per cent, of the cases of the boys and 4.4 per cent, of those of the girls. The foregoing illustrations, while they point in the same direction, namely, that physical defect is only one cause of backwardness, and perhaps not so prominent as has frequently been assumed, show at the same time the paucity of the data directly bearing on these points. In view of this scarcity of data, attention may be called to some preliminary results of a more comprehensive investigation now in pro- gress, but still incomplete. During May and June of 1908 the authors of this volume have conducted an investigation into some conditions existing among children in fifteen schools of New York City in the Borough of Manhattan. The total membership of the schools is some- thing over 20,000 and it is almost equally divided among boys and girls. The schools themselves are located in different sections of the city, from the lower East Side to the Bronx. The school records of all of these pupils have been gathered and a careful study undertaken to determine, if possible, conditions bearing on the phenomena of retarda- 192 Medical Inspection of Schools tion. For the purposes of the study, pupils have been divided into two groups : normal age and above normal age. All pupils in the i A grade (lower first) who at the end of the school year are 8^ years old or younger are considered of normal age, those older than 8^ of above normal age. In the I B grade (upper first) 9 years marks the limit of the normal age group and those older are considered above normal age. In the 2 A grade (lower second) the limit is 9^, in the 2 B (upper second) 10, and so on up to 16 years of age in the 8 B grade (upper eighth). In the endeavor to find out the relation between physical defect and retardation, the records of all pupils who have been examined by the physicians of the Board of Health have been carefully compiled and studied. Among the 20,000 children, 7,608 have had physical examinations. As the results of this study are to be fully presented in a separate report, it has been thought best to give here as original data merely the tables showing the distribution of these pupils by grades and defects, and by ages and defects. The derivative tables are all in terms of percentages, in order to render them more clear, and the results are given by full grades rather than by half grades for the same ptupose. Tables A and B present the original data. TABLE A.— DISTRIBUTION OF PUPILS BY GRADES AND DEFECTS @«5 ^g No.Ex- H Defec- tive H S Defec- tive Sri Ade- Other De- Total De- AMINED. Vision. Op5 Teeth. H 3 ps noids. fects. fects. lA.... 678 104 288 22 141 427 277 142 120 1,417 iB 1,151 17s 503 39 290 749 454 293 191 2,519 2A 951 102 364 159 252 660 359 275 194 2,263 2B.... 788 -^33 274 193 155 416 253 164 108 1,563 3A..- 663 96 183 153 III 358 177 98 79 1,159 3B- — 620 119 107 128 55 350 163 59 93 955 4A.... 533 139 52 137 52 227 100 57 75 700 4B.... 531 152 59 138 40 209 127 71 81 725 SA— - 338 "5 48 86 29 lOI 65 28 22 379 SB.... 299 122 5 72 13 97 41 15 14 257 6A.... 314 122 II 84 48 91 38 10 31 313 6B.... 167 55 7 34 12 64 25 II 13 166 7A.... 212 55 8 56 31 76 24 16 28 239 7B.... 159 69 12 44 12 17 30 3 17 ^2,5 8A.... 134 27 II 38 8 64 II 4 15 151 8B.... 70 19 7 28 3 7 15 2 5 67 7,608 1,604 1,939 1,411 1,252 3,913 2,159 1,248 1,086 13,008 Retardation and Physical Defects 193 TABLE B.— DISTRIBUTION OF PUPILS BY AGES AND DEFECTS Q . gg Q S"5 Ages. No. Ex- bB Defec- tive P Defec- tive HZ Ade- Other De- Total De- amined. 2 2 ^0 Vision. Ppq Teeth. « noids. fects. fects. 5--- 9 2 6 4 4 I I 2 18 6.... 586 100 231 24 124 37« 23s 135 105 1,232 7.... 1,286 173 530 81 321 850 508 322 210 2,828 8.... 1,197 169 427 210 241 728 439 259 188 2,492 9---- 1,019 i«5 286 206 166 567 290 188 136 1,839 10 911 202 178 228 118 453 209 124 127 1,437 II «39 219 132 201 103 3SS 177 q8 109 1,175 12 663 199 bS 176 70 222 128 ss S7 806 13.... 510 163 35 121 SO 182 84 33 67 572 14 393 125 26 109 37 112 60 23 37 404 15.... 144 S3 10 37 13 45 21 S 10 141 16.... 42 12 5 IS 4 15 7 I 6 53 17.... 7 2 I 2 I 2 I 2 9 18...- 2 .. I I .. .. 2 7,608 1,604 1,939 1,411 1,252 3,913 2,159 1,248 1,086 13,008 Among the 7,608 pupils, 6,084 fell within the normal age group and 1,524 in the above normal age group. The following table shows the percentage of physically defective pupils in each group by grades : Normal Age. Above Normal Age. Grade. Per cent. Per cent. defective. defective. 1 85 81.3 2 86.8 84.5 3 83.2 83.3 4 71-6 74-7 5 63.8 60.2 6 63.8 61.7 7 68.2 60.2 8 77-1 75 Total 79.8 74.9 Of course, the immediately striking feature of this table is that nearly 80 per cent, of the normal age children are found to have physical defects, while only about 75 per cent, of the above normal age children are defective. This feature was an unlooked for surprise to the inves- tigators. The second noteworthy point is that the percentage of defective children in the lower grades is decidedly greater than in the upper grades. It is to be remarked^ too, that the percentage of defectives 13 194 Medical Inspection of Schools in the first grade would have been decidedly greater than that in the second grade had it not been for the fact that practically no children are tested for defective eyesight in the first grade, thereby decidedly reducing the percentage of defectiveness. It is likewise true that the seventh and eighth grades show a much higher per cent, than would normally be the case. This is due to the facts that the figures for the seventh and eighth grades are almost exclusively. for one school having ' a high percentage of defectives, and for comparatively small numbers of cases. The reason for this is that in rnpst schools no physical ex- aminations were made in the upper grades. Our investigations lead us^to believe that under normal conditions physical examinations as now conducted in New- Yorls:: City would show — if the eyesight of children in the first grade could be tested — a percentage of defectives of about 90 in the first grade and that this per cent, would gradually reduce through the grades to about 50 in the eighth. A computation of the average number of defects per child in the normal age and above normal age groups gives results not dissimilar from those discussed. AVERAGE NUMBER OF DEFECTS PER DEFECTIVE CHILD Grade. Normal Age. Above Normal Age. 1 2.5 2.3 2 2.5 2.6 3 1-9 2.1 4 1.8 1.8 S i-S 1-6 6 i-S 1-5 7 IS 1.5 8 1-3 1-6 Total 2.1 2.0 Here again we are confronted by the same phenomena of more defects among the children of normal age than among those of above normal age, and of the reduction in the number of defects from the first grade to the eighth. Of comrse, a question which immediately presents itself is whether this unlocked for discrepancy between the num- ber of defects among normal age children and the number among those of more than normal age is to be accounted for by a consistent pre- ponderance of each separate kind of defect among the normal age chil- dren, or whether some sorts of defects are more prevalent among those Retardation and Physical Defects 195 of normal age and others among those of greater than normal age. Light is shed on this problem by the following table: PER CENT. HAVING EACH DEFECT BY DEFECTS Normal Age. Above Normal Age, Examined loo loo Defective 79.9 74.8 Enlarged glands 26.9 19.5 Defective vision 23.5 26.9 Defective breathing 16.7 15.2 Defective teeth 53.3 43.8 Hypertrophied tonsils 29.9 22.0 Adenoids 17. i 13.4 Other defects 14.1 14.9 Here we see that each separate sort of defect is found more frequently among children of normal age than among those of greater than nor- mal age, with two exceptions. These are vision and "other defects." The difference in regard to vision is striking. Whereas in the case of the other defects there is considerable preponderance among the normal age pupils, in the case of vision only 23.5 per cent, are found to be defec- tive in the normal age group, while 26.9 of those in the above normal age group have defective vision. This at once leads to the suspicion that in its relation to retardation, vision does not follow the same rules as do other forms of defects. Having discovered that the same rules do not uniformly apply to all of the several sorts of defects, it becomes worth while to study each defect separately by grades and ages. The following table pre- sents the per cent, of those of each individual age suffering from each defect. PER CENT. HAVING EACH DEFECT BY AGES Ages. 6 7 8 9 10 II 12 13 14 IS Defec- tive. 82.9 86.5 85.8 81.8 77.8 73-8 69.9 68.0 68.1 63.1 En- larged Glands. 39-4 41.6 35-6 28.0 19-5 15-7 9.8 6.8 6.6 6.9 Defec- tive Vision. 17-5 20.2 25.0 23-9 26.5 23-7 27.7 25.6 Defec- tive Breath- ing. 21. 1 24.9 20.1 16.2 12.9 12.2 10.5 9.8 9.4 9.0 Defec- tive Teeth. 64-5 66.0 60.8 55-6 49-7 42.3 33-4 35-6 28.4 31.2 Hyper- tro- phied Tonsils, 40.1 39-5 36.6 28.4 22.9 21.0 19-3 16.4 15.2 14-5 Ade- noids. 23.0 25.0 21.6 18.4 13.6 11.6 8.7 6.4 S-8 3-4 Other De- fects. 17.9 16.3 iS-7 ^3-3 13-9 12.9 13-1 I3-I 9.4 6.9 196 Medical Inspection of Schools A study of the table reveals additional characteristics of the several sorts of defect. For instance, under enlarged glands we note that the percentage steadily falls from about 40 among six and seven year old children to something over 6 among thirteen and fourteen year old children. In the case of vision, on the other hand, it increases from 17 per cent, among eight year old children to 25 per cent, among fifteen year old children. The percentage of defective breathing, again, decreases somewhat as does that of enlarged glands, falling from about 25 per cent, among seven year old children to 9 among fifteen year old children. A similar steady decrease is found in the case of defective teeth, where the percentage falls from 66 among seven year old children to 31 among fifteen year old children. A like condition is found in the case of h)rpertrophied tonsils. In the case of adenoids the phenomenon is even more marked, the percentage falling from 25 among seven year old children to 3.4 among those fifteen years old. A steady, although not nearly so rapid fall, is also found in the case of other defects. In compiling this table, data for the ages of five, sixteen, seventeen, and eighteen years have been omitted, for the reason that the number of cases under each of these ages is so small as to render them insignifi- cant. Percentages of defective vision at the ages of six and seven are not given because pupils at those ages are almost without exception in the first grades, and as they cannot write, they are not tested for defective vision. In all of these cases attention must be called to the fact that the decrease in the per cent, of defective children is not due to the falling out or leaving school of the children suffering from these 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 charac- teristic decrease did not take place until the age of fourteen or fifteen; but such is not the case. We have to do with children of from six to fifteen years of age, and the marked decrease begins among the eight, nine, and ten year old children, and continues steadily. As the older children in general are found in the upper grades and the younger children in the lower grades, it is certainly to be expected that a tabulation of defects by grades will show the same characteristic reductions, and the same exception in the case of vision. This expecta- tion is realized in the tabulations made. Retardation and Physical Defects 197 PER CENT. DEFECTIVE BY DEFECTS AND WHOLE GRADES Grades. Enlarged Glands. Defective Vision. Defective Breathing. Defective Teeth. Hypertro- PHIED Tonsils, Adenoids. I 2 3 4 5 6 7 8 43-2 36.6 22.6 10.4 8.3 3-7 5-4 8.8 20.2 21.9 25.8 24.8 24-5 26.9 32-3 23-5 23-4 12.9 8.6 6.5 12.4 5-3 64.2 61.8 55-1 40.9 31.0 32.2 25.0 34-8 39-9 35-1 26.5 21.3 16.6 13.0 14-5 12.8 237 25.2 12.2 12.0 6.7 4.3 5-1 2.9 Apart from the fact that the eighth grade, for reasons already stated, cannot be considered as representative, the table presents many analo- gies with the preceding. The percentage of defects dwindles as the grades advance, though here again vision stands in a class by itself, increasing rather steadily with the higher grades. The foregoing tables have shown clearly the fact that age is the important factor in considerations having to do with the percentage of physically defective school children. It is evident that it is not enough to say merely that in a given city 66 per cent, of the pupils are found to be physically defective to a greater or less extent. We need to know the percentage of defectiveness for each separate defect and something of the age of the children. It is evident that if vision were omitted, the general percentage of defectiveness might be expected to be great if examinations were conducted among the lower grades, and comparatively small if they were conducted among the upper grades. The same would, of course, be true if the results were tabulated by ages rather than by grades. For instance, in the investigation in point a computation was made to find the number of defects per hundred children in each grade, omitting vision and defective teeth, and basing the calculation solely on cases of enlarged glands, defective breathing, hypertrophied tonsils, and adenoids. The computation resulted as follows : Grades Defects per 100 Children. Grades. .130 .120 • 74 ■ 52 Defects per 100 Children. 38 35 36 29 iqS Medical Inspection of Schools The same striking falling off is shown if a similar computation is made by ages, instead of by grades. Defects per Defects pee Grades. ioo Grades. loo Children. Children. 6 123 II 68 7 131 12 47 8 114 13 39 9 91 14 24 10 69 It is entirely probable that had the results of the physical examina- tions performed in the schools by the physicians of the Board of Health of New York City taken into account age and grade, the announced results and conclusions would have been very different. Reports on the examinations of more than 100,000 school children have been pub- lished and the per cent, of defectives has run from 66 to 72. From these results it has been argued that as there was no reason to believe that these were exceptional children, it might fairly be concluded that they were typical of school children in New York and even of children throughout the United States. On this hypothesis calculations have been based, showing the probable number of children in the United States in need of medical, surgical, or dental attention, and of the probable number of cases of enlarged glands, defective eyesight, poor teeth, adenoids, etc., existing among them. Now, it must be remembered that the examinations performed in New York have very largely been among the very young children in the first and second grades. As these children represent a larger proportion of defectives and very much greater percentages of those suffering from such defects as enlarged glands, hypertrophied tonsils, and adenoids, it is at once evident that they are not only not representative of children in the United States, but not even of children in New York or in Manhattan. They are representative only of very young school children in Manhattan, and it is, to say the least, dangerous to argue anything concerning the number of children in the United States having each of the different sorts of defects from data published so far by the New York Board of Health. Another question which so far has had little attention is that of the relation of sex and physical defects. The tabulation of the percen- tages of defectiveness by sexes for each kind of defect gives the following results : Retardation and Physical Defects igg PER CENT HAVING EACH DEFECT BY SEXES Boys. Gikls. Defective 78.5 79.2 Enlarged glands 32.2 20.3 Defective vision 15.7 20.8 Defective breathing 19. i 14.3 Defective teeth 48.4 53.5 Hypertrophied tonsils 33.1 24.7 Adenoids 17.4 15.6 Other defects 13.6 14.7 DEFECTS PER CHILD Boys. Girls. 1.8 1.6 Here again we have some surprising variations; 32.2 per cent, of the boys are suffering from enlarged glands, while we fovmd only 20.3 in the case of the girls. Again, under defective breathing we have 19. 1 per cent, for the boys and 14.3 per cent, for the girls; while hyper- trophied tonsils are present in 33.1 per cent, of the cases among the boys and only 24.7 per cent, among the girls. On the other hand, the boys outstrip their sisters in regard to vision and teeth. These results are derived from the examination of a comparatively large number of cases, the boys numbering 3,301 and the girls 4,305. The results that have been discussed, showing so consistently as they do that retarded or above normal age pupils have fewer defects than do those of normal age, furnish food for careful thought. Were further data not available, it would certainly be difficult to explain the seeming anomaly, but the data showing the percentage of defectives by ages and grades are illuminating. We see at once that age is the important factor. With the exception of vision, the percentage of pupils found to be suffering from each separate sort of defect decreases rapidly as age increases. Naturally, similar conditions are found when children of upper grades are compared with those of lower grades. It is evident that we have here a field for many further interesting and important investigations. Without entering into any one of them, however, we are confronted by one consideration of prime importance, which is that dejects decrease with age. The importance of this on all investigations into the influence of physical defects on school progress is at once evident. Whether the term ''retarded" is used to express a condition or an explanation, it 200 Medical Inspection of Schools will always follow from the definition itself that retarded children will be older than their fellow-pupils in the same grades. This condition will exist, whether time in grade or an arbitrary age dividing-line be taken as the criterion for separating pupils into "retarded" and "not retarded," or "normal age" and "above normal age" groups. In any case 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. There- fore, it is not surprising that we find that 80 per cent, of all children of normal age have physical defects more or less serious, while only 75 per cent, of those of above normal age 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. Why this should be so it is not easy to explain. It is probable that we have here a condition brought about by a number of influencing factors. In the first place, it must be remembered that the higher grades are to a certain extent made up of the survivors of the more fit. Those who reach the higher grades are at least to some extent made up of the brighter, the more ambitious, the more physically fit, those of higher social standing, and those whose parents are in better economic circumstances. If the child whose physical defects and mental dullness render him exceedingly slow in his school studies leaves school at the earliest possible moment permitted by the compulsory education laws, or even anticipates that moment, he naturally is not present to be counted among the older children or those in the higher grades. This factor, while undoubtedly operative, is probably not one of comparatively great importance. A second consideration, and one of probably far greater weight, is that children do actually outgrow their defects. No other conclusion seems possible as an explanation of such great falling ofi as we have in the case of enlarged glands, with which 40 per cent, of the six year old children suffer, but which are foimd present in only 12 per cent, of the sixteen year old ones; or in that of defective breathing, where the reduction is from 21 to 10 per cent.; or in that of adenoids, with a fall from 23 to a little over 2 in the same years. Even in the case of defective Retardation and Physical Defects 201 teeth it is found that nearly 65 per cent, of the six year old children are included among those needing attention, and only 35 per cent, of the sixteen year old ones. Of course, in this connection it must be remem- bered that the older children have their permanent teeth, and tmdoubtedly too a much larger proportion of them have received dental attention. In studying the problems of school progress and physical defects, we must not forget that school success is to only a limited extent a true measure of real ability. It may often be rather an indication of adapta- bility and docility. Indeed, it would not be surprising to find that the child of perfect physical soundness and exuberant health had so many outside interests as to render him not particularly successful in school work, and that he found the rigid discipline of the schoolroom so irk- some as to cause him to fail of approbation by his teachers. It is, of course, obvious that this whole subject of the relation of physical defects to school progress is one of great importance and one which will require a great deal of painstaking investigation and careful study. Nevertheless, from the brief data here presented a few conclu- sions of value may be drawn. Among them are the following: (i) Successful medical inspection results in indirect, not direct, financial economies. (2) It does have an effect on the problem of retardation, but does not affect accommodation and "half time." (3) Since our investigation shows that defects decrease with age, statistics dealing with physical defects among school children are not significant unless they are presented in terms of grades and ages. Most defects decrease with age, and backward or retarded children have fewer defects than those of normal age because they are older. (4) Physical defects constitute a cause, not the cause, of retardation. The foregoing conclusions — so different from those which have been emphasized in current discussion — must be briefly examined with respect to their significance for the general problem of medical inspection. Our first conclusion is that successful medical inspection results in indirect, not direct, financial economies. There is an economy which means the abstention from expenditure. There is another 202 Medical Inspection of Schools economy which means the production of greater efficiency. The economies effected by medical inspection are of this second or indirect sort. While they cannot be measured in dollars and cents, they are nevertheless far-reaching and important. Everyone brings into the world a certain capital of mental ability and physical soundness. On these his value to the state will depend when he is grown. Any reason- able expenditure which wiU result in their enhancement is in the end an economical expenditure of public fimds to promote the public welfare. Our second conclusion is that physical defects are related to the problem of retardation, but not to that of accommodation. Measured in terms of school progress, we naturally expect the sound and healthy child to advance further than the physically defective one. We must face the fact that the school period is brief and that its effectiveness largely depends upon how far the child advances. Indeed, in the vast majority of cases it depends upon how far the child advances by the time he reaches the age of fourteen. Our studies of the problem of retardation lead us to the conclusion that the greatest factor affecting the problem of the child's progress through the grades is that of regular and continuous attendance. Any influence which tends to reduce absence results in an increased use of school facilities, and so in greater economy, a higher degree of efficiency, and better results, as measured by educational standards of progress. Medical inspection, in banishing contagious diseases from the schools and in preventing or removing physical defects, has a large and important influence in bringing about this greatly to be desired result. Conclusions three and four have to do with the statistical aspects of the problem. The evidence of current statistics on the need for physical inspection is twofold. It proves that physical defect is wide- spread. It enforces thereby the conclusion that there would be a gain in many respects by the elimination of such defects as are capable of prevention or removal by medical science. On the other hand, current statistics do not establish physical defects as the cause of retardation. Under the broad definition of the former it embraces, say 80 per cent, of the school population — retarda- tion say 20 to 40 per cent. Hence it is clear that there must be cases of defects among the non-retarded. If all the retarded were defective, we should have — were 20 per cent, retarded — 100 per cent, defective; Retardation and Physical Defects 203 and among the non-retarded 75 per cent defective. But some of the retarded are not defective. Their retardation is due to other causes. Hence there must be a certain per cent, of physically normal children among the retarded. All of these facts tend to equalize the percentage of defectives among the retarded and non-retarded. It must not be inferred that physical defects exercise no influence upon school progress. They undoubtedly do, but we have not yet discriminated among physical defects. We group together all kinds. Some have a direct bearing, others none at all. Defective hearing undoubtedly exercises an important influence on a pupil's success in school, but the fact that a child has a club-foot has no such significance. 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Uni- versity of Iowa, Studies in Psychology, Vol. I, pages 1-39. 2o8 Medical Inspection of Schools Gorst, Sir John E. : "The Children of the Nation: How their Health should be Promoted by the State." "Medical Inspection of School Children." Pages 50-66. New York, E. P. Button &Co. Greenwood : " Heights and Weights of Children." Report of the Board of Education of Kansas City Schools, 1890-1. Amer- ican Public Health Asso. Reports, Vol. XVII, pages 199-204. Gulick, Luther H. : " Department of School Hygiene." Boston Med. and Surg. Jour., July 25, 1907. "How Can the School make Contribution of Permanent Value?" Proceedings of the Dept. of Superintendence, Nat. Ed. Asso., Washington, D. C, Feb., 1908. "Departments of Hygiene under Boards of Education." School Hygiene, Boston, Jime, 1908. Gutenberg, Berthold : " Zum Kapitel der Zahne und Zahnpflege bei den Schulkindem." Zeitschrift fiir Schulgesundheitspflege, 1901, pages 452-66. Harrington, Thomas F. : "Medical Inspection in Public Schools." Proceedings of the Dept. of Superintendence, Nat. Ed. Asso., Washington, D. C, Feb., 1908. Hartwell : Reports of the Director of Physical Training, Boston, 1891, 1894, 1896. "Application of the Laws of Physical Training to the Prevention and Cure of Stuttering." Proceedings of the Nat. Ed. Asso., 1893^ pages 738-49- et al.: Anthropometry, Papers upon. American Statistics Associa- tion, 1894. Hedler, Albert : " Medical Examination of the Children of the Franklin School." Minneapolis Join:., March 17, 1908. Heilman, J. D. : "A Clinic Examination Blank for Backward Children in the Public Schools." Psych. Clinic, Dec. 15, 1907. HeitmuUer, G. H. : "Medical Inspection of Schools." Washington Med. Ann., March, 1907. Henderson, C. R. : "Dependent, Defective, and Delinquent Classes." Page 394. Boston, 1901. Henie, C. : " Untersuchimgen iiber die Zahne der Volksschiiler zu Hamar in Norwegen." Zeitschrift fur Schulgesimdheitspflege, Feb., 1898, pages 65-71. Bibliography 209 Herdman, Elliott Kent: "Medical Inspection of Schools." Public Health, State Dept. of Health, Lansing, Mich., Jan.-March, 1908. Hertel : " Overpressure in the High Schools of Denmark." London, 1885. Hinchey: "Medical Inspection of School Children." Medical Fort- nightly, pages 360 S. Jackson, Edward : " Considerations regarding Medical Inspection in Public Schools." Bulletin of the Amer, Aca. of Medicine, 6: 923-32. Jackson : " Care of the Eyes during School Life." Bulletin of the Amer. Aca. of Med., Oct., 1898, Vol. Ill, No. 9, page 517. James, Dr. J. H. : " Suggestions to Teachers Regarding Visual Defects of School Children." Mankato, Minn, Jarrett, Elizabeth: "Health of our High School Children." New York Med. Record, April 11, 1908. Jeffries, B. Joy : "Report of the Examination of 27,927 Children for Color-Blindness." Boston, 1880, Rockwell and Churchill. Jessen, Dr. Ernst : " Kostenpimkt einer stadtischen Schulzahn- klinik." Internationales Archiv fiir Schulhygiene, Vol. IV, No. 4. "Die stadtische Schulzahnklinik; ihr Verhaltnis zu Stadt, Schule, imd ortsansassigen Zahnartzten." Odontolische Blatter XII, No. 7-8. Berlin. Johnson, G. E.: "Condition of the Teeth of Children in Public Schools." Pedagogical Sem., March, 1901, 8: 45-58. Johnson, H. P. : " Medical School Inspection in the City of New York." Transactions, Medical Society of New York, 1903, pages 183^. Jordan, Walter R. : "Medical Inspection of School Children." Path- ologist, 8: 70-7. Kalle, Fritz: "Die Losung der Schulartzfrage in Wiesbaden." Deutsche Vierteljahrsschrift fiir oflFentliche Gesundheitspflege, 1898, Vol. XXX, pages 433-447- Keen, Dora: "Medical Inspection of Schools." Reprint from Phila- delphia Med. Jour., June 18, 1898; also Public Health, August, 1898, Vol. III. 14 210 Medical Inspection of Schools Key : " School Life in Relation to Growth and Health." Pop. Sci. Monthly, 1890-1, Vol. XXXVIII, pages 107-112. Krohn: "Habitual Postures of School Children." Child Study Monthly, Oct., 1895. "Nervous Diseases of School Children." Child Study Monthly, April, 1896, Vol. I, pages 354-68. Lederle, Ernst J. : "Medical Inspection of Schools." Conference of Eastern Public Education Associations, Bulletin No. 2, 1904. Lee: "Interdependence of Healthy Bodies and Healthy Brains." Bulletin of the Amer. Aca. of Med., Oct., 1898, III, page 534. Lee, Joseph, and Margaret Curtis : " Medical Inspection in the Public Schools." Leaflet No. 7, Mass. Civic League, 1906. Loring, L. G. : " Examinations of Eyes of Four Hundred and Twenty School Children." Boston Med. and Siu-g. Jour., Dec. 13, 1906; abstract in Jour, of the Amer. Med. Asso., Jan. 5, 1907, page 79. Lovett, R. W. : "Medical Inspection of Schools." Boston Med. and Surg. Jour , Feb. 21, 1907. McCallie, J. M. : "The Vision of the Pupils of an Elementary School, tested by the Snellen Alphabet and Illiterate Cards." Psych. Clinic, Nov. 15, 1907, I, 175-82. McDonald : " Children with Abnormahties, Based upon the Reports of Teachers." Reprint from Medical Times and Register, June, 1899. " Growth and Sociological Conditions." Reprint from the Boston Med. and Surg. Journal, Sept. 14, 1899. McMahon, J. P. : "Necessity for Annual Systematic Examination of School Children's Eyes, Ears, Noses and Throats by School Teachers." Wisconsin Med. Jour., Dec, 1907. Mackenzie, W. Leslie : "The Medical Inspection of School Children." Glasgow and Edinburgh, 1904. "The Health of the School Child." Methuen, London, 1906. Macmillan, D. P. : "The Physical and Mental Examination of Public School Pupils in Chicago." Charities and The Commons, Dec. 22, 1906, 17: 529-35. Mahony, John J.: "The Problem of the Poor Pupil." Education, Dec, 1907. Bibliography 21 1 Mangenot : L'inspection hygienique et medicale des ecoles. Page 64. Paris, 1887. L'examen individual et la bulletin sanitaire des ecoliers. Paris, 1894. Martin, Geo. H. : "School Hygiene in Massachusetts." Reprint from 71st Report of the Massachusetts Board of Education. Menninger; "Medical Inspection in Schools." Northwestern Monthly, July, 1897, pages 66-67. Mulford : "The Throat of the Child." Educational Review, March, 1897, XIII, pages 261-72. Newmayer, S. W. : "The Trained Nin-se in the Public Schools as a Factor in the Education of the Children." Amer. Jour, of Nursing, Dec, 1906. "Physical Defects of School Children Causing Subnormal and Mentally Deficient Pupils." New York Med. Jour., Nov. 2, 1907. "A Practical System of Medical Inspection with Trained Nurses adapted for Public Schools of Large Cities." New York Med. Jour., April 4, 1908. "Defective Vision and the Mentally Subnormal Child." New York Med. Jour., May 9, 1908. Oppenheim: " Development of the Child." New York, 1898. Porter: "The Physical Basis of Precocity and Dullness." Transac- tions of the Aca. of Science of St. Louis, Nov., 1893, Vol. VT, pages 161-81. "The Relation between the Growth of Children and Their Devia- tion from the Physical Type of Their Sex and Age." Trans- actions of the Aca. of Science of St. Louis, Nov., 1893, Vol. VI, pages 233-50. Powell, W. B. : "Medical Inspection of Schools." Addresses of Nat. Ed. Asso., Washington, D. C, 1898, pages 454-62. Prentice : "The Eye in Its Relation to Health." Chicago, 1895. Punton : "Relation of the Science of Medicine to Public School Educa- tion." Kansas City, Mo. Randall : " The Hygienic and Scientific Value of Examinations of the Eyes and Ears of School Children." Chicago, 1895. Report of Committee on Examination and Care of Eyes during School Life. Chicago, 1895. 212 Medical Inspection of Schools Richards, H. M. : " Organized Medical Inspection of Schools." Public Health, Nov., 1906, 19: 87-96. Risley: "Weak Eyes in the Public Schools of Philadelphia." Phila- delphia, 1 88 1. "Defective Vision in School Children." Educational Review, New York, April, 1892, III, pages 348-54. Roberts, Charles : " Manual of Anthropometry." London, 1878. "The Medical Inspection of, and Physical Inspection in. Secondary Schools." Royal Commission of Secondary Education, 1895, Vol. V, pages 352-75. Rogers, Lina L. : "Niirses in the Public School." Conference of Eastern Public Education Associations, Bulletin No. 2, 1904. Ryerson : " Defective Vision in the Public Schools." Transactions of the Canadian Institute, 1889-90, Toronto, 1891, pages 26-7. Rose, Karl : " Die Zahnpflege in den Schulen." Zeitschrift fur Schulgesundheitspflege, 8: 65-87. Routzahn, E. G. : "A City School Tooth-Clinic." Chautauquan, Feb., 1905, 40: 571-2. Schaefer, Dr. : " Ueber die Gefahr der Verbreitung ansteckender Krankheiten dinrch den Schulbesuch und die in dieser Hinsicht erforderlichen Massnahmen." Deutsche Vierteljahrsschrift flir offentliche Gesundheitspflege, 1898, Vol. XXX, pages 617-666. Scharfe, Dr. N. W. : "Municipal Medical Inspection of Schools." Philadelphia Med. Joiu:., April 29, 1899. Schenck, H. D.: "The Detection of Defects of the Eye, Ear, Nose, and Throat." Report of the 7th Anuual Conference of Sani- tary Officers of the State of New York, 1907. Schiller, Hermann : "Die Schulartzfrage." Sammlung von Abhand- lungen aus dem Gebiete der Padagogischen Psychologie und Physiologie, Vol. Ill, No. i, page 56. Schmid, Dr. Fr. : Die Schulhygienischen Vorschriften in der Schweiz. Zurich, 1902. Schmid, H. D. : "The Detection of Communicable Disease in School as a Part of Medical School Inspection." Report of the 7th Annual Conference of Sanitary Officers of the State of New York, 1907. Schubert, Paul : Das Schulartzwesen in Deutschland, Hamburg and LeipsiC; 1905. Bibliography 213 Schuschny, H. : " Geschichte und Entwickelung der ungarischen Schulartzfrage." Deutsche Vierteljahrsschrift fur offentliche Gesundheitspflege, 1897, Vol. XXIX, page 530. Scripture: "Tests on School Children." Educational Review, New York, Jan., 1893, Vol. V, pages 52-61. Seashore, C. E. : " Suggestions for Tests on School Children." Educa- tional Review, June, 1901, 22: 69-82. Shattinger, Dr. Charles : " Municipal Medical Inspection of Schools." St. Louis Med. Jour., April 28, 1899, Shaw: *' School Hygiene." Page 252. New York, 190 1. Shepherd, Fred S. : " Medical Inspection of Public Schools." (Supt., Public Schools, Asbury Park, N. J.) Somers, B. S. : "The Medical Inspection of Schools; a Problem in Preventive Medicine." Medical News, Jan. 17, 1903. Southard: "The Modern Eye; with an Analysis of 1300 Errors of Refraction." Page 32. San Francisco. Steiger: " Astigmatismus und Schule. Schulhygienische Studie." Correspondenzblatt fur Schweizer Artzte, Bern, 1897, No. 10, pages 289-98. Steinhardt, Dr. Ignaz : Zum augenblicklichen Stand der Schulartz- frage in Deutschland. Page 20. Munich, 1899. Stuver: "The Relation of Food, Air and Exercise to Healthy Growth and Development." Reprint from Jour, of the Amer. Med. Asso., Feb., 1898. Suck, Hans : Die gesundheitliche Uberwachung der Schule. Ein Beitrag zur Losung der Schulartzfrage. Page 36. Hamburg and Leipsic, 1899. Thompson, T. W. : "The Natural History of Infectious Diseases." Stevenson & Murphy's Treatise on Hygiene, II, pages 243-381. Tornell, M. G. : " Medical Supervision of Secondary Schools in Sweden." Med. Press and Circular, Sept. 25, 1907; abstract in Jour, of Amer. Med. Asso., Oct. 26, 1907, page 1479. Twitmyer, Geo. W. : " Clinical Studies of Retarded Children." Psych. Clinic, June 15, 1907. 214 Medical Inspection of Schools Tyler, John N. : "Abstract of 8 Lectures on the Physical Basis of Education." Pubhshed by Twentieth Century Club, Boston, 1906. "The Girl in the Grammar School." Address before Amer. Phys. Ed. Asso., Dec. 26, 1906, Springfield, Mass. Veasey, C. A. : "Importance of Active Co-operation between Parents and Teachers, in Order to Promote and Maintain the Health of Children's Eyes during School Life." Conference of Eastern Public Education Associations, Bulletin No. 2, 1904. Wald, L. D. : "Medical Inspection of Public Schools." Annals, Amer. Aca. of Political and Social Science, 1905, Vol. XXV, pages 290-298. Waldsworth, R. C. W. : " Crusade for a Thousand Eyes." Charities, 10: 141-7. "Warner: "An Inquiry as to the Physical and Mental Condition of School Children." Reprint from British Med. Jour., March 12-19, 1892, page 14. Report on the Scientific Study of the Mental and Physical Condi- tions of Childhood. (Report is based upon the examinations of 100,000 children.) London, 1895. "The Study of Children and Their School Training." Page 264. New York, 1897. Weeks, J. E. : "The Care of the Eyes of Children While at School." Teachers College Record, March, 1905, 6: 30-42. Wells, David W. : "Sight and Hearing of School Children." Jour, of Education, 51: 99-100; 117: 121-2, Feb. 15, 22, 1900. West: "Eye Tests on Children." Amer. Joiu*. of Psych., August, 1892, Vol. IV, pages 595-6. "Worcester School Children: the Growth of Body, Head and Face." Science XXI, Jan. 6, 1893, pages 2-4. "The Anthropometry of American School Children." Proceed- ings, International Congress, Chicago, 1893, page 50. "Observations of the Relation of Physical Development to Intel- lectual Ability Made on the School Children of Toronto, Canada." Science, New Series, 1896, IV, pages 156-9. Williams, Linsly R. : "A Plea for the Physical Examination of all School Children." Joiu". of Amer. Med. Asso., Nov, 16, 1907. Wingate : "National PubHc Health Legislation." North American Review, Nov., 1898, Vol. 167, pages 527-533. Bibliography 215 Wintsch, C. H. : "Medical School Inspection." North American Journal of Homeopathy, 51: 210-7. Witmer, Lightner: "The Hospital School." Fed. Clinic, Oct. 15, 1907, i: 138-46. Wolfe : "Defects of Sight." Northwestern Monthly, July, 1897, pages 35-9- Wood : " Kindergarten and Primary Grade Work in the Public Schools and Its Influence on the Eyesight." Bulletin of the Amer. Aca. of Med., Oct., 1898, III, pages 539-44. Worrill : " Deafness among School Children." Transactions of the Indiana State Medical Society, Indianapolis, 1883, pages 25-33- Wyche, G. : " Inspection of School Children, with Special Reference to Ear, Nose, and Throat." St. Louis Med. Rev., May 4, 1907. Zirkle, Homer W. : "Medical Inspection of Schools." Investiga- tions of the Dept. of Psychology and Education of the Uni- versity of Colorado, June, 1902. ADDITIONAL REFERENCES American Academy of Medicine, Vol. Ill, Oct., 1898. "Brief Statement of the Results obtained by the Commissioner of the British Dental Association appointed to Investigate the Teeth of School Children." British Dental Journal, London, 24: 809-16. "Care of the Eyes." Sanitary Home, June, 1899, P^-ge 79- "Causes of Contagious and Infectious Diseases in Schools (The)." Rocky Mountain Educator, Dec. 23, 1899; from Indiana School Journal. "Considerations respecting Medical Inspection in the Public Schools." Bulletin of the Amer. Aca. of Medicine, April, 1905, 6: 923-32; bibliography, pages 929-32. "Cult of Infirmity (The)." Public Opinion, Oct. 19, 1899, page 493; from National Review, London. "Defective Eyesight." Pop. Sci. Monthly, XXIV, page 357, " Defective Vision in School Children." Educational Review V, page 42. " Dental Clinic for School Children (New York City)." School Jovurnal, Jan. 12, 1907, 74: 54. 2i6 Medical Inspection of Schools "Effects of Study on the Eyesight." Pop. Sci. Monthy, Vol. XXII, page 74. "Effects of Student Life upon Eyesight." Circular No. 6, Bureau of Education, page 2.9. "Examination of Railway Employees." Jour, of Amer. Med. Asso., Chicago, Oct. 21, 1899. "Eye Defects in Students and Children." Ped. Sem., Oct., 1897; Science, Jvily 16, 1897. "Eye Strain and 'Optic Crutches.' " Medical Herald, July, 1900. "Free Eye Glasses for School Children." School Journal, April 27, May II, June 29, 1907; 74: 419, 475, 487, 655. Charities and The Commons, April 27, 1907, 18: 130-1. " Growth of Children." Science, Vol. XIX, pages 256, 281-2 ; Vol. XX, pages 351-2. " How to Test the Vision." Child Study Monthly, I, No. 6. "Hints on the Use and Care of the Eyes." Scribner's XIV, 700. "Hygiene for the School Boy and Girl." The Outlook, Dec. 24, 1898, 1016. "Influence of Schools in Accentuating the Spread of Certain Infectious Diseases (The)." Lancet, 1898, Jan. 21, page 184; Jan. 28, page 256; Feb. 4, page 330, and passim. "Inspection of Schools." Educational Times, Dec. i, 1894, pages 505-11- La Medecine Scolaire. (Monthly publication of the Society of Medical Inspectors of Schools.) Librarie, Ch. Delagrave, Paris. " Medical Examiner for our Public Schools (A) ." Medical Herald, July, 1900. "Medical Inspection of Schools," in "Making a Municipal Budget," pages 92-107. Bureau of Municipal Research, New York, 1907. Northwestern Monthly, July, 1897. "Nutrition. Investigations at the University of Tennessee." Scien- tific American, supplement to, March 11, 1899, page 194; also Bulletin of the Department of Agriculture, Nos. 29 and 53. " Oiu- Eyes and How to Take Care of Them." Atlantic Monthly, XXVII, 62, 177, 332, 462, 636. Psychological Clinic, Vol. I, No. i, March 15, 1907. (Most scientific exponent of the work for backward and mentally retarded children.) Bibliography 217 " Relation of Diseases of the Eye to Diseases in General (The)." Medi- cal Times, Jan., 1898. "School Life and Eyesight." Pop. Sci. Monthly, I, page 766. "School Work and Eyesight." Science XII, page 207. " Shall We Put Spectacles on School Children ?" Pop. Sci . Monthly, XXV, page 429. "Sight Training." Literary Digest, Oct. 9, 1898; The Hospital, London, March 5, 1898. "Statistics on Blindness and Deafness." New York Med. Jour., July 17, 1897, page 85. "Suggestions to Teachers and School Physicians regarding Medical Inspection." Special pamphlet, Massachusetts Board of Educa- tion, 1907. "Tests on School Children." Educational Review, V, page 42. Zeitschrift fiir Schulgesundheitspfiege. Edited by Kotelmann 1888-98; since that time by Erismann, Hamburg. (This contains many articles relative to the progress of medical inspection the world over.) SCHOOL REPORTS Baltimore, Md. : Seventy-eighth Annual Report of the Board of School Commissioners, 1906. Birmingham, Ala. : Annual Report of the Birmingham Public Schools, 1907. Boston, Mass. : Annual Report of the Public Schools, 1895. Twenty-seventh Annual Report of the Superintendent of Public Schools of the City of Boston, 1907. Brockton, Mass. : Annual Report of the Superintendent of Schools, 1907. Cambridge, Mass. : Annual Report of Public Schools, 1898. Annual Report of the School Committee, prepared by the Superin- tendent of Schools, Cambridge, Mass., 1907. Camden, N. J. : Annual Report of the Board of Education, 1906. Chicago, 111. : Forty-sixth Annual Report of the Board of Education, 1900. Cincinnati, 0. : Seventy-eighth Annual Report of the PubUc Schools of Cincinnati, O., 1907. 21 8 Medical Inspection of Schools Cleveland, 0. : Annual Report of the Board of Education, Cleveland, O., 1901. Annual Report of the Superintendent of Schools, Cleveland, O., 1907. Dallas, Texas : Eleventh Biennial Report of the Dallas Public Schools, 1906. Dayton, 0. : Annual Report of the Board of Education of the City School District of Dayton, O., 1907. Fall River, Mass. : Annual Report of the City of Fall River, 1907. Fitchburg, Mass. : Thirty-fifth Annual Report of the School Committee of the City of Fitchburg, 1907. Harrisburg, Pa. : Annual Report of the Public Schools of Harrisburg, Pa., 1907. Hoboken, N. J. : Annual Report of the School Department of Ho- boken, N. J., 1907. Lawrence, Mass. : Sixtieth Annual Report of the School Committee of the City of Lawrence, Mass., 1906. Sixty-first Annual Report of the School Committee of the City of Lawrence, Mass., 1907. Los Angeles, Cal. : Annual Report of the Board of Education of the City of Los Angeles, Cal., 1906-7. Lowell, Mass. : Eighty-second Report of the School Committee of the City of Lowell, and Forty-fourth Annual Report of the Super- intendent of Public Schools, 1907. Milwaukee, Wis. : Annual Report of the Board of School Directors, Milwaukee, 1900. Forty-eighth Annual Report of the Board of School Directors of the City of Milwaukee, 1907. Newark, N. J. : Fifty-first Annual Report of the Board of Education of the City of Newark, N. J., 1907. Newburyport, Mass. : Annual Report of the School Committee by the Superintendent of Schools of the City of Newburyport, 1907. New Haven, Conn. : Annual Report of the Board of Education of New Haven City School District, New Haven, 1907. Newton, Mass. : Annual Report of the School Committee of the City of Newton, Mass., 1906. Bibliography 219 New York, N. Y. : Ninth Annual Report of the City Superintendent of Schools, City of New York, 1907. Northampton, Mass. : Twenty-third Annual Report of the School Committee of the City of Northampton, Mass., 1906. Twenty-fourth Annual Report of the School Committee of the City of Northampton, Mass., 1907. Pawtucket, R. I. : School Report, 1901. Reading, Pa. : Minutes of the Reading School Board, March 15, 1904. San Antonio, Texas : Annual Report of the San Antonio School Board, 1907. Somerville, Mass. : Thirty-sixth Annual Report of the School Com- mittee of the City of Somerville, Mass., 1907. Syracuse, N. Y. : Fifty-eighth and Fifty-ninth Annual Reports of the Department of Public Instruction of the City of Syracuse, 1906-7. Waltham, Mass. : Annual Report of the School Committee and Super- intendent of Schools of Waltham, Mass., 1908. Wilmington, Del. : Thirty-fourth Annual School Report of the City of Wilmington, Del., 1905. Yonkers, N. Y. : Twenty-seventh Annual Report of the Board of Edu- cation in the City of Yonkers, N. Y., 1907. REPORTS FROM BOARDS OF HEALTH Briinn, Austria : Dritter Bericht liber die Tatigkeit der stadt. Be- zirksartzte in Briinn als Schulartzte, 1903. Vierter Bericht liber die Tatigkeit der stadt. Bezirksartzte in Briinn als Schulartzte, 1906-7. Cambridge, Mass. : Annual Report of the Board of Health, Cam- bridge, 1896. Everett, Mass. : Fifteenth Annual Report of the Board of Health, 1907. Montclair, N. J. : Thirteenth Report of the Board of Health, 1907. New York, N. Y. : Working Plan of the System of Medical Inspection and Examination of School Children in the City of New York, Department of Health, New York, 1906. Springfield, Mass. : Annual Report of the Board of Health, 1907. 220 Medical Inspection of Schools OTHER REPORTS Commissioner of Education : Report of the Commissioner of Educa- tion, 1897-8, Vol. II, "Medical Inspection of Schools," pages 1489-1512. Report of the Commissioner of Education, 1902, "Medical Inspec- tion of Schools Abroad," pages 509-526. Report of the Commissioner of Education, 1902, "Report of Com- mittee on Statistics of Defective Sight and Hearing of Public School Children," pages 2 143-2 155. Report of the Commissioner of Education, 1906, "Medical Inspec- tion of School Children," Vol. I, page 327. Detroit, Mich. : Bulletin No. i, Child Study Committee, Detroit Public Schools, Dec, 1907. Dundee, Scotland : Report on Housing and Industrial Conditions and Medical Inspection of School Children. Dundee Social Union, Dundee, 1905. Dunfermline, Scotland : First Annual Report of Medical Inspection of School Children, Dunfermline, 1906. Second Annual Report of Medical Inspection of School Children, Dunfermline, 1907. Edinburgh, Scotland : Report on the Physical Condition of 1400 School Children in the City of Edinburgh, together with some account of their Homes and Surroundings. London, 1906. Harrisburg, Pa. : Report of the Special Committee to Investigate and Report on Medical Inspection in the Schools. Harrisburg School District, Harrisburg, Pa., April 27, 1908. London, England : Report of the Education Committee of the London County Council, Submitting the Report of the Medical Officer (Education) for the Year ended 31st March, 1905. Report of the Education Committee of the London County Council, Submitting the Report of the Medical Officer (Education) for the Year ended 31st March, 1906. Report of the Education Committee of the London County Council, Submitting the Report of the Medical Officer (Education) for the Year ended 31st March, 1907. Board of Education. Memorandum on Medical Inspection of Children in Public Elementary Schools, under Section 13 of the Education (administrative provisions) Act, 1907. London, 1907, Eyre & Spottiswoode. (Great Britain Board of Educa- tion, circular 576.) Report of International Committee on Medical Inspection and Bibliography 221 Feeding of Children attending Public Elementary School. 2 v., London, Wyman & Sons, 1905. Lucerne, Switzerland : Bericht und Antrag des Stadtrates von Luzern betreffend Errichtung einer Schulpoliklinik. Lucerne, Dec. 8, 1906. Massachusetts (Board of Education) : Sixty-fourth Annual Report of the Board of Education, 1899-1900, pages 375-380. Seventieth Annual Report of the Board of Education, 1905-1906, pages 110-118. "Medical Inspection in the Public Schools." New York City : New York Committee on the Physical Welfare of School Children. "Physical Welfare of School Children." Quarterly of the American Statistical Association, June, 1907. Appendix I " SUGGESTIONS TO TEACHERS AND SCHOOL PHYSICIANS 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 igo6, 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, repre- senting 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 experience 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 disability or defect tending to prevent his receiving the full benefit of his school work, or requiring a modification of the school work in Suggestions to Teachers and School Physicians 223 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. The following are the subjects treated, with the names of the physi- cians who have contributed suggestions: — 1. Infectious Diseases. — Dr. John H. McCoUom. 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. Chales 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. BuUard, 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 224 Medical Inspection of Schools 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 upon the physical condition of the children. Any hoarseness or any thickness 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 the 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) shoiild 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 retvim 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 ruinute 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 Suggestions to Teachers and School Physicians 225 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. Whooping-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 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 body 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] 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 * See Diseases of the Skin. 226 Medical Inspection of Schools complain 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 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 tonsillitis 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 difi&cult breathing, diphtheria should be suspected. 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-breathing, 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 tonsillitis 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 pedicuK 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. Suggestions to Teachers and School Physicians 227 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. Pediculi Capitis (Head Lice). — An extremely common accident among children, either from wearing each others' hats and caps, or hanging them on each others' pegs, or from combs and brushes. No person should be blamed for having lice, — only for keeping them. The irritation caused by vermin in the scalp leads to scratching, which in turn causes an inflammation of the skin of the neck and scalp. The skin then easily becomes infected with some of the pus-producing germs, and large or small scabs and crusts are formed from the dried matter and blood. Along with this condition the glands back of the ears and in the neck become swollen, and may be very painful and tender. The condition of pediculosis is most easily detected by looking for 228 Medical Inspection of Schools 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. 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 fiat 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; Suggestions to Teachers and School Physicians 229 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 habitually raised or dropped, or when the child leans to the side, or shows persis- tent 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 v^^hich 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 anaemia. Pallor in young girls usually means chlorosis, — a form of anaemia 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 pufl5ness of the face. Ptiffiness 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. Shortness 0} 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. 230 Medical Inspection of Schools 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 characteristic. There is usually a sore throat in connec- tion 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 sweUing of the neck and difficulty in swallowing, are of importance. They may mean nothing but tonsillitis, 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. Suggestions to Teachers and School Physicians 231 A spasmodic cough, that is, a cough which occurs in paroxysms and is 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 diges- tive 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- 232 Medical Inspection of Schools 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 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 inabihty 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 awkward, or interfere with buttoning the clothes, writing or drawing. Such children are often scolded for being inattentive or careless. These symptoms are the sUghter 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 with- drawn 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. II. — Another class of symptoms requiring investigation are repeated faintings, especially if the child's lips become blue; attacks, often only Suggestions to Teachers and School Physicians 233 momentary, in which the child stares fixedly and does not reply to questions, 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. 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. 234 Medical Inspection of Schools 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. 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 Suggestions to Teachers and School Physicians 235 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 hable 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 intellectual 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 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 236 Medical Inspection of Schools 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 heat- ing 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 cleanKness of the school- room is of importance, and the admission of sunhght 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. 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 Suggestions to Teachers and School Physicians 237 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 back-rest that will support the "small of the back" properly, without having the scholar lean back excessively. Wliether 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 A TYPICAL SET OF EUROPEAN BLANKS AND FORMS (Translations of those used in Briinn, Austria) FORM I Notice to Parents As a result of the physical examination of your child , which examination was made in accordance with the provisions of the town council of the city of Brunn, it has been found that he (she) is suffering from In the interests of your child, as also for the welfare of the school, is urgently required. Briinn, 19 Medical Inspector To 238 A Typical Set of European Blanks and Forms 239 FORM II Notice to Parents To Mr. (Mrs.). At the recent medical examination made of your child , the hair was found to contain vermin. In the interests of your child, of your family, and of the school, a thorough cleansing is lu-gently requested. By Order of the City Council: Briinn, 19 . . Note: The cutting of the hair is recommended; or rub- bing the head with petroleum (taking care of the eyes and of proximity to a light), then enveloping the head in a closely fitting cap for twelve hours, thereafter washing with warm water and soap; or saturating the hair with a fatty substance, frequent combings, and rubbing with vinegar to eUminate the nits. 240 Medical Inspection of Schools FORM III Health Report of son (daughter) of Born I Vaccinated i School since i . Revaccinated i Date and School Year. General Constitu- tion. Ht. CM. Wt. KG. Size OF Chest CM. Chest and Abdomen (Tuberculo- sis AND Her- nia, ETC.). Skin Dis- eases (Parasites). Spine and Extremities (Scrofula, Rickets.) I Winter Summer . . 1 Winter Summer III Winter Summer IV Winter Summer V Winter Summer VI Winter Summer Vll Winter Summer Vlll Winter Sum.mer A Typical Set of European Blanks and Forms 241 (Reverse of Form III) Date and School Year. Eyes and Eye- sight. Ears AND Hearing. Mouth, Nose and Speech. Recommen- dations for Treatment IN School. Remarks. Notices to Parents. Remarks'of Teacher (Illnesses, Number op Hours Ab- sent, ETC. Instruction in, 7). 1 Winter Summer II Winter Summer III Winter Summer IV Winter Summer V Winter Summer VI Winter Summer VII Winter Summer VIII Winter Summer 16 242 Medical Inspection of Schools o o a> w o a H «> a a o a o o o Re- marks OF Teach- er. w« - Recommenda- tions as to Treatment in School (Physi- cian's Certifi- cate). Remarks. Pi < w >*< „- p. Q s < Para- sites. Skin Dis. Chest AND Abdo- men. z o H H H O O <: H Z M o 1 a 1 O O o o § 5 o A Typical Set of European Blanks and Forms 243 ci :i -o > > s nd pl^ d i^ T3 a at a o CO S *© o 4) o Pi OH o o z B CL, < W Q No. OF Indi- vidual Examin- ations. No. OF Pupils Exam- ined. f» ,'r, 2;u No. OF Visits BY Physi- cians. a .;2 t-i 1 05 244 Medical Inspection of Schools FORM VI Physician's Report Born. . School Street. General Constitution Mentality Chest Organs (Tuberculosis) Abdominal Organs (Hernia) Spine and Extremities Skin (Parasites) Eyes, Eyesight Ears, Hearing Mouth, Nose and Speech Remarks Physician's Recommendations regard- ing Instruction Briinn, 19 Practising Physician Note. — ^Physicians are requested to make out the report as carefully as possible. The first section, "General Constitution," must always be filled out, and according to the category of "good," "medium," and "bad," bracketing (chlorosis, tuberculosis, etc.). The other sections need only be filled out in case of symptoms. A detailed statement in the section, "Remarks," is particu- larly desired when questions arise as to absences of the child or questions of excuses from lessons and from physical training. FORM VII Memorandum Blank With Reference to Unhygienic Conditions found in School Houses by Medical Inspectors Date of Visit. School. Remarks, Suggestions, etc. Briinn, 19.. Medical Inspector I A Typical Set of European Blanks and Forms 245 Questions to Parents or Guardians In the interests of the pupil, so that due consideration may be ac- corded to him in school, it is requested that careful answers be given. Name of Pupil During what years of life did sickness occur? Name the illnesses. Did you observe continued ill effects of such sick- ness ? What effects and since when ? Has the child sustained injuries of lasting conse- quence? When, and what injuries? When did the child (a) learn to walk, (b) learn to talk? Has the child weak eyes, or is he nearsighted? Since when and what is the cause ? Has the child difficulty in hearing? Since when and what was the cause ? Is the child suffering from other defects or weak- nesses? (Frequent headaches, nose bleeding, lassitude, frequent loss of appetite, convulsions, nervous irritability, difficiilties in speech, psychic peculiarities.) Has puberty been reached? Since when? Are the periods regular? Are there difficulties? What difficulties? Does the child regularly partake of alcohol? Does he drink beer, wine, tea with rum, and if so, in what, quantities? A regular system of medical inspection has been introduced into the school. Parents or guar- dians are, therefore, requested to indicate clearly as to whether they grant or refuse their consent for the examination of the child by the school physician. Briinn, 19 Signature 246 Medical Inspection of Schools (Individual Report Giving Results of Semi-Annual Physical Examinations During the School Life of Eight Years.) Health Report Name Born. . . Vaccinated Class I II III IV V VI VII VIII Terms I 2 I 2 I 2 1 2 I a I 2 I 2 I 3 Examined (Date) General Condition of Body Height in cm. Weight in kg. I. Condition of the Body and the Blood 1. Anaemia 2. Chlorosis 3. Scrofula 4. Enlarged Glands 5- II. Osseous Structure 1. Malformation of Skull 2. Malformation of Sternum 3. Scoliosis 4. Deformities of Limbs S- III. Condition of Bones, Joints, and Muscles 1. Chronic Inflammation of the Bones 2. Chronic Inflammation of the Joints 3. Rachitis 4. Wry-neck 5. IV. Skin 1. Eczema 2. Psoriasis 3. Furunculosis 4. Prurigo S- V. Mouth, Throat, Nose 1. Adenoids 2. Ozena 3- VI. Condition of Lungs 1. Asthma bronchiale 2. Tuberculosis 3. Chronic Catarrh VII. Condition of the Heart 1. Funktionelle 2. Malformation, or defective heart 3- A Typical Set of European Blanks and Forms 247 (Reverse of Health Report) Class I II III IV V VI VII VIII Terms I 2 I 2 I 2 I 2 I 2 1 2 I 2 I 2 VIII. Abdominal Organs 1. Chronic Catarrh of Stomach and Intestines 2. Hemorrhage from Stomach 3. Nycturia 4- S- IX. Eyesight 1. Myopia 2. Hypermetropia 3. Weak Eyesight 4. Twitching of the Eyes 5. Strabismus 6. - X. Diseases of the Eyes 1. Chronic Inflammation of the Conjunctiva 2. Chronic Inflammation of the Cornea 3. Chronic Inflammation of the Eyelids 4. Trachoma 5. Scars and Spots 6. XI. Hearing I. Ability to hear Whisper 2. XII. Diseases of the Ear I. Discharge from Ears 2. XIII. Speech t. Stammering 2. Stuttering XIV. Defects of Develop- ment 1. Defective Palate 2. Inguinal Hernia 3. UmbiUcal Hernia 4. Goitre XV. Nervous System 1. Convulsions 2. Epilepsy 3. Paralysis 4- 5. Ataxia 6. Chorea 7. Abnormal Reflexes, Twitchings 8. - XVI. Psychic Peculiar- 1. Unusual Irritability 2. Particular Inclinations 3- ities XVII. Parasites 1. Scabies 2. Pediculosis 3- Condition of Teeth Develop- ment Remarks. Absences from school on account of illness. Mention them and give dates and periods of each sickness. 248 Medical Inspection of Schools FORM I (Dental) Briinn, 190 .. . Name: Pupil in class of school , residing at requires prompt dental treatment. If it meets with your consent to have him (her) undergo such treatment, it is requested that you signify your willingness by signature. Treatment is conducted at the expense of the city. Medical Inspector School Principal Affirmation I hereby testify my willingness to have my child..... ^ . •« ^ ^ >. ... . .undergo dental treatment. Signature: A Typical Set of European Blanks and Forms 249 (Reverse of Form I — Dental) Care of the Mouth and Teeth Food well chewed is half digested. Badly kept teeth hinder mastication; they create a disagreeable odor, and are often the cause of interferences with health. Pieces of food lodge and decay in carious teeth; and disease germs are found in the oral cavity. Therefore, from the standpoint of breathing and from that of good digestion, the hygiene of the mouth is most essential. For this reason the mouth and teeth should be rinsed daily, in the morning and in the evening, with clean, lukewarm water. The teeth and gums should be cleansed with a clean, moistened brush, using as a tooth powder finely ground chalk, and by moving the brush up and down. Finally the mouth and throat should be rinsed throroughly with water. Food eaten very cold or very hot, that which is too sweet or too sour, as well as food highly spiced, is injurious to the teeth. The moistening of postage stamps, envelopes, or ink spots with the tongue; the putting of the fingers, of play- things or any other objects into the mouth; the insertion of hard substances, such as a fork, penknife, pen, pin, etc., between the teeth may cause great damage. None but wooden or quill toothpicks should be used. In the case of a diseased tooth, the sooner a dentist is consulted, the sooner is it possible to remove the difl&culty. 250 Medical Inspection of Schools FORM II (Dental) No Briinn 190 To Dr Dentist in Briinn. Upon consent having been obtained from the parents of pupil in class , school located at , for dental treatment of their child, you are hereby requested to undertake such treatment and to make appointments. City Physician (Reverse of Form II same as reverse of Form I) Appendix III RULES ISSUED TO MEDICAL INSPECTORS OF SCHOOLS IN CHICAGO, ILL., DETROIT, MICH., AND SPRINGFIELD, MASS. I. Rules for Medical Inspectors and School Medical Inspectors, Department of Public Health, City of Chicago Medical Inspectors should familiarize themselves with the City Health Ordinances. (Copies can be had by applying to the Secretary.) Beginning at 9 o'clock Medical Inspectors will call daily at the schools assigned them, and request principals to have all pupils in readi- ness for examination who have been absent from school for four con- secutive days. The principal will also refer to the Inspector any pupils in school who are suspected to be suffering from infectious or contagious diseases. The examinations will be made at the school. The principal of school should have all children to be examined sent to a room by themselves where the other pupils will not come in contact with them, and where the school inspector can examine them. Inspection is to be made in reference to communicable diseases and the vaccinal status of pupils only. Examinations are to be made for the following diseases: Scarlet fever, diphtheria, measles, rotheln, smallpox, chickenpox, tonsillitis, pediculosis, ringworm, impetigo contagiosa or other transmissible diseases of the skin, scalp and eye. Tuberculosis, when thought to be far enough advanced to be a menace to the public health, must be reported to the Chief Medical Inspector before excluding the pupil from school. Scarlet-fever cases must not be allowed to return to school until all desquamation is completed, and there is an entire absence of dis- 251 252 Medical Inspection of Schools charge from ears, nose, throat or suppurating glands and the child and premises are disinfected. This requires at least six weeks — severe cases eight weeks or longer. Diphtheria cases must be excluded until two throat cultures made upon two consecutive days show absence of the Klebs-LoefSer bacilli. Those exposed to diphtheria should be excluded one week from last exposure. Measles cases are very infectious in the early stages, and must be excluded at least three weeks and longer if there is present bronchitis, inflammation of the throat, nose or abscess of the ear. Those exposed to measles should be excluded two weeks from date of last expostire. Whooping Cough: Cases should be excluded until after the spasmodic stage of cough — usually about eight weeks. Whooping cough is very infectious in the early stages of the disease. Those ex- posed to whooping cough should be excluded two weeks from date of last exposure. Mumps : Exclude ten days after all swelling has subsided. Those exposed to mumps should be excluded three weeks from date of last exposure. Chickenpox: Exclude until scabs are all off and skin smooth — two to three weeks, according to the severity of the attack. Rotheln, German Measles: Exclude from school two weeks. Those exposed to rotheln must be excluded from school three weeks from date of last exposure. Cases of tonsillitis must be excluded on the clinical evidence alone, and throat cultures made for further diagnosis. Cases presenting suspicious throats, but not definite evidence of disease clinically, must have throat cultures made, allowed to return to their classes until the cultures have been examined, and only excluded in case the bacteriologic examination shows exclusion to be necessary. In making inspections care must be used to disturb the child as little as possible, and throat cultures are to be made only when good rea- son therefor exists. In making throat examinations, the wooden tongue depressors supplied must be used, to the exclusion of all other tongue depressors. Each tongue depressor must be used only once and then burned. Asep- tic methods must be employed in all examinations. Rules Issued to Medical Inspectors 253 If a child is excluded, brief but sufficient reason therefor must be written on the exclusion card. Inspectors are forbidden to make any suggestions as to the treat- ment or management of pupils who are sick. This is imperative. Children recovering from measles, whooping cough, mumps, chicken- pox, scarlet fever, diphtheria and smallpox — must not re-enter school without a permit from the Department of Health. When a pupil is taken sick with an infectious disease in a school- room, the pupils in the room must be dismissed, and the room disinfected. If smallpox is found in the eruptive stage, the child can be taken to his home, if near, and there isolated until the ambulance arrives, or isolate in the room where found. In doing this no one should be allowed to come near the infected child. Children properly vaccinated who have been exposed to small- pox need not be excluded from school. Those exposed and not vacci- nated must be excluded twenty days. Pupils living in apartment buildings, where an infectious disease exists, should be excluded from school by the principal. A visit to the building by the Inspector will determine who can return to school with safety. It depends upon the construction of the building and the habits of the inmates whether it is safe to let any from the building continue in school. The Inspector must be the judge. Usually if families use the same entrance there is some risk, and yet a case can be so well isolated and cared for that all others in the building are safe. A visit to the building is necessary to determine this. All cases of infectious diseases coming under the observation of the Inspector which are not properly safeguarded should command his attention. Give proper instructions to the family, leave the Department cir- cular applicable to the case, and take any other measures necessary to protect the pubhc health. Investigate all suspected cases of infectious diseases in your territory and take proper measures for safeguarding against the spread of infection. Make daily reports to the Chief Medical Inspector upon blanks provided for the purpose of each case inspected or investigated. Beginning Oct. 15, School Medical Inspectors will vaccinate free of charge any child or pupil who may apply to them for vaccination, and must issue a certificate of vaccination to those entitled 254 Medical Inspection of Schools to the same. The inspectors will vaccinate no child without the con- sent of parent or guardian. The Department prefers that the family physician should perform vaccination; but if the parent or guardian of a child wishes it done by the Department the child may be taken or sent to the School Medical Inspector or Public Vaccinator, whose duty it then is to vaccinate such child and furnish a certificate without charge. Examine every school pupil's arm to determine the vaccinal status. Any discovered not complying with the vaccination ordinance must be excluded from school by the principal. Read the ordinance carefully and be governed by it in the matter of vaccination. Inspectors must make monthly reports upon blanks furnished for that purpose, giving the number of tubes of vaccine received during the month, the number of primary vaccinations performed, the number of re-vaccinations performed, the number of certificates issued to those previously vaccin- ated within seven years and entitled to a certificate without a re-vac- cination, the number of attempted vaccinations on primary subject resulting in failure to take, and the number of attempts at vaccination in previously vaccinated subject resulting in failure to take. Inspectors must carry with them a supply of the Department circu- lars to hand out for instruction in cases of infectious diseases. The circulars are: Information for the family in case of contagious diseases. Circulars on prevention of consumption. The Vaccination Creed. Special circulars on each of the infectious diseases and warning slips to distribute and paste up for the public to read. Spatulas for tongue depressors. Culture mediums and outfits for Widal test. Additional Duties of School Medical Inspectors The city has been divided into eleven districts. A Medical Inspec- tor, a Sanitary Inspector and a Milk Inspector is placed in each of these districts. Each of these districts is subdivided into nine districts with a School Medical Inspector in each of these minor districts. The nine School Medical Inspectors will be under the direction of the Medical Inspector. Each morning before 9 o'clock the location of the infectious diseases reported to the Department will be telephoned to the School Inspector in the district from which the case is reported. The Medical Inspector will have the same information from the nine districts. The Rules Issued to Medical Inspectors 255 School Inspector will visit all cases reported from his district, see that proper isolation is established, determine who from contiguous fiats or houses can safely remain in school, and see that the warning card is on the door or where it will best serve the purpose of warning any who may approach the infected premises. See also that a warning card is posted where the milk man who delivers milk will see it, leave the Department circulars giving information in cases of contagious diseases and distribute and post the small warning leaflet in the near-by neigh- borhood and mail a notification card to the principal of school. The Inspector notified will take smears in cases of diphtheria to determine when the case is ready for termination. When the District Medical Inspector has more antitoxin work than he can attend to, the School Medical Inspector will aid in this work. When the School Inspector is in doubt about a diagnosis he will call upon the District Medical Inspector to help in making a diagnosis. The School Inspector is to have charge of all infectious diseases in his restricted territory and will be held responsible for the work in the territory assigned him. The Medical Inspector will be held responsible for the work of the nine School Inspectors in his district. To assist the Medical Inspectors three diagnosticians have been designated — one on each of the three sides of the city. In making inspections and investigations you will observe the following instructions: Inspectors must keep in close touch with the Department of Health so they may be reached without delay when wanted. Contagious diseases and suspected contagious diseases reported to the Department of Health are assigned to the Medical Inspectors and School Medical Inspectors either for inspection or investigation. Cases for inspection are those reported by physicians. In these cases see that the family receives a copy of the Department "Circular of Information Upon the Management of Contagious Diseases," and give them such further advice concerning the best methods to pursue for preventing the spread of contagion as you deem necessary. Especially instruct the family in regard to the length 0} time cases should be isolated and impress upon them the necessity of a thorough disinfection after the case has terminated. Tell them to have their doctor notify the Department when the case is free from giving off contagion and the house is ready for disin- 256 Medical Inspection of Schools fection — and not before. Disinfectors are frequently sent to families only to find that the patient is still in the contagious stage, especially in scarlet fever. This means loss of time to the disinfecting force. Notify by postal card provided the principal of every school in the vicinity, both public and parochial, during vacation as well as while school is in session, whom to exclude from school and take such other measures in the case as may be needed to protect the public health. You are the judge of whom it is safe to permit to attend school from flats or houses contiguous to infected premises. If you find the family disregarding the doctor's instructions concern- ing isolation, disinfection of excretions, etc., supplement his instructions and through your own efforts see that the family observes proper pre- cautions. If the case is in any way connected with a shop or store, at once make the case safe to the public by one of the following plans: 1. When it is best to do so, the Department of Health will remove the patient to a hospital. No one can move a person sick with an infectious disease without the consent of the Commissioner of Health. 2. If the patient remains, the room must be shut off from the store by sealing cracks of doors and keyholes with paper and paste. All communication between the sickroom and the store must be stopped. 3. If neither of the above plans is followed the store must be closed, the door locked and the public excluded. Cases for investigation are supposed cases, such as are reported •to the Department through other sources than physicians. These you will visit and ascertain the nature of the disease, and if found to be scarlet fever, diphtheria, whooping cough or measles, see that the attending physician, if there be one, reports the case to the Department, or report it yourself by card, as you do in a case where there is no physi- cian. Put up a warning card and take the same precautionary measures as in cases for inspection. Send notices to principals of schools of any and all contagious diseases encountered while inspecting and investigating cases. Make daily reports to the Department of all cases inspected or investigated. Endeavor to learn the source of infection in every case: milk sup- ply, fruit, infected clothing, or persons, etc., and communicate to the Rules Issued to Medical Inspectors 257 Department any information of interest which you may learn concern- ing this subject. When notified of a suspected case of smallpox the Inspector must go to the case forthwith. An hour's delay may result in many needless exposures. The following suggestions as to conduct in the presence of smallpox should be observed so far as the circumstances of the case will permit with safety. The Inspector must supply any deficiency in these instruc- tions which the case may demand for the safety of the public. When entering a house where there is a suspected case of contagious or infectious disease do not remove your hat or overcoat; keep the overcoat buttoned. Do not shake hands with any one in the house. Do not sit down or touch anything in the house and especially avoid touching the patient or bed clothing. To expose the patient for examination call upon the patient or some one present to remove the clothing for you. When leaving the house have some one open the door so as to avoid touching any infected doorknob. Except to vaccinate the inmates of the house, it is not necessary to touch anything about the premises except the floor with the soles of your shoes. If these precautions are observed there is no danger of carrying the disease to others. When it is determined the case is one of smallpox, fill out the history blank provided for the purpose (Form 2), telephone the information to the Department and promptly mail the filled blank to the Chief Medical Inspector. Telephone instructions as to the disposal of the case, whether an ambulance or a carriage is needed, the amount of disinfecting to be done and the number of vaccinators needed. In filling out the blank secure a list of all who have in any way been exposed to the contagion since the first day of the sickness, learn if letters or laundry have been sent out from the house and where and to whom sent. Give the vaccinal status of those exposed so far as you can. It is the duty of the Inspector to vaccinate or see that some other medical inspector vaccinates all who are known to be exposed to the infection. Do not leave or allow this duty to be done by the "family 17 258 Medical Inspection of Schools physician." It is the duty also of the Inspector to secure the consent of the patient or family for the removal of the patient to the Isolation Hospital. Do not leave this duty to the ambulance driver. Until the ambulance comes the case must be made safe. If it is necessary to police the house to secure safety, do so. After securing the prompt vaccination of all exposed it is the Inspector's duty to see the exposed every other day for fifteen to twenty days. If the vaccina- tion does not take, repeat until it does take. If there is doubt about the diagnosis, vaccinate the inmates of the house, make the case safe to others and see the patient later. A Medical Inspector must be courteous and should be tactful in all his relations to cases of smallpox, the same as a doctor should be in his private practice. He should be a complete master of the situation, able to dispose of complications and duties as they arise, in a proper manner. It should not be burdensome to do so, for the reward is always present, the consciousness that it is life-saving work. Use discretion and secure compliance with the ordinance without force. This can almost always be done, but if necessary the police power can be used to enforce compliance with the law. II. Instructions to Medical Inspectors of Public Schools Detroit, Mich. 1. The pupils to be inspected will be referred to the inspectors by the principal for two reasons : A. Those who have been absent one or more days. B. Those in the school whom the teacher may suspect to be suffering from communicable diseases. These two classes must be kept separate in the reports. 2. The inspection is to be made with reference to communicable diseases only, and pupils are to be excluded for the following diseases: Scarlet Fever Mumps Pediculosis Diphtheria Smallpox Ringworm Tonsillitis Chickenpox Impetigo Rotheln Whooping cough Scabies Rules Issued to Medical Inspectors 259 or other communicable diseases of the skin and scalp, and communi- cable diseases of the eye. 3. In making throat examinations, the wooden tongue depressors supplied must be used to the exclusion of all other depressors. Each tongue depressor must he used only once. Aseptic methods must be employed in all examinations. 4. Whenever a child is excluded, brief but sufl&cient reason therefor must be written on the exclusion card. 5. Medical inspectors will use their own judgment about the accept- ance of family physician's certificates. You have the right to ignore them if such action is justified by your personal investigation of a case at school. 6. The principal excludes children from school, the inspector recommends to the principal exclusions when justified, the principal acts accordingly. Do your utmost to maintain harmony and coopera- tion with principals. 7. Be sure and give exclusion cards in every instance, so parents will be notified 8. Remember you have no jurisdiction as inspector beyond the threshold of the public schools of your district. DO NOT examine pupils at your ofiice or any place outside of the public schools. 9. Use great discretion in examining pupils. Do not keep them waiting any longer than necessary. 10. On discovery of smallpox, diphtheria, or scarlet fever cases notify Health Officer AT ONCE by telephone. Blanks for reports, etc., can always be obtained at the Board of Health Building, 233 St. Antoine Street. 11. Report promptly to Health Officer whenever illness or accident prevents you from going to your work. 12. Send in your weekly reports PROMPTLY. 13. Medical inspectors are paid on the fourth Saturday of each month. Checks are at City Hall, office of City Treasurer. 26o Medical Inspection of Schools III. Rules for the Medical Inspection of the Public School Children, Health Department, Springfield, Mass. Under the authority of the revised laws of the State of Massachusetts, the Board of Heakh of this city has arranged a system of medical in- spection of pupils attending the pubHc schools. The objects of the medical inspection of school children are: (i) Identification of all pupils requiring medical care. (2) Prompt ex- clusion from school of all pupils suffering from communicable diseases, (3) Detection of ailments and diseases other than communicable diseases. (4) Detection of defects of sight or hearing or other disability injurious to pupils. Under the law, the tests of sight and hearing shall be made by the teachers, and the necessary rules of instruction, test cards, etc., will be distributed as soon as they are ready. It is desirable that the Medical Inspector have the use of a room for the examination of children. The Medical Inspectors wiU visit each school twice weekly, — Monday and Thursday mornings. The Principal of the school and the Medical Inspector should agree upon the hour of inspection, which should, as far as possible, serve the best interests of the two or more schools to which the inspectors are assigned. The Medical Inspector will examine such children as are indicated by the teachers. The following described children should be sent to the Inspector at the appointed time: A. Every child returning to school without a certificate from the Board of Health after absence on account of illness, or from unknown cause. B. Every child who shows signs of being in ill health, or suffering from infectious or contagious disease. C. Every child returning to school after having been excluded by the Inspector. Children showing symptoms of the following diseases are to be sent home immediately: Rules Issued to Medical Inspectors 261 Smallpox Diphtheria Mumps Scarlet Fever Influenza Scabies Measles Tonsillitis Trachoma Chickenpox Whooping Cough Ringworm Tuberculosis Pediculosis Impetigo contagiosa. In case exclusion from school is warranted, the exclusion card is to be filled out and put in a sealed envelop and given to the child to take home. A record of each case must be made upon the card provided for the purpose, to be kept by the rinpcipal, and upon the large blank to be returned to the Board of Health at the end of each week. In case any of the above mentioned diseases be found, the Board of Health is to be at once notified on blanks provided for this purpose. In many cases of exclusion, children should be allowed to return to school promptly if they can furnish evidence that they are under treat- ment for the disease indicated. In this way many children suffering from ailments of a special nature will be permitted to attend school instead of being kept out of their classes. Swabs should be taken by the Inspector from all suspicious throats. Medical Inspectors (or the family physician) are expected to vacci- nate such children as require it. No prescription or medical treatment is to be given any child by the Medical Inspector while in the perform- ance of his duties except as follows: In special cases prescriptions, furnished by the Health Department, are to be provided free of charge for the following diseases : Impetigo contagiosa, ringworm, scabies, animal parasites in the hair. Rules governing the admission of children to school after illness with contagious disease: School children may return to school after — Diphtheria when two negative cultures have been obtained. Scarlet fever after three weeks, or when peeling has ceased. Measles when catarrhal symptoms have ceased. Whooping cough after cough has stopped. Mumps when swelling has disappeared. , , Chickenpox when skin is free from crusts and scabs. 262 Medical Inspection of Schools During the continuance of diphtheria and scarlet fever in the house- hold, school children exposed to the contagion cannot retiurn to school. The Medical Inspector's attention should be called to any of the following conditions: Skin and Hair A. Animal parasites or nits in the hair. B. Crusted or scaly patches or sores about the face, neck, or hands, C. Crusts in the scalp or loss of hair. D. Scaling about the fingers, E. Pimples in the spaces between the fingers. F. Swollen glands. G. Any evidence of pronounced itching on the part of the child. Eyes A. Sensitiveness to light. B. Redness of the eyes, C. Discharge from the lids, D. Crusted condition about the eyelashes. Ears Running from the ears and crusty patches thereon. Children who are slightly hard of hearing sit with their mouths partially open, which gives them a somewhat dull expression. They hear questions imperfectly, hence are slow and often stupid in their answers, since they try to conceal the hardness of hearing. Inde X Adenoids — EiTect on pupils of 15 Study of, in Philadelphia 189 Data concerning, in New York City ...192, 193, 195, 196, 197, 199 Aix-la-Chapelle — Salaries of school inspectors in. . 144 Alabama- Inquiries regarding medical in- spection unanswered in 182 Albany, N. Y.— Medical inspection in 26 List of symptoms of disease fur- nished to teachers in 55 Albany County Medical Society — Medical inspection conducted by 26 Allen, Dr. William H.— Quotation from 16 Allport, Dr. Frank- Quotation from 106 Instructions prepared by 129 America — Salaries of school physicians in i Comprehensive systems rare in.. 82 American School Hygiene Asso- ciation — Second Congress of 159 Ann Arbor, Mich. — Medical inspection in 26 Dr. Elliott Kent Herdman, medi- cal inspector of 53 Card of notification to parents. . 96 Antwerp — Development of medical inspec- tion in 19 Argentine Republic — Medical inspection in i Scope of medical inspection in.. 23 Arizona — Inquiries regarding medical in- spection unanswered 182 Arkansas — Inquiries regarding medical in- spection unanswered 182 Asbury Park, N. J. — Medical inspection in 26 Teacher's request to inspector, card 59 Quotation from Superintendent of Schools 154 Associated Charities — Of Minneapolis, Minn 26 Associated Charities and Wo- men's Club — Medical inspection conducted by, in Minneapolis, Minn 26 Atlantic City, N. J.— Medical inspection in 26 Congress of American School Hygiene Association in 159 Attendance, Average — In seventeen cities 140 In Springfield, Mass 146 In Montclair, N. J 146 Austria — Development of medical inspec- tion in 20 Backward Children — Study of problems of 14 Discussion concerning 185, 186 Investigation concerning, in Camden, N. J 190 Investigation concerning, in New York City 192 Conclusions regarding 201 263 264 Index Baltimore, Md. — Medical inspection in 26 School nurses in 67 Dr. H. W. Buckler, medical in- spector in 72 Weekly report of nurse in 79 Medical inspection under city ordinances 172 Bannon, Dr. John H. — Appointed school physician, Lawrence, Mass 155 Bayonne, N, J. — Defective vision in schools of . . .82, 83 Belgium — Medical inspection in i Development of medical inspec- tion in 19 Blake, Dr. Clarence J. — Opinion signed by 105 Blauvelt, Dr. A.— Appointed Chief Medical Inspec- tor in New York City 24 Boas, Dr. Franz — Work of, in Toronto and Wor- cester, Mass 6 Boston — Work of Dr. H. P. Bowditch in. . 6 Population of foreign parentage in 7 First medical inspection in 24 Children referred to medical in- spectors in 53 School nurses in 67 Department of School Hygiene in 73 Facts concerning medical inspec- tion in 140 Salary of nurses in 143 Extract from report of Superin- tendent of Schools of 153 Medical inspection begun 168 Bowditch, Dr. H. P.— Work of, in Boston 6 Breathing, Defective — Data concerning, among New York City children 192, 193, 19s, 196, 197, 199 British Board of Education — Quotation from Memorandum of 1, 21, 168, 184 Reference to Memorandum of . . 160 Brockton, Mass. — Exclusion card used in 30 Monthly report of medical in- spector 31 Examinations and exclusions in. 49 Facts concerning medical inspec- tion in 140 Brussels — Development of medical inspec- tion in 19 Bryan, Dr. James E. — Investigation conducted by 190 Buckler, Dr. H. W.— Medical inspector of Baltimore. 72 Buffalo, N. Y.— Medical inspection in 26 Bulgaria — Medical inspection in i Bureau of Education, United States — Bulletin of 188 Cairo, Egypt — Salaries of school physicians in. . 23 California — Eyesight and hearing tests by State Board of Health 25 Legal status of medical inspec- tion in 176 Camden, N. J, — Medical inspection in 26 Defective vision in schools of 83 Facts concerning medical inspec- tion in 140 Reference to school conditions in 188 Investigation by Superintendent of Schools in 190 Chart— Of teeth, used in Northampton, Mass 97 Pray Astigmatic 106 Snellen in, 129, 130 For testing vision, Connecticut State Board of Education 122, 123, 124, 125 Chelsea, Mass. — Facts concerning medical inspec- tion in 140 Index 265 Chicago — Population of foreign parentage in 7 First medical inspection in 24 System of inspectors' reports in. 41 Exclusion notice 42 Envelope report of medical in- spector 43 Number of medical inspectors employed in 138 Medical inspection begun 168 Legal status of medical inspec- tion in 174 Chicopee, Mass. — Results of physical examinations in 88 Children per Inspector — In seventeen cities 140 Chile- Development of medical inspec- tion in 23 Cincinnati, O. — Medical inspection in 26 Cleveland, O. — Work of George W. Ehler in 6 Population of foreign parentage in 7 Medical inspection in 26 Defective vision in schools of 82, 83 Reference to report of Superin- tendent of Schools of 102 Free eyeglasses in 148 Extract from report of Superin- tendent of Schools 153 Code Card — New York City 36 Colorado — Legal status of medical inspec- tion in 176 Connecticut — Medical inspection law i Law concerning testing of eye- sight 25, 104 Reference to medical inspection law 137 Legal status of medical inspec- tion in 176 Contagious Diseases — Excluded in New York City ^s Postal card of notification con- cerning 43 For which pupils are excluded in various cities 48 Rules for, in Providence, R. I. . . 56 Cornell, Dr. Walter S.— Quotations from 66, 76, 102 Work of, in Philadelphia 77 Reference to studies by 189 Cornman, Dr. O. P. — Reference to article by 188 Craps — Game of 10 Cronin, Dr. John J. — Work of, in New York City 6 Quotation from 66 Opinion of 143 Dallas, Texas — Medical inspection in 26 Dayton, O. — Medical inspection in 26 Defective Hearing — In various school systems 83 Defective Vision — Problem of pupil with 15 In various school systems 83 Data concerning in New York City . . . 192, 193, 195, 196, 197, 199 Defects, Physical — Decrease with age 2, 199 Reported in Massachusetts 49 Not discovered by teachers 81 Delaware — Inquiries regarding medical in- spection unanswered 182 Dental School of Harvard Uni- versity — New Bedford leaflet endorsed by 98 Dental School of Tufts College- New Bedford leaflet endorsed by 98 Des Moines, Iowa — Medical inspection in 26 Detroit, Mich. — Medical inspection in 26, 179 Diseases for which pupils are ex- cluded in 48 266 Index Detroit, Mich. — Cont'd. System of sending pupils to in- spectors in 52 Facts concerning medical inspec- tion in 140 Diseases — Reported in Massachusetts 49 Dispensary — Founded in Havre, France 19 District of Columbia — Legal status of medical inspec- tion in 174 Dresden — Development of medical inspec- tion in 19 Dunfermline, Scotland — Data on defective teeth of chil- dren in. 97 Defective vision in schools of 83 Durgin, Dr. Samuel H. — Opinion of 50 E's— Direction for using chart of 115 Chart of 125 East Sussex, England — Cost of medical inspection in 147 Edinburgh — Defective vision in schools of 83 Edison, Dr. Cyrus — Sanitary Superintendent, New York City 24 Egypt- Salaries of school physicians in. . 23 Ehler, George W.— Work of, in Cleveland, 6 Elgin, 111.— Medical inspection in 26 England — Medical inspection in i Salaries of school physicians in . . i Feeding of school children 16 Society of Medical Ofl&cers for Schools 22 Payment of school physicians ac- cording to work done 144 Medical inspection act 159 Englewood, N. J. — Medical inspection in 26 Epidemics — Closing of public schools during 12 Evansville, Ind. — Medical inspection in 26 Everett, Mass. — Combined directions and pre- scriptions 44, 45, 46 Examinations — And exclusions in five cities 49 Exclusion Card — Brockton, Mass 30 New York City 35 Chicago 42 Exclusions — Inspector's daily report of. New York City 38 In five cities 49 In Haverhill, Mass., and Newark, N.J 150 In Massachusetts and in New York City 151 Eyeglasses — By whom furnished 147 Given away in Cleveland, O 148 Furnished at $1.00 in Lowell, Mass 14S Furnished at cost price in Phila- delphia 148 Eyesight — Problem of pupil with defective. 15 (See also Vision) Eyesight and Hearing Tests — Under state boards of health 25 (See also Vision) Falkner, Dr. Roland P.— Reference to article by 188 Florida — Legal status of medical inspection 177 Foreign Parentage — Population of, in various Amer- ican cities 7 Fort Dodge, Iowa — Medical inspection in 26 Index 267 Fort Worth, Texas- Medical inspection in 26 Fourth Section, Philadelphia — Work in schools of 69 Work of trained nurse in 70 France — Medical inspection in i Feeding of school children in 16 Development of medical inspec- tion in i8 Society of Medical Inspectors of Schools 22 La Medecine Scolaire 22 Galveston, Texas — Medical inspection in 26 Georgia — Legal status of medical inspec- tion in 177 Germany — Development of medical inspec- tion in 19 Care of teeth of children in 97 Salaries of school physicians ac- cording to work done 144 Glands, Enlarged — Data concerning, among New York City children 192, 193, 195, 196, 197, 199 Grand Rapids, Mich. — Medical inspection in 26 Dr. C. Koon of 52 School nurses in 67 Greece — Golden Age of 8 Guildford, England — Salaries of inspectors in 142 Hackensack, N. J. — Medical inspection in 26 Half Time- Discussion concerning 185, 186 Conclusions concerning 187, 201 Harrington, Dr. Thomas F. — Quotation from 53, 66, 152 Harrisburg, Pa. — Medical inspection in 26 Quotation from Report of School Nurses 103 Reference to report to School Board of 141 Hartford, Conn. — Medical inspection in 26 Harvard College, Dental School of— New Bedford leaflet endorsed by 98 Haskin, Frederick J. — Extract from article by 23 Haverhill, Mass. — Exclusions in 150 Extract from report of Superin- tendent of Schools 156 Havre, France — Free public dispensary 19 Hazleton, Pa. — Medical inspection in 26 Hearing Tests — Time of 2 In Massachusetts 109 Report of, in Massachusetts no Record of, in Massachusetts 112 By New York State Department of Health 113, 116 Report of teacher on 1 19 By State Board of Health, Utah. . 129 Report on, Utah 131, 132, 133 Herdman, Dr. Elliott Kent- Quotation from 54 Houston, Texas — Medical inspection in 26 Association of Opticians and Aurists 26 Hungarian — Children, statement concerning . 103 Hungary — Development of medical inspec- tion in 20 Hypertrophied Tonsils — Effect on pupils of 15 Data concerning, among New York City children 192, i93> 195. 196, i97> 199 268 Index Idaho — Legal status of medical inspec- tion in 177 Illinois — Per cent, of urban population in 6 Legal status of medical inspec- tion in 174 Index Card — New York City 37 Indiana — Legal status of medical inspec- tion 176 Iowa — Inquiries regarding medical in- spection unanswered 182 Italian — Directions printed in 40, 46 Japan — Medical inspection in i, 23 Jersey City, N. J.— Medical inspection in 26 Juvenal — Quotation from 12 Kansas — Legal status of medical inspec- tion in 178 Kentucky — Legal status of medical inspec- tion in 178 Knowles, Dr. William F.— Opinion signed by 105 Koon, Dr. C. — Quotation from 52 Lancet, The — Advertisements in 142 Lansing, Mich, — • Medical inspection in 26 Dr. Burt Nottingham of 52, 53 Lawrence, Mass. — Examinations and exclusions in. 49 Facts concerning medical inspec- tion in 140 Conflict between Board of Health and Board of Education 155 Laws on Medical Inspection — Connecticut i, 25, 104, 137, 176 English 159 Massachusetts I, 16, 25, 104, 137, 159, 162 New Jersey i, 16, 25, 171 New York i66 Vermont i, 25, 137, 181 Leaflets — On care of teeth, New Bedford, Mass 98 On care of teeth, Waltham, Mass. 99 Lederle, Dr. Ernest J. — Quotation from 66 Leipsic — Development of medical inspec- tion in 19 Salaries of school inspectors in. . 144 Leslie, Prof. George L. — Quotation from 94, 106 Lice — (See Pediculosis) 44 Liege, Belgium — Development of medical inspec- tion in 19 Lincoln, Neb. — Medical inspection in 26 Littleton, Mass. — Salary of school physician in 141 Lockstep — In physical matters 13 In promotions 188 London — Children referred to medical in- spectors in 53 School nurses in 66 Long Beach, Cal. — Medical inspection in 26 Los Angeles, Cal.— Medical inspection in 26 Superintendent of Schools, E. C. Moore, of 52, 53 School nurses in 67 Physical examinations in 89, 139 Louisiana — No medical inspection laws in 182 Index 269 Louvain, Belgium — Development of medical inspec- tion in 19 Lowell, Mass. — Eyeglasses furnished at uniform price in 148 Maddox— Multiplex Rod 106 Maine — No medical inspection laws in.. 182 Mannheim, Germany — Salaries of school inspectors in.. 144 Martin, George H. — Quotation from 157 Maryland — Extract from code of public health laws in 172 Massachusetts — Medical inspection in i Medical inspection law in i, 16, 25 Extent of medical inspection in 25, 27 School membership in 49 Diseases and defects reported in 49 Pamphlet issued by State Board of Education 54 Defective vision in schools of 83 Medical Society of 106 Reference to medical inspection law in 104, 159 Extract from medical inspection law in 137 Exclusions in 151 Medical inspection law quoted in full 162 Maxwell, Dr. William H.— Quotation from 151 Measles — Statistics concerning mortality from, in Munich 50 Medical Academy of Dental Science — New Bedford leaflet endorsed by 98 Medical Inspector — Monthly report of, Brockton, Mass 31 Teacher's request to, Providence, RI 59 Teacher's request to, Asbury Park, N. J 59 Teacher's request to, Washing- ton, D. C 60, 61 Teacher's request to, Somerville, Mass 62 Number of, in seventeen cities. . 140 Children per, in seventeen cities. 140 Salaries of, in seventeen cities 140 Medical Journal, New York — Reference to article in i8g Medical Society of Pennsyl- vania — Paper read before 69 Michigan — Conference of health ofi&cers in . . 54 Legal status of medical inspec- tion in 178 Milwaukee, Wis. — Population of foreign parentage in 7 Medical inspection in 26 Medical Society 26 Defective vision in schools of 83 Miimeapolis, Minn. — Medical inspection in 26, 179 Associated Charities and Wo- men's Club 26 Defective vision in schools of 83 Physical examinations in 87 Minnesota — Legal status of medical inspec- tion in 179 Mississippi — No medical inspection laws in . . 182 Missouri — No medical inspection laws in.. 182 Montana — No medical inspection laws in . . 182 Montclair, N. J. — Medical inspection in 26 Examinations and exclusions in. 49 Facts concerning medical inspec- tion in 140 Cost of medical inspection in. . . 146 Montgomery County Medical Society — Medical inspection conducted by 26 270 Index Monthly Report — Of medical inspector, Brockton, Mass 31 Moore, E. C. — Reference to 52 Quotation from 53 Morse, Dr. Moreau — Appointed Medical Inspector of Schools, New York City 24 Moscow — Medical inspection in 21 Mount Holly, N. J.— Medical inspection in 26 Munich — Statistics concerning mortality from measles in 50 National Educational Associa- tion — Extract from address delivered before Department of Super- intendence of the 53 Nebraska — Legal status of medical inspec- tion in 179 Nevada — No medical inspection laws in.. 182 Newark, N. J. — Medical inspection in 26 Diseases for which pupils are ex- cluded in 48 Examinations and exclusions in. 49 Facts concerning medical inspec- tion in 140 Exclusions in 150 Extract from report of Superin- tendent of Schools 153 Statement of Superintendent of Schools of 171 New Bedford, Mass. — Leaflet on care of teeth in 98 New Hampshire — Legal status of medical inspection in 179 New Haven, Coim. — ri: Medical inspection in 26 j^ School nurses in 67 Facts concerning medical inspec- tion in 140 New Jersey — Medical inspection law in I, 16, 25, 171 Newmayer, Dr. S. W. — Quotation from 58, 66 Card used by, in Philadelphia.. 63 Reference to paper by 69 New Mexico — Inquiries regarding medical in- spection unanswered 182 New Orleans, La. — Medical inspection in 27 Newport, R. I. — Medical inspection in 26 Newton, Mass. — Quotation from Superintendent of Schools loi New York City- Work of Dr. John J. Cronin in . . 6 Population of foreign parentage in 7 First medical inspection in 24 Medical inspection in 27 Description of system in 30 Diseases for which pupils are ex- cluded in 48 Salaries of nurses in 66, 143 Corps of nurses established in . . 67 Duties of school nurse in 74 Defective vision in schools of 83 Physical examinations in 85, 87 Quotation from Superintendent of Schools of 102, 151 Physical examinations in 139 Facts concerning medical inspec- tion in 140 Exclusions in 151 Account of medical inspection in 169 Physical defects of children in.. 188 Investigation conducted in 191 Physical examination by Board of Health of 198 New York State- Percent, of urban population in. 6 Eyesight and hearing tests by State Board of Health in 25 Examinations conducted by De- partment of Health in 104 Index 271 New York St&te— Cont'd. Law concerning children in insti- tutions in 166 Norristown, Pa. — Medical inspection in 27 Northampton, England — Salaries of inspectors in 142 Northampton, Mass. — Teeth chart used in 97 North Carolina — Inquiries regarding medical in- spection unanswered 182 North Cumberland, England — Salaries of inspectors in 142 North Dakota- No medical inspection laws in. . . 182 Norway — Development of medical inspec- Nose and Throat Defects — Data concerning 189 Nottingham, Dr. Burt — Reference to opinion of 52 Quotation from 53 Nurses — Appointment of, in New York City 32 Work of, in Fourth Section, Phil- adelphia 70 Visits to homes 71 Work of, in New York City 74 Weekly report of, Philadelphia. 78 Weekly report of, Baltimore 79 Quotation from report of 103 Ogden, Utah- Medical inspection in 27 Teacher's report to principal in. 133 Card of warning to parents in 133 Excuse for absence of pupil in . . 134 Ohio- Percent, of urban population in. 6 Legal status of medical inspection 180 Oklahoma — Legal status of medical inspection 180 Ophthalmologist — In Philadelphia 148 Orange, N. J. — Medical inspection in 27 School nurses in 67 Oregon- Legal status of medical inspection in 180 Osier, Prof. William- Quotation from 141 Parents — Notice to. New York City 86 Notice to, Somerville, Mass 96 Notice to, Ann Arbor, Mich 96 Notice to, Massachusetts 113 Paris — Development of medical inspec- tion in 18 Part Time- Discussion concerning 185, 186 Conclusions concerning 187, 201 Pasadena, Cal. — Medical inspection in 27 Physical examinations in 89 Passaic, N. J. — Medical inspection in 27 Paterson, N. J. — Medical inspection in 27 Facts concerning medical inspec- tion in 140 Pawtucket, R. I.— Defective vision in schools of 83 Pediculosis — Directions for, Everett, Mass.. .44, 45 Mention of card concerning, Utica, N. Y 46 Pupils excluded for, in five cities 48 Pupils excluded for, in New York City 69,74 Proportion of exclusions for 151 Pennsylvania — Hospitals 76 No medical inspection legislation in 173 Per Capita Cost — Of medical inspection in America i 272 Index Per Capita Cost — Cont'd. Of inspection for detection of con- tagious diseases 2 Of physical examinations 2 For salaries in seventeen cities . . 140 In twenty-four cities 141 Pericles — The Age of 8 Philadelphia — Resolution of Bureau of Health of 24 Medical inspection in 27 Diseases for which pupils are ex- cluded in. 48 Dr. Newmayer of 58 Card used by Dr. Newmayer 63 School nurses in 67 Report of work of nurses in schools of Fourth Section of . . 70 Visits of nurse to homes in 71 Card recommending pupil for treatment in 77 Weekly report of nurse in 78 City ophthalmologist of 148 Medical inspection begun in 168 Legal status of medical inspec- tion in 173 Physical Defects — Decrease with age 2, 199 Per cent, attended to by parents. 10 1 Physical Examinations — Per capita cost of 2 In New York City 85 In Minneapolis and in New York City _. 87 In Sioux City, Iowa 88 In Chicopee, Mass 88 In Los Angeles, Cal 89 In Pasadena, Cal 89 Physical Record Cards — Pasadena, Cal 90 Los Angeles, Cal 92 Utica, N. Y 94 Asbury Park, N.J 95 Pinard, Prof. — Use of term " puericulture " by. . 22 Plainfield, N. J.— Medical inspection in 27 Play- Changed conditions of 9 Polk County Medical Associa- tion — Medical inspection conducted by 26 Port Chester, N. Y.— Medical inspection in 27 Porter, Dr. Eugene H. — New York State Board of Health instructions signed by 117 Porter, Dr. William H.— Work of, in St. Louis, Mo 6 Portland, Oregon — Medical inspection in - -27, 180 Pray — Astigmatic Charts 106 Providence, R. I. — Medical inspection in 27 Printed material used in 40 Rules for contagious diseases in. 56 Rules distributed to pupils in 57 Teacher's request to inspector.. 59 Psychological Clinic — Reference to publication of 188 Reference to article in 189 Reading, Pa. — Medical inspection in 27 Rebuck, Dr. C. S.— Medical inspection by, in Harris- burg, Pa 26 Record Cards — Individual, New York City 84 Giving teacher's comment, Pasa- dena, Cal 90 Physical, Los Angeles, Cal 92, 93 Physical, Utica, N. Y 94 Physical, Asbury Park, N. J. 95 Sight and hearing tests, Massa- chusetts 112 Reports — Monthly, of medical inspector, Brockton, Mass 31 Inspector's daily, of exclusions, New York City 38, 39 Envelope, daily, Chicago, 111. — 43 Weekly, of nurse, Philadelphia, Pa 78 Weekly, of nurse, Baltimore, Md. 79 Of sight and hearing, Massa- chusetts 1 10 Index 273 Reports — Cont'd. Of teacher, New York State. . 1 18, 1 19 Of teacher, Connecticut 127, 128 To State Board of Health, Utah 132 Of teacher to principal, Ogden, Utah 133 Retarded Children- Study of problems of 14 Discussion concerning 185, 186 Investigation concerning, Cam- den, N. J 190 Investigation concerning, New York City 192 Conclusions regarding 201 Rhode Island — Per cent, of urban population in. 6 Legal status of medical inspec- tion in ^^^ Rochester, N. Y.— Medical inspection in Opinion of Deputy Superinten- dent of Schools 176 27 Schamberg, Dr. — Reference to Roumania — Development of medical inspec- tion in 21 Salaries — Of school physicians in America and in England i Of medical inspectors in Cairo, Egypt ; 23 Of medical inspectors m seven- teen cities 140 Of school physicians in Shelburne and Littleton, Mass 141 Of medical inspectors in England 142 Of school nurses in New York and Boston i43 Of school nurses in New Haven, Conn 144 Of medical inspectors in Wies- baden, Germany - - i44 Of medical inspectors in Leipsic, Aix-la-Chapelle, and Mann- heim, Germany I44 Salt Lake City, Utah- Medical inspection in 27 San Antonio, Texas- Medical inspection in 27 San Francisco, Cal. — Population of foreign parentage in 7 18 76 Schenectady, N. Y.— - Medical inspection in 27 School Hygiene, Department of— Boston 73 Schubert, Dr. Paul- Quotation from 144 Seattle, Wash.— Medical inspection in 27 Facts concerning medical inspec- tion in 140 Shelburne, Mass. — Salary of school physician in. Shepherd, Dr. Fred S.— Quotations from Sioux City, Iowa- Medical inspection in . . Physical examinations in 141 154 27 Snellen — Test types 106 Chart I" Directions for using chart .. .129, 130 Society— ^ , , Of Medical OflScers for Schools . . 22 Of Medical Inspectors of Schools 22 Medical, of Pennsylvania 69 Visiting Nurse, of Philadelphia . . 69 Medical, of Massachusetts 106 Somerville, Mass. — Card of statement of physician and teacher in - - 62 Card of notification"of parents in 96 Quotation from Superintendent of Schools of ; loi Facts concerning medical inspec- tion in 140 South Carolina — Legal status of medical inspec- tion in ^°^ South Dakota — No medical inspection laws m . . . 182 Springfield, Mass. — Examinations and exclusions m. 49 274 Index Springfield, Mass. — Cont'd. Facts concerning medical inspec- tion in 140 Cost of medical inspection in . . . 146 Quotation from report of School Board of 156 Standish, Dr. Myles — Opinion of 105 Stanley, Annie L. — Work of, in Philadelphia 69 Stewart, Dr. Hackworth — Quotation from 161 St. John, Dr. S. B.— Instructions prepared by 121 St. Joseph, Mo. — Medical inspection in 27 St. Louis, Mo. — Work of Dr. William H. Porter in 6 Medical inspection in 27 Suffolk County, Mass.— Defective vision in schools of — 83 Superior, Wis. — Medical inspection in 27 Sweden — Medical inspection in i Development of medical inspec- tion in 21 Switzerland — Medical inspection in i Development of medical inspec- tion in 21 Syracuse, N. Y. — Medical inspection in 27 Description of record card used in 46 Directions furnished teachers in. 56 School nurses in 67 Teeth- Chart used in Northampton, Mass 97 Care of, in Germany 97 Data from Dunfermline, Scot- land 97 Leaflet on care of. New Bedford, Mass 98 Leaflet on care of, Waltham, Mass 99 Defective, data concerning, among New York City chil- dren ...192, 193, 195, 196, 197, 199 Tennessee — Inquiries regarding medical in- spection unanswered 182 Texas — Legal status of medical inspec- tion in 181 Thorndike, Dr. Edward L.— Reference to publication of 188 Time— Of vision and hearing tests 2 Of physical examinations 2 Of examinations as basis for re- muneration 143 Tonsils — Enlarged, effect on pupils 15 Enlarged, study of, in Phila- delphia 189 Enlarged, data concerning, among New York City chil- dren... 192, 193, 195, 196, 197, 199 Toronto — Work of Dr. Franz Boas in 6 Tufts College, Dental School of— New Bedford leaflet endorsed by 98 Union Hill, N. J.— Medical inspection in 27 United States — First medical inspection in 24 Cities of, having medical inspec- tion 26 Urban Population — Change in 6 Percentage of, in various states . . 6 Utah- Eyesight and hearing tests under State Board of Health of 25 Examinations conducted by State Board of Health of 104 Legal status of medical inspec- tion in 181 Utica, W. Y.— Description of record card used in 46 Defective vision in schools of 83 Index 275 Vandiver, Almuth C. — Reference to paper by 159 Vermont — Medical inspection law in i Reference to medical inspection law 25,137 Legal status of medical inspec- tion in 181 Virginia — Inquiries regarding medical in- spection unanswered 182 Vision and Hearing Tests — Time of 2 By school teachers, opinions con- cerning 105 In Massachusetts 107 Report of no, 118, 127, 132, 133 Snellen's chart for in Record of 112 By New York State Department of Health 113 By State Board of Education, Connecticut 120 Charts used in 122, 123, 124, 125 By State Board of Health, Utah 129 Vision, Defective — In various school systems 83 Data concerning, in New York City.... 192, 193, 195, 196, 197, 199 Visiting Nurse Association — Of Harrisburg, Pa 26 Visiting Nurses' Society — Of Philadelphia 69 Wadsworth, Dr. O. F.— Opinion of 106 Walker, Dr. D. Harold- Opinion signed by 105 Waltham, Mass. — Diseases for which pupils are ex- cluded 48 Attention to children's teeth in. . 98 Leaflet on care of teeth 99 Washington, D. C— Medical inspection in 27 Meeting of Department, National Educational Association in 53 Teacher's request to inspector. 60, 6i Washington State — Legal status of medical inspec- tion in 182 Waterbury, Conn. — Medical inspection in 27 Waverly, R. I.— Medical inspection in 27 Webster, R. H.— Opinion of 176 Wells, Dr. David W.— Quotation from 106 Westchester, N. Y.— Medical inspection in 27 West Riding District, England — Salaries of inspectors in 142 West Virginia — Inquiries regarding medical in- spection 182 White Plains, N. Y.— Medical inspection in 27 Directions furnished teachers in. 56 Wiesbaden, Germany — Method of medical inspection 19 Salaries of school inspectors in. . 144 Wilkes-Barre, Pa,— Printed rules distributed to pupils 57 Williams, Dr. Charles H.— Opinion of 106 Wilmington, Del. — Medical inspection in 27 Reference to study of school con- ditions in 188 Wisconsin — Legal status of medical inspection in 182 Witmer, Dr. Lightner — Founder of Psychological Clinic. 188 Women's Club — Of Minneapolis, Minn 26 Woonsocket, R. I, — Medical inspection in 27 276 Index Woonsocket, R. I. — Cont'd. Facts concerning medical inspec- tion in 140 Worcester, Mass. — Work of Dr. Franz Boas in 6 Defective vision in schools of 83 Facts concerning medical inspec- tion in 140 Wyoming — Inquiries regarding medical in- spection unanswered 182 Yiddish- Directions printed in 40 Yonkers, N. Y.— School nurses in 67