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Lee, Ph.D. Appendix containing comparative schedules of hours and extracts from laws regulating women's labor. 8vo. 358 pages. 3rd ed. Post- paid, $2.00. WOMEN IN THE BOOKBINDING TRADE. By Mary Van Kleeck. IIIus. I2mo. 290 pages. Postpaid, $1.50. \iCO-OPERATION IN NEW ENGLAND: Urban and RuraL By James Ford, Ph.D. I2mo. 260 pages. Postpaid, $1.50. SIX SPECIAL BOOKS recently published by Charities Publica- tion Committee. / Waiting for the school physician in Toledo, Ohio . . .148 Throat inspection in the Orange, N. J., schools . . . 148 ' About lb per cent of the school children of our cities suffer from malnutrition 155 Typical adenoid faces showing mouth breathing, flattened noses, and protruding eyes 170V 7 xiv LIST OF TABLES TABLE PAGE 1. Cities of United States having medical inspection, by groups of states. 191 1 15 2. Cities of United States having systems of medical inspection in each year from 1894 to 191 1 16 3. Cities of United States having systems of medical inspection, cities employing school physicians, and number of physicians employed, by groups of states. 191 1 17 4. Cities of United States having systems of medical inspection, cities employing school nurses, and number of nurses em- ployed, by groups of states. 191 1 .18 5. Cities of United States having systems of medical inspection, and cities employing school dentists, by groups of states. 191 1 . 19 6. Status of medical inspection in 1,046 municipal school systems in the United States. 191 1 20 7. Exclusions for contagious diseases in four cities .... 32 8. Exclusions for contagious diseases in four cities: Relative figures on the basis of i ,000 exclusions in each city . 33 9. School membership, exclusions for contagious disease, and number of exclusions per thousand pupils enrolled, for eight cities . 33 10. Cities of the United States having examinations for the detection of physical defects, by groups of states. 191 1 . ■ 3^ 11. Resultsof physical examinations of schoolchildren in nine cities . 38 12. Results of physical examinations of school children in nine cities: Relative figures on basis of each 1,000 children examined in each city 38 13. Results of physical examinations of school children, New York, N. Y., 1911 40 14. Enrollment in day schools and number and per cent of pupils ex- amined in nine cities 41 13. Vision and hearing tests conducted by physicians and teachers in American cities, by groups of states. 191 1 -5' XV LIST OF TABLES TABLE PAGE 1 6. Results of vision and hearing tests in Massachusetts, Connecticut, and Maine 52 17. Results obtained by medical inspectors aided and not aided by school nurses. Eight schools, Philadelphia, 1910 ... 66 18. Results obtained by medical inspectors aided and not aided by school nurses. Philadelphia, 19 10 67 19. Salariesof nurses in 106 American municipalities .... 70 20. Physical defects reported by medical inspectors, and number and per cent of these defects treated. New York City, 19 11 . 92 2 1 . Four classes of physical defects reported and number and per cent of these defects treated. Newark, N. J., 1910-1 1 ... 93 22. Physical defects recommended for treatment and number and per cent of these defects treated. Harrisburg, Pa., 1909-10 . 94 23. Physical defects reported and number and per cent of these defects treated. Pasadena, Cal., 1909-10 94 24. Defects reported, number referred to physicians, and per cent of these in which physician was consulted. Summit, N. J., 1909-10 95 25. Defects reported and the number and per cent of these defects treated, in four cities 96 26. Cases of physical defects treated by private practitioners and by institutions. New York, 191 1 96 27. Percentages of cases of defects of eyes and ears treated profes- sionally. Somerville, Mass., 1906-10 97 28. Recommendations for treatment by medical inspectors and num- ber and per cent of treatments in 24 English areas. 1910 . 99 29. Number and salaries of medical inspectors and school nurses, average school attendance, and total annual expenditure and expenditure per pupil in average attendance for salaries of medical inspectors and school nurses in 77 American cities of more than 8,000 population. 191 1 104 30. Annual salaries of physicians and nurses in all cities reporting . 108 31. Results of dental inspection of 447 children, ages six to sixteen, Elmira, New York, 1910 115 32. Cities of the United States having dental inspection and cities hav- ing dental inspection by dentists, by groups of states. 191 1 122 33. Dental inspection of school children in twelve German municipal districts. Year ending April, 191 1 126 xvi LIST OF TABLES TABLE PAGE 34. Administration of systems of medical inspection in cities of United States, by groups of states. 191 1 145 35. Per cent of children examined found defective, among 907 "ex- empt" and 687 " non-exempt " children, in Philadelphia, Penn. 1 52 36. Physical defects among 3,587 exempt and 1,418 non-exempt children, in Philadelphia, Penn., 1908 153 37. Defects of vision and hearing among 8,110 normal and 2,020 retarded children in Camden, N. J., 1906 134 38. Physical defects and irregular attendance among 1,279 normal and 573 retarded children who failed of promotion in Camden, N. J., 1906 154 39. Physical defects among 1,093 children promoted and 303 children not promoted in elementary schools, in Manchester, Con- necticut, 1910 155 40. Physical defects among 449 retarded children, of whom 345 had been in the first grade two years, 86 three years, and 18 four ormoreyears. Elmira, New York, 1909-10 .... 156 41. Per cent of dull, normal, and bright pupils suffering from each sort of defect. Ages ten to fourteen, inclusive. All grades. New York, 1908 158 42. Average number of grades completed by pupils having no physical defects compared with number completed by those suffer- ing from different defects. Central tendency among 3,304 children, ages ten to fourteen years, in grades one to eight. New York, 1908 159 43. Extent to which children suffering from each sort of physical defect show slower progress than do children with no de- fects. New York, 1908 160 44. Number of years required by defective and non-defective chil- dren to complete the eight grades. New York, 1908 . .161 45. Principal features of state laws and regulations providing for medical inspection. 191 1 166 XVll LIST OF FORMS PAGE Exclusion card, Brockton, Massachusetts 22 Monthly report of medical inspector, Brockton, Massachusetts . . 23 Exclusion notice with detachable stub, Chicago 25 Envelope daily report of medical inspector in which are forwarded to Board of Health copies of exclusion notices, Chicago . 26 Combined directions and prescription, Everett, Mass 28 Report of sight and hearing tests to superintendents of schools, Massachusetts 48 Snellen chart for testing eyesight 49 Recordof sight and hearing tests, Massachusetts 50 Notice to parent or guardian of defect of eyes or ears, Massachusetts . 50 Individual record card. Physical examinations, Chicago, 111. . 54 Individual record card. Physical examinations, Pasadena, Cal. . 55 Individual record card (Face, Physical Record). Berkeley, Cal. . 56 Individual record card (Reverse, Scholarship Record). Berkeley, Cal 57 Noticetoparent or guardian, Massachusetts 73 Post card notification form, Birmingham, Alabama .... 74 Parent's consent blank, St. Louis, Missouri 75 Notification of defects and of opportunities for consultation, Oakland, California 77 Notification of defects and of opportunities for consultation, Pasa- dena, California 78 Notification to parents of school physician's office hours ... 79 Notification of nurse's call and of school physician's office hours, Oak- land, California 79 Agreement between dentists and schools, Muskegon, Mich. . . . 123 Combined directions and prescription for tooth powder, Philadelphia . 128 Individual dental record Card, Philadelphia (Face) . . . .135 Individual dental record Card, Philadelphia (Reverse) 136 xix LIST OF FORMS Notice to parent, Philadelphia .... Certificate for free treatment, Philadelphia Appointment card, Philadelphia Principal's record, Philadelphia Weekly report of dental inspector, Philadelphia PAGE 138 L39 140 141 XX CHAPTER I THE ARGUMENT FOR MEDICAL INSPECTION M EDICAL inspection is an extension of the activities of the school in which the educator and the physician join hands to insure for each child such conditions of health and vitality as will best enable him to take full advantage of the free education offered by the state. Its object is to better health conditions among school children, safeguard them from disease, and render them healthier, happier, and more vigorous. It is founded upon a recognition of the intimate relationship between the physical and mental conditions of the children, and the consequent dependence of education on health conditions. When Boston initiated medical inspection in Am^ica in 1894, by dividing her schools into 50 districts and placing a physician in charge of each district, she did so in the hope that the new measure would curb the waves of contagious disease that repeatedly swept through the ranks of the children, leaving behind a record of suffering and death. The experiment was successful, and when other cities learned how Boston was solving the problem, they too began to employ school physicians and to organize systems of medical inspection. During the first years the spread of the movement was slow, only one or two cities taking it up each year; then these pioneers were followed by dozens of their sister cities, later by scores, and in the past few years by hundreds. This sudden recognition of the imperative necessity for safeguarding the physical welfare of school children grew out of the discovery that compulsory education under modern city con- ditions meant compulsory disease. With the great changes which have been coming over American life, former conditions have disappeared and undisturbed indifference to the physical welfare of our school children has become impossible. We have changed from an agricultural MEDICAL INSPECTION OF SCHOOLS people to a race of dwellers in towns and cities. The school year has changed from a three months' winter term to one of five hours per day for ten months during the year. The number of years of school life has greatly increased. We have passed com- pulsory education laws. Going to school has become not only the normal but the required occupation of all children for a considerable number of years. The results of these changed conditions on the health of children have become so marked as insistently to demand atten- tion. The parents, school authorities, and health authorities have been unable to avoid recognizing the fact that in the nature of the case the school has become the most certain center of infection in the community. The state, to provide for its own protection, has decreed that all children must attend school, and has put in motion the all-powerful but undiscriminating agency of compulsory education, which gathers in the rich and the poor, the bright and the dull, the healthy and the sick. The object was to insure that these children should have sound minds. One of the unforeseen results was to insure that they should have unsound bodies. Medical inspection is the device created to remedy this condition. Its ob- ject is prevention and cure. Wherever established, the good results of medical inspection have been evident. Epidemics have been checked or avoided. Improvements have been noted in the cleanliness and neatness of the children. Teachers and parents have come to know that under the new system it is safe for children to continue in school in times of threatened or actual epidemic. But medical inspection does not stop here, nor has it limited its activities to the field outlined. Other problems have been insistently forcing themselves on the attention of school men; and they, knowing something of the wonderful advances made in the field of medicine, have turned for aid to the physicians. With the changes in the length of the school term, and the increase in the number of years of schooling demanded of the child, has come a great advance in the standards of the work required. When the standards were low, the work was not beyond the capac- ity of even the weaker children; but with close grading, fuller 2 ARGUMENT FOR MEDICAL INSPECTION courses, higher standards, and constantly more insistent demands for intellectual attainment, conditions have changed. Pupils have been unable to keep up with their classes. The terms " back- ward," "retarded," and "exceptional," as applied to school chil- dren, have been added to the vocabularies of school men. School men discovered that the drag-net of compulsory education was bringing into school hundreds of children who were unable to keep step with their companions, and because this interfered with the ordinary administration of our school systems they began to ask why the children were backward. The school physicians helped to find the answer when they showed that hundreds of these children were backward simply because of removable physical defects. And then came the next great forward step, the realization that children are not dullards through the will of an inscrutable Providence, but rather through the law of cause and effect. This led to an extension of the scope of medical inspection to include the physical examination of school children with the aim of discovering whether or not they were suffering from such defects as would handicap their educational progress and prevent them from receiving the full benefit of the free education furnished by the state. This work was in its infancy five years ago, but today more than 200 American cities have systems of physical examination of their school children. Surprising numbers of children have been found who, through defective eyesight, have been seriously handicapped in their school work. Many are found to have defective hearing. Other conditions are found which have a great and formerly unrecognized influence on the welfare, happiness, and mental vigor of the child. Attention has been directed to the real significance of adenoids and enlarged tonsils, of swollen glands and carious teeth. Communities are seeing the whole matter in a new light. Gradually they are beginning to ask, not whether they can afford to take steps to safeguard in schools the welfare of their children, but whether they can afford not to take such steps. The realiza- tion is dawning that it is unbusinesslike to count carefully the cost of the school physician, but to disregard the cost of death and disease, of wrecked hopes and dependent families. 3 MEDICAL INSPECTION OF SCHOOLS Teachers and parents are beginning to realize that the prob- lem of the pupil with defective eyesight may be quite as important to the community as that of the pupil who has some contagious disease. A child who is unable to see distinctly is placed in a school where physical defects are unrecognized and disregarded ; headaches, eyestrain, and failure follow all his efforts at study. He cannot see the blackboards and charts; printed books are indistinct or are seen only with much effort, everything is blurred. Neither he nor his teacher knows what is the matter, but he soon finds it impossible to keep pace with his companions, and, becom- ing discouraged, he falls behind in the unequal race. In no better plight is the child suffering from enlarged tonsils and adenoids, which prevent proper nasal breathing and compel him to keep his mouth open in order to breathe. Perhaps one of his troubles is deafness. He is soon considered stupid. This impression is strengthened by his poor progress in school. Through no fault of his own he is doomed to failure. He neglects his studies, hates his school, leaves long before he has completed the course, and is well started on the road to an inefficient and despondent life. Public schools are a public trust. When the parent delivers his child to their care he has a right to insist that the child under the supervision of the school authorities shall be safe from harm and shall be handed back to him in at least as good condition as when it entered school. Even if the parent does not insist upon it, the child himself has a right to claim protection. The child has a claim upon the state and the state a claim upon the child which demands recognition. Education without health is useless. It would be better to sacrifice the education if, in order to attain it, the child must lay down his good health as a price. Education must comprehend the whole man and the whole man is built fundamentally on what he is physically. The objection that the state has no right to permit or require medical inspection of the children in the schools will not bear close scrutiny or logical analysis. The authority which has the right to compel attendance at school has the added duty of insist- ing that no harm shall come to those who go there. The Mass- achusetts law, with its mandatory "shall," is certainly preferable 4 Mouth breathing means adenoids; adenoids mean deadened intellects. ARGUMENT FOR MEDICAL INSPECTION to the Connecticut law, with its permissive "may." The exercise of the power to enforce school attendance is dangerous if it is not accompanied by the appreciation of the duty of seeing that the assembling of pupils brings to the individual no physical detri- ment. When the subject is considered both from the standpoint of the individual and from that of the state, the wonder is, not that medical inspection is now being practiced, but rather that it was not begun long ago. Nor is the state, in assuming the medical oversight of the pupils in the public schools, trespassing upon the domain of private rights and initiative. Under medical inspection what is done for the parent is to tell him of the needs of his child, of which he might otherwise have been in ignorance. It leaves to the parent the duty of meeting those needs. It leaves him with a larger responsibility than before. Whatever view be taken of the right of the state to enforce measures for the correction of defects discovered, the arguments for and against do not enter into the present discussion. It is difficult to find a logical basis for the argument that the state has not the right to inform the parents of defects present in the child, and to advise as to remedial measures which should be taken to remove them. The justification of the state in assuming the function of education and in making that education compulsory is to insure its own preservation and efficiency. Whether or not it is to be successful will depend on the intelligence of its individual members. But the well-being of a state is as much dependent upon the strength, health, and productive capacity of its members as it is upon their knowledge and intelligence. In order that it may insure the efficiency of its citizens, the state through its compulsory education enactments requires its youth to pursue certain studies which experience has proved necessary to secure that efficiency. Individual efficiency, however, rests not alone on education or intelligence, but is equally dependent on physical health and vigor. Hence, if the state may make mandatory training in intelligence, it may also command training to secure physical soundness and capacity. Much time may elapse before there will be put in practice in all schools the measures, now so successfully pursued in some, 5 MEDICAL INSPECTION OF SCHOOLS for conserving and developing the physical soundness of rising generations. But the movement is so intimately related to the future welfare of our country, and has so signally demon- strated its value, that it is destined to be universal and perma- nent. For nineteen centuries the educational world has held as the most perfect expression of its philosophy that half line of Juvenal in which he pleads for the sound mind in the sound body. It has remained for the first decade of the twentieth century to awake to a startled realization that Juvenal was wrong — wrong because he bade us think that mind and body are separate, and separately to be provided for. Only now have we come to realize the error and to take steps to rectify it. Only in the last few years have we begun to see that, educationally at least, mind and body are inseparable, and that the sound mind and the sound body are inextricably related — both causes and both effects. All these things mean that it is our splendid privilege to see and to be a part of a movement which is profoundly trans- forming our traditional ideas of education. They mean that our children and our children's children will be a better race of men and women than are we or than were our fathers. Not alone our unwillingness to be outdone in this public service by foreign nations, not alone our sense of practical fore- sight, but our inherent feeling of obligation toward our children and our recognition of this service as one of necessity for the national well-being, are forcing upon us the incorporation of this phase of public activity as an integral part of our public education. The human race will be a better race because of the lessons that have been taught us by the child having contagious disease, the backward child, and the physically defective child. Because of these lessons, the youth of the future will attend a school in which health will be contagious instead of disease, in which the playground will be as important as the book, and where pure water, pure air, and abundant sunshine will be rights, and not privileges. He will attend a school in which he will not have to be truant, tuberculous, delinquent, or defective, to get the best and fullest measure of education. 6 M CHAPTER II HISTORY AND PRESENT STATUS EDICAL inspection of schools was first provided for some eighty years ago but it is only during the past quarter of a century that it has assumed the proportions of a world-wide movement. It is found in all the continents, and the extent of its development in different countries is in some measure proportionate to their degree of educational enlightenment. In the most important countries it has now become national in scope. France The earliest work in the field of medical inspection seems to have been done in France, where the law of 1833 and the royal ordinance of 1837 charged school authorities with the duty of providing for the sanitary conditions of school premises and supervising the health of the school children. A few years later, in 1842 and 1843, governmental decrees were promulgated in Paris, directing that all public schools should be regularly inspected by physicians. In spite of these early beginnings, however, it was not until 1879 that genuine medical inspection in the modern sense of the term was begun in France. In that year the general council of the Department of the Seine reorganized the medical service in the schools of Paris and passed an appropri- ation for the payment of salaries to the physicians. Eight years later medical and sanitary inspection were made obligatory in all French schools, public and private. At the present time the work is carried on in Paris by a force of 210 school physicians who are selected on the basis of competitive examination and each of whom has supervision of not more than 1,000 children. These physicians visit each school at least twice every month and make careful examinations of the sanitary conditions, paying special attention to lighting, ventila- 7 MEDICAL INSPECTION OF SCHOOLS tion, cleanliness, and water supply. Visits are made to each school room and a general inspection of the pupils conducted. Following this general inspection, individual examinations are conducted in the inspector's private room. The children examined are of three classes: first, those whom the physicians have selected as apparently needing special attention; second, those referred to them by teachers and parents; and third, those who have returned to school after absence because of illness or some unknown cause. The first object of the examinations referred to is to detect and exclude cases of contagious disease. In addition to these inspections each child, during the first months of his school life, is given a thorough physical examination, and a careful record of the findings, entered on an individual record sheet, follows the child through his subsequent school career. Every six months measurements of height and weight are made and the results entered on these record sheets, together with data of any illnesses suffered during the period, and the results of subsequent physical examinations. Parents are informed of any defect or disease discovered and urged to secure remedial treatment. In other cities of France the systems followed are modeled after that of Paris, but in general are less thorough, and in the smaller places are not infrequently restricted to inspections for the detection and exclusion of cases of contagious disease. Germany In Germany the city of Dresden began medical inspection in 1867, when tests of vision were instituted. The first genuine system of medical inspection, however, appears to have been inaugurated by Frankfort-on-the-Main, which appointed a school physician in 1889, an example which was soon followed by many other localities. In the city of Wiesbaden a plan was developed that was widely copied and became a model, not only throughout the empire but in other countries. The plan adopted by the physi- cian on his monthly visits to each school closely resembles that already described as being followed in Paris. General inspec- tions are first made of class rooms and school premises and these HISTORY AND PRESENT STATUS are followed by individual examinations of pupils selected be- cause they are suspected of suffering from contagious diseases. Previous to entering, each child has been given a physical examina- tion, and this is repeated in the second, fourth, sixth, and eighth years of school life. On each of these occasions an examination of heart, lungs, throat, spine, skin, and the higher sense organs is made, and (in the case of boys) an examination for hernia. The findings are entered on a report blank which accompanies the child from grade to grade. Twice a year the teacher records the height and weight of individual pupils. Whenever it is deemed necessary, the school physician takes chest measurements. The records of children who seem to require the regular care of a physician are marked accordingly, and these children report at regular intervals to the school physician. It is the duty of the school physician to give advice to the teacher with reference to the child. Parents are notified of the results of the examinations. There is wide variation in the thoroughness of medical inspection in different parts of the empire. Thoroughly organized systems under state regulations exist only in Saxe-Meiningen and Hesse-Darmstadt where every school, both public and private, in the country as well as in the city, is provided with a state-appointed physician. In other states the school physicians are appointed by and work under the municipal Magistrat, the local board of education, or the board of health. In the year 1908 some 400 towns and cities had systems of medical inspection of schools, employing about 1,600 physicians. There are three common plans of employing and remunerating these school physicians. Under the first form of organization the physician is employed on full time, is paid a salary ranging from ^1,750 to ^2,750 per annum, and has the right to a pension. Under the second plan, a salary of from ^i 50 to ^250 a year is paid for part time services, and work is usually carried on in addition to other public health services, for which separate payment is made. Under the third plan, payment is made on a per capita basis, according to the number of children inspected, and the scale of payment ranges from 6 to 16 cents per child per year, the average being about 12 cents. Payment is also sometimes made at the rat^ of from 60 cents to ^i .00 for each class examined. 9 MEDICAL INSPECTION OF SCHOOLS As yet the movement for the employment of school nurses has not made great progress in Germany, Charlottenburg and Stuttgart being, in 19 lo, the only cities having nurses. On the other hand, notable progress has been made in the development of other movements closely allied to medical inspection, such as open air schools, school feeding, dental inspection, and the organi- zation of special classes for exceptional children. Great Britain* In England and Wales the medical inspection of schools is carried on under the provisions of the Education Act of 1907 which is mandatory in nature. In Scotland the work is carried on under the Education Act of 1908 which confers on school boards the powers necessary for a universal system of medical inspection. In Ireland alone compulsory medical inspection does not exist. Such work as is carried on is in the main performed by the school in- spectors of the national board of education, who are not medical men. The object of medical inspection in Great Britain, as stated by the memorandum of the board of education, is "to secure ultimately for every child, normal or defective, conditions of life compatible with that full and effective development of its organic functions, its special senses, and its mental powers, which consti- tute a true education." f While medical inspection in England has been universal and compulsory only since the passage of the Act of 1907, it has existed in London since 1891, when the first school physician was appointed. From that date up to the passage of the National Act the development of the movement was sporadic. The details of organization are in the main left in the hands of the local authorities, subject to the minimum requirements laid down by the memorandum of the board of education. These minimum provisions include the physical examination of each pupil at the time of his entrance to a public elementary school, and if possible three subsequent examinations, the first of which takes place during the third year of school life or about the seventh year of age, * For full discussion of the English law, and methods of enforcement, see p. 174 ff. t See p. 176. 10 HISTORY AND PRESENT STATUS the second during the sixth year of school hfe or about the tenth year of age, and the third at the time the child is about to leave school and go to work. England was the pioneer in the employment of school nurses, the first having been appointed in London as early as 1887. However, the first school nurses in the modern acceptation of the term were appointed in 1901 by the London school board, and their employment is now becoming general in other cities. Other Countries In Belgium medical inspection is the rule in the more impor- tant municipalities, and Brussels is credited with having estab- lished the first system of medical inspection in the full modern sense of the term in 1874, when school physicians were appointed and charged with the duty of inspecting every school three times a month. This system was remarkably successful from its incep- tion, was copied in other cities of Belgium, and served as a model for systems in Switzerland. Some of the earliest work of school dentists and oculists was done in Belgium. In Norway medical inspection has progressed steadily since 1885, when some localities began to support regular school physi- cians. Permissive regulations were passed in 1889 and were followed two years later by mandatory ones. Sweden is probably the country where the term "school physician" was first used in its modern sense. As far back as 1868 medical officers were attached to the staff of every public secondary school. Their duties and spheres of activity have been progres- sively extended, beginning first with the higher schools, and since 1895 including the primary ones. In Denmark there is no regular system of medical inspection nor any legislation directly providing for it. Nevertheless, some . work is carried on in the elementary and secondary schools of her larger towns and cities, Copenhagen having led the way in 1896. Russia has made provision for medical inspection since 1871 but with a few exceptions it has not extended beyond the secondary and higher schools. Austria was the first country to enact effective legislation providing for medical inspection in the elementary schools, by a 1 1 MEDICAL INSPECTION OF SCHOOLS ministerial decree of 1 873 which provided for the regular employ- ment of school physicians. In Hungary the oifice of school physician was established by the act of 1885. In Bulgaria organized work dates from 1904, while in Roumania adequate legislation has existed since 1899. In Switzerland the medical inspection of schools and school children is recommended, but not enforced, by the federal govern- ment. Nevertheless some 13 cantons now carry out the recom- mended inspection and thorough work is done by the school physicians of some cities. In Japan medical inspection has been compulsory and universal since 1898, only small towns and country districts being exempt. In Egypt, Cairo appointed the first school physician in 1882, and the system has been in force ever since. In Australia and Tasmania the work dates from 1906 and includes not only measures for the prevention of contagious diseases but physical examinations, together with much scientific study of results. This renders the reports from these countries unusually valuable. In America a number of countries besides the United States have more or less fully developed systems of medical inspection. In Canada, Montreal began in 1906 with the appointment of 50 school physicians. Halifax and Vancouver followed in 1907. In all of the provinces there is inspection; and in Ontario, Manitoba, and Alberta, it is provided for by law. In Mexico medical inspection dates from 1896, when the department of medical inspection and school hygiene was organized under the director general of elementary instruction and a few phy- sicians were appointed. Since that time there have been several reorganizations of the system, with constant extension. In the city of Mexico and its suburbs, it is now very complete and notably efficient. From the capital the work has spread until it is now fully organized in the state of Chihuahua, and partly so in Guana- juato and San Luis Potosi. In South America, the Argentine Republic and Chile began medical inspection in 1888 and in both countries the systems are thoroughly developed. 12 A throat culture in time may save nine weeks of diphtheria HISTORY AND PRESENT STATUS DEVELOPMENT AND PRESENT STATUS IN THE UNITED STATES Boston was the first city in the United States to estabHsh a regular system of medical inspection, starting in 1894 with a staff of 50 school physicians. The movement came as a result of a series of epidemics among the school children. Chicago began in 1895. New York City followed in 1897 when the board of health appointed a corps of 134 medical inspectors for the public schools, and Philadelphia in 1898. In all these instances medical inspec- tion in its inception had as its sole object the reducing of the number of cases of contagious disease among the pupils. The movement rapidly spread from the greater cities to the smaller ones, the first step in many cases being taken by a local med- ical society offering to carry on the work for a limited time with- out expense to the municipality, in order to demonstrate its desirability. Beginnings of State Legislation* So rapidly and convincingly did the movement establish itself that it was soon provided for by laws in the more progressive states. In 1899 the legislature of Connecticut passed a law provid- ing for the testing of vision in all the public schools of the state. New Jersey authorized boards of education to employ medical inspectors in 1903. In the following year Vermont enacted a law requiring the annual examination of the eyes, ears, and throats of school children. The first mandatory legislation providing for state-wide medical inspection in all public schools was passed by Massachu- setts in i9o6.t From these beginnings the movement spread rapidly until by 19 12 seven states had passed mandatory laws, 10 had passed permissive ones, and in two states and the District of Columbia medical inspection was carried on under regulations promulgated by the boards of health and having the force of law. J The fact that the Massachusetts statute, passed in 1906, is the oldest of the laws now in force, shows that the whole body of legislative enactments which crystallize the views, beliefs, and the * See also Chap. XII, Legal Provisions, p. 164 flf. t See pp. 164, 168, and 177. j See map, p. 165. 13 MEDICAL INSPECTION OF SCHOOLS results of experience of educators and physicians, is of distinctly recent origin. Present Status The best body of evidence as to the present status of medical inspection in American municipalities is furnished by the results of an investigation conducted by the Russell Sage Foundation during the school year 1910-1 1. This investigation gathered the facts on medical inspection and school hygiene from 1,046 school systems in 1,038 cities and towns, or nearly 90 per cent of the American municipalities which have regularly organized systems of public schools under superintendents. For the purpose of tabulating the results, the states of the union were divided into five groups, following the order adopted by the Bureau of the United States Census. These groups are as follows: NORTH ATLANTIC DIVISION Maine New Hampshire Vermont Massachusetts Rhode Island Connecticut SOUTH ATLANTIC DIVISION New York New Jersey Pennsylvania Delaware Maryland District of Columbia Virginia West Virginia North Carolina SOUTH CENTRAL DIVISION South Carolina Georgia Florida Kentucky Tennessee Alabama Mississippi Louisiana Texas NORTH CENTRAL DIVISION Arkansas Oklahoma Ohio Indiana Illinois Michigan Wisconsin Minnesota Iowa Missouri WESTERN DIVISION North Dakota South Dakota Nebraska Kansas Montana Wyoming Colorado New Mexico Arizona Utah Nevada Idaho Washington Oregon California 14 HISTORY AND PRESENT STATUS Forty-three per cent of the cities and towns which reported to the Foundation had regularly organized systems of medical inspection in their public schools. The number of municipalities reporting, the number having systems of medical inspection, and the per cent having such systems in each state group, are shown in the following table: TABLE I. — CITIES OF UNITED STATES HAVING MEDICAL INSPECTION, BY GROUPS OF STATES. I9I I Division Cities reporting Cities having medical inspection Number Per cent North Atlantic ..... South Atlantic South Central North Central . . . . ; Western 411 74 lOI 382 70 236 23 35 109 40 57 31 35 •57 United States 1,038a 443 43 a Representing 1,046 school systems. The percentage figures in the final column show that medical inspection has made the best progress in the North Atlantic and Western divisions, where 57 per cent of the cities had taken up the new work. In the two southern divisions the percentages are 31 and 35, and the poorest showing is made by the North Central division, where only 29 per cent of the cities had medical inspec- tion systems. It has been stated that the first system of medical inspection was inaugurated by Boston in the year 1894. Ten years later, in 1904, 36 cities and towns had such systems. From this time on, the increase was exceedingly rapid until in 191 1, as shown above, the number of municipalities which had systems of medical inspection had increased to nearly 450. Out of the 443 cities and towns reporting systems of medical inspection, 32 did not state the year in which work began. From the records of the 41 1 cities 15 MEDICAL INSPECTiON OF SCHOOLS which gave this information a table has been compiled showing the total number of cities having medical inspection systems in each year since the pioneer work in Boston. TABLE 2. — CITIES OF UNITED STATES HAVING SYSTEMS OF MEDICAL INSPECTION IN EACH YEAR FROM 1 894 TO I9I I Year 1094 1897 1898 1899 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 Cities having medical inspection 4 5 8 9 II 17 23 28 37 55 77 III 167 263 400 411 The reason for the comparatively slight increase in the year 191 1 is that the data were gathered in the early spring, so that cities which adopted medical inspection later in the year were not included. The chart on page 17 represents graphically the number of cities having medical inspection each year since 1894, and shows how the growth of the movement, at first slow and gradual, has become in the later years increasingly rapid. School Physicians The returns of the investigation show that 354 of the 443 cities having systems of medical inspection, or about 80 per cent of them, employed school physicians, and that the total number of physicians employed was 1,415. More than half of these were in the North Atlantic states and more than half of the remaining number in the North Central states. Their distribution in the several divisions is shown in Table 3. 16 HISTORY AND PRESENT STATUS '10 'O6 '04 '97 '9^ -99 -00 'o. ^;!^ 04 □n ddD bs" '0€> '07 '09 » 4 ^ & Q n iz z^ ze 57 5"cr 77 nt lefZGi&^oo^n Diagram I. — Cities of United States Having Systems of Medical Inspec- tion IN Each Year from 1894 to 191 1. TABLE 3. CITIES OF UNITED STATES HAVING SYSTEMS OF MEDICAL INSPECTION, CITIES EMPLOYING SCHOOL PHYSICIANS, AND NUMBER OF PHYSICIANS EMPLOYED, BY GROUPS OF STATES. 191 I Division Cities having systems of med- ical inspection Cities employ- ing school physicians Number of physicians employed North Atlantic .... South Atlantic .... South Central .... North Central .... Western 236 23 35 109 40 215 14 27 70 28 852 48 41 417 57 United States .... 443 354 ",415 17 medical inspection of schools School Nurses The school nurse is now almost universally admitted to be one of the most necessary adjuncts of a well developed system of medical inspection. The total number employed in American cities in 1911 according to the returns of the same investigation was 415, of whom 375, or 90 per cent, were in the North Atlantic and North Central states. Their distribution in the diiferent divisions was as follows: TABLE 4. — CITIES OF UNITED STATES HAVING SYSTEMS OF MEDICAL INSPECTION, CITIES EMPLOYING SCHOOL NURSES, AND NUMBER OF NURSES EMPLOYED, BY GROUPS OF STATES. I9I I Division Cities having systems of med- ical inspection Cities employing school nurses Number of nurses employed North Atlantic .... South Atlantic .... South Central .... North Central .... Western 236 23 35 109 40 52 5 4 28 13 261 II 5 114 24 United States .... 443 102 415 Dental Inspection Increasing attention is being paid in American schools to the inspection of children's teeth, and the work is being more and more commonly carried on as a branch of medical inspection in a semi-independent way. In a number of the large cities the local dental associations have established clinics at which school children are given treatment either gratis or at small expense. In most of these cases dentists serve without remuneration, but in a few cities they have been added as regularly paid members of the corps of medical inspectors. Sixty-nine cities had dental inspection conducted by dentists in 191 1, and of these, 54, or 78 per cent, were in the North Atlantic and North Central states. Their distribution by divisions was: 18 HISTORY AND PRESENT STATUS TABLE 5. — CITIES OF UNITED STATES HAVING SYSTEMS OF MEDICAL INSPECTION, AND CITIES EMPLOYING SCHOOL DENTISTS, BY GROUPS OF STATES. I9I I Division Cities having systems of medical inspection Cities employing school dentists North Atlantic .... South Atlantic .... South Central .... North Central .... Western 236 23 35 109 40 24 8 3 30 4 United States .... 443 69 Four Principal Features of Medical Inspection Systems of medical inspection in different parts of the United States vary from simple and rudimentary ones to the more com- plex organizations designed to safeguard every phase of tl^ child's physical life in the school. There are four principal features which constitute component parts of these different systems, and they are found in almost every possible combination. These features are: 1. Medical inspection conducted by physicians for the detec- tion and exclusion of cases of contagious diseases; 2. Examinations conducted by teachers for the detection of defects of vision and hearing; 3. Examinations conducted by physicians for the detection of defects of vision and hearing; 4. Complete physical examinations conducted by physicians. The figures showing how these different features are com- bined in the systems of medical inspection in this country reveal the relatively chaotic condition and lack of uniformity existing in this branch of educational work. These conditions are shown in Table 6. The data that have been reviewed show that 443 school systems out of the i ,046 which reported had regularly organized systems of medical inspection in 191 1. But these data fall far short of doing justice to the situation in the United States. While 19 MEDICAL INSPECTION OF SCHOOLS it is true that only 443 systems, or about 42 per cent of all, had regularly organized work, 722 systems, or nearly 69 per cent, were carrying on some sort of medical inspection. TABLE 6. — STATUS OF MEDICAL INSPECTION IN 1,046 MUNICIPAL SCHOOL SYSTEMS IN THE UNITED STATES. I9II. (THE x's INDICATE FEATURES INCLUDED.) Inspection for contagious disease Vision and hearing tests by teachers Vision and hearing tests by physicians Physical examinations by physicians Number of school systems having the fea- tures specified X 277 X X X X X 92 80 X X X X 65 X X X 52 X X X 43 X 37 X X X X X 16 II X X 7 X X X 4 X X 3 X X 3 Total Systems not having medical inspection of any kind 722 324 Grand total 1,046 Summary. — Medical inspection is provided for by law in something less than half of the American states. Regularly organized systems of medical inspection are in force in something less than half of the American cities, while a beginning has been made in nearly three-fourths of them. About four-fifths of the 443 cities having systems of medical inspection employ school phy- sicians, almost a quarter of them employ school nurses, and in about one city in seven school dentists are employed. 20 > CHAPTER III INSPECTION FOR THE DETECTION OF CONTAGIOUS DISEASES N' EARLY all American systems of medical inspection have had for their object at the time of their inception merely the — detection of cases of contagious diseases in their early stages. To this simple aim have always soon after been added the detection and exclusion of parasitic diseases. In towns and small cities medical inspection of this sort is a comparatively elementary matter involving few difficiflties in organization or administration. In such places the teacher who thinks she sees suspicious symptoms in one of her pupils, and fears they may portend the beginning of some illness, notifies the principal of her fears. He notifies the school physician by tele- phone or messenger and the physician comes to the school and examines the pupil, sending him home if necessary. In addition, provision is frequently made, as in the Massachusetts law, that the school authorities shall refer to the school physician for exami- nation and diagnosis every child returning to school after absence on account of illness or unknown cause. BLANKS AND FORMS Such simple systems as those outlined require little in the shape of blanks or forms. Notification cards or blanks are used for informing the parents of the exclusion of the child, and weekly or monthly reports are made out by the school physician stating how many children he has examined, how many he has excluded, and for what diseases, and what other diseases he has found which did not require exclusion. A good example of such an exclusion card is the one used in Brockton, Massachusetts. 21 MEDICAL INSPECTION OF SCHOOLS EXCLUSION CARD, BROCKTON, MASSACHUSETTS Commonwealth of Massachusetts. CONTAGIOUS DISEASE. NOTICE TO PARENT OR GUARDIAN. In accordance with Chapter 502 of the Acts of 1906, you are hereby notifiedthat has been examined by me as School Physician, and found to have symptoms of This child is excluded from the schools until he brings a statement from a regular practitioner certifying his complete re- covery. School Physician. 190 The monthly report of the medical inspector of the same city is also a good specimen of forms which have given satisfaction in simple systems, and which might well be adapted for use in any locality where the number of cases handled is comparatively small and the pupils are individually known to the school authorities so that it is easy to keep track of them. Large systems require somewhat more complicated organiza- tion and records. Efficiency and economy of labor demand that printed forms be provided wherever their use obviates the neces- sity for any considerable amount of writing. The same considera- tion demands that on these forms underlining or checking of printed words be used wherever possible, instead of the filling in of blank spaces. The object is to attain the desired results with a minimum of clerical work consistent with efficiency. This is particularly important when the clerical work is to be performed by a high- priced man, as in the case of a high-class physician. Let us consider a case where the school physician has examined a child and found him to have unmistakable symptoms 22 INSPECTION FOR CONTAGIOUS DISEASES O ^ o CO CO Q X 5 •sniSuXiBiij *S3p;tUJ0J3Q BnOlSBJUOQ.UOJvJ .5 i> -S3se35;^ snoAjaj^ 1 SnOlSBJUOQ-UOfjJ s o -Si •epiouapv 1 o 3 < 3Ai)SJnddnc ^ ^ •sassasjQ uijjg •S!imA enojfloiuoQ 'Sdtun^ •lJ?nOQ Juidooi)^ •XOJ llBUig •43A3J ISpOg ■ouaiimdiQ ■«'1"'W papn|3x3J3C)mnN|8I0X 2 -IViOi ■S31VW3J •S31VIM ^ 2 i ■ie a; z gen ^^ QZ O i^ §^ 5 OS < 03 O BQ 23 MEDICAL INSPECTION OF SCHOOLS of a contagious disease. It is necessary that the office system enable him to dispose of the case so as to notify fully every one con- cerned. This requires (i) an exclusion notice to be sent to the parents; (2) a record for the school authorities; (3) a record for the board of health; (4) a record for the physician himself. The record for the board of health and the exclusion notice require, in addition to the name of the child and the disease, the name and address of the parent. Under many systems these notices are made out on four separate cards or sheets, and often the work is still further increased by having a separate card for the record of exclusions from each room in the school. This makes it necessary to secure the appro- priate card before the record can be made. Under such conditions the physician spends five or six times as much time in making entries on different cards as he does in inspecting the child. A large part of this waste of time and money can be obviated by a carefully planned system of records. In the case in point, for example, the work can be greatly reduced by adopting a system similar to the one in use in Chicago. Instead of being furnished with supplies of cards for making the several records, each inspector is given a book similar in size and shape to an ordinary check book. The leaves of the book are alternately of light and heavy paper perforated for separation, and have stubs like the leaves of a check book. The thin leaves and stubs are printed as shown on page 25. The heavy sheet underneath this thin leaf is an exact dupli- cate, except that in the lower left hand corner instead of the words " Hand to pupil excluded" it has the words " Mail this card to Chief Medical Inspector same day pupil is excluded." Between the two leaves a sheet of copying carbon is inserted. When an exclusion case is found the method of procedure is simple. The inspector fills out the blank and its stub. The original blank is the exclusion notice and is taken home by the pupil. The stub is handed to the school authorities as their record of the case. The carbon copy on the heavy sheet is torn out to be sent to the board of health as their notification of the case, and the stub of the carbon copy is left in the book as the inspector's record. 24 INSPECTION FOR CONTAGIOUS DISEASES X H J < X o Z H a: ;?^ D-. Q O o < u X u o H ^ « u. -a M-i o -a < o -C3 -o o ID o ^ ^ T3 trt ra u S rj -C 3 a> (L> j=: o +-> •4-1 o OJ CU >. 0) Cu -a a< 3 < u M CO > a; CO z o u UJ :::: 2^ Q CO .„ "^ o ■M U CX 6 ^ £-= ^ > '^ &c . 3 ^ O &0 2 c -^ Is I 6 ^ c3 E c jz: 3 &C Si I' 3i -c oj b (U o !-• S-i +-• ti-. 'S I (U OO o3 a> 1/2 ■a U] i ir\ o ■t-l C 3 a ITS E ^ •— Q -t-J T3 < ■!-> C H .2- o3 < 'o Q CO E V, tJ C cu cr r!3 ^ d E '2 o CO 0) S2 "d 3 o CO CQ -5 < ex < o H P^ bJb Vi 1 CO +-" +-» c« J3 & o 0) CO OS (U ■«-> t/2 -t-> i fc ex '-a < ■(-> Z o sh t cap. c 3 o c^ ^ jg o ^ 'c '5 o NS: ter a c 03 E o 1 £>D 1—4 _c RECT warm o S -6 0) CX 5:S c lU 03 CO i s ^ 28 INSPECTION FOR CONTAGIOUS DISEASES COMBINED DIRECTIONS AND PRESCRIPTION, EVERETT, MASS. (con- tinued) to c^ J3 0) to oj Ui H) QC CO i d d -5 ■4-> £5 C 3 3 ^ a> Q c c3 < 1 T3 H '-"' C^ 1) < 0^ !5 3 ■4-" u^ O o g:^ PQ H < < O H (Sr bb a ^ 4> (^ C/5 o Ci, Oj CO Cl, OJ J3 c3 C/5 "O C/5 ■♦-J c -. 3 cS O 2 +-* V3 bJD-G dJ 3 2P ^ O '5 oi OJ o Td o > c ,^ o g >. c^ o t^ d D c> a: Q <1> < "o ■(-> E- JZ, ?^ < -5 H ^ kS ct V5 J 3 ^-1 C/5 l-J j:^ >^ E o. 03 "5. Cl, CO 3 on CQ < < o H bb % c75 ^ ^ E ^ 3 1 ->-> CTJ -C >- ^ O 3 j=: t; t^ •^ i •5.2 _c <4- U ■)-> ^ S3 c C ^ > .2 3 5 0.& _>. cS J= -M J- "c3 ^H 3 *-> .3 on 29 MEDICAL INSPECTION OF SCHOOLS 1. It is impracticable to have the physician inspect all the pupils every day. 2. He should see them all sometimes. (In some systems such routine inspections of all pupils are made once in two weeks, in others once a month, and in still others once a term.) 3. Where school nurses are employed the problem largely disappears, as the teacher and nurse together readily decide which pupils should go to the inspector. In localities where systems have been carefully worked out, teachers are provided with printed instructions as to the symptoms which they should notice and on account of which children should be referred to the school physicians. Probably the most carefully worked out set of such instructions is given in a pamphlet issued by the Massachusetts state board of education. This little book, which so well fills the need that it has been reprinted for use in many other localities as a good example of what such a manual should be, is reprinted in its entirety in this volume.* Under the heading " Some General Symptoms of Disease in Children which Teachers should Notice, and on Account of which the Children should be Referred to School Physician" it gives explanatory directions under each of the following headings: Emaciation Eruptions of any sort Pallor Cold in the head with running eyes Puifiness of the face Irritating discharge from the nose Shortness of breath Evidence of a sore throat Swellings in the neck Coughs General lassitude and other evi- Vomiting dences of sickness Frequent requests to go out Flushing of the face EXCLUSIONS In most cities examinations are made for the following diseases: scarlet fever, diphtheria, measles, small-pox, chicken-pox, tonsilitis, pediculosis, ringworm, impetigo contagiosa, trachoma, and other transmissible diseases of the skin, scalp, and eye. Tu- * See Appendix I, p. 183. 30 ^A ; 0^ ■■fi: " If Mail 1 «liM4*i ^.•:'*^5jd ^P^-Jli ^^^hT^^bB 'tt ^^1^^^^ ^ft H^^BI. ■. .K ^IHf No exclusion for ringworm when cases are treated by the nurse at school First aid for small ailments in Toledo, Ohio. INSPECTION FOR CONTAGIOUS DISEASES berculosis, when thought to be far enough advanced to be a menace to public health, is generally reported to the chief medical inspector before the pupil is excluded from school. In general, the procedure with respect to the more common contagious diseases is substantially as follows: Scarlet fever cases are not allowed to return to school until all des- quamation is completed and there is an entire absence of discharge from the ears, nose, throat, or suppurating glands, and the child and premises are disinfected. Diphtheria cases are excluded until two throat cultures made on two consecutive days show absence of the Klebs-Loeffler bacilli. Those exposed to diphtheria are excluded one week from last exposure. Measles cases are excluded for three weeks or longer if there is present bronchitis, inflammation of the throat or nose, or abscess of the ear. Those exposed to measles are excluded two weeks from the date of last exposure. Whooping cough cases are excluded until after spasmodic stage of the cough — usually about eight weeks. Those exposed to whooping cough are excluded two weeks after the date of the last exposure. Mumps cases are excluded for ten days after all swelling has subsided. Chicken-pox cases are excluded until the scabs are all off and the skin smooth. Cases ojtonsilitis are excluded on clinical evidence alone and throat cultures are made for future diagnosis. In making throat examinations wooden tongue depressors are used to the exclusion of all other tongue depressors. Each tongue depressor is used only once and then burned. Aseptic methods are employed in all examinations. When children are excluded sufficient reasons are written briefly on an exclusion card which is sent to the parents. One copy is filed with the school authorities and one with the board of health. School physicians are forbidden to make any suggestions as to treatment and management of sick pupils. This rule is nearly universal and is made imperative. Children recovering from measles, whooping cough, mumps, chicken-pox, scarlet fever, diphtheria, and small-pox are not al- lowed to re-enter the school without a permit from the department 31 MEDICAL INSPECTION OF SCHOOLS of health. If they have been taken sick with any of these infec- tious diseases in the school room, the pupils of the room are dis- missed and the room disinfected. In the accompanying tables figures are presented showing the number of exclusions for each of the more important diseases in four cities. In Table 7 the figures are the original data taken from the latest available reports. In Table 8 the figures are relative, showing the number of exclusions for each disease among each thousand children excluded. They indicate the variations which are encountered in this work. These varia- tions exist not only between cities but between different years in the same city, and are mostly due to the fluctuations caused by local epidemics. The commonest disorder, and the one causing the largest number of exclusions, is pediculosis. TABLE 7. — EXCLUSIONS FOR CONTAGIOUS DISEASES IN FOUR CITIES Exclusions Cause of exclusion Chicago Detroit Newark New York 1910 1909-10 1910-11 1911 Pediculosis 1.455 426 925 1,475 Tonsilitis 2,957 170 337 Chicken-pox 1,010 90 217 1,347 Mumps . 1,128 33 135 1,475 Impetigo 986 520 227 Measles 1,004 84 167 414 Conjunctivitis 672 1.137 Scabies . 579 254 U5 215 Diphtheria . 708 7 28 848 Ringworm . 494 116 162 138 Whooping cough 298 108 83 329 Scarlet fever 579 19 27 198 Other causes 2.783 948 1,925 351 Total •4,653 2,775 4,121 8,154 Further data showing the great variations between cities in the matter of exclusions are presented in Table 9, which compares the number of exclusions with the total school mem- bership in eight cities. The figures for exclusions are taken 32 INSPECTION FOR CONTAGIOUS DISEASES TABLE 8. — EXCLUSIONS FOR CONTAGIOUS DISEASES IN FOUR CITIES: RELATIVE FIGURES ON THE BASIS OF 1,000 EXCLUSIONS IN EACH CITY Exclusions Cause of exclusion Chicago Detroit Newark New York 1910 1909-10 1910-11 1911 Pediculosis 99 154 224 181 Tonsilitis 202 61 82 Chicken-pox 69 32 53 165 Mumps . 11 12 33 181 Impetigo 67 187 28 Measles 68 30 41 51 Conjunctivitis 46 140 Scabies . 40 92 28 26 Diphtheria . 48 2 7 104 Ringworm 34 42 39 17 Whooping cough 20 39 20 40 Scarlet fever 40 7 6 ^ 24 Other causes 190 342 467 » 43 Total 1,000 1,000 1,000 1,000 TABLE 9. — SCHOOL MEMBERSHIP, EXCLUSIONS FOR CONTAGIOUS DISEASE, AND NUMBER OF EXCLUSIONS PER THOUSAND PUPILS ENROLLED, FOR EIGHT CITIES School membership Exclusions for contagious DISEASE City and year Number Number per thousand pupils Chicago, 1910 . Cincinnati, 19 10 Cleveland, 1908-09 Detroit, 1909-10 Newark, 1909-10 New York, 1909-10 Philadelphia, 1910 Rochester, 19 10 301,172 47.454 69,764 57,996 57,742 744,148 174,441 26,664 14,653 1,606 1,798 2,775 4,955 8,884 6,794 1,050 49 34 26 48 86 12 39 39 33 MEDICAL INSPECTION OF SCHOOLS from the annual reports as indicated in the table, whereas the figures for school membership are those given in the report of the United States commissioner of education for the corresponding years, showing the total number of different pupils enrolled in the day schools. The figures in the third column show the num- ber of exclusions per thousand children enrolled. The significant feature is that exclusions range all the way from 12 per thousand in New York to 86 per thousand in Newark. ■ Summary. — In order to render inspection for the detection of contagious disease effective, the most important feature to be striven after is the reduction of the machinery of administration in order that the school physicians may devote the largest possible amount of time and energy to actual inspection, and the smallest to merely clerical details. Experience demonstrates that it is impracticable to have the physicians inspect all the pupils every day, and it is equally clear that complete inspection should be made occasionally. Where the work is done successfully and adequately the num- ber of cases of contagious disease among the children is greatly reduced, and the necessity for closing schools because of epidemics is largely done away with. Exclusions on account of contagious disease during the school year vary from about one in 100 to one in 10 of the school membership. The lower figure is approached only when school nurses are a part of the permanent corps of the school medical department. 34 CHAPTER IV PHYSICAL EXAMINATIONS THE theory on which physical examinations are based rests on a different foundation from that underlying medical inspection for the detection of contagious diseases. The latter is primarily a protective measure and looks mainly to the immediate safeguarding of the health of the community. The former aims at securing physical soundness and vitality and looks far into the future. Physical examinations have come into existence because of the mass of evidence showing conclusively that a large percentage of school children — probably from one-tenth to one-fourA — suffer from defective vision to the extent of requiring an oculist's care if they are to do their work properly, and if permanent injury to their eyes is to be avoided. These conclusions are based on examinations of hundreds of thousands of children in all parts of the world. There is little doubt as to the substantial accuracy of the results. More than this, a considerable percentage of school children are so seriously defective in hearing that their school work suffers severely. Most important of all, only a small minority of these defects of sight and hearing are discovered by teachers or known to them, to the parents, or to the children themselves. When children attempt to do their school work while suffering from these defects, among the results may be counted permanent injury to the eyes, severe injury to the nervous system due to eye strain, and depression and discourage- ment, owing to inability to hear and see clearly. Moreover, there are other defects, in particular those of nose, throat, and teeth, which are common among children and which have an important bearing upon their present health and future development. The importance of these defects is emphasized by the fact that, if discovered early enough, they may easily be 35 MEDICAL INSPECTION OF SCHOOLS remedied or modified, whereas neglect leads, almost without fail, to permanent impairment of physical condition. In America, comprehensive systems embracing thorough physical examinations of all pupils are still far from general. The investigation conducted by the Russell Sage Foundation in the spring of 1911 showed that while 443* cities reported systems of medical inspection, in only 214, or a little less than half, did the work include complete physical examinations conducted by school physicians. Moreover, the cities having physical examinations were mostly in the North Atlantic division, where the work is oldest and most highly developed.! The accompanying table presents figures showing the number of cities in each division which include in their medical inspection systems full physical examinations for the detection of defects. In this table the states are classified by divisions according to the basis adopted by the United States Census. TABLE 10. — CITIES OF THE UNITED STATES HAVING EXAMINATIONS FOR THE DETECTION OF PHYSICAL DEFECTS, BY GROUPS OF STATES. 191 I Division Number of Cities North Atlantic . ... South Atlantic South Central North Central Western 135 10 12 38 19 United States 214 When these figures are compared with those giving the entire number of cities which have systems of medical inspection,* they show that the cities having physical examinations are more than half of all in the North Atlantic states, less than half of all in the South Atlantic and Western ones, and only about one-third of those in the South Central and North Central groups. * See p. 15. t Divisions adopted by the U. S. Census. 36 See p. 14. Listening for trouble. I eslin" heart and lun»s in New ^ ork Citv. PHYSICAL EXAMINATIONS CONDUCT AND RESULTS OF EXAMINATIONS Examinations for the detection of physical defects are usually conducted after the school physician has made his regular morning inspection for the detection of contagious diseases. The examinations are made in the physician's special room, which should be at least 20 feet long in order to allow sufficient space for the vision tests. In the older school buildings, where special rooms are not provided, the hallways are frequently utilized as unsatisfactory substitutes. The children are brought into the room in groups of three or four, and in making the examination the physician usually begins at the child's head and proceeds downward over the body. The object of the examination is to detect such physical conditions as interfere with the child's health and vitality or militate against his receiving the full benefit of the education furnished by the state. This means that the examinations are purely practical in intent and hence they should avoid unnecessary refinement. For ex- ample, it is futile for the physician to record history as to height and weight unless some real end is to be attained from the study of these data. Again, it is generally useless to make records of physical defects so unimportant that, although their existence can be detected, they do not require attention from the physician, oculist, or dentist. The defects which are looked for, and which should be recorded, are defects of teeth, throat, eyes, nose, glands, ears, nutrition, lungs, heart, nervous system, and bodily structure. The records of physical examinations show that from one- half to two-thirds of all the children examined are suffering from physical defects sufficiently serious to require the attention of the physician, the oculist, and the dentist. The most important kinds of defects which go to make up these large totals are those of teeth, throat, eyes, and nose. Indeed, these four combined constitute more than four-fifths of all the defects found. Table 11, on the following page, presents the data showing the results of physi- cal examinations among more than half a million children in nine American cities. The significance of these data is more clearly shown by referring to Table 12, which presents the same 37 MEDICAL INSPECTION OF SCHOOLS moo t^ -^00 -^ m rrs — -^vo (S — -^ — irxLTvi-rN — \0— — — l>-\0 \£) OM^ t^OO '^ Tt- ']§ y - Ti-oo 00 -^ a\ - "N- ^00 — u-v m LTN r^\o 00 rr\ ^t i-o\o — "^ -^ rr\ ts C^ -^ rAi^-^r) u^cs '^ ■^ m rr\ 00 rTi U5 •MCAC. CnN — fSrr\ H UJ ■ " -^ f<\^^ — \o - 00 N - - - r^ w ^2 (N cn r^ - — Q G^ rri — -^ rn 00 . - vo - ■ Tj- • n . r^ 0\0 LTN Tt- - - 00 > m ^ Tf -^vo VO Cn (S N 00 00 ON X rr^l-r^rr^C^— C\0 imO u^ t^ l>. C^ ON rr\0O M ^ 00 M :^ z ^ a\ i^ cs t^ (N o u, O t^ r^^ >0 00 c^ Ti- (S "J^ !>. « VO 00 r^OO rr\ rr, -^ "^ "^ m P u^ M I> itnVO r^ m - ^ (S -^ i-nOO 00 ro "^ ITS o^ -^ - 00 r^ ts r^^ rr\ •k: m n-N\0 l> u-s r^ — vo 00 m "^ — m VO ~ cs rt- — -^ rVN ir\VO t^ rr, rr\ tS 0"0 — ■^— roiA,— ^ ^ ^ S (S imoo rr\ r) — !>• 00 U 2i 1 M -^ ^ -^ "^^0 0\ 0OtS"->Mrr,— — — -^ '^s - M \r\ 13 - - - 2 s 'G 5^ 2 5^ 2^ J 5n 2^ r 2^ C tJD-2 'C >- c vs ro — U-\ LTN — t^ t^ C\00 LTS r'^'^ 00000 ^^ » r^ C\ ITS t>\o M 00 1^00 !>. ro ■* rn^ t^ — •"■ "" "" tL, 00 ir\ ^ 0^ c?N c\oo ^ (s HM k: ■^mmts u>Tt-rr\T|-LrN ^ 000000000 ^ •"S "" s 000000000 -« S 'S 000000000 Q '^ s 1 »r -^ « - • •"■ — — '" T — ^ hk~o^^k ^ 2 5^ 2^ J 5n 2^ r 2^ Mass. ill., I d, 0., N.J. rk, N. , Cal., a, Cal er, N. s. Mo. ^13 rt-^ ^-0 ^ > < 0-C-*i School, Town J I 9 Number of pupils enrolled in the school " found defective in eyesight " found defective in hearing " of parents or guardians notified Teacher or Principal. In addition to these reports the teacher is required to notify the parent or guardian of each child found to have some trouble with the ears or eyes. Notification cards like the one repre- sented on page 50 are furnished by the state board of education. 48 PHYSICAL EXAMINATIONS SNELLEN CHART FOR TESTING EYESIGHT (Printed on heavy white cardboard, size ii x 14 inches) Commonwealth of Massachusetts CHAPTER S02, ACTS OF 1906 SNELLEN'S TEST LETTERS FOR MEASURING THE ACUTENESS OF VISION 50 Feet T C L D 40 Feet L O E D T 30 Feet O T P E C L 20 Feet P T O L D E C 4 49 MEDICAL INSPECTION OF SCHOOLS RECORD OF SIGHT AND HEARING TESTS. MASSACHUSETTS The Commonwealth of Massachusetts CHAP. 502, ACTS OF 1906 RECORD OF SIGHT AND HEARING TESTS 19 City or Town School Class NAME. [If notice is sent to patent or guardian, stainame.] EXAMINATION OF EYES. HEARING. REMARKS. Whisper heard (distance in feet). Eyesight. Right Eye. Left Eye. Right Ear. Left Ear. NOTICE TO PARENT OR GUARDIAN OF DEFECT OF EYES OR EARS, MASSACHUSETTS The Commonwealth of Massachusetts NOTICE TO PARENT OR GUARDIAN IN ACCORDANCE WITH CHAPTER 502 OF THE ACTS OF 1906 YOU ARE HEREBY NOTIFIED THAT THE SCHOOL EXAMINATION OF SHOWS THAT THERE IS SOME TROU- BLE WITH THE Iyes' WHICH NEEDS COMPETENT MEDICAL AD- VICE. PLEASE ATTEND TO THIS AT ONCE. TEACHER 19 50 PHYSICAL EXAMINATIONS The methods described for making tests of vision and hearing in Massachusetts are typical of the best practice in other states. The practicabiHty of having these tests made by teachers has been abundantly demonstrated by extensive experience, and in many localities this work has been the opening wedge for the establish- ment of complete systems of medical inspection. According to the investigation, tests of vision and hearing were in 191 1 established features in the schools of 552 municipali- ties. Moreover, 349 of these cities had begun the work without legal requirement, for they are located in states which had not made legal provision for these tests. The distribution of the 552 municipalities and of 258 others in which vision and hearing tests are made by physicians is as follows: TABLE 15. — VISION AND HEARING TESTS CONDUCTED BY PHYSICIANS AND TEACHERS IN AMERICAN CITIES, BY GROUPS OF STATES. 191 I Division Tests by physicians % Tests by teachers North Atlantic .... South Atlantic .... South Central .... North Central .... Western 125 12 23 73 25 261 29 43 182 37 United States .... 258 552 Data are available giving the results of vision and hearing tests in Massachusetts for the years 1907-10 inclusive. Similar data for Connecticut and Maine for the years 1908 and 191 1 respectively are also matters of record. In brief summary form, results from these three states are as shown in Table 16. The figures for Massachusetts show a constant and somewhat rapid falling off in the percentage of children reported each year as having defective vision and hearing. Just what has caused this falling off is difficult to determine, and indeed, has not been satisfactorily explained by the educational authorities of the state. Whatever the cause may be, the more important lesson of the table 51 MEDICAL INSPECTION OF SCHOOLS is that in all these states the examinations result in the discovery each year of many thousands of pupils with defective vision and hearing. This means that each year large numbers of these chil- dren receive treatment for defects which otherwise would in all probability have continued uncared for and would have con- stantly grown more serious. TABLE 1 6. — RESULTS OF VISION AND HEARING TESTS IN MASSACHU- SETTS, CONNECTICUT, AND MAINE Pupils examined Number OF PUPILS Per cent of pupils State and year Defective in vision Defective in hearing Defective in vision Defective in hearing Massachusetts: 1907 . 1908 . 1909 . 432.464 437.435 441,463 96,607 81,158 73.129 27.387 22,601 20,167 22.3 18.6 i6.6 6.3 4.6 1910 Connecticut, 1908 . 454.058 142.554 71,902 12,217 17.329 15.8 8.6 3.8 Maine, 191 1 . 87.954 11,145 4.075 12.7 4.6 RECORDS Individual records are a most important feature of a system of physical examinations. General information about the health of the pupils as a whole will not do; there must be a complete individual record for each child. The record card or blank must have spaces for entering the results of subsequent examinations as well as the initial one. If the work is to be of real practical value, there must be the closest connection between the records of the physical examinations and those of the class room. Three classes of forms are essential. In the first place, there must be a system for notifying the parent of the results of the physical examination of the child. Forms of this sort are con- sidered in Chapter VI entitled, Making Medical Inspection Effective.* In the second place, there is the individual record for each child. To be effective, this record must be an integral part of the child's educational accounting and must be always available, * See p. 72 flf. 52 PHYSICAL EXAMINATIONS constantly kept up to date, and frequently referred to as an aid in reaching decisions affecting the child's welfare. It does no good to have a record on a card filed away in the principal's office or in the office of the board of health, to the effect that Willie is stone deaf in the right ear, if the teacher knows nothing of his defect and still has Willie seated in the back left-hand corner of the room. Moreover, the records must follow the child from room to room and, in case of transfer, from school to school, for otherwise much of the information obtained is soon rendered useless. These are some of the reasons why systems for conducting physical examinations constitute entirely different problems from systems of medical inspection which aim only at the detection of cases of contagious disease. The latter sort of work can quite satisfactorily be handled by representatives of the board of health, while systems for conducting physical examinations, if they are permanently to succeed, must have the active co-operation of the educational authorities. Few cities have developed record systems which satisflctorily fulfill the requirements outlined above. A fairly well devised card for keeping the individual record of physical examinations is that in use in the Chicago schools. It is reproduced on page 54. This card measures 4x6 inches and has spaces which provide for eight annual examinations. On the reverse side are spaces for "diag- nosis" and "treatment received" with dates. A somewhat more complete record is the one kept in the public schools of Pasadena, California. This card, shown on page 55, has the added advantage of providing spaces for the recording of data by the teacher as well as by the physician. This feature insures the intimate interest of the class room teacher in the work and in the records. The reverse of the Pasadena card has spaces designed to record the dates of physical examinations, and the dates and results of visits made by the school nurse to the pupil's home. A still more complete record is called for by the card used in Berkeley, California, which provides on its face for the data of the physical examinations, and on its reverse has spaces for keeping the scholarship record. This card, face and reverse, is given on pages 56 and 57. 53 INDIVIDUAL RECORD CARD. PHYSICAL EXAMINATIONS, CHICAGO, ILL. DEPARTMENT OF HEALTH— CITY OF CHICAGO Name Address PHYSICAL RECORD Sex Age Birthplace Nationality of Father Mother No. OF Children in Family His. of Measles DiPH. Pertussis Pneu. Scarlet Fever School Vaccinated? Date ist Exam. 19 Placed in Square Means Absence of Defects. X Denotes Defects I Grade I 2 3 4 S 6 7 8 2 Years in School 3 Revaccination 4 Diseases During Year S Date of Phys. Exam. 6 Height 7 Weight 8 Nutrition 9 Anemia 10 Enlarged Glands II Goitre 12 Nervous Diseases 13 Cardiac Disease 14 Pulmonary " IS Skin 16 Defect Orthopedic 17 Rachitic Type 18 Defect OF Vision 19 Other Diseases of Eye 20 Defect OF Hearing 21 Discharging Ear DEFECT OF NASAL ^^ BREATHING 23 Defect of Palate 24 " " Teeth 25 Hypertrophied Tonsils 26 Adenoids 27 Mentality 28 Conduct 29 Effort 30 Proficiency 31 WasTreatm't Advised 54 PHYSICAL EXAMINATIONS o CO CU erf C a CO Oh c > 2 a! o 1^; 2 J3 H •a a a O B 1 1 o 0) Q _y •3 01 a o t-i o J3 Ik e .2 ■c 3 2 'ij a 1 J3X >> 1) o 3 o O .2 c 0) C < > to < uv 4-> J3 '53 a aq 4-> J3 BO OX 55 MEDICAL INSPECTION OF SCHOOLS "t3 O W c< "^ a! <3 C VJ 'r3 5^ £ cS^ TtI rt >'. z ^ UJ Pi o a n >^ >i X 3 te § O a: X O w w ti n: " C/J p U fe CO O g fe 2 O o ^ o H ac P? z M o s S ^ < Dh UJ Q O Q Pi O o w pii OT u 3 ai < Q W 1 a < a Pi w 1 1 0) 00 »: 1 1 1 1 w 1 O t^ Pi 1 1 '3 w 1 o Pi a E 3 1 un Pi 1 1 a 1 1 1 ■* Pi 1 » 1 1 'S o E 3 ro Pi 1 1 w 1 « Pi 1 1^ w 1 1 Pi " Pi 1 1 1 1 1 w 1 1 1 3 t: "v 'u 1 .a a 5 p5 >< O K o i Pi Q O Q 2 < I) a o 'u 3 1 s 1 ni 1 2 J3 H J3 to M a i 5 1 C '■3 .s s 1 01 u 3 o > . >. ss ? ID ••■* S ~2 u ■3 "3 c .9 4-1 ^<« o o .2 4-> •>«: 13 ^ V) H W Pi < 1 1 Pi H PLH In p P 2; gg 1 "o % U fa t ^ w UJ Z 1 ni (U w Pi < "0 3 1 J -, ^ Pm Q u H-} i^ ffi o S U o a ffi 1 ^ ac« J a ^~ (J fe H i1 en o « tJ^S bi? -J s 8 o p< p Q Is IT" ^ X> 00 Ov << ! S" § Q Pi II 5 fa o w i fa P fa w Pi Q H ^ x 5>^ inches, which are designed for distribu- tion among parents and children. They give in condensed and effective form authoritative information concerning the impor- tance of the more common physical defects. Several of them are reproduced in Dr. Hoag's excellent little book The Health In- dex of Children. This method of public education is so effective and Dr. Hoag's Health Pamphlets are so admirably designed to serve their purpose that two of them are reproduced herewith. Another of the same series dealing with the teeth is reproduced in the chapter on dental inspection. HEALTH PAMPHLET NO. i by Dr. Ernest Bryant Hoag The Results of Nose, Throat and Ear Troubles in Children An examination of school children shows that many of them suffer from nose, throat and ear troubles. Probably at least 25% of our children in the schools of the United States have such defects. Why this is so we do not know. Parents are very likely to be unfamiliar with these con- ditions. Often they do not know when their own children are afflicted in this way. It is the business of the School Med- ical Examiner, employed by the Boards of Education or Boards of Health, to discover children who need medical at- tention. 80 MAKING MEDICAL INSPECTION EFFECTIVE No child can do his best work in school if he is suflfering from some nose, throat or ear trouble. The commonest con- ditions found in such children are enlarged diseased tonsils, adenoids and deafness. The tonsils are glands in the throat, one on each side of the root of the tongue. When they are in a healthy con- dition they are barely visible. They often become much in- flamed and sometimes there is pus present in them. They may obstruct breathing. Any child with diseased tonsils is likely to be sickly. Any child with diseased tonsils is likely to have many attacks of sore throat, or tonsilitis. Any child with diseased tonsils is very susceptible to contagious diseases. Any child with diseased tonsils Has A TENDENCY TOIVARD CONSUMPTION. No child can be well or do his best work in school with diseased tonsils. Diseased tonsils should usually be removed and should^l- ways be treated. The operation is not dangerous. It al- ways improves the child's health. Adenoids are soft spongy growths behind the soft pal- ate, between the nose and throat. A child with adenoids usually breathes with his mouth open. He cannot breathe well through his nose. Mouth breathing is not a habit. If a child breathes with his mouth open it is because there is some obstruction in the nose. Adenoids cause a child to sleep with his mouth open. Adenoids often cause a child to snore. Adenoids nearly always make the teeth come in crooked. CROOKED AND PROMINENT TEETH ARE NEARLY ALWAYS CAUSED BY ADENOIDS. Adenoids make a child take cold easily. Adenoids often give a child a stupid appearance. Adenoids often RESULT IN ACTUAL STUPIDITY, because the child cannot get enough air. Adenoids often cause ear ache and deafness with some- times a running ear. Catarrh, deafness, ear ache and dis- charge from the ear are more often due to some obstruction in the nose or throat than to anything else. Adenoids usually result in delicate health. MEDICAL INSPECTION OF SCHOOLS Adenoids MUST BE REMOVED if you expect a child to be healthy or mentally bright. It is an injustice to children to neglect caring for them when adenoids or diseased tonsils are present. It is very poor economy on the part of the parent to neglect the treat- ment of children so affected. Any child will grow up health- ier, happier, and more useful if these conditions are taken care of. HEALTH PAMPHLET NO. 2 by Dr. Ernest Bryant Hoag The Results of Defective Eye-Sight Defects of eye-sight in school children are very common. Probably at least 20% of the children of our American schools suffer from such defects. These defects not only cause a great deal of trouble in the eyes themselves, but often produce many other serious results, which do not at first seem to be connected with the eyes. The proper treatment of children's eyes will nearly al- ways bring good results. In this way they will often be saved from life-long suffering. A child's education will not be worth much to him if he does not have good eye-sight. The ability to earn a living depends very largely upon good eye-sight. It is very poor economy to neglect to care for defects in the eyes of children, for sooner of later such children may become burdens upon some one. The common defects in the eyes of children are as follows : 1. NEAR SIGHT This condition is very serious. It not only limits the child's range of vision and prevents his taking part in health giving sports and recreation, but it produces changes in the eyes which often result in practical blindness. 2. FAR SIGHT This condition is more common than near sight. It results in eye strain and often causes squinting, red eyes, headache, nervousness, backwardness in studies, and some- times digestive disorders and poor health generally. 82 MAKING MEDICAL INSPECTION EFFECTIVE 3. ASTIGMATISM This is the most common of all eye defects. It results in blurred vision, headache, nervousness, and other kinds of discomfort. It may be associated with either near sight or far sight. 4. CROSS EYES OR SQUINT This is often the result of FAR Sight. It is absolutely necessary to have this defect corrected. In children this can usually be done with glasses alone. If the trouble is not cured the vision of the crossed eye will become poorer and poorer UNTIL AT LAST THIS EYE BECOMES BLIND. 5. INFLAMED OR RED EYES This condition is often caused by a defect in vision, but frequently it is due to INFECTION. That is, some- thing has gotten into the eyes and carried PUS-PRODUC- ING GERMS WITH IT. Serious eye disorders are sometimes "caught" from dirty towels, public bathing pools, dirty hands, or dust. * Each child and grown person should use only his own towel. Red sore eyes ought never to be neglected. Remem- ber that many cases of sore eyes are contagious and that all such cases need the attention of a doctor. Peculiar postures, holding the head on one side, squint- ing, miscalling words and headache should always raise the suspicion of possible eye trouble. LEGAL COMPULSION Two of the states which have framed regulations or enacted laws on medical inspection have provided for compulsory action against parents who fail to act upon notification of disease or defect in their children. Colorado, in the law passed in 1909, provided that "If the parents or guardian of such child [i.e., one found defective concerning whom notification of need of treatment has been sent] shall fail, neglect, or refuse to have such examination made and treatment be- gun within a reasonable time after such notice has been given, the said principal or superintendent shall notify the State Bureau of Child and An- imal Protection of the facts . . . ." 83 MEDICAL INSPECTION OF SCHOOLS The procedure regarding such cases is further elaborated in a circular letter of instructions to teachers and principals : "The Physician's Report is to be returned to the Teacher. If within a reasonable time the Physician's Report is not received by the Teacher or proves to be unsatisfactory; or where in lieu thereof the par- ent or guardian sends a written statement that he has not the necessary funds wherewith to pay the expenses of such examination and treatment the Teacher will send a Failure Notice (with such written statement if any) to the Principal or County Superintendent, recording same on the pupil's Teacher's Record Card. "The Principal or County Superintendent will record the Failure Notice on Pupil's Record Card and forward the Notice to the State Bu- reau of Child and Animal Protection, State House, Denver. "If a written statement of inability to pay accompanies a Failure Notice, the Principal or County Superintendent will at once 'cause such examination and treatment to be made by the County Physician of the District wherein said child resides'; who if unable to treat such child shall forthwith report such fact to the County Commissioners with his recommendation. If satisfactory results are not had within a reasonable time, the Failure Notice, written statement of inability to pay, statement of reference to County Physician, etc., with other information germaine to the case is to be forwarded by the Principal or County Superintendent to the State Bureau of Child and Animal Protection. "What constitutes a 'reasonable time' will be left to the judg- ment of the Teacher, under the advice and direction of the Principal or County Superintendent. If, after taking all the circumstances into con- sideration, doubt exists, refer the matter to the Bureau of Child and Animal Protection, with full particulars. "Whatever unpleasant or difficult duty may arise in the enforce- ment of the law for the examination and care of School Children, is laid by the law, not upon the Teacher, the Principal, the County Superin- tendent or the State Superintendent of Public Instruction, but upon the State Bureau of Child and Animal Protection. "Whenever the State Bureau of C. and A. P. receives a Failure Notice it will at once send its own notice to the Parent or Guardian re- questing compliance with the law, and will, at the same time notify the Teacher of that action. "In most cases a notice from the Bureau will be sufficient to in- duce prompt obedience to the law. If, however, they still 'fail, refuse or neglect,' the Teacher will send a second Failure Notice, marked 'No. 2,' 84 MAKING MEDICAL INSPECTION EFFECTIVE to the Principal or County Superintendent, who will forward it to the State Bureau of C. and A. P. at the State House, Denver. "When the Bureau of C. & A. P. receives a Failure Notice accom- panied by a written statement of inability to pay, etc., it will investigate and assist. "When the Bureau receives a second Failure Notice it will send an officer who will first consult with the Teacher, if possible with the Principal or County Superintendent, and acting under the direction of the Bureau will take charge of the case." Regarding action under this law, the report of the Colorado State Superintendent of Public Instruction for 1909-10 has this to say: "Out of the 41,546 cases of defectiveness reported to the State Superintendent of Public Instruction as having been discovered, and pre- sumably reported to the parents of the children, 221 cases were reported by teachers to the State Bureau of Child and Animal Protection for failure of parents to have the medical examination indicated by the teachers' examination made. Whether this was the total nuftiber of cases which should have been reported we have no means of knowing. In the absence of further information it may be assumed that it does not depart far from the total which should have been referred. "With one exception the parents in all these cases were induced by letter or by the visit of our officer to do whatever the children's con- dition required. In the one case where it was necessary to bring the parents into court the child's throat was nearly closed by enlarged tonsils and his health seriously affected. At the trial the father was sentenced to thirty days' imprisonment." The New Jersey law, passed also in 1909, provides as follows: "If the cause for exclusion is such that it can be remedied, and the parent, guardian or other person having control of the child excluded as aforesaid shall fail or neglect within a reasonable time to have the cause for such exclusion removed, such parent, guardian or other person shall be proceeded against, and, upon conviction, be punishable as a dis- orderly person." No record of action under this provision of the law has been found. Neither the report of the New Jersey Superintendent of Public Instruction for 1909-10 nor any of the 21 reports from county superintendents, or the 30 reports from city superintend- 85 MEDICAL INSPECTION OF SCHOOLS ents contained in the same volume, mentions this clause of the law, though most of them contain statements regarding medical inspection. One county superintendent writes: "The weakest place in the system seems to be lack of efficient remedy when defects are discovered of a nature not infectious or contagious." In England many fines have been imposed (some under attendance by-laws, others under a clause of the children's act) upon parents who failed to cleanse or keep clean the bodies and heads of their children. Parents who neglected and ill-treated their children have also been imprisoned or fined, another clause of the children's act being invoked in their cases. In this latter group of cases are included those of children suffering from defec- tive eyesight, enlarged tonsils and adenoids, decayed teeth, and ulcerated mouths. Many such children were treated after the cases had been brought into court, with the result that proceedings against the parents were stopped. SCHOOL AND HOSPITAL CLINICS Wherever systems of medical inspection become highly developed and the authorities attempt to make the work effective, they are confronted with the problem of what to do to secure adequate treatment for children whose parents either cannot pay for it at all or can pay only a small fee. The services of the school nurse are effective in securing action on the part of many parents who would otherwise take no action whatever, but there always remain a considerable number of parents who are willing that their children should receive treatment but who are unable to meet any large expense involved. Thus the school nurse alone cannot meet the situation and some agency must be provided to cope with the problem. In most cases this agency is a hospital, more rarely a clinic established within the school itself. In either case it is generally true at the present time in American cities that facilities are inadequate to meet the need. In Great Britain the policy of the board of education since the adoption of the medical inspection law in 1907 has been to urge local school authorities to secure the utmost possible degree 86 MAKING MEDICAL INSPECTION EFFECTIVE of co-operation from existing hospitals and clinics. Where such institutions have been of high character, but limited in capacity by their small endowments, special government subsidies have in some instances been approved in order to permit the extension of their work to care for cases referred from the public schools. Nevertheless, these measures have frequently been found inadequate, and prior to 191 1 school clinics for the treatment of skin and scalp diseases and in some instances for the care of defective teeth, eyes, ears, and throats, had been established in 30 cities. Almost the only writer on medical inspection in America who has faced the problem of inadequate treatment squarely is Dr. George J. Holmes, supervisor of medical inspection in Newark, New Jersey, whose views are outlined in the following quotations from his article published in the Journal of the Medical Society of New Jersey, 191 1. " I have suggested that free public school clinics be established to care for all diseases and defects common to school pupils. No pupil to be admitted unless attending a public school, presenting a printed slip showing that he or she has been referred for treatment by a medical in- spector, and that his or her home has been visited by a school nurse, find- ing such poverty that free treatment is necessary and right. "Were such a clinic established by the Board of Education and conducted by the supervisor of medical inspection and his assistants, both physicians and nurses, it would no longec be necessary for a pupil to leave school during session for treatment or examination. Pauperism would not be fostered. Such a clinic should be held from three to six p. m. daily, except Sundays. "Other benefits resulting from school clinics would be the creating of greater interest among the physicians and nurses of the department, in their being able to follow the cases and see the results. Greater op- portunity would be afi'orded both physicians and nurses to meet parents of the children afflicted, and opportunity for preaching and impressing the common facts relating to personal and home hygiene on the parents. Greater results would be obtained and better opportunity would be given the supervisor to observe the work of each member of the department." It is probable that few of the educational authorities in this country would be prepared to accept so radical a proposition 87 MEDICAL INSPECTION OF SCHOOLS as that of Dr. Holmes. So far as is known, the only strictly school clinics conducted in the United States are the dental clinics in Rochester, Cincinnati, Muskegon, Philadelphia, and Elmira, and the eye clinic in Cleveland. The time is undoubt- edly at hand, however, when some solution to the pressing prob- lem created by needy children left untreated must be sought out and applied. Frank facing of the problem is needed if medical inspection is to fulfill the hopes of its friends. Summary. — Invitations to parents to be present at examina- tions of children, follow-up visits by nurses, arrangements for children to attend hospitals and clinics, the establishment of office hours when medical supervisors may be consulted by parents, and the education of the community through printed bulletins explaining the nature and importance of defects, are five measures of great value in rendering medical inspection effective. Mere notifications of defects, unsupplemented by such measures as the above, can never be expected to secure more than a small proportion of the treatments needed. The possibilities of increasing the effectiveness of medical inspection by legal measures to compel neglectful parents to take action have not yet been thoroughly tested in this country, but the working of Colorado's experiment along this line is worth study. The presence throughout the schools of the country of large numbers of children whose parents cannot afford to pay current rates for treatment creates a problem which is pressing for solution. The suggestion that dental and medical school clinics be estab- lished to deal with this class of cases will increasingly demand the attention of school authorities who are dissatisfied with the inadequate returns secured by present systems of medical inspec- tion. CHAPTER VII RESULTS DEFINITE information as to the actual results achieved by medical inspection for the detection and correction of physical defects is exceedingly meager. Superintendents and health officers frequently state in their annual reports that the response of parents to notifications is unsatisfactory, and urge the adoption of more effective follow-up methods. Where nurses have recently been installed, satisfaction is generally expressed and the statement made that a marked increase of co-operative action has resulted. Definite statistical evidence is, however, rarely offered with regard to any phase of the problem. % The success of a system of medical inspection of schools is to be measured by the results achieved. The mere piling up of statistical data as to defects would be valueless unless action of some sort followed. In printed reports, the meaning attached to the word "results" is the crux of the whole matter. In most cases where any mention is made of results secured it takes the form of "treatments reported," "attention given," or "physician consulted." Occasionally some detail is entered into, as the num- ber of pairs of glasses obtained or the number of operations per- formed. Very rarely a notation as to improvements following treatment is made. The type of report on results which a school physician makes is naturally determined by his conception of the function of his office. On the side of results, four possible functions may be formulated : 1. To bring parents to the point of taking their children to a physician or dentist, cHnic or hospital. 2. To ascertain whether the consultation is a genuine one and whether appropriate treatment has been instituted. 3. To ascertain, where no treatment or inadequate treatment only 89 MEDICAL INSPECTION OF SCHOOLS has been given, what is the reason for such failure (i. e. parental igno- rance, indifference, hostility or poverty, lack of clinical resources, etc.)- 4. To ascertain the ultimate results of treatment upon the child's physical health and mental development. The first function is inevitably the one first recognized, as it is undoubtedly the most important. The second function is almost forced upon the inspector where later contact with a child reported "under treatment" leads to the discovery that no effective measures to remedy bad conditions have been taken. It is especially important in large cities where unprincipled practitioners find it easy to connive with parents in a pretense of consultation. Yet assumption of the duties and responsi- bilities it implies is rare in American cities. The third function follows naturally upon the second and would call for but little additional work. The fourth function is as yet recognized by scarcely any American community. It can be developed to its fullest possible limits only where there is active and enthusiastic co-operation of teachers and principals with medical officers. Such following up of children as it requires is far more difficult in large cities than in small towns, since transfers from school to school mean re- examinations by different inspectors, in which case comparison of "before" and "after" conditions becomes unreliable. Records of re-inspections by physicians when sufficient time has elapsed after treatment so that definite results are discoverable, and records by teachers of their observations during extended periods are, however, essential features of any scheme for testing the value to the child and to the community of medical inspection. The report of a school physician who based his work on the assumption that all the above functions belonged to his office would be likely to contain several features not now generally found in such reports. Among them would probably be: A statement of the number of children enrolled, the number ex- amined, the number having specified defects and combinations of defects, and the number reported as having consulted a private physician or dentist, or as having been taken to a clinic or hospital for treatment. A statement of the number of these children found on investiga- tion, after a stated period following the reported consultation has elapsed, 90 RESULTS to have received adequate treatment, the kind of treatment being speci- fied. A statement of sources of treatment; that is, private physicians or dentists, specialists, clinics, hospitals, etc., with number of children treated by each. A statement of the number of children who failed to receive ef- fective treatment, classified to show causes of failure; that is, parental neglect or opposition, poverty, lack of adequate or accessible clinics, lack of intelligent co-operation by clinics and family physicians, etc. A statement of ultimate results on health and school standing pro- duced by specified kinds of treatment in children suffering from each sort of defect. Such a report would furnish a basis for the formulation of policies now generally lacking. If, for example, it revealed a large amount of parental neglect of serious conditions when adequate means of securing treatment for such conditions existed in the community, the need of a new type of educational activity directed toward the older generation would be made evident. If on the other hand there were revealed many cases where lack of facilities for medical, surgical, or dental treatment was the cause of unsatisfactory results, the problem of securing adequate facili- ties for treatment would be placed squarely before the educational and health authorities with its alternative of continued waste of public funds in ineffective inspection. RECORDS OF DEFECTS TREATED IN NEW YORK CITY New York occupies the first place in the discussion of this subject, both on account of the size of its problem and because the history of its endeavor to cope with that problem is an unusually long and instructive one. Treatments, as reported by the Division of Child Hygiene of the Department of Health for the year 191 1, include all cases where report of attention received was made by physicians. Instructions in mouth hygiene by nurses, said to have been given in all cases where defective teeth were discovered, are not included. The figures undoubtedly include many cases where treatment never went beyond the initial visit to a physician. Moreover, according to the director of the Division of Child Hygiene of the Department of Health, they include cases where 91 MEDICAL INSPECTION OF SCHOOLS physicians, without examination and for a fee of 25 cents, have furnished diagnoses agreeing with those of the medical inspectors on the sHps brought them by the children. There is, however, no reason to suppose that the figures given are any less reliable than those reported from other cities. The data showing in detail the number and per cent of defects treated are presented in Table 20. TABLE 20. PHYSICAL DEFECTS REPORTED BY MEDICAL INSPECTORS, AND NUMBER AND PER CENT OF THESE DEFECTS TREATED. NEW YORK CITY, I9I I Defect Cases reported Cases treated Per cent treated Vision .... Hearing .... Nasal breathing . Hypertrophied tonsils Tuberculous lymph nodes Cardiac disease . . Pulmonary disease Chorea .... Orthopedic . . . . Malnutrition Teeth .... Palate .... Total .... 24,514 1,491 27,319 34,639 418 1,661 483 861 1,190 5,845 135,843 85 16,633 847 22,839 22,647 295 1,286 377 483 522 3,632 18,164 40 68 57 84 65 71 77 78 56 44 62 13 47 234,349 87,765 37 In the case of four of the defects, further details are given as to the character of the remedial treatment. These details are as follows : Defective vision: Treated by supplying glasses 11,304 Receiving medical treatment 5>329 Defective nasal breathing: Receiving operative treatment 1 1,284 Receiving medical treatment 1 1,555 Hypertrophied tonsils: Receiving operative treatment 9,808 Receiving medical treatment 12,839 Defective teeth: Treated by extraction 7,373 Treated by filling 10,791 It is interesting to note that the highest percentage of treatments was that reported in cases of defective nasal breath- 92 RESULTS ing where over 80 per cent were treated, more than 40 per cent by operation. In nearly all other classes of defects, upwards of 50 per cent of cases were reported treated, but the very low per- centage of cases of defective teeth which received attention is in striking contrast, and evidently accounts for the fact that but 37 per cent of all the defects needing attention received it. Lack of appreciation of the need of dental care, and lack of clinics where teeth can be put in order at a moderate cost, are doubtless alike reflected in the low percentages of extractions and fiUings. REPORTS FROM OTHER CITIES In the report of medical inspection in the schools of Newark, New Jersey, occurs the following statement showing the definite action taken on defects of vision, hypertrophied tonsils, adenoids, and defective teeth; that is, provision of glasses, operations for tonsils and adenoids, and dental treatnient. % TABLE 21. — FOUR CLASSES OF PHYSICAL DEFECTS REPORTED AND NUMBER AND PER CENT OF THESE DEFECTS TREATED. NEWARK, N. J., I9IO-I I Defect Cases reported Cases treated Per cent treated Vision Tonsils Adenoids Teeth 3,003 4,588 1,866 7,124 989 416 238 772 33 9 13 II Total 16,581 2,415 15 As the table shows, the percentage of defects receiving the specified remedial treatment was 15. The corresponding figures cited for New York City give a percentage of nearly 23. In the New York report the term "defective nasal breathing" is con- sidered equivalent to the term "adenoids" in the Newark one. In general, the figures make it appear that Newark is somewhat behind its larger neighbor in the treatment of eyes, ears, and throats, and about on a par in the treatment of defective teeth. Harrisburg, Pennsylvania, gives the following statement of reported treatments for the school year 1909-10: 93 MEDICAL INSPECTION OF SCHOOLS TABLE 22. — PHYSICAL DEFECTS RECOMMENDED FOR TREATMENT AND NUMBER AND PER CENT OF THESE DEFECTS TREATED. HARRISBURG, PA., I909-IO Defect Cases recommended for treatment Cases reported treated Per cent of recommended cases reported treated Malnutrition .... 72 24 33 Enlarged cervical glands 17 4 24 Chorea 8 4 50 Cardiac disease 8 3 38 Pulmonary disease . 5 4 80 Skin disease .... 61 30 49 Defective vision 677 268 40 Defective hearing 143 51 36 Defective nasal breathing 204 83 41 Defective teeth 187 48 26 Deformed palate 8 2 25 Hypertrophied tonsils 805 249 31 Adenoids 432 153 35 Total 2,627 923 35 The numbers here are small, in some cases so small that the percentages are hardly worth considering. In general, it would appear that from 20 to 40 per cent of cases needing treatment received it. In Pasadena, California, during the same year, the propor- tions of cases treated were not very different. The report of action taken is as follows : TABLE 23. — PHYSICAL DEFECTS REPORTED AND NUMBER AND PER CENT OF THESE DEFECTS TREATED. PASADENA, CAL., I909-IO Defect Cases reported Cases treated Per cent treated Eyes 685 242 35 Ears 117 21 18 Nose 202 69 34 Throat 240 91 38 Teeth 1,230 375 30 Nutrition 195 64 33 Nervous system 48 12 25 Total 2,717 874 32 94 RESULTS From Summit, New Jersey, comes a report of the numbers of cases discovered, the number referred to a physician, and the cases in which a physician was consulted. TABLE 24. DEFECTS REPORTED, NUMBER REFERRED TO PHYSI- CIANS, AND PER CENT OF THESE IN WHICH PHYSICIAN WAS CONSULTED. SUMMIT, N. J., I9O9-IO Defect Cases reported Cases referred to phy- sician Cases in which physician was consulted Per cent of cases refer- red to physi- cian in which phy- sician was consulted Defective vision .... Defective hearing Hypertrophied tonsils Adenoids Defective teeth .... 185 21 124 35 383 132 10 43 18 1 12 79 8 12 6 44 60 80 28 33 39 Total 748 315 149 % 47 The striking feature of this report is the large proportion of cases discovered which were not considered important enough to be referred for treatment. It is to be assumed that all cases regarded as needing treatment were referred. The percentage of eye and ear cases in which physicians were consulted, based upon the numbers referred, is much higher than in Harrisburg or Pasa- dena; but the number of cases under the head of "hearing" is so small that discussion as to their disposition is hardly worth while. INTER-CITY COMPARISONS The foregoing data, cited from the reports of the different cities, give a general idea of the degree to which inspection for the detection of physical defects results in remedial treatment. It must be remembered that these data are gathered from cities where the problem has been given special attention and undoubt- edly reflect conditions distinctly better than the average. When the figures from four of the cities are brought together the result is as shown in the following table: 95 MEDICAL INSPECTION OF SCHOOLS TABLE 25. — DEFECTS REPORTED AND THE NUMBER AND PER CENT OF THESE DEFECTS TREATED, IN FOUR CITIES City and year Defects reported Defects treated Per cent treated New York City, 191 1 . Pasadena, Cal., 1909-10 Harrisburg, Pa., 1909-10 . Summit, N. J., 1909-10 234,349 2,717 2,627 748 87,765 874 923 149 37 32 35 20 Several other cities report the number of children given remedial treatment, rather than the number of defects remedied. These figures reduced to percentages for three cities are as follows : St. Louis, Mo., 1909-10 24 per cent Trenton, N. J., 1909 39 per cent Oakland, Cal., 1910-11 52 per cent As has been noted, statements as to improvement resulting from treatment are rare. In Trenton, according to the report referred to above, 172 out of the 190 children treated were "im- proved." Our ignorance as to kinds of defects included, nature of treatment, and standards by which improvement was judged, makes the statement of slight value. Treatment by Physicians and Institutions Statements with regard to the agency from which treatment was obtained are made by two cities — New York and St= Louis. Those for New York are as follows: TABLE 26. — cases OF PHYSICAL DEFECTS TREATED BY PRIVATE practitioners and by institutions, new YORK, 191 1 Defect Cases treated by private practitioners Cases treated by institutions Glasses Operative Medical Physical culture Instructions Extraction of teeth .... Filling teeth 5,530 9,777 20,604 17 836 1,222 3,666 10,048 10,684 42 341 232 '5' Total 37,986 27,164 96 RESULTS The St. Louis report for 1910-11 states that during that school year the number of cases treated by family physicians or dentists was 825 as compared with 1,088 cases treated at free dispensaries or clinics. Treatment Following Examinations by Teachers All the reports thus far cited have been of results following more or less complete physical examinations by physicians. Two Massachusetts cities, Lowell and Somerville, offer figures bearing on treatments resulting from teachers' examinations of sight and hearing. Lowell reports that of 922 cases of defective eyes and ears referred to parents in 1910, 349, or 37.8 per cent, were "professionally treated." Somerville's percentages of "pro- fessionally treated" cases during five successive years are as follows : TABLE 27. — percentages OF CASES OF DEFECTS OF EYES AND EARS TREATED PROFESSIONALLY. SOMERVILLE, MASS., I906-IO Deject 1906 1907 1908 1909 1910 Eyes 25-3 14.3 24.9 13.4 10.8 Ears 20.9 12.5 10.2 12.3 12.3 It is evident that a larger proportion of cases received attention in the first year in Somerville than have ever been treated since. The result is the more difficult to explain, since the percentage of children examined who were found defective, both in eyes and ears, has steadily decreased from year to year. Comparison of the Somerville and Lowell percentages of eye and ear treatments with the data from other cities already cited reveals the fact that Lowell's results approximate those secured in Harrisburg and Pasadena, while Somerville's are far behind. This contrast may be due to the fact that Somerville is the only one of the group which does not employ a nurse or home visitor to follow up cases needing attention. 7 97 MEDICAL INSPECTION OF SCHOOLS The diverse reports made by the lo cities mentioned in this chapter indicate that anything in the nature of a general conclusion as to the value of results achieved by medical inspec- tion for physical defects cannot be drawn. It is, however, safe to assume that scarcely any American city has yet succeeded in securing the benefits of genuine treatment for as many as half the children needing it. While a certain irreducible minimum of defectiveness must doubtless always remain uncorrected, it seems certain that this minimum has nowhere yet been reached. Doubtless continuing efforts for adjustment will result in the devising of new methods for meeting the need. One of the most practicable plans now being urged is that for the establishment of school dental clinics, which is discussed in another chapter.* The correction of all dental defects, which are everywhere the most common defects, would mean a long step in advance. The establishment of open air schools for tuberculous and anemic children is also a measure the effectiveness of which has been abun- dantly demonstrated in many cities both here and abroad. REPORTS OF TREATMENT IN ENGLISH COMMUNITIES Reports of treatment for physical defects are more common in England than in this country, but from the comments of the chief medical oificer of the board of education it is evident that there is some uncertainty as to what is meant by the word "treatment." In his report for 1 910 he states that more accurate description of results cannot be achieved "until the report on the results is based on actual re-examination by the medical officer." The medical officer should inform himself on four points: 1. Whether treatment was obtained. 2. The nature of the treatment, e. g., whether by medication, the provision of food, a visit to a convalescent home, or the performance of an operation. 3. By what agency the treatment was obtained, e. g., by parent, nurse, charitable society, private practitioner, at the hospital, or through the Poor Law. 4. The exact results of such treatment, or the causes, so far as can be ascertained, of failure to obtain treatment. *See Chap. IX, p. 114. 98 RESULTS Reported treatments are tabulated in 24 areas, 12 of them counties, 12 of them boroughs or urban areas. The defects and diseases reported on are: defects of vision (including in some cases squint), defects of the external eye, of tonsils and adenoids, defective hearing, ear and skin diseases. Not all of these defects are, however, reported on from every area. Report is also made from some areas regarding "uncleanliness and vermin." The figures relative to these conditions are omitted in the accompany- ing summary : TABLE 28. — RECOMMENDATIONS FOR TREATMENT BY MEDICAL INSPECTORS AND NUMBER AND PER CENT OF TREATMENTS IN 24 ENGLISH AREAS. I9IO County areas Cases recommended for treatment Cases treated Per cent of recommended cases treated Anglesey Devonshire . Ely, Isle of . Essex Kent Middlesex Norfolk Nottinghamshire . Surrey . Sussex (West) Worcestershire Yorks (East Riding) Total . 374 2,525 257 3.643 6,290 2,481 1,303 626 1,417 505 598 312 204 557 144 1.735 2,502 1,169 692 284 688 358 419 176 5I.5 22.1 56.0 47.6 39.8 47.1 53-1 45-4 48.6 70.9 70.1 56.4 20,331 8,928 43-9 Borough and Urban Areas Beckenham Blackburn . Darlington Derby, C. B. Leicester, C. B.. Lincoln, C. B. Middlesborough Morley Penge . Salisbury . South Shields Wolverhampton Total 204 803 608 334 1.235 133 992 350 179 202 732 322 6,094 52 458 281 83 639 88 545 73 38 1 19 420 148 2.944 255 57.0 46.2 24.9 517 66.2 54-9 20.9 21.2 58.9 57-4 46.0 99 MEDICAL INSPECTION OF SCHOOLS It would appear that the EngHsh communities are con- siderably in advance of those of the United States, as exactly 12 out of the 24 included in this summary report over half of their defects as treated, while but one American city was found which reported as high as 50 per cent of treatments. Summary. — ^American cities which offer statistical reports regarding defects treated are exceptional. Such reports as are offered show roughly from 1 1 per cent to 50 per cent of treatments, figured in some cases on a basis of number of defective children, in others on a basis of number of defects. Reports from England are far more numerous and show a higher range of percentages treated — from 20 per cent to 70 per cent — ^while the average for 24 areas is about 50 per cent. Definitions of what is meant by "treatment" are seldom given in either country, but such evidence as exists indicates that the figures published generally tend to overstate rather than to understate the proportion of cases genuinely treated. 100 CHAPTER VIII PER CAPITA COSTS AND SALARIES SINCE systems of medical inspection vary in scope from vision and hearing tests conducted by teachers to complete physical examinations conducted by physicians, and because the attendant expense may range anywhere from the slight cost of printed material supplied to teachers to high salaries paid physicians and nurses, it follows that generalizations concerning per capita costs must be somewhat indefinite. Cost of Inspection for Contagious Disease The sort of medical inspection which has for its object the discovery of incipient cases of contagious disease and their exclu- sion from school, is in reality merely an extension of the work which has been done by boards of health. It is not inherently expensive in terms of time or money. In most cities the work is carried on by having the school physicians call each day, or two or three times a week, and inspect the children referred to them by the teachers as seeming to be in ill health, or who have returned to school after an unexplained absence. In most cases, the physician comes at stated times, without being notified. In some places the less efficient method is followed of having the principal notify the physician by telephone when he is wanted. The annual per capita cost for this sort of medical inspection averages about 1 3 cents. Cost of Vision and Hearing Tests Given by Teachers By far the least expensive of all systems are those consisting solely of examinations conducted by teachers for the detection of defects of vision and hearing. They are prescribed by state law or regulation in Massachusetts, Colorado, Indiana, Maine, lOI MEDICAL INSPECTION OF SCHOOLS Minnesota, Rhode Island, and Utah, and are conducted without legal enactment in many towns and cities of other states. The only expenses incurred in such examinations, in addition to the cost of the teacher's time, are for printed material consisting of directions, test cards, record blanks, notices to parents, etc. Even for a large number of children, the expense is low. The amount appropriated by the Massachusetts act is ^800 per year, and of this appropriation only ^592 was actually expended in 1910-11. As there are approximately half a million children in the public schools of Massachusetts, this means an annual per capita expenditure of slightly more than one mill. In Connecticut, where tests of vision are conducted trien- nially, the total expense for the state is about ^700 for each test, which means a per capita cost of nearly one-half cent. The time necessary to conduct these examinations is from three to five minutes per pupil. These figures show that both in time and in money, the necessary expenditure for conducting vision and hearing tests by teachers is slight. Such tests do not take the place of thorough examinations by competent trained experts. It cannot be gainsaid, however, that they are of great and real value, and it is to be doubted whether, in the whole range of educational endeavor, there can be discovered another field where so great returns for good are to be secured at so small an expenditure of time and money. SALARIES AND PER CAPITA COST FOR SALARIES The great variation in the amount and character of work done in different systems of medical inspection renders a discus- sion of salaries most difficult. This is because of the inherent difficulty in comparing the work done in one locality per unit of salary with that performed in another. An idea of the salaries paid to school physicians and nurses in American cities may be gained from Table 29.* This table presents conditions in 191 1 in 77 American cities of more than 8,000 population where the work was conducted under the auspices of the board of educa- tion. Data are taken from the investigation conducted by the *See p. 104 ff. 102 The equipment of this Rochester dental clinic cost about S^o. Dental treatment costs less than the extra schooling bad teeth involve. PER CAPITA COSTS AND SALARIES Russell Sage Foundation in the spring of 191 1, and the figures for attendance are taken from the report of the United States Commissioner of Education for the year 1909-10. Data have been restricted to the cities where the work is conducted under the department of education, because it is frequently the case in systems under the board of health that part of the salary paid is in return for other sorts of inspection work conducted for the board of health. It will be noted that the per capita figures presented in the table refer only to expenditures for salaries of inspectors and nurses and do not take into account sums paid for printing, supplies, equipment, and so forth. Cities where the systems of medical inspection do not include examinations for physical defects are indicated. All other rates thus apply to relatively complete systems, including physical examinations as well as inspections for the detection of contagious disease. In the 52 cities where physical examinations are conducted, the average per capita rate is 24 cents, while in the other^5 cities it is slightly over 13 cents. Only six cities pay more than 50 cents per child for medical inspection, and of these, two are in California and four in New Jersey. Unfortunately, it is impossible from the data at hand to determine a minimum per capita rate for efficient medical inspection including adequate follow-up work. It is worthy of note, however, that among the 19 cities listed in this table employing school nurses the average per capita rate is 30 cents, and it is probable that this sum may fairly be regarded as a mini- mum for securing an adequate and efficient system. Salaries of School Physicians and Nurses Professor William Osier is credited with saying, as already quoted, in regard to the work of medical inspection in England : " If we are to have school inspection, let us have good men to do the work and let us pay them well. It will demand a special training and a careful technique." It is certainly to be regretted that this point of view has not been more generally taken in Amer- ica. In this country the financial remuneration of school physi- cians and school nurses is almost invariably inadequate. The salaries paid range from nothing to $4,000 per annum. 103 MEDICAL INSPECTION OF SCHOOLS O o X u w <; o u <1, < I> > Z z < '-' J p, t/j w "-) oi ^ Z C^ ;^ PJ J cu o ■J o Z o o UJ X o Cd. u m U) t/2 H CI H Q < (0 hJ U z r) Q z < fc ?: w n <: X Di c. t/5 u U ^ D< H p) o Q U o U Z < w a; D H UJ a, Z < 00 z < a: H < Q Z rn u s u o Q CL, ?> ^ W y s w o o O PQ z Di H z < CI Di < hJ < < z hJ J UJ -v2 1 'T3 S al in rs an nurs S ,^ i~. r5 ^ RS U 104 < CQ T3 2 u -; o ,5 D a. — Z (U CQ PER CAPITA COSTS AND SALARIES V£) i-A u-s Tj-00 i^ Tt-00 OOO^O — O — 0000>00 t^OO — "~> — CO N "^OO O 0O"> — "OO — — «^0"^— m moo (S ^ m -^vo \o — O 00 res ;^ ^O 00 Cn ^O O — moo ■^00 vo"OOtSMMOOm"^— O^C}I>.cs '^'^ 'C"^ — (N ri — tsod rn — " — rn — " — ts — \o" cs rn ^f — -^ — --'' (NOo" (S -^ m^ ooo ooooooooooooooooooooo oo go OOO 000000'^"~^00"^000"^Lr\00000 O"^ O ir\ .M ■ OOOOOi^OOOOLrsOOOOOOOOO 00000(N"^000tS00'^"^00000 mMro,rj-(srq mmts — MCSVO OO — — MM Tt— Mm— — M"^— MCnM"-" — — m— TJ-— — ir\ a; nS J 105 MEDICAL INSPECTION OF SCHOOLS X ^ so 1^00 Tt- r^m— C\0C^"^O'. t^OG\0 oo" ri — r^ (s" rf ^o" — i>. ts" ts" ts^" tA -^ S h ^ s s ; -^s^ -^ ^ u^ o - O rr\ — OOOOOOOOOOOO 0\ u CQ < s,« o o ^ ITS O - o rr\ — OOOOOOOOOOOOOO - -^VO — G\ :; ^ ■ a; oj _^ ^ V) ca >■ -t 2 c 0 1> m o o o o 9, 9, rr\ rn o o o O O ir. O 00 8 od" . If* . . :| : : ! f* : ! : : ! r* : : : ^ OO OOOOO OO O ir\ 0^'^000 OO OOO — Tt-li^^J^o M^ cT — OOO O "^ o o o o o O o o O O >r^ -- VO M - - - 00 2- 00 E X n a. ■ sc c E "■^ c ^ equip- ment for school physicians and school nurses are taken from an article* published in 191 1 by Dr. George J. Holmes, Supervisor of Medical Inspection of Newark, N. J. They are based upon ex- tended and successful experience. The school physician's room should be "well lighted, painted white or light colored, wood floor." It should contain the follow- ing equipment: One or two small, flat-top tables with a drawer, painted white enamel Chairs rather than benches Wash basin and running water Paper towels White enamel pail for waste materials Screen Window shades operated from below upward Wooden tongue depressors Eye charts (Snellen's and illiterate) Medical cabinet of wood, with lock and key for medical and surgi- cal supplies of nurses and physicians * Journal of the Medical Society of New Jersey, 191 1 I I I MEDICAL INSPECTION OF SCHOOLS File boxes and index for filing physical examination cards Absorbent cotton, bandages, alcohol, bichloride tablets, tincture of green soap, quart jar with screw top for bandages and dressings Full list of printed forms used by inspectors For School Nurses The following is a list of supplies used by nurses in schools : Absorbent cotton, yi lb. pkg. Lysol Adhesive plaster, 2 in. by 10 yds. Sulphur ointment Alcohol, grain, 95 per cent Sweet oil Bandages, i in. by 10 yds., Linton Stearate of zinc (powder, in boxes) gauze White precipitate Bandages, 2 in. by 10 yds., Linton Zinc ointment gauze Bottles, 4 oz., with corks Plain gauze, i yd. long, i yd. wide Ciliary forceps No. 1,628 Argyrol, 5 per cent Clinical thermometers Bichloride tablets, 7^ gr. Ointment jars, 4 oz. Flexible collodion Tooth picks Iodine, tincture Full list of printed forms used Summary. — In summing up the problems of administration which relate to expense it can only be said that in this, as in all other branches of organized endeavor, cost varies with the extent and kind of work done. Examinations by teachers for the dis- covery of defects of vision and hearing involve only the added expense of the simple printed material required. Inspection by physicians for the detection of contagious diseases is inexpensive and of great value in its results. Systems of medical inspection which include careful physical examinations of all children cost the most and are by far the most valuable. From a social and economic point of view they are by far the cheapest in the better sense of the word, as they are the most far-reaching both in their immediate and in their indirect results. If, however, a system of medical inspection is to be efficient and effective for any considerable length of time, it is clear that adequate salaries must be paid to those in charge of the work. 1 12 PER CAPITA COSTS AND SALARIES Efficient work can not long be expected from volunteers, and perhaps even less will it be given by physicians who receive a bare pittance in return for their time and skill. Neither can it be expected that first class men will long be content to spend the greater part of their time in doing the purely clerical work of filling out blanks in duplicate and triplicate. Permanent efficiency will require skilled workers, careful administration, and adequate remuneration. 113 CHAPTER IX DENTAL INSPECTION DR. WILLIAM OSLER is credited with saying, " If I were asked to say whether more physical deterioration was produced by alcohol or by defective teeth, I should say unhesitatingly, defective teeth." The history of the movement for dental inspection of school children shows that during the past decade educators and hygienists all over the world have been awakening to a realization of the truth and significance of Dr. Osier's statement. Although the development of dental inspection both in America and abroad has come almost entirely within the past decade, the beginnings date back more than a quarter of a century. So far as is known the first free dental clinic in the world was established in Rochester, New York, more than twenty-five years ago. While this was not strictly a school clinic, work with children was done and the present movement might have had its inception there had not lack of support resulted in the closing of the clinic after some two years of existence. Fifteen years later dental work for school children was seriously started in Germany and was soon followed by similar work in England, in the United States, and to some extent in other countries. The movement owes its rapid development to the world- wide awakening to the importance of dental conditions and still more directly to the publication of the findings of school physicians employed in the work of medical inspection. These reports have shown with convincing consistency that a large proportion of all school children are suffering from decayed teeth. These results come from all civilized countries and reveal especially serious conditions in the poorer quarters of our great cities. Thus Unghavari reported* as a result of his studies of dental conditions among school children in Hungary that 87 per * Unghavari (Hungarian physician): A study in Scedegin. Referred to by W. H. Burnham in Hygiene of the Teeth, Pedagogical Seminary, September, 1906, p. 293. 114 Too late for effective treatment. Each missing upper tooth renders useless the corresponding lower tooth. DENTAL INSPECTION cent had diseased teeth. An extensive investigation in Prussia* showed that among almost 20,000 children in 19 cities, 95 per cent were afflicted with dental caries. Dr. Henief examined school children in Norway and found 97 per cent with decayed teeth. Investigations conducted in Dunfermline, Scotland,! showed that 96 per cent of the children needed dental attention. Among 2,200 pupils in the public schools not a single child was found who had had dental care or whose teeth were filled or otherwise attended to. In America conditions are little if any better than abroad. The serious significance of dental conditions existing among school children in a typical American city may be appreciated by studying the record of the examination of 447 school children ranging in age from six to sixteen years in Elmira, New York. These children were examined by local dentists in i9io.§ The findings are given in Table 3 1 . TABLE 31. — RESULTS OF DENTAL INSPECTION OF 447 CHILDREN, AGES SIX TO SIXTEEN, ELMIRA, NEW YORK, I9IO No. of children examined • . 447 No. of children with teeth in perfect condition 22 No. of cavities needing filling 2063 No. of teeth and roots needing extraction 617 No. of children needing teeth cleaned 425 No. of children needing gums treated 18 No. of children suffering with pus-discharging abscesses 15 No. of children in need of surgical treatment for irregular teeth ... 60 No. of teeth prematurely lost by extraction 315 No. of children with malocclusion 9 No. of children using tooth brush daily (condition of mouths did not verify this claim) 127 No. of children who had been to a dentist (in most cases for extractions only) 100 182 or 40 per cent of the children had fairly good masticating capacity. 1 19 or 27 per cent of the children had three-fourths masticating capacity. 106 or 24 per cent of the children had one-half masticating capacity. 38 or 8 per cent of the children had one-fourth masticating capacity. 2 children had no masticating capacity. * Investigation made by an association of dentists in the province of Schles- wig-Holstein. Zeitschrift fiir Schulgesundheitspflege, No. 7, 1900. Referred to by W. H. Burnham, op. cit. t Dr. C. Henie (School physician in Hamar, Norway): Untersuchungen iiber die Zahne der Volksschiiler zu Hamar in Norwegen. Zeitschrift fiir Schulge- sundheitspflege, February, 1898, Vol. II, pp. 65-71. Referred toby W. H. Burn- ham, op. cit. I Second Annual Report on the Medical Inspection of School Children in Dunfermline, Scotland, 1907, pp. 12-14. § Annual Report of Don C. Bliss, Superintendent of Schools, Elmira, N. Y., 1909-10, p. 30 ff. 115 MEDICAL INSPECTION OF SCHOOLS The importance of these conditions is emphasized by a mass of information showing with startHng distinctness that as civihza- tion advances human teeth tend to become less efficient and even to disappear. According to Dr. Rose* only about 2 per cent of the Eskimos have defective teeth, 3 to 10 per cent of the American Indians, 3 to 20 per cent of Malays, 40 per cent of Chinese, and 80 to 96 per cent of Europeans and Americans. There is evidence showing that for centuries the lower face and jaws of civilized man have been deteriorating. An examination of 402 British soldiersf revealed the fact that only eight had a width of jaw equal to the average jaw width of the Roman soldier. The average American jaw has been found to be more than one-third of an inch narrower than that of the ancient Roman. These facts mean that we are here dealing with a problem in which we must do far more than merely let nature have her own way if we are to conserve normal healthy conditions. There is another mass of evidence tending to show in definite, quantitative terms the importance of good teeth among school children. In Chapter XI, on Physical Defects and School Prog- ress, are quoted data taken from an investigation in New York City which showed that, on the average, children having defective teeth take one-half a year longer to complete the elementary school course than do children not so afflicted. In the Nineteenth Century for July, 1899, Dr. CollinsJ reports an investigation indicating that children with good teeth stand appreciably higher in scholarship and school promotion than do those having poor teeth. In 1901, Dr. Johnson conducted an investigation in the schools of Andover, Massachusetts, § which showed that in physi- cal development as indicated by weight, children with good teeth were on the average about half a year ahead of children with poor * Dr. Karl Rose, Die Zahnpflege in den Schulen. Zeitschrift fiir Schulge- sundheitspflege, 1895, Vol. VIII, pp. 65-87. Referred to by W. H. Burnham, op. cit. t Examination of British and American Soldiers. Referred to by E. S. Talbot: Degeneracy, Its Causes, Signs and Results. Contemporary Science Series. t Collins, Dr. Edwin: The Teeth of the School Boy. Nineteenth Century, July, 1899, p. 84. § Johnson, Dr. George E.: The Condition of the Teeth of School Children in Public Schools. Pedagogical Seminary, March, 1901, pp. 45-58. 1 16 DENTAL INSPECTION teeth. Again, Superintendent Verplanck of South Manchester, Connecticut, reported in 1910* that only 25 per cent of the children promoted at the end of the year had seriously defective teeth as compared with 38 per cent of the non-promoted children. While such statistical evidence is not abundant, the data which exist show consistently a relation between dental conditions and mental ability. DENTAL INSPECTION ABROAD Germany The first dental clinic for school children in Germany seems to have been established by Dr. Jessen in Strassburg in 1902. From its inception the work has had a marked success and has rapidly grown. At present Strassburg has a |6o,ooo building for a school dispensary. The children are examined upon their entrance into the public schools and twice a year thereafter until they reach the age of thirteen. The treatment furnishec^includes cleaning, fillings, and extractions. Parents able to pay are charged for the service, but the most necessitous cases are treated gratis and the deficit is made up by the municipality. The dentists are state officers receiving regular salaries and are not permitted to engage in private practice. One feature of the work is the supplying of tooth brushes to all patients. The work initiated in Strassburg rapidly spread to other German cities and served as a model in the organization of many of the new systems. Cologne established a dental clinic in 1908 at an initial cost of ^5,500. The school children are referred to the clinic by the teachers but they must secure the consent of their parents before being given dental treatment. The cost of main- tenance amounts to from $6,000 to |6,500 annually, this sum serving to meet the salary expense of one director on part time, two assistants on whole time, and two nurses on whole time. In the city of Hamburg work was begun in 1911 in connection with the dental clinic of the Municipal Insurance Committee. This clinic occupies twelve rooms and was designed to provide * Annual Report of Fred. A. Verplanck, Superintendent of Schools, South Manchester, Conn., 1910, p. 37. 117 MEDICAL INSPECTION OF SCHOOLS dental attention for domestic servants receiving the benefits of compulsory industrial insurance. It was found that the force and equipment were so ample that other work could be undertaken and the clinic arranged to treat 40 school children per day. Its support is guaranteed by a municipal appropriation of $2,000 per year for the three years 1911-14. The children treated are referred to the clinic by the school physicians. In all, some 78 German cities and towns give some kind of dental treatment to school children. Of these 78 localities, 70 are cities of more than 10,000 population. The fact that the remaining eight cities have populations of less than 10,000 indi- cates that in Germany they have begun to realize that dental inspection, like medical inspection, is no less important in the small towns and rural districts than it is in the great centers of popula- tion. In about 30 locahties the authorities have come to regard dental treatment as a necessary accompaniment of education and have made it free and universal. In twelve localities a more conservative course is followed and free treatment is furnished poor children only. A still more conservative attitude is represented by the course followed in 26 cities where the parents make small annual payments for the treatment furnished their children. These annual contributions vary in amount from 12 to 50 cents per child. Of the 78 school dental clinics in the Empire 38 are municipal, three are attached to universities, three are in private hands, and the remaining 34 are conducted by dentists who give part-time service. The clinics vary in size from small ones of one or two rooms to those in Strassburg and Hamburg containing 10 and 12 rooms respectively. There are three general plans of administration. In the first the dental clinic is maintained by the school authorities as an integral part of the educational system. In the second the clinics are supported by means of municipal grants to local dental associations. In the third, commonly adopted in smaller com- munities, arrangements are made with private dentists whereby school children needing treatment are sent to them on certain specified days. The dental clinic has passed the experimental stage in 118 DENTAL INSPECTION Germany. In no part of the public medical service have such valuable results been obtained through the expenditure of such small funds. The experience of many cities demonstrates that the health of the children has been markedly improved by dental treatment and that the work has been of genuine value in the campaign against tuberculosis and contagious disease. The number of children requiring treatment each year is steadily declining, and with the development of better conditions the num- ber of extractions is becoming constantly smaller. Moreover, both children and parents appreciate the value of the dental work and voluntarily apply for treatment instead of having to be urged to submit to it as was formerly the case. England In England the first dental clinic was started in Cambridge in 1907 as a private venture. Two years later the work was taken over by the city. At the present time provisions for the dental treatment of school children are made in 16 cities. In three of these the clinic is connected with a public infirmary ^nd sup- ported by municipal contribution. In 12 cities the dental clinics are supported by separate institutions, and in five of these cases the dentists are employed on whole time and in the other seven on part time. One city employs part-time dentists but does not support a clinic. Perhaps the most significant and interesting school dental work now being carried on in England is that conducted by the county of Somerset. In that county ten dentists are employed to care for the teeth of children in the villages and country districts as well as in the larger towns. They are paid at the rate of $7.50 per six-hour day and are allowed to give their time in either whole or half days. They are allowed 12 cents for material for each child treated and are granted allowances to cover reasonable traveling expenses. Wherever possible the work is done in the private office of the dentist, and where this cannot be arranged the school authorities set aside a room for the purpose. The instruments and appliances are supplied by the dentists. Conditions among the English children have been found so serious that in general the object of the work is to prevent the 119 MEDICAL INSPECTION OF SCHOOLS progress of dental deterioration rather than to cure the already existing conditions. The problem is to administer a limited force and limited funds so as to do the greatest permanent good to the greatest possible number of children. The solution has been found through beginning with the youngest children and, after once treating a child, assuming the responsibility for keeping its permanent teeth in good condition. This plan makes it possible to advance the age limit of caring for the children annually by one year, and in a few years will make it possible to include all, the oldest as well as the youngest. The basis of this plan is the proposition that it is better to clean and care for the teeth of nine children who have one decayed tooth apiece than it is to spend the same time caring for one child with nine decayed teeth. While this policy results in leaving many serious cases almost uncared for, it secures the maximum advantage for the minimum expenditure and will make it possible to cope with the entire problem within a few years. Other Countries Dental inspection is well under way in Wales and notably good work has been done in Scotland, especially in the town of Dunfermline. Dental clinics have been established for school children in several of the cities of Switzerland, Austria, and France, and the latest report from Russia tells of the establishment of nine dental clinics in the city of St. Petersburg. DENTAL INSPECTION IN THE UNITED STATES After the pioneer work carried on temporarily in Rochester, New York, a quarter of a century ago, the city again became a pioneer by establishing the first American school dental clinic in the modern sense of the term in 1905. This was made possible by the public spirited enterprise of Mr. Henry Lomb, who person- ally gave |6oo and was instrumental in securing an equal amount from local merchants with which to purchase a ^1,200 equipment. Premises for the clinic were supplied by the Public Health Asso- ciation and work was at first carried on two afternoons each week. A little later there was a re-organization which resulted in the 120 E\ ery pupil in Rochester, N. Y., needing dental inspection recei\'ls it. Toothbrush drill in New York City. DENTAL INSPECTION employment of two dentists, one of whom was on duty each week- day from 2 to 5 p.m. These men were paid at the rate of $50 a month. This expense was met by Mr. Lomb. Since that time two other cHnics have been established in two of the public schools. In New York City there are 17 dental clinics. Fourteen of these are connected with general dispensaries or dental colleges and treat both adults and children ; the other three are independent and are exclusively for school children. In 1907 the Children's Aid Society of New York opened a clinic for the treatment of children enrolled in its schools. This clinic was so successful that another was established in 1909. The society meets the expense of equipment and maintenance, and members of local dental societies give their services. In January, 1910, through the generosity of Judge Peter T. Barlow and several of his friends, a free dental clinic was opened to care for New York City school children whose parents are too poor to pay for dental treatment. Two dentists are employed and are on duty every afternoon from Monday to Friday inclusive, and on Saturday mornings. The board of health supplies a nurse to assist the dentists and to instruct the children in the care of the teeth. In the year 1909, the work was begun in Cleveland, Ohio, and in Reading, Pennsylvania, and both cities have been leaders in demonstrating its value and contributing to its technique. From these early beginnings the movement for dental inspection spread rapidly over the United States until in 19 11 some 198 cities reported that such inspection was being carried on in their local schools. This does not mean, however, that the work has been in every case of the type under consideration. It frequently means only that the local medical inspector examines the children's teeth and advises them to secure dental treatment. However, dental inspection carried on by dentists was being con- ducted in 89 American cities at the close of the year 191 1. The number of cities in each division carrying on dental inspection and the number of cities where this work is done by dentists are shown in the following table: 121 MEDICAL INSPECTION OF SCHOOLS TABLE 32. — CITIES OF THE UNITED STATES HAVING DENTAL INSPEC- TION AND CITIES HAVING DENTAL INSPECTION BY DENTISTS, BY GROUPS OF STATES. I9I I Division Cities having dental inspection Cities having dental inspection by dentists North Atlantic .... South Atlantic .... South Central .... North Central .... Western 94 15 8 59 22 30 8 4 39 8 United States .... 198 89 Administration In nearly all cases dental inspection in America has had its inception in volunteer work of the local dental association. This generally results in an arrangement whereby the association carries on demonstration work in the public schools. When the experimental stage is past the dental inspection in the public schools and the remedial work carried on through clinics are usually administered by the public school authorities and the dental association, acting in co-operation. A good example of this sort of co-operation is found in Read- ing, Pennsylvania, where the medical inspectors in the public schools examine the children and select those needing treatment. The local charity organization society investigates the home condi- tions of candidates for gratuitous treatment and the local dental society supports the clinic and contributes professional services. In New York City the clinics exclusively for school children are supported through the co-operation of the children's aid society, the dental societies, the board of health, and private individuals who have no connection with the public schools. In both Milwaukee, Wisconsin, and Ann Arbor, Michigan, a woman dental inspector is employed as a member of the staff of medical inspectors and recommends children for treatment, send- ing them either to clinics or to private dentists as their finan- cial condition makes advisable. 122 DENTAL INSPECTION The situation in Philadelphia is of particular interest because so far as is known that city is the only one which started dental inspection entirely through public funds. The work was begun by co-operative endeavor in which the municipality appropriated money for the establishment and equipment of a dental clinic for school children and the local dental societies carried on volun- teer demonstration work for nearly a year. The success of this experiment led to the appointment of eight dentists on half time at a salary of ^700 per year each, and the establishment of a second clinic in one of the public schools. In Valparaiso, Indiana; Muskegon, Michigan; Cincinnati, Ohio; Elmira, New York; and in many other localities the work is carried on by arrangements between the public schools and the individual dentists in the locality. The case of Muskegon is particularly interesting because of the nature of the agreement entered into between the public schools and the dentists, and also because of the marked success attained. This agreement is shown by the accompanying reproduction of the blank used for the purpose. % AGREEMENT BETWEEN DENTISTS AND SCHOOLS, MUSKEGON, MICH. To the Honorable, The Board of Education of the Public Schools of the City of Muskegon Gentlemen: I, the undersigned, am in favor of a Free Dental Clinic and agree to give at least one-half day of my time every three months, for a period of one year (from the date of the opening of the office), to the clinic estab- lished by the Board of Education in the Hackley School. My understanding is that the dates of assignment shall be by lot. I will take charge of the office on the dates assigned to me, or send a sub- stitute, provided I receive notice of the assignment two weeks before each date. Muskegon, Mich.,— 1911. Signature. In Boston plans are under way looking toward the es- tablishment of a free dental infirmary on a more extensive scale than any that exists elsewhere in the world. This will be made 123 MEDICAL INSPECTION OF SCHOOLS possible through the gift of Mr. Thomas A. Forsyth who under- took the work in the desire to estabHsh a highly practical charity in memory of his brothers. Mr. Forsyth's gift amounts to about $500,000 and it is hoped that this sum will be increased by other donations to a total of something like $2,000,000. The object of the foundation will be to co-operate with the school authorities in extending popular education in dental hygiene and in furnishing dental services free to every child in the city from early childhood to the age of sixteen. Already a charter has been granted by the Massachusetts legislature and land purchased for the erec- tion of a building. The plan contemplates the most modern and complete equipment possible. Legal Provisions Up to the present time New Jersey is the only state that has passed a legal enactment specifically providing for the public support of free dental clinics. This act was passed in March, 191 1, and is as follows: Be it enacted by the Senate and General Assembly of the State of New Jersey: - I. Section one of an act of the Legislature of this State, entitled, "An Act to authorize cities of this State to make annual appropriations to incorporate dental associations of this State conducting and maintain- ing dental clinics in such cities for the free treatment of indigent persons," approved April ninth, one thousand nine hundred and ten, be amended so that the said section shall read as follows: 1. Whenever any dental association regularly incorporated under the laws of this State shall maintain and conduct in any city of this State a dental clinic or clinics where indigent persons residents of such city may receive treatment and relief without charge or fee therefor, it shall be law- ful for the board or body having control of the finances of such city to appropriate and pay to such association, each year, such sum or sums, not exceeding in all the sum of five thousand dollars, as it shall deem advis- able, to be used and applied by such association only for the support, maintenance and equipment in such city of a dental clinic or clinics, for the free treatment of indigent persons, residents of such city and for no other purpose whatsoever. 2. This act shall take effect immediately. Approved March 30, 191 1. 124 dental inspection Cost of Supplies and Equipment Experience in the equipment of dental clinics shows that the cost of a complete, high grade equipment with one chair is approxi- mately $700. As the number of chairs increases, the cost per chair becomes somewhat less because all of the equipment does not have to be duplicated for every new chair installed. The common items of expense are about as follows: Chair $170 Table 10 Flush spittoon with water attachment .... 60 Electric engine 140 Electric heater and sterilizer 25 Excavators 18 Chisels ........... 25 Appliances for use with engine 75 Miscellaneous hand instruments 50 Initial supplies 127 $700 These figures are taken from the accounts of the Philadelphia clinic. They agree substantially with data from other cities. In New York City it has been found that the expanse for establishing a clinic is about $750, and the annual maintenance costs about ^250, not including payment for the services of the dentists. In one clinic of two chairs, where equipment and supplies, the expense of rent, salaries of two dentists and a nurse, etc., were met from clinic funds, the total expenses for one year were $4,631.31. Of this sum $1,129.61 was expended on permanent equipment; the remaining $3,501.70 represented the cost of maintenance. The directors of the Elmira clinic figure that with an annual appropriation of $400 they can meet the running expenses of the clinic, including supplies, laundry, and incidentals. In Muskegon, Michigan, an equipment with one chair cost $750 and in Rochester, New York, one with two chairs cost $1200. In Reading, Pennsylvania, a most excellent outfit with one chair was secured for about $600, but because of donations and specially reduced prices this represents a real value of more nearly $1000. Per Capita Cost The best data as to per capita cost are drawn from the European experience. In Hamburg it is found that the average 125 MEDICAL INSPECTION OF SCHOOLS cost of treatment per child is about 26 cents. Of this amount 14 cents is paid out of the municipal grant and the remaining 12 cents is paid by the parents, or in necessitous cases by the Poor Law Committee. German experience in general shows a per capita cost for children treated varying from 20 cents to 47 cents. The ex- perience of 1 2 municipal districts is shown in the accompanying table. TABLE 33. — DENTAL INSPECTION OF SCHOOL CHILDREN IN TWELVE GERMAN MUNICIPAL DISTRICTS. YEAR ENDING APRIL, I9I I Annual COST Municipal district Number of school Num- ber of rooms Initial capital OF MAINTENANCE Number of chil- dren treated Per capita children in clinic outlay Salaries Ma- terial cost Berlin I . 230,000 6 $1,944 $2,736 $486 12,000 $0.27 Berlin II 7 2,586 2,620 13,132 .20 Charlottenburg . 24,000 6 3,353 9,949 •34 Cologne . 69,293 10 3.475 2,187 Dortmund 35,000 7 1,944 2,430 729 Dinsburg 34,000 5 1,166 2,916 1,215 8^735 •47 Schoneberg . 12,696 4 875 1,944 340 8,311 .27 Stuttgart 20,000 4 2,187 1,604 6,778 .24 Darmstadt 9.057 6 1,458 1,312 486 Colmar . 6,200 3 972 1,045 170 3,095 •39 Miilhausen . 19,500 3 1,312 267 3,610 •44 Strassburg 20,680 10 2,775 7,094 -39 According to the English experience one dentist working five days a week may be expected to care for the teeth of a school population of from 3,000 to 4,000 children. In the county of Somerset an allowance of 12 cents per child is made for material. Reports from Rochester, New York, show that for 1910 the per capita cost for dental treatment was 57 cents. Of this sum 1 1 cents was for material used. In 191 1 there was a per capita increase of 12 cents. This increase was due to the fact that during 1910 most of the material had been given, while in 1911 practically all of it was purchased from the clinic funds. According to the charter of the Elmira School Dental Infirmary no charges can be made for treatment. The Newark, New Jersey, clinic treats all school children free, but they can donate any sum they wish toward the support of the clinic. 126 DENTAL INSPECTION In Lynn, Massachusetts, the dental dispensary in connec- tion with a Neighborhood House makes a flat charge of 1 5 cents for cleaning, 10 cents for extractions, and 25 cents for each filling. In Winchester, Massachusetts, nine local dentists devote half a day a week to treating poor school children at a flat rate of 25 cents per case. Salaries In Strassburg, Germany, the dental clinic employs one director on part time, two assistants on whole time, and two nurses at an annual expenditure of $6,000 to $6,500. In England, as has been mentioned, the dentists in the county of Somerset are paid at the rate of $7.50 for each six-hour day. In Philadelphia the eight dentists employed are paid $700 a year for half-time services. In Rochester, New York, dentists working from two to five o'clock each afternoon are paid at the rate of $50 per month. The staff of the two Newark, New Jersey, clinics consists of one chief and four consulting dental surgeons, who give their services; four dentists, who are on half-time for six day^a week, at an annual salary of I500 each; and two attendants on whole time at $520 each. In addition to this force several local dentists work without pay. Ann Arbor, Michigan, has a woman dental inspector who in- spects the children's teeth twice a year at an annual salary of $400. Education in Dental Hygiene One of the most valuable features of the work in dental inspection is the education of teachers, children, and parents in dental hygiene. Dentists have been wide awake to the importance of this feature and are carrying on, both abroad and in this coun- try, an active campaign, the keynote of which is prevention and conservation. Work is carried on by m.eans of leaflets, illustrated lectures, magazine and newspaper articles, and dental exhibits. In New York the state board of health has four dentists on its staff of lecturers and these men give illustrated lectures to teachers and parents in cities and towns throughout the state. The Virginia state board of health in March, 1911, issued for general distribution a bulletin on Good Teeth and Bad: The Essentials of Oral Hygiene. 127 MEDICAL INSPECTION OF SCHOOLS In Valparaiso, Indiana, in 191 1, local dentists made careful examinations of school children, and the results of their findings were made into tables and diagrams showing existing conditions. These were explained by one of the dentists at a teachers' meeting and the need for instruction on the care of the teeth was discussed. The result was the awakening of interest on the part of the teachers and the beginning of class-room instruction in dental hygiene. This was followed up by a dental exhibit shown in every school house of the city. Local cartoonists interested in the movement contributed drawings. In 1 910, through the activity of the Rochester, New York, Dental Association a lecturer who knew how to interest children was secured. For two weeks he gave illustrated talks in the different school rooms on the teeth and their care. At the end of the second week a mass meeting of citizens addressed by men of national prominence was held. This resulted in general and active support of the movement. In Philadelphia every child receives a tooth brush and box of tooth powder when the work on its teeth is completed. Direc- tions for brushing the teeth and the formula of the powder are printed on the label of the box. The following is a reproduction of the label: COMBINED DIRECTIONS AND PRESCRIPTION FOR TOOTH POWDER, PHILADELPHIA . DIRECTIONS Turn out about a teaspoonful of powder into the palm of one hand, touch the powder with the wet brush, and brush, (i) up and down the in- side of the lower front teeth, (2) the right, and (3) the left side of the lower back teeth, (4) inside of the upper front teeth, (5) right, and (6) left side of the upper back teeth, (7) outsides of all teeth, upper and lower, brush- ing up and down. To clean each of these seven divi- sions, first wet the brush, then dip it in the powder in the hand. Brush the teeth at night and rinse the mouth night and morning with table salt dissolved in warm water. PHILADELPHIA Department of Public Health and Charities BUREAU OF HEALTH DENTAL DISPENSARY Room 706, City Hall TOOTH POWDER FORMULA Precipitated Chalk 95% Castile Soap. 3% Oil of Birch. . 1% Saccharin . . .H% Oil of Pepper- mint i4% , ComplimenU of the DENTAL CORPS 128 ?, >^ Qi DENTAL INSPECTION The Children's Aid Society of New York City sells tooth brushes for three cents apiece. A leaflet containing directions for the care and use of the teeth is distributed. This leaflet reads as follows : DIRECTIONS FOR THE CARE AND USE OF THE TEETH A clean mouth is essential to good health Clean teeth do not decay :): ^ 4: 4: 4: 4: Prepared by the SCHOOL DENTAL CLINIC OF THE CHILDREN'S AID SOCIETY For free distribution among the patients of the School Dental Dispensaries WHAT ARE YOUR TEETH FOR? To grind the food into fine particles, and mix it with the saliva. % Food which is not thoroughly chewed causes indigestion and constipation. HOW LONG SHOULD THE TEETH LAST? Throughout life. HOW DO WE LOSE THEM? By decay and loosening. WHAT CAUSES TEETH TO LOOSEN? Deposits of tartar upon the teeth in contact with the gums, uncleanliness, and lack of use in chewing the food. WHAT CAUSES TEETH TO DECAY? Particles of food and candy sticking to them, lack of exer- cise in the thorough chewing of food, irregular teeth, also a poor physical condition. WHERE DOES THE FOOD LODGE? Between the teeth, in the crevices of the grinding surfaces, and along the margin of the gums. CAN DECAY BE PREVENTED? Yes, to a large extent. 9 129 MEDICAL INSPECTION OF SCHOOLS HOW CAN DECAY BE PREVENTED? By the thorough chewing of the food, by keeping the mouth clean through the careful use of the tooth brush with tooth powder or paste, and waxed silk, also by keeping up the general health. Such care will also pre- vent the teeth from loosening. HOW OFTEN SHOULD THE TEETH BE CLEANED? At least twice each day, before breakfast and at bed time. Better after each meal. Tooth powder or paste should be used morning and night. HOW SHOULD THE TEETH BE BRUSHED? In an up and down direction, allowing the brush to come well up over the gums in both jaws. This should be done on the outer surface of all the teeth. Then open the mouth and carefully brush the grinding sur- faces, special care being given to those in the back part of the mouth. Then by tilting the brush, cleanse the inner surfaces of the teeth again allowing the brush to come well up on to the gums. The tongue should also be extended from the mouth and brushed. ARE THE GUMS INJURED BY BRUSHING? No, if brushed in an up and down direction. They will be strengthened by such brushing and rendered less liable to disease. HOW OFTEN SHOULD THE TEETH BE EXAMINED BY A DENTIST? At least twice each year. WHAT IS THE PURPOSE OF THE DENTAL CLINIC OF THE CHILDREN'S AID SOCIETY? To provide free dental treatment to the children of the school. To teach them the care and use of the teeth. To help them to understand that a clean mouth is as important as a clean body. That food thoroughly chewed is more easily digested. That good digestion is the first essential to health. That well cared for teeth and a clean mouth help prevent tuberculosis. That cleanliness and fresh air are the best safeguards against disease. 130 DENTAL INSPECTION Waltham, Massachusetts, distributes a leaflet on the care of the teeth, addressed to the parents of the school children: THE TEETH AND THEIR CARE Waltham, Mass. To Parents: You are reminded of the necessity for early care of children's teeth. With such care, the teeth may be preserved throughout life. This will not only save much inconvenience and discomfort in later life, but it may enable the child in the meantime to live a more vigorous and hence a more successful life. The condition of the teeth has much to do with the gen- eral health. The following cautions, abbreviated from those issued to teachers and school physicians by the Massachusetts board of education, are commended to your attention: Unclean mouths promote the growth of disease germs, and cavities in the teeth are centers of infection. ^ Irregularities of the teeth, especially those which make it impossible to close the teeth properly, thus leading to faulty digestion and faulty breathing, should receive careful treat- ment. The first permanent molars are perhaps the most impor- tant teeth in the mouth. They come at about the sixth year, immediately following the temporary teeth, and are the most frequently neglected because they are often mistaken for temporary teeth. It should be known that decay of the teeth is caused primarily by the fermentation of starchy foods and sugars, and that the greatest factor in preventing disease of the teeth is the removal of food particles by frequent brushing. Chil- dren should be prevented from eating crackers and candy between meals, and when possible the teeth should be cleaned after eating. Inspection of the teeth by a dentist should be made at least once or twice a year. Your attention is also called to the prevalence of mala- dies of the nose and throat. The health of a child and his ability to do his school work may be seriously impaired by the presence of adenoid growths. When a child shows obstruction of the nose by mouth breath- 131 MEDICAL INSPECTION OF SCHOOLS ing, snoring, continual discharge, or recurrent ear trouble, adenoids should be suspected. Enlarged tonsils, recurrent tonsilitis, and enlargement of the glands in the neck also constitute a serious handicap to the child. Either condition must be remedied before he can have a fair chance in the world, and the earlier the better. The family physician should be consulted and the child given such treatment as he may advise. Waltham, Mass., January i, 1908 In many California cities the school authorities distribute a series of health pamphlets prepared by Dr. Ernest Bryant Hoag.* In this series belongs the following on The Causes, Results, and Prevention of Poor Teeth. HEALTH PAMPHLET NO. 3 by Dr. Ernest Bryant Hoag The Effects of Decayed Teeth It has been shown by examination of school children throughout the United States that from seven to eight out of every ten have decayed and defective teeth, needing the care of a dentist. The condition of the teeth has a very important hearing on the health of the child. By early attention not only much inconvenience, discomfort and greater expense in later life may be saved, but it will enable the child in the meantime to live a more vigorous life and be more healthy. Very often business men do not want in their employ people whose breath is oflfensive, whose teeth are decayed, blackened and unsightly. It is the best of economy on the part of the parent to have the teeth of the children examined once or twice a year by a dentist. If the cavities become large the expense of filling and the pain suflFered will be greater, or the tooth will be lost. It is frequently thought that baby teeth may be neg- lected, that the cavities are of no importance. This is wrong. Digestive troubles and poor nutrition are frequently traced to the neglect. * For other pamphlets in this series, see pp. 80-82. 132 DENTAL INSPECTION Baby teeth can be filled with cement easily and with little pain. Neglect of baby teeth is often the cause of the coming in of irregular permanent teeth. Irregular teeth are unsightly. The irregularity often causes imperfect closure and inability to chew the food. Poor mastication of food in childhood is often the cause of serious stomach disorders. This means prolonged suffering and doctors' bills. Food which is not thoroughly chewed causes constipa- tion and indigestion. Decay of teeth can be prevented. An unclean mouth is an excellent place for the growth of disease germs. It is a fact that tuberculosis often gains entrance to the glands of the neck and so to the lungs through decayed places in the teeth. Abscesses of the jaw and glands of the neck come from decayed teeth. Bad conditions of nose, throat and ears are made worse by decay of teeth. Causes of Decay Small particles of food lodging along the gums, in cavi- ties and between the teeth ferment. The protecting enamel is dissolved by the substances formed by this fermentation. Cavities result. The gums are also liable to become dis- eased. The loosening of teeth and disease of the gums is, in nearly all cases, caused by collections of tartar. Tartar collects on the teeth of every person. It fre- quently collects along the teeth down under the gums where it can only be reached by the dentist's instrument. The Armenians are noted for their beautiful and perfect teeth. The children are taught to clean their teeth after any- thing being taken into the mouth, even an apple. If a child is taught to use a tooth brush in early life he will be apt to take proper care of the teeth throughout life. It is very important to establish cleanly habits. // is more important for children to brush the teeth than to wash the face. 133 MEDICAL INSPECTION OF SCHOOLS RECORD FORMS AND BLANKS The simplest systems of record keeping used in connection with dental inspection consist merely of small charts showing in outline a full upper and lower set of teeth. By marking these pictured teeth the medical inspector indicates which of the child's teeth are in need of attention. In a fully developed system of dental inspection including dental clinics and examinations of children in the schools by dentists, work is facilitated by using a set of nine or ten records each serving its own end. Perhaps the most satisfactory record system of this sort is that in use in connection with the dental clinics of Philadelphia. Because these records are so well adapted for the work they are designed to do it seems worth while to present the series in detail. The individual record card, the face and reverse of which appear on pages 135 and 136, measures 5x8 inches and is designed to record the salient data concerning the teeth of one child. After the child has been examined and a condition found which requires treatment, a notice, reproduced on page 1 37, is sent to the parent telling him what has been discovered and advising that the child be treated by a competent dentist. If the notification to the parent brings to light the fact that he desires to have his child receive dental attention but is unable to pay the cost, the dental inspector and the principal jointly issue a certificate, shown on page 138, authorizing the child to be treated at the dental dispensary. When the child visits the dispensary he is given a small appointment card — see page 139 — measuring 2>^ x 3>^ inches, on which are written the date and hour of his appointment and which contains spaces where the dentist indicates the dates on which he worked. One end served by this card is to insure that the same dentist shall carry the case through to a conclusion. Directions for brushing the teeth are on the reverse of the card. These are the same as those already reproduced on page 128 as part of the label on the tooth powder box. 134 INDIVIDUAL DENTAL RECORD CARD, PHILADELPHIA (Face) 0) 01 < X U z o < z i < X I ~X\0< r w 2 -i '^ 's. ^ ^ ^ ^ ^ ^ o 3 o o o o o o o o o o f- H H H H H 5 < < o u 2 H O W 2 135 INDIVIDUAL DENTAL RECORD CARD, PHILADELPHIA (Reverse) ». ! 5 _(U U S z Ji o J 0) B S pi2 (1) § ^ CO t/i c 03 < rt z o H "o J D. CU u •T3 •^ *n o Si SCHOO DREN 0) X 4) U 1 J5 o 3 -2 s u z o 3 O U -J Iju a 6 o o: ^ _ o id CO o >?^ !-« U 9^ Q _(D 0) u u c o c 'c ^ - < >- DENTAL ROOM 7 Report frc >- < a > < a CD U Q in tu Z Q UJ < Q en >- < < H S H ^ H u- 141 MEDICAL INSPECTION OF SCHOOLS For administration purposes the dental clinic keeps detailed monthly reports which are summaries of the individual reports received from the children and the schools. There are two princi- pal record forms which are sheets designed for use in loose leaf binders. The first of these has spaces for recapitulating the work during each day of the month. The column headings are: Day of Month Canals Pericementitis Daily Number of Dressed Alveolar Abscess Patients Filled Gingivitis Fillings Pulps Stomatitis Amalgam Pulpitis Cleansing Gutta Percha Capped Extractions Cement Devitalized Miscellaneous Copper Cement Extracted The second of the two recapitulation sheets has spaces for recording the work done each month by the individual inspec- tors. The column headings across the top of the sheet are: Inspectors, Schools Assigned, Visits Made, Pupils Examined, Treat- ment Recommended, Parents Notified, Parents Called on Principal, Treated by Private Dentist, Recommended by Dispensary, Treated at Dispensary, Treatment Secured, Remarks. Summary. — In summarizing the situation with respect to the dental inspection of school children the most salient fact is that the commonest of all physical defects among school children is decayed teeth. Cases of dental defectiveness are frequently greater in number than are all other sorts of physical defects combined. Moreover, it is probably true that there is no single ailment of school children which is directly or indirectly responsible for so great an amount of misery, disease, and mental and physical handicap. Within the past decade those having the greatest interest in the physical welfare of children have awakened to the existence of these conditions and vigorous steps have been taken to remedy them. First in Germany, next in England, and more recently in the United States dental inspection has been inaugurated and school dental clinics established. The means and methods developed have so conclusively demonstrated their usefulness that the movement is everywhere extending rapidly and steadily. 142 CHAPTER X CONTROLLING AUTHORITIES IN AMERICAN MUNICIPALITIES UNDER American systems of municipal government, the question as to whether medical inspection of schools is a proper function of the board of education or the board of health is bound to arise as soon as the organization of such a system is contemplated. The claims of both are certain to be warmly argued. On the side of the board of health is the argument that the machinery of government already existing for the conservation of the health of the community may properly be extenaed to include new activities, and that another branch of the government should not duplicate social machinery already existing. It is further argued that an important feature of the medical inspection of schools is the detection and segregation of cases of contagious disease. This is a protective measure relating to the safety of the whole community, and as such should remain a function of the board of health. The argument for keeping the work in the hands of the board of education is that the whole work, to be effective, must be closely related to school work and school records; that friction is inevitably produced when those in charge are in the employ of an outside body, neither responsible to nor perhaps in sympathy with those who have the schools in charge. This results in a loss of efficiency. The further claim is made, and substantiated by referring to records in many cities, that the exclusion of cases of contagious disease is after all a comparatively small part of the work of med- ical inspection. Thus in Newark, New Jersey, in 1909-10, the total exclusions amounted to 4,955 in a school membership of 143 MEDICAL INSPECTION OF SCHOOLS 57,742, or about 8 per cent. In Cincinnati and Rochester in the same year the exclusions amounted to between 3 and 4 per cent, in Philadelphia and Spokane to 4 per cent of the membership. In the state of Massachusetts in 1907, towns and cities having an average attendance of 342,000 reported something more than 1 5,000 exclusions during the year. Again the percentage is 4. It should be mentioned that in many cities cases of pediculosis form a very large proportion of the diseases listed as communicable. In New York City, where only the worst cases of this class are excluded, the total exclusions in 1909-10 amounted to little more than I per cent (8,884) of a total membership of 744, 148. These facts have a direct and important bearing on the question at issue. The data showing that the proportion of cases requiring exclusion on account of contagious disease does not exceed 4 per cent of the school membership indicate that the por- tion of the work falling within the purview of the department of health is specific and limited. On the other hand, the fact that all the children need medical and sanitary supervision with respect to exercises, suitable seats and desks, type, paper, suitable hours of study and recreation, drinking water, physical and mental defects, and the like, indicates that the portion of the work which legitimately forms a function of the educational authorities is general in nature and almost unlimited in scope. By far the most important evidence bearing on the problem is that drawn from the experience of American commonwealths and municipalities. Medical inspection laws, or regulations equivalent to laws, are now in force, as has been stated, in 19 states and the District of Columbia. It is most significant that in 17 of these 20 cases the administration of the provisions is placed in the hands of the educational authorities. In one case administra- tion may be through either the department of health or the depart- ment of education, and in only two cases is it entirely in the hands of the health authorities. No less striking is the situation among American municipal systems. In the early days of medical inspection practically all systems were administered by local boards of health, but as experience has accumulated the tide has turned until at the present time only about one-quarter are under boards of health and in 144 CONTROLLING AUTHORITIES the remaining three-quarters the board of education is the con- trolling authority. In the investigation conducted in 1911, as has been stated, the facts concerning medical inspection were gathered for 1,046 school systems in 1,038 cities and towns. Among these, 443 had systems of medical inspection. The following table shows how these systems were divided between the two forms of administra- tion. TABLE 34. — ADMINISTRATION OF SYSTEMS OF MEDICAL INSPECTION IN CITIES OF UNITED STATES, BY GROUPS OF STATES. I9I I Division Cities having systems of medical inspection North Atlantic South Atlantic South Central North Central Western . United States 236 23 35 109 40 443 Cities having administra- tion by board of health 58 7 12 21 106 Cities having administra- tion by board of education 178 16 23 32 337 A good idea of the feeling of those in charge of the work in localities where the question as to administration has been raised may be gained from reading some extracts, mostly taken from official reports made by executive officers. In his report for 1907 (pages 142-3), William H. Maxwell, city superintendent of schools of New York, says : " Dual responsibility in the school — that of the board of education and that of the department of health — always has resulted and always will result in confusion and inefficiency in the work effected. It is owing to this dual responsibility that the large annual appropriation made by the city for the physical examination of school children is to a great degree wasted. Efficient service will be obtained only when the board of educa- tion is made solely responsible for all the work that goes on in the schools. "The physicians employed by the board of health do not perform any of the functions which it is highly advisable should be performed by a truly educational department of hygiene, such as studying hygienic condi- 10 145 MEDICAL INSPECTION QF SCHOOLS tions in the schools and advising teachers\ regarding the pedagogical treatment of children in cases of fatigue and nervousness. "The nurses employed by the department of health have done good work in visiting the homes of sick children, in giving advice and assistance to mothers, and in looking after slight ailments in the school. The fact, however, that they are under the control of an outside organization is a constant hindrance to their work. It is another instance of the evil effects which arise from dual control or divided responsibility. I risk nothing in saying that the school nurses would do much more and better work if they were made responsible to the educational authorities." Dr. Thomas F. Harrington, of the department of hygiene, Boston, says * in speaking of the system of medical inspection by physicians in the employ of the department of health : "The greatest criticism against this system of inspection is that it lacks uniformity; that it excludes pupils, and does not provide any means of 'follow up' nor any guarantee that the child will receive medical care; that the duties of the inspector as an agent of the board of health bring him in contact with much contagion in the homes; and finally, that the dual duties and divided responsibility are not conducive to the best in the health and efficiency of school children." Speaking of the work of the school nurses, he says:* " It does not seem possible to conceive a more satisfactory arrange- ment, nor a more effective piece of school machinery, than nurses under school supervision. With a corps of medical inspectors under this same supervision, who would conduct a daily clinic in their respective school districts, there are no problems connected with the health and efficiencv of school children which could not be quietly, rationally, economically, and effectually solved. Until such an organization is perfected in part or in whole, little progress can result from the efforts to promote the health and eificiency of our school children." The superintendent of schools of Boston in his twenty- seventh annual report, July, 1907 (page 39), says in regard to the Massachusetts law making medical inspection compulsory: "In this connection it should be stated that while the school physi- cians were concerned solely with contagious diseases, they were properly to be controlled by the board of health. Under the new law, the work * School Hygiene, Sept., 1908, p. 21. 146 CONTROLLING AUTHORITIES of examining into any defect that interferes with the progress of the chil- dren in school is not in the main a question of public health. It is rather an educational question and is so directly allied to the work of the depart- ment of physical training that the school physician should be appointed by the school board and become a part of this department. The highest efficiency will be impossible until this action is taken." The superintendent of schools of Cleveland says in his report for 1907 (page 42), after making an able plea for the establishment in the schools of the city of a system of medical su- pervision: "While it has been suggested that the kind of service here treated should be performed by the board of health, it is the belief that medical supervision is peculiarly a function of the department of physical training and school hygiene, and that the board of health's relation to the schools should relate to the matter of communicable disease." In his report for 1907 (page 119), Dr. Poland, the superin- tendent of schools of Newark, New Jersey, states that the medical inspection as conducted by the board of health has been satisfac- tory, but adds that the only objection that can be raised against it relates to the executive control of the staff of medical inspectors. He says: "By additions to the staff, the number of medical inspectors now employed in the schools is 16. The direction and control of this large number requires some one who can give more time to it than is possible for the busy and overworked, but exceedingly efficient, health officer. It seems hardly fair to impose upon him in addition to his other duties the duty of overseeing daily the work of sixteen medical inspectors." Dr. Fred S. Shepherd, superintendent of schools of Asbury Park, New Jersey, says in his report for 1907: "Again, if the system is to work harmoniously, the medical in- spector should work under the direction of the superintendent of schools, as do the teachers. If the medical inspector should regard himself as not called upon to accept any suggestions whatsoever from the school officers of administration, such as superintendents or school principals, it is plain that friction might arise. In this connection we should not overlook the fact that medical inspectors are human and have a few of the faults com- 147 MEDICAL INSPECTION OF SCHOOLS mon to humanity. It is possible for them, as it is for teachers and others higher in authority, to slight their duties or to perform them in an ineffi- cient and unsatisfactory manner. School boards are not able to pass judgment upon these inner workings of the system, and somebody should have the responsibility for holding even medical inspectors, if necessary, to the letter if not to the spirit of their obligations." It is to be noted that Superintendent Shepherd is speaking, not from the point of view of the theorist, but from that of one experienced in conducting a school system which has a successful system of medical inspection conducted by physicians appointed by the board of education. In describing the workings of this system in actual practice, Dr. Shepherd goes on to say: "It has been suggested in some quarters that medical inspection of school children should be one of the functions of the local board of health, in order to prevent clashing of authority. As boards of health are organized in our own state, however, I can see no likelihood of such cross purposes. I presume it does devolve upon local boards of health to inspect for sanitary purposes all public buildings, including the public schools. This, I judge, is also, or should be, one of the duties of the medical inspector. To have the public schools inspected intelligently by two such departments seems to me a good thing. What one might overlook, the other might see. Aside from this apparent overlapping of jurisdiction, I see little opportunity for any clashing of interest. On the contrary, it is possible for the very closest relations to be established between boards of health and the school medical authorities. How it might be in other cities of the state, I am not aware; but in the city of Asbury Park every case of contagious or infectious disease is reported immediately by the board of health to the school authorities, and vice versa." That the fears expressed by Dr. Shepherd are not groundless is shown by experience in cities where the dual system of control is in practice. Such an example comes to light in the city of Lawrence, Massachusetts. There medical inspection is, of course, con- ducted under the provisions of the state statute, which provides for the appointing of school physicians by either the school com- mittee or the board of health. In Lawrence the threatened con- flict occurred in August, 1907, when the board of health appointed 148 1 Waiting for the school physician in Toledo, Ohio. Throat inspection in the Orange, N. J., schools. CONTROLLING AUTHORITIES five physicians to inspect both pubHc and private schools. By an order of the school committee the principals and teachers were forbidden to extend official recognition to any but Dr. Bannon, who had been appointed by the school committee in August, 1906, for a term of three years. This state of affairs continued for some time and the schools were under a double inspection, with much consequent unavoidable friction. One of the strongest arguments in favor of medical inspec- tion under the authority of boards of education undoubtedly is that efficiency demands that there shall be the closest co-operation between the medical and educational authorities. If the children are to be benefited, if diligent effort is to be made to correct the defects found, if the physical conditions brought to view are to be used for the guidance of the teacher in the class room, then certainly such intimate relationships are essential. It has been claimed that where inspection is conducted under the board of health this is difficult or impossible. Cert^nly an examination of the annual reports of some of the superintendents of schools in cities where it is so conducted would indicate that the educational authorities know little of the work that is being done, and so regard it as of slight importance as a guide in the class room. Examples of such an attitude as this are found in reports of the superintendents of schools of Haverhill and Springfield, Massachu- setts, for 1907. The superintendent of schools of Haverhill dis- poses in his report of the subject of medical inspection with the following brief remarks (pages 32-33) : "The school physicians have continued their work on the same basis as last year, under appointment from the board of health. I am permitted to make the following summary of such portions of their work as admit bf classification. A large proportion, perhaps the largest portion of their work, is not such as can be shown in the form of statistics." Then follows a brief list of the diseases noted by the school physicians and of the statistics concerning vaccination. No details are given, nor is there any mention made even of the number of pupils examined. The report is confined to some 10 lines. Such comment certainly does not seem to indicate intimate knowledge 149 MEDICAL INSPECTION OF SCHOOLS of what is being done, or a close relationship between the work of the school physicians and that of the educational authorities. A similar condition seems to be revealed in Springfield, where the sole comment of the school board on the work of the physicians appointed by the board of health is (page 17), "So far as we can learn, the inspectors are fulfilling their requirements and parents generally follow the advice given." In Massachusetts, medical inspectors are appointed in some of the cities by the boards of health and in others by the school committees. After watching the operation of the two systems for more than a year under the state law, Secretary George H. Martin of the state board of education writes:* "The movement now in progress, which has reached different stages in diflferent countries, seems to be shaping itself so as to include as necessary features the following elements: "(i) Physicians. A sufficient number of trained physicians to carry on the necessary examinations and exercise the needed oversight of all the children in the public and private schools, these physicians to act under the direction of the local educational authority, but in co-operation with local health authorities. In the larger cities the physicians should act under the immediate direction of a chief medical officer, who should be a permanent member of the educational staff." Summary. — In summing up, then, we may conclude as a result of the evidence presented: 1. The detection of contagious diseases in the schools, involving daily visits by physicians and the power of the law, is in the nature of an extension of the powers heretofore exercised by boards of health; and where medical inspection is to include nothing more than this work, systems may well be administered by boards of health, if care be taken to establish and maintain sufficiently close and friendly relations with the school officials. 2. Those activities which have to do with the child's phy- sical condition and the hygiene of school work — seating, exercise, hours of home study — that is to say, all functions of the medical inspection of schools except those pertaining to contagious diseases, * Massachusetts State Board of Education, 71st Annual Report, 1906-07, p. 123. 150 CONTROLLING AUTHORITIES are, in the nature of the case, an integral part of school interests and must not be divorced from them. Moreover, the records of the examination of school children for physical defects likely to interfere with proper growth and education must, if they are to serve their end, follow the child from grade to grade and from school to school, and each case must be followed up constantly; that is, they are an important part of the school records and must be so made and administered. In brief: (a) Medical inspection for the detection of contagious dis- eases may well be a function of the board of health. (b) Physical examinations for the detection of non-contagious defects should be conducted by the educational authorities, or at least with their full co-operation, because they are made for educational purposes. (c) The records of physical examinations must be constantly and intimately connected with school records and activities. (d) They do not need to be connected with other wojj^ of the board of health. 15' CHAPTER XI PHYSICAL DEFECTS AND SCHOOL PROGRESS THE literature of the newer school hygiene contains many references to the close relation between physical defec- tiveness and school retardation. Unfortunately, however, few investigations have been conducted to find out just what relation exists between progress and the physical condition of the pupil, and the published reports of such investigations as have been carried on are meager and unsatisfactory. Six American studies bearing on the problem are suificiently significant to warrant review. The first of these was an investiga- tion carried on by Dr. Walter S. Cornell and reported in the Psychological Clinic ior ]3.nua.Yy, 1908.* Defects Among "Exempt" and "Non-Exempt" Children In Philadelphia, where Dr. Cornell's work was done, the pupils were divided into so-called "exempt" children, those whose work had been so thoroughly satisfactory that they were advanced to higher grades without examination, and "non-exempt," those whose work was less satisfactory. Among 1,594 children in five schools who were given physical examinations, he found the follow- ing: table 35. — percent of children examined found defective, AMONG 907 "exempt" AND 687 "NON-EXEMPT" CHILDREN, in PHILADELPHIA, PENN. Exempt children Non-exempt children Number examined Per cent defective 907 28.8 687 38.1 *Cornell, Waiter S., M.D.: The Relation of Pliysical to Mental Defect in Schoolchildren. Psychological Clinic, Jan. 15, 1908, pp. 231-234. 152 PHYSICAL DEFECTS AND SCHOOL PROGRESS Here the figures show that the percentage of defectives is much higher among the non-exempt than among the exempt children. We are given no details, however, as to defects found and so no data indicating which particular sort or sorts of defects caused the preponderance on the side of the non-exempt pupils. Some light, however, seems to be thrown on this problem by the results of an investigation conducted in 1908 by Dr. S. W. New- mayer in the schools of Philadelphia* and covering the examina- tions of 5,005 children, of whom 3,587 were exempt and 1,418 non- exempt. Defects were found among them as follows : TABLE 36. — PHYSICAL DEFECTS AMONG 3,587 EXEMPT AND 1,418 NON-EXEMPT CHILDREN, IN PHILADELPHIA, PENN., I908 r)^f/>/-y Cases among Cases per 100 children AMONG Exempt children Non-exempt children Exempt children Non-exempt children Defective vision Defective hearing Defects of nose . Defects of throat Orthopedic defects Mentally defective Skin disease Miscellaneous 371 49 54 137 25 6 918 214 171 29 21 53 25 80 423 128 10 1 2 4 I 26 6 12 2 2 4 2 5 30 Total 1,774 930 50 66 With two exceptions the defects are distributed between the two classes of children with surprising equality. The brighter pupils seem to be afflicted in about the same degree as their duller companions. The two exceptions occur in the cases of "mental defects" and "skin diseases," both of which are more frequent among the duller children. That the former should be more common is to be expected. That the non-exempt children should be found to suffer more commonly from skin diseases is probably a reflection of poorer home conditions rather than a cause of their lower school standings. * Report not in print. 153 MEDICAL INSPECTION OF SCHOOLS Defects Among Normal and Over-Age Children In 1906 Superintendent James E. Bryan of Camden con- ducted an extensive study* of the relation between school prog- ress and physical condition. In all, 10,130 children were given physical examinations. Of these children, 8,110 were of normal age and 2,020 retarded. The results of the vision and hearing tests were as follows : TABLE 37. — defects OF VISION AND HEARING AMONG 8,1 10 NORMAL AND 2,020 RETARDED CHILDREN IN CAMDEN, N. J., I906 Children of normal age Retarded chil- dren Number examined 8,110 2,020 Per cent having defective vision .... Per cent having defective hearing 27 4 29 6 From these data one would hesitate to draw conclusions as to any relation between retardation and defective vision and would feel doubtful with regard to defective hearing. Among the children studied 1,852 had failed of promotion.. These children were given still further examinations. Among them 1,279 were of normal age for their school grade and 573 were retarded. The results of the examinations were as follows: TABLE 38. — PHYSICAL DEFECTS AND IRREGULAR ATTENDANCE AMONG 1,279 NORMAL AND 573 RETARDED CHILDREN WHO FAILED OF PROMOTION IN CAMDEN, N.J., I906 Children of normal age Retarded chil- dren Number examined 1,279 573 Per cent having defective vision .... Per cent having defective hearing Per cent having bad health Per cent attending irregularly .... 51 14 21 30 40 1 1 2. 40 *AnnuaI Report of the Board of Education of the City of Camden, New Jersey, 1907, pp. 81-120. PHYSICAL DEFECTS AND SCHOOL PROGRESS These data furnish still further surprises. The children of normal age actually show higher percentages of defective vision and hearing than do the retarded ones, and the significant feature disclosed seems to be that irregular attendance rather than physical defects is the important factor affecting school progress. Defects Among Promoted and Non-Promoted Children In his report for 1910 (page 37), Superintendent Verplanck of South Manchester, Connecticut, reports results of physical ex- aminations among 1,396 children, of whom 1,093 were promoted at the end of the year and 303 failed of promotion. The find- ings are as follows: table 39. — physical defects among 1,093 children promoted AND 303 children NOT PROMOTED IN ELEMENTARY SCHOOLS, IN MANCHESTER, CONNECTICUT, I9IO Defect Cases among children Cases per ioo children among those Promoted Not promoted Promoted Not promoted Teeth .... Throat .... Adenoids Eyes .... Other defects 272 156 162 4> 23 116 39 61 9 8 25 14 15 4 2 38 13 20 3 3 Total .... 654 233 60 77 These figures show that a greater percentage of the non- promoted than of the promoted pupils had adenoids and defective teeth. In the case of the other defects the difference in the figures is so slight as to be non-significant. Defects Among Retarded Children In his report for 1909-10 (page 28), Superintendent D. C. Bliss of Elmira, New York, reports the results of the physical examinations among 449 children who had been in the first grade of the Elmira schools for from two to seven years. The findings are presented in Table 40. 155 MEDICAL INSPECTION OF SCHOOLS TABLE 40. — PHYSICAL DEFECTS AMONG 449 RETARDED CHILDREN, OF WHOM 345 HAD BEEN IN THE FIRST GRADE TWO YEARS, 86 THREE YEARS, AND 18 FOUR OR MORE YEARS. ELMIRA, NEW YORK, 1909-10 Cases per 100 children Cases AMONG CF;ILDREN AMONG THOSE Defect 4 or .^ or 2 years J years more 2 years ^ years more in grade in grade years in grade tn grade in grade years tn grade Adenoids 67 18 9 19 21 50 Hypertrophied tonsils 141 25 9 4' 29 50 Anemia 52 15 5 15 17 28 Enlarged glands . 77 •9 6 22 22 33 Defective vision . 72 21 5 21 25 28 Defective hearing 17 3 I 5 3 6 Rachitis 38 •9 4 II 22 22 Total .... 464 120 39 134 '39 217 A study of the figures of the last three columns shows in general an increase in the percentage of defects found as we pass from the pupils who had been in the first grade two years to those who had been there three years and to the most retarded group who had been there from four to seven years. This increase of defects with progressive retardation is particularly evident in the case of the pupils who had adenoids or were anemic. DEFECTS AND PROGRESS IN NEW YORK In a study of retardation in the New York public schools, conducted in 1908 by the Russell Sage Foundation, a careful tabulation was made of the records of the physical examinations of 7,608 children who had been examined by school physicians. When these records were tabulated the astonishing condition was brought to light that nearly 80 per cent of the children who were of normal age for their grades were found to have physical defects, while only about 75 per cent of the retarded children were defective. Another noteworthy point was that the percentage of defec- tive children in the lower grades was decidedly greater than in the upper grades. The discovery of these unlooked-for results led 156 PHYSICAL DEFECTS AND SCHOOL PROGRESS to further study of the figures. The data were retabulated by ages, and the findings showed a marked and consistent falHng off of children who had each sort of defect from the age of six up to the age of fifteen. Defective vision alone increased slowly but steadily with advancing age. Moreover, these decreases were not due to the falling out or leaving school of children suffering from defects. This might be put forward as an explanation if we had to do with children above the age of compulsory attendance, or if the characteristic decrease did not take place until the age of fourteen or fifteen; but such was not the case. The children were from six to fifteen years of age, and the marked decrease began with the seven, eight, nine, and ten-year-old children and continued steadily. Were further data not available, it would be difficult to explain the seeming anomaly that retarded children have fewer defects than do children of normal age; but the data showing the decrease of physical defects with increasing age are illuminating. It is evident that here age is the important factor. The^impor- tance of this factor in all investigations into the influence of physical defects on school progress is evident. Whether the term " retarded," referring to over-age children, is used to express a condition or an explanation, it will always follow from the definition itself that retarded children will be older than their fellow pupils in the same grades. In all cases it will always be true that the "backward" pupils will be the older pupils. Now, the older pupils are found to have fewer defects. This is true whether they are behind their grades or well up in their studies. Therefore, it is not surprising that we find 80 per cent of all children of normal age have physical defects more or less serious, while but 75 per cent of the retarded children are found to be defective. This does not mean that pupils with more physical defects are brighter mentally. It simply means that those who are above normal age are older, and that older pupils have fewer defects. In order to ascertain what correlation may exist between physical defects and school progress, the records of the children were retabulated, using age instead of grade as a basis, so that the findings should not be vitiated by the heterogeneous age composi- tion of the grades. 157 MEDICAL INSPECTION OF SCHOOLS The children were arbitrarily divided into dull, normal, and bright groups, using as a standard, age in grade. For instance, it was considered that the eleven-year-old child in the first grade may as a rule be safely classed as dull, whereas the ten-year-old child in the sixth or seventh grade may safely be considered bright. Using the age-in-grade criterion as a basis, the records of the ten, eleven, twelve, thirteen, and fourteen-year-old children were re- tabulated and assigned to the dull, normal, and bright classes. Results are shown in Table 41 . TABLE 41. PER CENT OF DULL, NORMAL, AND BRIGHT PUPILS SUFFERING FROM EACH SORT OF DEFECT. AGES TEN TO FOURTEEN, INCLUSIVE. ALL GRADES. NEW YORK, IQ08 Defect Dull Normal Bright Enlarged glands Defective vision Defective breathing Defective teeth Hypertrophied tonsils Adenoids 20 24 •5 42 26 15 13 25 1 1 40 19 10 6 29 9 34 12 6 Here we have figures which demonstrate that there is a real relation between physical defectiveness ^and school progress. In each case, save that of vision, a larger per cent of the dull pupils is found to be defective than is the case among the normal pupils, and these again are more defective than the bright pupils. The fact that defective vision does not follow this same rule is somewhat difficult of explanation. There can be no ques- tion that seriously defective vision constitutes a real handicap to the progress of the child. On the other hand, it has long been a matter of common observation that the brightest and most studious pupils are often afflicted with defective eyesight. It may very well be that these two factors somewhat more than counter- balance each other. That is to say, while defective vision is undoubtedly a real handicap and is the cause of backwardness among some children, there are found in the same classes unusually bright children who have so injured their eyesight through undue strain and use that they too have very defective vision. This 158 PHYSICAL DEFECTS AND SCHOOL PROGRESS explanation cannot be put forward as conclusive for there are no data to substantiate it. It seems, however, a reasonable explana- tion and one which coincides with the known facts in the case. TABLE 42. — AVERAGE NUMBER OF GRADES COMPLETED BY PUPILS HAVING NO PHYSICAL DEFECTS COMPARED WITH NUMBER COM- PLETED BY THOSE SUFFERING FROM DIFFERENT DEFECTS. CEN- TRAL TENDENCY AMONG 3,304 CHILDREN, AGES TEN TO FOURTEEN YEARS, IN GRADES ONE TO EIGHT. NEW YORK, I908 Defect No defects Defective vision Defective teeth Defective breathing Hypertrophied tonsils Adenoids Enlarged glands . Average number of grades completed 94 4.94 4.65 58 50 4«4 4.20 Scale of Grades 2345 No defects — ^4.94 grades Defective vision — 4.94 grades Defective teeth — 4.65 grades Defective breathing — 4.58 grades Hypertrophied tonsils — 4.50 grades Adenoids — ^4.24 grades Enlarged glands — 4.20 grades 159 MEDICAL INSPECTION OF SCHOOLS The results shown in Table 41 (page 158) indicate that there is a distinct relation between progress and physical defects. They do not, however, show what the relation is in terms of any given units. They do not show how many more grades are completed by the non-defective than by the defective child. In order to arrive at such a measure new computations were made showing the average number of grades completed by the ten-year- old pupils, by the eleven-year-old pupils, and so on for each of the other ages. The central tendency of all of these sets of results was then computed. The findings are shown in Table 42 and the dia- gram which follows. The notable feature of the table is the fact that in every case, except that of defective vision, the children suffering from each sort of physical defect made less progress in their school work than did those not so handicapped. The seriousness of these handicaps in terms of percentages is shown in Table 43. TABLE 43. — EXTENT TO WHICH CHILDREN SUFFERING FROM EACH SORT OF PHYSICAL DEFECT SHOW SLOWER PROGRESS THAN DO CHILDREN WITH NO DEFECTS. NEW YORK, IQoS Defect Defective vision Defective teeth Defective breathing Hypertrophied tonsils Adenoids Enlarged glands Per cent of loss in progress 6 7 9 14 15 Average In this table the average loss of 9 per cent which appears in the last line is not the numerical average of the percentages of loss corresponding to the different sorts of defects, but the general loss of progress discovered among all the children having physical defects. In other words, the children suffering from physical defects made on the whole 9 per cent less progress than did those having no physical defects. 160 PHYSICAL DEFECTS AND SCHOOL PROGRESS In order to show more definitely in terms of school prog- ress just what these handicaps mean we may apply them to the cases of hypothetical non-defective and defective children. If we assume that the average child without physical defects of any kind will complete the eight grades in just eight years, how long will it take defective children to complete eight grades? The answer to this question may be found in Table 44 and the accom- panying diagram. TABLE 44. — NUMBER OF YEARS REQUIRED BY DEFECTIVE AND NON- DEFECTIVE CHILDREN TO COMPLETE THE EIGHT GRADES. NEW YORK, 1908 Defect Years required to complete eight grades No defects Defective vision Defective teeth Defective breathing Hypertrophied tonsils Adenoids Enlarged glands 8.0 8.0 8.5 8.6 8.7 9.1 9.2 Scale of Years 012 34 567 89 No defects — 8 years Defective vision — 8 years Defective teeth — 8.5 years I I I I I Defective breathing — 8.6 years j | | Hypertrophied tonsils — 8.7 years | Adenoids — 9.1 years Enlarged glands — 9.2 years II 161 I I I I I I I I I I I I I II I I I I I i rr MEDICAL INSPECTION OF SCHOOLS If these figures are substantially significant for all New York City school children, their educational and economic import is great. According to the data, the child with seriously defective teeth requires half a year more than a non-defective child to com- plete the eight grades. About one-half of the children have seriously defective teeth. The handicap imposed by defective breathing means six-tenths of a year. About one child in seven has defective breathing. The child with hypertrophied tonsils takes about seven-tenths of a year more than he should. About one child in every four has hypertrophied tonsils. The extra time required by the child with adenoids is about one and one- tenth years. About one child in eight has adenoids. The pupil with enlarged glands requires one and two-tenths years extra. Nearly half of the children have enlarged glands. The sums of money spent annually by New York City for public education reach high into the millions. It would be a simple matter to compute how many dollars are wasted each year in the futile attempt to impart instruction to pupils whose mental faculties are dulled through remediable physical defects. Roughly speaking, about 60 per cent of all the children suffer from such defects. If, then, we should show that the instruction given these children suffers a loss in effectiveness of nearly 10 per cent because of remediable physical defects, it is evident that the direct financial bearing of the problem is of great significance. Such a computation, while it would undoubtedly prove interesting, is perhaps better left unmade because we do not know that the data discussed are either truly reliable or generally representative. They are based on a comparatively small number of cases in one city, in one year, and could similar data be se- cured for longer periods of time and in more localities it is not only possible but probable that they would show different results. The examination is important because it establishes the principle that, except in the case of vision, older children have fewer defects. It shows that when children who are badly retarded are compared with normal and very bright children in the same age groups, the children rated as "dull" are found to have higher percentages of each sort of defect than the normal 162 PHYSICAL DEFECTS AND SCHOOL PROGRESS and bright children. In this generalization defective vision must be excepted. Moreover, the investigation gives us quantitative measures of the retarding forces of the different kinds of defects. In general, children suffering from physical defects are found to make about 9 per cent less progress than children having no physical defects. The figures do not really show the retarding influence of each sort of defect separately for the reason that the same child is often suffering from several sorts of defects. Because of the reasons that have been mentioned, the figures may be accepted as having distinct value in revealing general tendencies, but must not be interpreted as showing with precision the relative retarding force of each separate sort of defect, or even of physical defectiveness in general. Before the attempt to draw detailed and final conclusions on this subject is made, a series of similar investigations covering large numbers of children in different cities should be conducted, and the results carefully analyzed and compared. Until some such program has been carried out, dogmatic statements making general application of partial results should be avoided, and the tentative character of all conclusions thus far formulated, clearly recognized. 163 164 CHAPTER XII LEGAL PROVISIONS THE first state law concerning the medical inspection of school children appears to have been passed by Connecticut in 1899. It did not provide for the complete sort of inspec- tion now carried on in many cities and states, but only for the test- ing of eyesight by teachers every three years. Complete medical inspection, with examinations for the detection of physical defects, was first provided for by state enactment in the permissive law of New Jersey passed in 1903. This was followed by the manda- tory law of Massachusetts, in 1906, which has been several times amended and has served as the basis for a majority of the bills which have since been presented in other state legislatuiies. By the beginning of the year 19 12, as has been stated, seven states had mandatory laws, 10 permissive ones, and in two states (Louisiana and Minnesota) and the District of Columbia medical inspection was carried on under regulations promulgated by the boards of health and having the force of law. The accompanying map shows graphically which states have mandatory laws, which permissive ones, and in which there are no laws at all. The past five years have furnished a large body of experience gained under varying conditions in widely separated localities. The lessons of this experience can be read in the substantial agreement of a majority of the laws in several salient features. This agreement is graphically shown by the tabular presentation of the principal features of the laws and regulations on page 166. On four points there is substantial agreement. The first is that the administration of the provisions of the law is placed in the hands of the school authorities. The second, third, and fourth are respectively the placing of inspection for contagious diseases, physical examination, and inspection of teachers, jani- tors, and buildings in the hands of school physicians. In seven cases provision is made for vision and hearing tests by teachers. 165 o < J D O U <. 1—1 to H W U w H < a- ■psxaaoostp not} -ipuoo iCp3UUX 0} p3-lp4-MO0 SJUPXVJ .:::::::: X ::;:":::: : aivj fo uoii '...'. X '.'''. '. S3sxnu fo fU9iuiCoi4^ -lup xof uotstaoxj '.'.'. X ::.:'.'.'.: X X ::.:. x Suuvpq puv fqSts fo sp3j ut p3UtVX1 ::::::: X X :: ■::;::: : sxaqovdi iCq sp3i Suuv3q puv tqSi^ . X . : X : X X X : : . : : X X : : : : sxopop iCq s^uipjtnq puv SXOpUvi 'SX3 -qjV3f fo UOIP34-SUJ : ; X X X .XXX : : : x x x : : . x x sxopop £q suoii -vuimvxa jvots/Cqj : . X : X . X X X X : X : x x x : : : x S3SV3Sip snoiSvfuoo xof s.iof -oop /Cq uoip3(fsuf : : X X X : X X X X : . x x x . x : x x sstjuoqinv qtjv^q M jooqos /Cq p3X3piutwpy X -i- o -^ iCxo^vp -uviu A.0 3aissmu3j i:^§o-S(x:St§S§o-a,ixS§:ga.aHC^§ p3}(}opV 3^VQ a\ a\ t^ t^ — — a\^ oono — o — — — ooo.- oooo— — oo-o— -— — -— — — o— G". C5^C>C5^C^C^C5^C?^C■, C^G^C^C^C^C^G^C^C^C^C^ "« ^ California Colorado . Connecticut . District of Columbia Indiana Louisiana Maine . Massachusetts Minnesota New Jersey . New York North Dakota Ohio Pennsylvania . - Rhode Island Utah ... Vermont Virginia . Washington . West Virginia < i66 LEGAL PROVISIONS A clear idea of the principal provisions of the different laws may be gained from the following abstract: Abstract of Laws and Regulations Covering Medical Inspection 1. California Adopted 1909. Permissive. Applies where adopted Administered by school authorities Provides for health and development supervision of teachers and pupils Inspectors may be either physicians or educators 2. Colorado Adopted 1909. Mandatory. Applies to all public schools Administered by school authorities Teachers or principals test sight, hearing and breath- ing of all pupils annually School authorities report to parents mental, moral or physical defectiveness discovered Enforcement by State Bureau of Child and Animal Pro- tection 3. Connecticut % Adopted 1907. Permissive. Applies where adopted Administered by school authorities Physicians inspect children for contagious diseases Physicians may examine teachers, janitors and school premises Physicians conduct sight, hearing and physical examina- tions annually Defects reported to parents School authorities may appoint school nurses 4. District of Columbia Regulations of health officer and board of education Adopted in present form in 1907. Mandatory. Ap- plies to all public schools Administered by health authorities Physicians examine for contagious diseases Physicians examine sanitary conditions of buildings Physicians may examine teachers and janitors 5. Indiana Adopted 191 1. Permissive. Applies where adopted Administered by school authorities Physicians inspect children for contagious diseases 167 MEDICAL INSPECTION OF SCHOOLS Teachers may test sight and hearing annually Physicians conduct physical examinations Defects reported to parents Not more than 2,000 children for one physician Compensation of physician not less than $5.00 for each school month Physicians may examine teachers, janitors and buildings If parents are too poor to provide necessary medical treatment it shall be paid for from public funds Penalty of ^5.00 to $50.00 for violation of provisions of act Louisiana Adopted 191 1. Regulations of sanitary code of state board of health having force of law. Mandatory. Applies to all public schools Administered by school authorities Principal of each school makes monthly report on phy- sical condition of children and sanitary condition of buildings on blanks furnished by state board of health Principals and teachers exclude children suffering from contagious disease Maine Adopted 1909. Permissive. Applies to cities and towns of less than 40,000 Administered by school authorities Not more than 1,000 pupils to a physician Physicians inspect children for contagious diseases Physicians may examine teachers, janitors and buildings Tests of sight and hearing annually by teachers or physicians Physical examination annually by physicians Defects reported to parents Massachusetts Adopted 1906; amended 1910. Mandatory. Applies to all public schools Administered by school or health authorities Physicians inspect children for contagious diseases Physicians may examine teachers, janitors and buildings Tests of sight and hearing made by teachers annually Physicians make physical examinations of children annually 168 LEGAL PROVISIONS Defects reported to parents Normal schools train students, in testing sight and hearing Physicians conduct examinatpns of minors applying for age and schooling certificates 9. Minnesota Regulations of board of health having force of law Adopted 1910. Mandatory. Applies to all public schools Administered by health authorities Physicians examine for contagious diseases Physicians may inspect teachers, janitors, and buildings Physicians conduct physical examinations annually Defects reported to parents Teachers test sight and hearing annually Normal schools train pupils in testing sight and hearing 10. New Jersey Adopted 1909. Mandatory. Applies to all public schools Administered by school authorities Physicians examine for contagious diseases Physicians conduct physical examinations, including sight and hearing tests Defects reported to parents Physicians deliver hygiene lectures to teachers Parents and guardians may be proceeded against as dis- orderly persons for failure to remove any pathological condition which may cause a child's exclusion from school 11. New York Adopted 1910. Permissive Authorizes school authorities to expend school funds for the support of medical inspection 12. North Dakota Adopted 191 1. Permissive. Applies where adopted Administered by school authorities Physicians conduct physical examinations annually Defects reported to parents Co-operates with board of health to curb contagious disease and to secure treatment for indigent children 169 MEDICAL INSPECTION OF SCHOOLS 13. Ohio Adopted 1 910. Permissive. Applies to cities Administered by school authorities, but powers may be delegated to health authorities Physicians inspect children and schools School nurses may be employed 14. Pennsylvania Adopted 191 1. Mandatory in districts of first and second class. Permissive in districts of third and fourth class. Districts of first class are those of more than 500,000 population, second class from 30,000 to 500,000, third class 5,000 to 30,000 and fourth class less than 5,000 Administered by school authorities Physicians conduct complete physical examinations of children annually Physicians make sanitary inspection of school premises annually In districts of fourth class medical inspectors are ap- pointed by state commissioner of health Provision for employment of graduate nurses 15. Rhode Island Adopted 191 1. Mandatory with permissive clause providing for employment of physicians Administered by school authorities Physicians, where employed, make annual examination of pupils, teachers, and janitors in public and private schools, and inspect buildings and surroundings Annual vision and hearing tests by physicians or teachers Defects reported to parents 16. Utah Adopted 191 1. Mandatory. Applies to all public schools Administered by school authorities Teachers or physicians examine all children annually for defects of sight or hearing, defective teeth or mouth breathing Defects reported to parents 17. Vermont Adopted 19 10. Permissive. Applies where adopted Administered by school authorities 170 LEGAL PROVISIONS Physicians inspect pupils as provided by rules of state board of health On request, physicians examine pupils of private schools i8. Virginia Adopted 1 9 10. Permissive. Applies where adopted Administered by school authorities Authorizes school boards to support systems of medical inspection 19. Washington Adopted 1909. Permissive. Applies to cities of first class Administered by school authorities Authorizes school boards to appoint medical inspectors who shall report monthly on health conditions in each school 20. West Virginia Adopted 191 1. Mandatory in cities, permissive in coun- try districts Administered by school authorities Physicians inspect children for contagious diseases Physicians conduct physical examinations annuall)% Physicians, on request of board, report on lighting, ventilation, etc. School nurses may be employed PROVISIONS NEW LAWS SHOULD INCLUDE A comparative study of the provisions of the different laws shows that with the added experience gained through knowledge of how the older measures have met the test of time, school physicians and educators have incorporated in some of the more recent measures features which are genuine improvements, and which should be provided for in bills for new medical inspection acts and for amendments of the old ones. The following are the features which it would seem ought to be included in bills for new medical inspection laws: I. A provision that the administration of the system of medical inspection shall be in the hands of the school authorities, but that they shall have the power to delegate their authority to the local health officials, and that in the treatment of cases of contagious diseases the school and health authorities shall co-operate. 171 MEDICAL INSPECTION OF SCHOOLS The principle here involved is that routine medical inspec- tion and physical examinations are primarily established to insure the health and vitality of the individual child and are preferably conducted by the school authorities who are charged with his daily care. The curbing of epidemics of contagious disease is primarily for the protection of the community, and in this the health authorities have the right as well as the duty to intervene. Examples of such provisions as those suggested are to be found in the laws of North Dakota and Ohio. 2. Provision for inspection by school physicians to detect and ex- clude cases of contagious disease. 3. Provision for annual examinations of all children by school phy- sicians to detect any physical defects which may prevent the children from receiving the full benefit of their school work or which may re- quire that the work be modified to avoid injury to them. This second provision should include the requirement that parents be notified of any defects discovered. 4. Provision that annual tests of vision and hearing shall be con- ducted by the teachers. This provision was adopted by Massachusetts on the advice of the specialists in these fields and its wisdom has been demon- strated by extensive experience in that state. 5. Provision that the school physicians may conduct examina- tions of teachers and janitors and shall make regular inspections of the buildings, premises, and drinking water to insure their sanitary condition. 6. Provision that pupils in normal schools shall receive training in conducting vision and hearing tests. This requirement is found in the Massachusetts law and the Minnesota regulations. 7. Provision for the employment of school nurses. This is provided for in the laws of Connecticut, Ohio, Pennsylvania, and West Virginia. 8. Provision for the enforcement of the law. Such provisions, not very well developed, are found in the laws of Colorado, Indiana, and New Jersey. The nature of the 172 LEGAL PROVISIONS provision must vary with local conditions. In states where muni- cipalities receive a large part of their school funds from the state, and where their school policies are consequently largely controlled through the state board of education, it seems clear that the enforcement of the law should be placed in the hands of that body. The most authoritative formulation of the features which should be included in acts providing for the medical inspection of schools is that embodied in a series of resolutions adopted by the state and provincial boards of health at their annual meeting held in Los Angeles, California, from June 30 to July i, 191 1. This body has for some years had a standing committee on medical inspection legislation and has devoted much time to the study of the problem; and each year, for the past three years, has made reports of progress at the annual conference. The resolutions adopted in 191 1 are as follows: RESOLUTIONS ADOPTED BY THE CONFERENCE OF STATE AND PRO- VINCIAL BOARDS OF HEALTH, LOS ANGELES, JUNE 3O- JULY I, 191 1 % We endorse legislation providing for the medical inspec- tion of schools, because extended and varied experience has demonstrated that efficient medical inspection betters health conditions among school children, safeguards them from disease, renders them healthier, happier and more vigorous, and aims to insure for each child such physical and mental vitality as will best enable him to take full advantage of the free education offered by the state. It is our judgment that every law providing for the med- ical inspection of schools should make provision for frequent in- spections of the children by duly qualified school physicians to detect and exclude cases of contagious disease. It should further provide for annual physical examina- tions of all the children by school physicians to detect any physical defects which may prevent the children from receiving the full benefit of their school work or which may require that the work be modified to avoid injury to the child. It should empower school physicians to conduct examina- tions of teachers and janitors and to make regular inspections of buildings, premises and drinking water to insure their sani- tary condition. 173 MEDICAL INSPECTION OF SCHOOLS We endorse the school nurse as a most valuable adjunct of medical inspection and believe that provision for the employment of school nurses should be included in each law. THE MASSACHUSETTS LAW AND THE ENGLISH ACT There are two medical inspection laws which are more important than any of the others as typifying the legislative enactments under which the views and beliefs and the results of experience of educators and physicians have been crystallized in Europe and America in the field of medical inspection of schools. These two laws are the English statute which became effective on January i, 1908, and that of the state of Massachusetts. This commonwealth, always foremost in pioneer and progressive legislation, placed upon its statute books in 1906 mandatory laws far more comprehensive in their provisions than the English laws. In view of the fact that these two laws have served as the basis for most of the bills which have since been presented in other state and national legislatures, it seems worth while to quote them in full here with some comment on their similarity and differences. The English Law The English law, known legally as Section 1 3 of the Admin- istrative Provisions of the Education Act of 1907, in its entirety is as follows: "13. (i) The powers and duties of a local education authority under Part III of the Education Act, 1902, shall include: (a) Power to provide for children attending public elementary schools, vacation schools, vacation classes, play centers, etc. (b) The duty to provide for the medical inspec- tion of children immediately before or at the time of or as soon as possible after their admission to a public elementary school, and on such other occasions as the Board of Education direct, and the power to make such arrangements as may be sanctioned by the Board of Education for attending to the health and physical condition of the children educated in pub- lic elementary schools : Provided, that in any exercise of powers under this section the local education authority may encourage 174 LEGAL PROVISIONS and assist the establishment or continuance of voluntary agencies, and associate with itself representatives of voluntary associations for the purpose. " (2) This section shall come into operation on the first day of January, nineteen hundred and eight." The English lawmakers are not quite so verbose and prolix in statute drafting as are their American contemporaries, and the interpretation and construction of this short act was compre- hensively treated by the Board of Education in a memorandum issued on November 22, 1907,* before the act became effective, for the guidance of the administrative officers charged with the execution of the statute. This course differs somewhat from the American system. In the United States, the construction and interpretation of statutes are left finally to the courts. This procedure is a lengthy and involved process. In view of the fact that the memorandum of the English education authorities referred to has the practical effect of a parliamentary enactment in the execution of^the law, it may be well to quote from it somewhat extensively. In stating the scope and purpose of the act the memorandum uses the following words: "The Board desire therefore at the outset to emphasize that this new legislation aims not merely at a physical or anthropometric survey or at a record of defects disclosed by medical inspection, but at the physical improvement, and, as a natural corollary, the mental and moral improvement, of coming generations. The broad requirements of a healthy life are comparatively few and elementary, but they are essential, and should not be regarded as applicable only to the case of the rich. In point of fact, if rightly administered, the new enactment is economical in the best sense of the word. Its justification is not to be measured in terms of money but in the decrease of sickness and incapacity among children and in the ultimate decrease of inefficiency and poverty in after life arising from physical disabilities." A further statement which concludes the same section of the memorandum is as follows : * Board of Education of Great Britain. Memorandum on Medical Inspec- tion of Children in Public Elementary Schools, Circular 576. MEDICAL INSPECTION OF SCHOOLS "It is founded on a recognition of the close connection which exists between the physical and mental condition of the children and the whole process of education. It recognizes the importance of a satis- factory environment, physical and educational, and, by bringing into greater prominence the effect of environment upon the personality of the individual child, seeks to secure ultimately for every child, normal or defective, conditions of life compatible with that full and effective development of its organic functions, its special senses and its mental powers which constitutes a true education." It will be observed that the burden of executing the pro- visions of the statute is specifically laid upon the education author- ities. This is a distinct departure from the established course heretofore pursued in matters relating to the public health. In the view of the English Board of Education, however, the present act is not intended to supersede the powers which have long been exercised by sanitary authorities under various public health acts, but is meant to serve rather as an amplification and a natural development of previous legislation. In order that friction between the education and health authorities may be avoided, if possible, the board of education in this memorandum advises a thorough and friendly co-operation with such authorities in the administration of the law. The second most noticeable feature about the act is that it makes medical inspection compulsory. Theretofore, medical inspection had been more or less in vogue in various localities under the supervision of the education authorities, sometimes in conjunction with the health authorities. The central authority for the execution of the law is the board of education. The instruments of the board are the local education authorities. In country areas this local authority is the county council. It is suggested in the memorandum that the county council instruct the county medical officer to advise the education committee and to supervise the new work. It is also suggested that the county medical officer have an assistant appointed by the county council, whose duty shall be the inspection provided for by the statute. In county boroughs the town council, which is at the same time the local authority for public health and the local education 176 LEGAL PROVISIONS authority, is counseled to instruct their medical officer of health to advise the education committee and assume responsibihty for the new work. Where no school medical officer has been appointed, it is suggested that his appointment be made by the education authorities. Where there are already school medical officers it is suggested that they be retained if competent and sufficient for the new duties. Although there is no provision for school nurses in the act, the board of education advises that wherever practicable such nurses be employed. The board decided that not less than three inspections during the school life of a child would be necessary to secure the results desired. In certain areas, the board may from time to time require inspection at shorter intervals and of a more searching character. The inspection of the sanitation of school buildings, the prevention of the spread of contagious diseases, and the super- vision of the personal and home life of the child are also suggested. Finally, it should be observed that neither the acJt nor the memorandum contains any section whatever requiring that parents of school children found diseased or defective after such inspection shall be compelled to provide proper medical attention at the hands of their own physician or of the hospital authorities.* As a means of securing the co-operation of parents the memoran- dum recommends "that each local educational authority should encourage one or both of the parents of the child to be present at the first inspection, and to this end a notification should be sent to the parents as to the time and place at which it will take place." The Massachusetts Law Let us now consider for comparison with the English statute the first legislative enactment in the United States which made medical inspection mandatory. As this Massachusetts law was the initial legislative effort in America along this line, it seems worth while to quote it in extenso. Legally it is known as Chapter * See Chap. VI, p. 86, for information regarding compulsory action taken in England. 12 177 MEDICAL INSPECTION OF SCHOOLS 502 of the Acts of 1906, and it became a law of the state of Mass- achusetts on the first day of September, 1906. It provides: APPOINTMENT OF SCHOOL PHYSICIANS, ETC. Section i. The school committee of every city and town in the Commonwealth shall appoint one or more school physicians, shall assign one to each public school within its city or town, and shall provide them with all proper facilities for the performance of their duties as prescribed in this act: provided, however, that in cities wherein the board of health is already maintaining or shall hereafter maintain substantially such medical inspection as this act requires, the board of health shall appoint and assign the school physician. EXAMINATION AND DIAGNOSIS TO BE MADE Section 2. Every school physician shall make a prompt examination and diagnosis of all children referred to him as hereinafter provided, and such further examination of teachers, janitors, and school buildings as in his opinion the protection of the health of the pupils may require. AUTHORITY OF SCHOOL COMMITTEES, ETC. Section 3. The school committee shall cause to be referred to a school physician for examination and diagnosis every child returning to school without a certificate from the board of health after absence on account of illness or from unknown cause; and every child in the schools under its jurisdiction who shows signs of being in ill health or of suffering from infectious or contagious disease, unless he is at once ex- cluded from school by the teacher; except that in the case of schools in remote and isolated situations the school commit- tee may make such other arrangements as may best carry out the purposes of this act. NOTICE TO BE SENT TO PARENT OR GUARDIAN Section 4. The school committee shall cause notice of the disease or defects, if any, from which any child is found to be suffering to be sent to his parent or guardian. Whenever a child shows symptoms of smallpox, scarlet fever, measles, chickenpox, tuberculosis, diphtheria or influenza, tonsilitis, whooping cough, mumps, scabies, or trachoma, he shall be sent home immediately, or as soon as safe and proper con- 178 LEGAL PROVISIONS veyance can be found, and the board of health shall at once be notified. TESTS OF SIGHT AND HEARING AND EXAMINATION FOR DIS- ABILITY OR DEFECTS Section 5. The school committee of every city and town shall cause every child in the public schools to be sepa- rately and carefully tested and examined at least once in every school year to ascertain whether he is suffering from defective sight or hearing or from any other disability or defect tending to prevent his receiving the full benefit of his school work, or requiring a modification of the school work in order to pre- vent injury to the child or to secure the best educational re- sults. The tests of sight and hearing shall be made by teachers. The committee shall cause notice of any defect or disability re- quiring treatment to be sent to the parent or guardian of the child, and shall require a physical record of each child to be kept in such form as the state board of education shall pre- scribe. STATE BOARD OF HEALTH TO PRESCRIBE DIRECTIONS: STATE BOARD OF EDUCATION TO FURNISH RULES, ETC. Section 6. The state board of health shall prescribe the directions for tests of sight and hearing and the state board of education shall, after consultation with the state board of health, prescribe and furnish to school committees suitable rules of instruction, test cards, blanks, record books, and other useful appliances for carrying out the purposes of this act, and shall provide for pupils in the normal schools instruc- tion and practice in the best methods of testing the sight and hearing of children. The state board of education may expend during the year nineteen hundred and six a sum not greater than fifteen hundred dollars and annually thereafter a sum not greater than five hundred dollars* for the purpose of supplying the material required by this act. The English statute and the Massachusetts one are simi- lar in that both make medical inspection compulsory, both place the administration in the hands of the educational authorities, and that neither provides for procedure against neglectful par- ents of defective children. They prescribe different methods of * Eight hundred dollars now appropriated under Chapter 189, Acts of 1908. 179 MEDICAL INSPECTION OF SCHOOLS securing the co-operation of parents for the correction of defects, the Massachusetts law requiring that notices of the results of inspections be sent, while the English memorandum recommends the summoning of parents to be present at the inspections. In the English statute there is no express provision as to the frequency of physical examinations, but as has been stated, the memorandum of the board of education prescribes three examina- tions as necessary during the school life of the pupil. In the Massachusetts statute an examination of every pupil at least once in every year for defective sight or hearing and any other physical disabilities, is provided for. The sight and hearing tests are given by teachers, while the other examinations are conducted by physicians. These are the leading statutes ot Europe and America on this subject. At the close of 191 2 the American statute will have been in effect for six years and the English statute for five. Both of these pieces of legislation may therefore be considered as having passed through the experimental stage. 180 APPENDICES APPENDIX I SUGGESTIONS TO TEACHERS AND SCHOOL PHYSI- CIANS REGARDING MEDICAL INSPECTION Issued by the Massachusetts Board of Education Commonwealth of Massachusetts State House, Boston, Jan. 23, 1907 In order to render the medical inspection required by chapter 502, Acts of 1906, effective and uniform throughout the State, His Excel- lency Governor Guild appointed a committee to prepare a circular of advice to the school physicians of the State. This committee consisted of Dr. Henry P. Walcott, Dr. Charles Harrington and Dr. Julian A. Mead, representing the State Board of Health; Mrs. Ella Lyman Cabot, Mr. George I. Aldrich and Mr. George H. Martm, representing the Board of Education; and Dr. Robert W. Lovett, Dr. Harold Williams and Dr. W. H. Devine, representing the medical profession. A sub-committee of this body arranged for conferences with the heads of departments and others connected with the medical schools and hospitals in and about Boston, and with physicians who have had ex- perience in school inspection. These gentlemen have given freely of their time and thought, and have furnished to the committee the suggestions contained in this circular. These suggestions cover the ground included in the clause in section 5 of the law: "The school committee of every city and town shall cause every child in the public schools to be separately and carefully tested and examined at least once in every school year, to ascertain whether he is suffering from defective sight or hearing, or from any other dis- ability or defect tending to prevent his receiving the full benefit of his school work, or requiring a modification of the school work in order to prevent injury to the child or to secure the best educational results." The Board of Education issues this circular in the assurance that it represents the highest professional authority in the specialties covered by the law, and commends it to the careful attention of all teachers, school physicians and other school officers. 183 MEDICAL INSPECTION OF SCHOOLS The following are the subjects treated, with the names of the physi- cians who have contributed suggestions: 1. Infectious Diseases. — Dr. John H. 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. Coifm. 6. Diseases of Bones and Joints. — Dr. Edward H. Bradford, Dr. Augustus Thorndike, Dr. Charles F. Painter, Dr. George H. Earl, Dr. Robert Soutter. 7. Children's Diseases. — Dr. Thomas M. Rotch, Dr. John L. Morse, Dr. John H. Moore, Dr. Robert W. Hastings, Dr. Edmund C. Stowell. 8. The Teeth.— Dr. Edward W. Branigan, Dr. George A. Bates, Dr. Eugene H. Smith, Dr. Samuel A. Hopkins. 9. Nervous Diseases. — Dr. James J. Putnam, Dr. George L. Walton, Dr. Morton Prince, Dr. William N. Bullard, Dr. Edward W. Taylor, Dr. John J. Thomas, Dr. Walter E. Fernald. 10. School Hygiene. — Dr. Henry J. Barnes. 11. School Furniture. — Dr. Frederick J. Cotton, Dr. R. Clipston Sturgis. 12. School Inspectors. — Dr. George S. C. Badger, Dr. H. Lincoln Chase, Dr. Harry M. Cutts. George H. Martin, Secretary. DISEASES Infectious Diseases Diphtheria. — It is a well-recognized fact that nasal diphtheria of a mild type without constitutional disturbance is one of the most impor- tant factors in causing the spread of the disease, and also that children very frequently have profuse discharges from the nose. It therefore follows that, in order properly to inspect the public schools, it is impor- tant that cultures should be taken from the nose in every case where there is a persistent discharge, particularly if there is any excoriation about the nostrils. The throat should be examined at varying intervals, depending 184 APPENDIX I upon the physical condition of the children. Any hoarseness or any thick- ness of the voice should cause an examination of the throat. If the tonsils are enlarged, if the mucous membrane is congested, if there is swelling of palate, a culture should be taken. These symptoms precede diphtheria. A child with positive cultures should be excluded from school until two consecutive negative cultures at an interval of forty-eight hours have been obtained. Scarlet Fever. — If there is a sudden attack of vomiting, if there is any redness of the throat, if the child complains of headache, if there is an unexplained rise in temperature, the child should be isolated at once. Any desquamation (peeling of the skin) should be looked upon with suspicion. If there are any breaks at the finger tips, if on pressing the pulp of the finger there is a white line at the juncture of the nail with the pulp of the finger, particularly if this occurs in the majority of the finger tips, the child should be excluded from the school. A child who has had scarlet fever should not return to school until the process of desquamation has been entirely completed, and all dis- charge from the nose and ears has ceased. Measles. — Running from the nose and slight intolerance of light may call for an examination of the mucous membrane of the^outh for Koplik's sign. Koplik's sign, so called, is the presence on the lining membrane of the mouth, near the molar teeth, of minute pearly white blisters, without any inflammation around them. There may be only two or three of these blisters, and they may easily escape detection if the patient is not carefully examined in a good light. These blisters are certain forerunners of an attack of measles. No child should return to school after an attack of measles until the desquamation is entirely completed, and the child has recovered from the intercurrent bronchitis. Mumps. — Any swelling or tenderness in the region of the parotid glands (situated behind the angle of the jaw) should be looked upon with suspicion. It is important to notice any enlargement or swelling about Steno's duct (inside the mouth, opposite the second upper molar tooth), as this is a very frequent symptom of mumps. A child should be excluded from school until one week has elapsed after the disappearance of all swelling and tenderness in the region of the parotid glands. 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 185 MEDICAL INSPECTION OF SCHOOLS the band connecting the lower surface of the tongue with the floor of the mouth is found in a certain number of cases. If there is no distinct ulceration, there may be a marked congestion of the band. As long as there is any cough, the child who has had whooping- cough should be looked upon with suspicion. Varicella {Chicken Pox). — A few black crusts scattered over the bodv are evidences of an attack of chicken pox. The crusting seen in impetigo must be differentiated from that of chicken pox.* No child should return to school until all crusts have disappeared from the body, particularly from the scalp, for in this region the crusts remain longer than elsewhere. The Eyes [Supplement to circular already issued f] There are certain children who show normal vision by the ordinary tests, yet whose parents should be notified to have the eyes examined. These are: (i) children who habitually hold the head too near the book (less than twelve to fourteen inches); (2) children who frequently com- plain of headaches, especially in the latter portion of school hours; (3) children in whom one eye deviates even temporarily from the normal position. It should be remembered that the following symptoms are at times indicative of trouble with the eyes: (i) habitual scowling, and wrinkling of the forehead when reading or writing; (2) twitching of the face; (3) inattention and slowness in book studies in a child otherwise bright. The Ears See circular of directions t for testing hearing, already in hands of teachers. The Throat and Nose In all cases of acute illness the throat should be examined for the presence of the eruption of scarlet fever and measles and for the exuda- tion or membrane of tonsilitis and diphtheria, and a culture taken in any suspected case of the latter. The presence of discharge from the nose should be noted, and if it is thick and creamy, a culture should always be taken. In all cases of severe hoarseness, with difficult breathing, diphtheria should be sus- *See Diseases of the Skin. t See pp. 45-47 for this circular. 186 APPENDIX I pected. If the discharge from the nose is only from one nostril, a foreign body in the nose should be looked for. In cases of chronic nasal obstruction, as evinced by mouth-breath- ing, snoring, continual post-nasal catarrh or recurring ear trouble, the presence of an adenoid growth (third tonsil) should be suspected, and the child referred for special examination and treatment. As a rule, digital examination for adenoids should be made only by the operating surgeon. Obviously large tonsils, recurring tonsilitis and enlargement of the glands of the neck, suggest the advisability of referring the child to the family physician as to the propriety of removing the tonsils. Recurring nose-bleed should be referred for special treatment. In cases of eczema about the nostrils, a cause may be sought in pediculi capitis (head lice). In referring cases for treatment, school physicians, in addition to the diagnosis, should state the symptoms upon which the diagnosis is based, for the benefit of the family physician or specialist. Diseases of the Skin Scabies (the Itch). — A contagious skin disease, due to an animal parasite which burrows in the skin, causing intense itching aitd 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. 187 MEDICAL INSPECTION OF SCHOOLS Pediculi Capitis {Head Lice). — An extremely common accident among children, either from wearing each others' hats and caps, or hanging them on each others' pegs, or from combs and brushes. No person should be blamed for having lice, — only for keeping them. The irritation caused by vermin in the scalp leads to scratching, which in turn causes an inflammation of the skin of the neck and scalp. The skin then easily becomes infected with some of the pus-producing germs, and large or small scabs and crusts are formed from the dried matter and blood. Along with this condition the glands back of the ears and in the neck become swollen, and may be very painful and tender. The condition of pediculosis is most easily detected by looking for the eggs (nits), which are always stuck onto the hair, and are not readily brushed off. The condition is best treated by killing the living parasites with crude petroleum, and then getting rid of the nits. With boys, this is easy, — a close hair cut is all that is needed; with girls, by using a fine-toothed comb wet in alcohol or vinegar, which dissolves the attach- ment of the eggs to the hair. All combs and brushes must be carefully cleansed. Children with pediculosis should be excluded from school until their heads are clean. By chapter 383, Acts of 1906, parents who neglect or refuse to care for their children in this respect may be prosecuted under the compulsory attendance law. Ringworm. — A vegetable parasitic disease of the skin and scalp. When it occurs upon the skin, it yields readily to treatment; but upon the scalp it is extremely chronic. Ringworm of the skin usually appears on the face, hands or arms, — rarely upon the body, — in varying sized more or less perfect circles. One or more, usually not widely separated, may be present at the same time. All ringed eruptions upon the skin should be examined for ringworm. When the disease attacks the scalp, the hairs fall or break off near the scalp, leavmg 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. APPENDIX I Care must be taken to see that all combs and brushes are thoroughly cleansed, and to prevent children wearing each others' hats, caps, etc. Children with ringworm should not be allowed to attend school. Impetigo. — A disease characterized by few or many large or small flat or elevated pustules or festers upon the skin. The condition is often secondary to irritation or itching diseases of the skin (hives, lice, itch), and scratching starts up a pus infection. The disease most often appears upon the face, neck, and hands, less often upon the body and scalp. The size of the spots varies very much, and they often run together to form on the face large superficial sores, covered with thick, dirty, yellowish or brownish crusts. The disease is contagious, and often spread by towels and things handled. Children having impetigo should not be allowed to attend school until all sores are healed and the skin is smooth. Diseases of the Bones and Joints All noticeable lameness, whether sudden or continued, may indicate serious joint trouble, or may be due to improper shoes. These cases, as well as curvatures of the spine, as indicated by habitual faulty postures at the desk or in walking, should be referred for medical inspection. Spinal curvature should be suspected when one shoulder is habitu- ally raised or dropped, or when the child leans to the side, or shows per- sistent round shoulders. Complaints of persistent "growing pains" or "rheumatism" may be the earliest signs of serious disease of the joints. Some General Symptoms of Disease in Children which Teacher should notice, and on account of which the children should be referred to the school physician Emaciation. — This is a manifestation of many chronic diseases, and may point especially to tuberculosis. Pallor. — Pallor usually indicates anemia. Pallor in young girls usually means chlorosis, — a form of anemia peculiar to girls at about the age of puberty. It is usually associated with shortness of breath; the general condition otherwise usually appears good. Pallor may also be a manifestation of disease of the kidneys; this is almost invariably the case if it is associated with puffmess of the face. Puffiness of the Face. — This, especially if it is about the eyes, points to disease of the kidneys; it may, however, merely indicate nasal ob- struction. 189 MEDICAL INSPECTION OF SCHOOLS Shortness of Breath. — Shortness of breath usually indicates disease of the heart or lungs. If it is associated with blueness, the trouble is usually in the heart. If it is associated with cough, the trouble is more likely to be in the lungs. Swellings in the Neck. — These may be due to mumps or enlarge- ment of the glands. The swelling of mumps comes on acutely, and is located just behind, just in front and below the ear. Swollen glands are situated lower in the neck, or about the angle of the jaw. They may come on either acutely or slowly. If acutely, they mean some acute condition in the throat. If slowly, they are most often tubercular. They may also be the result of irritation of the scalp or lice in the hair. General Lassitude, and Other Evidences of Sickness. — These hardly need description, but may, of course, mean the presence or onset of any of the acute diseases. Flushing of the Face. — This very often means fever, and on this account should be reported. Eruptions of any Sort. — All eruptions should be called to the atten- tion of the physician. It is especially important to notice eruptions, because they may be the manifestations of some of the contagious diseases. The eruption of scarlet fever is of a bright scarlet color, and usually appears first on the neck and chest, spreading thence to the face. There is often a pale ring about the mouth in scarlet fever, which is very charac- teristic. There is usually a sore throat in connection with the eruption. The eruption of measles is a rose or purplish red, and is in blotches about the size of a pea. It appears first on the face, and is usually associated with running of the nose and eyes. The eruption of chicken pox appears first as small red pimples, which quickly become small blisters. A Cold in the Head, with Running Eyes. — This should be noticed, because it may indicate the onset of measles. Irritating Discharge from the Nose. — A thin, watery nasal discharge, which irritates the nostrils and the upper lip, should always be regarded with suspicion. It may mean nothing more than a cold in the head, but not infrequently indicates diphtheria. Evidences of Sore Throat. — Evidences of sore throat, such as swelling of the neck and difficulty in swallowing, are of importance. They may mean nothing but tonsilitis, but are not infrequently manifestations of diphtheria or scarlet fever. Coughs. — It is very important to notice whether children are cough- ing or not, and what is the character of the cough. In most cases, of course, the cough merely means a simple cold or slight bronchitis. A spasmodic cough, that is, a cough which occurs in paroxysms and is 190 APPENDIX I uncontrollable, very frequently indicates whooping-cough. A croupy cough, that is, a cough which is harsh and ringing, may indicate the disease diphtheria. A painful cough may indicate disease of the lungs, especially pleurisy or pneumonia. A long-continued cough may mean tuberculosis of the lungs. Vomiting. — Vomiting usually, of course, merely means some di- gestive upset. It may, however, be the initial symptom of many of the acute diseases, and is therefore of considerable importance. Frequent Requests to go out. — Teachers are too much inclined to think that frequent requests to go out merely indicate restlessness or perversity. They often, however, indicate trouble of some sort, which may be in the bowels, kidneys or bladder; therefore, they should always be reported to the physician. The Teeth Unclean mouths promote the growth of disease germs, and cavities in the teeth are centers of infection. Pus from diseased teeth seriously interferes with digestion and poisons the system. It causes a lowering of vitality and renders mental effort difficult. Diseased teeth, tempo- rary as well as permanent, are frequently the cause of abscflfeses, and should be carefully watched and treated. Irregularities of the teeth, especially those which make it impossible to close the teeth properly, lead to faulty digestion, to mouth-breathing, and to other diseases and evils which an insufficient supply of oxygen produces. The first permanent molars are perhaps the most important teeth in the mouth, and are the most frequently neglected, because they are so often mistaken for temporary teeth. (It should be remembered that there are twenty temporary teeth, ten in each jaw, and that the teeth that come at about the sixth year immediately behind each last temporary tooth — four in all — are the first permanent molars.) The teacher should be on the lookout for pain or swelling in the face. When the child keeps the mouth constantly open, an examination of the teeth should be made. When symptoms of indigestion occur, or physical weakness or mental dullness is observed, the teeth should be inspected. It should be remembered that disease of the ears, disturb- ances of vision and swelling of the glands of the neck may be caused by diseased teeth. It should be known that decay of the teeth is caused primarily by the fermentation of starchy foods and sugars, and that the greatest factor in preventing dental caries is the removal of food particles by 191 MEDICAL INSPECTION OF SCHOOLS frequent brushing. Children should be prevented from eating crackers and candy between meals, and when possible the teeth should be cleaned after eating. Inspection of the teeth by a dentist should be made at least once in six months. Nervous Troubles and Mental Defects Teachers and medical inspectors of the schools should investigate children who show certain physical and mental symptoms. Especially should they take notice of the presence of these symptoms in a child who did not formerly show them. The most important of these are the following: I. — Restlessness and inability to stand or sit quietly, in a previously quiet child, especially if to this is added irritability of temper and loss of self-control, as shown by crying for trifles, or inability to keep the attention fixed. There may also be present quick, twitching movements of the mus- cles of the trunk, face, and especially of the hands, fingers, arms or legs. If severe, these may cause the child to drop things, render its work awk- ward, or interfere with buttoning the clothes, writing or drawing. Such children are often scolded for being inattentive or careless. These symptoms are the slighter ones of chorea (St. Vitus' dance). With these should not be confounded other forms of twitching of mus- cles, such as the blinking of the eyelids, the slower twitching movements of the face or shoulders, or other parts of the body, often called habit spasms, which may be due to defects of vision, adenoid growths or other reflex causes. These latter cases do not usually need to be withdrawn from school work, though often requiring treatment; while the former class should be removed from school at once, both for the child's sake and to prevent an epidemic of imitative movements, such as sometimes occurs. . II. — Another class of symptoms requinng investigation are repeated faintings, especially if the child's lips become blue; attacks, often only momentary, in which the child stares fixedly and does not reply to ques- tions, or in which he suddenly stops speaking or whatever he is doing, and is unaware of what is going on about him. These lapses of consciousness may be accompanied also by rolling up of the eyes, drooling, or unusual movements of the lips, and often appear like a "choking" attack. Sudden attacks of senseless movements of various sorts, such as twisting and pulling at the clothes or handkerchief, fumbling aimlessly at the desk, especially if there is no recollection afterwards of what was done, are often another expression of the same conditions. 192 APPENDIX I Such attacks, particularly if repeated at varying intervals, even when not accompanied by complete loss of consciousness, are frequently as characteristic of epilepsy as the severe convulsions. Epileptic convulsions usually involve the entire body in sharp jerking movements, with blueness of the face or lips, complete loss of consciousness, and are usually followed by a period of sleep or drowsi- ness, and are frequently accompanied by frothing at the mouth, biting of the tongue, and occasionally by wetting or soiling of the clothes. Another class of convulsions is the hysterical, which are often difficult to distinguish. The hysterical convulsion, however, differs from the epileptic in the following respects. The hysterical patient often shouts, cries or raves, not only previous to but frequently throughout the attack, and is often able to reply to questions during the convulsion. The epileptic gives a single cry, immediately followed by unconsciousness and the spasm. The movements in the hysterical convulsion are often accompanied by bowing of the body backward, and very frequently simulate intentional or voluntary movements, such as tearing the hair, pulling at the clothes, and such things; while the epileptic movements are characterized by their jerking or twitching character. The hysterical patient, also, in place of a convulsion, may strike an attitude, such as of fear or entreaty, often accompanied by raving or singing, i his again may follow the convulsion, taking the place of, and strikingly contrasted with the almost invariable sleep of the epileptic, which is almost never seen in hysteria. Hysterical patients if they fall seldom injure them- selves by the fall, as epileptics frequently do. Biting the tongue almost invariably indicates an epileptic seizure, as does wetting or soiling the clothes when it occurs. Cases of epilepsy, whether mild or severe, require treatment, and advice as to whether they should be removed from school. Many cases do not require to be withdrawn from school, and are benefited by its discipline. III. — Excessive nerve fatigue, which is shown by irritability or sleeplessness, may indicate a neurasthenic condition, that is, a threatened nervous breakdown. Such symptoms may be due to irregular habits, want .of proper sleep, lack of suitable food, poor hygienic conditions, or simply from the child being pushed in school beyond its physical or mental capacity. Excessive fear or morbid ideas, bashfulness, undue sensitiveness, causeless fits of crying, morbid introspection and suspiciousness may also be symptoms of a neurasthenic condition, and call for investiga- tion, and for the teacher's sympathy and winning of the child's confi- dence, to prevent developments of a more serious nature. 13 193 MEDICAL INSPECTION OF SCHOOLS This nerve fatigue may result in a child being unable for the time being to keep up in its work in school. Forgetfulness, loss of interest in work and play, desire for solitude, untidiness in dress or person, and like changes of character, are some- times incidental to the period of puberty. IV. — Mentally defective children in the public schools exhibit cer- tain common characteristics. The essential evidence of mental defect is that the child is persistently unable to profit by the ordinary methods of instruction, as shown by lack of progress or failure of promotion through lack of capacity. After one, two or three years in school, they are either not able to read at all, or they have a very small and scanty vocabulary. One of the most constant and striking peculiarities is the feebleness of the power of voluntary attention. The child is unable to fix his attention upon any exercise or subject for any length of time. The moment his teacher's direction is withdrawn, his attention ceases. These children are easily fatigued by mental effort, and lose interest quickly. They are not observant. They are often markedly back- ward in number work. They are especially backward in any school exercise requiring judgment and reasoning power. They may excel in memory exercises. They usually associate and play with children younger than themselves. They have weak will-power. They are easily influenced and led by their associates. These children may be dull and listless, or restless and excitable. They are often wilful and disobedient, and liable to attacks of stubbornness and bad temper. The typical "incorrigible" of the primary grades often is a mentally defective child of the excitable type. They are often destructive. They may be cruel to smaller children. They are often precocious sexually. They may have untidy personal habits. Certain cases with only slight intel- lectual defect show marked moral deficiency. The physical inferiority of these defective children is often plainly shown by the general appearance. There is generally some evidence of defect in the figure, face, attitudes or movements. They seldom show the physical grace and charm of normal childhood. The teeth are apt to be discolored and to decay early. It is a most delicate and painful task to tell a parent that his child is mentally deficient. This duty should be performed with the greatest tact, kindness and sympathy. It would be a great misfortune for the school physician and teacher, as well as for the child, to designate a pupil as feeble-minded who was only temporarily backward. Temporary backwardness in school work may be due to removable causes, such as defective vision, impaired hearing, adenoid growths in 194 APPENDIX I nose or throat, or as the result of unhappy home conditions, irregular habits, want of proper sleep, lack of suitable food, bad hygienic condi- tions, etc. Great care must always be used in order not to confound cases of permanent mental deficiency with cases of temporary back- wardness in school work, due to the causes mentioned above, or those described under the head of excessive nervous fatigue. In some cases, where the existence of mental defect is in doubt, accurate information is usually to be obtained in the early history of the child. The time of first "taking notice," the time of recognition of the mother, that of beginning to sit up, to creep, to stand, to walk and to talk should be learned. Marked delay in development in these respects is usually found in all pronounced cases of mental deficiency. It may be found useful to require teachers to refer at stated intervals to the medical inspectors for examination all children who, without obvious cause, such as absence or ill health, show themselves unable to keep up in their school work, who are unable to fix their attention, or are incorrigible, — though it does not follow that all such cases have either physical or mental defects. School Hygiene • The school physician should notice the ventilating, lighting and heating of the rooms, and the location of the source of water supply with reference to possible pollution. In case pollution of the water supply is suspected, application should be made to the State Board of Health for an examination of the water. The general cleanliness of the school- room is of importance, and the admission of sunlight when possible is desirable. The Closets. — The school physician, accompanied by the janitor of the school, should inspect the toilet rooms, to see if the floors are clean and dry, that the bowls of the closets are properly emptied and kept clean. (If outhouses are used, a large supply of earth will aid in keeping the place in a sanitary condition.) A few simple directions as to the cleanliness of the room should be posted in the closets. Cups. — The use of one drinking cup for a number of children is to be condemned, as tending to spread the infectious diseases from child to child. The so-called hygienic drinking fountain, now in more or less general use in progressive cities and towns, is to be recommended where running water is available. If there is no running water, each child should use his own cup. 195 medical inspection of schools School Furniture Any proper sort of school furniture should furnish a seat of such height that the feet will rest easily on the floor. It should have a desk high enough not to touch the knees. It should have a desk low enough for the arm to rest on comfortably without much raising of the elbow; not, however, so low that the scholar must bend down to write on it. The seat should be near enough so that the scholar may reach the desk to write on it without leaning forward more than a little, and without entirely losing the support of the backrest. The seat should not be so close as to press against the abdomen nor near enough to interfere with easy rising from the seat. This means a distance of ten and one-half to fourteen and one-half inches from the edge of the desk to the seat back; it also means that the seat must not project under the desk more than an inch at most. The seat should have a backrest that will support the "small of the back" properly, without having the scholar lean back excessively. Whether it also supports the rest of the back or not is of small conse- quence; support of the back carried up to the level of the shoulder blades is likely to do more harm than good. These are given as the minimum requirements. Whether or not regular adjustable furniture is in use, we should not be content with less than the accomplishment in one way or another of these primitive adjustments. More accurate adjustment is desirable, and less care in adjusting would be hard to justify, in the light of our present knowledge of the results of faulty attitude. 196 APPENDIX II ANNUAL REPORT FOR 1910 OF THE CHIEF MEDICAL OFFICER OF THE BRITISH BOARD OF EDUCATION The following pages reproduce the table of contents of the Annual Report of the Chief Medical Officer of the British Board of Education. This table is printed to show the range of subjects and topics treated in a thorough and comprehensive report of a system of medical inspection. The report from which this material is taken is probably the clearest, most thorough, and most complete report on medical inspection that has yet appeared. It may well serve as a model for medical officers reporting on work in American communities. % CONTENTS Page I. The Administration of Medical Inspection by the Local Educational Authorities 3 Requirements of the Code 4 Schedule of Medical Inspection 1 1 Organization of School Medical Service 12 The School Medical Officer 14 Qualifications of Medical Officers 17 School Nurses 17 Special Inquiries 18 Closure of and Exclusion from School 20 Medical Inspection of Secondary Schools 22 II. The Physical Condition of School Children as revealed by Medical In- spection 24 Malnutrition 26 Uncleanliness 33 Defective Vision 36 Defective Hearing 45 Adenoids, Enlarged Tonsils and Glands 49 Ringworm 56 Miscellaneous Conditions 62 Addendum on Sanitation of School Premises 65 197 MEDICAL INSPECTION OF SCHOOLS Page HI. Tuberculosis in School Children 69 Findings as regards Tuberculosis from the Reports of School Medical Officers 71 Existing Provision for the Treatment of Tuberculous Children .... 79 Suggestions for the Treatment of Tuberculous Children by the Local Education Authority 85 IV. The Proceeding known as " Following Up" 96 The Part played by the School Doctor and Parent 97 The Part played by the Teacher 98 The School Nurse ,. 100 The School Attendance Officer 103 Voluntary Agencies and Care Committees 108 The Results of " Following Up" 108 Addendum on the Employment of School Children 116 V. Action taken by Local Education Authorities in respect to Medical Treatment 119 Introduction ' 1 19 The Kind of Treatment Necessary 119 Treatment by Medical Practitioners 121 Modes of Treatment Available 122 1 . Treatment under special Acts of Parliament 123 2. Treatment under the Poor Law (see Section VI) 123 3. Treatment under Section 13 of the Education (Administra- tive Provisions) Act, 1907 123 Existing Provision for Medical Treatment out of Public Funds .... 126 Employment of School Nurses 126 Provision of Spectacles 127 Contributions to Hospitals 128 The London County Council Hospital Scheme 132 VI. Medical Treatment for School Children under the Poor Law 143 VH. School Clinics 146 The Inspection Clinic 146 The Treatment Clinic 152 Treatment Clinics now established 155 VIII. Dental Diseases and Dental Treatment 1 66 Causation of Dental Caries 171 Diet in Relation to Dental Disease 172 The Use of the Toothbrush 173 The Treatment of Dental Diseases 175 School Dentistry in Germany 177 Existing Arrangements for Dental Treatment in England and Wales 179 198 APPENDIX II Page IX. The Special Schools for Blind, Deaf, Physically Defective and Epileptic Children 187 Schools for the Blind 188 Schools for the Deaf 193 Schools for Physically Defective Children 201 Schools for Epileptic Children 203 X. Education of Feeble-minded Children 206 Adoption of the Elementary Education (Defective and Epileptic Children) Act, 1899 208 Classification of Mentally Defective Children 209 Educational Provision for Mentally Abnormal Children 211 The After-care of the Feeble-minded 214 Conclusion 219 XI. Open-air Education 22 1 The Open-air Classroom 222 Playground Classes 223 Country Schools 225 Open-air Schools 226 Premises 226 Classification of Children Admitted 227 Cost of Open-air Schools % 228 Provision of Meals 229 Time-Table 229 Results 230 Permanency of Results 23 1 XII. The Teaching of Hygiene and Physical Training 233 The Teaching of Hygiene in the Training Colleges 233 The Teaching of Hygiene in Public Elementary Schools 236 The Teaching of Infant Care and Management 238 Physical Training 242 In Training Colleges 242 In Secondary Schools 243 In Public Elementary Schools 243 XIII. Provision of Meals 245 I ntroductory 245 Historical Note 246 The Act of 1906 247 Returns from Local Educational Authorities for 19 10 249 Selection of Children and Duties of School Medical Officer 252 Provision of Meals during Holidays 254 Conclusion 256 199 MEDICAL INSPECTION OF SCHOOLS APPENDICES Page A. List of Medical Oificers, etc 259 B. Prosecutions by Local Education Authorities 270 C. Memorandum on the Teaching of Infant Care and Management in Public Elementary Schools (Circular 758) 277 D. Memorandum on Physical Training in Secondary Schools (Circular 779) .. 289 E. Syllabus of Hygiene 299 F. The Training of Teachers of the Blind and the Deaf 302 G. Statistical Tables Relating to the Provision of Meals 303 200 BIBLIOGRAPHY BIBLIOGRAPHY Books Allen, William H.: Civics and Health. New York, Ginn and Com- pany, 1909. 411 pp. ^1.50. Contains chapters on physical welfare of school children, mouth- breathing, eye-strain, dental sanitation, and departments of school hygiene. Ayres, Leonard P.: Medical Inspection Legislation. New York, Russell Sage Foundation, 191 1. 56 pp. 30 cents. Summary of legal status in United States. BergerStein, Leo: Schulhygiene. Second edition. Leipzig, B. G. Teubner, 1910. Cornell, Walter S. : Health and Medical Inspection of School Chil- dren. Philadelphia, F. A. Davis Company, 19 12. 644 pp. 195 illus. $3.30. The most comprehensive treatment yet published. Based on extended experience. Indispensable in the library of the school physician. Crowley, Ralph H.: Needs, Objects and Methods of the Medical In- spection of Primary Schools. London, J. and A. Churchill, 1907. 24 pp. Crowley, Ralph H.: The Hygiene of School Life. London, Methuen and Co., 1910. 403 pp. Contains practical suggestions for dealing with problems confront- ing local boards of education, medical officers, and parents. Chap- ters on physical condition of school children, special groups, school feeding, baths, exercise, open-air schools, infectious disease, treat- ment and school buildings. DuFESTEL, Louis: Guide pratique du medicin-inspecteur des ecoles. Preface de M. le Dr. Le Gendre; avec 19 figures dans le texte. Paris, O. Dion et fils, 19 10. 236 pp. 203 MEDICAL INSPECTION OF SCHOOLS HoAG, Ernest B.: The Health Index of Children. San Francisco, Whitaker, Ray-Wiggin Co., 191 o. 188 pp. 80 cents. A manual designed to show teachers and parents how to detect ph^'sical defects in children and to suggest means for correcting such defects and maintaining health afterwards. Hogarth, A. H.: Medical Inspection of Schools. London, Henry Frowde, Oxford University Press, 1909. 360 pp. 6s. Kelynack, T. N.: Medical Examination of Schools and Scholars. London, P. S. King and Son, 1910. 434 pp. Compilation of articles on the different divisions of work and the status of the movement in different countries. Best general survey of the entire field. Mackenzie, Wm. Leslie: The Health of the School Child. London, Methuen and Co., 1906. 2s. 6d. Lectures dealing with the hygiene of school life, normal growth during school ages, and medical inspection and supervision of school children. Gives details of methods of medical inspection in Wies- baden and Nuremburg. Mackenzie, Wm. Leslie, and Matthew, Edwin: The Medical In- spection of School Children. Edinburgh and Glasgow, William Hodge and Co., 1904. 455 pp. los. 6d. net. The most extensive and thorough treatise. Technical rather than popular. Schubert, Paul; Das Schularztwesen in Deutschland. Bericht iiber die Ergebnisse einer Umfrage bei den grosseren Stadten des Deutschen Reiches. Hamburg und Leipzig, Verlag von Leopold Voss, 1905. 166 pp. Steven, Edward M.: Medical Supervision in Schools. London, Bailliere, Tindall and Cox, 1910. 268 pp. A first hand description of the workings of the system in Great Britain, Canada, the United States, Germany, and Switzerland. Wood, Thomas D.: Health and Education. The Ninth Yearbook of the National Society for the Study of Education. Part I. Chicago, The University of Chicago Press, 1910. 1 13 pp. Chapters on health examinations, school sanitation, hygiene in- struction, and physical education. Intended for the use of teachers rather than the specialist in school hygiene or physical education. 204 bibliography Reports, American Bureau of Municipal Research: A Bureau of Child Hygiene. Re- port of co-operative studies and experiments by the Department of Health of New York City and the Bureau of Municipal Research. New York, Bureau of Municipal Research, 1908. 41 pp. 35 cents. Report on the Division of Child Hygiene, Department of Health (New York City), with constructive suggestions. New York City, Bureau of Municipal Research, 191 1. 66 pp. Massachusetts Board of Education: Suggestions to Teachers and School Physicians Regarding Medical Inspection. Special pamphlet. Boston, 1907. Medical Inspection. By G. H. Martin. 72nd Annual Report, 1907- 08, pp. 87-109. Boston, Public Document No. 3, 1909. Medical Inspection in the Public Schools of Massachusetts. By G. H. Martin. 74th Annual Report, pp. 164-193. Boston, Public Document No. 2, 191 1. National Society for the Study of Education: The Nurse in Education. The Ninth Year-book, Part II. Chicago, The Uni- versity of Chicago Press, 191 1. 76 pp. * Chapters on The Educational Value of the Nurse in the Public School, by Isabel M. Stewart and M. Adelaide Nutting; and Profes- sional Training of Children's Nurses by Mary L. Read. Russell Sage Foundation: What American Cities are Doing for the Health of School Children. Bulletin, Dept. of Child Hygiene, New York, 191 1. 24 pp. 15 cents. Summary of conditions in 1,032 American cities. Reports, Foreign Board of Education (British): Annual Report for 19 10 of the Chief Medical Officer. London, Wyman and Sons, Fetter Lane E. C. 1911. 313 pp. Bradford (England) Education Committee: Report of the School Medical Officer (Lewis William, M.D.) for year ending December 31, 1909. 1910. 117 pp. Dunfermline, Scotland: Fourth Annual Report on the Medical In- spection of School Children in Dunfermline. By J. C. Bridge. -Car- negie Institute, 1909. 205 MEDICAL INSPECTION OF SCHOOLS New South Wales: Department of Public Instruction. Report upon the Physical Condition of Children Attending Public Schools in New South Wales (with special reference to height, weight, and vision), based upon statistics obtained as a result of the introduction of a scheme of medical inspection of public school children, 1907-08, with anthropometric tables and diagrams. Sydney, Wm. A. Gul- lick, Government Printer, 1908. 66 pp. Report upon the Physical Condition of Children Attending Public Schools in New South Wales, based upon observations made in con- nection with the medical inspection of public school children, 1908-09, with anthropometric tables and diagrams. Sydney, Wm. A. Gul- lick. Government Printer, 1910. 35 pp. London County Council: School Dentistry in Germany. Report of the Education Officer presented to the Education Committee, June 22, 1910. London, Southwood, Smith and Co., 1910. 10 pp. Report of the Medical Officer (Education) for twelve months end- ing Dec. 31, 1909. London, Southwood, Smith and Co., 1910. 96 pp. Tasmania: Report on the Work of the Medical Branch. J. S. C. Elk- ington, M.D., Chief Health Officer. Hobart, John Vail, Government Printer, 1908. 15 pp. Bibliographies Teachers College, Columbia University: A Bibliography on Edu- cational Hygiene and Physical Education. By Dr. Thomas D. Wood and Mary Reesor. New York City, Teachers College, 191 1. 41 pp. 20 cents. United States Bureau of Education: Bibliography of Child Study for the Years 1 908-1 909. By Louis N. Wilson. Washington, D. C, Bureau of Education Bulletin No. 11,1911. 84 pp. Bibliography of Education for 1909-10. Washington, D. C, Bureau of Education Bulletin No. 10, 191 1. 166 pp. Contains sections on ventilation and lighting, cleaning and dis- infecting of school rooms, school hygiene, medical inspection, con- tagious diseases, feeding of school children, open-air schools, eyes, ears, and teeth. 206 INDEX INDEX Adenoids: among children promoted and not promoted in South Man- . chaster, 155; among retarded children in Elmira, 156; and associated defects, 58; and school progress in New York, 158-162; classed with cases of defective breathing, 39; handicap in school work, 3, 4, 162; treated in English communities, 99 ; treated in Harris- burg, 94; treated in Newark, N. J., 93; treated in Summit, N. J., 95 Administration: of dental clinics in Germany, 118, in United States, 122; of medical inspection in cities of the United States, 143-15 1 ; of medical inspection in England, 176; placed in hands of school authorities by most state laws, 164; provision regarding, which new laws should contain, 171 Age of Children: the important factor in physical defects, 157, 162 Alberta, Canada: medical inspection in, 12 America: frequency of examinations in, 41; salaries of school physicians and nurses in, compared with those in England, 103, 109, no. See also United States American School Hygiene Associa- tion: data regarding nurses' work presented to, 66 Americans: teeth and Jaws of, 116 Andover, Mass. : report on weight and teeth of school children in, 116 Anemia: among retarded children in Elmira, 156 Anemic Children: open air schools for, 98 Anglesey, England: treatments in, 99 Ann Arbor, Michigan: woman denta inspector in, 122, 127 Argentine Republic: medical inspec- tion in, 1 2 Attendance, School: and retardation, 154; authority to compel, carries with it duties, 4; figures taken from United States Commissioner of Education's report, 103; in cities of United States, 104-107 Australia and Tasmania: medical inspection in, 1 2 Austria: dental clinics in, 120; medi- cal inspection in, 11 Authorities Controlling JV^dical Inspection. See Medical inspec- tion Backward Child: lessons taught by, will make a better race, 6 "Backward Children": term added to vocabulary of school men, 3 Backward Pupils. See Retarded Bannon, Dr.: appointed by school committee of Lawrence, 149 Barlow, Peter T., and his friends: dental clinic given by, 121 Beckenham, England: treatments in, 99 Belgium: medical inspection in, i i Berkeley, California: consultations with medical director in, 77, 79; record of physical examinations used in, 53, 56, 57 Berlin: dental work in, 126 Birmingham, Alabama: post card notification used in, 73, 74 Blackburn, England: treatments in, 99 > •4 209 INDEX Blake, Clarence John: opinion on teachers' ability to test hearing, 45 Bliss, D. C: study of defects among retarded children by, 155 BoAED OF Education. See Education Boards of Health. See Health Bodily Structxjee: defects of, 37. See also Orthopedic Defects Boston: follow-up system not well developed in, 42; medical inspec- tion in, I, 13; number of pupils examined in 191 2, 41, 42; plan for dental chnic in, 123; results of physical examinations in, 38, 39; superintendent of schools in, quoted, 146 Breathing, Defective : among school children in New York, 40; and school progress in New York, 158- 162; cases classed with adenoids, 39; treated in Harrisburg, 94; treated in New York, 92 Breathing, Nasal: prevented by en- larged tonsils and adenoids, 4 British Board of Education: chief medical ofi&cer, quoted, 98; in- spections provided for by, 41; memorandum of, quoted, 10, 75, 175, 176 British Soldiers: jaws of, compared with those of Roman soldiers, 116 Brockton, Massachusetts: forms used in, 22, 23 Brussels: medical inspection in, 11 Bryan, James E.: study of school progress and physical condition by, 154 Buildings, School: inspection of, under state laws, 165; provision for inspection of, in new laws, 172 Bulgaria: medical inspection in, 12 Bulletins on Physical Defects, 80, 82, 129, 131, 132 Bureau of Child and Animal Pro- tection, Colorado State, 83-85 Cairo : medical inspection in, 1 2 California: abstract of medical in- spection law, 167; and New Jersey cities lead in salaries to school physicians and nurses, 103; cities, health pamphlets used in, 80, 82, 129, 132 Cambridge, England: dental clinic in, 119 Camden: study of retarded children in, 154 Canada: school physicians appointed in, 12 Cardiac Disease: among school chil- dren in New York, 40; treated in Harrisburg, Penn., 94; treated in New York, 92. See also Heart Census Bureau, United States: grouping of states by, 14 Charity Organization Society of Reading: investigates for dental clinic, 122 Charlottenburg: school nurses in, 10; dental work in, 126 Chest Measurements : taken in Wies- baden, 9 Chicago: exclusions for contagious diseases in, 32, 33; medical in- spection in, 13; number of pupils examined in, 1910, 41; record of physical examinations used in, 53, 54; records of contagious disease inspection used in, 24, 25, 26; re- sults of physical examinations, 38 Chicken-pox: exclusions for, 30-33 Chihuahua: medical inspection in, 12 Child and Animal Protection, Col- orado State Bureau of, 83-85 Child Hygiene, Division of: of New York Department of Health, 91 Child, School: has right to claim protection, 4 Children: defects and school progress, 152-163; number per school nurse, 68; older, have fewer defects, 162; payments according to num- ber examined, in Germany, 9; pro- portions found defective, in cities of United States, 37-39; treated 10 INDEX Children {Continued) for defects, in three cities of United States, 96. See also Pupils; De- fects Children's Aid Society, New York City: dental clinics of, 121; direc- tions issued by, 129; sells tooth brushes, 129 Chile : medical inspection in, 1 2 Chinese: teeth of, 116 Chorea: among school children in New York, 40; treated in Harrisburg, Pa., 94; treated in New York, 92 Cincinnati, Ohio: dental work in, 88, 123; exclusions and school mem- bership in, 33 Clemcal Assistance to medical inspec- tors, no. III Cleveland, Ohio: dental clinic in, 121; exclusions and school membership in, 33; number of pupils examined in, 1910-11, 41; results of physical examinations in, 38; school clinic for eyes in, 88; superintendent of schools in, quoted, 147 Clinic, Eye : in Cleveland, 88 Clinics, Dental: cost of supplies and equipment for, 125; established by dental associations, 18; established in Rochester, N. Y., 114; in En- gland, 119, 120; in Germany, 117, 118, 126; law regarding, in New Jersey, 1 24; per capita cost for treat- ment in, 125-127; plan for, in Bos- ton, 123; salaries of dentists in, 127 Clinics : parents' consent to treatment of children at, 73; school and hospital, 86-88; subsidies to, in England, 87 Collins, Edwin: scholarship and con- dition of teeth reported on by, 116 Colmar: dental work in, 126 Cologne: dental clinic in, cost of, 117; dental work in, 126 Colorado: abstract of medical inspec- tion law, 167; compulsory action against parents in, 83-85; vision and hearing tests prescribed in, loi Commissioner of Education: figures from reports of, 42, 103 Compulsory Action Against Par- ents: in England, 86; in United States, 83-86 Compulsory Education and compul- sory disease, I, 2, 3 Conjunctivitis: exclusions for, 32, 33 Connecticut: abstract of medical in- spection law, 167; medical inspec- tion legislation in, 4, 13, 164; vision tests, cost, 102; vision tests, results, 52 Consultations with School Physi- cians: in cities of United States, 76-79 Contagious Diseases: cost of inspec- tion for, loi, 112; exclusions for, in cities of United States, 32, 33; exclusions for, in New York, 63, 65; exclusions for, reduced by school nurses' work, 63, 65; for which children are excluded f|pm school, 30, 31; inspection, a smaU part of medical inspection, 143, 144; inspection in Germany, 9; inspec- tion in Paris, 8; inspection in United States, 19, 20, 21-34; in- spection in Wiesbaden, 9; inspec- tion placed in physicians' hands by state laws, 164; instructions regard- ing s}Tnptoms of, 30; medical inspection due to, i, 13, 21; provision regarding, which new laws should contain, 172. See also Exclusions; Epidemics Copenhagen: medical inspection in, ii Cornell, Walter S.: report on defec- tive children, 152 Cost: annual per capita for medical inspection, 102-110; clerical assist- ance, iio-iii; dental clinics in Germany, 117, 126; dental treat- ment, per capita, 125-127; inspec- tion for contagious disease, loi, 112; physical examinations in United States, 43, loi-iio; sup- plies and equipment for dental climes, 125; vision and hearing tests by teachers, loi, 102, 112 21 I INDEX Darlington, Eng.: treatments in, 99 Darmstadt: dental work in, 126 Deafness: as a handicap in school work, 4. See also Hearing; Ear Defective Child: lessons taught by, will result in a better race, 6 Defective Children. See Children: Pupils; Defects Defects of Eye and Ear: treatments following discovery of, by teachers, 97. See Eye; Ear; Vision; Hearing Defects, Physical: and school prog- ress, 152-163; common among school children, 35, 37, 39; decrease with age, 157, 162; found among children in New York, 40 ;_ found among children in nine cities, 38; records of combinations of, 58-61; treated by private practitioners and institutions. New York, 96, St. Louis, 97; treated in England, 98- 100; treated in Harrisburg, Penn., 94; treated in Newark, N. J., 93; treated in New York City, 91, 92; treated in Pasadena, Cal., 94; treat- ments in American cities compared, 95-97; treatments in United States and England compared, 100 Denmark: medical inspection in, ii Dental Association, Rochester, N. Y. : secured lecturer for children, 1 28 Dental Associations: clinics estab- lished by, 18, 122 Dental Clinics. See Clinics Dental Hygiene: education, 127-133 Dental Work for School Children: in England and other countries, 119-120; in Germany, 10, 117-119, 126; in United States, 18, 19, 120- 124 Dentists, School: early work of, in Belgium, 11; employed in United States, 18, 19, 121, 122; salaries of, in Germany, England and United States, 127; state officers in Strassburg, 117 Derby, C. B., England: treatments in, 99 Detroit, Michigan: exclusions for contagious diseases in, 32, 7,3, Devonshire, Eng.: treatments in, 99 Dinsberg: dental work in, 126 Diphtheria: exclusions for, 30-33 Disease: unbusinesslike not to coimt cost of, 3. See also Contagious Diseases District of Columbia: regulations on medical inspection in, 13, 144, 164, 167 Dortmund: dental work in, 126 Dresden: medical inspection in, 8 Dunfermline, Scotland: dental con- ditions among children in, 115; dental work in, 1 20 Ear Diseases: treated in English communities, 99 Ear Troubles: health pamphlet on, 80 Ears, Defective: found among chil- dren in different cities, 38; treated in English school clinics, 87; treated in Lowell and Somerville, Mass., 97; treated in Pasadena, 94. See also Hearing Education: compidsory, and compul- sory disease, i, 2; without health useless, 4 Education Act of 1907 for England and Wales, 10 Education Act of 1908 in Scotland, 10 Education Authorities: co-opera- tion needed in physical examina- tions, 53; execution of medical inspection law in England laid on, 176 Education, Boards of: medical in- spection under, 143-150 Education, English Board of: chief medical officer quoted, 98; inspec- tions provided for by, 41 ; memo- randum on medical inspection, quoted, 10, 75, 175, 176 Education, Massachusetts Board of: directions issued by, 45, 47 212 INDEX Education, United States Commis- sioner or: enrollment figures from report of, 42; attendance figures taken from reports of, 103 Egypt: medical inspection in, 12 Elmira, New York: dental conditions among school children in, 115; dental work in, 88, 123; no charges for treatment in dental infirmary, 126; running expenses of dental clinics in, 125; study of defects among retarded children in, 155, 156 Ely, Isle of: treatments in, 99 Enforcement: provision for, which new laws should contain, 172. See also Compulsory Action England: children per school dentist in, 126; dental work for school children in, 114, 119; fines imposed on parents of school children in, 86; frequency of examinations re- quired by board of education in, 41 ; medical inspection in, 10; pioneer in employment of school nurses, 11; presence of parents at ex- aminations of children in, 73, 75, 76; salaries of school physicians in, 109-110; treatments in, 98, 99, 100 Enrollment: and exclusions, in eight cities, 33; and physical examina- tions, in nine cities, 41; figures, from report of United States Com- missioner of Education, 34, 42 Epidemics: among school children in Boston, 13; checked by medical inspection, 2, 34. See also Con- tagious Diseases; Exclusions Equipment: and supplies for dental clinics, 125; school nurses, 112; school physicians, in Eskimos: teeth of, 116 Essex, England: treatments in, 99 Europeans: teeth of, 116 Everett, Massachusetts: directions and prescriptions used in, 27-29 Examinations, Physical: by physi- cians, in United States, 19, 20; cities conducting, by . groups of Examinations, Physical (Continued) states, 36; conduct of, 37; cost of, 43, loi-iio; forms needed in con- nection with, 52, 58; frequency of, 40, 41 ; in Australia and Tasmania, 12; in Great Britain, 10; in Paris, 7; medical inspection extended to include, 3; need of, summarized, 61; new laws should provide for, 172; placed in hands of school physicians by state laws, 164; presence of parents at, 73, 75, 76; resvilts of, in cities of United States, 38,39; results of, in New York, 40; time required for, 43; theory and origin of, 35; Wiesbaden system, 9 Examinations, Vision and Hearing. See Vision and Hearing Tests Exceptional Children : special classes for, in Germany, 10; use of term, 3 Exclusion Notices to parents, and their use, 21, 22, 24-27 Exclusions: diseases for which chil- dren are excluded, 3^ 31; in various cities of United States, 32-34, 143, 144; in New York City, 63, 65; reduced by school nurses' work, 63, 65. See also Com- tagious Diseases; Epidemics Exempt and Non-exempt Children in Philadelphia: defectiveness among, 152, 153 Eye and Ear Examinations. See Vision and Hearing Tests Eye Clinic: in Cleveland, 88 Eyes, Defective: among children in different cities, 38; among chil- dren promoted and not promoted in South Manchester, 155; one of four commonest classes of de- fects, 37, 39; treated in English communities, 87, 99; treated in LoweU and Somerville, 97; treated in Pasadena, 94. See also Vision; Eyesight Eyesight: directions for testing in Massachusetts, 45, 47; health pamphlet regarding, 82; Snellen chart for testing, 49. See also Vision 213 INDEX Feeding, School: in Germany, lo FoLLOW-tJP System: not so well de- veloped in Boston as in New York, 42 FoLLOW-up Visits: by nurse, to secure action, 76 Foiuiis: used in medical inspection. See Records; List of Forms, p. xix Forsyth, Thomas A. : gift of, to estab- lish dental clinic in Boston, 1 24 France: dental clinics in, 120; medical inspection in, 7-8 Frankfort-on-the-Main: medical in- spection in, 8 Germany: dental work for school chil- dren in, 114, I I 7-1 18, 126; fre- quency of physical examinations, 40, 41 ; medical inspection in, 8-10; presence of parents at examina- tions of children in, 73, 76; school nurses and movements allied to medical inspection in, 10 Glands, Enlarged: among children in different cities, 38; among re- tarded children in Elmira, 156; and school progress in New York, 158-162; cities which do not re- port, 39; treated in Harrisburg, Penn., 94 Glasses: obtained by school children in Newark, N. J., 93; obtained by school children in New York, 92, 96 Grades, School: completed by chil- dren with and without defects, 159, 160; years required to com- plete, by defective children, 161, 162 Great Britain: medical inspection in, 10; co-operation between school authorities and hospitals in, 86, 87. See also England; Education, English Board of; Legislation Guanajuato : medical inspection in, 1 2 GxnLFORD, England: salaries of medi- cal officers in, no Halifax: medical inspection in, 12 Hamburg: dental work in, 117, 118; per capita cost of dental treatment, 125 Harrington, Thomas F.: quoted, 146 Harrisbulig, Pennsylvania: physical defects treated in, 94 Haverhill, Massachusetts : superin- tendent of schools, quoted, 149 Health Authorities: co-operation with, in medical inspection urged by EngUsh board of education, 1 76 Health, Bad: among normal and re- tarded children in Camden, 154 Health, Board of: Massachusetts, directions prepared by, on sight and hearing tests, 45, 47; New York City, division of child hy- giene, 91 ; New York City, supplies nurse to dental clinic, 121; New York State, dentists employed by, to lecture, 127;. Virginia, bulletin on teeth issued by, 127 Health, Boards of: can conduct con- tagious disease examinations, 53; medical inspection under, 143-150; regulations of, on medical inspec- tion, 13; resolutions adopted at conference of, 1 73 ; salaries of medi- cal inspectors under, 103 Health Pamphlets: by Dr. Ernest B. Hoag, 80, 82, 132 Hearing, Defective: among exempt and non-exempt children in Phila- delphia, 153; among normal and retarded children in Camden, 154; among retarded children in Elmira, 156; among school children in New York, 40; effect on school work, 35; treated in English com- munities, 99; treated in Harris- burg, 94; treated in New York, 92; treated in Summit, 95. See Ears, Defective Hearing Tests: by teachers and phy- sicians in United States, 19, 20; directions for making, issued in Massachusetts, 46; made by phy- sicians and teachers in cities of United States, 51, 52; new laws should provide for, 172; opinions of specialists as to teachers' ability 214 INDEX Hearing Tests {Continued) to make, 44, 45; provision for, in state laws, 165; section of Massa- chusetts law on, 179. See also Vision and Hearing Tests Heart: examination of, 9, 37. See Cardiac Disease Height and Weight: records futile, 37; records in Paris, 8; records in Wiesbaden system, 9 Henie, Dr. C: dental conditions among school children in Norway found by, 115 Hernia: examination for, in Wiesba- den, 9 Hesse-Darmstadt: medical inspection in, 9 HoAG, Ernest Bryant: author of Health Index of Children, 80; health pamphlets by, reproduced, 80, 82, 132 Holmes, George J.: equipment for school physicians and nurses recommended by, 111,112; quoted, 87 Hospital Clinics, 86, 87 Hospitals: parents' consent to treat- ment of children at, 73; subsidies to, in England, 87 Hungary: dental conditions among school children in, 114; medical inspection in, 12 Hygiene, Dental: education in, 127- 133 liiPETiGO Contagiosa: directions and prescription for, 27, 28; exclusions for, 30, 32, 33 Indiana: abstract of medical inspec- tion law in, 167 ; vision and hearing tests prescribed in, loi Indians, American : teeth of , 1 1 6 Infirmary, Dental: in Boston, For- syth gift to establish, 124. See also Clinics, Dental Inspection: for contagious disease, cost of, loi, 112; of teachers, jani- tors, and buildings under state laws, 164-165, 172; intervals at which to take place in England and the United States, 40, 41; mini- mum per capita cost for efl&cient, 103 See also Medical Inspection Inspectors, Medical: corps appointed in New York, 13; results obtained by, with and without aid of nurses, 66, 67; salaries of, 102-110. See also Physicians, School Institutions: treatments by, New York, 96; treatments by, St. Louis, 97 Ireland: medical inspection in, 10 Janitors: inspection of, under state laws, 165, 172 Japan: medical inspection compulsory and universal in, 12 Jaw, width of: among ancient and modem peoples, 116 Jessen, Dr.: dental clinic established by, in Strassburg, 117 Johnson, George F.: weight and con- dition of teeth reported on by, 116 Juvenal: on the soimd mind in the sound body, 6 Kent, England: treatments in, 99 Knowles, Wm. F.: opinion on teach- ers' ability to test hearing, 45 Lawrence, Massachusetts: conflict between health and educational authorities in, 148 Laws : compulsory education, 2 Laws, Medical Inspection: abstract of, in United States, 167-171; authorities with which administra- tion placed, 144; early, in United States, 13; history and present status of, 164; mandatory pref- erable to permissive, 4, 5; of Eng- land, quoted, 174; Massachu- setts, text of, 178; points on which 215 INDEX Laws, Medical Inspection {Con- tinued) there is substantial agreement among, 164, 165; principal fea- tures of, 166; provisions which should be included in, 171, 172; similarities between those of Eng- land and Massachusetts, 179, 180. See also names of states and coun- tries; Education Act; Legislation; Regulations Legal Action: against parents, 83-86 Legal Provisions: regarding dental clinics, 124. See also Legislation; Laws Legislation, Medical Inspection: endorsed by boards of health in conference, 173; in different coun- tries of Europe and the United States, 7-13. See Laws, Medical Inspection; Regulations; Education Act Leicester, England: treatments in, 99 Lincoln: England: treatments in, 99 Lome, Henry: gift by, to establish dental clinic in Rochester, 120, 121 London: medical inspection in, 10; school nurses in, 11, 62 Los Angeles: resolutions adopted by boards of health in meeting at, 173 Louisiana: medical inspection regula- tions in, 164, 168 Lowell, Massachusetts: treatments following examinations by teachers in, 97 Lungs : examined in medical inspection, 9, 37. See also Pulmonary Dis- ease Lynn, Massachusetts: charges of dental dispensary in, 127 Maine: abstract of medical inspection law, 168; vision and hearing tests prescribed in, loi; vision and hear- ing tests, results, 52 Maintenance: cost of, for dental clinics in Germany, 1 26 Malays: teeth of, 116 Malnutrition: among school children inNew York, 40; treated in Harris- burg, Penn., 94; treated in New York, 92. See also Nutrition Manchester. See South Manchester Manitoba: medical inspection in, 12 Martin, George H.: quoted, 150 Massachusetts : appointment of medi- cal inspectors in, 150; Board of Health, directions as to methods of testing vision and hearing, quoted, 45, 46, 47; forms used in connection with vision and hearing tests in, 48, 50; history of medical inspection legislation in, 13; instructions regarding symp- toms of contagious diseases issued in, 30; methods, typical of practice in other states, 51; notice to parent used in, 72, 73; results of vision and hearing tests in, 51, 52; tests by teachers in, influence of, 44, lOI Massachusetts Medical Inspection Law: abstract of, 168; and Eng- lish Act, most important, 174; examinations required by, no; mandatory, 4, 164; provisions re- garding school children returning after illness, 21; similarities to English Act, 179, 180; text of, 178 Maxwell, William H.: quoted, 145 Measles: exclusions for, 30-33 Medical Association, British: salary standard for medical inspection established by, 109 Medical Associations, Local: con- duct medical inspection, 108 Medical Inspection: administration in cities of United States, 143-151; administration in England, 176; four features of, 19, 20; forms of records used in, 21-27, 48, 50, 52- 58, . 73-75, 77-79, 134-142; per capita cost for, 102-110; results should be stated with moderation, 40; statistical statements of re- sults rare, 89; status of, in cities of United States, 15-20; treatments resulting from, 91-100. See also Examinations; Contagious Diseases; names of countries and cities 216 INDEX Medical Inspectors. See Physicians, School; Inspectors Medical Officer, Chief: English Board of Education, quoted, 98 Medical Society of New Jersey: quotation from journal of, 87 Medical Treatments : in New York, 92, 96. See also Treatments; names of cities Memorandum: English board of edu- cation, provisions of, 10, 41, 175, 176 Mental Defects : among exempt and non-exempt children in Philadel- phia, 153 Mexico: medical inspection in, 12 Middlesborough, England: treat- ments in, 99 Middlesex, England: treatments in, 99 Milwaukee, Wisconsin: woman den- tal inspector in, 122 Minnesota: regulations on medical inspection in, 164, 169; vision and hearing tests prescribed in, 102 Montreal: school physicians ap- pointed in, 12 MoRLEY, England: treatments in, 99 Mouth Hygiene: instruction in, by nurses, 91 MtJLHAusEN: dental work in, 126 Mumps: exclusions for, 31-33 Municipal Insurance Committee of Hamburg dental clinic, 117 Muskegon, Michigan: cost of equip- ment for dental clinic in, 125; dental work in, 88, 123 Nasal Breathing: prevented by adenoids, 4. See Breathing, Defec- tive Nervous System, defects of: looked for in medical inspection, 37; treated in Pasadena, 94. See also Chorea Newark, N. J.: children treated free in dental cHnic, 126; exclusions Newark, N. J. {Continued) for contagious diseases in, 32, 2)3\ four physical defects treated in, 93; number of pupils examined in, 1910-11, 41; results of physical examinations in, 38; rules for nurses in, 68; staff and salaries in dental clinics of, 127; supervisor of medical inspection in, quoted, 87 New Jersey: law regarding dental clinics in, 124; medical inspec- tion legislation in, 13, 164, 169; provision for compulsory action against parents in, 85 New Jersey and California: highest costs for salaries in cities of, 103 Newmayer, Samuel W.: data pre- sented by, to prove effectiveness of nurses' work, 66, 67; investi- gation of defects among school children by, 153 New York City: beginning of medical inspection in, 13; Children's Aid Society issues directions regarding teeth, 129, sells tooth brushes, 129; dental clinics, 121, 122, 125; ex- clusions for contagious diseases, 32,33; funds wasted in attempting education of defective children, 162; number of pupils examined in 1 9 II, 41 ; origin of school nursing, 63; records of defects treated in, 91, 92; reduction of exclusions after introduction of school nursing, 63, 65 ; results of physical examina- tions in, 38, 40; study of retarda- tion in public schools of, 156-163; treatments by private practi- tioners and institutions in, 96 New York State : abstract of medical inspection law, 169; board of health employs dentists to lecture, 127 Nineteenth Century: article in, referred to, 116 Norfolk, England: treatments in, 99 Normal Schools: provision regarding, in new laws, 172 Northampton, England: salaries of medical inspectors in, no 217 INDEX North Dakota: abstract of medical inspection law in, 169 Norway: dental conditions among school children in, 115; medical inspection in, 1 1 Nose, Defects of: among exempt and non-exempt children, 153; im- portance among school children, 35 ; number of children having, in different cities, 38; one of four commonest classes of defects, 37, 39; treated in Pasadena, 94. See also Breathing; Adenoids Nose Troubles: health pamphlet on, 80 Notice of resiilts of vision and hearing tests used in Massachusetts, 50 Notification to Parents: form used for, 73 ; not always sufficient to se- cure action, 72, 88 Nottinghamshire, England: treat- ments in, 99 Nurses, School: and school clinics, 87; average per capita cost for medical inspection in cities employing, 103; cannot meet situation alone, 86; duties of, 64, 71; effectiveness of work of, 34, 65-67; employment of, advised by English board of edu- cation, 177; equipment for, 112; follow up visits to secure action, 76; in Germany, 10; in London, 11; in United States, by groups of states, 18, 20; in United States, number employed, 63; instruc- tions in mouth hygiene given by, in New York, 91; proportion of children to, 68; provision for, in new laws, 172; qualifications of, 64; record results of examination, 43; rules for, in Newark, N. J., 68; salaries, 70, 71, 102-108; under school supervision, 146; work of, in contagious disease cases, 30; value of, unquestioned, 62 Nursing, School: history of, 62 Nutrition, Defective: looked for in medical inspection, 37; treated in Pasadena, 94. See also Malnu- trition Oakland, California: consultations with director of health develop- ment in, 77, 79; number of pupils examined in, 1910-11, 41, 42; results of physical examinations in, 38; treatments of defective children in, 96 Oculist, School: early work of, in Belgium, 11 Ohio: abstract of medical inspection law of, 170 Ontario: medical inspection in, 12 Open-air Schools: establishment of, desirable, 98; in Germany, 10 Operative Treatments: in Newark, 93; in New York, 92, 96. See also Treatments; Defects Orthopedic Defects: among exempt and non-exempt children in Phila- delphia, 153; among school chil- dren in New York, 40; treated in New York, 92 OsLER, William: quoted, viii, 103, 114 Over-age Children: defects among, compared with those among nor- mal, 154- See Retardation Palates, Defective: among school children in New York, 40; treated in New York, 92 Palates, Deformed : treated in Harris- burg, 94 Parasitic Diseases: detection and exclusion of, 21 Parents of School Children: com- pulsory action against, 83-86; English medical inspection act has no provision for compulsory action against, 177; imprisoned and fined in England, 86; instruc- tion by printed bulletins, 80; left with larger responsibility by medi- cal inspection, 5 ; means of seciiring co-operation of, 72-79, 177; new laws should provide for notification of, 172; notified in Paris, 8; noti- fied in Wiesbaden, 9; payments by, for dental treatment, in Germany, 117, 1x8; poverty of, creates prob- 218 INDEX Parents of School Children {Con- tinued) lem, 86, 88; presence of, at ex- aminations, 73, 75, 76; right to insist that child in school shall be safe, 4 Paris: medical inspection in, 7, 8 Pasadena, California: consultations with medical examiner in, 77, 78; number of pupils examined in, 1909-10, 41; record of physical examinations used in, 53, 55; re- sults of physical examinations in, 38; treatments in, 94 Payments: for dental treatment, by parents in Germany, 117,118. See Salaries Pediculosis: directions and prescrip- tion for, 27, 28; exclusions for, 30-33 Pence, England: treatments in, 99 Pennsylvania: abstract of medical inspection law of, 170 Pensions for School Physicians, 9 Per Capita Cost: for dental treat- ment of school children, 125-127; for salaries of inspectors and nurses, 102-107. See also Cost Philadelphia: beginning of medical inspection in, 13; data on effective- ness of nurses' work in, 66, 67; defective exempt and non-exempt children in, 152, 153; dental work in, 88, 123; directions and prescrip- tion for tooth powder in, 128; ex- clusions and school membership in, 33; salaries of school dentists in, 127; supplies and equipment for dental clinic in, 125 Physical Culture Treatments in New York, 96 Physical Examinations. See Ex- aminations Physicians, Private: treatments by. New York, 96; treatments by, St. Louis, 97 Physicians, School: and school clinics, 87; conduct of physical examinations by, 37; contagious disease work of, 21, 30; equipment for, in; examinations by, in Physicians, School {Continued) cities of United States, 19, 20; four possible functions of, 89, 90; forbidden to make suggestions as to treatment, 31; have varying standards, 39; in Belgium, 11; in Boston, 13; in Cairo, 12; in France, 7; in Hungary, 12; in London, 10; in Montreal, 12; in New York City, 13; in Sweden, 11 ; in Switzerland, 12; in United States, 16, 17, 20; in Wiesbaden, 9; inspections placed in hands of, by state laws, 165; office consiiltations with, 76, 77, 78, 79; report of, features desirable in, 90; salaries in England, 109-110; salaries in Germany, 9; salaries in United States, 102-110; section of Massa- chusetts law on, 178; tests of vision and hearing made by, in cities of United States, 51; time taken by clerical work, 24, no, III, 113. See also Inspectors Poland, Dr.: quotation from, on medical inspection under board of health, 147 % Premises, School: provision for in- spection of, in new laws, 172 Progress, School: and physical de- fects, 152-163 Promoted and Non-promoted Chil- dren: defects among, in South Manchester, 155 Promotion: normal and retarded children who failed of, in Camden, 154 Provisions which new medical inspec- tion laws should include, 171, 172 Prussia: dental conditions among school children in, 115 Psychological Clinic: article in, 152 Public Health Association of Roch- ester: supplied premises for clinic, 120 Public Schools: a public trust, 4. See Buildings; Premises Pulmonary Disease: among school children in New York, 40; treated in Harrisburg, Perm., 94; treated in New York, 92. See also Lungs 219 INDEX Pupils: enrolled and examined, in nine cities, 41; found defective in vision and hearing, 52; proportion of nurses to, 68. See also Children Rachitis: among retarded children in Elmira, 156 Rate, per Capita: for efficient medical inspection, 103. See also Cost Reading, Pennsylvania: dental clinics in, 121, 122, 125 Records, Forms, and Blanks used in medical inspection, 21-27, 48) 5°) 52-58, 73-75, 77-79, 134-142. See List of Forms, p. xix Records: individual, should follow children, 53; making entries on, consumes inspectors' time, 24, no, III, 113; of combinations of de- fects, 58-61; of physical examina- tions in Paris, 8; in Wiesbaden system, 9; of physical examina- tions, three essential classes of, 52, 58; used in connection with vision and hearing tests in Massa- chusetts, 48, 50 Regulations: on medical inspection, states having, 164. See Laws Reports of School Physicians: features they might contain, go, 91; rarity of statistical statements of results in, 89 Reports. See List of Forms, p. xix Resolutions: adopted at conference of boards of health, 173 Results of Medical Inspection: features desirable in reports on, 90, 91; records of treatments, 91- 100; should be stated with modera- tion, 40; statistics on, rare, 89 Retardation and Defectiveness: conclusions reached on, tentative, 163; study in Camden, 154-155; study in Elmira, 155-156; study in New York, 156-163 Retarded Children. See Retarda- tion Rhode Island: abstract of medical inspection law of, 170; vision and hearing tests prescribed in, 102 Ringworm: directions and prescrip- tion for, 27, 29; exclusions for, 30, 32, 33 Rochester, New York: dental clinics in, 88, 114, 120; equipment of dental clinic in, 125; exclusions and school membership in, 2,3\ lecturer to children secured by dental as- sociation in, 128; number of pupils examined in, 1910, 41; per capita cost for dental treatment in, 126; results of physical examinations in, 38; salaries of school dentists in, 127 Rogers, Lina L.: first school nurse in America, 63 Roman Soldiers: jaws of, compared with those of British soldiers, 116 Rose, Karl: on teeth of different peoples, 116 Roumania: medical inspection in, 12 Rules for Nurses: Newark, N. J., 68 Russell Sage Foundation: investiga- tion regarding medical inspection conducted by, 14, 36, 63, 103; study of retardation by, 156 Russia: dental clinics in, 120; medical inspection in, 1 1 St. Louis, Missouri: concentration of examinations on 19 schools in, 42; number of pupils examined in, 1910-11, 41; parents' consent blank used in, 73, 75; results of physical examinations in, 38; treat- ments of defective children in, 96; treatments by family physicians and institutions in, 97 St. Petersburg: dental clinics in, 120 Salaries : and per capita cost, 102-1 10; of school dentists in clinics, 127; of school dentists in Somerset, England, 119; of school nurses in cities of United States, 70, 71, 102-108; of school physicians in cities of United States, 102-109; of school physicians in England, 220 INDEX Salaries {Continued) 109, no; of school physicians in Germany, 9 Salisbury, Eng. : treatments in, 99 Sanitary Inspection: in France, 7 San Luis PoTOSf: medical inspection in, 12 Saxe-Meiningen: medical inspection in, 9 Scabies: directions and prescription for, 27, 29; exclusions for, 31-33 Scalp, Diseases of: treated in English clinics, 87 Scarlet Fever: exclusions for, 30-33 ScHONEBERG: dental work in, 126 School Authorities: administration of medical inspection by, 164 School Clinics. See Clinics School Feeding: in Germany, 10 School Membership: and exclusions, in eight cities, 33. See also En- rollment School Nurses' Society formed in London, 62 School Progress: and physical de- fects, 152-163 Schools: closing of, because of epi- demics, 34 Schools, Open-air: establishment de- sirable, 98 Scotland: dental work in, 120; medi- cal inspection in, 10 Sense Organs: examined in Wies- baden, 9. See Eye; Ear; Nose; Sight; Hearing; Vision Shepherd, Fred S.: quoted, 147, 148 Sight and Hearing, Defective: as handicaps in school work, 3, 4. See Ears; Eyes; Hearing; Vision Skin: examined in Wiesbaden, 9 Skin Diseases: among exempt and non-exempt children in Phila- delphia, 153; treated in English communities, 87, 99; treated in Harrisburg, Penn., 94. See also Impetigo; Ringworm; Scabies Small-pox: exclusions for, 30, 31 Snellen Chart: used in Massa- chusetts, 47; reproduced, 49 Somerset County: allowance for materials for dental work in, 126; rate of payment to school dentists in, 127; school dental work in, 119 Somerville, Massachusetts: treat- ments following examinations by teachers in, 97 South America: medical inspection in, 12 South Manchester, Connecticut: study of defective children in, iSS; teeth of school children in, 117 South Shields, England: treatments in, 99 Spine: examined in Wiesbaden, 9. See Orthopedic Defects Spokane, Washington: exclusions in, 144 Springfield, Massachusetts: superin- tendent of schools, quoted, 150 Stafford, England: salaries of medical inspectors in, no State : duties and rights of, in medical inspection, 4, 5 State Regulations: in Germany, 9; in Norway, 11. See Regulations; Laws Statistics: showing results of medical inspection rare, 89 Strassburg: dental clinic in, 117, 118; salaries of school dentists in, 127; dental work in, 126 Stuttgart: school nurses in, 10; dental work in, 126 Summit, New Jersey: defects treated in, 95 Supplies: and equipment for dental clinics, 125; for school nurses, 112 Surrey, England : treatments in, 99 Sussex: treatments in, 99 Sweden: medical inspection in, ii 221 INDEX Switzerland: dental clinics in, 120; medical inspection in, 11, 12 Symptoms or Disease: which teachers should notice, 30 Syracuse, New York: use of colored forms in, 27 Tasmania: medical inspection in, 12 Teachers: duties of, in medical inspection in Colorado, 84, 85; examinations of, provision for, in state laws, 164, 172; opinions as to ability to test vision and hearing, 44, 45; plan of having physical records made by, 43; practicability of tests by, demonstrated, 51; record height and weight, Wies- baden system, 9; treatments following examinations by, 97; work of, in detection of contagious disease, 21, 27, 30. See also Vision and Hearing Tests Teeth: directions for care of, issued by Children's Aid Society of New York, 129; leaflet on care of, issued in Waltham, Massachusetts, 131; pamphlet on, by Dr. Hoag, 132 Teeth, Defective: among children promoted and not promoted in South Manchester, 155; among different peoples, 116; among school children in different cities, 38; among school children in different countries, 114, 115; among school children in New York, 40; and school progress in New York, 158-162; early discovery of, im- portant, 35; extractions and fillings among school children in New York, 92, 96 ; handicap imposed by, in terms of retardation, 162; in children with adenoids and enlarged tonsils, 58; instruction in mouth hygiene by nurses in New York, 91 ; one of four commonest classes of defects, 37, 39; physical deter- ioration caused by, 114; treated in English school clinics, 87; treated in Newark, N. J., 93; treated in New York, 92; treated in Pasadena, Cal., 94; treated in Simimit, N. J., 95 Throat, Defects of: among children in different cities, 38; among exempt and non-exempt children, 153; early discovery of important, 35; one of four commonest classes of defects, 37, 39; treated in Pasadena, Cal., 94 Throats: examined in Wiesbaden, 9; treated in English school clinics, 87 Throat Troubles: health pamphlet on, 80 Time and cost of physical examinations, 43 Time necessary for vision and hearing tests, 102 Tonsilitis: exclusions for, 130-133 Tonsils, Hypertrophied: among re- tarded children in Elmira, 156; among New York school children, 40; and associated defects, 58; and school progress in New York, 158-162; handicap imposed by, in terms of retardation, 162; how classified, 39; treated in English communities, 99; treated in Harrisbiirg, 94; treated in Newark, N. J., 93; treated in New York, 92; treated in Summit, 95 Tooth Brushes: and powder given to children in Philadelphia dental clinic, 128; sold to children by Children's Aid Society of New York, 129; supplied to patients in Strassburg clinic, 117 Trachoma: exclusions for, 30 Treatment, Dental: in Strassburg clinic, 117 Treatment of Children: securing parents' consent to, 73 Treatments for Physical Defect: in cities of the United States, 91-98; in English communities, 98-100 Trenton, New Jersey: treatments of defective children in, 96 Tuberculous Children: open air schools for, 98 222 INDEX Tuberculous Lymph Nodes: among school children in New York, 40; treated in New York, 92 Unghavari: studies in dental condi- tions, results of, 114 United States: administration of systems of medical inspection in, 14s; census bureau's grouping of states, 14; cities of, employing school dentists, 19; cities of, em- plo3ang school nurses, 18; cities of, employing school physicians, 17; cities of, having medical inspection, 15, 16, 17; cities of, having exami- nations for physical defects, 36; dental work for school children in, 114, 120-142; development and present status of medical inspec- tion in, 191 1, 13-20; treatment of defects in, compared with that in England, 100 United States Commissioner of Education: figures from reports of, 34, 42, 103 Utah: abstract of medical inspection law of, 170; vision and hearing tests prescribed in, 102 Utica, New York: use of colored forms in, 27 Valparaiso, Indiana: dental work in, 123, 128 Vancouver: medical inspection in, 12 Vermin and Skin Diseases: forms used in cases of, 27, 28, 29. See also Pediculosis Vermont: abstract of medical inspec- tion law of, 170; medical inspec- tion legislation in, 13 Verplanck, Fred. A.: report on teeth of school children by, 117; study of defective children by, 155 Virginia: abstract of medical inspec- tion law of, 171; State board of health, bulletin on teeth issued by, 127 Vision and Hearing Tests: by teach- ers, cost of, loi, 102, 112; by teachers, do not take place of thorough examination, 102; by physicians and teachers in cities of United States, 20, 51, 52; directions for making, issued by Massachusetts Board of Health, 45-47; forms used in Massachu- setts, 48, 50; opinions of special- ists as to teachers' ability to make, 44, 45; new laws should provide for, 172; provision for in state laws, loi, 165; results of, in Massa- chusetts, Connecticut, and Maine, 52; section of Massachusetts law on, 179; time necessary to conduct, 102; treatments following, in Lowell and Somerville, Mass., 97 Vision, Defective: among children in New York schools, 40; among exempt and non-exempt children in Philadelphia, 153; among nor- mal and retarded children in Camden, 154; among retarded chil- dren in Elmira, 156; and school progressinNew York, ^8-161, 163; effect of, on children, 35; increases with age, 157, 158; percentage of children suffering from, 35; treated in English communities, 99; treated in Harrisburg, Penn., 94; treated in Newark, N. J., 93, in New York, 92; treated in Summit, 95. See also Eyes; Eyesight Visits to Homes: made by nurses, 76 Wald, Lillian D.: lent services of nixrse for school work, 63 Wales : dental inspection imder way in , 120; medical inspection in, 10 Walker, D. Harold: opinion on teachers' ability to test hearing, 45 Waltham, Massachusetts: leaflet on care of teeth issued in, 131 Washington: abstract of medical in- spection law of, 171 Water, Drinking: provision for in- spection of, in new laws, 172 22^ INDEX Weight and Height, Records of: futile, 37; inParis, 8; in Wiesbaden system, 9 West Virginia: abstract of medical inspection law of, 171 Whooping Cough: exclusions for, 31- 33 Wiesbaden: 8-9 medical inspection in, Winchester, Massachusetts: rates for dental treatment of school children in, 127 Wolverhampton, England: treat- ments in, 99 Worcestershire, England: treat- ments in, 99 YoRKS (East Riding), England: treat- ments in, 99 224 ruu o ii7id ^itiaiiiuytiiiiUiiiiiiimiiiiiiiimiiUiM LIBRARY OF CONGRESS i|ii||jli||i|iji|llij|{p iiilMHi ill iiillliiiiii llili:i!liHiihli!lil!lMII{l; iiiiiiiiiiiiiiiinniiiiiiiiiiiiilmliimiitiiiJiiitiiiiHtHHiitil'