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MEDICAL INSPECTION OF
PUBLIC SCHOOLS
MEDICAL INSPECTION OF PUBLIC SCHOOLS
BY LILLIAN D. WALD,
Nurses' Settlement, New York.
Within the past twenty-five or thirty years there has been
produced a considerable literature on school hygiene, but much
of this has dealt with the subject in a general way, without furnish-
ing any definite plan for enforcing its requirements in practice.
Systematic medical inspection of public schools is a regulation of
comparatively recent establishment. It is perhaps fair to say that
New York City alone, through the co-operation of its educational
department, with its able department of health, had definitely com-
mitted itself to a policy that will admit of future expansion and
eventually include oversight of the schools and school children.
Education should aim to develop good minds, good habits, good
characters and good citizens, and this cannot be accomplished unless
the mental training and the methods of education are directly in-
fluenced by the physical life and constitution of the individual
child. The relation between the mental and the physical in school
training appears plainly when the causes of dullness or other defects
become subjects of investigation. In a report upon the mental
condition of 50,000 school children in London, 1892-94, Dr. Francis
has grouped the main classes of defects as follows:
“(a) Defects in development of the body in size, form or pro-
portion of parts.
“(b) Abnormal nervous signs; certain abnormal actions, move-
ments and balances.
“(c) Low nutrition as indicated by a child being thin, pale
or delicate.
“(d) Mental dullness. Teachers’ report of mental ability below
average registered as dull.
“(e) Eye cases, defects or disease.
“(f) Rickets.
“(g) Exceptional children.”
[290)
Medical Inspection of Public Schools 89
Children of school age are subject to attacks of certain diseases,
which because of the possibility of transmission to others assume
a public interest apart from the effect upon the individual child.
New York, Philadelphia, Boston, Chicago, Baltimore and other
cities maintain supervision of the schools for the purpose of pre-
venting the spread of contagious disease. Broadly viewed, how-
ever, medical inspection embraces besides the examination of the
child, the sanitation and hygiene of the building, its structure, ven-
tilation, heating, lighting, plumbing, seating and cleaning; the print-
ing and paper of books used; the proper use or non-use of slates,
pencils and stationery, and the acoustic properties to save wear and
tear of the voice.
Such inspection as has occurred has usually come directly
through the board of health co-operating with the department of
education. In Chicago the department of education is said to
have more direct charge. Some five or six years ago, as a result
of civil service examinations, fifty physicians were appointed med-
ical inspectors of schools. Each inspector was given a district
and required to visit the schools three times a week, but unfort-
unately this is said to have lasted but one year, and after that all
but twelve of the inspectors were dropped. These are now em-
ployed as emergency inspectors, each being on duty ten months
of the year, during which time he is expected to visit schools when
sent for by the principal. The character of the cases inspected
varies naturally according to the inclinations of the individual prin-
cipals. Some principals send for the inspector to treat scabies or
eczema; others only when there is a suspicion of diphtheria, scarlet
fever or small-pox. The physicians are forbidden to visit the chil-
dren in their homes. Although this medical inspection is under
a superintendent of the board of education, that department seems
to restrict its authority to arranging calls and the time of service
in districts. The physicians refer all matters involving serious ques-
tions to the board of health.
In New York an investigation by an inspector of the depart-
ment of health was made in October, 1896, to ascertain the part
played by the schools in spreading contagious diseases. The schools
from which cases of these diseases had been reported to the depart-
ment were visited and an examination made of all children present
in classes where sick children had been in attendance. Children
[291]
i52569
9 o The Annals of the American Academy
who were absent from the classes were visited at their homes to
ascertain the cause of absence. ‘This investigation showed that a
great number of these children were sick with contagious diseases
and that they had been directly infected in school rooms where con-
ditions were most favorable to such results. These conditions
included not only the presence of sick children but heat, overcrowd-
ing and other unsanitary surroundings. It was also found that
children had continued in school when a member of the family was
at home ill with some contagious disease. Others who returned
to school after an absence of a day or two, confessing to a slight
sore throat, were found, when submitted to a bacteriological test,
to be affected with diphtheria. Investigation for measles and other
diseases brought forth similar evidence of infection in the schools.
The writer once saw a child who, after two weeks’ absence from
school on account of scarlet fever, had returned to class and was en-
tertaining his fellow pupils by pulling the desquamating skin from his
hands and fingers and passing it around for trophy. This and more
detailed facts were embodied in a special report presented to the
board of estimate, which at once appropriated money to pay one
hundred and fifty inspectors, at the rate of $30 per month.
In March, 1897, these inspectors were assigned to duty and
the system was inaugurated. Each inspector was instructed to
report before ten o'clock in the morning to examine all children
whom the teacher had sent to his office (in the school building),
and who were suspected of having anything contagious. This was.
a good beginning, but the inspection was, in fact, very superficial,
and dependent upon the school teacher, who was naturally unable
to detect symptoms, unless well marked. With the heavy weight
of her class upon her, she was unable, however willing, to give
close observation to the individual child. Although incomplete, this
supervision was regarded, as it proved to be, a source of some ad-
vantage. The presence of a physician in the school had provided
at least for the immediate disposal of the doubtful cases discovered:
by the teachers. The report of the first year's work showed, inspec-
tions, IoS,628, exclusions for all diseases of an infectious or con-
tagious nature, 6,829.
In June, 1902, an eminent eye specialist, member of the advisory
board of the department of health, urged examination of the
children in the schools for the detection of trachoma, a serious and
[292]
Medical Inspection of Public Schools 9 I
contagious eye disease. Sixteen trained oculists examined the chil-
dren in thirty-five schools, with the following results:* Pupils .
examined, 55,470; found to have contagious opththalmia, 6,770, or
I2 per cent., as follows: severe trachoma, 2,328, or 4.2 per cent. ;
mild trachoma, 3,243, or 5.82 per cent. ; acute conjunctiva, I,099,
or 1.98 per cent.
This examination, followed up by the earnest efforts of the
health commissioners, resulted in important changes in the methods
and routine of the service. Provision was made in September, 1902,
in all the schools for the inspection and examination of every child
by a medical inspector. Selection of about one-third was made
from the men and women on the staff, and the salaries of inspectors
were raised from thirty to one hundred dollars per month, the
department demanding practically their whole time. From the open-
ing of school, September 15th, to April 1st, five and one-half months,
5,381,616 inspections were made resulting in 57,986 exclusions.
The following cases of disease were excluded during the quar-
ter ending December 31st: Measles, 18; diphtheria, I4o; scarlet
fever, I3; whooping cough, 61 ; mumps, 9; trachoma, I2,647; pedi-
culosis, 8,994; chicken-pox, I72; skin disease, 662; miscellaneous,
I,823; total, 24,538.
There was naturally much argument and protest against this
“wholesale exclusion.” The honestly administered health depart-
ment was charged with demoralizing the department of education
by emptying the school rooms. In some quarters the evidence of
such extensive pediculosis was regarded as alarming. This, how-
ever, was not the view of the more intelligent. “It is no disgrace,”
said one physician quoted by Dr. Lederle, “for a child to be affected
with head trouble, but it is a disgrace to have the trouble and not
treat it.” The most serious charge, however, was that neither the
public nor the children were protected. The children excluded from
school waited on the doorsteps to play with their classmates or romped
with them through the halls of the tenement. Well meaning but
overworked mothers were not able to properly care for their children.
Indifferent or ignorant parents took no action, unscrupulous ones
took this means to avoid the compulsory education law and avail
* The tables of diseases and statistics have been compiled from the reports of Dr. Lederle,
Commissioner of Health, New York, 1902–04; Dr. Darlington, Commissioner since 1904; Dr.
Cronin, Assistant Chief Medical Inspector; Miss Rogers, Superintendent of Nurses' Depart-
ment of Health and from the Eastern Public Education Association
[293]
92 The Annals of the American Academy
themselves of the child's service. From the child's point of view
exclusion often amounted to permanent loss of education. The
period of school life which for the poor child is limited by the law's
demand (unless further diminished by violation) as a result of medi-
cal inspection, was shortened still more.
To meet the perplexities of this situation the Nurses’ Settle-
ment in Henry Street offered the services of one of its trained
nurses for one month to assist the department in working out a
practical plan. At the end of the month of twenty school days,
six of which were Jewish holidays, when there were naturally a
large number of absences, the nurse had cared for and treated 829
cases. Ninety-three children who had been absent and receiving
no treatment returned to school, and 137 visits were made to the
homes. At the conclusion of the month the medical inspector,
principals and parents voted the plan of providing a nurse for the
children a success and the board of estimate early in November
appropriated money for the continuance of the work. It has since
been enlarged until under the present administration there are
assigned to this work a supervising nurse and thirty-four nurses,
as follows: Manhattan, 20; Brooklyn, Io; Bronx, I ; Queens, 2.;
Richmond, I. -
With the advent of the nurse the objective point of medical
inspection was reversed. Formerly when a child was sent home
with a disease the case was considered closed, but under the new
regulations it becomes the duty of the nurse to see that the case is
properly treated. Practically all diseases except diphtheria, scarlet
fever, measles, varicella, whooping cough, mumps and acute coryza
are placed under treatment and returned to the class. The aim
of the inspection is now to minimize the number of exclusions.
The routine established at the beginning has in its essential
features been since maintained. The medical inspector must visit
all schools assigned to him before ten o'clock each morning. This
is called the morning visit, and consists in seeing all children isolated
by the principal under suspicion of having some contagious disease,
children who for reasons unknown have been absent from school
for a certain number of days, and children excluded from school.
After the morning inspections have been made the inspector returns
to one of his schools for an examination of all children present.
The physician enters the classroom, standing in a favorable position,
[294]
Medical Inspection of Public Schools 93
with his back to a window, and the children pass in procession before
him; in passing the pupils pull down their own eyelids and open
their mouths wide, while the physician examines eyes, throat, hair
and hands, not, however, touching the pupils in the classroom.
The children suspected of having trouble are taken out of the
procession and ordered to the inspector's office in the school building
for a more thorough examination. Those found to be suffering
from pediculosis, eye or skin disease are allowed to return to class
and are excluded at the next recess. Cases of measles, scarlet
fever and the like are telephoned to the inspector of the central
office of the department, and thus come under the district inspector,
who visits the child at his home. If the diagnosis is not verified the
district inspector reports to the school inspector, who orders the
child back to school. Children absent from school for no known
reason are visited and a great number of contagious diseases un-
reported to the department are thus discovered. From November I,
1903, to May 12, 1904, 891 such cases were found, and this had
also had the incidental effect of stimulating negligent physicians to
report contagious cases.
The doctor is followed by the nurse, to whom all cases are
sent with a diagnosis, in cipher. It was found necessary to use
a code in order to save embarrassment to the children who were
sent for unclean heads. To prevent classmates from obtaining too
much information, pediculosis has several code numbers; for the
same reason children who have nothing the matter with them are
also sometimes sent to the office. The nurse receives definite pre-
scriptions from the physician and gives treatment wherever pos-
sible in the place assigned to her in the school building, sending the
child back to class immediately. After she has made her rounds
in the school she visits the homes of the children who have been
excluded, explaining the case to parents and, if necessary, making
demonstrations. Where further medical attention is required, un-
less the family has its own physician, the nurse indicates places
where clinics are to be held. Children without guardians to properly
care for them are taken to dispensaries for treatment or operation.
When a child is found to be totally uncared for the case is referred
to the proper agencies for relief. One nurse reported after a year's
experience but one exception to the rule of courteous treatment by
the families.
[295]
‘94 The Annals of the American Academy
The superintending nurse made the following report for the
year 1904: Cases treated—pediculosis, 509, I42; eye diseases, 2O4,-
277; scabies, 1,448; ringworm, 18,808; impetigo, 3,619; sovus, 279;
miscellaneous, 46, II2; total, 783,685. Tenements visited, 27,OIO;
schools visited, 26,703; miscellaneous, 964; total visits, 54,677.
An unexpected problem presented itself in the occasional refusal
of children and parents to permit treatment. This was met by the
district superintendent of schools co-operating with the district at-
torney, who declared that any parent who refused to put a child
under proper treatment was commiting a violation of the compulsory
education law, and was punishable by fine. A test case was brought
and the father fined ten dollars.
The success of this whole movement has been due in large part
to the harmonious way in which the health department and the
department of education have worked together toward the same
end. Attention has already been called to the assistance which is
rendered the board of health in discovering contagious diseases by
the investigation of all cases of absence from school without known
cause. Not only are many cases directly discovered in this way, but
negligent physicians are at the same time stimulated to make prompt
reports. On the other hand, the school inspection is facilitated by
reporting daily to the schools all cases of contagious disease known
to the department of health. For the nurses’ work, supplies are
furnished by the department of education upon requisition of the
principals. The most intelligent co-operation naturally comes from
those principals who have given the subject some thought and who,
apart from the more specifically hygienic reasons, welcome a service
which assists in keeping up attendance.
With improvement in the facilities for nurses’ work more com-
plete preventative measures can gradually be developed. Printed
instructions about the care of the head are now given to the children
in sealed envelopes, and provision for thorough examination by eye
specialists for error of refraction will probably soon follow. In a
recent limited investigation of 981 children, 30 per cent. showed
refracted error in one or both eyes. In some communities where
no medical board exists to perform such duty, annual examinations
of the children's eyes have been made by the teachers. At a recent
meeting of the American Medical Association, the following resolu-
tion was adopted:
[296)
Medical Inspection of Public Schools 95.
“WHEREAs, The value of perfect sight and hearing is not fully appre-
ciated by educators, and neglect of the delicate organs of vision and hearing
often leads to disease of these structures; therefore be it
“Resolved, That it is the sense of the American Medical Association
that measures be taken by Boards of Health, Boards of Education, and
school authorities, and when possible legislation be secured looking to the
examination of the eyes of the children, that disease in its incipiency may be
discovered and corrected.”
In New York the question of furnishing glasses is likely to
arise, and when it does, may be expected to bring complications.
Concerning the wisdom of such a policy, there would doubtless be
some difference of opinion, but it is not difficult to predict that some
fair and just provision will ultimately be effected. The proper
position of the child, both standing and sitting, care of ears,
teeth and other similar matters of cleanliness and health are
all destined sooner or later to receive the public attention they
deserve. Sanitation and care of school buildings, including the
proper removal of dust must be provided for with greater care, even
though it involve the education of the janitor. One of Boston's
honored scientists has said, “So long as Boston pays one thousand
dollars a year for feather dusters, her citizens cannot pose as re-
formers.”
It is difficult to place a limit upon the service which medical
inspection should perform. Many children suffer physical strain
from the too great weight of books which they are carrying home;
such cases are obviously proper subjects of medical attention. But
what is to be done with children suffering from anaemia, under-
feeding and who are consequently unable to assimilate the educa-
tion provided for them? Is there not here involved a question to
which the state should give its attention? In too many cases the
child returns to school after the noon recess without having par-
taken of a noon meal. If provision were made that this time should
be spent in the school, a suitable hot meal approved by the medical
inspector would seem to be an appropriate provision. The state
recognizes its responsibility for the development of citizens. To
meet this responsibility, the school is its most efficient agency. If
for safe-guarding the state, mental training is made compulsory,
is it not logical to conclude that physical development—the sound
body as well as the sound mind—should as far as possible be de-
[297]
96 The Annals of the American Academy
manded? From the obligation to cure to the obligation to prevent
is but a single advance step in the growth of civic conscience. Ade-
quate and intelligent medical inspection would perhaps meet with
less resistance if regarded, not as reform, but rather as a natural
development of ideas held by the founders of the republic who
placed the school on the same level with the home in responsibility
for the maintenance of good citizenship.
DATE DUE
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