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 an'iI 
 
SCHOOL HEALTH 
 ADMINISTRATION 
 
 BY 
 
 LOUIS W. RAPEER, M.A., Ph.D. 
 
 rv^W YORK TRAINING SCHOOL FOR TEACHERS 
 
 PUBLISHED BY 
 
 tE^eacljerg College, Columbia ^nibersJitp 
 
 NEW YORK CITY 
 
 1913 
 
 i^v 
 

 Copyright^ 1913, by Louis W. Rapeer 
 
 THE HOWARD-GEAY CO., PRINTEES, 
 NEW YORK CITY 
 
 SlCI,A358239 
 
PREFACE 
 
 The problem of this dissertation is to find what Ameri- 
 can cities are doing for national health and vitality through 
 the agency of the public schools, and how this work may 
 be made more efficient and socially useful in solving our 
 individual and national health problems. The scope of the 
 work is enormous and necessarily in the nature of a rough 
 survey, rather than an intensive study of a narrow portion 
 of the field. Only one of the newest phases of educational 
 hygiene, medical inspection of schools, has been very thor- 
 oughly investigated, and the multiplicity of limitations in 
 this field has made great accuracy impossible. No very 
 conclusive results have been obtained, and the volume is 
 offered merely as a beginning on a new problem, and for its 
 suggestive value in practical administrative improvement. 
 
 The investigation began with the practice of such work 
 in the writer's own school when a principal in Minneapolis, 
 and more directly with a study of data collected by the 
 Child Hygiene Department of the Russell Sage Founda- 
 tion on the health provisions of 1,038 graded school systems 
 under superintendents. It has since broadened into a study 
 of national health and vitality, a survey of educational 
 hygiene in twenty-five of forty cities visited for the pur- 
 pose, and an intensive study of health problems in one 
 school system by invitation of the Board of Education. 
 The tentative standard plan for the administration of medi- 
 cal inspection as an organic part of the whole of educational 
 hygiene here offered for criticism, is an outgrowth of the 
 last mentioned study. The hope back of the dissertation is, 
 of course, that the health conditions of our nation may 
 be improved. 
 
 3 
 
4 PREFACE 
 
 To prosecute such an investigation requires the co-oper- 
 ation of a great number of individuals. In this case, super- 
 intendents, school physicians and nurses, dentists, directors 
 of physical education, members of state and local boards 
 of education, health officers, principals, teachers, school 
 janitors, and business managers, in great numbers, in the 
 twenty-five cities especially, have cheerfully contributed to 
 make the study possible. For their never-failing courtesy 
 and unstinted helpfulness I here publicly give grateful 
 acknowledgment. To Professors George D. Strayer, Ed- 
 ward L. Thorndike, and Henry Suzzallo of Teachers Col- 
 lege, Columbia University, and to Doctor Leonard P. 
 Ayres of the Child Hygiene division of the Sage Founda- 
 tion, the author is much indebted for encouragement and 
 many valuable constructive suggestions. My wife has con- 
 tributed at every step to make the study possible. 
 
 22a..W. I20th Street, . ^ fT^ • i ^^ dji/'t 
 
 New York City, fe S»t T^ > «i 5<u.» ** "" * •- 
 
 Sept., 1913. tMt^^it QM^'^t^ n\el, 
 
CONTENTS 
 
 Outline Abstract 7 
 
 PART ONE 
 
 The National and School Health Problem and 
 How It is Being Met 
 
 Chapter 
 
 I. The National Health Problem 17 
 
 II. The School Health Problem 28 
 
 III. How THE Health Problem is Being Met 
 
 IN Schools and Nation. 
 
 54 
 
 PART TWO 
 
 How the Problem of Educational Hygiene is Being 
 Solved in Twenty-Five Cities 
 
 IV. General Phases of Health Administra- 
 
 tion 71 
 
 V. The Nature and the Efficiency of the 
 
 Work Done 107 
 
 VI. The Ailments of Public School Chil- 
 dren. A. Physical Defects 134 
 
 VII. B. Common Non-Infectious Ailments.. 182 
 
 VIII. C. & D. Communicable Ailments, Para- 
 sitic AND Infectious 203 
 
 IX. Special Phases of Medical Inspection in 
 
 These Cities 228 
 
 X. Physical Education and Other Phases 
 
 OF Educational Hygiene 262 
 
 PART THREE 
 
 XI. The Administration of Medical Inspec- 
 tion — A Tentative Standard Plan. . . 295 
 
 5 
 
Number. 
 I. & II. 
 III. 
 
 IV. 
 
 V. 
 
 VI. 
 
 VII. 
 
 VIII. 
 
 IX. 
 X. 
 
 XI. 
 
 XII. 
 
 XIII. 
 
 XIV. 
 
 XV. 
 
 XVI. 
 
 XVII. 
 
 XVIII. 
 
 XIX. 
 
 TABLES AND FORMS 
 
 Page. 
 Causes of Death in the Registration Area. .22-23 
 Preventability of Death of Elementary 
 
 School Children 29 
 
 Preventability of Deaths of High School 
 
 Children 30 
 
 General Administration of Medical Inspec- 
 tion 76-77 
 
 The Work of Doctors and Nurses 80-81 
 
 Accom-plishment in Medical Inspection. . 116- 1 17 
 Ailments of School Children. Physical De- 
 fects 138-139 
 
 Common Non-Infectious Ailments. . 184- 18 5- 186 
 Communicable Ailments, Parasitic and In- 
 fectious. Deaths of Children. .. .205-206-207 
 
 Ailments in Order of Frequency 226-227 
 
 Efficiency Data. Estimated Needs of Cities 253 
 
 Approximate Rank of the Cities 254 
 
 Physical Education 263 
 
 Divisions of Educational Hygiene 296 
 
 Individual Health Record, Number One.. 311 
 Individual Health Record, Number Two. . 315 
 Weekly Report of Doctors and Nurses. .345-346 
 Classification and Frequency of Ailments.. 351 
 
SCHOOL HEALTH ADMINISTRATION 
 
 OUTLINE ABSTRACT 
 I. GENERAL METHOD OF THINKING 
 
 In general, the thought is that before we can say what 
 the pubHc schools are or should be doing for individual 
 and public health we must determine as accurately as 
 possible with present-day statistics what the health needs 
 and problems of individuals and the nation actually are, 
 and how serious the health problem is, compared with other 
 grave problems of life. The public school's share in the 
 responsibilities for public health amelioration is very great, 
 and growing, due to the lack or inefficiency of other insti- 
 tutions for such a purpose, to the admirable conditions of 
 control in a state institution and with compulsory attend- 
 ance and general community support, and to the fact that 
 such a large share of health mal-adjustment is due to health 
 ignorance, and the lack of adequate health habits and ideals 
 which it is so largely the special function of the public 
 school to replace with positive health qualities. The princi- 
 pal problems of life, whatever they may be, and to be 
 discovered only by a study of life through surveys or any 
 other efficient means, furnish the problems of public edu- 
 cation. 
 
 II. PART ONE. THE NATIONAL AND SCHOOL HEALTH PROB- 
 LEM AND HOW IT IS BEING MET IN SCHOOL AND 
 NATION. (summarized AT END OF CHAP- 
 TERS TWO AND THREE.) 
 
 Health and physical vitality are all-important to the 
 
 attainment of the goal of life (happiness through social 
 
 efficiency), but they are being very poorly provided for, 
 since : 
 
8 SCHOOL HEALTH ADMINISTRATION 
 
 A. The national health losses are enormous and largely 
 preventable, for: 
 
 1. Approximately 1,600,000 of our population die each 
 year, 42 per cent, or about 670,000, of reasonably 
 preventable diseases. The economic loss in deaths 
 is approximately a billion dollars. 
 
 2. Approximately 3,000,000 persons are constantly 
 seriously /// in the United States, largely of prevent- 
 able diseases ; and this occasions an economic loss of 
 about another billion dollars. 
 
 3. A very large number of persons suffer from many 
 minor ailments which lower their efficiency and cause 
 absence from work, which makes an economic loss 
 of another very large sum. 
 
 4. Other nations, such as Sweden and Germany, are 
 succeeding by adequate national and school provi- 
 sions in lowering the losses much below our own. 
 
 5. Competent authorities have estimated in various 
 ways the large preventahility of these losses by 
 reasonable application of present knowledge. 
 
 6. Such preventahility can be seen from the effects of 
 such civic improvements as pure water and pure 
 milk supplies. 
 
 B. The school health losses are enormous and largely 
 preventable, for : 
 
 1. Approximately 100,000 children of elementary and 
 high school age die each year in the United States, 
 65,000 of whom have been during the year en- 
 rolled in a pubhc school. Of these 40,000 and 
 perhaps 50,000 are reasonably preventable. Their 
 education has been socially wasted expenditure of 
 energy and money. 
 
 2. The illness losses of both teachers and pupils of the 
 public schools are enormous, coming in the form 
 of personal and public financial loss, of lowered 
 vital efficiency and happiness, and of elimination, 
 non-promotion and retardation at school. Tentative 
 guesses at the amount of each of these last three 
 
SCHOOL HEALTH ADMINISTRATION 9 
 
 due to Illness as the chief or only factor are : elim- 
 ination, about 12 per cent; non-promotion, about 
 II per cent; retardation, about 10 per cent. 
 
 3. The physical defects losses are also enormous and 
 largely preventable. They function largely in caus- 
 ing about: five per cent of elimination, six per cent 
 of non-promotion, and seven per cent of retarda- 
 tion. 
 
 4. Combined, the two factors of ill-health and physical 
 defects function largely in causing about: 15 per 
 cent of elimination, 16 per cent of non-promotion, 
 and 17 per cent of retardation. 
 
 5. These results are not the only ill-health results, of 
 course, but whenever these are related to the 
 twenty million school children in the United States, 
 the problem of school health stands out as one of 
 the greatest before the public. 
 
 6. The studies reviewed for their school health data 
 here are : Strayer's Introductory Survey to the 19 10 
 Report of the U. S. Bureau of Education, Fisher's 
 National Vitality, U. S. Mortality Statistics for 
 19 10, Dr. Keyes' "Progress Through the Grades 
 of City Schools," the studies of Retardation by 
 Ayres, Strayer and Thorndike, Dr. Bachman's re- 
 port in the New York City School Inquiry of 
 "Promotion, Non-Promotion and Part Time," Supt. 
 Demarest's 19 11 Study, the Boston Non- Promotion 
 Study, Supt. Broome's 191 1 Study, Supt. Mackey's 
 19 II Study, Supt. Verplanck's 191 1 Study, Supt. 
 Brubacher's 191 1 Study, the Newark Quarantine 
 and Absence Reports, the Ayres, Cornell, and Wal- 
 lin studies, and a few others. 
 
 7. This phase has not been exhaustively studied be- 
 cause the crux of the investigation is the work of 
 the twenty-five cities. Other data to emphasize, by 
 facts, the health problem of schools could easily be 
 furnished and are given in the later study of the 
 ailments of school children. 
 
10 SCHOOL HEALTH ADMINISTRATION 
 
 C. The national provisions for public health, in the fed- 
 eral, the state, and local governments are comparatively 
 numerous, heterogeneous, and entirely inadequate to meet 
 the national health needs and problems. 
 
 Likewise the school provisions for public health are 
 numerous, growing, heterogeneous and entirely inadequate, 
 both as to quantity and to efficiency, to solve satisfactorily 
 the school health problem. The science and the practice 
 of educational hygiene are in their infancy. 
 
 Many of the agencies and a large number of other facts 
 relating to national, school, and private provisions for public 
 health are concisely stated in chapter three. 
 
 Among the most important agencies to work for are : 
 The national, state, and local departments of health and 
 their increased scope and greatly improvable (the last two) 
 efficiency, and, secondly, efficient and scientific departments 
 of Educational Hygiene in federal, state, and local school 
 systems with the following working divisions : medical in- 
 spection, the teaching of hygiene, school sanitation, physical 
 education, and the hygiene of teaching. The promise for 
 the greatest usefulness lies in such departments under expert 
 direction. 
 
 III. INVESTIGATION OF EDUCATIONAL HYGIENE IN 
 TWENTY-FIVE CITIES 
 
 A. The method was to visit forty cities and select from 
 these twenty-five that had both school doctors and nurses 
 and had had the work in progress for nearW a year or 
 longer. Most of the visits were made in 191 1, but for wide 
 acquaintance with the work they have been continued when- 
 ever time could be found from the fall of 19 10 to the 
 spring of 1913. One city was intensively studied for the 
 Board of Education of that city. All reports, blank forms, 
 the methods of work, and all public provisions for public 
 health In charge of the school or other organizations dealing 
 with school children were studied so far as data could be 
 found and time permitted. The work is in the form of 
 a survey with some intensive study of several phases, and 
 
SCHOOL HEALTH ADMINISTRATION ii 
 
 the motive has been to avoid any tendency toward muck- 
 raking and to make the study entirely constructive. The 
 writer was prejudiced against board of health control of 
 medical inspection at the start, and this has been offset 
 by giving these bodies especially favorable consideration 
 throughout. 
 
 B. The work of medical inspection is in its infancy and 
 is yet very heterogeneous and inefficient. The organization is 
 poor and the amount of money spent not commensurate 
 with the needs, as compared with other legitimate needs. 
 
 C. Board of Health control of this work, even though 
 it has some marked advantages, is, on the whole, less efficient 
 and less promising for the future than Board of Education 
 control. 
 
 D. Medical inspection is at present isolated from other 
 phases of educational hygiene. Many promising features 
 of the development of the four other phases of educational 
 hygiene in these cities are given in chapter ten. 
 
 E. The chapters on the ailments of school children 
 give a close view of the fifty-four classes of ailments accord- 
 ing to the tentative standard classification presented, and 
 attempt to state the probable frequency of such ailments in 
 an elementary school population that has not had long and 
 efficient medical supervision. Our estimates are much lower 
 than those usually given. 
 
 F. The reader is here referred to the summary of con- 
 clusions regarding medical inspection found in chapter nine, 
 in the tables, and especially in the tentative standard plan 
 for the administration of this work. 
 
 IV. TENTATIVE STANDARD PLAN FOR THE ADMINISTRATION 
 OF MEDICAL INSPECTION 
 
 A. The plan here offered, and later to be re-printed for 
 separate use, is intended to be applicable as a beginning 
 for most cities, for rural areas, and for any group of 
 small cities. It has been critically tested in part by a com- 
 mittee that has studied the systems of reporting and ad- 
 ministration in seventy-five cities, and is believed to be 
 
12 SCHOOL HEALTH ADMINISTRATION 
 
 superior to any system now in operation; and may be put 
 into operation at practically the same expenditure of money 
 as any well-provided city on present lines. 
 
 B. Every administrative area, a city, a group of cities, 
 or a rural area such as a district, township, or county, 
 depending upon the number of children, should have a 
 director, or supervisor, of (educational) hygiene. Over 
 these, each state should have a supervisor of hygiene. This 
 officer should have the qualifications both of a physician 
 and of a specialist in educational hygiene. Such men are 
 now to be had, and indications point toward the introduc- 
 tion of training courses for doctors of educational hygiene 
 in medical schools and teachers' colleges. The salary at 
 present must be, at least, between two and four thousand 
 dollars a year, of eleven months. The supervisor's function 
 will be to correlate and supervise all phases of hygiene 
 (medical inspection, physical education, school sanitation, the 
 teaching of hygiene, and the hygiene of teaching) , in con- 
 junction with the general superintendent, and in many cases 
 to do part of the work of medical inspection. In many 
 systems the number of part-time school physicians, phy- 
 sical training teachers and truant officers who can be elim- 
 inated will be great enough to make necessary little or no 
 increase of expenditure for his salary. Many other savings 
 through such a system will be evident. 
 
 C. At present, no good plan for the complete elimina- 
 tion of part-time work on the part of assistant school phy- 
 sicians has been devised, although this is to be desired. 
 The plan here is to have physicians do practically no other 
 work than that of the (physical) examination of pupils, 
 and to have the supervisor of hygiene, where possible, do 
 the work of one physician. To begin with, have one 
 physician, counting the supervisor, for each three thousand 
 children, elementary and high school, and one nurse for 
 each two thousand children, depending upon circumstances 
 as to the exact numbers. Have the physicians give two 
 hours a day in one school building each, making medical 
 examinations of the pupils (also teachers and janitors) and 
 
SCHOOL HEALTH ADMINISTRATION 13 
 
 such individual inspections as are urgent, and completing 
 the examination of the allotted number of pupils, with the 
 help of an assisting nurse, before the end of the school year. 
 The nurses are to do most of the inspecting, aside from 
 the routine September room-inspection of all children, and 
 also the home visiting. 
 
 D. The details of the work are given in the plan. The 
 reporting and record system should be adapted and adopted, 
 including the tentative standard classification of school ail- 
 ments. The doctor has no traveling about from school 
 to school on school time to do, and he is likewise freed 
 from making reports. Clerical work is almost entirely 
 placed in the hands of the nurse. This is the greatest piece 
 of economy in the entire plan, when seen in comparison 
 with present systems, many of them requiring far more 
 time at clerical work, and inter-school traveling than in 
 actual school medical service. 
 
 E. The nurse-alone plan is probably best in very poor 
 districts, unable to provide a complete system. Later, phy- 
 sicians can be added. This is the direct opposite of the 
 usual plan, of employing physicians and then, if possible, 
 adding nurses. The nurse's service is usually cheap, efficient, 
 and directed toward getting the results that count: preven- 
 tion and cures. So far as inspection goes, nurses are able 
 to find most of the serious cases needing care and treat- 
 ment. We very much need better training of nurses for 
 school work, but not any more than we need such train- 
 ing for school physicians. We prophesy that well-trained 
 school nurses will soon take the place of part-time physicians 
 in medical supervision. There will be a supervisor of 
 hygiene with assistants, and physicians in school clinics. 
 
 F. The plan as here offered for trial is not guaranteed 
 perfect. It is very imperfect, and nothing will take the 
 place of careful study of local conditions, careful adaptation 
 of this and other plans, and careful training of doctors, 
 nurses, teachers, and pupils in carrying it out efficiently. 
 The skilled medical supervisor will be necessary for this 
 work with any plan, and scientific supervision and study will 
 be sure to bring health results. 
 
EXPERIMENTAL EDUCATION FOR 
 SCHOOL PROBLEMS 
 
 "My first and in some respects my deepest im- 
 pression of the evening spent so enjoyably in 
 Edison's laboratory is not directly connected with 
 the educational value of his motion picture 
 scheme. It is rather of the immense advantage 
 a great commercial enterprise has over the great- 
 est of our existing educational institutions in the 
 matter of conducting systematically an experi- 
 mental development of a new proposal before 
 putting it into general practice. 
 
 "No intimation zvas given of the sum of money 
 that is being put into the development of this 
 new undertaking. But it is clear that a large 
 staff is employed to develop 'scenarios' to make 
 suggestions and criticisms, and to try out various 
 schem,es, in addition to the expense involved in 
 taking the pitcures themselves. A large sum of 
 money will have been spent before pecuniary 
 returns begin to come in — a good deal of it strict- 
 ly experimental inquiry. 
 
 "Where is there a school system having at 
 command a sum of money with which to investi- 
 gate and perfect a scheme experimentally, be- 
 fore putting it into general operation? And can 
 we expect continuous and intelligent progress in 
 school matters until the community adopts a 
 method of procedure which is now a common- 
 place with every great industrial undertaking? 
 Is not the existing method of introducing re- 
 forms into education a relic of an empirical cut- 
 and-try method which has been abandoned in 
 all other great organisations? And is not the 
 failure to provide funds so that experts may 
 work out projects in advance a pennywise and 
 poundfoolish performance?" — John Dewey, in 
 the Survey for September 6, 1913. 
 
PART ONE 
 
 THE NATIONAL AND SCHOOL HEALTH PROBLEM 
 AND HOW IT IS BEING MET 
 
THE NATIONAL HEALTH PROBLEM 
 
 "In the continental United States with over 90 
 million souls probably 23^ million children are 
 annually born. When we think of the influence 
 of a single man in this country, of a Harriman, 
 of an Edison, of a William James, the poten- 
 tiality of these 25^ million annually can be dimly 
 conceived as beyond computation. But for bet- 
 ter or worse this potentiality is far from being 
 realised. Nearly half a million {one- fifth) of 
 these infants die before they attain the age of 
 one year; and half of all are dead before they 
 reach their twenty-third year — before they have 
 had much chance to affect the world one way 
 or another. However, with only one and a 
 quarter million of the children born each year — 
 destined to play an important part for the nation 
 and humanity we could look with equanimity on 
 the result. But alas! only a small part of this 
 army will be fully effective. On the contrary, 
 of the 1200 thousand who reach full maturity 
 each year 40 thousand will be ineffective through 
 temporary sickness, 4 ^0 5 thousand will be 
 segregated in the care of institutions, unknown 
 thousands will be kept in poverty through mental 
 deficiency, other thousands will be the cause of 
 social disorder and still other thousands will be 
 required to tend and control the weak and un- 
 ruly. We may estimate at not far from 100 
 thousand, or 8 per cent., the number of non- 
 productive or only slightly productive, and prob- 
 ably this proportion would hold for the 600 
 thousand males considered by themselves." — 
 Davenport, in "Heredity in Relation to Eu- 
 genics." 
 
CHAPTER ONE 
 THE NATIONAL HEALTH PROBLEM 
 
 I. EDUCATION AND PUBLIC HEALTH 
 
 Health is the fundamental prerequisite for both indi- 
 vidual and social happiness and efficiency. It stands in such 
 intimate and vital relationship to existence itself and to the 
 first law of life, self-preservation, that it must ever be a 
 foremost problem of individual and social policy. The 
 primary business of a sick man is to get well and to stay 
 well; likewise, the primary business of the public and the 
 state is to provide for healthful conditions and healthy lives. 
 Private and social practice which preserves and promotes 
 health and abundant life is, from this standpoint, good; 
 that which contributes to ill-health or race-degeneracy, 
 though it bring forth some of the best of the goods of life, 
 is wrong. Theoretically, at least, everyone will agree with 
 the thought emblazoned in great letters over the stage in 
 Der Mensch building at the recent International Hygiene 
 Exhibition at Dresden: No Wealth Is Equal to Thee, 
 O Health.i 
 
 That a very much larger proportion of people than nec- 
 essary are not realizing this great eternal value of life, 
 good health, is also a matter of common knowledge. The 
 progress of medical and sanitary science in the last fifty 
 years has brought, one by one, most of the insidious destroy- 
 ers of life and health into the light of day. These discov- 
 eries have not only overturned hoary health traditions, such 
 as the commonly accepted opinion that malaria and yellow 
 fever were caused by "night air" instead of by the bills 
 of certain ubiquitous mosquitoes, but they have followed 
 
 17 
 
1 8 SCHOOL HEALTH ADMINISTRATION 
 
 each other in such rapid succession that health science, 
 known by the few, is today, at least twenty, and in many 
 ways forty, years ahead of common knowledge and general 
 practice.^ It is the purpose of this chapter to face the health 
 problem of the nation and, so, of the schools, endeavoring 
 to determine something of its nature and extent and the 
 responsibility it places upon public school systems. 
 
 Probably the most important scientific studies of public 
 health in America recently are Professor Fisher's "National 
 Vitality"^ and Flexner's "Medical Education in the United 
 States and Canada"'^ ; the first, by the statistical methods 
 evolved by the great life insurance companies, outlining 
 the enormous extent and the tremendous importance of the 
 problem ; and the second, by personal visitation and scientific 
 methods, determining the almost criminal inadequacy of 
 many of the present instruments for providing health lead- 
 ers.^ In the first is given at length the evidences and facts 
 relating to the improvability of health conditions in this 
 country. Fisher shows the methods by which eighteen ex- 
 perts in various diseases, mortality statistics, and sanitary 
 science determined the ratio of preventability for the ninety 
 different causes of death into which mortahty is classified. 
 This ratio is defined as "the fraction of all deaths which 
 would be avoided if knowledge now existing among well- 
 informed men in the medical profession were actually ap- 
 plied in a reasonable way and to a reasonable extent."^ That 
 the ratios thus determined are careful, conservative figures, 
 not implying, for example, any advance in medical discov- 
 eries nor the complete socialization of health knowledge 
 now possessed by the few, an inspection of his table of 
 ratios will quickly show. Most persons, perhaps, would In- 
 crease many of these ratios, since the race is slowly coming 
 to take the view expressed by Pasteur when he said that 
 "it is within the power of man to rid himself of every para- 
 sitic disease." We have reason to believe in "the improv- 
 ability of man," and we know that the first step and con- 
 dition of such conscious evolution is health and life itself. 
 
NATIONAL HEALTH PROBLEM 19 
 
 II. NATIONAL HEALTH LOSSES 
 
 A. In Preventable Deaths 
 
 The recently published federal "Mortality Statistics"^ 
 for the year 19 10 show that in the "registration area" 
 of continental United States over eight hundred thousand 
 persons died (805,412). The registration area consists of 
 those states and cities that are conscious enough of their 
 health problems to enforce such recording of deaths as will 
 be accepted by the Census Bureau.^ This area consists of 
 twenty-two states, counting the District of Columbia 
 (City of Washington) as a state, and forty-three cities in 
 non-registration states, and including about three-fifths of 
 the population of continental United States (53,843,896 out 
 of 92,309,348 or 58.3 per cent).^ The registration area for 
 births is very much smaller. 
 
 It is impossible, then, for the people of the United 
 States, as contrasted with several modern nations, to know 
 accurately either the national birth rate or death rate. Com- 
 paratively lax enforcement of registration laws in many 
 places makes even the statistics from the registration area 
 underestimates. The statistical death rate of this area for 
 the year 19 10 is, however, 15 per 1000 population, the 
 annual average for ten years being about sixteen ; and, for 
 the year 1910, 16. i in registration cities, 14.7 in registra- 
 tion states, 15.9 in cities of registration states, 13.4 in the 
 rural portion of registration states, and 16.9 in the regis- 
 tration cities of other states.^" Wilcox estimates the true 
 average death rate for the United States as 18 a thousand. -^^ 
 
 Using the ratio of registration-area population to the 
 total population, 58.3 per cent, and the number of deaths 
 occurring in the registration area, 805,412, we can com- 
 pute the probable death loss for the country. Or, we can 
 find what an average death-rate of fifteen a thousand would 
 mean for the entire population, 92,843,896 (July i, 19 10, 
 estimate). From such computation we get a total death 
 loss to continental United States of 1,392,660. Applying 
 the estimate of Wilcox, 18, we obtain a loss of 1,671,228, 
 Professor Fisher considers 18 as a minimum true rate, and 
 
20 SCHOOL HEALTH ADMINISTRATION 
 
 this seems reasonable, so a death loss for 19 lo of 1,600,000 
 seems entirely conservative, and would probably be, too, 
 very near the average number of deaths year by year. In 
 other words, a little less than two per cent of our total pop- 
 ulation dies each year, and at the exceedingly low median 
 age of 38.^^ How much of this astounding death loss is 
 unnecessary and preventable we shall now tr3^ to see. 
 
 PREVENTABLE VITAL AND ECONOMIC LOSSES 
 
 The average ratio of preventability for these death 
 losses, as computed by Fisher from the combined conser- 
 vative estimates furnished by the eighteen experts, ranging 
 in eighteen cases from zero for such diseases as epilepsy 
 to 85 per cent preventable for typhoid fever, alcoholism, 
 and puerperal septicemia. Is found to be 42.3 per cent.^^ In 
 other words two-fifths of the deaths now occurring in the 
 United States are reasonably preventable or postponable. 
 With the advance of medical science each year this ratio 
 will rise. Even as the above lines were being written, 
 March 22, 19 12, word came from the United States Hy- 
 gienic Laboratory that Director Anderson and Surgeon 
 Goldberger had scientifically demonstrated that the "prin- 
 cipal, if not the only, means of spreading typhus fever" was 
 pediculae (head lice), the trouble found more frequently 
 and more commonly in most cities by medical inspectors of 
 schools than any other ailment, with the exception of den- 
 tal carles. ^^ 
 
 Applying this figure, 42 per cent, to the estimated num- 
 ber of deaths each year we get as the number of pre- 
 ventable deaths occurring annually, 672,000. 
 
 What does the preventable and unnecessary loss of life 
 of over 670,000 persons in a normal year mean in anguish, 
 illness, and money to the people of the United States? 
 The psychological losses of this character, although the 
 most terrible of earth's sorrows, we are as yet unable to 
 estimate. The average family is about four, so, at least, 
 three times as many persons (2,010,000) annually are ex- 
 tremely intimately and seriously affected. 
 
NATIONAL HEALTH PROBLEM 21 
 
 ECONOMIC DEATH LOSSES 
 
 Various methods of computing the economic losses have 
 been worked out. Doctors Locke and Floyd of the Out- 
 Patient Department of the Boston Consumptives Hospital 
 have recently patiently investigated the economic loss re- 
 sulting from 500 male consumptives, who had visited the 
 hospital in the last five years. ^^ The capitalized value of 
 the earnings cut off by the deaths of 244 of the men is 
 computed as about a million and a half dollars, or an 
 average of about $6,164 each. 
 
 Professor Fisher's calculated "average economic value 
 of the lives now sacrificed by preventable deaths, using the 
 age distribution of deaths, and the percentages of preven- 
 tability" is $1700 each.^^ 
 
 For the 670,000 preventable deaths in this country in 
 19 10, we should have a financial loss to the nation equal to 
 the product of these two figures (670,000 times $1700) 
 which is $1,139,000,000, considerably over a billion dollars. 
 
 The accompanying table and summary have been made 
 by condensing the U. S. Mortality Statistics which give 189 
 causes of death. Table II, given in italics, is here included. 
 B. National Illness Losses. Vital and Economic 
 
 But many are ill for each one who dies. "Few who have 
 not studied the facts realize how common illness is, although 
 we all know it is sufficiently common to make the question 
 'How are you?' the ordinary form of salutation." The 
 above mentioned Report of the National Conservation Com- 
 mission on National Vitality (page 741) furnishes the 
 estimate that in the United States there are constantly three 
 million persons on the sick list. It is computed that 750,000 
 of these cases (in 1907) are those of persons thrown out 
 of employment by their illness. The average earnings, 
 computed as $700 a year, lost each year in this way would 
 then be 750,000 times $700, which is over $500,000,000, 
 a half billion dollars. 
 
 If we take more recent statistics of annual wages and 
 the present amount of illness, we obtain other figures. Pro- 
 fessor Scott Nearing computes from a wide study of our 
 wage statistics in industrial sections "that half of the adult 
 
22 SCHOOL HEALTH ADMINISTRATION 
 
 TABLE I. 
 
 CAUSES OP DEATH FOR THE REGISTRATION AREA 
 
 All Children of School Ages. 
 
 Ages. 5 to 9 10 to 14 15 to 19 
 
 All Causes 805,412 17,943 11,736 19,772 
 
 I. General diseases 215,692 8,891 4,978 9,770 
 
 1. Typhoid fever 12,673 684 854 1,681 
 
 2. Malaria 1,167 58 40 67 
 
 3. Small pox 202 6 6 17 
 
 4. Measles 6,598 588 152 112 
 
 5. Scarlet fever 6,255 1,731 442 232 
 
 6. Whooping cough 6,146 228 17 10 
 
 7. Diphtheria and croup 11,521 2,938 700 228 
 
 8. Influenza 7,774 122 73 119 
 
 9. Cholera nostras 536 14 8 7 
 
 10. Dysentery 3,446 47 15 IS 
 
 II. Erysipelas 2,442 8 14 35 
 
 12. Other epidemic diseases.... 198 23 11 3 
 
 13. Purulent infection, etc 1,877 73 62 86 
 
 14. Rabies 64 13 9 6 
 
 15. Tetanus 1,373 162 153 88 
 
 16. Pellagra 368 4 5 12 
 
 17. Tuberculosis (of lungs) 73,214 489 1,048 5,166 
 
 18. Tuberculosis (other) 13,095 933 586 933 
 
 19. Rickets 455 13 8 4 
 
 20. Syphilis 3,221 24 11 36 
 
 21. Gonococcus infection 197 . . 1 17 
 
 22. Cancer and other m. tumors 41,039 83 76 152 
 
 23. Other tumors 553 9 4 6 
 
 24. Acute articular rheumatism. 3,328 327 357 261 
 
 25. Diabetes 8,040 144 206 258 
 
 26. Leuchemia 864 44 35 39 
 
 27. Anemia, chlorosis 2,614 39 40 70 
 
 28. Other general diseases 5,014 4 10 67 
 
 11. Nervous Sys. — Special Sense 77,991 1,368 889 976 
 
 29. Encephalitis 761 34 37 39 
 
 30. Meningitis 7,619 683 365 294 
 
 31. Spinal cord, other dis 4,101 264 146 130 
 
 32. Aploplexy, cereb. hem 39,701 47 46 103 
 
 33. Paralysis, without spec, cause 7,756 27 21 29 
 
 34. Epilepsy 2,287 79 118 172 
 
 35. Convulsions (nonpeuperal) . 200 54 9 18 
 
 36. Chorea, St. Vitus Dance... 123 13 18 41 
 
 37. Nervous system, other D. . . 2,069 70 58 63 
 
 38. Ear diseases 967 92 64 46 
 
 III. Circulatory System 100,106 999 1,319 1,447 
 
 39. Pericarditis 650 32 32 14 
 
 40. Endocarditis, acute 4,792 203 226 196 
 
 41. Organic D. of the heart 76,178 716 1,011 1,158 
 
 42. Angina pectoris 3,869 7 12 17 
 
 43. Embolism and thrombosis. . 1,990 20 19 33 
 
 44. Lymphatic system, Dis 255 14 9 9 
 
 IV. Respiratory System 100,835 2,035 956 1,517 
 
 45. Nasal fossae Disease 135 9 9 5 
 
 46. Larynx, Dis. of 746 90 13 11 
 
 47. Bronchitis, acute 7,229 90 21 21 
 
 48. Bronchitis, chronic 5,391 62 30 36 
 
 49. Bronchopneumonia 25,337 522 148 158 
 
 50. Pneumonia 54,187 1,138 664 1,140 
 
 51. Pleurisy 2,150 66 32 83 
 
 52. Pulmonary cong't'n, P. Ap 24,499 28 17 17 
 
 53. Other D. of Resp. System.. 1,174 16 13 28 
 
 V. Digestive System 104,801 1,669 1,270 1,429 
 
 54. Mouth and annexa, D 423 11 4 6 
 
 55. Pharynx 840 123 51 40 
 
 56. Ulcer of stomach 2,203 13 18 47 
 
 57. Other D. of stomach (not c) 8,403 116 57 73 
 
 58. Diarrhea and enteritis 63,180 469 132 91 
 
 59. Appendicitis and typhlitis.. 6,128 571 718 754 
 
 56. Hernia 2,192 8 6 21 
 
 57. Intestinal obstruction 4,486 127 88 117 
 
 58. Other diseases of the Intest. 1,571 25 20 22 
 
 * Condensed from the table giving 189 different causes. 
 
 1910.* 
 
 Age 
 
 
 group 
 
 Total. 
 
 f most 
 
 5-14 
 
 deaths 
 
 29,679 
 
 0- 1 
 
 13,869 
 
 25-29 
 
 1,537 
 
 20-24 
 
 98 
 
 20-24 
 
 12 
 
 0- 1 
 
 740 
 
 1- 2 
 
 2,173 
 
 5- 9 
 
 245 
 
 0- 1 
 
 3,638 
 
 5- 9 
 
 195 
 
 70-74 
 
 22 
 
 0- 1 
 
 62 
 
 0- 1 
 
 22 
 
 0- 1 
 
 34 
 
 0- 1 
 
 135 
 
 0- 1 
 
 22 
 
 5- 9 
 
 315 
 
 0- 1 
 
 9 
 
 30-34 
 
 1,537 
 
 25-29 
 
 1,519 
 
 20-34 
 
 21 
 
 0- 1 
 
 35 
 
 0- 1 
 
 1 
 
 0- 1 
 
 3 
 
 60-64 
 
 13 
 
 65-74 
 
 684 
 
 10-14 
 
 350 
 
 60-64 
 
 79 
 
 40-55 
 
 79 
 
 60-64 
 
 14 
 
 0- 1 
 
 2,257 
 
 70-74 
 
 71 
 
 0- 1 
 
 1,048 
 
 0- 1 
 
 410 
 
 65-69 
 
 93 
 
 70-74 
 
 48 
 
 70-74 
 
 197 
 
 25-29 
 
 63 
 
 5- 9 
 
 31 
 
 15-19 
 
 128 
 
 50-54 
 
 156 Underl 
 
 2,318 
 
 65-69 
 
 64 
 
 65-69 
 
 429 
 
 55-59 
 
 1,727 
 
 70-74 
 
 19 
 
 65-69 
 
 39 
 
 65-69 
 
 23 
 
 0- 1 
 
 299 
 
 0- 1 
 
 14 
 
 0- 1 
 
 103 
 
 0- 1 
 
 111 
 
 75-79 
 
 92 
 
 75-79 
 
 670 
 
 0- 1 
 
 1,802 
 
 0- 1 
 
 98 
 
 60-64 
 
 45 
 
 0- 1 
 
 29 
 
 0- 1 
 
 2,939 
 
 0- 1 
 
 15 
 
 0- 1 
 
 174 
 
 5- 9 
 
 31 
 
 45-49 
 
 173 
 
 0- 1 
 
 601 
 
 0- 1 
 
 1,289 
 
 15-18 
 
 14 
 
 65-69 
 
 215 
 
 0- 1 
 
 45 
 
 0- 1 
 
NATIONAL HEALTH PROBLEM 
 
 23 
 
 TABLE I.- 
 
 59. Cirrhosis of liver 7,485 
 
 60. Other diseases of liver 3,092 
 
 61. Peritonitis (nonpuep) 2,419 
 
 62. Other D. of digestive system 329 
 
 VI. Genito-urinary Sys. Nonv 62,559 
 
 63. Nephritis acute 5,665 
 
 64. Bright's disease 47,665 
 
 65. Kidneys, other D. of 1,389 
 
 66. Other D. of uterus 774 
 
 67. Salpingitis, and other F. D. 1,298 
 
 VII. The pueperal state 8,455 
 
 VIII. Skin and cellular tissue. 3,008 
 
 68. Gangrene 1,748 
 
 69. Abscess, acute 506 
 
 IX. Bones and locomotion organs 1,317 
 
 70. Bones, not T. B 1,145 
 
 71. Joints, not T. B. or Rheum. 119 
 
 X. Malformations 7,998 
 
 72. Hydrocephalus 685 
 
 73. Congen. M. of heart 4,821 
 
 XI. Early Infancy 
 
 XII. Old age 
 
 XIII. External Causes 57,196 
 
 74. Suicide 8,590 
 
 75. Accidental or undefined.... 45,416 
 
 XIV. Ill Defined Diseases 12,462 
 
 ■Continued. 
 
 
 
 
 
 15 
 
 16 
 
 25 
 
 31 
 
 50- 
 
 54 
 
 36 
 
 35 
 
 34 
 
 71 
 
 60- 
 
 64 
 
 132 
 
 109 
 
 162 
 
 241 
 
 20- 
 
 24 
 
 9 
 
 4 
 
 7 
 
 13 
 
 50- 
 
 54 
 
 509 
 
 447 
 
 780 
 
 956 
 
 70- 
 
 ■74 
 
 253 
 
 165 
 
 199 
 
 418 
 
 40-44 
 
 224 
 
 263 
 
 440 
 
 487 
 
 70- 
 
 ■74 
 
 22 
 
 6 
 
 16 
 
 28 
 
 0- 
 
 ■ 1 
 
 1 
 
 5 
 
 29 
 
 6 
 
 25- 
 
 ■29 
 
 1 
 
 2 
 
 75 
 
 3 
 
 25-29 
 
 
 11 
 
 620 
 
 11 
 
 25- 
 
 -29 
 
 26 
 
 14 
 
 31 
 
 40 
 
 0- 
 
 ■ 1 
 
 10 
 
 7 
 
 8 
 
 17 
 
 75- 
 
 -79 
 
 12 
 
 5 
 
 9 
 
 17 
 
 0- 
 
 1 
 
 100 
 
 95 
 
 89 
 
 195 
 
 0- 
 
 . V 
 
 93 
 
 90 
 
 81 
 
 183 
 
 0- 
 
 • 1 
 
 6 
 
 4 
 
 5 
 
 10 
 
 35- 
 
 39 
 
 76 
 
 36 
 
 20 
 
 112 
 
 0- 
 
 - 1 
 
 30 
 
 11 
 
 4 
 
 41 
 
 0- 
 
 - 1 
 
 33 
 
 25 
 
 13 
 
 55 
 
 0- 
 
 0- 
 
 80- 
 
 ■ 1 
 • 1 
 
 ■84 
 
 2,193 
 
 1,678 
 
 3,024 
 
 3,871 
 
 25- 
 
 30 
 
 1 
 
 31 
 
 326 
 
 32 
 
 35- 
 
 39 
 
 2,161 
 
 1,599 
 
 2,525 
 
 3,760 
 
 20- 
 
 24 
 
 74 
 
 43 
 
 68 
 
 117 75-79 
 
 males of the United States (at least east of the Rockies 
 and north of the Mason and Dixon line) are earning less 
 than $500 a year; that three-quarters of them are earning 
 less than $600 annually; that nine-tenths are receiving less 
 than $800 a year, while less than ten per cent receive 
 more than that figure. "^'^ $5 50 or $600 w^ould then be, 
 perhaps, a more characteristic figure than the $700 taken by 
 Fisher. However, considering the increase In average num- 
 ber of Illnesses since 1907 and the conservative character 
 of the findings, we may let the annual potential-earnings- 
 loss through illness stand as five hundred million dollars. 
 
 The Nearing wage statistics, in the light of the com- 
 puted minimum standards of living, will be found useful 
 later on in throwing light on the cause of malnutrition 
 and other ailments of school children and the necessity of 
 free treatments of children in school clinics. 
 
 The Locke and Floyd investigations, above referred to, 
 show that, of the 500 male consumptive cases (41 per 
 cent between the ages of twenty and thirty-nine), by May i, 
 
24 SCHOOL HEALTH ADMINISTRATION 
 
 191 1, the date of the investigation, the 244 dead men had 
 lost an average of 58.03 weeks of work from the onset of 
 their disease until death. Their average weekly wages had 
 been $11.89 and their total loss was, therefore, $170,965. 
 The 256 living cases had lost an average of 89.3 weeks 
 of work at an average wage of $11.38, a combined loss 
 of $255,074, making a total loss in wages alone to the 
 five hundred men of $426,039, an average of $852 each. 
 
 ECONOMIC LOSSES IN MEDICAL CARE 
 
 But lost wages are not the only illness losses. There 
 is the further expenditure for medical attendance, medicine, 
 nursing, etc. These five hundred sick men selected at ran- 
 dom, cost the city of Boston in public hospital and other 
 institutional care $73,984. This is exclusive of large sums 
 spent by private organizations on 406 out of the 500 cases. 
 This makes the loss of wages and cost of medical care at 
 least $500,023 plainly accounted for. With the first item 
 of loss-of-potential-earnings through preventable death of the 
 244 men, we have a total economic loss of about $2,000,000; 
 and 256 cases were not yet ended by death or cured. 
 
 The first group lost in wages $618.28 in a year of 52 
 weeks; the second group lost $591.76 in the same time. So 
 we could say that the annual loss in wages for these men 
 was on the average $600. The total number of weeks lost 
 by both groups was 37,020, an average of 74 each. In a 
 year of 52 weeks of this time, their cost to the municipality 
 of Boston was about 52/74 of $73,984, or $51,988. 
 This is an average cost for each man of over a hundred 
 dollars a year ($103.97, practically $104). 
 
 The cost in care to the relatives of these men and the 
 cost to private philanthropic institutions is not given. 
 
 "The cost per day or year of other illnesses than tuber- 
 culosis is presumably greater, and also the cost per day for 
 other classes is higher than for the poor."^^ Applying to 
 the three million and more persons constantly ill in the 
 United States this partial annual cost to public institutions 
 
NATIONAL HEALTH PROBLEM 25 
 
 of $100 for each consumptive, we have a total annual loss 
 for public care of $300,000,000. 
 
 OTHER ESTIMATES 
 
 A second estimate for total illness expenses to the con- 
 sumptive poor, set at $1.50 a day by Dr. Biggs of New 
 York, applied to the three million persons constantly ill, 
 gives a total of a billion and a half dollars. 
 
 Another estimate is based upon an investigation by the 
 United States Department of Labor of five thousand work- 
 ingmen's families. Their average expenditure for illness 
 and death amounted to $27 a year. For the more than 
 eighteen million families in the country this estimate, more 
 than conservative for all classes, would make over $486,- 
 000,000. The three estimates, the first and last very pains- 
 takingly made, are : 
 
 $300,000,000 estimate for public institutional care of 
 sick. 
 
 $500,000,000 estimate for total cost of illness. 
 
 $486,000,000 estimate for cost to all families. 
 
 The first and last give only very partial costs. It would 
 seem, then, that $500,000,000 v/ould be a very conservative 
 estimate of the actual cost of illness care for the people of 
 the United States each year. 
 
 Adding together, finally, the capitalized earning power 
 of the workers dying from preventable diseases and acci- 
 dents each year, over a billion dollars, the annual idleness 
 loss enforced by serious illness of over five hundred million 
 dollars, and the cost of institutional and private care of 
 the sick amounting to more than another five hundred mil- 
 lion dollars and we have a total annual loss to this country 
 and its people of over two billion dollars, certainly a sum 
 of sufficient proportions to warrant the most serious con- 
 sideration of public health measures by all citizens. 
 
 In terms of direct or indirect illhealth losses (some 
 form of taxation) it means for each family a loss con- 
 siderably over a hundred dollars a year. (For eighteen 
 million families, $111 each.) And this, in the Fight of 
 
26 SCHOOL HEALTH ADMINISTRATION 
 
 the Nearing efficiency wage statistics, means about twenty 
 per cent, or more, of the median family income. When 
 a majority of a people, already near or below a satisfactory 
 standard of living, are forced to throw away such a large 
 proportion of their meager incomes and to render up so 
 many victims to health ignorance we evidently have a 
 national problem which should receive first attention and 
 speedy solution everywhere. 
 
 C. Losses Due to Minor Ailments, Physical Defects, 
 Undue Fatigue, and Generally Lowered Efficiency 
 The morbidity losses above computed are those of deaths 
 and relatively acute and serious illnesses. These are all that 
 curative medicine has to any considerable extent so far 
 recognized. Modern and future preventive medicine will 
 look more and more to incipient and beginning diseases. 
 The vicious sequences, like undue fatigue, then "bad cold," 
 then consumption, and finally death, are entirely too frequent 
 for a schooled and civilized people. Different estimates 
 by competent observers^® show that on the average for "well" 
 persons from three to five days are lost each year because 
 of such indispositions as indigestion, sick headache, tooth- 
 ache, neurasthenia, and bad colds.*^^ That most of these 
 are easily preventable losses a host of competent witnesses 
 give assurance. Doctor Luther H. Gulick, for example, 
 says that "something like nine-tenths of all the minor ail- 
 ments that we have, and which constitute the chief source 
 of decreasing our daily efficiency, could be removed by 
 careful attention." And further, "With the removal of 
 nine-tenths of our disabilities and the conservation and 
 further development of our natural powers the average 
 person can increase his efficiency lOO per cent, that is, 
 he can be twice as effective. This does not refer to doing 
 merely or mainly twice as much work, of course, but by 
 making less mistakes, and by working at a higher degree 
 of speed when he does his work." 
 
 We shall not attempt to compute in financial terms 
 these widespread losses of efficiency from minor ailments. 
 
NATIONAL HEALTH PROBLEM 27 
 
 They constitute a large part of the general unnecessary- 
 health losses of the nation. These great and serious 
 problems of the nation are the first problems of 
 its institutions. In the case of the health problem 
 we have a universal need which, because of its foundation 
 m ignorance, is peculiarly the problem of the public school, 
 the fundamental agency of social improvement and reform. 
 Legislative changes bringing to families pure water, light, 
 air and foods, or better incomes and hours of labor, or 
 better protection from disease germs — all these wait on the 
 generation with more adequate health knowledge, health 
 habits, and health responsiveness. Better health knowledge, 
 better health habits, and greater sensitiveness to bad health 
 conditions must come very largely with the children from the 
 public schools. What the health problem means to the 
 schools themselves let us now inquire. 
 
 Complete references at end of Chapter Two. 
 
CHAPTER TWO 
 THE SCHOOL HEALTH PROBLEM 
 
 PREVENTABLE SCHOOL LOSSES^ VITAL AND ECONOMIC 
 
 /. Death Losses 
 
 The death losses of the boys and girls of the public 
 schools, are, in the light of their preventability, appalling. 
 The 1 9 10 Mortality Statistics show that in the registration 
 area alone a total of about fifty thousand children, between 
 the ages of five and nineteen inclusive, died during the 
 year. Very few cities in the United States give separate 
 statistics of the deaths of school children. Children elim- 
 inated by death have received little more attention or study 
 in the past than those retarded or eliminated by illness and 
 other causes. So neither the Census Bureau nor the Bureau 
 of Education have the facts. An approximate computation 
 may, however, be made. 
 
 In the age group, 5 to 9 years, in 19 10 there died in 
 the registration area 17,943 children (2.2 per cent of all 
 deaths) ; in the 10 to 14 years' group, 11,736 children died 
 (1.5 per cent) ; and in the 15 to 19 years' group there was 
 a death loss of 19,772, or 2.5 per cent of the total number 
 of deaths of all ages. (I have been unable to get the 
 number dying at each year of Hfe.) For the 5 to 14 years' 
 group the total is approximately thirty thousand (29,679) ; 
 and for the 5 to 19 years' group the total is about fifty thou- 
 sand (49,451). Most school children will, of course, be 
 found in the first group, 5 to 14, although many will be 
 found in the second group because of the higher deathrate, 
 and the number in secondary schools. 
 
 38 
 
SCHOOL HEALTH PROBLEM 29 
 
 Calculated as was the total number of deaths in the 
 United States, we find that the deaths between the ages five 
 and nineteen would be 6.2 per cent (sum of the above per- 
 centages) of the total number of deaths in continental 
 United States (1,600,000), or practically a hundred thou- 
 sand (99,200), 
 
 Not all these children were enrolled school children. 
 Dr. G. D. Strayer's "Introductory Survey" to the 19 10 
 report of the Commissioner of Education shows that in the 
 school year, 1908-9, more than seventy (72.22) per cent 
 of the children between the ages 5 and 18 inclusive were 
 enrolled in the '"'"common schools." This does not, how- 
 ever, take in the nineteen-year group included above, nor 
 the private school enrollment. 
 
 72.22 per cent of 99,200 is 71,642. Deducting very 
 liberally for the nineteen-year group, by methods largely 
 estimations, we should say that, at the very least, 65,000 
 of the children enrolled in the public schools died during 
 the calendar year. 
 
 TABLE III. 
 SHOWING THE PREVENTABILITY OP DEATHS OP CHILDREN OP ELEMEN- 
 TARY SCHOOL AGE, 5-14, FOR 25 MOST NUMEROUS 
 CAUSES OP DEATH, 1910 
 
 No. deaths Per cent Total No. No. Pre- 
 
 in regis- Pre- deaths ventable 
 
 Causes of Deaths. tration area. ventable. in the U. S. deaths. 
 
 1. Accidents 3,760 . . 6,300 .... 
 
 2. Diphtheria and croup 3,638 70 6,200 4,340 
 
 3. Scarlet fever 2,173 50 3,700 1,850 
 
 4. Pneumonia 1,802 45 3,050 1,370 
 
 5. Heart, organic disease 1,727 25 3,000 750 
 
 6. Typhoid fever 1,537 85 2,600 2,210 
 
 7. Tuberculosis of lungs 1,537 75 2,600 1,950 
 
 8. Tuberculosis, other 1,519 75 2,560 1,920 
 
 9. Appendicitis 1,218 50 2,160 1,080 
 
 10. Meningitis 1,048 70 1,600 1,120 
 
 11. Measles 740 40 1,250 500 
 
 12. Rheumatism, articular 684 10 1,150 116 
 
 13. Broncho-pneumonia 670 50 1,140 570 
 
 14. Diarrhea and enteritis 601 60 1,020 612 
 
 15. Brighfs disease, kidneys 487 40 820 328 
 
 16. Endocarditis, heart 429 25 730 182 
 
 17. Nephritis, acute, kidneys 418 30 700 210 
 
 18. Spinal cord, others 410 . . 690 
 
 19. Diabetes 350 10 500 60 
 
 20. Tetanus, lockjaw 315 80 530 424 
 
 21. Whooping cough 245 40 410 164 
 
 22. Peritonitis 241 55 400 220 
 
 23. Intestinal obstruction 215 25 390 97 
 
 24. Epilepsy 197 . . 330 
 
 25. Influenza, grippe 195 50 330 82 
 
 26,227 67* 44,270** 20,155 
 
 Total number of deaths, 5-14, in registration area, 29,679. 
 Total number of deaths, 5-14, in the U. S., about 50,000. 
 Total number deaths preventable, about 33,500. Based upon 1910 U. S. 
 Mortality Statistics and Fisher's Preventability Tables. 
 
 *Pisher's average. **Estimated. 
 
30 SCHOOL HEALTH ADMINISTRATION 
 
 TABLE IV. 
 
 SHOWING THE PREVENTABILITY OP DEATHS OP CHILDREN OF HIGH 
 
 SCHOOL AGE, 15-19, FOR 25 MOST NUMEROUS CAUSES 
 
 OF DEATH IN 1910. 
 
 No. deaths . Per cent Total No. No. Pre- 
 
 in regis- Pre- deaths veritable 
 
 Causes of Deaths. tratlon area. veritable. in the U. S. deaths. 
 
 1. Pulmonary Tuberculosis 5,166 75 8,650 6,487 
 
 2. Accidents and undefined 2,525 .. 4,230 .... 
 
 3. Typhoid Fever 1,681 85 2,830 2,405 
 
 4. Heart Disease, Organic 1,158 25 1,940 485 
 
 5. Pneumonia 1,140 45 1,920 864 
 
 6. Tuberculosis, other parts 933 75 1,750 1,177 
 
 7. Appendicitis 754 50 1,270 63r. 
 
 8. Bright's Disease 440 40 740 296 
 
 9. Suicide 326 . . 550 .... 
 
 10. Meningitis 294 70 500 350 
 
 11. Rheumatism, Articular 261 10 450 45 
 
 12. Diabetes 258 10 450 45 
 
 13. Scarlet Fever 232 50 400 200 
 
 14. Diphtheria and Croup 228 70 400 280 
 
 15. Nephritis, Acute 199 30 340 102 
 
 16. Endocarditis (Heart) 196 25 340 85 
 
 17. Epilepsy 172 . . 300 
 
 18. Peritonitis 162 55 280 154 
 
 19. Broncho-pneumonia 158 50 280 140 
 
 20. Cancer and other tumors 152 . . 260 .... 
 
 21. Spinal Cord, other Dis 130 .. 220 .... 
 
 22. Influenza, Grippe 119 50 200 100 
 
 23. Intestinal Obstruction 117 25 200 50 
 
 24. Measles 112 40 190 76 
 
 25. Apoplexy, Cerebro. Hem 103 35 180 63 
 
 17,016 *67 28,780 14,039 
 
 ♦Fisher's average for all causes of death. 
 
 Total number of Deaths, 15-19, in Registration Area, 19,772. 
 Total number of Deaths, 15-19, in the U. S. about 34,000. 
 Total number of Deaths, 15-19, Preventable, about 24,100. Based upon 1910 
 U. S. Mortality Statistics and Fisher's Preventability Tables. 
 
 PREVENTABILITY, AND ECONOMIC LOSS TO SCHOOLS FROM 
 DEATHS OF SCHOOL CHILDREN 
 
 Professor Fisher's ratio of preventability for childhood, 
 with the median years 2 to 8, is 67 per cent. The percent- 
 age for the children of school age would be considerably 
 higher, not only because of the good means of social control 
 but because of the greater bodily resistance and consequent 
 fewer deaths in the school period as compared with those 
 on either side, older or younger. Seventy per cent would 
 probably be a very low estimate. Seventy per cent of 
 65,000 is over forty-five thousand (45,500). A truer 
 figure would probably be fifty thousand. For an entirely 
 conservative number of preventable deaths of children en- 
 rolled in the public schools (not counting private school 
 children) of the United States, let us take forty thousand 
 (40,000). This is the annual price we pay in the deaths 
 of our school children for inadequate health measures. The 
 two accompanying tables state the facts concretely. 
 
SCHOOL HEALTH PROBLEM 31 
 
 That this is probably a very conservative number future 
 statistics will show. Germany and Sweden have already 
 cut down their death rate for the school ages even more 
 than this.^^ 
 
 MONEY LOSSES 
 
 The biggest problem of the public schools is to get 
 sufficient money to carry on their work. How much have 
 the schools spent In educating these forty thousand children 
 dying of preventable deaths in any one year? Multiplying 
 the average per capita cost of public schools (enrollment 
 basis) of about $23, by this number (23 times 40,000) 
 we have for one year a wasted expenditure of $920,000, 
 probably in all about a million dollars. The median num- 
 ber of years that these children had been in school was 
 probably five. This would make a total annual expenditure 
 by society for which it received no return (in educating 
 pupils who die during school age) amounting to about 
 five million dollars. This sum is exceeded by the total 
 annual 1909-10 school expenditures of only four cities In 
 the United States. 
 
 A statistical fallacy probably creeps in here similar to 
 that evident In the calculated enormous economic losses 
 due to retardation found so frequently In superintendents' 
 reports and statistical studies.^^ The cost of one pupil 
 one year, due to the economic law of diminishing expense, 
 cannot rigidly be called the per capita expenditure, perhaps. 
 But that there is a very large economic loss to a city through 
 educating children who die before the age of productivity, 
 and that a very large share of It is preventable Is In- 
 disputable. 
 
 //. Illness Losses 
 
 A. THEIR EXTENT 
 
 As In the case of actual deaths among pupils, very few 
 school systems keep a separate record of absence due to 
 illness, and so the actual effect of Illness absences as well as 
 lowered pupil efficiency upon retardation and poor school 
 
32 SCHOOL HEALTH ADMINISTRATION 
 
 work are unsolved problems. The amount of absence due 
 to Illness is enormous and can partially be determined by 
 the number of exclusions for contagious diseases, the num- 
 ber of school children, both ill and well, quarantined dur- 
 ing the school year, and the number absent voluntarily be- 
 cause of illness as it may be recorded on the teachers' record 
 books. That at least 50 per cent of such absence Is 
 preventable can be judged from the ratio of preventabllity 
 of deaths for childhood and the fact that much of this 
 loss is due to minor ailments like toothaches and colds. 
 
 The general absence from all causes can rather accur- 
 ately be told. Dr. Strayer's statistics mentioned above^^ 
 show that the "average number of days the schools were 
 kept during the year" for all public schools in the United 
 States was 155.3, while the "average number of days at- 
 tendance by each pupil enrolled" was only 11 2.6. Although 
 the difference of 43 days does not, for various reasons, ac- 
 curately show the total average absence by pupils. It cer- 
 tainly cannot be very far from at least 22 days absence 
 each, an average attendance of 85 per cent. City schools 
 alone have a longer school year and better attendance, of 
 course. This number (22) applied to the total number of 
 pupils enrolled in 1909-10, 17,506,175 (not counting the 
 estimated 1,498,701 private school pupils) gives the total 
 number of days lost in the public schools of the United States 
 through absence, while enrolled, as nearly four hundred 
 million (385,135.850)- 
 
 The recent Sage Foundation Investigation entitled "A 
 Comparative Study of Public School Systems In the Forty- 
 eight States," page 13, shows an average absence ranging 
 from 44.2 per cent In Mississippi to 12.2 per cent in Oregon. 
 The question Is as to the amount due to illness. 
 
 Farr's estimate, used by Fisher, of two persons con- 
 stantly seriously ill for each annual death, applied to the 
 sixty-five thousand deaths of school children would mean 
 a daily-absence through serious illness of 135,000 days, or 
 for the school year of 155 days, 20,925,000 days. This 
 
SCHOOL HEALTH PROBLEM 33 
 
 estimate does not include absences for minor ailments or 
 physical defects, 
 
 THE KEYES' INVESTIGATION 
 
 Dr. Keyes' study of the "Progress Through the Grades 
 of City Schools" gives the average annual amount of 
 absence incurred by 2,033 pupils In a school system (Hart- 
 ford, Conn.) with good attendance, as ten days each, or 
 20,330 days in all.^^ He further says that "this loss of 
 time, under the general acceptance and rigid enforcement 
 in the community of the laws requiring constant attendance 
 and prohibiting child labor, is practically a measure of the 
 amount of illness in all grades from two to eight inclusive.'* 
 Applying this low average loss of ten days annually to the 
 school children of the country, we have an illness loss of 
 ten times eighteen million or 180,000,000 days, about nine 
 times the estimate given above for serious illnesses. The 
 attendance laws were probably very much better enforced 
 in this city than is common, and fewer children were out 
 for minor illnesses than is general. 
 
 This would probably make the illness loss to the great 
 common schools of the country something like two hundred 
 million days annually. In terms of school years of 155.3 
 days each this means a loss of schooling equal to consider- 
 ably over a million school years, 1,290,000. This might 
 be classed as wasted or ineffective expenditure at $23 a 
 year. 
 
 Many other relatively inaccurate methods of computing 
 illness losses might be used. The need is for more accurate 
 and more general records. We shall leave the matter with 
 the probably conservative estimate of an average of two 
 weeks (ten days) for each child in the public schools of 
 the country. This is on the average about seven per cent 
 of the time. When we remember how few days of school- 
 ing in their lifetime most children get this largely prevent- 
 able loss due to illness of from four to seven per cent stands 
 forth in all its enormity. 
 
34 SCHOOL HEALTH ADMINISTRATION 
 
 B. ILLNESS LOSS IN RETARDATION^ ELIMINATION AND NON- 
 PROMOTION 
 I. THE PROBLEM 
 
 Since the classic studies of retardation by Thorndike,^^ 
 Ayres^*', and Strayer^^ there has been a national agitation 
 over this matter. Our mass education has made necessary 
 a large amount of repeating of grades. Children who have 
 not been able to keep up with the large classes have been 
 left behind, to do the half or whole year's work again. 
 The number of such "repeaters" in any school system is 
 large. For the United States as a whole, the number of 
 children repeating grades each semester of the year, is 
 astounding in size. The number of whole years repeated 
 in any one year, equivalent to the same number of children 
 repeating a whole year's work, must be considerably over 
 a half million (600,000)^^ or about two or three pupils to 
 a school room, the country over. Almost half of our pupils 
 are above "normal age." 
 
 Realizing the inaccuracy of all such figures at the present 
 time let us raise also the problem of the effect of illness on 
 retardation. There are at least three ways in which this 
 retarding effect from illness Is felt: the retarding influence 
 of absence, especially long absence due to a contagious 
 disease, for the children ill, the retarding effect on those 
 quarantined or otherwise kept out of school by other school 
 children's quarantine (those In the same house or family), 
 and, third, the effect of lowered physical vitality due to 
 illness. 
 
 A few school superintendents have said privately that 
 pupils absent from illness '''grom while they are out and 
 generally make up their work when they get back to school." 
 Dr. Keyes' study of the actual, yearly. Individual records 
 of a great many children does not bear out this opinion. 
 He shows (page 54) that pupils losing more time than 
 normal pupils have also more arrests; and lose very much 
 more time on the average than accelerates or honor pupils. 
 The average annual loss in days for 683 arrests was 12.3 
 days; for 606 normals 10.2 days; for 613 accelerates still 
 
SCHOOL HEALTH PROBLEM 35 
 
 less, 9.7 days; and for 131 honor pupils 6.8 days, about 
 half the first sum. 
 
 For the longer absences (considered as practically all 
 due to illness) we have the same showing. The per cent 
 of children losing four weeks or more in some one year 
 is: For arrests, 76.6 per cent; for normals, 68.4 per cent; 
 for accelerates 66.6 per cent; and for honors, 45.3 per 
 cent. 
 
 In table 28, Dr. Keyes shows the surprisingly close 
 relationship existing between the number of days school- 
 ing lost and the per cent of arrests during the year of loss. 
 The number of days lost increase as follows: o, 5, 10, 15, 
 20, 25, 30, 35, 40, 45, 50 or more, and the corresponding 
 percentage of arrests in the year of loss increases con- 
 comitantly, as follows: 14, 15, 17, 23, 40, 48, 47, 48, 
 51, 48, 72. This is a correlation of about ninety per cent. 
 
 According to this detailed study of the individual, cumu- 
 lative record cards of pupils, at least twenty-five per cent 
 of all pupils are retarded when they are absent for any 
 length of time less than a month. Absences varying from 
 one to two months stay the progress of fifty per cent of 
 the absentees; and when the loss amounts to fifty days or 
 more, as in the cases of serious illness or long quarantine, 
 nearly seventy-five per cent of all pupils sustaining such ab- 
 sence fail of promotion. 
 
 2. DR. BACHMAN's study OF THE RELATION OF ABSENCE 
 TO NON-PROMOTION 
 
 In his investigation entitled "Report Upon Promotion, 
 Non-Promotion and Part Time" as a part of the recent 
 New York City school inquiry, and distributed about the 
 first of March, 19 13, Dr. Frank P. Bachman gives the 
 methods and results (pages 63-70) of an attempt to dis- 
 cover the relation of absence from school to non-promotion 
 among 568,612 elementary school pupils for the second 
 term, February to June, 19 11. Unfortunately, late entrance 
 to the schools, which is frequent in a city with a large 
 floating population like this, could not, from the data col- 
 
36 SCHOOL HEALTH ADMINISTRATION 
 
 lected, be separated from irregularity of attendance. The 
 effect of such late entrance can be estimated from the data 
 given later for Boston, where 650 of the 8,496 cases of 
 non-promotion, or nearly 8 per cent, were judged to be due 
 to this factor alone. 
 
 "Of the 568,612 pupils on register in regular classes 
 June 30, 191 1," he says, "382,406, or 67.25 per cent, were 
 absent during the February- June term, 191 1, ten days and 
 less; 97,512, or 17.15 per cent, eleven to twenty days; 
 39,391, or 6.93 per cent, twenty-one to thirty days; 19,297, 
 OJ* 3-39 P^i* cent, thirty-one to forty days; and 30,006, or 
 5.28 per cent, forty-one days and above." (Italics mine and 
 used only to distinguish.) 
 
 The following tables are well worth study, but cannot 
 be given here. A very large part of the absence is in the 
 first half of the first grade, especially for long absences. 
 The children of the upper grades have more short absences 
 and very much less long absences. 60.27 per cent of the 
 one A grade were absent twenty days and less in this half 
 year and the percentage gradually rises up to the highest, 
 eight B grade, where it is 95.17. The average is 84.4 
 per cent for all grades. But for the long absences of 21 
 days or more, there were 39.73 per cent of the lowest 
 grade and only 4.83 per cent of the highest, with an average 
 of 15.6 per cent for all grades. The first and second grades 
 have a very large amount of long absence, while the seventh 
 and eighth have comparatively very little, the averages be- 
 ing 23.42 per cent and 8.21 per cent. 
 
 What has all this varying and extensive absence for one 
 term to do with the rate of school progress, economy of 
 time, retardation and non-promotion? Dr. Bachman con- 
 cludes : "Absence is a very large factor in increasing the 
 number of non-promotions, and hence in increasing con- 
 gestion. With the exception of the lA grade, absence 
 affected more seriously the rate of promotion in the higher 
 than in the lower grades; and, in all grades, the rate of 
 promotion varies inversely with the amount of absence." 
 (Page 70.) 
 
SCHOOL HEALTH PROBLEM 37 
 
 The average rate of promotion for pupils absent 20 
 days and less he finds was 92.03 per cent; for those absent 
 more than 20 days the rate was only 70.57 per cent; a 
 difference of 21.46 per cent. 
 
 Dr. Bachman does not work out the chances of failure 
 in different grades for the varying amounts of absence, but 
 a good deal of light is thrown on the problem; and his dif- 
 ferences by grades in rates of promotion for those above 
 20 and those below 21, and his table showing the "Per Cent 
 of Decrease in Non-Promotions at Rate of Promotion for 
 Pupils Absent From Zero to Ten Days" (an average of 
 64.3 per cent) are good substitutes. 
 
 All these amounts of absence should be multiplied by 
 two to approximate the annual loss in days for this city 
 that year. 
 
 We see here that there is a close correlation of amount 
 of absence with the chances of non-promotion, and so of 
 retardation. All we should need to do would be to find 
 this numerically for grades and amounts of time lost, and 
 then the part which ill-health played in causing this absence, 
 in order to isolate and define the force of this health factor. 
 Other factors than absence enter in, of course, but it will 
 not be an impossible problem to compute for a given system 
 or for many what the chances are that a child in a given 
 grade has to pass for various amounts of absence from 
 school. 
 
 3. THE TEACHERS-REPORTS METHOD 
 
 Another method of investigating the causal relationship 
 between illness and retardation is to have teachers state the 
 cause of each case of failure of promotion. A number of 
 school superintendents have used this method in the last 
 two years. Great care must be taken in using it, for the 
 judgments of teachers frequently are wrong in these mat- 
 ters and plurality and composition of causes come in to 
 complicate the question. However, they do point toward 
 the relative force of different retarding factors. 
 
 THE HOBOKEN STUDY 
 
 Superintendent A. J. Demarest, of Hoboken, found that 
 
38 SCHOOL HEALTH ADMINISTRATION 
 
 19 per cent of the pupils of the schools had failed of pro- 
 motion in February, 191 1. A study of the probable causes 
 
 of 1706 of these failures gave the following: 
 
 Pupils 
 
 1. Irregular attendance; sickness one of the causes.. 297 
 
 2. Quarantine of pupils 14 
 
 3. Personal illness 65 
 
 4. Poor school work by pupils and teachers, transfers, 
 
 substitutes, etc 1,066 
 
 5. Foreigners, and ignorance of the English language 100 
 
 6. Late entrance into school for various reasons 91 
 
 7. Truancy 3 
 
 8. Physical defects: nervous troubles, adenoids, 
 
 tonsils, vision, etc 28 
 
 9. Early entrance, too young for school work 19 
 
 10. Sluggish mentality and mental defects 23 
 
 Total 1,706 
 
 Personal illness alone (2 and 3) seems to account for 
 less than five per cent of the cases of retardation. We 
 should, however, have to pick out from the first, fourth, 
 sixth and tenth groups those others whom illness quite 
 largely made fail. This would raise the percentage prob- 
 ably to 10 per cent. 
 
 THE BOSTON NON-PROMOTION STUDY 
 
 Boson made a study of this serious problem for the 
 pupils failing of promotion for the half year ending June, 
 1910 (School Document 14, 1910, page 26). "The sum- 
 mary of these returns, which follows, is of great interest as 
 revealing the real causes for retardation based upon an 
 actual and individual investigation of a large number of 
 cases for a definite and specific period." This judgment of 
 the school committee is, of course, unsound, for a number 
 of serious causes of non-promotion, and so of retardation, 
 are not here listed. It would be very interesting, indeed, 
 to take up just one other cause of non-promotion along 
 health lines. What effect has the absence of teachers due 
 to illness (not their inefficiency, but the relative inefficiency 
 
SCHOOL HEALTH PROBLEM 39 
 
 of the substitutes and changes Incident thereto) have upon 
 the amount of non-promotion? The amount of such ab- 
 sence among women teachers of most school systems is 
 enormous and easily ascertained. In general, does the num- 
 ber of failures of the children increase with the amount of 
 absence of their teachers? 
 
 "In June, 19 10, the total registration in the elementary 
 grades was 809,908. Out of this number, 10.5 per cent 
 (8,496) were retarded, i.e., not permitted to progress to 
 the next grade on the opening of school in September, 19 10. 
 A blank form was sent to each principal requesting him 
 to state the reason why each child in this group (8,496) 
 had not been promoted. The following is a summary of 
 the replies received: 
 Illness (diphtheria, scarlet fever, measles, surgery, etc.). 1,25 2 
 
 Mentally deficient 369 
 
 Defective vision 241 
 
 Defective hearing 83 
 
 Defective speech 53 
 
 Deformities 31 
 
 Adenoids 13 
 
 Nervous 7 
 
 Total 2,049 
 
 Mentally Immature (slow mental development) 2,803 
 
 Entered late In the school year 650 
 
 Lazy . 538 
 
 Inattentive 495 
 
 Absence caused by truancy, neglect, home work 468 
 
 Came from other schools 405 
 
 Came recently from foreign countries 331 
 
 Promoted on trial at beginning of year 239 
 
 Causes unknown 196 
 
 Repeated change of schools 181 
 
 Miscellaneous 127 
 
 Cigarette smokers 14 
 
 Total 8,496 
 
40 SCHOOL HEALTH ADMINISTRATION 
 
 No account is taken here of plurality or composition 
 of causes and it seems remarkable that teachers could say 
 so definitely that just one thing caused a pupil's failure 
 of promotion, when undoubtedly in perhaps a majority of 
 cases several causes contributed to the failures. As we have 
 arranged the items of the table, the first eight items are 
 clearly within the scope of medical inspection, with the pos- 
 sible exception of "mentally deficient." Until separate 
 divisions of psychology are formed, however, and then only 
 in very large school systems, we have the item rightly 
 placed. Cigarette smokers are reported by many nurses 
 as a part of their regular duties and a number of other items 
 not among the eight were more or less matters of ill-health 
 and physical defects but could not be ascertained by the 
 teachers. The large nursing staff of the schools was set 
 to work to improve the health conditions of these delayed 
 children, with what results I have not learned. 
 
 These eight reported causes applied to 2,049 children 
 of the 8,496. This is nearly twenty-five per cent (25%). 
 Bringing in the other health factors in other items of the list, 
 we should probably have much over 30 per cent. 
 
 If we were to take the judgments of the teachers and 
 principals of the elementary schools of Boston at their 
 face value, we should have to say that over one-fourth of 
 all retardation in the elementary schools is due to some form 
 of ill-health. But much of this was undoubtedly due to the 
 inefficiency of the teachers and their substitutes, to a poorly 
 adapted curriculum, to lack of proper administrative 
 measures for getting pupils to school and inciting their max- 
 imum efforts, to bad home conditions preventing opportunity 
 for study, to lack of ventilation and adequate play and 
 energizing facilities, etc., etc. However, it does show that 
 in the opinion of these persons, and what is undoubtedly 
 true, ill-health, physical defects, deformities, lowered vital 
 efficiency, and the like, do have a serious retarding influence 
 and prevent efficient economy of time in education. 
 
 THE MT. VERNON STUDY 
 
 Supt. Edwin C. Broome, of Mt. Vernon, N. Y., in his 
 
SCHOOL HEALTH PROBLEM 41 
 
 191 1 report, pages 35-38, gives the results of a study made 
 with the help of principals and teachers of the causes of 
 the non-promotion of 562 pupils in June, 191 1. The teach- 
 ers were asked to give the probable causes of the failure 
 of their pupils. They did not, of course, list poor teaching 
 as a cause; neither did they mention the absences of teach- 
 ers, when pupils were in the not too-efficient hands of 
 substitutes. There were 707 causes given for the non- 
 promotion of 562 pupils that term, so more than one cause 
 was given for several pupils. The table is as follows: 
 
 Reasons assigned Cases 
 
 1. Irregular attendance or late entrance to 
 
 class 158 — 22.3% 
 
 2. Lack of physical vitality 18 — 2.5% 
 
 3. Mental dullness 133 — 19.0% 
 
 4. Mentally deficient, or abnormal 30 — 4.2% 
 
 5. Physical defects 14 — 2.0% 
 
 6. Immaturity (applies to lowest grades) . . 96 — i3-4% 
 
 7. Below grade, or conditioned, at entrance 
 
 to class 125 — 17.7% 
 
 8. Inability to use English 28 — 3-i% 
 
 9. Inattention, carelessness, indolence 83 — i3-3% 
 
 10. Miscellaneous 22 — 2.5% 
 
 Total 707 — 100 % 
 
 We can only guess at the amount of the irregular at- 
 tendance which was due to illness, quarantine, exclusion by 
 doctors and nurses, and the like. Absence is a big causal 
 factor and illness is a factor lying back of much of this. 
 A large part of the first five items would come under the 
 head of bad health conditions. The smallness of the phy- 
 sical defects item may well be questioned because the city 
 did not have physical examinations of the pupils adequately 
 to locate the defects, only inspection. A large number of 
 cases of inattention, carelessness and indolence may have 
 been due to such undiscovered defects. If we could say 
 that probably at least 50 children were retarded because of 
 illness alone this term, we should have a proportion of 
 nearly ten per cent. This can be only an estimate, of course. 
 
42 SCHOOL HEALTH ADMINISTRATION 
 
 THE TRENTON STUDY 
 
 Superintendent Ebenezer Mackey, of Trenton, N. J., In 
 his 191 1 report, shows, first, the causes of elimination from 
 school, second, of non-promotion, and, third, of retardation, 
 according to this method. Of 2,218 pupils who left school 
 and did not return ("eliminated"), the following causes 
 come within our perview: 
 
 CAUSES OF ELIMINATIONS 
 
 Withdrew because of poor health 192, or 8.7% 
 
 Withdrew because of sickness in the family 33, or 1.5% 
 
 Withdrew because of physical defects 9, or .4% 
 
 Withdrew because of death 22, or 1.0% 
 
 11.6% 
 
 CAUSES OF NON-PROMOTIONS 
 
 There were 8,394 pupils promoted during the year and 
 1,943 not promoted, 1,055 of whom are called repeaters. 
 1,918 causes are given for these 1,055 repeaters. The fol- 
 lowing are the causes which concern us here : 
 
 1. Ill-health 122, or 6.3% of the causes 
 
 2. Physical defects 68, or 3.5% of the causes 
 
 3. Dull 369, or 19.3% of the causes 
 
 4. Irregular attendance 340, or 17.7% of the causes 
 
 5. Absent at time of promotion. 109, or 5.6% of the causes 
 
 6. Immaturity (mostly in the 
 
 first 3 years) 133, or 6.8% of the causes 
 
 These six of the twenty-one causes given are either 
 directly connected with ill-health or should be studied 
 further from the health standpoint. Undoubtedly back of 
 several of these factors ill-health stands out in some way 
 as a determining cause. There were physical examinations 
 made of most of the elementary children in this city, so the 
 percentage for physical defects must be based upon more 
 definite knowledge than in Mt. Vernon, where they made 
 up less than two per cent of the causes given. If teachers 
 had more accurate knowledge of the health conditions of 
 their children this factor would probably be raised. As 
 
SCHOOL HEALTH PROBLEM 43 
 
 it is, ill-health makes up 6.3 per cent of the factors given. 
 Further analysis would probably show that ill-health alone 
 was the cause in about 8 or 10 per cent of the cases. We 
 need further studies along these lines. 
 
 Besides studying elimination and non-promotion Super- 
 intendent Mackey gives, third, the causes of retardation, 
 i.e., of all the pupils who are below the grades they should 
 normally be in at their respective ages. For 4,184 pupils 
 in the elementary schools who were above normal age for 
 their grades, the following excuses or reasons, among ten 
 given, are offered, page 93 (3,682 mentions of the 10 
 causes) : 
 
 1. Sickness 257, or 7.0% of the causes 
 
 2. Physical defects 2 19, or 6.0% of the causes 
 
 3. Irregular attendance 550, or 15.0% of the causes 
 
 4. Lack of ability 406, or 11.1% of the causes 
 
 5. Lack of application 453, or 12.3% of the causes 
 
 All of the last three mentioned causes may refer to 
 pupils many of whom have an ill-health basis for their poor 
 attendance, ability or application. Sickness is at about 
 the same percentage as previously given. 
 
 Data from many other cities might be offered. For want 
 of space and time, and because of their relative inaccuracy, 
 we must be content with these few. Until we have more 
 careful health records of children, we can only guess at the 
 influence of illness on school progress. 
 
 4. GATHERING-THE-FACTS METHOD 
 
 Another method used by superintendents of schools 
 eliminates personal judgments quite largely, but still leaves 
 the difficulty of separating combinations of causes. 
 
 THE SOUTH MANCHESTER STUDY 
 
 Superintendent F. A. Verplanck, of South Manchester, 
 Conn., in his 191 1 report (see also 19 12 report, pages 12 
 to 17) gives the results of a study of elimination and non- 
 promotion, based upon the records of the pupils kept by 
 the schools. Of 188 pupils eliminated from the schools, 
 
44 SCHOOL HEALTH ADMINISTRATION 
 
 ill-health and death were the causes of 17 and 4 respectively, 
 together making a percentage of 11.2 per cent. 
 
 Two hundred forty-one pupils, or 17.4%, were not pro- 
 moted. Of this he writes : "I am confident that the figures 
 would have been still better had it not been for the pre- 
 valence of contagious disease, which seriously Interfered 
 with the attendance." 
 
 The attendance factor is shown by comparing the aver- 
 age number of days attended by those promoted and those 
 not promoted. The schools were In session 186 days, and 
 the promoted pupils lost on the average 32 days, while the 
 non-promoted pupils lost 52 days, a difference of four 
 weeks, a month in favor of the promoted pupils. A very 
 large part of this low attendance of all was due to the 
 epidemics of diphtheria, scarlet fever, and measles, and 
 other forms of illness. How much we cannot say. 
 
 The physical defects causes given in the report will be 
 offered under that heading later. 
 
 ATTENDANCE OFFICERS^ REPORTS 
 
 Another way to get at the amount of absence due to 
 ill-health Is through the reports of attendance officers, given 
 in many superintendents' reports, but in only a few adequately 
 analyzing the causes of non-attendance. In South Man- 
 chester, 755 absentees were looked up, with the following 
 results of interest to us here: 
 
 Causes of Absences from School, for 755 Pupils. 
 
 Personal illness 305, or 40.4% 
 
 Illness in the family 57, or 7.8% 
 
 362, or 48.0^ 
 - Here we have a proportion of almost 50 per cent due, 
 according to the officer's statement, to ill-health. We have 
 shown that there is a close correlation between absence and 
 failure of promotion. What percentage of the cases of 
 non-promotion in South Manchester were due to the vari- 
 ous ill-health factors such as exclusions by medical officers, 
 quarantine of pupils 111 and only exposed, actual personal 
 
SCHOOL HEALTH PROBLEM 45 
 
 illness, and illness in the family which makes necessary 
 an older child's help at home or the younger ones to stay 
 at home "because mother was sick and could not get them 
 ready," we cannot say. The writer's personal judgment 
 based upon the tables given and other factors in the situa- 
 tion places it at nearly 20 per cent of the non-promoted 
 pupils. There was probably, however, an abnormally large 
 amount of infectious disease in this city during the year. 
 
 - THE SCHENECTADY TABLE 
 
 In the Schenectady report for 191 1 Superintendent A. 
 R. Brubacher gives a table, page ^3^ which potentially might 
 throw some light on this problem. Unfortunately only facts 
 for unpromoted pupils are given, without a control class, 
 or the possibility of comparing the data with promoted 
 pupils, so we can draw no satisfactory conclusions. The 
 total registration was 11,074, of whom 385 failed outright 
 and 263 failed on condition, 648 in all. 
 
 For these pupils, all in the elementary schools, we are 
 given the following facts: 
 
 Defective sight 58 
 
 Defective hearing 43 
 
 Absences : 
 
 Because of sickness 457 
 
 Because of quarantine 34 
 
 Unexcused 99 
 
 Absence of 20 or more days 113 
 
 These facts are interesting here, but to derive from them 
 any conclusions we should have to have the six items of 
 data for at least the number of: 
 
 Pupils promoted unconditionally. 
 Pupils failing, with a condition. 
 Pupils failing unconditionally. 
 To which might well be added the same data for 
 
 Pupils promoted, but with a condition. 
 It is probably true that these figures show abnormal con- 
 ditions for retarded children in the direction of ill-health. 
 It is significant that 113 of the 648 pupils were absent a 
 
46 SCHOOL HEALTH ADMINISTRATION 
 
 month or more (whether of one of the two groups or 
 the other, or of both, and In what proportions, we do not 
 know), which, according to Keyes, would tend to fail over 
 50 per cent of the number. 
 
 5. QUARANTINE ABSENCE AND RETARDATION 
 
 Another way of studying the effect of ill-health is to take 
 the children who have been quarantined and see what their 
 chances of promotion are in comparison with other chil- 
 dren. No person has yet attempted such a study so far 
 as the writer is aware. 
 
 Absence due to quarantine is given in a number of cities. 
 Newark in the 19 11 report furnishes the following strik- 
 ing data: 
 
 Absence due to quarantine 56,517 days 
 
 Total absence due to all causes 1,055,560 days 
 
 Total attendance of all pupils 8,890,974 days 
 
 Here we see that the attendance is only eight or nine 
 times the amount of absence, and that quarantine absence 
 makes up over 5.3 per cent of the total amount of absence. 
 The average length of quarantine for 1,892 pupils given 
 separate mention was over 21 days each. 
 
 If statistics were gathered regarding these quarantined 
 pupils in any city and their promotions much light could 
 easily be thrown on the problem. 
 
 6. EXCLUSION ABSENCE AND RETARDATION 
 
 Many pupils are excluded by physicians and nurses who 
 are not quarantined. The number of days lost is frequently 
 reported. Thus in Philadelphia the exclusions for different 
 ailments caused an average loss ranging from favus with 
 60 days, or 12 school weeks, and chorea with an average 
 loss of 57 days, over 11 weeks, down to exclusions for lack 
 of cleanliness of one day and pediculosis with an average 
 of three days. The average loss for each ailment was 
 (1910 report of Board of Health) 17 days, or over three 
 weeks. 
 
 In the Hoboken 19 11 report we find that 383 pupils 
 lost by exclusions 4105 days, an average of nearly 11 
 
SCHOOL HEALTH PROBLEM 47 
 
 days, or over two weeks, each. We cannot obtain the medi- 
 an, but we see how serious exclusions are. 
 
 These figures show not only what a great factor In ab- 
 sence Ill-health Is, but point out new fields for the investiga- 
 tion of this serious problem of health In the schools and 
 homes. 
 
 NEED OF RIGOROUS INDUCTIVE METHODS 
 
 Each of these problems must be solved through Inten- 
 sive and extensive investigation and by persons skilled In 
 inductive thinking and the technique of discovery in educa- 
 tional fields. There are very many difficulties and pitfalls 
 of which the general administrator or Investigator Is un- 
 aware. It may happen, for example, that the Illness ab- 
 sentees are a selected group who became ill because of 
 general hereditary or sociological causes, and that these, not 
 so much the absence, are the cause of poor school work. 
 Practically all the fallacies of inductive thinking lie before 
 each one who adds to the science of education, and the 
 school health problem seems to be peculiarly Infested with 
 them. 
 
 SUMMARY FOR ILLNESS LOSSES 
 
 In summing up the case for illness we can give a general 
 quantitative statement of Its effect upon elimination, non- 
 promotion and retardation in only the most hypothetical 
 way. Our purpose has been accomplished if the tremend- 
 ous Importance of this source of waste in education has 
 been adequately emphasized, and the necessity for serious, 
 technical Investigations of Its causes and prevention in each 
 school system has been shown desirable. 
 
 Such study will probably show that Illness In one form 
 or another, directly or indirectly, but not Including physical 
 defects, is responsible, as a single factor, for nearly twenty, 
 five per cent of absences from school, for ten to fifteen 
 per cent of the elimination, for ten to twelve per cent of 
 non-promotion, each term, and for at least ten per cent of 
 retardation. 
 
48 SCHOOL HEALTH ADMINISTRATION 
 
 ///. School Losses Due to Physical Defects, and Lowered 
 Vital Efficiency 
 
 A little more study has been made of the effects of 
 physical defects upon school progress. Dr. L. P. Ayres 
 summarizes these in the 19 13 edition of his book on "The 
 Medical Inspection of Schools," Chapter II. In his book 
 on "Laggards in Our Schools," Dr. Ayres develops statistic- 
 ally the conclusion that "in general children suffering from 
 physical defects are found to make 8,8 per cent less progress 
 than do children having no physical defects." 
 
 Serious strictures are made by Dr. W. S. Cornell in 
 his book on "Health and Medical Inspection of School 
 Children," pages 387 to 391, on the Ayres' findings, and 
 by the writer in a later chapter, enough, perhaps, entirely 
 to invalidate the quantitative conclusions; but of one thing 
 we are sure, that physical defects do have a serious influ- 
 ence upon school efficiency and school progress, exactly how 
 much we can, at present, only estimate. 
 
 DR. WALLIN^S STUDY 
 
 A very technical study by Prof. J. E. W. Wallin, on the 
 relation of oral hygiene to mentality, reinforces to some 
 extent these conclusions. A squad of 27 school children in 
 Cleveland, O., were given free dental treatment and hygienic 
 instruction — filling of cavities, cleaning of gums, instruc- 
 tion In the care of teeth, "fletcherizing" of food, etc. — 
 and before, during, and from three to five months after 
 this treatment were given a series of five mental tests to 
 determine whether or not the remedy of these physical 
 defects had produced a corresponding increase in mental 
 power. 
 
 "In spite of much individual variation, the results showed 
 a decided gain in every test. The best proof of the benefit, 
 and therefore of the importance of the work, is that, al- 
 though all the members of the squad were laggards of from 
 one to four years, only one failed of promotion in the term 
 immediately following the treatment. The beneficial effect 
 on general health of the children was noticeable to chil- 
 
SCHOOL HEALTH PROBLEM 49 
 
 dren, parents, and teachers alike." {Dental Cosmos for 
 April and May, 19 12. Article on "Experimental Oral 
 Euthenics.") 
 
 The conclusiveness of this elaborate investigation is lost, 
 however, because no control squad of pupils was used. If 
 another like class had been given the same treatment with 
 the single exception of the oral hygiene treatment and in- 
 struction and real differences found, we might suspect the 
 truth of the conclusion that there is such causal relationship. 
 We may reasonably suppose, however, that had any group 
 of retardates such as these been selected and given special 
 attention reaching into the homes with the help of nurses, 
 with money rewards, with special testing by principal and 
 physician, and with a small class for the teacher — had any 
 similar class been given all this attention with no attention 
 to mouth hygiene, or with the emphasis on some other 
 factor, say deep breathing, or removal of enlarged tonsils 
 and adenoids, or open-window classroom, or personal 
 courtesy even, nearly, if not quite, the same results might 
 have been obtained. That "during the experimental year 
 only one of the 27 pupils failed of promotion," is not sur- 
 prising, regardless of the oral hygiene. Pragmatically, such 
 findings do good in getting a proper emphasis on certain 
 features of health provision by school officials and others. 
 How much is fact, and how much is the fallacies of plur- 
 ality and composition of causes no one knows. We may 
 demonstrate that "on the whole . . . the average child 
 improved about 50 per cent in all the tests during the ex- 
 perimental year," but, as the writer points out, there was 
 a "paramount need of testing such a parallel group," and 
 "our knowledge in this field is largely pretense, sham, 
 illusion." 
 
 superintendents' methods 
 
 Another method of getting an idea of the effect of phy- 
 sical defects on school progress and elimination is the 
 teacher-report and studying-the-facts methods described 
 above under illness effects. Looking back over these and a 
 
50 SCHOOL HEALTH ADMINISTRATION 
 
 number of other such studies we can draw the following 
 very tentative hypotheses: 
 
 Physical defects are probably causal factors in about the 
 following proportions among other causes: 
 
 Five per cent of eliminations from school; 
 
 Six per cent of non-promotion; 
 
 Seven or more per cent of retardation. 
 A pupil may, of course, miss promotion and still be 
 young for his class, and, so, not retarded. It is the per- 
 sistent "repeaters" who make up a large portion of the re- 
 tarded. 
 
 IV. Summary of Chapters One and Two 
 The problems of life furnish the problems of education, 
 and one of the most important of these is that of good 
 health. No serious and extended attempt has previously 
 been made by school officials to discover in a comprehensive 
 manner the nature and the importance of this problem of 
 the nation and of the schools. 
 
 NATIONAL LOSSES 
 
 The national health losses are those of preventable 
 deaths, preventable serious illness, and preventable minor 
 ailments and defects. 
 
 Approximately 1,600,000 people in the United States 
 die each year, or nearly two per cent of our population. 
 Our most reliable computations, derived from life insur- 
 ance records and health experts' estimates, indicate that 
 probably 670,000 of these deaths, or 42 per cent, are 
 reasonably preventable. Conservative and carefully cal- 
 culated estimates of the national economic losses due to these 
 preventable deaths indicate an annual loss of over a billion 
 dollars. 
 
 There are approximately three million persons seriously 
 ill at all times in the United States. The chief national 
 illness losses computable are those of lost wages and private 
 and public care of the sick. These two forms of economic 
 loss, very largely preventable, each amount to about five 
 hundred million dollars annually. 
 
SCHOOL HEALTH PROBLEM 51 
 
 Combined, we have a largely preventable economic loss 
 in deaths and in Illness amounting to two billion dollars an- 
 nually, a sum great enough to cover the land with preven- 
 tive agencies. 
 
 Added to these losses are those due to minor ailments, 
 physical defects, and loiwered vital efficiency, largely pre- 
 ventable. These ailments help to lower the working 
 efficiency, cause much absence from daily employment, and 
 are a serious source of expense to a large proportion of 
 our population. Any study of the attendance of teachers 
 in the schools, of workers in the factories and stores, or of 
 day laborers, will point to enormous losses In these fields, 
 decreasing national Wealth and increasing race degeneracy. 
 
 SCHOOL LOSSES 
 
 The principal school losses are in the form of deaths 
 of school children, educated for a number of years and 
 dying before the age of productivity, illness losses, and losses 
 due to physical defects and lowered vital efficiency. Much 
 can be done on this side of eugenics in eliminating these 
 school losses. 
 
 Nearly a hundred thousand children of school age die 
 in this country each year. Strayer's government report 
 makes possible an estimate of 65,000 deaths of enrolled 
 public school children each year. No estimate is made for 
 those In private schools, but the number is probably near 
 five thousand. Fisher's estimate of preventability of the 
 deaths of children makes possible an estimate of an annual 
 unnecessary death loss of over 40,000 public school chil- 
 dren. This is only part of the price we pay for inadequate 
 health measures in home, school, community and nation. 
 The socially ineffective school expenditures for the educa- 
 tion of children who die before the age of productivity are 
 enormous but, as yet, uncomputed. Generous health meas- 
 ures In schools may well be justified on this basis alone. 
 
 The illness losses to the schools are for both teachers 
 
 and children, but only those for the latter are studied.* 
 
 * Professor Terman has made an investigation of the former in a 
 book entitled "The Teacher's Health," Houghton, Mifflin Co. 
 
52 SCHOOL HEALTH ADMINISTRATION 
 
 These illness losses come in the form of economic losses 
 to the school and in personal losses through elimination, 
 non-promotion, retardation, and lowered vital and school 
 efficiency. The chief outward result of school illness Is 
 that of non-attendance, and the effect of such absence has 
 been studied in a number of ways, several of which are 
 given, but none of which are conclusive. Tentative sug- 
 gestions are reached that illness is the chief or only factor 
 in perhaps lo to 15 per cent of elimination from school, 
 10 or 12 per cent of non-promotion each term, and at least 
 10 per cent of retardation. Beyond this, many pupils do 
 poor work and barely pass from term to term because of 
 lowered vitality due to illness past or present. 
 
 The school losses due to physical defects have also been 
 problems of a number of investigations, but none of these 
 arrives at a quantitative statement which warrants belief. 
 The whole problem is open for investigation. That the 
 losses are large and serious seems quite evident. Physical 
 defects are probably the chief or only factors in about five 
 per cent of the elimination from school, six per cent of 
 non-promotion, and seven per cent of retardation. Careful 
 studies will probably raise these tentative estimates, made 
 here only for the purpose of emphasizing these health 
 problems as an introduction to the later chapters. The 
 lowered vital efficiency due to physical defects of the pupils 
 who barely pass with very low standards from term to term 
 must also be considered in this problem. 
 
 Since illness and physical defects frequently go together, 
 'their combination in any one pupil or pupils offers a very 
 serious menace to school efficiency, probably causing, as 
 combined factors, almost fifteen per cent of elimination, six- 
 teen per cent of non-promotion, and seventeen per cent of 
 retardation. When we consider the enormous proportion 
 of the twenty million school children who fall into one or 
 more of these classes, according to the best estimates, the 
 school health problem stands out as one of the acute 
 problems of modern life. 
 
 The following chapters will attempt to show what 
 
SCHOOL HEALTH PROBLEM 53 
 
 American cities are doing for the health of the children and 
 the nation ; what twenty-five cities are doing in detail with 
 critical consideration of their efforts; and, finally, what 
 probably can be done in the administration of educational 
 hygiene along more effective and economical lines. 
 
 References 
 
 1. Beyer, Popular Science Monthly, February, 1912. 
 
 2. Ditman, "Education and its Economic Value in the Field of Pre- 
 
 ventive Medicine," Columbia University Press. 
 
 3. Fisher, "National Vitality" in Report of the National Conserva- 
 
 tion Commission, Senate Document No. 676. 
 
 4. Flexner, "Bulletin 4," Carnegie Foundation. 
 
 5. Terman, "Professional Training for Child Hygiene," Popular Sci- 
 
 ence Monthly, March, 1912. 
 
 6. National Vitality, page 736. 
 
 7. Durand, Census Bureau, 1910 Mortality Statistics. 
 
 8. Bruere, in Harper's Magazine for April, 1912. 
 
 9. Page 8, Mortality Statistics. 
 
 10. Page 10, Mortality Statistics. 
 
 11. Quoted in National Vitality, page 741. 
 
 12. National Vitality, Chapters I and II. 
 
 13. National Vitality, page 728. 
 
 14. Annual Report. 
 
 15. Journal of Outdoor Life, March, 1912. 
 
 16. National Vitality, page 741. 
 
 17. Popular Science Monthly, March, 1912. 
 
 18. Biggs, National Vitality, page 741. 
 
 19 and 20. National Vitality, Chapter III. 
 
 21. Fisher, in private letter. 
 
 22. Ayres, "Laggards in Our Schools," 1913 edition of "Medical In- 
 
 spection of Schools," and bulletin on the Money Cost of Repeti- 
 tion; and Elson, Cleveland, 1912 Report, and many other in- 
 vestigators. 
 
 23. Strayer, Bureau of Education bulletin No. 451. 
 
 24. Keyes' Doctor's Dissertation, "Progress through the Grades of 
 
 City Schools," Columbia University Contributions to Education. 
 
 25. Bureau of Education bulletin No. 4, 1907, and articles in Psycho- 
 
 logical Clinic, Jan. and Feb., 1910. 
 
 26. Ayres, "Laggards in Our Schools." 
 
 27. Strayer, Bureau of Education bulletin No. 451. 
 
 28. Ditto. 
 
CHAPTER THREE 
 
 HOW THE HEALTH PROBLEM IS BEING MET IN 
 SCHOOLS AND NATION 
 
 I. PUBLIC HEALTH PROVISIONS 
 
 The emergence of the health problem as one of serious 
 national importance Is of recent date. In these few open- 
 ing years of the twentieth century the gradual Increase of 
 health needs and health knowledge has flowered forth in 
 what one writer terms "the renaissance of the physical 
 conscience of the race,"^ after lying dormant since the time 
 of Pericles. Why health has for so long been a matter of 
 relative unconcern ; why a fatalistic attitude not only toward 
 plagues, sweeping off millions of people,^ but toward sick- 
 ness and high death-rates in general, has been maintained, 
 is not easily explained. This attitude of the race In its 
 long health-middle-ages, stands out, however. In remark- 
 able contrast both to that of the Greeks, health as a religion, 
 and that of the present, health as a science. The reverent 
 teaching and practice of sound life and normal physical 
 development in Athens; the ignorant asceticism and plagues 
 of the later periods; and the discovery of the causes of 
 disease and early death with the growing ideal of health 
 as an individual and public duty — these are the three ages 
 of Health. The great number of years does not adequately 
 express the gaps existing betwteen the Olympic games with 
 Hygieia; the Black Death with Simon Stylites; and the 
 present when a German or American soldier Is punished for 
 getting an Increasing number of diseases and Colonel Gorgas 
 is scientifically overcoming death at Panama.^ 
 
 Among the explanations must be, of course, the general 
 
 54 
 
MEETING THE HEALTH PROBLEM 55 
 
 causes of the dark ages; theologic asceticism; the poverty 
 of the masses which made life cheap and perhaps most 
 additions to the hving undesired; the tremendous general 
 ignorance, especially of health mlatters; the open, relatively 
 healthful life of an agricultural people; and the general 
 individualistic form of life and government. The marvel- 
 lously rapid change in public opinion and practice with 
 regard to health matters is due quite largely to the in- 
 dustrial revolution with its development of factory life, 
 congested business cities, and dependent poverty; to the 
 transformation of preventive and curative medicine and 
 sanitation into relatively exact sciences; the growth of demo- 
 cracy and the altruistic conscience ; the consequent rise of 
 public health agencies;^ the better conditions for adequate 
 social control of health and disease, especially in cities; the 
 great increase of wealth in the hands of a few and the 
 accompanying possibilities of health philanthropy (e.g., the 
 Rockefeller Foundations, the Sage Bureau of Child Hy- 
 giene, the Forsythe Dental Dispensary at Boston, and many 
 other private health charities, educational, preventive and 
 curative) ; the increase in the organs of public opinion and 
 the increased attention of newspapers and magazines to 
 public health instruction; and, finally, and fundamentally, 
 the growth of the public school system in recent years with 
 its unparalleled opportunity for health control of the 
 younger generations and their education as to how to live 
 healthily, happily, and efficiently in the modern world. 
 
 DEVELOPMENT OF GENERAL HEALTH AGENCIES 
 
 This universal health awakening in progressive nations 
 can be admirably illustrated by the recent rise and rapid 
 growth of public and private organizations for the promo- 
 tion of more universal health, A plotted curve of such 
 growth in its entirety would show little rise since the tim^es 
 of Harvey and Jenner until about the third quarter of the 
 past century, when it would rise abruptly and continuously 
 and have a still sharper ascent in these opening years of 
 the twentieth century. The first rapid rise shows, quite 
 largely, the acquisition of health knowledge; the second the 
 
S6 SCHOOL HEALTH ADMINISTRATION 
 
 increasing application of such knowledge. Public and per- 
 sonal hygiene, in its practice, is yet several decades behind 
 the health knowledge held by the few.^ President Butler's 
 terse and accurate statement of the situation from the school 
 point of view, well expresses general conditions: "It is 
 not too much to say that health, its preservation and de- 
 velopment, is all-controlling in present-day educational 
 theory, although it is unfortunately far from being so in 
 practice. The chief reason for this discrepancy between the 
 ideal and the real is simple ignorance."^ 
 
 To make private science public health knowledge and 
 practice, is the mission of a great number of new agencies, 
 often starting as private bodies and gradually becoming 
 public institutions, according to a rather universal method 
 of social evolution. Among such private bodies are: The 
 International Congresses on School Hygiene beginning in 
 1904 at Neuremberg; the American Medical Association; 
 the health foundations endowed by Rockefeller, Sage, Car- 
 negie and others; the Playground Association of America, 
 beginning in 1907; social settlements and Christian associa- 
 tions everywhere; the Congresses of Sanitary Engineers; 
 the Committee of One Hundred on National Vitality; the 
 National Associations for the Study and Prevention of 
 Tuberculosis, for the Conservation of Vision, for Sanitary 
 and Moral Prophylaxis, for the Study and Prevention of 
 Infant Mortality, for the Study of the Feeble Minded; the 
 National School Hygiene Association; the National Con- 
 sumers League, the National Child Labor Committee, the 
 New York and other bureaus of municipal research,^ the 
 National Educational Association to same extent since 
 1900; tenement house commissions, and various health 
 magazines and general magazines with health articles and 
 departments. These and a great many other organizations 
 in this country and abroad are either directly or indirectly 
 working for public health.* 
 
 *G. Stanley Hall gives a list of ninety and more in his "Educational 
 Problems," chapters XI and XII. 
 
MEETING THE HEALTH PROBLEM 57 
 
 One of the most interesting developments has been the 
 efforts of hfe insurance companies to Iceep down the death 
 rate of their policyholders. Certain companies^ distribute 
 free literature on various phases of the preservation of 
 health, hire visiting nurses, and give free annual medical 
 examinations to policyholders. The Lubin Vitagraph Com- 
 pany has even dramatized the idea and is sending over 
 the world films portraying an insurance president saving 
 his company from paying a big death loss at a financial 
 crisis by sending at some expense a bankrupt family South 
 to restore the father's health, and brought to such an atti- 
 tude by the naive request of the sick man's little boy : "We 
 want the money to make father well now; we won't need 
 it when he gets well." 
 
 Some of the other public health movements and agencies 
 are: the municipal, county and state Boards of Health with 
 their rapidly enlarging scope and powers, the latter now 
 more extensive than those of any other division of the public 
 service not excepting the police; the Boards of Education, 
 in response to the needs of the times, similarly widening 
 their community service; the United States Department of 
 Labor with Its mortality census bulletins from the Bureau 
 of the Census and other health studies in the field of labor; 
 the Department of Agriculture, working almost entirely In 
 the past for the health of domestic animals rather than 
 the people; the Bureau of Education, which has as yet con- 
 tributed very little to public health; and the United States 
 Public Health and Marine Hospital Bureau, and several 
 others which, inevitably, will be united into one compre- 
 hensive National Department of Health for the more 
 organized and energetic development of health conditions 
 in the entire country, similar to the work of the Depart- 
 ment of Agriculture for the health of live-stock. 
 
 There has recently been established also the Children's 
 Bureau and placed in the Department of Labor. What is 
 much needed Is a great increase In the scope and support 
 of the Bureau of Education, corresponding somewhat with 
 present-day needs and present-day ability in promoting 
 
58 SCHOOL HEALTH ADMINISTRATION 
 
 child welfare. Following the rapid development of many 
 private and public instrumentalities for health promotion, 
 a correlating movement is setting in which will help to 
 systematize and make more efficient the multitudinous scat- 
 tered efforts. In America we have yet a long way to go 
 in health provisions to equal the splendid work which Ger- 
 many and Sweden have been doing for a number of years. 
 (Dr. Irving Fisher says in a private letter: ^''Sweden, which 
 has made the greatest progress in Hygiene of any country, 
 is believed to have done so largely because of the medical 
 investigations of its schools.") 
 
 II. SCHOOL PROVISIONS FOR PUBLIC HEALTH 
 
 While the health movement is but beginning in the schools 
 very much has already been accomplished in this country 
 and elsewhere. We shall not stop here to review the move- 
 ment abroad as this has ably been done in a number of 
 books and articles.^ It seems desirable to preface the 
 special detailed investigation of what school systems are 
 doing for public health in a limited number of cities, with 
 a brief general statement of some of the more prominent 
 features of this recent movement in the schools of our own 
 country. 
 
 This investigation began with a study of data gathered 
 by the Child Hygiene Bureau of the Sage Foundation under 
 the direction of Dr. Leonard P. Ayres in the fall of 19 lo. 
 A number of investigations into this problem then beginning 
 were thus correlated into one comprehensive investigation 
 which would give a bird's-eye view of the field and the 
 general aspects of the movement in the schools. The fol- 
 lowing questionnaire was printed on a return postal card 
 and sent to every superintendent in the country (1285 in 
 all), and after a second request was made of a number, 
 returns were received from 1038 graded school systems: 
 
 Date 
 
 Have you a system of medical inspection? 
 
 Year work was begun 
 
 Does system cover inspection for contagious diseases? 
 
MEETING THE HEALTH PROBLEM 59 
 
 Are vision and hearing tests made by teachers? 
 Are vision and hearing tests made by doctors? 
 Is there full physical examination by doctors? 
 
 Is medical inspection administered by Board of Health or Board of 
 Education? 
 
 Number of school doctors Annual salary • 
 
 Number of school nurses Annual salar)' 
 
 Have you dental inspection? Is it by dentists? 
 
 Do elementary children have regular outdoor recesses? 
 
 Are recesses given in all elementary grades? 
 
 Hovir many schools are supplied vi^ith individual drinking cups? 
 
 Hov\7 many schools have sanitary drinking fountains? 
 
 Are moist cloths used for dusting? 
 
 Are dust absorbing compounds used for sweeping? 
 
 How many schools have vacuum cleaning outfits? 
 
 How often are classroom windows washed? 
 
 How often are classroom floors swept? 
 
 How often are classroom floors washed? 
 
 Are adjustable desks in general use? 
 
 How often are they adjusted? 
 
 Do pupils receive special instruction on alcohol and tobacco? 
 
 Do pupils receive special instruction on tuberculosis? 
 
 Do pupils receive special instruction on first aid to injured? 
 
 Name 
 
 Place 
 
 The disadvantages of getting facts by such means Is well 
 known and has been further discovered through visits by 
 the writer to a number of the towns replying and checking 
 up reports. Nevertheless, for a general view such as this 
 and covering the entire country, it is the best that can 
 be done in a short time and at reasonable expense; and 
 probably gives a fairly correct general notion of the present 
 status of the health movement in the schools. ^° Some of 
 the main facts discovered by this investigation are here 
 summarized: 
 
 1. Of the 1038 cities reporting 443, or 43 per cent, had medical 
 inspection of some kind. 
 
 2. The very rapid growth of medical inspection since 1890 is shown 
 by the following series, giving the number of cities having medi- 
 cal inspection systems for each year (duplications where figures 
 are not known or there were no additions) : i, i, i, i, 4, 4, 4, 5, 
 8, 9, II, 17, 23, 28, 37. 55, 77, III, 167, 263, 400, 443. In 1900 
 eleven cities had such inspection; in 1905 there were 55. The 
 very rapid increase has been since then. Probably at this writing 
 
6o SCHOOL HEALTH ADMINISTRATION 
 
 not far from half of the cities of the country are attempting 
 this work. 
 
 3. In 443 cities reporting on this item, 336 had the work admin- 
 istered by Boards of Education and 106 by Boards of Health. 
 Formerly this work was all done by the Boards of Health but 
 by state law and municipal agitation the work is being trans- 
 ferred to Boards of Education and given a larger educational 
 purpose. Not only inspection for contagious diseases, but careful 
 physical examinations once a year, follow-up work, treatment, 
 prevention, and cure are being developed. 
 
 4. 405, or 39 per cent, of the 443 cities, report inspection for con- 
 tagious diseases. It is probably correct to say that practically 
 all cities, however, look out for contagious diseases by inspection. 
 
 5. "In no fewer than 552 cities vision and hearing tests are con- 
 ducted by teachers, and in addition the work is carried on by 
 doctors in 258 cities." The tendency is for this work, required 
 by law in certain states, to go into the hands of the school nurses. 
 As practically applied a single teacher in a school has generally 
 made these tests. The nurse or physical training teacher saves 
 the regular teacher's time by doing such work. 
 
 6. Of the 443 cities reporting medical inspection systems 214, about 
 half, have thorough examinations by doctors. The annual physi- 
 cal examination of every child, teacher and janitor in the school 
 system by specially trained nurses and doctors will probably soon 
 become an integral part of all health work in the schools. Life 
 insurance companies are now beginning to offer free medical 
 examinations to save the lives of their policyholders. The State 
 has a greater interest than any private group in the health of 
 its people. 
 
 7. The returns showed that there were 141 5 school physicians and 
 415 school nurses employed. While both are sure to increase 
 rapidly in numbers it is the opinion of the writer that the ratio 
 of three to one will shift in the direction of one to three, because 
 of the greater value of the nurse's work in getting cures. Doc- 
 tors will probably make the more technical parts of the annual 
 physical examination; nurses will assist in this and make inspec- 
 tions and follow-up cases. An increasing number of cities have 
 nurses without doctors. 
 
 8. Decayed teeth is the great "people's disease" and are the source 
 of perhaps most ailments. At least fifty per cent of school children 
 suffer from this malady. Only 69 cities have dental inspection 
 by dentists. The number is rapidly increasing, however, and free 
 dental treatment is bound to become as common as free text-books 
 and free schools once fought as "socialistic." 
 
 9. Medical supervision of schools, like most other improvements 
 and the very schools themselves, has grown quite largely out of 
 private efforts. We, therefore, find 75 doctors and 21 nurses 
 receiving no pay from the schools. From this the salaries increase 
 to four thousand dollars for one physician and fifteen hundred 
 
MEETING THE HEALTH PROBLEM 6i 
 
 dollars for two nurses. The median salary for nurses is about 
 $70 a month and for doctors about $35. Of course, the nurse 
 gives five to forty times as many hours a week as the physician 
 in most cities. 
 
 HYGIENE OF THE SCHOOL ROOM. 
 
 10. Of the 1038 cities reporting 947 or about 91 per cent have out- 
 door recesses. There is a bad tendency the other way in north- 
 eastern United States. 
 
 11. 264 or about 25 per cent of the cities are abolishing the common 
 drinking cup in the schools by the use of individual cups, and 
 in 785, or about 75 per cent, by the installation of sanitary drink- 
 ing fountains. Cheap, durable, h}'gienic and easily workable types 
 of such fountains are being developed and they will undoubtedly 
 become as common as blackboards in our schools. 
 
 12. In 643, or over 60 per cent, of the cities the old feather duster 
 or dust creator, is being displaced by the damp cloth. Unfor- 
 tunately the latter requires more effort and constant vigilance 
 is needed to keep up the standard. 
 
 13. 894, or about 90 per cent, of the cities reported the use of dust- 
 absorbing compounds for sweeping. Scientific tests are much 
 needed in this field. The writer has seen ten cent oil work better 
 under scientific control than two-dollar oil, sold to unsuspecting 
 but health loving school boards. 
 
 14. Cleanliness is perhaps the greatest health virtue. Eleven cities 
 report the daily! washing of school floors and the frequency 
 ranges down to 51 cities reporting never. The latter attempt 
 to clean the floors with oil, not an impossibility. Once a month 
 to once in three months seems to be the most common frequency. 
 
 15. The frequency of floor sweeping gives 813 cities reporting daily, 
 70 once in three days, and 106 once in four days. From these 
 it ranges off to one city reporting "once in two months." Daily 
 sweeping when there are eighty or more little feet in and out 
 of a single room all day seems to be none too often. 
 
 16. The washing of windows varies from "weekly" to "never." The 
 mode is near once in three months. 
 
 17. 428 cities report the use of adjustable desks, about 41 per cent. 
 They are adjusted very uniformly. One city reports a daily 
 adjustment, 13 once a year. The modes seem to be "as needed" 
 and once in five months, each term. 
 
 18. As to instruction in hygiene, 95 per cent (982) of the cities 
 report the teaching of the effects of alcohol and tobacco; 63 per 
 cent (649) help the children to understand and to combat the 
 great white plague of tuberculosis; and 57 per cent (592) give 
 occasional lessons on first aid to the injured. 
 
 Had we the same statistics in each case for ten years 
 ago with which to compare each of these items, remarkable 
 improvement would undoubtedly be shown along most lines. 
 
62 SCHOOL HEALTH ADMINISTRATION 
 
 Any detailed and rigorous investigation of particular cities 
 would show, however, very much yet to be accomplished 
 before the schools are practicing existing health science. 
 
 STATE LAWS RELATING TO MEDICAL INSPECTION 
 
 Through state legislation, great advance in the work 
 of medical inspection has recently been fostered. Other 
 phases of educational hygiene have also been improved but 
 we shall give here only the main facts regarding this newest 
 phase of hygiene. 
 
 According to Ayres,^^ the first state law on medical in- 
 spection is credited to Connecticut (1899) ^^id provided for 
 sight and hearing tests by teachers. New Jersey stands 
 first for an all-round scheme of medical inspection in the 
 law of 1903. This act was permissive, however. Massa- 
 chusetts again stands at the head, as having the first com- 
 pulsory medical inspection law, in 1906. No state has yet 
 (19 13) a state supervisor of educational hygiene. 
 
 Up to May, 19 II, seven states had mandatory laws; 
 ten had permissive ones; and in two states and the District 
 of Columbia "medical inspection is carried on under regula- 
 tions promulgated by the boards of health and having the 
 force of law." This legislation has nearly all come about 
 in the last five years, an evidence of the very rapid growth 
 of the movement, and likewise of the spread of public 
 opinion in a democracy. Much of this legislation, like the 
 Massachusetts law of 1906, will need to be amended many 
 times as the movement grows. One prominent physician, 
 for example, writes from a Massachusetts town, "We are 
 compelled by law to employ a physician as medical inspector 
 but we have experimentally proved the nurse-alone plan 
 best." With such a physician for consultation it is quite 
 probable that specially trained school nurses may do most 
 of the work, and the law will need amending to cover this 
 development if it is generally followed. 
 
 From Dr. Ayres' pamphlet previously mentioned the 
 following table giving the principal features of state laws 
 and regulations providing for medical inspection has been 
 taken, with the author's kind permission. The five states 
 
» <u s 
 
 ih" S -2 o 
 
 ■s e 
 
 a « 
 
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 a ■;!• * M " t- 
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 o ^-. ^ 
 
 cL f^ ■'-■ *I3 CO TI 
 
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 c' 1 >> WI 
 
 ■~ to tj 
 
 CS 03 >. 
 
 ■.X 
 
 :x : -.x -.^i -x : XX : : : X 
 
 XX : [X : :xx \ xx -xx 
 
 ■XX 
 
 wS g5 XXX -x 
 
 •X • XXx '-X X 
 
 (i-Bo g XXX \x : -xx :xx -.xx \x -.xx 
 
 
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 7 5 
 
 o 3 
 
 I I" OhSSOhS Oh^SphS ^S&.ii.S Scu^feS 
 
 t-COWOr-l OJffil-rHiH 03 O rH O H H O O 01 rH 
 
 OoOiMt-l 00®'-l'-l OrHHlHTH ,-1 tH rM O rH 
 
 03 Oi 03 05 Oi <Xi Ci'^ Oi Ci d CiCiCiOi CiCiCi C:'C^ 
 
 rH^rHiHrH rH rH '^ i-H rH tH rH i-l iH tM rH H ri rH H 
 
 
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 cS 
 
 c3 
 
 Ml^ 
 
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 o o- 
 
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 1 to ^ ^ O 
 
 ^ r-ilNCO-^'w <»t-oo030 th'iNcOtiJiO CDC-^OOOIO 
 63 
 
64 SCHOOL HEALTH ADMINISTRATION 
 
 covered by the investigation set forth in the following 
 chapter are placed at the head of the list for easy reference. 
 The tendency toward mandatory legislation in this mat- 
 ter is worth noticing, as is also the uniformity of opinion 
 that the Board of Education should have charge of it. State 
 supervision, encouragement, and correlation are bound to 
 come not only for medical inspection, but for all five divi- 
 sions of school health provisions. 
 
 THE PLAYGROUND MOVEMENT 
 
 Recent statistics^^ show the same forward movement of 
 supervised playgrounds. There are at least 332 cities main- 
 taining supervised playgrounds. The 257 cities reporting, 
 employed during the year ending November i, 1911, 4132 
 men and women exclusive of caretakers on 1,543 play- 
 grounds, and expended for the work $2,736,506.16. 
 Thirty-six cities employed 377 workers all the year round. 
 In 39 of the 257 cities the playgrounds were administered 
 by school boards. This movement, also, is only about five 
 years old. 
 
 III. CONCLUSIONS 
 
 In preceding chapters we have attempted to learn the 
 magnitude of the national and school health problem. This 
 chapter is the by-product of an effort to determine how 
 adequately the present national and school health agencies 
 measure up to the health needs. Many agencies and move- 
 ments have necessarily been omitted, such as the abolition 
 of the common drinking cup in public places in so many 
 states ;^^ but we must confess, that, after looking most of 
 them over in the light of the magnitude, complexity, and 
 national character of our health problem, the present 
 agencies seem rather purile and seriously inadequate. We 
 are still quite largely in the volunteer, private stage of health 
 provision evolution. 
 
 A great many good movements have been started in 
 many parts of the country; several states and cities seem 
 to be fairly conscious of how much of an effort should be 
 made to stamp out their preventable deaths and lowered 
 
MEETING THE HEALTH PROBLEM 6s 
 
 vital efficiency in school and out; the National Government 
 seems near to the provision of a national health bureau or 
 department; but on the whole the few fairly adequate 
 state health laws, the few strong city or state health depart- 
 ments, the few school systems to which we can point that 
 seem to comprehend the seriousness of the school health 
 problem and are meeting it adequately; all these simply 
 show us that we have but started on the road toward school 
 and national health and normal physical development. It 
 is a pleasure and inspiration to live in an age of such change 
 and transition towiard better things. 
 
 The speed and accuracy with which we adjust ourselves 
 to our health needs will undoubtedly depend very much upon 
 how well we study our health problem, determining just 
 where it lies in personal, community, state, or national con- 
 ditions; how adequately we plaii to meet the need; and how 
 scientifically we test the effect our newly devised instruments 
 have upon the conditions we started to ameliorate. 
 
 We shall not proceed far in our health provisions until, 
 as Davenport and others have shown, we shall find that a 
 great deal of our ill-health and physical defects are heredi- 
 tary and that much is brought out or created by bad socio- 
 logical conditions. The evolutionist, Wallace, asserts that 
 our social system is "rotten from top to bottom," that it 
 produces most of the evils which eugenists would alleviate, 
 and that eugenic reform must wait on social reform. It 
 will be the part of wisdom, I think, to combine both 
 methods of conscious social evolution, hereditary and en- 
 vironmental. 
 
 While the general administrative and special technical 
 phases of health provisions in communities and schools are 
 frequently difficult and complex, yet the ends to be reached 
 are not many, and comparatively few hygienic principles 
 are involved, 
 
 "When people have pure food, pure water, pure air, 
 and are freed from the dust of houses, streets, and manu- 
 facturing industries; when they have good light and abund- 
 ant sunshine, sanitary houses, barns, and outbuildings; when 
 
66 SCHOOL HEALTH ADMINISTRATION 
 
 they are protected from germ-carrying agencies, such as flies, 
 mosquitoes, rats, mice, and all such pests; when they are 
 protected from people who are carriers of disease germs, 
 and taught how to disinfect their homes and communities; 
 when they are taught to work and play, eat and sleep, dress 
 and bathe, according to the laws of health; when they learn 
 to care for their teeth and their eyes, the main problems 
 of hygienic living will be solved and human life relieved 
 of its greatest sources of suffering and disease." 
 — Fletcher B. Dresslar, Ph.D., Specialist in School Hygiene 
 for the United States Bureau of Education, in his in- 
 troduction to bulletin 528, on The Fifteenth Interna- 
 tional Congress on Hygiene and Demography. 
 
 REFERENCES 
 
 I. R, C. Newton, M.D., The Renaissance of the Physical Conscience 
 Popular Science Monthly, 1909. 
 
 2. Ditman, Education in Preventive Medicine, Columbia University 
 
 Publications. 
 
 3. See 1913 articles in Scribner's Magazine, and many other publica- 
 
 tions. 
 
 4. Robert Bruere's article in the March, 1912 number of Harper's 
 
 Magazine. 
 
 5. Ditman, above referred to. 
 
 6. Quoted by Elkington, in his "Health in the School." 
 
 7. Generally to be found listed in the Survey Magazine. 
 
 8. Metropolitan, and a few others. Bulletins are furnished persons 
 
 requesting them. 
 
 9. Books by Stevens, Kelynack, Wood, Crowell, Hogarth, Dresslar, 
 
 Burks, Gulick and Ayres and the magazines such as The Child, 
 and the Pedagogical Seminary. 
 
 10. Ayres, What American Cities are Doing for the Health of School 
 
 Children, bulletin of the Sage Foundation, division of Child Hy- 
 giene. 
 
 11. Ayres, Medical Inspection Legislation, bulletin from above Founda- 
 
 tion. 
 
 12. The Playground Magazine, January, 1912, and later numbers. , 
 
 13. Dresslar, "School Hygiene," Macmillan. 
 Burks' "Health and the School," Appleton's. 
 
 Davenport, "Heredity in Relation to Eugenics," Holt & Co. 
 Wallace, "Social Environment and Moral Progress." 
 
 OTHER REFERENCES USED 
 
 A. Articles in English, French and German in the Transactions of the 
 Second International Congress on School Hygiene. 
 
MEETING THE HEALTH PROBLEM 67 
 
 B. The Annual Reports of the Chief Medical Officer of the Board 
 
 of Education of England, London, England, 1909-1912. 
 
 C. The recent volumes of the National Education Association which 
 
 is devoting much attention to health matters and has even changed 
 the name of one division from that of Child Study to that of 
 Child Hygiene. The 1912 Report has about 30 articles, reports, 
 etc. (173 pp.) devoted to various aspects of Educational Hygiene, 
 a change from little above zero before 1900. 
 
 D. Many of the flood of articles, reports, investigations, etc., appear- 
 
 ing in current books and periodicals, entirely too numerous to 
 mention. 
 
 E. The very valuable and suggestive account of "Typical Health- 
 
 Teaching Agencies of the United States," Chapter 12, Vol. i, of 
 the 1912 Report of the Commissioner of Education, by Dr. 
 F. B. Dresslar, Specialist in School Hygiene. 
 
 F. Reports of the National School Hygiene Association. 
 
COMPULSORY EDUCATION AND 
 CONTAGIOUS HEALTH 
 
 "The human race will he 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. Be- 
 cause of these lessons, the youth of the future 
 will attend a school in which health will be con- 
 tagious instead of disease, in zvhich the play- 
 ground will be as important as the book, and 
 where pure water, pure air, and abundant sun- 
 shine will be rights, and not privileges. He 
 will attend a school in which he will not have 
 to be truant, tuberculous, delinquent, or defec- 
 tive, to get the best and fullest measure of edu- 
 cation." — Gulick and Ayres, in "Medical Inspec- 
 tion of Schools." 
 
PART TWO 
 
 HOW THE PROBLEM OF EDUCATIONAL HYGIENE IS 
 BEING MET IN TWENTY-FIVE CITIES 
 
TEACHERS OF THE WHOLE CHILD 
 
 "The teacher should be held to more rigid re- 
 quirements in regard to hygiene. Every teacher 
 should he something of a physician. Our indif- 
 ference to the physical phase of education is sug- 
 gested by the fact that today a teacher may have 
 passed from the kindergarten and through the 
 university and still not know how to prevent or 
 cure a cold. Not to know something about the 
 preservation of health, to say nothing of the 
 detection of physical defects such as adenoids, 
 enlarged tonsils, bad eyes, faulty heart, weak 
 lungs, etc., is, on the part of the teacher, inex- 
 cusable ignorance. A doctor of philosophy with 
 a cold in the head suggests a humorous interpre- 
 tation of the old doctrine that nature abhors a 
 vacuum." — Howerth, in Education for May, 
 1907. 
 
CHAPTER IV 
 GENERAL PHASES OF HEALTH ADMINISTRATION 
 
 A. The Investigation. 
 
 I. THE PROBLEM 
 
 Because of the tremendous sociological importance of 
 the schools' health functions; because so little, comparatively, 
 is known about what the schools are actually doing for 
 health in a detailed way; and because cities, getting the 
 social contagion of the health movement, are hastily copy- 
 ing the work of other localities without definite standards 
 for the newer health provisions in the schools, it was con- 
 sidered desirable that personal visits be made to a large 
 number of typical cities, and studies made of their admin- 
 istration of educational hygiene, and especially of medical 
 inspection. The problem is too vast for any complete 
 description or evaluation of health provisions by one person 
 in two or three years. Adequately to determine the health 
 needs, and to describe and evaluate the work of educational 
 hygiene in one city is an enormous, but much needed, task. 
 Consequently, only the larger phases can be dealt with, and 
 only one phase, medical inspection, can be dealt with in 
 any detail. 
 
 Some of the problems with which the investigation 
 began are as follows: 
 
 1. How much does it cost? 
 
 2. What are the types of administration and their relative 
 efficiency ? 
 
 3. Is there better scientific management of medical supervision 
 by Boards of Health or by Boards of Education? 
 
 4. What effect has such work on the health of the children? 
 
 5. What effect has it upon pupil-efficiency in the schools? 
 
 6. What is the relative merit of school nurses and doctors? 
 
 71 
 
72 SCHOOL HEALTH ADMINISTRATION 
 
 7. What are found to be the principal ailments of school children, 
 how may they be classified, and what is their relative frequency? 
 
 8. What is the attitude of the public and the physicians to the 
 enlargement of such work? 
 
 9. Of all the ailments and defects found how many are actually 
 treated and cured? 
 
 10. How great is the need for free treatment, and how are the 
 cities responding? 
 
 11. How much preventive work is being done by the cities in the 
 way of play and playgrounds, open air schools, better school ventilation, 
 physical training, education of parents along health lines, school baths 
 and swimming pools, investigations into the health condition of school 
 children, and the like? 
 
 These and many other questions, gradually reshaping 
 themselves as the investigations went on, were prominent. 
 Only a few can be satisfactorily answered. Our ignorance 
 of school health is vast and profound. Educators have been 
 engrossed largely with other matters. A partial list of the 
 great host of unsolved problems in this field has been well 
 set forth by Professor Lewis M. Terman in the March 
 (1912) Popular Science Monthly. It is significant that there 
 are but two or three chairs of educational hygiene in the 
 universities of this country. 
 
 2. THE DATA AND THE METHOD 
 
 Those cities were selected for investigation which had 
 both school doctors and nurses and were in the eastern 
 part of the United States. They were located from the 
 Russell Sage Foundation investigation previously men- 
 tioned. There were about forty-five such cities that had both 
 school doctors and nurses at or near the beginning of the 
 school year 1910-11. After visiting most of these and 
 several others (forty in all) fifteen were finally eliminated 
 for one reason or another. New York City, Baltimore and 
 Philadelphia because they were too vast to be typical; others 
 because too little definite data could be discovered; others 
 because the work had begun too late in the school year; 
 and still others because either the nurse or physician was 
 employed by private organizations; or the work had just 
 changed over from the Board of Health into the hands of 
 the Board of Education (e. g., Ithaca, N. Y.). 
 
THE TWENTY-FIVE CITIES 73 
 
 At least one visit, a half day to a week in length, was 
 made to each city, and as many as ten visits were made 
 to certain nearby cities. The time of visiting was in the 
 school years of 19 10- 11 and 1911-12 and the intervening 
 summer when playground and other such work could be 
 seen. Additional visits have been made in the school year 
 of 19 1 2-13, A weak point of the investigation was the 
 inadequate time for many cities, and the frequent inability 
 to see the various health agencies in actual operation. 
 Where medical inspection was administered by the Boards 
 of Health these agencies were studied as well as the schools, 
 and where several agencies carried on the work all were 
 studied. Board of Health reports from all the cities have 
 been used as well as the United States Mortality Statistics 
 for 1 9 10 and the reports of the United States Bureau of 
 Education. It has been found necessary, also, to study the 
 work of cities having only school doctors, or only school 
 nurses for comparison with the group selected. The experi- 
 ences of European and other countries have also been drawn 
 upon. The attempt throughout has been to fit the investiga- 
 tion to the actual conditions found, not the facts to a pre- 
 arranged theory or questionnaire. The heterogeneity of 
 the findings by such a method, for work so new and tenta- 
 tive, beggars description. 
 
 Late in the study the writer had the good fortune to be 
 employed by the Board of Education of one of the twenty- 
 five selected cities, probably nearest of all to the city of 
 typical size in this country, to investigate the work of the 
 so-called medical inspection and to report a tentative, 
 standardized plan for reorganization and growth. Full 
 powers were given In the way of calling for the judgments of 
 teachers, principals, physical trainers, physicians and nurses; 
 and for looking into the work. Though the time available 
 was entirely too short, a good deal of fresh light was thus 
 thrown on the general problem. 
 
 We shall first take up the work of medical inspection 
 with its display of pathological conditions and consequent 
 health needs, in the schools and homes. Later, brief descrip- 
 
74 SCHOOL HEALTH ADMINISTRATION 
 
 tions and evaluations of other phases of educational hygiene 
 of a preventive and development nature will be offered. 
 
 3. MEDICAL INSPECTION OF SCHOOLS IN TWENTY-FIVE 
 
 CITIES 
 
 The following tables attempt to display in convenient 
 form some of the main facts about the work of medical 
 inspection in the twenty-five cities. Some general facts 
 relating to the city and the schools, necessary for compre- 
 hension of the situation and for later efficiency tests, are 
 given first. Many facts refuse to enter the squares of a 
 statistical table, and foot-notes, description and qualifica- 
 tions are necessary. Even then the data are relatively 
 inaccurate, for many reasons, but chiefly because of the lack 
 of efficient records in practically all cities. When, for 
 example, a medical inspector has been discharged for sending 
 in reports based on nothing more than entering the lower 
 hall of a school and signing his name in a book, some doubt 
 is cast over his and perhaps others' statistics in that city. 
 Further, most of the blank forms for recording the work 
 are, as yet, so poorly devised that it is almost impossible to 
 record or summarize work done, or correlate it with results 
 accomplished. The poor clerks, devoid of medical knowl- 
 edge, who have to make up a majority of the summaries 
 from such data help to make even more inaccurate the 
 results. Some cities have met the situation by making no 
 annual reports or very meager and inadequate summaries. 
 To get back of this difficulty it was necessary to spend 
 several months in summarizing the daily, weekly or 
 monthly reports of doctors and nurses in a number of cities. 
 The knowledge gained from such work was, however, well 
 worth the tedious labor. The large number of cases proba- 
 bly helps some to cover up many inaccuracies, and the gen- 
 eral facts here selected and presented are probably as accu- 
 rate as can now be obtained. Our hope is that the study 
 will lead to greater efficiency in this field. 
 
THE TWENTY-FIVE CITIES 75 
 
 B. Correlations JVith Population of the Cities. 
 
 From these statistics it can be seen that the cities and 
 towns studied are scattered over five states and range in 
 size from 7,500 population to 670,583, 1910 census. Within 
 this range are included most of the municipalities of the 
 country so the data of our study can be regarded as fairly 
 typical in this respect. Since the cities are arranged in 
 order of size (Columns i, 2, 3), questions immediately 
 arise as to the correlation of this increase with the admin- 
 istrative provisions. In the next column (4) it can be seen 
 that as the cities increase in size more and more of them 
 have medical inspection administered by Boards of Health. 
 This may be due to chance, but is more probably due to the 
 fact that when medical inspection began a few years ago it 
 was confined for the most part to the larger cities, and was 
 under the Boards of Health. The 1906 Massachusetts 
 law prevents cities from taking the work, where already 
 begun, out of the hands of the Boards of Health and put- 
 ting it into the hands of the Boards of Education. The 
 smaller cities, as shown by the column giving the dates when 
 medical inspection was begun, have started the work for 
 the most part since the change of public opinion and state 
 laws have placed the work in the hands of the Boards of 
 Education. In New Bedford and Boston the work is di- 
 vided, the Boards of Health having the school doctors and 
 the Boards of Education the nurses. 
 
 I. SALARIES AND SIZE OF CITY 
 
 Only the larger cities have special supervisors of medi- 
 cal inspection, Syracuse under the Board of Health, Jersey 
 City and Newark under the Boards of Education, and Bos- 
 ton with a supervisor employed by each board.* No signifi- 
 cant correlation exists between the size of the city and the 
 salary paid either to physicians or nurses. Some small 
 cities pay little and some much; the same is true of the 
 larger ones. The supervisors' salaries tend to increase with 
 
 *The Board of Education in Boston has both a general Director 
 of Hygiene and a Supervisor of Nurses. 
 
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78 SCHOOL HEALTH ADMINISTRAION 
 
 the size of the city, indicating, perhaps, a recognition of the 
 possibilities of more responsibihty if not more work in the 
 larger places (Columns 19 and 20). 
 
 2. NUMBER OF DOCTORS AND NURSES 
 
 When we come to the number of doctors and nurses 
 (Columns 19 and 20), a surprisingly low correlation is 
 found. The numbers by no means increase proportionately 
 with the size of the city or the number of pupils in the 
 school systems. If the first five cities require the entire 
 time of one nurse each, then, taking 1,735, their average 
 enrollment as a trial standard, Boston should have about 
 63 nurses instead of 34 and Newark 45 instead of eight. 
 Providence would have 20 instead of one. It is evident 
 from these figures that there are as yet no very definite 
 standards established or attained in this field. The writer 
 found the nurse's time well occupied in these smaller cities. 
 Since the problem increases somewhat with the size and 
 congestion of the city it would seem reasonable from this 
 correlation that while the smaller cities may be fairly well 
 supplied with nurses, the larger cities have a woeful insuffi- 
 ciency. However, the number of physicians, the size of the 
 schools and the distances between them are all factors. 
 
 There is a closer correlation between the number of 
 physicians and the size of the city, than for the nurses. 
 Physicians were the first to be appointed and the cities have 
 been districted largely on the basis of physicians, not nurses. 
 Taking the same average enrollment for the first five cities 
 (15735) we find that if these small cities each need one 
 physician two hours a day, Boston should have, on this basis, 
 (counting each supervisor as two physicians), 63 physi- 
 cians instead of 82, Newark 45 instead of 39, and Provi- 
 dence 20 instead of four. It can be seen that most cities have 
 fewer physicians than this trial standard calls for. 
 
 PHYSICIAN-NURSE UNIT 
 
 But the number of physicians employed depends largely 
 upon the number of nurses in the system and, vice versa, it 
 may be said; so the unit standard should really be the 
 
THE TWENTY-FIVE CITIES 79 
 
 physician-wf^/z-the-nurse, the physician-nurse unit. Applying 
 again the average-pupil-enrollment standard, Boston would 
 have 63 doctors and 63 nurses, and the other cities 
 proportionate numbers. The combined number for Boston 
 would be 126 instead of the present 120, (80+2) + 
 (34+2+2), a very small difference. (Column 47). For 
 Newark the combined number would be 90 instead of 47, 
 (37+8+2) ; and for Providence 40 instead of five. The 
 combined number based on this standard is given in con- 
 trast to the actual combined numbers for each city in 
 columns 46 and 47. The ratio of the actual combined 
 number to the standard number is given in column 48. 
 Glancing down this column (48) we note an increasing 
 falling away from the tentative trial standard number of 
 physicians and nurses until we reach the last city, Boston, 
 (95.47), where a surprisingly close correspondence Is 
 reached. The only city having more than the standard 
 number is Montclair and its superiority Is apparent rather 
 than real, for its physicians visited the schools only twice 
 a week instead of five times, and spent, on the average, 
 only about one hour's time to a visit. 
 
 THE PHYSICIAN HOURS A WEEK NURSE STANDARD 
 
 This shows the necessity for a trial standard which will 
 include the number of hours a week the physicians actually 
 spend in the school work. Later a general working stand- 
 ard will be developed which will include the number of 
 daily visits a year, and other matters, but for the quick 
 comparison of cities the following plan may be used: Count 
 as a physiclan-worklng-unit one who gives five hours a 
 week (an hour a day) to the schools. Rules and regula- 
 tions are extremely chaotic; and It is difl[icult in^the hetero- 
 geneity to learn exactly how many hours physicians actually 
 do put in, on the average (See columns 30-32) ; still column 
 49 will show approximately on this comparable basis the 
 relative standing of the cities as to numbers of doctors and 
 nurses. At Montclair, for example, the five physicians 
 putting In two hours a week are roughly equivalent to two 
 physicians giving five hours a week. Adding the nurse 
 
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82 SCHOOL HEALTH ADMINISTRATION 
 
 (Column 49) to the physicians we have the equivalent 
 (other things equal) of a working staff of three instead of 
 six. While it will be shown later that probably tmo hours 
 a day, jive days a week is a more ideal arrangement, "stand- 
 ard" here means only a trial unit of measurement for put- 
 ting variant facts on a comparable basis. Fractions should 
 be considered as parts of working-units, not of physicians, 
 of course. 
 
 Leaving off the decimals, we see what a variety of things 
 the statement that a city "has medical inspection of schools" 
 may mean. (Column 50). Meriden stands at 100 per 
 cent; while Yonkers stands at 1 1 per cent. Ten times as 
 many hours of medical service were given in the former 
 city (not counting the number of hours, nor daily visits a 
 year)^ and to one-third the number of elementary pupils. 
 Taking the average of the first five cities again as a basis 
 of comparison (2, a physician with a nurse each), and 
 1735 as the average enrollment, we can see how many 
 physicians and nurses the cities would have were they to 
 keep up to the trial standard set by the first five. Boston 
 again practically maintains the custom of the small towns. 
 Other cities coming near to it, after the five used as a 
 standard, are: Meriden and Newark. Counting office 
 assistance in Boston and Newark there would be almost the 
 same proportionate amount of medical inspection units as 
 in the smaller cities. In other words, the two largest cities 
 almost keep up the standard set by the smallest towns while 
 other cities fall considerably below. 
 
 The percentage figures in the next column (50) show 
 how nearly the different cities come to the working stand- 
 ard. When we see such large and relatively efficient cities 
 as Newark (95 per cent), and Boston (95 per cent), 
 practically coming up to the standard set by the smallest, 
 and then see Meriden starting out (October, 19 10) on an 
 ably constructed plan of administration of this work and 
 practically taking up this standard, it appears that the 
 working standard used here must not be far from what 
 actually seems necessary. Its limitations will be shown 
 
THE TWENTY-FIVE CITIES 83 
 
 later. In Summit, for example, with a first-class suburban 
 population the medical inspector really has to put In more 
 than an hour a day five days In the week, and, to get the 
 work well done, should be employed for two hours in 
 actual medical work daily; but in the year studied he made 
 only 125 daily visits In the school year of 188 days. 
 
 Interpreted, some of the cases In this column mean, for 
 example, in Rochester and Jersey City,* that these cities 
 have about half (50%) as many inspectors and nurses as 
 would meet the standard of the largest and smallest towns; 
 Yonkers has about 11% as many, being most poorly sup- 
 plied of all the cities. These figures, then, show the approx- 
 imate relative standing of the cities as to the amount of 
 medical Inspection forces per unit of school enrollment not 
 counting the relative number of weeks employed In a school 
 year. This does not state what should be, but what was. 
 The number of nurses put into a school system would Influ- 
 ence the number of physicians needed. It is probable that 
 there should be at least an equal number, and perhaps more. 
 No data are here given on this problem. 
 
 3. BOARDS OF EDUCATION VS. BOARDS OF HEALTH 
 
 Is there any light thrown by these comparative figures 
 on the relative efficiency of Boards of Health and Boards 
 of Education? If Boards of Health are more responsive 
 generally to the needs of the schools with respect to patho- 
 logical health conditions than are Boards of Education 
 then we should expect these figures to show them better 
 manned for the work of medical inspection, especially since 
 they are, on the average, nearly three times as old. What 
 are the facts? Leaving out the two cities. New Bedford 
 and Boston, where the responsibility of caring for the 
 health of the school children is divided between the two 
 
 *This was the first complete year of medical "inspection" for Jersey 
 City and the plan was not completely carried out. The rules require 
 two hours a day, five days a week, for each physician. Were the actual 
 average ten hours a week, the combined number would be i2X2-|-4H-6. 
 The twelve M. D.'s would be equivalent to twenty-four, the supervisor 
 to four, and the nurses to six; in all, thirty-four, instead of twenty. 
 
84 SCHOOL HEALTH ADMINISTRATION 
 
 boards, we can take the average standing of those cities 
 where this work is administered by Boards of Education 
 and compare it with the average of the cities under Boards 
 of Health (Column 50). The average for the fourteen 
 cities administered by Boards of Education is 76% 
 (omitting Brockton,* 81%) while the average for the 
 nine cities where the work is in the hands of the Boards of 
 Health is a little over 45%. This would seem to indicate 
 that Boards of Health are not as responsive, or not as 
 successful, in getting an adequate force of medical inspectors 
 and nurses as are Boards of Education. Even leaving off 
 the first five cities and comparing the nine remaining cities 
 with the nine others, the Boards of Education stand at 
 about 62% while the Boards of Health stand at about 
 
 45%- 
 
 An alternative, however, remains: That the Boards of 
 Health may be able to use more efficiently a given number 
 of medical inspectors and nurses than could the Boards of 
 Education. This remains for later solution when the 
 amounts and quality of work done are compared. It may 
 be said here, however, that in general they seem to use 
 them far less efficiently than do Boards of Education. 
 
 Under Boards of Education. Under Boards of Health. 
 
 Montclair 75 Mt. Vernon 83 
 
 Meriden lOO Newton 87 
 
 Brockton* 20 Schenectady 20 
 
 Hoboken 58 Waterbury 28 
 
 Yonkers 11 Cambridge 35 
 
 Trenton 83 New Haven 28 
 
 Lowell 71 Syracuse 64 
 
 Jersey City 50 Rochester 50 
 
 Newark 95 Providence 12 
 
 563 407 
 
 Average, 62%, without Brockton, 67%. Average, 45%. 
 
 4. TENDENCIES IN MEDICAL SUPERVISION 
 
 Without carrying any further the correlations between 
 
 *Brockton is exceptional for the reason that it is practically elim- 
 inating physicians, using them for consultation by the nurse only. This 
 marks the begininng of a growing tendency. 
 
THE TWENTY-FIVE CITIES 85 
 
 the increase in size of the cities and their school populations, 
 we can see something of the tremendous heterogeneity and 
 relative status of cities in this work. Another preliminary 
 problem arises as to the tendencies shown by these 25 cities. 
 How rapidly is medical supervision coming into our cities, 
 and is its administration going into the hands of the Boards 
 of Education or the Boards of Health? The facts are 
 shown by the following table (Column 5) : 
 
 Two began Medical Supervision in 1894, both by Board 
 of Health. One now partly Board of Education. 
 
 Two began Medical Supervision in 1901, one Health 
 and one Education, formerly Health. 
 
 One began Medical Supervision in 1903, Education. 
 
 One began Medical Supervision in 1904, Health. 
 
 Four began Medical Supervision in 1905, two Health 
 and two Education. 
 
 Four began Medical Supervision in 1906, three Health 
 (one partly Education) and one Education. 
 
 Two began Medical Supervision in 1907, both Health, 
 one partly Education. 
 
 Three began Medical Supervision in 1908, all Educa- 
 tion. 
 
 Three began Medical Supervision in 1909, all Educa- 
 tion. 
 
 Three began Medical Supervision in 19 10, all Educa- 
 tion. 
 
 None of the nine cities starting since 1907 has 
 Intrusted this work to Boards of Health. The work began 
 with the Boards of Health but it is now being placed in 
 the hands of the Boards of Education. In New Jersey the 
 1909 law placed all the systems then existing under the 
 Board of Education, four of these cities. 
 
 This table for these twenty-five cities corresponds closely 
 to the one made for 1,038 cities giv^en earlier. It shows 
 a very remarkable acceleration since 1904-5, an increase 
 so rapid as to point to the movement spreading soon to all 
 cities. In these cities, too, the nurses have all been added 
 since 1906 when Boston started the movement on a large 
 
86 SCHOOL HEALTH ADMINISTRATION 
 
 scale, practically all having been added, indeed, since 1908. 
 (Column 6). A tendency, not yet to be shown in figures, 
 exists toward increasing the number of nurses and decreas- 
 ing the number of physicians. One city, Brockton, dropped 
 three of its physicians (keeping two paid and one volun- 
 tary physician for consultation only) , and put one nurse in 
 their place. This was at the instance of physicians them- 
 selves, one of whom is on the Board of Education. 
 
 Newark is now changing to almost the same plan, using 
 a few physicians as district medical supervisors of a large 
 number of nurses. Oakland, Cal., and Albany, N. Y., have 
 the same general plan. 
 
 C, WHAT DOES MEDICAL SUPERVISION COST? 
 
 a. Salaries of Supervisors and Office Help 
 
 The salaries of physicians range from $200 to $1,200 
 as regular examiners or inspectors. One, a member of a 
 Board of Education, gives his services free of charge (at 
 Brockton). The salaries of the head-physicians, or super- 
 visors, range from $800 to $3,780, as follows: 
 
 Syracuse, $800. 
 
 Jersey City, $1,500. 
 
 Newark, $1,800. 
 
 Boston: Board of Health, $2,500; Board of Educa- 
 tion — General Supervisor Department of Hygiene, $3,780; 
 Supervisor of Nurses, $1,500. 
 
 None of these supervisors gave full time to the work, 
 excepting the woman who is supervisor of nurses in Boston. 
 From three to four hours a day was expected or given by the 
 other supervisors. These figures, of course, do not give 
 credit to the large amount of supervising time given either 
 by the superintendents of schools or of boards of health in 
 certain cases. They refer only to those officials who have 
 been definitely set apart for this specific work alone and 
 who are paid a salary for it. Each of these supervisors has 
 office help, either the general office force as in boards of 
 health, or special assistants as in the case of the schools. 
 Jersey City has one stenographer on half time, and here 
 only records of excluded children are summarized. In New- 
 
THE TWENTY-FIVE- CITIES 87 
 
 ark, the supervisor has a well appointed office and two 
 efficient clerks on full time. Even these are not able to 
 do all the work desirable to keeping track of 37 to 38 
 inspectors and eight nurses with daily reports, a sani- 
 tary inspector and large amounts of medical supplies. 
 Analysis of results and adequate checking up and reporting 
 are difficult. In Boston, the school Supervisor of Hygiene 
 and the Supervisor of Nurses have but one clerk. To meet 
 this situation nurses are there required to hand in reports 
 only every three months. Of course, there are no physicians 
 to look after as they are under the direction of the Board 
 of Health. The efficiency of reporting only every three 
 months instead of daily or weekly is very doubtful. 
 
 b. Salaries of School Physicians 
 
 The gross salaries of physicians seem very low. The 
 average salary is $398, practically $400 a year.* The 
 median salary is, however, only about $300, half of the 
 cities having less than this salary and half having more, 
 while only six pay more than $400. The three cities which 
 pay $1,000 and over are exceptional. In two of these, as 
 will be shown later, the salary is probably higher in pro- 
 portion to services rendered than is necessary. Distinctions 
 must continually be made between the number of hours 
 required by the rules or expected by the Board and the 
 number of hours which are actually given to the school 
 work. These three cities require twice or three times as 
 much time a day as is customary, two and three hours 
 instead of one. Boston had 80 physicians at a dollar or 
 less an hour; for some physicians put in more than the 
 required hour a day. This has since been changed to two 
 hours a day and $500 a year. 
 
 A salary of $300 for ten months, counting twenty 
 school days to a month, and a visit of an hour a day, five 
 days in the week, means $30 for 20 hours, or $1,50 a visit, 
 
 *Newark has since changed from thirty-seven physicians at $300 
 a year to thirty-eight physicians at $400, giving strictly two hours to 
 the school work each day since many physicians have but one school. 
 Further changes emphasizing the nurse are now taking place, however. 
 See page 84. 
 
88 SCHOOL HEALTH ADMINISTRATION 
 
 or hour. $400 means $2 an hour. These are not far 
 from the regular charges of average physicians in private 
 practice. The public service is far more regular, very few 
 patients indeed requiring a physician's services daily nearly 
 180 times a year. It, moreover, brings the physician into 
 touch with a great number of present and future citizens, 
 which will, in many cases, increase his practice. The main 
 drawbacks seem to be, first, that the school hour, or hours, 
 should be given at practically the same time each day, thus 
 interfering with possible private practice; second, that the 
 work is of such a routine character that the physician very 
 soon tires of it; and third, that the conscientious physician 
 is frequently disheartened in the attempt to do in an hour, 
 an hour-and-a-half, or even two hours, all that needs to be 
 done in service to the children. To emphasize the second 
 point, Dr. Cornell's frequent mention of the physical strain 
 of prolonged examinations may be quoted from his book 
 on "Health and Medical Inspection of School Children." 
 In speaking of vision testing, page 42, he says: "Anyone 
 who has examined for two hours, alternately standing beside 
 a test card with a pointer and going to a table or desk to 
 make the record, using constantly the eyes, voice, and body, 
 with the added effort of instructing each child clearly what 
 to do and how to do it, will testify to absolute fatigue experi- 
 enced, as well as the feeling of eye-strain ensuing." And 
 again on page 43, "An hour and a half of eye testing is 
 almost sufficient to start up a headache in any examiner, 
 no matter how perfect his eyesight, and phlegmatic his 
 temperament." These effects are practically universal and 
 are mentioned by most of the English writers on this siib- 
 ject. It would seem that the strictly medical examination, 
 not including vision or hearing tests, is just as fatiguing and 
 that those who claim physicians should be employed for 
 the entire day (excepting the supervisor who could vary 
 his work) as is the teacher or nurse, are wrong; and the 
 best scientific management would make the physician's 
 expert services last little longer than two hours daily. For 
 full-time service the problem becomes one of providing 
 other work for each half day. The nurse, of course, can 
 
THE TWENTY-FIVE CITIES 89 
 
 easily alternate her work with home visiting. It is doubtful 
 if any first-class physicians could be found who would de- 
 vote their entire days to medical examinations of pupils. 
 All the writer has questioned asserted this emphatically. 
 The ideal for the physician at present would seem to be 
 two hours a day, taking no part of the two hours in going 
 from one school to another. Inevitably school physicians 
 will, however, be provided on full time. The problem 
 has not yet been solved. Several very large cities now 
 have full-time physicians, of course, but the salaries are 
 large, and we are looking here more to average or typical 
 cities. 
 
 These salaries as printed, however, do not show com- 
 paratively what the real salaries are. The number of hours 
 a day, week, and year, the quality and the difficulty of the 
 service must all be considered. Leaving out the last two 
 for the present, let us see what the salaries are in terms of 
 hours spent in the school service. Columns 32 and 51 give 
 respectively the number of hours a week each physician 
 gives on the average, as nearly as could be determined, and 
 what each hour cost the city. The second column then 
 gives fairly accurately the real comparative salaries, omit- 
 ting the number of daily visits in the school year, which 
 varies greatly. Where cities have no rules governing this 
 matter or have physicians only "on call" estimates have 
 been made, with the help of some supervising official, of the 
 average number of hours a week inspectors spent in the 
 schools. Likewise, where the work is new and the adminis- 
 trative measures not yet perfected estimates have necessarily 
 been used. Some inspectors will perhaps find that their 
 individual amount of time is underestimated by these figures; 
 others, overestimated. Had we facts for all cities the num- 
 ber of daily visits a year should be taken into consideration 
 as an important item. Wholesale absence is common in 
 some cities. 
 
 These salaries stated in terms of wages-per-hour 
 range from $1 to $6.25. If it could be shown that the 
 physicians at Yonkers gave an average of more than an 
 hour a day twice a week, then this largest salary would be 
 
90 SCHOOL HEALTH ADMINISTRATION 
 
 decreased, and perhaps some other city would stand highest. 
 The facts are for the year 1910-11. The average wage per 
 hour for the 25 cities is $2.30 and the median wage is $2, 
 half of the cities paying less than this amount and half pay- 
 ing the same or more. Only five cities pay more than $2.50 
 an hour and only three pay as low as one dollar. If the 
 four cities paying over three dollars actually had a larger 
 average number of hours service for each physician, which 
 may be possible, the average and the median for all would 
 not be far from $1.50 an hour. The Newark change from 
 $1.50 to $2 a visit of two hours each, five days a week, is in- 
 teresting in this connection. Of course, where the calendar, 
 instead of the four-weeks school month, is used, physicians 
 get a little less an hour. It is very doubtful if it is an effi- 
 cient use of public money to pay more than $1.50 an hour 
 (three dollars for a two-hour visit). If Boston can get 80 
 physicians year after year, Newark 38, and many other 
 smaller cities can get good average physicians for a dollar 
 an hour, this sum, especially in the two hour a day plan, 
 would seem to be a reasonable minimum. Sixty dollars a 
 month regularly ($1.50 an hour) seems to be average 
 physicians' earnings, much better than many, and better than 
 the teachers in the schools obtain. Where more is paid, 
 say two dollars an hour or $800 a year, diminishing returns 
 bring in the school nurse who can be had on full-time 
 eleven instead of ten months in the year, and who is often 
 more efficient hour by hour for the relatively simple work 
 of school Inspection than the physicians. 
 
 c. Nurses' Salaries 
 
 The salaries of nurses are fairly well standardized. 
 Nurses in a large number of schools work from 8 :30 or 
 9:00 in the morning until 4:00 to 6:00 in the afternoon, 
 with a half hour to an hour off for lunch. Generally the 
 plan Is to have the nurse at the school about fifteen minutes 
 before school begins in the morning; and to require her to 
 do home visiting after school until five-thirty or a little later. 
 Home visiting may also be done in school hours in many 
 places. On Saturday, the nurse makes home visits from 
 
THE TWENTY-FIVE CITIES 91 
 
 eight or nine to twelve o'clock. For these five-and-half 
 days a week with Saturday afternoons frequently devoted to 
 statistical records and reports, the nurses receive salaries 
 ranging from a little over fifty, to ninety dollars a month, 
 ten, and, in some cases, eleven or twelve months in the 
 year. Boards of health quite regularly, though with excep- 
 tions, employ the nurses for twelve months with salaries of 
 eight or nine hundred dollars a year. In the summer and at 
 other times when not engaged in school medical inspection, 
 the Board of Health nurses do the regular district and 
 other nursing. 
 
 In Schenectady the nurses each spend a month of the 
 summer in the Open Air School with one month vacation 
 each. In Boston, the school nurses are paid in twelve 
 annual installments and may be called upon for service 
 during the summer vacation, but as yet they have been 
 free. The tendency is toward keeping a part or all of the 
 nurses in relays during the summer (each nurse getting a 
 month's vacation) for the inspection of children in vacation 
 schools and playgrounds and for the home visiting which 
 seems necessary to prevent immense accumulations of cases 
 of pediculosis, impetigo, and the like for the beginning of 
 the school term. The salary of the only head nurse, or 
 supervisor of nurses (in Boston), is $1,500.* She and the 
 other nurses are on a salary schedule which rises with years 
 of experience and growing skill. This latter desirable 
 measure tends to put the nurses on the same professional 
 plane as the teachers. The tendency is for the nurse's 
 salary to be as high as that of the teacher. Her work is 
 perhaps a little longer but on the average her professional 
 training and years of preparatory schooling are much less. 
 Her night work also Is probably very much less than that 
 of teachers. 
 
 The average salary in the 25 cities Is $756 while the 
 median is $750, for ten months. A number of nurses are 
 paid for an extra month In the summer over this sum. 
 
 *More now. 
 
92 SCHOOL HEALTH ADMINISTRATION 
 
 d. Total for all Medical Supervision Salaries 
 The total for all salaries of doctors and nurses is given 
 in column 25. The seeming discrepancy for Newark arises 
 from the fact that until February of the school year, 19 10- 
 191 1, there were 16 doctors on a salary of $400 a year, 
 ten hours a week; while after that date there were 37 doctors 
 on a salary of $300 a year, ($ .75 an hour) giving the 
 same time.* In three cases, as shown (Montclair, Cam- 
 bridge, and Lowell), the Boards of Health have employed 
 other physicians to inspect the parochial schools. The 
 physicians of no Board of Education as yet inspect private 
 and parochial schools. The Boards of Health have exer- 
 cised such rights because their general health powers are 
 so great. Where state laws require medical inspection 
 of parochial schools, the latter are coming to ask boards 
 of education to do it, however. 
 
 2. SUPPLIES AND OTHER EXPENDITURES 
 
 a. Carfare. {Column 26.) 
 
 As physicians frequently have automobiles or other con- 
 veyances, they are not usually given car tickets. The 
 nurses are nearly always given such tickets. In some cases, 
 e.g., the small towns near Boston or New York, railroad 
 fare is also included whenever a nurse takes a pupil or a 
 group of pupils in to a free clinic or specialist. Permission 
 is, of course, granted by the parents for such cases. The 
 median allowance for carfare, so far as it could be dis- 
 covered, seems to be about thirty-five dollars a year for 
 each nurse. The 35 nurses in Boston required only $408.50 
 for the year, an average of less than $12.00 each ($11.66) ; 
 and this sum Includes the supervisor who probably spent 
 far more on the average than the other nurses. Where a 
 large city Is well districted and there are many nurses, such 
 expenditure, will be, of course, largely reduced. 
 
 b. Printing 
 
 The printing expenditures (Column 27) are for medical 
 supervision blank forms, notices to parents, and the like. 
 Where daily reports are made on printed postal card forms 
 
 *From February 1st, 1912, there have been thirty-eight doctors on 
 a salary of $400 a year each, a rate of about one dollar an hour. 
 
THE TWENTY-FIVE CITIES 93 
 
 or sent in stamped envelopes, postage becomes a large item. 
 In Newark, counting 180 school days, for 45 medical 
 assistants (doctors and nurses) and two cents for each daily 
 report, the item amounts to about $162. This cost is 
 included in this column. Meriden, the seventh city, hap- 
 pens to show the initial cost of printing, when the system 
 was started. After a system has been well started and a 
 reasonable supply of materials laid in, little needs to be 
 paid for further printing. Where poorly considered forms 
 have been printed in quantities, great amounts of obsolete 
 forms and waste of money accumulate. Certain cities have 
 so many different forms that the whole system is confusing, 
 and doctors spend almost as much and even more time in 
 making the daily reports, in their school time, as in inspect- 
 ing or examining children. For a city of about thirty to 
 fifty thousand population the cost of introducing a com- 
 plete system of blank forms, nurses' equipment, etc., need 
 not be much over $200. 
 
 c. Medical Supplies 
 
 The cost of medical supplies (Column 28) varies very 
 greatly because of the great variance of opinion on treat- 
 ments. Some hold that the schools have no business in this 
 field while others contend that free treatment is not any 
 worse and just as desirable as free books and free school- 
 houses, especially since we have compulsory attendance and 
 so compulsory danger of infection and unhealthful school 
 environment. Some cities have such supplies in large quan- 
 tities kept at the central school supply center and deliver 
 them when needed, on requisitions from the principals. 
 Others keep all the supplies in the separate schools; while 
 some have the only supplies used in the nurse's bag (e.g.. 
 New Haven) which she carries from school to school. 
 Again, some cities buy as the supplies are needed from the 
 local druggists while others buy for a year at a time from 
 wholesale medical supply houses, choosing the lowest bidder. 
 Very little study by school business managers and others 
 has been made of the most efficient buying in this field. 
 Buying of local druggists seems to be quite expensive as 
 
94 SCHOOL HEALTH ADMINISTRATION 
 
 items are overcharged. The investigator found in one city, 
 for example, twenty-five cent hair brushes (for vermin 
 cases) sold at $1.50 each. Most supplies keep well enough 
 to be purchased for a year ahead, and this seems to be the 
 best method, if the requisitions are made out with sufficient 
 care and real public bidding by the best firms is solicited. 
 A list of the principal supplies found necessary in the most 
 progressive school systems will be given later. The cost 
 of such supplies in the most liberal cities is comparatively 
 very little. In these twenty-five cities the expenditure ranges 
 from about zero to nearly three thousand dollars (New- 
 ark) . The tendency will inevitably be in the direction of 
 increasing the amount of free treatment. The writer's 
 judgment on the matter will be found in the tentative 
 standard plan offered for criticism in the last chapter. 
 
 3. TOTAL EXPENDITURES FOR PUBLIC SCHOOL MEDICAL 
 
 INSPECTION 
 
 The total expenditures for Medical Inspection in the 
 schools studied are given in column 29. In cases where the 
 cost of supplies and other items could not be separated from 
 general expenditures, the expenditures would be somewhat 
 larger. Where the Board of Health has the school physi- 
 cians and the Board of Education the nurses, numbers 
 above are those for the latter, and those below for the 
 former. The relationship of these expenditures to the total 
 running expenses of the schools is given in column 53. The 
 general correlation with total school expenditures can be 
 seen from inspection to be very slight, as has before been 
 pointed out in another connection. 
 
 D. Management of Medical Supervision Work. 
 
 I. TIME EMPLOYED BY DOCTORS AND NURSES 
 
 The school nurse, as suggested, works, on the average, 
 five and a half days a week, giving seven to eight hours a 
 day on school days and three to four on Saturday. Her 
 total weekly hours are, therefore, very much in excess of 
 the time put in by the average physician. In actual hours 
 the average weekly time in hours of the physicians is to 
 
THE TWENTY-FIVE CITIES 95 
 
 the average of the nurses in these twenty-five cities as i to 
 7 or 8. This ratio, by a coincidence, is that often given by 
 those in charge of such work as to the relative worth to 
 the schools of doctors and nurses. When a system has been 
 properly organized, however, the physician will do only such 
 highly skilled work as the nurse cannot do, and for the 
 same amount of time the ratio will be smaller. Fortunately, 
 the most common ailments of school children are so simple 
 that they can be easily and efficiently handled by the well- 
 trained nurse. There is no such responsibility for life and 
 limb as the physician carries when he takes his cases in pri- 
 vate life. For the nurse, there is nearly always the family 
 physician or dispensary to check up her management of 
 cases. The disadvantages of having physicians call at 
 schools only once or twice a week, cultivating their private 
 practice on other days at the regular school time, are so 
 great and so numerous that it is being found best to have 
 them go to the schools at the same time every school day. 
 As will be shown later there is also a decided advantage 
 in having the time spent by the physicians in the schools not 
 less than two hours. And further, in this connection, in 
 order to save the vast amount of time lost in traveling from 
 school to school on any one day, it will be found more 
 efficient to have the physician visit only otie school a day; 
 perform only the technical part of the annual examinations; 
 and spend all of the two hours or more required in the one 
 school, visiting, perhaps, five schools in the five days. The 
 time for physicians each day should begin about ten min- 
 utes before school begins, so they may, in the schools where 
 they examine, individually inspect such pupils, also, as have 
 been out of school for several days or such as seem to the 
 teachers or nurses to require immediate and skilled atten- 
 tion at the opening of school. 
 
 2. CHECKS ON THE WORK OF MEDICAL SUPERVISORS 
 
 School Physicians. No very efficient and entirely satis- 
 factory checks on the work of physicians have yet been 
 devised. Supervisors who have had experience in medical 
 
96 SCHOOL HEALTH ADMINISTRATION 
 
 inspection work realize most the importance of devices for 
 obtaining regularity and punctuality as well as accuracy of 
 reporting and conscientiousness of pupil examination. The 
 work is often looked upon as a "public plum" to be had for 
 the picking — a little necessary money and very little work. 
 The schemes devised for appearing to be at schools where 
 they have done no work by physicians who have been turned 
 off or reprimanded are startling in the extreme. One 
 Board of Health officer said if he had his way he would 
 turn off all his inspectors but one, but politics kept them in, 
 though inefficient. 
 
 The checks at Newark are Interesting and seemingly 
 quite effective. Physicians are carefuly selected by the 
 supervisor with the help of a written examination. Further- 
 more the supervisor (Dr. Geo. J. Holmes) frequently 
 visits the schools and sees the Inspectors at work. There 
 are also monthly meetings of all doctors and nurses with the 
 supervisor. But the checks, proper, come in the following: 
 
 1. A daily report of work done, in detail. 
 
 2. Occasional telephone calls to physicians or nurses at 
 the schools, on business. 
 
 3. A schedule of visitation, so each doctor knows where 
 he is expected to be at any time. 
 
 4. Principals' reports on the work of doctors. 
 
 5. Physician must sign a book in the principal's office on 
 coming to the school and on leaving, and must give the time 
 spent, in his dally report. 
 
 6. A monthly summarized report. 
 
 7. Conferences with teachers and nurses on their co- 
 operation with the physicians. 
 
 8. Requirement of early notice on days when sickness 
 keeps the physician (or nurse) at home so a substitute may 
 be sent, the latter drawing the former's pay. 
 
 The necessity for careful checking up on physicians at 
 work in the schools grows out of the psychological nature 
 of the situation. There Is a strong tradition that public 
 office is a public sinecure; school work Is monotonous and 
 uninteresting to many; It furthermore Interferes with the 
 
THE TWENTY-FIVE CITIES 97 
 
 regular practice of the physician; and, finally, the pay Is 
 small; so the best and even the most public-spirited physi- 
 cians are not, as a rule, drawn into the work. Where a sys- 
 tem of medical inspection has, for example, been taken 
 over by the Board of Education after having been in the 
 hands of the Board of Health for a number of years, it has 
 been found necessary, in order to get real efficiency in the 
 work, gradually to dispense with the services of practically 
 all physicians who had participated in the old, shiftless, 
 time-serving system. A man once habituated in such a 
 system will not usually change over into an efficient exam- 
 iner or inspector under the new order. It is necessary as 
 soon as possible to get new men and start them in right. 
 
 The checks for physicians found in these cities are 
 given in column 37 and are seen to vary from zero and 
 so-called "annual reports" down to an elaborate system of 
 daily reporting. The efficiency of the systems will, in gen- 
 eral, be seen to correlate closely with the shortness of the 
 period reported. Especially where there is a very large 
 number of physicians is this true. In a small system with 
 a superintendent interested in the efficiency of the work, 
 elaborate checks and daily reporting are not so necessary. 
 Where in a small sytem a supervisor of (educational) 
 hygiene is put over the work, mere checks are not so 
 important as the need for accuracy of reporting; and this, 
 of course, is all the way through an important reason for 
 frequent reports carefully made out and balanced in some 
 way. Close personal supervision decreases the need for 
 checks. 
 
 There are good arguments for either a report sent In 
 daily, or a weekly report which gives each day's work and 
 in some way rounds out the week. The latter is especially 
 desirable where there Is not an adequate central clerical 
 staff for summarizing reports, and where it Is desired to 
 have the doctor's and nurse's reports sent in as one sum- 
 mary, giving both the number of ailments and what was 
 done with them. No city yet follows this plan. The daily 
 reporting systems now In vogue have for the most part. 
 
98 SCHOOL HEALTH ADMINISTRATION 
 
 it seems, been devised, and are being supervised and car- 
 ried out, by men who have been school inspectors and 
 know the nature of the problem. Monthly reporting, or 
 any reporting for a longer time than a week seems to lead 
 in most cases to inaccuracy and less careful work. I shall 
 try to show this later where the factors which go to make 
 up efficiency are set forth in figures. 
 
 One of the most exasperating sources of inefficiency in 
 this field, as suggested, is a complicated system of reporting 
 which tediously takes up much of a physician's time. Dr. 
 Cornell shows the physician's side of the matter quite 
 lucidly in his book, "iHealth and Medical Inspection of 
 School Children," page 46: 
 
 "In our large cities, however, there is a tendency toward 
 too much book-keeping by the school physician, and it is not 
 unusual for one-half or two-thirds of the medical examiner's 
 time to be consumed in the writing of multiple reports and 
 complex records. Many of them are futllely devised to 
 take the place of personal supervision, which, as has been 
 noted, is essential in the conduct of miedical inspection on 
 a large scale. Their aim is not to record useful facts, but 
 to check up the inspector's work and personal honesty. 
 Failing to do this, because it Is just as easy to record a false 
 entry four times as It Is to record It once, hundreds of 
 dollars worth of stationery and thousands of dollars worth 
 of salaries are wasted." 
 
 Any system that can be devised which will save the 
 physician's time in making reports and at the same time 
 insure careful work and accurate reporting is greatly to 
 be desired. The standard plan offered in a later chapter 
 dispenses with practically all reporting by the physician and 
 gives it to the nurse. The nurse costs on the average for 
 each hour of service about $ .50 (38 hours a week, 152 a 
 month, at $75); while the physician costs, at least, twice 
 this sum. It is poor scientific management which does not 
 limit the physician to such technical work as the nurse cannot 
 do well. The nurse can make out reports for herself and 
 for the physician; and she can do much of the other work 
 
THE TWENTY-FIVE CITIES 99 
 
 which the physician is now doing. The nurse, giving full 
 time to the schools, can, moreover, be held more strictly 
 to account and will feel more the whole scope and continu- 
 ity of the work if she makes the combined report. In some 
 school systems visited the nurse went her way and the 
 physicians went their ways, each disregardful, quite largely, 
 of what the others were doing. They should work as a 
 team, each complementing the work of the other. 
 
 3. VISITS AND SCHEDULES 
 
 Many of the cities more experienced in the work have 
 definite daily schedules for both physicians and nurses. For 
 nurses, the schedule is practically universal. The number 
 of schools assigned to each physician and nurse is given in 
 columns 41 and 42, and the number of pupils in columns 
 39 and 40, and in later columns. Boston had a physician 
 for each school, elementary and high, on the average, 
 and one nurse for each two schools (now nearly as many 
 nurses as large elementary schools). Waterbury has seven- 
 teen schools, many quite small, for the physician; while 
 Providence has 40 schools for the one nurse. Since many 
 or most of the cities, excepting Brockton, throw many ob- 
 stacles in the way of the nurse doing much work of inspec- 
 tion, rules quite frequently prohibiting it except for very 
 minor cases, it can be seen that daily inspection of pupils at 
 all schools by physicians is out of the question in the short 
 daily time in most cities. The time would be used up in 
 mere school to school travel. Yet daily inspection at each 
 school is the ideal of all these cities. The usual plea is for 
 more physicians with which to meet this condition. Two 
 alternatives seem not to have occurred to any city. First, 
 combine all the phases of educational hygiene into one de- 
 partment; dispense with the services of the physical train- 
 ing supervisor, if any, and make director of the hygiene 
 department for full time a man who is both a physician 
 and a physical educator. This will give correlation and 
 skilled supervision, making easily possible, second, the limi- 
 tation of physicians to such medical work as cannot well be 
 
loo SCHOOL HEALTH ADMINISTRATION 
 
 done by nurses, and the Increase of the powers of the nurses 
 so they may do much or most of the work of daily inspection. 
 This is, however, the tendency. The Brockton nurse uses 
 the physicians only for consultation purposes; New York 
 City (Bureau of Municipal Research and Board of Health) 
 has demonstrated that the nurses can inspect for infectious 
 diseases and in some of the twenty-five cities nurses have 
 found more cases of infectious disease then have the doctors 
 (Norwood, Winchester, Montclair, Providence, and Bos- 
 ton, Cols. 206 and 207). If the nurse can make the daily 
 inspections, which are almost entirely for the purpose of 
 nipping epidemics of infectious diseases in the bud, the 
 physicians need not spend time traveling from school to 
 school, but can go to but one school a day, five a week, or 
 ten in two weeks, if desired, thus reaching each school once 
 a week, or once in two weeks, on a routine schedule and at 
 the same time being on call from the nurse in case she is 
 perplexed at any other school. The nurse could be on a 
 schedule, and when her teachers were trained to detect the 
 symptoms of infectious disease, she could avoid travel to 
 all of her schools each day by judicious use of the telephone. 
 (See the last chapter.) 
 
 4. EXAMINATIONS AND INSPECTIONS 
 
 Another great source of waste and confusion in this field 
 Is the almost universal failure to distinguish between making 
 a careful, complete physical examination, similar to or better 
 than an insurance examination, of a pupil, and a very partial 
 examination, such as looking at only the hair of pupils of 
 a room or passing up and down the aisles looking at only 
 the hands and faces, for vermin or for Infectious diseases. 
 As a consequence, it has been almost impossible for the 
 writer to determine for each city how many children have 
 been given a complete physical examination. Some use the 
 term "physical examination" and "examination" to distin- 
 guish but this merely leads to confusion. The writer has 
 been driven to adopt for his own use the following defini- 
 tions, which he recommends for standard usage. 
 
THE TWENTY-FIVE CITIES loi 
 
 Physical examination, or better, merely examination is to 
 mean the complete, physical examination of a pupil to learn 
 his general health condition, his physical defects and any- 
 thing about his physical make-up which will militate against 
 his school or physical progress. The examination will prob- 
 ably best be made once a year; and may be made by one 
 or more persons, preferably, perhaps, by the nurse for vision 
 and hearing tests and any other phases she can do well, by 
 the medical examiner (heart and lungs, adenoids and ton- 
 sils, and certain other technical phases), and, third, by the 
 teacher of physical training (height, weight, and chest ex- 
 pansion if these are thought desirable and required). To 
 this in some schools (e.g., Cleveland) is now added the 
 examiner for mental defects. Other systems have dental 
 examiners and oculists. All of these persons together make 
 the single, annual examination. 
 
 Inspection is a good word to use to mean any partial ex- 
 amination outside of the complete physical examination. Our 
 first school medical work was "medical inspection'' because 
 no physical examinations were given, we might say. Any 
 looking at a pupil for any special signs, or any study of him 
 by health officials apart from the complete annual physical 
 examination is an inspection. Cities are trying to give each 
 pupil one (physical) examination a year; they may give a 
 pupil fifty inspections in a year if he requires it. A case 
 of pediculosis may easily require fifty inspections before it 
 is thoroughly cured. It may have been found first by doctor 
 or nurse at the time of the examination. 
 
 If the nurse working alone examines fifty pupils today 
 as to sight and hearing, how shall she record her work? It 
 is only a part of the annual examination. This makes neces- 
 sary a distinction between the "medical" and the "scholastic" 
 examination; or, she may record so many examinations of 
 vision and hearing and these can be combined with the re- 
 port of the medical examinations by the doctor when they are 
 made. This will prevent reports of two or three hundred 
 or more "examinations" for from twenty-five to a hundred 
 pupils. There can not be more physical examinations than 
 
I02 SCHOOL HEALTH ADMINISTRATION 
 
 there are pupils examined. Re-examinations can be called 
 inspections or simply re-examinations. 
 
 Bringing together here the writer's classification of the 
 many kinds of work being attempted in these cities in the 
 field of inspection and examination we should have for 
 any city with a fairly complete system : 
 
 A. Examinations — complete physical, once a year. 
 
 1. Medical, only such phases as the nurse cannot do 
 
 well, by doctors and dentists. 
 
 2. Scholastic, vision and hearing, and perhaps other 
 
 phases by the nurses. This is now being done 
 by teachers in three or more of the five states. 
 Vision may be tested by oculists. Principals may 
 make both tests. 
 
 3. Anthropological, height, weight, chest expansion 
 
 and other similar measurements, by physical 
 training teachers or nurses, if required. They 
 are of no value as usually taken, and are practi- 
 cally never used or needed where well taken. 
 
 4. Psychological, for suspected cases of mental de- 
 
 ficiency, or other abnormal mental conditions. 
 5. Work Certificate, probably not necessary in elfi- 
 cient systems. 
 
 B. Inspections — as many a year for any child as he 
 needs to be seen, after or before the examination — also used 
 for school building and home. 
 
 1. September room-inspection — quick inspection of all 
 
 pupils at the beginning of the school year or term, 
 room by room, doctor and nurse working as a 
 team, one medically inspecting, the other record- 
 ing. May be had oftener if desired. If so, 
 they should be called general, or routine room- 
 inspections. 
 
 2. Occasional room-inspection, any other room inspec- 
 
 tion after the general one in September; might 
 also be called a special room-inspection. 
 
 3. Individual inspection — any inspection of a pupil 
 
THE TWENTY-FIVE CITIES 103 
 
 apart from group inspection — pupils in their 
 
 homes, pupils returning after exclusion or other 
 
 absence, pupils referred to either doctor or 
 
 nurse, etc. 
 
 4. Home-hygiene inspection — by nurses. Recorded 
 
 on pupils' individual health record cards. 
 5. Sanitary inspection of the school, or "school sani- 
 tary inspection." By any competent person dele- 
 gated for this work. Recorded on a special 
 school sanitation record card for each school, 
 such as is used by the Philadelphia Board of 
 Health. See Burks' "Health and the School," 
 pages 187-8. 
 With this distinction between inspection and examination 
 in mind it is possible to see where most cities stand in this 
 matter and to determine whether they have merely "medical 
 inspection" systems or something broader and more educa- 
 tional which the writer frequently calls "Medical Super- 
 vision" for want of a better term. Health Supervision has 
 been suggested, but this is bad in that all phases of educa- 
 tional hygiene are really Health Supervision. Health In- 
 spection is weak at both ends, as a term. Cities with no 
 physical examinations are medical inspection systems; those 
 having examination require a broader term. There seem to 
 be only two disadvantages in the adoption of the term Medi- 
 cal Supervision, namely, that "Medical Inspection" is the 
 term now used in most cities and state laws, and that directors 
 of different phases of school work are usually called "super- 
 visors," e.g.. Supervisor of Drawing; and Supervisor of 
 Medical Supervision does not make a very good term. He 
 may, of course, be called director of hygiene if head of the 
 whole department of school health, or "director" of medical 
 supervision, if not. On the other hand, a good term can be 
 helped to win its way; and only in the largest cities will there 
 need to be directors of medical supervision, for in smaller 
 cities the general health and physical development super- 
 visor in whose department medical supervision is but one di- 
 vision, can be termed Director (or Supervisor) of Hygiene. 
 
104 SCHOOL HEALTH ADMINISTRATION 
 
 Since medical inspection is only part of the school medical 
 work, it is very awkward and unfortunate to use it as part 
 of the term covering all school medical work, as is now so 
 often done. Considerable reflection on the already fixed 
 character of medical "inspection" in state laws and common 
 thought leads, however, to its reluctant use here. We shall 
 hereafter use the term medical inspection. After this analysis 
 and classification of school medical work, we can look at the 
 tables to see at what stage our cities stand, from mere in- 
 spection for infectious diseases, very few of which ailments 
 are found in schools, up to all-round, effective medical pro- 
 visions, including annual examinations and frequent inspec- 
 tions for all pupils, and putting the emphasis upon cures and 
 prevention instead of merely finding "cases." 
 
 5. NUMBER OF PUPILS FOR EACH DOCTOR AND NURSE 
 
 The number of children supervised by each doctor and 
 nurse depends upon the kind of system, from mere inspection 
 for infectious diseases up to the most intensive kind of edu- 
 cational health work and consequently fewer children, and 
 upon the degree of development of the system. Many school 
 systems start out with a few doctors and nurses in the hope 
 of later obtaining an adequate number. The great danger 
 here is that the first tentative steps may be taken as a per- 
 manent standard, just as emergency and monitorial teaching 
 of fifty to eighty pupils in a school room has grown into 
 established custom In many places. The number of children 
 for each doctor and nurse is given for elementary children 
 for the reason that most of the cities give very little or no 
 attention to high school pupils in this particular. 
 
 The reasons given for the neglect of the high schools are 
 as follows: — 
 
 a. Most medical work Is found in the first four or five 
 grades of the schools. Very little, comparatively, Is found in 
 the upper grades and high school. 
 
 b. High school students belong to a social class that does 
 not respond well to the efforts of doctors and nurses. Fur- 
 
THE TWENTY-FIVE CITIES 105 
 
 thermore, the pupils are older and better able to care for 
 themselves and to obtain private medical service. 
 
 c. High school teachers are not so helpful as are the 
 elementary teachers in referring ailing and defective pupils. 
 
 d. Departmental work in the high schools makes room- 
 inspection of pupils more difficult. 
 
 e. The physical training directors of the high school in 
 certain cases call the attention of pupils to ailments or de- 
 fects urging attention by the individual pupil or by family 
 physician, especially in the few fortunate places where such 
 teachers are also physicians. 
 
 /. The age of the high school pupils makes them more 
 sensitive and reticent. Cities (e.g., Newark) that have 
 tried to give adequate and thorough medical examinations by 
 baring pupils to the waist have had some trouble in carrying 
 the work on. All, however, have not. 
 
 The best example of what need there is In high schools 
 for medical supervision and what can be accomplished there, 
 has perhaps best been shown by Prof. Thos. Storey, M.D., 
 in charge of the gymnasium at the College of the City of 
 New York and the high school connected with it. (See 
 report of this work in the next chapter. Dr. Storey shows 
 that medical work in the high school is of very great im- 
 portance and that very much can be accomplished in the 
 way of cures.) 
 
 The neglect of the high school and even the fifth to the 
 eighth grades by many of the twenty-five cities studied (only 
 three or four having done anything at all with the high 
 school problem) makes It necessary to base computations as 
 to the number of children for each doctor and nurse on the 
 number of elementary pupils. These numbers are given in 
 columns 39 and 40. For physicians, the average number of 
 pupils each ranges fromi about 651 In Montclair to 12,077 in 
 Waterbury. Since the physicians give irregular time, how- 
 ever, it is necessary to use the "equated physician" unit which 
 takes into consideration the number of hours a week the 
 physician works. The number of pupils for each equated 
 physician Is given in column 43 with the number of schools 
 
io6 SCHOOL HEALTH ADMINISTRATION 
 
 for each in column 42. The average number of elementary 
 pupils for each physician on this basis is 3,407 and the 
 median number 1,631. 
 
 The number of elementary pupils for each nurse ranges 
 from 1088 up to 15,702. 
 
 Where the physician is unnecessarily called upon to make 
 vision and hearing tests, to count the number of decayed 
 teeth with the use of a tooth mirror requiring sterilization 
 for each child, to make anthropological measurements of 
 height, weight, chest expansion, etc., and, finally, to make 
 out duplicate or triplicate cards of several varieties, forms 
 and colors, it can be seen that fewer children can be handled 
 In a year by each physician than in a more efficient system 
 which eliminates much of this labor or gives it to the lower 
 salaried and full-time nurse. 
 
CHAPTER V 
 THE NATURE AND EFFICIENCY OF THE WORK DONE 
 
 After a study of the agents of medical inspection, their 
 number, their cost, and their administration, comes naturally 
 the problem of their accomplishment. The work of medical 
 inspection in public schools easily divides into ( i ) the finding 
 of the children who need medical attention, (2) getting them 
 cured of their ailments and defects, and (3) preventive 
 measures for making the former effort unnecessary. To 
 make a simple, adequate classification, statement and test of 
 the heterogeneous work now being done in these twenty-five 
 cities, with their reports of all degrees of completeness and 
 accuracy, is a task at present practically impossible. What 
 is here presented is only a beginning and cannot lay claim to 
 very great accuracy or finality. The hope is that certain 
 general tendencies may be brought out and that future in- 
 vestigations of this subject may be made more easily. We are 
 interested here not so much in the purely medical or purely 
 scientific aspects of the problem as in the actual administra- 
 tion and its improvement. 
 
 In general, it may be said that the physicians, nurses and 
 teachers find the ailing pupils, the nurses do most in getting 
 treatments and cures, while there are no single preventive 
 agents unless we might mention here the physical training 
 teachers, the teachers in open-air schools, and a few others. 
 As a brief introduction to the following tables setting forth 
 the work done we shall give some of the generalizations 
 which developed while travehng about from city to city study- 
 ing this work : — 
 
 a. The focus of attention in most medical inspection sys- 
 
 107 
 
io8 SCHOOL HEALTH ADMINISTRATION 
 
 tems Is not on prevention and cure but on the finding (in- 
 specting) of the cases. When asked for the purpose of the 
 medical inspection work, In only one or two cases out of many 
 have school physicians emphasized getting and recording 
 treatments and cures. Even though all these cities have 
 nurses, therefore, it Is impossible from most reports or any 
 other records to show the real efficiency of medical inspection 
 In the amehoratlon of, health conditions. 
 
 b. Most medical inspection Is "Inspection" and little more. 
 Very few cities give complete physical examinations to even a 
 part of the children each year. South Manchester is prob- 
 ably the only city that examined all school children in the 
 school year studied, and exceedingly few examine high school 
 pupils. The word "examination," as related, is often used 
 for inspection : an Incomplete physical study of a child, usu- 
 ally for only a few symptoms like those of infectious dis- 
 eases, pediculosis, or cleanliness. Further, teachers, nurses, 
 and physical training teachers often make the parts of an ex- 
 amination, especially those relating to vision and hearing, and 
 this has complicated matters. In some cases, too, voluntary 
 agents have come In — dentists especially — and have made 
 the oral and teeth examinations. Most physicians and nurses 
 met distinctly favored one complete physical examination 
 for each elementary and high school pupil In the school sys- 
 tem annually, but did not unanimously think it feasible to at- 
 tempt it where there was but a small inadequate force. Only 
 certain deep-lying. Incipient, or Insidious ailments are 
 missed when there is careful "Inspection" without the annual 
 examination. The more serious heart, lung, nervous or di- 
 gestive system ailments, vision and hearing defects, adenoids, 
 and the like, are frequently suspected, and the pupils re- 
 ferred to family physicians or dispensary without it. The 
 Importance of the many cases missed, however, is the reason 
 for the thorough and complete examination. To repeat, we 
 shall use here the term "examination" to refer to the single 
 complete study, often made by more than one person, and 
 the term "inspection" to refer to any medical study or look- 
 ing at the child outside of this examination. 
 
EFFICIENCY OF HEALTH WORK 109 
 
 c. The difficulty of accurately recording the total number 
 of children examined and inspected with the number of new 
 cases found and the number of inspections ("old cases") 
 that were necessary to get these cases treated and cured has, 
 with the poor record forms in use, made it impossible in 
 most cities to discover how many cases of any one ailment 
 were found, treated, or cured or how many children were at 
 any given time or at the end of the year affected with a 
 certain ailment. When the physician gives a list of "cases" 
 we cannot tell whether these are the same which the doctor 
 has found or new ones or how many of these "cases seen" 
 represent a single child. A child with pediculosis may be 
 seen several times by the physician and twice or three times 
 a week for several months by the school nurse or janitress; 
 yet there has been but one case or child. A case of defective 
 vision may be seen once by the nurse or doctor and never 
 again recorded. Until clear distinctions are made between 
 these matters in more efficient reports, medical inspection (or 
 supervision) will be on a hearsay, theoretical basis and there 
 will exist both the greatest enthusiasm, and ungrounded 
 belief in its wonder-working influence upon school and com- 
 munity progress alongside of the greatest indifference and 
 skepticism as to its utility. 
 
 To obtain adequate reporting and accurate data, the ail- 
 ments, new and old, found by the physician should be placed 
 side by side with those found by the nurse in such a way to 
 show exactly how many new ailments were found altogether, 
 how often they were re-inspected and what was the outcome. 
 It would be well if a plan could be devised whereby one per- 
 son, the nurse, could do all the reporting on a single form.* 
 In the following tables the work of the doctor and nurses 
 for each ailment is listed together, but the distinctions men- 
 tioned could not be made except for one or two cities. 
 
 These facts should make us cautious about making dog- 
 matic statements about the number of children affected with 
 various ailments in these cities or the country at large. 
 
 *See author's plan in the last chapter. 
 
no SCHOOL HEALTH ADMINISTRATION 
 
 d. Doctors, for the most part, record only the cases that 
 are printed on the record cards or report sheets. They will 
 not, usually, take time to write in the names of the cases not 
 named in the report. This has been proved in a number of 
 satisfactory ways. It throws light not only on the following 
 tables but on the kind of record cards and reports which are 
 necessary to get the best results. They must give all the dif- 
 ferent ailments and be very simple and convenient. The 
 seventeen ailments making up 90 per cent of the cases found 
 in all cities (Table IX) are not those appearing on record 
 cards and reports. By the use of our classification of school 
 ailments on the report forms, however, we can obviate the 
 printing of a necessarily limited list of ailments on the 
 individual record cards. 
 
 e. Although school inspection by doctors was started by 
 boards of health to keep down epidemics of infectious dis- 
 eases through the exclusion of germ-carrying children, on the 
 theory that the school was the chief, if not practically the 
 only place of spread, nevertheless, comparatively few cases 
 of infectious disease are found in the schools, and the amount 
 of spread at school is seriously questioned. Mothers rarely 
 are wrong in their interpretation of the children's condition, 
 and keep the children at home so the ailments cannot be 
 found at school. The first notice the school gets in the usual 
 system is the report of the board of health on quarantine. 
 Children are, however, sometimes found who have returned 
 to school too early. The surprise is in the small number of 
 cases found in school in proportion to the number which actu- 
 ally existed. Table IX gives the actual number of ailments 
 found, and the probable true number for the 54 classes of 
 ailments. 
 
 /. There is a great lack of correlation and integration 
 among the various phases of hygiene in the school systems 
 which have adopted medical inspection. The proper kind of 
 organic unity will probably not come in the health work for 
 most cities until a full-time physician, physical-educator is 
 made director of all school health provisions. Only then will 
 there be real supervision, careful work, adequate reporting, 
 
EFFICIENCY OF HEALTH WORK iii 
 
 and testing of results. If this dissertation does no more than 
 to emphasize this need it will have served a worthy purpose. 
 Such a director can now be obtained at a salary of about 
 $3,000, but the added cost need not be so great because in 
 most cases one or more physical training teachers and several 
 part-time physicians can be dispensed with. The recom- 
 mended plan, as well as the needed number of directors, 
 physicians and nurses with salaries (Table XII) is given 
 later.* 
 
 g. Very much dependence is placed upon the teachers in 
 Inspecting the children for ailments and referring them to 
 the doctors and nurses. In many cases it may almost be said 
 that the chief function of the physician has been to remind 
 the teachers to look for the ailments, when the bell was rung, 
 announcing his presence In the building. Where there Is no 
 annual routine inspection nor examination of all children the 
 inspection has been more truly teacher inspection than medi- 
 cal Inspection. So we shall find a teacher bias In the tables 
 following. The need of Inspection of the teachers, and of 
 their training in this work in their professional courses and 
 In their classrooms Is very much neglected, to the great edu- 
 cational and economic loss to schools and teachers. 
 
 h. Teeth and such minor ailments are frequently given 
 little notice by physicians, partly because their practice has 
 omitted this element of health and partly because they find 
 It of little value to record defective teeth when there is no 
 school dental clinic or other adequate free agency for put- 
 ting teeth In repair. Yet defective teeth are probably the 
 chief source of many of the worst ailments of childhood 
 and youth, not to mention later life. The words of the great 
 Osier are familiar: "If I were asked to say whether more 
 physical deterioration was produced by alcohol or by defec- 
 tive teeth, I should unhesitatingly say by defective teeth." 
 
 i. If the writer were asked which of the ailments In the 
 
 *See also the article on this subject by the writer in the New 
 England Journal of Education for Feb. 27, 1913, the address at the 
 1913 N. E. A. convention and the address at the 1913 meeting of the 
 International School Hygiene Congress. 
 
112 SCHOOL HEALTH ADMINISTRATION 
 
 following tables had taken up most time of the doctors and 
 nurses, which had actually absorbed most of the expenditure 
 for medical inspection, he should unhesitatingly reply with 
 the horrid word — lice. A child, especially a girl with her 
 long hair, may be cured of this ailment a dozen times a term 
 and still have it. One doctor on a comparatively very large 
 salary spent most of his time during the year in going down 
 the aisles of classrooms from the rear, using a small hand 
 glass with which to spy out nits and other signs of vermin 
 (pediculosis). His theory was that if children are taught 
 to rid themselves of these larger parasites they will be better 
 ready to accept the germ theory of disease and act upon 
 it. The recent studies pointing to the larger parasites as 
 the carriers of disease germs [the tick of spotted fever, the 
 louse of typhus fever and perhaps other contagious diseases, 
 not to mention the analogous work of the flea for bubonic 
 plague or Black Death, the mosquito for malaria and yel- 
 low fever, the stable fly (Stomoxys) for the infection of 
 infantile paralysis (Poliomyelitis), and the house fly for 
 various summer ailments, especially ravaging infancy], all 
 would strengthen this point of view. 
 
 While the theory is probably sound, the administrative 
 question here Is : "Would it not be far more economical and 
 just as good service if the city were to use the money to 
 employ two nurses on full time for such work instead of the 
 one part-time physician at $1,200?" 
 
 Another interesting fact in this connection is that medical 
 inspection was put into the school of one small town (South 
 Manchester) in 1905 in the hope that the schools would 
 soon be delivered of this parasitic plague (pediculosis) ; but 
 even with the help of the nurse, the trouble has not been by 
 any means eliminated, an irreducible minimum seeming to 
 remain of those who furnish the parasites to others. The 
 table shows a decrease in the number of children inspected 
 as well as the number of times ailing, so the number has 
 hardly decreased as rapidly as it appears. 
 
EFFICIENCY OF HEALTH WORK 113 
 
 Total 
 Number 
 
 Pupils Cases of No. Pupils 
 
 "Examined." Pediculosis. Excluded. 
 
 First year 421 216 150 
 
 Second year 458 282 I35 
 
 Third year 477 227 125 
 
 Fourth year 342 96 108 
 
 Fifth year 318 84 89 
 
 Sixth year 117 66 55 
 
 "Examined" here means referred cases inspected. 
 (Physical) examinations, one a year for each pupil, were 
 begun in the year of this study. While there has been an 
 increase in school population, there has been a decrease in 
 cases reported and in the number of exclusions. It would 
 be interesting to know whether the inspector has changed the 
 meaning of "case" as time went on, and if standards of ex- 
 clusion are not changing. The reports of this city should be 
 followed up to see if the ailment is eliminated. 
 
 GENERAL EFFICIENCY OF THE MEDICAL INSPECTION SERVICE 
 
 Let US turn our attention first to the general accomplish- 
 ment by the entire school medical service, and examine 
 table VII which gives a bird's-eye view of this field. In 
 order to separate unlike elements and to make clear what is 
 actually being done, we have been driven to certain defini- 
 tions which, we hope, may be of value not only for the 
 purposes of this study, but also in actual school administra- 
 tion. The first distinction is between Examination and In- 
 spection, already mentioned: — 
 
 a. Examination shall refer only to the complete physical ex- 
 
 amination of a pupil by one or many persons, and re- 
 corded on an individual, cumulative health record card 
 for each pupil. The standard is one such examination 
 a year, in this country, less often in Europe. 
 
 b. Re-exatninationj or re-examined, shall refer to the vi^ork done 
 
 by any person who duplicates any part of the physical 
 examination because of a need for more technical ex- 
 amination, because of doubt as to the reliability of the 
 first findings, or for the purpose of checking up one or 
 more of the first examiners. 
 
 c. Inspection shall refer, when relating to pupils, to any partial 
 
 examination, looking at, or study of a child or children 
 
114 SCHOOL HEALTH ADMINISTRATION 
 
 with a view to learning the condition of their health, 
 outside of the two forms of examination given above. A 
 pupil should be examined thoroughly once a year, perhaps, 
 but he may be inspected fifty or more times. 
 d. Inspection, as a term, may be used also to refer to any 
 study of school sanitation, home hygiene, or any other 
 external feature. 
 
 a. Examinations. Nearly every city that attempts com- 
 plete routine examinations of pupils has provided an 
 Individual, cumulative health record card for each pupil, and 
 this definition will not exclude any city of the twenty-five 
 that actually gives examinations. The work of examina- 
 tion Is usually divided; and we find all agents from teachers 
 to oculists making the vision examinations, and nurses, den- 
 tists and doctors making the medical examinations, and 
 hearing tests. Some, also, have physical-training teachers 
 make certain measurements of height, weight, chest expan- 
 sion, and the like; and have In each school, or haul about, 
 platform scales with attached height standards. These lat- 
 ter measurements are probably not worth the effort taken 
 to get them. Doctors use other Indexes In making diagnoses, 
 and the examinations as usually made with shoes and cloth- 
 ing on are entirely valueless. The usual fate of such meas- 
 urements, In the writer's experience, has been to fill physical 
 training or medical inspection supervisor's offices with waste 
 paper. As principal for several years, the writer made such 
 measurements for an entire school, and found just one value 
 In them : they could be used as a means of teaching the 
 pupils the principles. Ideals, and habit of correct carriage 
 and deep breathing. The best development of these anthro- 
 pological measurements seen by the writer will be found in 
 the 1910 and 1911-12 reports of medical Inspection In 
 Dunfermline, Scotland. Even here they seem to have little 
 pragmatic value and It Is significant that chest expansion 
 measurements, given with doubt as to their value In the 
 19 10 report, are not mentioned in the last. Here, we can 
 only raise the problem. 
 
 It seems the better and growing practice that nurses in- 
 stead of doctors, teachers, principals, or physical-training 
 
EFFICIENCY OF HEALTH WORK 115 
 
 teachers make the vision and hearing tests, where there is 
 no school ocuHst for visual examination, or only for re- 
 examination of actual cases as at Providence. The nurses 
 can learn to make these examinations as easily as any of the 
 other officials, and they have the several advantages of being 
 the ones to get treatments, glasses, etc., of having a number 
 of schools to examine in, thus giving more skilled practice 
 and more uniformity, of being cheaper workers than phy- 
 sicians, of doing the work without turning aside and being 
 "bothered," as Is often the case with teachers, principals and 
 physical-training teachers. States do well to have teachers 
 do this work where there are no nurses; but cities and rural 
 districts having nurses should, very probably, place the 
 matter in their hands and give them training for doing It 
 well. Oculists can be employed for re-examining the cases 
 the nurses find and for prescribing glasses, treatment or 
 operations for those who need them. 
 
 Aurlsts can be attached to school clinics for the hearing 
 and discharging-ear cases. 
 
 h. Re-examinations . The nature of this process has, 
 possibly, been clearly enough stated. It Is very little used. 
 
 c. Inspections of pupils. These will be explained in 
 detail in the tentative standard plan given later. Here it 
 may be repeated that they are either routine or occasional 
 inspections of all the children in rooms or schools for any 
 general affections of a serious character, or for some special 
 ailment such as pediculosis, infectious diseases, uncleanllness, 
 and the like. 
 
 Individual inspections are made of pupils referred to 
 nurses and doctors by teachers, principals or parents; of 
 pupils returning from over two or three days' absence or 
 longer, either voluntarily absent, excluded, quarantined, or 
 for any other reason; and of pupils entering the school for 
 the first time, after the first two weeks or more of school. 
 The September room-inspection, or such Inspection after 
 each vacation or at the beginning of each term, will catch 
 pupils entering in the first two or three weeks. 
 
K m 
 
 
 
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ii8 SCHOOL HEALTH ADMINISTRATION 
 
 THE TABLE 
 
 Turning, then, to table VII we see that only eight of the 
 twenty-five cities have complete examinations; and that all, 
 of course, have more or less of inspection. A city may have 
 only inspections by doctors and nurses, and have vision and 
 hearing examinations by teachers. The latter are only par- 
 tial examinations, and are not always recorded on individual 
 cumulative health record cards as described. Some do not 
 have the complete examinations, and must, therefore, be 
 classed simply as medical inspection systems in the narrow 
 sense, and yet have the vision and hearing tests (partial- 
 examinations) by nurses, teachers, doctors, or others. The 
 strong tendency is, however, in the direction of the complete 
 examination along with the inspection. 
 
 Only one city seems to have examined all children in the 
 school system, including the high school pupils, South Man- 
 chester, although a few had some inspection in the high 
 school. The Boston Board of Education employed a special 
 physician (salary, $i,oo8) for the high school examina- 
 tions, but no record was obtained of his work. In Newark 
 and Jersey City the directors of the departments of medical 
 Inspection examined a number of pupils in the high schools. 
 The results are not included in this report of cases, or exami- 
 nations. Summit began examining high school pupils in 
 1912-13. 
 
 The percentage of the enrolled elementary pupils medi- 
 cally examined varies from about 42 per cent in Newark to 
 100 per cent in South Manchester. The average for the 
 eight cities (not including Syracuse, where we have only a 
 record of work certificate examinations, by the Board of 
 Health) is about 84 per cent. In Newark, the number 
 would have been greater had more of the inspections and 
 vision and hearing tests been made by nurses or teachers 
 instead of by the doctors. (There were but eight nurses 
 for the entire city with nearly sixty thousand elementary 
 pupils.) The same may be said for Hoboken in part, for 
 Rochester, Jersey City, and Meriden. 
 
 The average number of pupils examined by each phy- 
 
EFFICIENCY OF HEALTH WORK 119 
 
 sician, with and without the help of the nurses, varies from 
 935 in Newark to 2,924 in Hoboken, with Jersey City not 
 far behind (2,797). The doctors in Hoboken, however, 
 were paid $100 a month instead of $30 and $40 as in 
 Jersey City and Newark. They were required to give three 
 instead of two hours a day as a rule, also. Other conditions 
 being about equal, according to time spent, they should have 
 50 per cent more examinations, and according to pay about 
 three times as many. The number of inspections made in 
 Newark, especially, is quite large, perhaps a reasonable 
 number in Jersey City, while the number is not given in 
 Hoboken, although the cases found by such inspections are 
 given. Both Jersey City and Newark give also the number 
 of room inspections, or "class inspections." None are given 
 for Hoboken. Newark has given the doctors very much 
 inspection to do, especially classroom inspection, and so gets 
 fewer examinations. 
 
 In Summit, the nurse assisted the physician at all ex- 
 aminations and made 350 "examinations" herself. The lat- 
 ter may have been only inspections. Where the nurse assists 
 the physician at the examinations there are many advantages 
 and few disadvantages: She learns a great deal of the 
 science and practice of medicine, with a good physician, 
 especially as related to the care of her school children; she 
 learns just what ails each pupil and what would probably be 
 the best ways of handling the different cases; she assists the 
 physician greatly by making the vision and hearing examina- 
 tions, getting the children ready for the examinations by 
 calling them from their rooms, calming their fears, keeping 
 them in control, getting them washed if necessary, removing 
 or loosening part of the clothing, etc. ; she frequently helps 
 to make all of the records, reports, notices, and the like; 
 she gets the physician's advice immediately regarding any 
 part of the examination she is making and over which she 
 is puzzled; she frequently observes, from her own experi- 
 ence, certain defects or ailments which the physician may 
 overlook; and last, but not least, she learns to know the 
 
I20 SCHOOL HEALTH ADMINISTRATION 
 
 abnormal child with respect to the normal child as a 
 standard. 
 
 In Summit, one school has an exceptionally fine medical 
 supervision room — large, well-lighted, even if in a partial 
 basement, and fairly well equipped with tables, desks, hot 
 and cold water, screens, a couch, medical cabinet, etc. It 
 is probable that the nurse and physician working together 
 as a team in the complete examinations of pupils can examine 
 better 125 pupils in the same time it would take them 
 separately to examine 100 pupils. No exact figures are ob- 
 tainable on this problem. I know of no special disadvan- 
 tages of such teamwork examinations. In Montclair, each 
 school has a janitress, as well as a janitor, and these women 
 are unusually helpful in all examinations and inspections, 
 saving very much time for all concerned. They even give 
 the treatments for pediculosis. 
 
 NUMBER OF EXAMINATIONS 
 
 Only 125 daily visits about an hour, on the average, in 
 actual medical work with pupils (not counting travel to and 
 fro) were made by the physician in Summit. How many of 
 these were visits when only inspections were made we are 
 not told; we judge from the report of many calls, probably 
 25, leaving 100 for examinations of 1,034 pupils. For, 
 say, 170 daily visits of two hours each and with the assist- 
 ance of the nurse, and with not a great many inspections to 
 make, we should expect the physician to make (100 is to 2 
 times 170 that 1,034 is to ?) or 3,515 examinations, say, 
 3,000 annually. With a good deal of the inspection of 
 referred cases to do, this 3,000 would probably be the maxi- 
 mum number annually. Here, however, the nurse was also 
 attendance officer, throwing more inspection to the doctor. 
 
 Jersey City physicians, working, according to the rules, 
 two hours a day and making the vision and hearing tests, 
 and without the continuous help of the nurse (6 nurses to 
 12 doctors) and with the same average number of individual 
 Inspections, besides 936 class-room inspections, report almost 
 the same average number, 2,797, doing better, probably, as 
 
EFFICIENCY OF HEALTH WORK 121 
 
 to quantity than any other city. We cannot judge as to the 
 quahty of these examinations, of course. 
 
 In Trenton, the doctors, without much help from the 
 nurses, except for vision testing, report an average of 1,323 
 examinations, and 1,047 inspections in 89 visits, on the aver- 
 age, of not much over an hour each in actual school medical 
 work. The school year was 196 days. Counting only 170 
 daily visits again, we should expect at this rate from each 
 physician giving the same time as now (89 is to 170 that 
 1,323 is to ?), or 2,250 examinations, and almost a propor- 
 tionate number of inspections. For twice the time, which 
 on the average would probably not exceed two hours, we 
 should have 4,450 examinations. Then 3,000 would seem 
 to be a minimum number, at least a very reasonable number, 
 especially since we have deducted no days from the 89 for 
 mere inspection visits. 
 
 At Rochester, for which we have the number of daily 
 visits but do not have the average number of hours a day 
 for each physician, our estimate, given in another table, is 
 one hour. At any rate, an average of 170 visits is given, 
 but how many mere inspection visits we do not know. The 
 highest number of examinations reported is 2,334 and the 
 lowest by a regular examiner (180 by a specialist) is 484. 
 The median is about 1,550. Since we have the figures, this 
 is a better figure perhaps than the average because of the 
 wide variation. For twice the time we should again expect 
 over 3,000 examinations as a median performance, and with 
 nurses making the vision and hearing tests and helping at 
 the examinations and making more inspections (only three 
 nurses for the city), we should expect 4,000. So 3,000 
 here for two hours a day seem not to be unreasonable. 
 
 Merlden physicians made an average of 1,207 complete 
 examinations without a nurse's assistance (only one nurse 
 for the city) after the first of November when the system 
 got started. For ten months the number could probably 
 have been 1,500. They averaged probably an hour each 
 day. For twice the time, and with no re-examination of 
 defective vision cases reported by teachers (leaving this to 
 
122 SCHOOL HEALTH ADMINISTRATION 
 
 nurses) and no measurements, we see that probably 3,000 
 pupils could easily have been examined during the school 
 year, and twice as many inspections made by each doctor. 
 
 Perhaps experience will show that desirable improve- 
 ment in the quality of examinations will force a reduction to 
 a lower maximum than 3,000. Ohio has been discussing a 
 state law for this maximum number for physicians and efforts 
 have been made to make the number 2,000. Careful ex- 
 periments have not yet been made which will make possible 
 any dogmatism. Lack of funds requires a large number of 
 pupils for each examiner, to start with. And if three thou- 
 sand can be examined by one man it will be desirable. 
 
 VISION AND HEARING TESTING BY TEACHERS, NURSES AND 
 
 OCULIST 
 
 These tests were all made by the teachers in Massachu- 
 setts and Connecticut, and to some extent in Providence. The 
 records are unsatisfactory. In Massachusetts the examina- 
 tions are made annually. The rules for Meriden, Conn., 
 were as follows: 
 
 "Teachers shall make the vision tests and the proper 
 records in connection therewith in September, or whenever 
 they may enter, for all new children above first grade; in 
 February for all children in first grade; and once in three 
 years for all children. Tests may be omitted in the kinder- 
 gartens." 
 
 Teachers reported all children with vision 20/40 or 
 worse, and pupils with even better vision but with evidences 
 of eyestrain, headaches, etc., to the doctors, and no others. 
 The latter re-examined the pupils, and had the nurse send 
 out messages. Had the re-examination been made by a 
 school oculist and prescriptions given it would have been 
 better. 
 
 The stop watch and whisper tests are chiefly used to test 
 hearing. Groups of children are often tested at a time 
 In this manner. The common test is whether the pupil can, 
 with each ear and without seeing the lips, hear distinctly 
 low spoken words or sentences at a reasonable distance. No 
 
EFFICIENCY OF HEALTH WORK 123 
 
 attempt of which I know has been made to use the audio- 
 meter. Probably nearly all cases are found with little 
 trouble in the present manner. Efforts should be made, 
 however, to standardize and make objective the meas- 
 urement. 
 
 The number of pupils tested for vision in proportion to 
 elementary school enrollment varies from zero in Mt. Ver- 
 non and Syracuse up to a hundred per cent in four cities. 
 Hoboken, perhaps, made more tests than are recorded by 
 the nurse. 
 
 Where the nurses tested for vision or hearing or both, 
 we are interested in the average number, for such tests take 
 up considerable time. We know the facts for only one city, 
 without qualification. Trenton's two nurses made on the 
 average 3,245 vision tests each. Their other work seems 
 to be little less than that of other nurses. 
 
 EXAMINATIONS 
 
 We have seen that the number of examinations may well 
 be nearly 3,000 for two hours a day, five days a week, the 
 nurse making vision and hearing tests and measurements, if 
 possible, the nurse assisting at the examinations, and the 
 work lasting through the school year. 
 
 This may be seen to be a probably reasonable number 
 by beginning at the other end, the number of examinations 
 in an hour. With no other work, and the nurse and doctor 
 working as a team, and with simple records, at least ten 
 pupils can be examined as a reasonable number, in an hour, 
 twenty in a two hour period. 
 
 Without many individual inspections, this would be in 
 185 school days, 3,700 pupils for each doctor with a nurse. 
 Counting off for all forms of inspection, but placing the 
 burden of it upon the nurse, we see again coming out the 
 estimate of a reasonable maximum number, perhaps, of 
 3,000 pupils. 
 
 In the long run, it seems best to give to nurses the vision 
 and hearing testing. How often these should be made is 
 doubtful, probably not as often as once a year for all pupils, 
 
124 SCHOOL HEALTH ADMINISTRATION 
 
 as a matter of routine. In Europe, the complete examina- 
 tions come only three or four times in a course of eight 
 years. The Meriden intervals are recommended for con- 
 sideration. Probably every other year would be wise. 
 
 In Newark and several cities, the children with 20/30 
 normal vision are recorded defective and referred. The 
 more universal and desirable practice is to follow the Eng- 
 lish and Massachusetts plan given, referring only those 
 20/40 or less, unless they have other symptoms of eyestrain 
 or other eye defects. 
 
 The Massachusetts' rules for hearing, quite generally 
 followed, give 25 feet in a still room as the easily heard 
 "standard whisper" (if there is such a thing), 35 to 45 
 feet for a low voice, and 45 to 60 feet for a loud voice. 
 Most medical rooms in schools, or the places assigned to 
 doctors and nurses in old buildings are very poorly adapted 
 for such work. Halls are frequently used to give the desired 
 space. 
 
 INSPECTIONS OF ELEMENTARY PUPILS 
 
 We can hardly discover the number of inspections of 
 the different kinds. The doctor at Waterbury reports as 
 many as 250 inspections an hour. This is by class-rooms and 
 principally pediculosis and infectious disease inspection. Dr. 
 Mercelis of Montclair estimates 50 children an hour as a 
 reasonable number to inspect by rooms. Individual inspec- 
 tions are, of course, scattered over days and weeks, and prob- 
 ably take from one to five minutes each. As we glance down 
 the columns, we see that Waterbury and Syracuse are count- 
 ing room-inspections as individual inspections. Newark and 
 Jersey City are the only cities giving the number of indi- 
 vidual and the number of room-inspections separately. 
 Several give only the individual inspections referred to them 
 by nurse and teachers. Room-inspections should be recorded 
 by rooms rather than by the number of individual pupils 
 in them. 
 
 Boston included a parochial group of children, but the 
 average is about 7,000 children inspected for each doctor. 
 
EFFICIENCY OF HEALTH WORK 125 
 
 How many room inspections are in this we could not learn. 
 It is an average of over 40 a day for 170 days, probably 
 more than any physician served. 
 
 Yonkers' physicians made no examinations and averaged 
 for the two, 7,437 inspections each. How many different 
 children this represents we do not know. Any pupil may 
 have been inspected many times in a year. There were only 
 71 school-visits (one school, one visit), with sometimes two 
 or three schools in a day. Unfortunately, the number of 
 daily visits was not kept separate. But even counting it as 
 71 school visits, the average number inspected at each 
 school visit was somewhat over a hundred. 
 
 Since we obtained from the reports, the facts regarding 
 the number of times different schools were visited in Yonkers 
 by the two physicians, and since the Superintendent has 
 characterized each one for us, we give here these data : 
 
 Six schools visited only once during the year, mostly small 
 country schools. 
 
 Four schools visited only twice during the year, partly 
 small country schools. 
 
 Three schools visited only three times during the year, 
 two in rich districts. 
 
 Two schools visited only four times during the year, one 
 rich, the other rural. 
 
 One school visited only five times during the year, aver- 
 age, city. 
 
 One school visited only seven times during the year, large 
 and poor. 
 
 One school visited only eight times during the year, large 
 and poor. 
 
 One school visited only nine times during the year, large 
 and poor. 
 
 One school visited only eleven times during the year, large 
 and poor. 
 
 In sum, 20 schools visited only seventy-one times during 
 the year, by the two physicians. 
 
 The average number of school-visits for the 20 schools 
 is less than 4 for each school, and ten or half of them were 
 visited less than three times, in 185 days of the school year. 
 The city had only one nurse to assist the doctors. The 
 enormous number of cases In proportion to the number of 
 doctors and nurse (given in a later table) shows a need, 
 probably greater than for any city visited, of an enlarged 
 
126 SCHOOL HEALTH ADMINISTRATION 
 
 force. (Yet the writer was told that Yonkers was a wealthy 
 city and needed little such work.) One school with 23 and 
 another with 27 teachers besides the principals were visited 
 but three times each, and another school with 25 teachers 
 was visited but twice. 
 
 In Brockton, the small number of inspections by doctors 
 is due to the fact that in this city the physicians are used 
 only for consultation over puzzling cases, by the nurse. An 
 average of 436 cases each is thus recorded. There was but 
 one nurse for the entire city. One of the physicians is on 
 the Board of Education, and donates his services. The 
 work here shows what nurses may do alone if properly 
 supervised. Oakland, California, has a large force of nurses 
 with one full-time directing physician ; and the system seems 
 to work well. No one is on part-time. Pupils fail to get 
 the same number of skilled routine examinations in such a 
 system, but the puzzling cases may be re-inspected for the 
 nurses ; and probably nearly all real ailments may be found. 
 
 The median number of individual inspections, throwing 
 out room-inspections which should be counted by rooms as 
 in Newark and Jersey City (rather than by the number of 
 pupils in them), is probably not far from 3,000. With the 
 system devised as given for examinations, this number could 
 probably easily be raised to 5,000, not counting room-in- 
 spections, of which there would be for each physician (3,000 
 pupils, divided by 40) 75 in the routine September room- 
 inspections. 
 
 In Jersey City, the average number of rooms inspected 
 for each physician was 78, and in Newark (counting an 
 average of 26 physicians), 383, or an average of two or 
 three a day. This large amount of room-inspections in 
 Newark probably accounts for the small number of exami- 
 nations. The average number of individual inspections is 
 also large, over 8,000. Most of this inspection work could 
 be placed in the hands of nurses at about half the salary 
 per hour with probably better results, since the work is rela- 
 tively simple when once learned, and since the nurse must 
 follow up the cases anyway. 
 
EFFICIENCY OF HEALTH WORK 127 
 
 The grades in which most inspection, probably eighty 
 per cent, is done are the first three or four. Most inspectors 
 wisely emphasize this age period not only because there are 
 many more cases, but because of the greater number of 
 serious diseases and deaths at this age and the desirability 
 of nipping pathological tendencies in the bud if possible. 
 
 INSPECTIONS BY NURSES 
 
 The number of inspections by nurses is given in the next 
 columns (65 and 66). They range upward from practically 
 zero, where nurses spend their entire time following up 
 cases found by physicians. Several of the cities, especially 
 those with board of health control of this work are in or 
 very close to this class. We need not specify, because in most 
 cities even nurses so restricted would probably find a num- 
 ber of cases without making any inspections (searches) for 
 them in the schools. In the list of ailments given in a later 
 table the fact that nurses in any city report more cases than 
 are reported by the doctor and possibly referred to them 
 would indicate, where she has not met the same case a 
 large number of times, that they were probably finding new 
 cases themselves. A great weakness in the reporting lies 
 here. It is impossible to discover how many new ailments 
 were found by both doctors and nurses, and how many were 
 merely referred from the former to the latter. The term 
 "case" should be avoided in all reports, "ailments" and 
 "children" are better, since a "case" may mean several dif- 
 ferent ailments. 
 
 The nature of the report, or the lack of a report, on 
 this item leaves a blank record of inspections for the nurses 
 of twelve cities. The reporting for nurses is so relatively 
 new that we should expect the emphasis to be placed in 
 reports upon the work of the physician. Most nurses here 
 probably deserve much better reports than they made or re- 
 ceived. The large average figures in Brockton, Schenectady 
 and Syracuse mean a large number of class-room inspections 
 where the number of pupils rather than the number of 
 rooms was recorded. But the record of Newark is ex- 
 traordinary, for not only were there an average of 20,000 
 
128 SCHOOL HEALTH ADMINISTRATION 
 
 individual inspections for each of the eight nurses, but there 
 were an average of 493 class-room inspections each, and an 
 average of an extra 750 inspections for uncleanliness each. 
 This, with an average of 1,118 home visits would seem to 
 place the amount of work done by each Newark nurse far 
 ahead of all others reporting. This is very probably due to 
 an excellent administration of their work as well as to 
 adequate reports and faithful performance of duty. How- 
 ever, it is difficult to make accurate comparisons. 
 
 For Trenton we give the number of inspections by a new, 
 and by an experienced nurse, the latter making 2,477 '^^' 
 spections to the other's 993. The more experienced the 
 nurse in this work the more of the service of inspections can 
 be given her. 
 
 Were we to divide the average of 41,205 pupils in- 
 spected by each nurse in Schenectady by an average sized 
 class, say 40, we should have a figure nearer the general 
 tendency. Were we to allow for 5,000 individual inspec- 
 tions we should still have 900 room inspections each. At a 
 half hour each, these would amount to 90 school days of 5 
 hours each. In Brockton, the 17,365 inspections (called 
 "examinations" as they are in most cities) were as follows: 
 throat inspections, 7,589; re-inspected (general), 605; in- 
 spected (general) next term, 7,971; re-inspections at office, 
 600. As before related, 1,309 were also re-inspected by the 
 doctors. 
 
 The median number of individual inspections for each 
 nurse, W/orking 35 to 44 hours a week, is probably near 
 4,000. How many class-room inspections can be added to 
 this depends upon the amount of home visiting and the 
 character of the supervision. First-class supervision means 
 in general first-class work. Lack of, or poor, supervision 
 generally means work of uneven quality and a low general 
 average. 
 
 The range of inspections is from 946 in Mt. Vernon, all 
 probably actual ailments referred by doctors and teachers, 
 up to the large numbers named. 
 
EFFICIENCY OF HEALTH WORK 129 
 
 What would be a good standard for a nurse with the 
 plan mentioned would probably not be far from ; 
 
 4,000 individual inspections Newark nurse 20,000 
 
 200 class-room inspections Newark nurse 493 
 
 1,000 home visits ^. .Newark nurse 1,1 18 
 
 500 treatments, by the nurse Newark nurse 5,623 
 
 300 taken to dispensary or physician Newark nurse 108 
 
 3,000 examinations, assisting the ph}'sician. . .Newark nurse ? 
 
 The examinations witii the physician would take prob- 
 ably one-fourth of the time. After school, before school 
 and on Saturday mornings the home visits and part of the 
 dispensary visits could be made. In the remaining three 
 hours of each day, the inspections and treatments could be 
 given. On the right, in the statement above, are given the 
 average figures for each nurse in Newark. They are far 
 ahead in all but dispensary visits and assisting at examina- 
 tions. If possible, the standard of number of treatments 
 by the Newark nurses should be equaled. Treatments by 
 the nurse should, however, be separated from treatments by 
 others outside of the schools. Nothing less than this and 
 school clinics will effectually root out or keep down a very 
 large number of bad filth and infectious ailments. Newark 
 has gone far ahead of all cities in the treatment of these 
 minor ailments of the poor, ignorant and needy, at least so 
 far as records go. Without such treatment, the expensive 
 system quite largely fails to function, even though, as in 
 Newark, a great many treatments were made by outside 
 agencies, such as hospital dispensaries, private physicians, 
 dentists, oculists and parents. 
 
 PERCENTAGE OF ELEMENTARY SCHOOL POPULATION 
 DEFECTIVE 
 
 It is again very difficult to learn the percentage of pupils 
 defective, because cases and not children In many instances 
 are reported. The approximate numbers so far as could be 
 learned by much patient delving and inquiry are given in 
 column 69. The percentages in the next column show the 
 proportion of the elementary school population affected. 
 The cases below 22 per cent are not representative and 
 
I30 SCHOOL HEALTH ADMINISTRATION 
 
 simply mean that the cases were not found, the inspections 
 being limited almost entirely to infectious ailments in certain 
 cities, as can be seen from the table of ailments found. The 
 six cities below 50 per cent could all be explained in this 
 manner. Hoboken alone, probably, has an unmerited low 
 standing. The facts could not be learned from the reports. 
 The eleven cities with no percentages would probably show 
 a similar range as the fourteen given. The highest per- 
 centage given is 66 per cent and this Is doubtful, because of 
 the confusion as to cases, ailments, and children. Newark's 
 report is definite on this; and 60 per cent seems to be near 
 the truth. 
 
 But most ailments are teeth defects, percentages ranging 
 up to 90 frequently being given for the number of children 
 so affected. Many children are In good health with but this 
 one exception. Leaving out such children with the great 
 people's disease, we have a series of ratios (column 70) in 
 the more representative cities hovering around 30 to 35 
 per cent. We should probably be quite safe In prophesying 
 that one out of three of all the pupils In a school system are 
 each year at some time seriously ailing or defective, not 
 counting defective teeth and about twice this percentage If 
 teeth are counted. Roughly, a third have no serious ail- 
 ments, a third have only teeth defects, and a third have teeth 
 defects and some other ailments or defects. We dare take 
 neither the space nor the time here to compare m detail 
 these results with those of other Investigators. The New 
 York percentages for 191 1, with 230,243 pupils examined, 
 are quite similar, only larger In defectiveness: 
 
 New York 
 My General Estimate. Results, 191 1. 
 
 With no ailments 33 per cent. 27 per cent. 
 
 With only defective teeth 33 per cent. 39 per cent. 
 
 With D. T. and other ailrnents. 34 per cent. 34 per cent. 
 
 The likeness Is striking, and shows the conditions of child 
 health In the various cities to be probably much more nearly 
 similar than are the doctors' reports. The general per- 
 centage for defectiveness in the whole elementary school pop- 
 
EFFICIENCY OF HEALTH WORK 131 
 
 ulation, taken together, and greater in the lower grades, is 
 about 67 per cent; for New York City it is 74 per cent. 
 
 If this standard is fairly accurate, dividing the ele- 
 mentary school children roughly into three equal groups 
 (good, fair, bad) we can use it as a measuring rod for de- 
 termining both the health problem of medical supervision 
 and how cities are meeting it. 
 
 We can say, for example, that systems which find less 
 than forty per cent of the pupils with defective teeth, prob- 
 ably are not examining carefully for decayed teeth, reach 
 only a part of the school population, or have had a wonder- 
 ful crusade of dentistry. 
 
 A number of the cities named fall far below these 
 standards. Eleven cities do not give the facts from which 
 to judge. 
 
 Likewise we can say that cities finding enormous per- 
 centages of defective teeth, for example, probably have their 
 standards for defectiveness too low, so, too many are 
 counted; or that the city is just beginning the work (if this 
 really makes much difference), or that here we have a fac- 
 tory town with much poverty, ignorance and immigrants. 
 
 Whether the standards stand the test of time or not, the 
 value is in the beginning of such standardization of school 
 health procedure. We hope the percentages of defective- 
 ness may be greatly lowered. Later chapters derive tenta- 
 tive standards for each ailment, and group of ailments. 
 
 CURES AND IMPROVEMENTS OF AILMENTS 
 
 The function of medical inspection (or of medical su- 
 pervision) is not only to find, but to promote the cure and 
 prevention, of pupils' ailments. The emphasis should be 
 strongly upon the side of cure and prevention. Prevention 
 is so much a social and economic, as well as a school prob- 
 lem, that we may be pardoned for a while in concentrating 
 upon cures, until our studies lead us back into those funda- 
 mental methods of prevention such as educational, economic, 
 and eugenic reform. To get cures there must be treatments. 
 We have recorded all the treatments by nurses alone, and by 
 
132 SCHOOL HEALTH ADMINISTRATION 
 
 other agencies, in separate columns (cols. 71 and 72). 
 They are not accurate, because the two forms of treatment 
 are frequently confused or reported together, or the records 
 are poor or misleading. That nurses should succeed so well 
 in getting all these thousands of treatments in one of these 
 early years of a great movement, is occasion for great praise 
 and satisfaction. We are sure that many more in the blank 
 spaces would make fair or good showings had we the facts. 
 
 But how many defective children, or what percentage of 
 the ailments received treatment? The data hardly permit 
 a guess. Newark records more than twice as many treat- 
 ments as children ailing, and three-fifths as many cures as 
 children ailing ("cases"). The number of cures is larger 
 than the number of children defective; and this is quite nor- 
 mal for the average number of defects to a child is about 
 two. We must find the number of new ailments rather 
 than the number of children defective in this problem, and 
 relate it to the number of ailments treated and cured. 
 
 The number of ailments found is given in another 
 column (82). After it comes the number referred, showing 
 that some cities record many minor ailments which they do 
 not set out to get cured. It were better that they remain 
 unrecorded, it seems. Until cities list for each ailment treat- 
 ments and cures, this problem of percentage of cases treated 
 will remain unsolved. Later we shall show that favus cases 
 in Dunfermline were treated in the school clinic in one year 
 on the average 94 times; so we have complicating features. 
 Newark's data would give the facts except that the exami- 
 nations covered less than half of the elementary school 
 population and the inspections covered all. Judging only 
 from the total number of ailments or children ailing found 
 by the examinations we should say that 60 per cent were 
 cured. But there were cases (ailments) found also by the 
 doctors in inspecting children not examined, those who had 
 been examined earlier in whom new ailments had arisen, 
 and also new cases (ailments) by the nurses not found by 
 the physicians and referred to them. When we have the 
 sum of all these new cases (ailments) and then the sum of 
 
EFFICIENCY OF HEALTH WORK 133 
 
 all cures, we can arrive at general conclusions as to efficiency. 
 In some way we must know the total number of children 
 afflicted and the number of ailments these children had and 
 what was done with them. 
 
 What the form of reports should be in this field we shall 
 attempt to work out in a final chapter. 
 
 The efficiency of the nurses is not adequately shown in 
 these figures of treatments, cures and improvements. Ex- 
 perience in Philadelphia and elsewhere has shown over and 
 over again that parents respond to only about five or six 
 per cent of the notices of children's ailments without the 
 assistance of the nurse. With an adequate force of nurses 
 and good backing, they will probably raise this percentage 
 up to fifty per cent or more. If doctors were more con- 
 servative about referring ailments this percentage would 
 be raised still higher, quite legitimately and easily, perhaps 
 up to eighty or more per cent. Better concentrate all 
 energies on the worst cases, than to disgust parents and 
 family physicians with notices of trivial ailments. "The 
 doctor sent us home a notice that my little sister was too 
 tall for her age," said one young lady to me. "What does 
 he expect us to do to her?" 
 
 See the comparison of results of work of doctors and nurses for 
 different ailments and for different social grades of population given in 
 the pamphlet entitled "Medical Inspection of Public Schools, Philadel- 
 phia, 1913," printed by the Board of Education for the Fourth Inter- 
 national Congress on School Hygiene. The charts show that parents 
 iseem to be responding better to doctors than formerly, but that the 
 jiurse is indispensable. 
 
 Further efficiency tables will be found in Chapter Nine. 
 
CHAPTER SIX 
 
 THE AILMENTS OF PUBLIC SCHOOL CHILDREN 
 
 A. PHYSICAL DEFECTS 
 
 THE AILMENTS OF PUBLIC SCHOOL CHILDREN IN 25 CITIES 
 
 The Classification of School Ailments 
 
 The first and most difficult problem connected with a 
 comparative study of the work done by doctors and nurses 
 as reported in these twenty-five cities has been that of mak- 
 ing a simple, working classification of the ailments of school 
 children. Several hundred different names for the various 
 ailments occurred in the various reports; many names for 
 the same ailment were used; and no one classification or 
 system of nomenclature seemed satisfactory. The word 
 "ailment" here is used to cover all defects and diseases, and 
 seems preferable to the term disorders used by Dr. Hoag, 
 although the latter serves the purpose. 
 
 There are a number of classifications of human ailments 
 but their bases are all pretty largely that of their death- 
 dealing character and the parts of the body affected. There 
 is, for example, the International Classification of Diseases 
 and Injuries, the Bellevue Classification (Bellevue Hospital, 
 New York City), the classification used by the U. S. Mor- 
 tality Statistics, and the various classifications used by local 
 and state boards of health. They are really classifications 
 of the direct causes of death. One of the first distinctions 
 here is the fact that the ailments most affecting school chil- 
 dren and school work are quite largely not death-dealing. 
 The proportion of ailments from which school children die 
 is a very small share of the total found. As can be seen at 
 the end of the table, columns 214 to 217 and 210 to 211, 
 the deaths of children of school age in each city are very 
 
 134 
 
AILMENTS OF SCHOOL CHILDREN 135 
 
 few in comparison with the number of cases of disease and 
 these of ailments which occur comparatively infrequently. 
 Moreover, the recorded school ailments are not all occurring 
 in the age population, 5-19 inclusive. The classification of 
 ailments here must be a school classification. 
 
 The problem then became a choice of names, or terms, 
 and of division, or classification, in the logical sense. The 
 classifications finally devised were one based upon the loca- 
 tion of the various ailments such as is used by the Boston 
 Board of Health, and a simpler classification, on a more 
 pragmatic, educational basis. These two classifications were 
 duplicated and sent out to a few nurses, medical examiners 
 and supervisors of medical supervision with the result 
 that the location-basis classification was rejected. There 
 were too many divisions; and after such a classification is 
 completed, there always appear ailments which must go into 
 a miscellaneous group almost as large in some cases as the 
 well-classified portion. We have a miscellaneous group in 
 our tables largely because of ailments recorded only as 
 "miscellaneous" in the reports. 
 
 The classification finally adopted and here offered for 
 criticism is as follows : 
 
 I. Communicable Ailments. 
 
 A. Parasitic and Minor. 
 
 B. Infectious Diseases. 
 
 II. Non-Communicable Ailments. 
 
 A. Physical Defects. 
 
 B. Common Ailments. 
 
 The work of placing the many terms used for the vari- 
 ous ailments under a few (54) rubrics was done with the 
 help of the following texts: 
 
 a. Holt's "Diseases of Childhood and Infancy," Ap- 
 pletons. 
 
 b. McComb's "Diseases of Children for Nurses," W. 
 B. Saunders Co. 
 
 c. Hoxie's "Practice of Medicine for Nurses," W. B. 
 Saunders Co. 
 
136 SCHOOL HEALTH ADMINISTRATION 
 
 d. Ditman's "Home Hygiene and Prevention of Dis- 
 ease," Duffield & Co. 
 
 e. Cornell's "Health and Medical Inspection of School 
 Children," F. A. Davis Co. 
 
 f. Hoag's "The Health Index of Children," Whitaker 
 & Ray-Wiggin Co. 
 
 g. Medical Dictionaries. 
 
 Some of the practical considerations which have in- 
 fluenced this selection of terms have been the following: 
 
 a. The names of ailments actually used most commonly 
 by school doctors and nurses. 
 
 b. The names which would be most easily understood 
 by the parents and citizens to whom reports are supposed 
 to be made. 
 
 c. Grouping the ailments according to the divisions of 
 the work. Nurses have almost exclusive control over 
 parasitic and minor infectious ailments, for example. 
 
 d. Emphasizing important and often neglected ailments 
 and divisions of ailments by position. This accounts for 
 placing the word "dental" before "teeth," for example. 
 Important divisions and ailments are placed high in the list 
 when possible. 
 
 e. The number of ailments which would be an optimum 
 number upon which to report, taking into consideration the 
 many practical exigencies. 
 
 For certain of these reasons the division of non-com- 
 municable ailments is placed first. These ailments are prob- 
 ably most important for school life, especially physical de- 
 fects. Diseases which occur very infrequently or have little 
 effect upon school life are omitted, blank places being left 
 after each group on our report for writing in these, if found. 
 (See final chapter.) We recommend that an N. E. A. 
 committee be appointed to further condense and standardize 
 the classification. 
 
 The reader should examine the complete classification 
 given in the last chapter. 
 
 All classifications are compromises and are to be judged 
 by the service they render. The many faults in this clas- 
 
AILMENTS OF SCHOOL CHILDREN 137 
 
 sification are probably obvious, but it serves our present pur- 
 pose of displaying in convenient form the ailments found, 
 and may be of value in bringing about a more serviceable 
 one for the use of schools. At present there is practically 
 no genuine and satisfactory classification in use by any 
 schools. 
 
 ANALYSIS OF TABLE VIII 
 
 One of the first tables made by the author was an at- 
 tempt to show the number of cases found by doctors and by 
 nurses and the number of ailments treated, improved and 
 cured. Such a table, while offering the possibility for needed 
 data, was very cumbrous and was conspicuous for its vacant 
 spaces, the data not being given by enough cities to count 
 for much. In the table as here offered, there are three 
 columns each for only six physical defects; the ailments 
 found by the physicians, by the nurses, and the number 
 treated, cured, or found treated or cured. For the most 
 part the ailments found by the physicians are referred to 
 the nurses, especially where parents do not respond within a 
 given time (and, to repeat, only about five or six per cent 
 of parents do respond to physicians' notices without the 
 nurses' visits) so the sum of the doctors' and nurses' cases 
 would not be the true total of ailments. Every ailment, too, is 
 not a new ailment. In certain cities, and for certain inspectors 
 and nurses within cities, every time a child is seen for a 
 given ailment we get a record for another "case," ailment. 
 This helps to account for some of the large sums and, pre- 
 sumably, very bad morbidity found in certain cities. Where 
 we find a record of very many more cases of an ailment 
 found by nurses (See adenoids in Cambridge, New Bedford, 
 Brockton, Winchester) than by physicians we may be sure 
 that here the sum given by the nurse represents nearly all 
 the ailments. These difficulties with double reporting seem 
 also to point to the nurse as the one to make the only and 
 complete reports of medical supervision. The record shows 
 In general the total number of cases found by doctors, re- 
 ferred to the nurses, and "seen," treated, procured treat- 
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I40 SCHOOL HEALTH ADMINISTRATION 
 
 or nurses. The nurse's column shows, then, for the most 
 part the cases which the nurses themselves treated or tried 
 to get treated and cured through the homes or other 
 agencies. There are many excuses, of course, for the poor 
 showing which many cities make on this chart, through the 
 absence of better reporting. For a board of health with 
 long experience in the health field, and with a system of 
 medical inspection organized for several years, there is, 
 however, hardly any good excuse. For five of the cities, the 
 writer made the summaries of the doctors' and nurses' re- 
 ports for the year studied. (Norwood, Montclair, Water- 
 bury, Yonkers and New Bedford.) For several others, 
 partial summaries were made, as for the nurses of Trenton. 
 This partly accounts for the greater detail of the records for 
 these cities. Most of these cities have since printed sum- 
 maries of this work and it has been interesting and instruc- 
 tive to get from these what such a report may mean, and 
 how much it may vary from the real work, and the monthly 
 and weekly records. The protracted and tedious labor of 
 making such summaries for a year, especially where there 
 were weekly reports from a number of doctors and nurses, 
 gave some valuable insight into what good reporting 
 should be. 
 
 Some cities, like Jersey City and some of the board of 
 health cities, reported only, or practically only, the excluded 
 cases, children so afflicted that they were sent out of school. 
 Such cases are, of course, but a small percentage of the 
 actual number, and such reports are of little value educa- 
 tionally. The efficiency of medical inspection cannot be 
 measured or recorded by such meager data. As they stand, 
 the records require interpretation city by city and almost 
 item by item, so many deductions of scientific exactitude 
 cannot be drawn from them. It will be necessary later to 
 take good records of several cities and make a special study 
 of them. 
 
 Another thing which must always be kept in mind in 
 looking over such reports is that many of the ailments listed 
 are only "suspected'^ ailments. This is especially true of 
 
AILMENTS OF SCHOOL CHILDREN 141 
 
 infectious diseases, adenoids and any other ailments which 
 are difficult of diagnosis. The children are referred to 
 family physicians, clinics and dispensaries for more careful 
 diagnosis and treatment. This lack of final responsibility 
 for an ailment sometimes makes school medical workers 
 careless. The writer has seen many children recorded as 
 having ailments, adenoids or enlarged tonsils, for example, 
 where, from his own study of medicine, and experience in 
 schools, hospitals and dispensaries, there were no such ail- 
 ments — the enlargement being quite normal, at least not 
 pathological enough to require attention or treatment. Such 
 cases are so frequently reported "negative" by family phy- 
 sicians as to disgust the parents and make the best results 
 hard to obtain. Exclusions, too, are in most cities far more 
 frequent than necessary. Every city should have such su- 
 pervision of this work as will adequately review the inspec- 
 tions, examinations, exclusions, etc., and hold physicians 
 and nurses as strictly responsible as the nature of the work 
 will permit. Nurses seem more careful than doctors, since 
 they must follow-up the cases. 
 
 A. PHYSICAL DEFECTS 
 
 I. Adenoids. Some cities report only "Obstructed 
 Breathing" for this defect, because physicians find it desir- 
 able to report the symptoms without making a manual ex- 
 ploration which frequently hurts and frightens the children. 
 The medical phases of this work are so well treated by 
 Cornell in his text on "Medical Inspection," referred to 
 before, and in other texts, that only some of the administra- 
 tive problems will be discussed, for the fifty-four ailments, 
 in this place. Of the 12,652 adenoid cases reported by 
 physicians and the 9,311 found or seen to by nurses, cer- 
 tainly many more than the 1,993 given were treated or 
 found cured on re-inspection. However, some cities make 
 the mistake of taking the teachers' reports as to cures. No 
 ailment should be counted "improved" or "cured" which 
 is not found so by competent re-inspection, or checking-up- 
 inspection, by the doctor or nurse. Such obvious cases as 
 the wearing of glasses after vision has been reported de- 
 
142 SCHOOL HEALTH ADMINISTRATION 
 
 fective, even, should be handled in the same way. The 
 glasses may not fit. This, in general, is an administrative 
 fact purchased very dearly in experience in a number of 
 progressive cities. 
 
 There were also more cases of adenoids and nasal ob- 
 struction found than are here reported. Several cities have 
 no records of this important school ailment. Meriden prob- 
 ably found many cases but for some unknown reason they 
 were not given in the report. 
 
 Our interpretation of the Summit report is that there 
 were 38 cases in all found, but no report was made of those 
 operated on, or treated. The same is true for Norwood: 
 i 9 cases found, no record of cures, although the nurse did 
 take a number of children to the free clinics of Boston for 
 operations. For Winchester, no cases are reported by the 
 physician and 80 are reported as found and 62 as cured by 
 operations, by the nurse. The report here is in this form: 
 "Operated upon for tonsils and adenoids. . . .62." We can- 
 not be sure that all were operated on for both adenoids and 
 tonsils though this method is quite general, since the two 
 ailments are very closely associated. For reporting, how- 
 ever, the two should be separated, since it is only a matter 
 of convenience that both operations take place at once. The 
 report would be better in this form using the terminology 
 of the report, "Mouth breathers," 80; operations, 62 ( ?) ; 
 negative, — ; not treated, — . Enlarged tonsils, 138 ; opera- 
 tions, 62 ( ?) ; negative, — ; not treated, — . 
 
 Although we have only about six or seven scientific 
 studies of the relation of school defects to school progress,* 
 and consequently cannot assert any more than that adenoids 
 and nasal obstructions have very serious effects upon health 
 and school progress, it seems clear that those cities which 
 have failed to keep record of the number of cases found, 
 and what was done in the way of getting them cured, stand 
 
 *See the new, rewritten edition of "Medical Inspection of Schools" 
 by Gulick and Ayres of the Russell Sage Foundation, Chapter IX; also 
 Wallin's study of Oral Orthogenics in the Cleveland schools in Dental 
 Cosmos for April and May, 1912. 
 
AILMENTS OF SCHOOL CHILDREN 143 
 
 in efficiency far below cities which make such efforts. Prac- 
 tically the only cities emphasizing the reporting of cure and 
 treatment are Newark and the nursing division of Boston. 
 
 Some of the chief weaknesses in the reporting of this 
 defect seem to be as follows: 
 
 a. Many cases are undoubtedly not "cases" at all, but 
 fillers for statistical columns, "to frighten citizens into pro- 
 viding a sufficient corps of doctors and nurses." The phy- 
 sician at Summit makes a good distinction between cases that 
 are slight and those that are really serious and demand im- 
 mediate attention, as shown for three defects as follows: 
 
 No. Cases No. Cases Percentage 
 
 Found. Referred to M.D. Referred. 
 
 Adenoids 34 34 100 
 
 Enlarged Tonsils 116 39 25 
 
 Defective Teeth 552 155 28 
 
 Defective Vision 194 85 43 
 
 Here it is evident that only such cases of adenoids as 
 were really serious were recorded and all were reported. 
 Why minor cases were not recorded as is the case of the 
 other three defects named is not told. 
 
 If such distinctions are made in all cases, the placing of 
 minor, unreferrable cases on the individual record cards may 
 prove of some slight value; but as a general principle of 
 reporting in this field, experience in a number of cities seems 
 to show that only such cases as need treatment and cure, 
 that are really serious and demand attention by parents and 
 family physicians, should be recorded and reported. This 
 would reduce the Summit cases to those of the second 
 column, and this proportion of reduction would probably 
 apply to each city. 
 
 b. Many of these cases are "re-inspections," instead of 
 new cases. At the time of some inspection of the child, or 
 at the time of the physical examination in the few cities that 
 have examinations, a pupil is found, for example, with ade- 
 noids. This is one new case. But the pupil does not obtain 
 treatment, say, and is referred to the school doctor again, 
 one or more times. These re-inspections, or better, "old- 
 
144 SCHOOL HEALTH ADMINISTRATION 
 
 cases," are frequently counted as if they were each a differ- 
 ent child with this defect, otherwise, on the poor report 
 forms supplied, the physician would get no credit for his 
 work. 
 
 Good reporting must show the number of children with 
 the defect as "new cases"; and all inspections to see if a 
 child has procured treatment, is keeping up treatment, or 
 is progressing well after an operation or other form of 
 treatment must be recorded and reported as "old cases" 
 inspected. See forms in last chapter, 
 
 c. Negative cases are not deducted from the total num- 
 ber of suspected cases. For example, a child is diagnosed as 
 having adenoids. No careful manual examination is made 
 or the adenoids are not very large or perhaps only tem- 
 porarily congested. The physician cannot say for sure that 
 this is a case for medical or operative treatment, but reports 
 it for the family physician to pass upon. The family phy- 
 sician examines the child and calls it negative, or no case. 
 Unless a very skilled specialist in nose and throat ailments 
 is the school physician, as is very seldom the case, later 
 reports should deduct this case from the total. I know of 
 no city that does this, although the Montclair reports make 
 it a possibility. 
 
 d. The nurses do not show how many cases have been 
 referred to them by the school doctors and how many they 
 have themselves found. Thus in Boston, for example, 
 where the physicians are under the Board of Health and the 
 nurses are not, we do not know how many of the 2,472 cases 
 reported by nurses have already been found by the phy- 
 sicians and referred to them, so we cannot tell how many 
 cases were found in the city, or how many pupils suffered 
 from adenoids. We suspect that the number is far less than 
 the sum of the doctors' and the nurses' cases. 
 
 In the case of Brockton, we know how many cases were 
 found by the nurse, since the doctors are used only for con- 
 sultation and consequently have no cases to report, all being 
 found by the nurse. The nurse, however, fails to state 
 the number of children who had adenoids, although we sus- 
 
AILMENTS OF SCHOOL CHILDREN 145 
 
 pect from the report that it Is almost as large as the number 
 of "cases." 
 
 Reports must distinguish cases merely handed on by the 
 physician from those found by the nurse, and must distin- 
 guish between pupils and cases, or re-inspections. 
 
 e. Treatments are frequently not recorded; many re- 
 corded on the teachers' or pupils' statement without an in- 
 spection by nurse or physician are really not treatments at 
 all. A pupil reports treatment when he hasn't had one, to 
 avoid trouble. Furthermore, a distinction should be made 
 in the kinds of treatment obtained, operative or medical. 
 A spray or gargle which has no beneficial effect is often used 
 and is called a "cure" when adenoids are still there after its 
 use as bad as ever. 
 
 Reports should show that a real cure or improvement 
 has or has not been effected. Only an inspection will estab- 
 lish this. 
 
 f. Another troublesome matter, influencing reports, is 
 the fact that adenoids "come back." The famous English 
 Board of Education (London) reports by Sir Geo. New- 
 man, M. D., consider this. The 191 1 report shows (page 
 50) that many children may be operated on three or more 
 times and the bad symptoms still remain. Even after an 
 operation which may well be called a treatment a child 
 should not be called cured unless the bad symptoms : mouth- 
 breathing, snoring respiration, nasal deformities, etc., cease. 
 In the case of adenoids, this result frequently cannot be 
 obtained without widening the child's nasal passages at the 
 time and after the operation, and without breathing exer- 
 cises directed by the regular or physical training teacher. 
 The latter has been tried and found valuable in Montclair, 
 N. J., by the physical training teachers. 
 
 After all these strictures what have we? How many 
 pupils In these cities suffered from actual, severe cases of 
 adenoids or other nasal obstruction which needed real treat- 
 ment, medical or operative; how many got such treatment; 
 and how many were cured of their ailment or were only 
 Improved? No one In the world can answer with accuracy, 
 
146 SCHOOL HEALTH ADMINISTRATION 
 
 and hardly approximately. We must remember, too, that 
 many severe cases missed attention in a number of cities 
 because the children were not examined and because not all 
 were even inspected for this defect. 
 
 The daily work of doctors and nurses cannot now be 
 reviewed; and the number of mere estimates necessary to 
 a complete summary for the twenty-five cities is probably so 
 great that the results will not carry conviction. The inspec- 
 tion in most cities has necessarily covered only part of the 
 elementary school population, so the figures would be much 
 reduced by the various considerations given above, and 
 would be raised if we were making the estimates for the 
 number of ailments in the entire elementary school popula- 
 tion. Tentative, empirical estimates seem to indicate that 
 the number of cases set down as the sum totals for doctors 
 and nurses is not far from the number of new cases, or 
 pupils affected, to be found by both officials in the total 
 elementary school population of 413,393 pupils, counting 
 all as new cases found by the doctors and all as new cases 
 found by the nurses and not referred to them by the doctors. 
 This would make the number of children having serious 
 cases of adenoids and nasal obstructions about five per cent 
 of the number of elementary school pupils. The figures 
 are only two per cent for Summit, the same in Winchester, 
 and 12 per cent in West Orange; but of the last 195 only 
 6^ were considered serious enough to refer to the parents 
 and family physicians for possible treatment, making only 
 about four per cent. 
 
 Wherever we get the actual number of these cases that 
 are really serious enough to be referred for treatment the 
 percentage does not rise above that for the total of nurses' 
 and doctors' cases for the twenty-five cities, five per cent. 
 This is about half the number, or percentage, usually given 
 as the number of cases. About ten per cent of all children 
 examined are usually reported as having adenoids or other 
 nasal obstruction.* In Milwaukee for the same year, 
 
 *See 1913 edition of "Medical Inspection of Schools," by Gulick 
 and Ayres, page 40. 
 
AILMENTS OF SCHOOL CHILDREN 147 
 
 1910-1911, 19,616 pupils were examined, of whom only 
 2,493 were recommended for treatment; the total number 
 of physical defects found were 18,299, of which 11,380 
 (over half) were defective teeth, and 1,049 adenoids and 
 nasal obstruction. If no cases were counted both adenoids 
 and "defective nasal breathing," and if all pupils with these 
 ailments were referred for treatment, which seems very 
 unlikely from the above figures, the percentage of cases of 
 this defect is only about five. It is Interesting to note here 
 also that there were on the average 6.2 defects for each 
 child. 
 
 2. ANEMIA 
 
 For summary purposes this ailment may as well have 
 been placed with malnutrition and debility, perhaps. It is 
 given separate record because of the large number of sep- 
 arate records given it In the reports. The sum of cases 
 found by doctors and nurses Is 4,539, or less than one per 
 cent of the total number of elementary children in the cities. 
 Boston has a combined number of 2,832 or over two per 
 cent of the school population but here quite evidently all 
 the doctors' cases were passed on to the nurses who counted 
 them again, and found 1,128 new cases themselves, unless 
 some of the latter were duplications, from meeting an 
 anemic child more than once. The number counted cured 
 of this ailment was so small that the figures given were not 
 put down. 
 
 In the cities where there were open-air schools (S. Man- 
 chester, Montclair, Schenectady, Cambridge, Providence, 
 and Newark) It is Important and surprising to notice that 
 this ailment Is one most frequently given as the cause of 
 admittance, not tuberculosis. The children are anemic and 
 run down, probably suffering from malnutrition, and need 
 rest, food, and recuperation. The number of tubercular 
 children of whom we hear so much are conspicuous by their 
 absence from these reports (columns 167 to 172 of the 
 table) only 81 cases being found by doctors that are not 
 marked merely suspects, and only 223 suspected and actual 
 
148 SCHOOL HEALTH ADMINISTRATION 
 
 cases together. The number of cases Is not great enough 
 to cause alarm; the important thing is to find those pupils 
 who will most surely become consumptives in early adult 
 life, and give them special health education, diet, outdoor 
 life, and treatment. 
 
 Probably one per cent of the pupils are anemic. 
 
 3. DEAFNESS, HEARING DEFECTS 
 
 For this ailment, too, the returns are very variable. In 
 Massachusetts and Connecticut the hearing and vision of 
 pupils are tested by the teachers. There are no very definite 
 standards of examination followed in this work; and the 
 great number of teachers and other persons engaged in It, 
 all with little or no supervision, makes for little accuracy 
 In results. Where the tests are made by teachers, we fre- 
 quently found that the teachers had got around the law 
 of 1906 by detailing one of their number in each building, 
 or a teacher on each floor, to make all the tests. A substitute 
 is called into the teacher's room who does this work for 
 herself and the other teachers, and thus a certain amount 
 of school interruption is dispensed with, and a degree of 
 uniformity is reached. In several cities many of the prin- 
 cipals make the tests. This feature and the fact that in 
 other places the nurses make these tests for the entire school 
 system without any need of a substitute and with a great deal 
 better opportunity for skilled work and uniform standards, 
 have furnished the suggestion for the tentative standard 
 plan found in the last chapter that only nurses should do 
 this work in all cities. The reports of specialists in these 
 fields to the legislature of Massachusetts before the law was 
 passed, to the effect that teachers could make such tests even 
 better than regular medical practitioners, would be even 
 stronger when said of the nurses.* It would be distinctly 
 uneconomical to employ relatively high salaried physicians 
 to do any work that can just as well be done by nurses who, 
 
 *See 1913 edition of "Medical Inspection of Schools," pages 179 
 and 44 to 53, by Gulick and Ayres. 
 
AILMENTS OF SCHOOL CHILDREN 149 
 
 hour for hour, receive only about one-third to one-half as 
 much remuneration. 
 
 The tests are chiefly the stop-watch and whisper tests, 
 and common-sense is about the only standard. Children in 
 outdoor life and in the school room should at normal dis- 
 tances be able to hear easily distinct speech lowly spoken; 
 consequently whisper or low-spoken sentences will probably 
 always be an important part of good testing. The Massa- 
 chusetts tests as given in detail in the book just mentioned 
 are the models which most of the other cities follow. Treat- 
 ment is rarely recorded, largely because the defect is often 
 permanent, and is generally treated, if treated at all, indi- 
 rectly by treatment or removal of adenoids, defective teeth, 
 enlarged tonsils, chronic catarrh, colds, discharging ear 
 (otitis media), and the like. 
 
 The teacher's treatment of the child should, of course, 
 be modified by reports of defective hearing; but the writer 
 has found that this matter has been much neglected for 
 frequently, and this is true of all ailments of school chil- 
 dren, not enough attention has been given to notifying the 
 teachers of the ailments and making it necessary and pos- 
 sible for them to readjust themselves to the children in the 
 light of this new knowledge of them. Some cities send a 
 record of every ailment immediately to the teachers of 
 the individual children, and some, like New Bedford, Mass., 
 have small room-filing-cases on each teacher's desk for this 
 purpose. It seems a good plan for the child to take such 
 a room card with him to the nurse or physician for each 
 examination or inspection, carrying it in a fold of clean, 
 blank paper for its protection, and having the physician or 
 nurse record their findings on the card and write any special 
 report for the teacher on the clean slip of paper. The 
 records of nurse and physician could be distinguished by the 
 nurse using, say, red ink in her fountain pen and the doctor, 
 black. I know of no city following this plan; but it is 
 these details which help most to bring about efficiency. 
 
 The percentage of defective hearing cases to total ele- 
 mentary or entire school population can hardly be made, for 
 
I50 SCHOOL HEALTH ADMINISTRATION 
 
 reasons given in connection with adenoids. In Summit, 
 there were 12 cases among 1,034 elementary school children, 
 reported as follows : 
 
 "Ears — The number of pupils with defective hearing or 
 discharging ears was twelve (about i per cent). This is 
 about one-half the number found last year, and is due 
 largely to the correction of defects by medical treatment, 
 or removal of adenoids and enlarged tonsils since the last 
 examination was made." 
 
 How many cases had defective hearing only, we are 
 not told. If there were eight serious cases, that were riot 
 merely temporarily defective because of bad colds, which 
 is probably a big estimate, the percentage would be .7 of 
 one per cent. 
 
 This caution is true for practically all nose, throat and 
 ear ailments, the proportion of cases found being greater 
 in the winter months when the children have bad colds. A 
 room inspection of children in September will give a certain 
 number of cases of adenoids, tonsils, defective hearing, dis- 
 charging ear, and the like; and if the same children are 
 again inspected in December or February a great many more 
 cases will be found. Physicians and nurses who are most 
 conscientious and intelligent in this work take care to distin- 
 guish between temporary and severe or chronic ailments. 
 
 The percentages for some of the cities are as follows 
 (for elementary children only) : Norwood, .9; Winchester, 
 i; West Orange, .3; Montclair, (16 cases), .5; Meriden, 
 .4; Brockton, 1.8; Hoboken, .7; Trenton, .5; Newark, .6: 
 in all an average of about .7. As these are cities where the 
 tests were made for most of the elementary school children, 
 we can see that the actual percentage is well under one per 
 cent. Taking the figures as they stand, the percentage for 
 New Bedford (414 cases) is over 3; for Rochester (628 
 cases), 2.6. These need not be taken seriously. The nurse 
 at New Bedford for the year was new to the work, and had 
 not a developed standard and the cases were first found by 
 the teachers; while the work at Rochester was done by 
 school physicians who evidently set the standard too low. 
 
AILMENTS OF SCHOOL CHILDREN 151 
 
 Although most investigations of this defect place it at one 
 per cent of the children examined in the elementary school, 
 the writer is convinced that half that amount, .5, would be a 
 truer statement of the actual number of cases where the 
 defect was a genuine handicap to the children; and that it 
 would be better, as said, to report only these, and make 
 adequate provisions for their special consideration and 
 treatment. 
 
 4. DENTAL, OR TEETH DEFECTS 
 
 The reason for using the term "dental" instead of 
 "teeth" is the same as that for using the words "eyesight," 
 "enlarged" before tonsils, and "glands" before enlarged: 
 for various administrative and other reasons these terms 
 must be emphasized by position. Some of the most im- 
 portant school ailments can be given a forward place in the 
 classification in this way, and physicians and nurses can 
 easily learn to use this form of nomenclature when it be- 
 comes standard. An alphabetical order makes some terms, 
 otherwise not so desirable, good for this purpose. 
 
 Defects of the teeth which require dental treatment 
 and advice are among the most important of the ailments 
 of childhood, both because of their frequency and because 
 of their indirect effect on general health. Defective teeth 
 might with truth be called "the great American disease" as 
 the figures in these columns show. In any general sum- 
 mary of the ailments of childhood and youth, such as shown 
 in the next table, defective teeth will probably always stand 
 at the top of the list in the number of children affected. 
 The figures given in these columns (58, 59, 60) represent 
 for the most part the number of children affected, not the 
 number of teeth decayed, or needing dental care. This is 
 especially true of the doctors' cases. One case of defective 
 teeth may give the nurse several inspections for toothache, 
 "gum-boils," etc.; but on the whole each child with defec- 
 tive teeth has been counted but once. 
 
 The chief administrative and statistical problems to be 
 considered in this rapid review of the table are : 
 
 a. Ratio of number of children with defective teeth to 
 
152 SCHOOL HEALTH ADMINISTRATION 
 
 number of elementary school children, and number of 
 pupils examined. 
 
 b. Percentage of children with teeth seriously defective. 
 
 c. Relative attention to teeth by Boards of Health and 
 Boards of Education. 
 
 d. Percentage of cases treated. 
 
 e. Effect of treatment upon school progress. 
 All, of course, cannot now be answered. 
 
 The following quotation from the report of the medical 
 examiner. Dr. W. J. Lamson, of Summit, In his June 30 
 report, 191 1, will serve as an illuminating preface to the 
 examination of these teeth columns : 
 
 "Teeth — Particular attention has been paid to the teeth, 
 as their condition is of so much Importance to the young 
 child. It is deplorable to find that over 50 per cent of the 
 school children have an unsound condition of the oral cavity 
 — either decayed or unclean teeth. A pupil, for instance, 
 with decayed teeth, Is constantly absorbing poisons Into the 
 system. The glands of the neck try to protect the rest of 
 the body, become enlarged, and frequently later become 
 tubercular. The child Is anemic, listless and unhealthy. 
 Parents neglect to have such teeth filled or extracted, because 
 the child is young. And yet It is of great Importance to 
 the child to have clean and sound teeth. One hundred and 
 fifty-five cases were urgently in need of dental care, and 
 their parents were notified. Each pupil was told the Im- 
 portance of oral hygiene and urged to use a tooth brush 
 dally." 
 
 The nurse In her report, which largely omits statistics 
 and gives only the personal side of the equation, also em- 
 phasizes the Importance of caring for defective teeth because 
 of their bad effect upon digestion, and strongly urges a 
 dental clinic. 
 
 Here we find 552 children with defective teeth, as de- 
 scribed, among 1,034 pupils examined, or 53 per cent. But 
 only 155 cases were "urgently In need of dental care" and 
 referred to parents for dentistry. This number Is only 15 
 per cent of the total number of children examined, and but 
 
AILMENTS OF SCHOOL CHILDREN 153 
 
 28 per cent of the number of children with defective teeth. 
 
 The ratio of defective teeth to elementary school en- 
 rollment Is 552 to 1,088, or about 51 per cent. For seri- 
 ously defective teeth It Is only 14 per cent. 
 
 How many temporary teeth are here recorded; why 
 unref erred cases were recorded; why parents of all children 
 with teeth defective enough to record were not Informed; 
 how many of the 155 received treatment that could be 
 called cures, we are not told. 
 
 One other fact, only, Is given: that "In school No. i 
 where the higher grades (seventh and eighth) are located, 
 27 per cent of the scholars had defective teeth, as compared 
 with 62) per cent for the rest of the schools." 
 
 This fact Is true for all cities, that all ailments decrease 
 with the age of the pupils from about the third or fourth 
 school years, except defective vision. In Summit, the 
 ratios of defects In the higher grades and In the lower grades 
 were as follows: Adenoids, i per cent and 4 per cent; en- 
 larged glands, 6.5 per cent and 11 per cent; defective 
 vision, 21 per cent and 18 per cent; enlarged tonsils, 9 per 
 cent and 12 per cent; vermin, 3 per cent and nearly 17 per 
 cent (16.6). What Ayres, In his book on "Laggards In 
 Our Schools," has shown to be true for his New York cases, 
 Is found true wherever studied. Most or all of childhood's 
 ailments decrease with age except defective vision, which 
 increases. Not a very great tribute to the hygiene of the 
 schools rooms and teachers of America ! For myopia Is a 
 school ailment. 
 
 DEFECTIVE TEETH IN SOUTH MANCHESTER 
 
 Here a "special physical examination was made of all 
 pupils in the school system" In October, 19 10. Of 1,725 
 pupils examined, 538 were reported as having defective 
 teeth, a percentage of 31. We should expect a smaller 
 percentage where high school pupils are Included in the 
 examination. 
 
 OTHER CITIES 
 Counting the number given by the nurse for Norwood 
 
154 SCHOOL HEALTH ADMINISTRATION 
 
 (984) we have a percentage of 62, or almost two-thirds of 
 the elementary school population, according to the stand- 
 ards of the nurse and doctor. Here record was kept of 
 112 children who received dental treatment, about 11 per 
 cent of those reported as needing it. 
 
 In Winchester, an excellent system of co-operation with 
 the dental association has been worked out, but the nurse's 
 report does not show it for the year put into this study. 
 717 children were examined by dentists with the aid of the 
 nurse; and 84 of these were taken to the clinic and were 
 treated at the small charge of 25 cents each. The 1910-11 
 report is better in this respect. The school dentists exam- 
 ined the teeth of 2,153 children and 1,665 cases were found 
 defective, or about 77 per cent of the children. To the 
 parents of 1,544 of these 1,665 children dental notices 
 were sent, about 71 per cent of the number examined. The 
 number who received treatment is not given, although 83 
 children received reduced rates at the clinic, or a little over 
 5 per cent of the referred cases (1,544). Little can be 
 told from these facts. It is probable that dentists count 
 too many very minor cases. The 19 12 report states that 
 in previous years "from 90 to 95 per cent of the pupils 
 examined were reported as needing dental attention," 
 
 West Orange and Montclair quite evidently overlooked 
 teeth almost entirely. Meriden physicians and dentists 
 found 1,648 children with defective teeth among 3,621 
 pupils examined. Of these, 167 cases, or 10 per cent, 
 obtained treatment (7 primary teeth and 160 permanent). 
 Here we have (where "only the most obvious cases were 
 noted," according to Superintendent Kelly, 1910-11 Report, 
 page 33), 45 per cent of the pupils examined with defec- 
 tive teeth. The report goes on, "But more startling still 
 is the indifference of many parents and their sympathizers." 
 He urges dental clinics which would be patronized very 
 generally, he thinks, A part of this indifference is due to 
 the fact that the work was so new at this time, really get- 
 ting started little earlier than the second month of the 
 school year. 
 
AILMENTS OF SCHOOL CHILDREN 155 
 
 Some of the other percentages are as follows: 
 
 Newton, 2207 cases, on elementary school population, 5,987 — 37 per cent 
 Yonkers, 3063 cases, on elementary school population, 12,562 — 24 per cent 
 
 There were very probably many more cases than this 
 latter number, because two physicians could not cover well 
 the entire city. Part of the nurse's cases may be new 
 cases not found by the physicians. Of these cases 1,235 
 cases are reported as cured, or about 40 per cent. The 
 author's own careful summary of the reports of the phy- 
 sicians, however, showed only 1,631 cases of defective 
 teeth; and only 12 cases of defective teeth were found 
 in the nurse's reports; and yet the printed summary made 
 by the nurse shows 2,474 cases and 662 treated. There 
 Is nothing in the monthly reports to back up these figures. 
 
 In Trenton, with a very much larger elementary school 
 population, and 8 physicians working five days a week each 
 Instead of two, as at Yonkers * — in Trenton, with 713 
 school visits, or an average of 89 each, the number of cases 
 of defective teeth found is only 3,276, or 31 per cent of 
 the 10,587 children examined. Here the principals also 
 report results, although some neglected it. Of 2,289 cases 
 reported by them, only 633 (less than 6 per cent of the 
 number examined) are recorded as being referred for treat- 
 ment, or only 28 per cent. Of these only 13 are reported 
 as cured, 76 improved and 292 not treated. These figures 
 simply show that the work of seeing what was accom- 
 plished was not done, and emphasizes the experience bought 
 dearly in New York and elsewhere that no cures, treat- 
 ments, improvements, or anything of the kind should be 
 reported without an inspection by the physician or nurse 
 to ascertain that fact. 
 
 Notice of the excellent dental clinic in the City Hall at 
 Trenton will be made in a later chapter. 
 
 *Where only 71 school visits were made by the two doctors in the 
 year, about 35 each, 6 schools visited but once, 4 schools but twice, 3 
 but thrice, 2 four times, i five times, and i seven, i eight, i nine and 
 I eleven times, not one of the 20 schools being visited by the physicians 
 more than 1 1 times, and the average less than four visits each. 
 
156 SCHOOL HEALTH ADMINISTRATION 
 
 In W aterhury the Dental Association made a careful 
 investigation of the condition of the children's teeth and 
 have worked out probably the best statistical reports of 
 teeth defects found in any of the cities. This report may 
 be found in the 1910-11 report of the superintendent of 
 schools and In later reports, and a complete summary for 
 seven schools Is here appended. In the annual report a 
 separate report on the same form is given for each school. 
 "The only cost to the Board of Education has been the 
 furnishing of a dental chair and some other necessary ap- 
 paratus, the whole expense amounting to less than two 
 hundred and fifty dollars ($250)." 
 
 SUMMARY OF DENTAL EXAMINATION OF SCHOOL 
 CHILDREN IN SEVEN SCHOOLS BY THE WATERBURY 
 DENTAL ASSOCIATION IN 1910. 
 Grades. 23456789 Totals. 
 
 Condition of the 
 mouth — 
 
 Good 256 389 279 351 236 233 137 126 2,007 54% 
 
 Bad 215 352 440 265 218 III 76 58 1,735 46% 
 
 Condition of the 
 gums — 
 
 Good 392 583 545 445 324 278 178 150 2,905 77% 
 
 Bad 83 178 172 160 129 64 33 34 583 23% 
 
 Use of the tooth 
 brush — 
 
 Yes loi 238 239 255 240 191 130 152 1,646 44% 
 
 No 362 522 361 357 221 152 83 42 2,100 56% 
 
 Teeth filled— 
 
 Yes 58 64 93 92 100 74 57 51 589 16% 
 
 No 426 694 601 523 345 267 158 131 3,145 84% 
 
 Mal-occlusion — 
 
 Yes 154 404 324 329 201 170 102 95 1,679 45% 
 
 No 327 456 373 286 251 173 105 87 2,058 55% 
 
 No. of teeth 
 
 decayed .. .2,721 4,583 3,631 3,105 2,008 1,699 i,i75 993 19,912 or 
 
 5.3 each 
 Total No. 
 pupils 474 758 693 618 455 342 214 182 3,736 
 
 Here, then, we have a table made by dentists them- 
 selves, and from it we can make the following more or less 
 pertinent observations : 
 
AILMENTS OF SCHOOL CHILDREN 157 
 
 a. The number of children with bad dental conditions 
 Is astonishingly large. Among 3,736 children in all grades 
 from the second to the ninth, inclusive, there were found 
 19,912 decayed teeth, an average of about 5 1/3 to each 
 child. Unfortunately, we are not told how many children 
 had defective teeth among the 3,736. The horizontal col- 
 umn marked "condition of the mouth bad" does not repre- 
 sent this number. Here we see that 1,735 children, or 46 
 per cent of those examined, had a bad condition of the 
 gums or mal-occlusion, but some were counted good who 
 had decayed teeth. 
 
 b. The figures are not accurate. The dentists evidently 
 tried to place all the children In one of two classes for the 
 first five items. If they had done so the sum of the two 
 numbers for each item would be the number of children 
 for the grade, given at the bottom. However, there Is a 
 fair degree of correspondence, the difference usually being 
 slight. 
 
 c. The number of cases of defects Is greatest In the 
 third grade, with a few less in the second grade, almost as 
 many or more in the fourth grade, and a gradual decrease 
 to the ninth. 
 
 For bad condition of the mouth we have the following 
 percentages of children defective : 
 
 Grades. 23456789 Totals. 
 No. pupils 
 
 examined ...474 758 693 618 455 342 214 182 3,736 
 
 No. defective.. .215 352 440 265 218 in 76 58 i,735 
 Per cent. 
 
 defective ... 45 46 63 43 48 32 35 31 46 
 
 Counting all children who have decayed teeth or other 
 bad condition of the oral cavity, we may conclude that 
 probably not far from 66 per cent of our elementary school 
 children are so affected, especially in the first years of med- 
 ical Inspection. 
 
 5. ENLARGED TONSILS 
 
 This ailment is quite closely associated with adenoids. 
 We should expect to find more cases of it than of adenoids, 
 
158 SCHOOL HEALTH ADMINISTRATION 
 
 because, as the superintendent at South Manchester puts 
 it, "when the examiner found a well defined case of en- 
 larged tonsils he did not take the time to make an accurate 
 diagnosis for adenoids, for it is the custom of all surgeons 
 who operate for tonsils to remove all adenoid tissue" (1911 
 Report, page 20). Enlarged tonsils are easily seen, while 
 adenoids very rarely can be seen.* This fact should help 
 to make our findings for enlarged tonsils more satisfactory 
 than those for adenoids. 
 
 Let us turn our attention first, again to the actual and 
 proportionate numbers of this ailment among the children 
 here represented. In Summit, "there were 116 cases. 
 Of these only 39 were so much enlarged as to 
 form a serious obstruction to breathing, and the pupils 
 advised to have them removed. This was done in many 
 cases." (Report, page 22.) Here is a percentage of the 
 number examined (1,034) of 11.2 for all cases and 3.7 
 for the serious ones. No mention is made by either doctor 
 or nurse of following-up pupils and parents to see that, or 
 if, they procured treatment. 
 
 In South Manchester, of 1,725 pupils examined in ele- 
 mentary and high schools, 276 children had enlarged ton- 
 sils, or 16 per cent; 27 of the 276, or 9.7 per cent, had 
 had operations before the report in June. 
 
 In Winchester, with an elementary school enrollment 
 of 1,505 pupils, after several years of thorough inspection, 
 138 cases were found, or 8.5 per cent; and 62 of the cases, 
 or 45 per cent, had operative treatment. 
 
 In Montclair, among 3,255 elementary children only 
 60 cases, less than 2 per cent, were found, but of these 37, 
 or 61 per cent, had operations. 
 
 Some of the other figures, where known, are as follows : 
 
 *Dr. Relic's helpful little book on "Safeguarding the Special Senses," 
 F. A. Davis Co., Philadelphia, gives an excellent illustration of visible 
 adenoids and tonsils, page 108. 
 
AILMENTS OF SCHOOL CHILDREN 159 
 
 ENLARGED TONSILS 
 
 Summit Exams.. 
 
 No. 
 Elementary 
 
 School 
 Children In- 
 spected or 
 Examined. 
 
 1,034 
 
 Prob- 
 able 
 Num- 
 ber of 
 Cases. 
 
 Num- 
 Per- ber of 
 cent- Opera- 
 age De- tions Re- 
 fective. ported. 
 
 Percent- 
 age of 
 
 Ailments 
 
 Given 
 Operative 
 
 Treat- 
 ment. 
 
 116(39)33-6% 11.2 
 Referred 
 
 S.Manchester .... 1,725 
 
 Winchester 1,505 
 
 Montclair 3,255 
 
 Brockton 7,589 
 
 Waterbury 12,077 
 
 Yonkers 12,562 
 
 N. Bedford ii,739 
 
 Trenton Exams... 10,587 
 
 Cambridge 15,445 
 
 Lowell 11,438 
 
 Rochester Exams. . 15,157 
 
 Providence 5, 601 
 
 New^ark Exams... 24,310 
 
 Boston 61,055 
 
 276 
 
 138 
 
 60 
 
 1,633 
 130 
 
 1,235 
 713 
 1,723 (510)30% 
 Referred 
 
 300 
 
 721 
 4,452 
 
 272 
 4,588 
 4,101 
 
 16 
 
 8.5 
 
 2 
 21% 
 
 I 
 
 9.8 
 
 6 
 16.4 
 
 27 
 62 
 
 37 
 125 
 "Many." 
 195 
 
 31 
 
 50 
 
 9-7 
 45 
 61 
 
 7-7 
 
 15 
 4-3 
 2.9 
 
 2 "366 home visits" 
 
 6.3 175 24 
 
 29 Not separately given 
 
 4.9 207 75 
 
 18.8 416 9 
 
 6.7 913 22.2 
 
 159.6 2,238 
 
 275.8 
 
 10.6 
 
 25. 
 
 average 
 
 average 
 
 10.7 9,808 
 
 28. 
 
 195,079 20,458 
 
 N. Y. City (1911). 230,243 34,639 
 
 RESULTS 
 What conclusions can we draw from these variant facts? 
 The average percentage of cases of enlarged tonsils, as 
 compared with the number of children examined, inspected, 
 or the entire elementary school enrollment, as the case may 
 be, is 10.6 per cent, while the average percentage of these 
 cases given operative treatment is 25. In Summit, where 
 we are given the facts, only 39 referable cases were found 
 among the 1,034 children examined, or 3.7 per cent, al- 
 though the number of recorded or minor cases is 11.2 per 
 cent. In Trenton, only 510 referable or serious cases were 
 found among 10,587 children examined, or 4.7 per cent, 
 although the total number of cases recorded makes a per- 
 
i6o SCHOOL HEALTH ADMINISTRATION 
 
 centage of 16.4. These figures alone would lead us to 
 suspect that the number of real, or serious, cases would 
 not for all cities give a percentage as high as 10.6. From 
 this and personal observation, I should say that each of the 
 five figures above 15 per cent could be divided by two and 
 a more accurate statement of the number of cases of 
 enlarged tonsils obtained. One reason for this is that the 
 examination covered only a part of the school population, 
 while children were inspected from all parts. Likewise, it 
 is believed, but cannot be demonstrated, that in those cities 
 with percentages of cases less than 6, physical examinations, 
 or even careful inspection for the purpose, would increase 
 the figures up to six or more. These changes would make 
 an average of a little over eight per cent. Half or two- 
 thirds this sum would be near the number of serious, refer- 
 able cases, perhaps. 
 
 As a general estimate and conclusion, we judge that 
 not far from eight per cent of elementary school children 
 have enlarged tonsils, and that about five or six per cent 
 have serious referable cases which should probably have 
 operative treatment. Probably half to two-thirds of these 
 children would need to be operated on for adenoids at the 
 same time. 
 
 Whether cities that have had medical "inspection" for 
 some time are freer from this ailment than others not hav- 
 ing had it, cannot be told from these figures. The average 
 for the newer systems is below that for the old. Meriden 
 and Jersey City, practically started in this year, have given 
 few or no facts. Whether the older cities had found fewer 
 cases each year is also difficult to determine. Ideals and 
 standards for the work change. Generally, when a system 
 is beginning, every slight deviation from the normal, if 
 nothing more than a bad cold and a slight swelling of ade- 
 noids and tonsils due to it, is recorded, and children are 
 excluded in great numbers for relatively trifling reasons. 
 Gradually, the physicians and nurses see that they will get 
 better results if they pick out only the serious and urgent 
 cases; keep children in school as much as possible, even 
 
AILMENTS OF SCHOOL CHILDREN i6i 
 
 cases of pediculosis (nits) under treatment; and then make 
 a good effort to get these important cases treated and cured. 
 This seems to be the road toward maximum efficiency. 
 
 As to the Board of Health versus the Board of Edu- 
 cation problem, we notice that the only cities giving no 
 attention to this serious ailment of childhood are boards 
 of health (Mt. Vernon, Newton and New Haven) with 
 the exception of Jersey City. No board of health has what 
 might be called physical examinations with individual health 
 record cards, except Rochester. The only board of educa- 
 tion city among three or four that have almost insignificant 
 numbers of cases found Is Montclalr. With the exception 
 of Rochester it can be said, In general, that even if they 
 (the board of health systems) are much older on the aver- 
 age than board of education systems they are very much 
 less efficient in this respect. 
 
 The proportion of school population seriously affected 
 in one year is about 6 per cent. 
 
 6. DEFECTIVE VISION 
 
 Defective vision Is very largely a school ailment. And 
 here again the work is almost inextricably intertwined with 
 other departments. In Massachusetts, Connecticut and to 
 a large extent in New York, vision tests are conducted by 
 teachers and principals. In several places the nurse does 
 the testing, in others the physician, while in others the 
 physical training teachers help. This shows again the need 
 of one integrated Department of Hygiene In a school system 
 under one director where we now have the following scat- 
 tered and uncorrelated agents: doctors, nurses, physical 
 training teachers, playground Instructors, open-air school 
 teachers, dentists, sanitary inspectors, etc. Perhaps in many 
 cities, as at Summit and Brockton, the nurses can be made 
 also truant officers. Why not do this work while very prob- 
 ably at or passing the home on regular nursing visits? 
 
 No very definite and fixed standards for testing the 
 vision were found. There are so many persons doing the 
 work, even where each principal of a school tests all his 
 
1 62 SCHOOL HEALTH ADMINISTRATION 
 
 own pupils, that the results must be taken with reservations, 
 and comparisons made only with great care. The Snellen 
 test charts are the ones principally used. Some call all 
 vision less than 20/20 defective; others, less than 20/30; 
 and all use their judgment in referring cases showing signs 
 of eye-strain, even though 20/20 may be easily read. The 
 Massachusetts directions for testing, as given in "Medical 
 Inspection of Schools," by Guhck and Ayres (1913 edi- 
 tion), page 45, are also commonly followed. The great 
 number of such cases declared negative, or not needing 
 glasses, after examination by oculists throw doubt, however, 
 on the 20/20 or 20/30 standards. It is normal for there 
 to be some variation in the vision of children; indeed varia- 
 tion is the most characteristic thing about children. This 
 whole problem needs investigation under competent super- 
 vision. Perhaps 20/30 or less, as used in Newark, would 
 be a better division line. We recommend 20/40, unless 
 there are other serious symptoms of eye-strain. 
 
 The Providence Board of Health has a school oculist 
 who gives a very detailed report of his findings, but not 
 of his methods, in the 19 10 report. He devotes two morn- 
 ings a week to the examination of children referred to him 
 by the school doctors. His salary is $500 a year. Free 
 prescriptions for glasses are given all needy children. We 
 need free prescriptions by the best school oculists for all 
 school children. 
 
 In Summit we find the following report by the phy- 
 sician: "Eyes. — While the total number of cases with defec- 
 tive vision and various other diseases of the eyes is rather 
 in excess of last year (194 and 185), yet more than one- 
 third of this number is made up of last year's cases, which 
 are almost all being treated by properly fitted glasses. It 
 is gratifying to note that when attention is called to the 
 need of correction of defective vision, the parents as a 
 rule attend to the matter promptly. Two cases of severe, 
 chronic trachoma (granulated lids) were operated on, with 
 complete cure. One pupil, 16 years old, had such bad 
 eyesight that he could only see letters at fifteen feet distance 
 
AILMENTS OF SCHOOL CHILDREN 163 
 
 which he should have been able to see at eighty feet. There 
 was a constant eye-strain and twitching of the lids, which 
 was completely cured by proper glasses, and his vision, by 
 their means, is now normal. Some pupils, by wearing 
 glasses for a time, have had their vision so much improved 
 that glasses are no longer necessary, and the accompanying 
 eye-strain, school headaches, watery eyes, etc., have dis- 
 appeared. In all, eighty-five new cases of defective vision 
 were advised to consult an oculist." The nurse reports 
 having "spent twenty-four afternoons at Dr. Vaughan's, 
 the eye specialist's, with children whose eyes needed atten- 
 tion." 
 
 The facts for defective vision, as nearly as they could 
 be obtained, are as follows: 
 
 DEFECTIVE VISION 
 
 Percentage 
 
 No. Elem. Probable Number of num- 
 
 children number Per- obtained ber of 
 
 examined. of cases. centage. glasses. cases. 
 
 Summit 1,034 194 19 (8) a h 
 
 Norwood 1,571 El. Pup. 60 3.8 5 8.3 
 
 Winchester 1,505 El. Pup. 220 15 70 29 
 
 Montclair 3,255 El. Pup. 51 1.5 47 
 
 Meriden 3,621 Bxam'd. . . . . 75 
 
 Hoboken 8,773 Exam'd. 247(1457) 3 (17) 82 33 
 
 Schenectady 10,121 El. Pup. 562(6568) 5.5(8) 21 3 
 
 Yonkers 12,562 El. Pup. 676 5.4 212 31 
 
 New Bedford 11,839 El. Pup. 637 5.4 
 
 Trenton 10,587 Exam'd. 619 5.8 67 11 
 
 Cambridge 15,445 EI. Pup. 194 1.2 14 7 
 
 Providence 31,946 El. Pup. 685* 2 250? 86? 
 
 Newark 24,310 Exam'd. 3003 12.4 989 32 
 
 Boston 61,055 Insp'cd. 2000 3.3 ? 1742 ? 87 ? 
 
 Sum 82.8 277.3 
 
 Average 6.4 28 
 
 a85 referred. &"Almost all." *491 prescribed glasses. ?Treatment. 
 
 Here again records are such that scientific data are 
 hardly obtainable, and generalization must proceed cau- 
 tiously. On the stand that only referable cases should be 
 reported. Summit would have a percentage of the number 
 of elementary school children examined of about 8, instead 
 of 19. The same would probably hold true of Winchester 
 and of Newark. Very low figures below 4 are probably due 
 to the fact that there were visual examinations made of only 
 a part of the elementary school population, those referred 
 by teachers, and those who were found by a partial routine 
 
1 64 SCHOOL HEALTH ADMINISTRATION 
 
 examination. The percentages of cases found here are 
 smaller than those usually given. 
 
 From my observations, and from these data, I am 
 convinced that most of the high percentages given in reports 
 of medical inspection are unnecessarily alarming, since they 
 really mean little when carefully analyzed. They are prac- 
 tically always based upon the number of cases found by 
 the standard used, and not by the number of cases referred 
 for treatment, which is nearer the actual number of genuine 
 cases. Many of the latter even are only "suspected" cases 
 on which the parents are advised to obtain advice. More 
 confidence must be placed in careful examinations, but even 
 these vary considerably in the above list. Where physical 
 examinations were made, as in the case of Newark, of only 
 part of the elementary pupils, and cases referred for vision 
 tests from among the non-examined children, we must lower 
 the percentages. 
 
 As a final judgment, I should say that the average given 
 above is not very far from the actual percentage of ele- 
 mentary school children with this defect, when the examina- 
 tion has covered all grades. Perhaps not far from 7 per 
 cent of elementary school children will be found to need 
 glasses as a remedy for their defective vision. This would 
 mean two or three children in each school room. The 
 number will be found to increase with age. This estimate 
 Is practically that made by eight ophthalmic surgeons who 
 by special appointment examined 2,000 school children in 
 London in 1904.* Their examinations demonstrated that 
 about 7.3 per cent of all children in the elementary schools 
 suffer from 20/60 or worse vision. The percentage near 
 20/40 and less was 12.6. This last seems to be about the 
 standard used at Newark, although in reality it is given 
 as 20/30. 
 
 The relative numbers of cases of various kinds are 
 given in great detail in the 19 10 report of the Providence 
 
 ^Cornell, page 579. 
 
AILMENTS OF SCHOOL CHILDREN 165 
 
 Board of Health, of which the following is a section with 
 percentages computed: 
 
 Vision 
 
 
 Number of 
 
 eyes 
 
 Percentage 
 
 20/15 
 
 
 12? 
 
 
 10 
 
 20/20 
 
 
 201 
 
 
 16 
 
 20/30 
 
 
 243 
 
 
 20 
 
 20/40 
 
 
 167 
 
 
 14 
 
 20/50 
 
 
 95 
 
 
 8 
 
 20/70 
 
 
 162 
 
 
 14 
 
 20/100 
 
 
 159 
 
 
 13 
 
 20/200 
 
 
 127 
 
 
 10 
 
 There were 
 
 685 
 
 cases which had been found by teachers, 
 
 nurse and physicians; and for these the oculist prescribed 491 
 pairs of glasses, or nearly 72 per cent. Ten eyes (not chil- 
 dren) were found with a total loss of vision; and 28 children 
 with supposed defective vision were found to be only 
 illiterate. 
 
 The question of whether vision testing should be done 
 only by oculists has not been scientifically answered. Prac- 
 tically, doctors, nurses, and teachers in the various cities 
 simply find the cases which, according to rough estimates, 
 should receive examination by an oculist. Until we have 
 clinics which will furnish prescriptions and possibly glasses 
 at public expense, as school books are now furnished, the 
 present system will probably be best. Another alternative 
 is to do as Providence has done In supplying accurate diag- 
 nosis with prescriptions for glasses to all who desire it, and 
 are recommended by the nurses, and glasses to those only 
 who are unable to pay for them. 
 
 The nurses have been very successful in many cities in 
 helping needy children to obtain glasses. In practically 
 every city there are numerous individuals and organizations 
 that are glad of the chance to furnish glasses to the children 
 of needy parents. In Lowell, Superintendent Whitcomb has 
 for years furnished needy children with money for glasses 
 out of his own pocket. Such sacrifice is needless, and stands 
 in the way of acquainting the public with school problems 
 
1 66 SCHOOL HEALTH ADMINISTRATION 
 
 and school needs. The numerous ways devised by superin- 
 tendents and others in obtaining assistance along a great 
 variety of health lines without school expenditure and with 
 benefit to the public, as found in a number of the cities 
 visited, almost leads to the conclusion that a superintendent 
 can get almost anything he wants for the schools free of 
 charge, if he knows how to mould public opinion and reach 
 the people who desire to give services or money or both to 
 some worthy cause, Denison's book on "Helping School 
 Children" (Harper's) is full of illustrations of this prin- 
 ciple, and points out an almost unworked field before us. 
 
 BOARDS OF HEALTH VS. BOARDS OF EDUCATION 
 
 What does the comparative treatment of defective vision 
 in the schools show as to the relative efficiency of Boards 
 of Education and Boards of Health? Of four cities giving 
 no attention to this very important school ailment, three 
 were board of health cities. In New Bedford, where the 
 doctors but not the nurses are under the Board of Health, 
 the former have practically neglected this ailment, finding 
 only five cases to the nurse's 632. There is good excuse for 
 this perhaps in that teachers are required by law to make 
 such examinations in Massachusetts. This would practically 
 excuse, also, the other boards of health in other cities, for 
 this ailment. By far the best report on this subject is found 
 in the report of the Board of Health of Providence, and 
 the 191 1 report is still better.* 
 
 In the cities given in the above table, however, where 
 boards of health have attempted this work, we could com- 
 pare the two forms of administration on the following bases 
 for which we have data : 
 
 a. Percentage of elementary school children examined 
 for vision. 
 
 b. The percentage of cases found. 
 
 *In general, the reports on Medical Inspection by Dr. Charles V. 
 Chapin, of this Board of Health, are in many ways quite superior to 
 those of many or most other cities. 
 
AILMENTS OF SCHOOL CHILDREN 167 
 
 c. The percentage of cases procuring glasses, or other 
 treatment. 
 
 The quality of the work done in examination cannot well 
 be put in the form of a numerical coefficient, although we 
 could say that the examinations of the oculist at Providence 
 were undoubtedly better than those in other cities. The 
 amount of work is shown to some extent by the number of 
 cases found; for those cities reporting percentages less than 
 three or four of the elementary school population, certainly 
 did not reach all the children. Six cities fall below four 
 per cent, 3 under the boards of health. But there are, in all, 
 9 board of education cities to 6 board of health cities, and 
 one of the latter, Boston, is partly administered by the Board 
 of Education. This would give the advantages to the boards 
 of education, the percentages falling below being about 33 
 for the boards of education and 50 for the boards of health. 
 Both Boston and New Bedford, especially the latter, are 
 lifted up by the school nurses in the department of education. 
 The three cities with high percentages are all board of 
 education cities. These higher percentages, may not be 
 virtues where discretion has not been used. In these three 
 cases, however, I think they represent careful, painstaking 
 work with a large percentage or all of the children. 
 
 GLASSES 
 
 Little can be judged from these figures. The average 
 percentage of cases treated or cured by glasses for the ten 
 cities reporting is 28. The average for the board of health 
 cities is 11 per cent, while the average for the boards of 
 education is 33. Boston is here counted as a board of edu- 
 cation city for this function, since the nurses reported 1,581 
 cases to the doctors' 617, and were the ones who got the 
 treatments and recorded them. 
 
 The following conclusion can probably be drawn legiti- 
 mately from these facts: 
 
 As a rule, these boards of health are less efficient than 
 are these boards of education with respect to finding cases 
 
1 68 SCHOOL HEALTH ADMINISTRATION 
 
 of defective vision, and especially in obtaining and reporting 
 cures. 
 
 Providence stands out as an exception. 
 
 191 I REPORT OF THE PROVIDENCE OCULISTS 
 
 This leads us to add some further facts from the last 
 Providence report on this problem of finding and curing 
 defective vision. 
 
 Two oculists are now employed (19 11 Report) two 
 afternoons a week for about two hours each afternoon at 
 the Fourth Ward Room for examining eyes, at salaries of 
 $500 each. All pupils who are found with defective vision 
 in the schools by teachers or nurses may now go to these 
 oculists for free examinations and prescriptions for glasses, 
 or medical treatment. One oculist has reported for only a 
 half year. Together, there were 646 cases, for whom were 
 prescribed 496 pairs of glasses (77 per cent) and of whom 
 the nurse saw 420 and obtained or reported 339 as "having 
 treatment," which if we were to interpret as meaning glasses, 
 would be 68 per cent of the number prescribed glasses, and 
 81 per cent of the cases seen by the nurse. A small per- 
 centage of the cases needed medical treatment. Two pos- 
 sible fallacies lie here : There were probably many children 
 with defective vision who did not go to these oculists, so the 
 percentage of cases treated was probably much smaller, and, 
 second, treatment may mean glasses in only a small per- 
 centage of cases. 
 
 This illustrates again the common failing to give the 
 facts upon which estimates can be made, even in the best 
 reports. (Our estimate of children needing glasses or an 
 operative treatment is seven per cent.) 
 
 7. STRABISMUS, CROSS-EYE, SQUINT 
 
 This is a vision defect which is emphasized by separation 
 from the others. Dr. Reik, in his "Safeguarding the Special 
 Senses," expresses sound medical experience when he says, 
 that "practically all cases of crossed eyes, even of many 
 years standing, can be rectified, and when one considers what 
 
AILMENTS OF SCHOOL CHILDREN 169 
 
 a difference in personal appearance it makes, the disagreeable 
 effect of such an eye upon those who must come in contact 
 with the afflicted person, and the simplicity of the operation, 
 it looks like a sin against the community to allow such per- 
 sons to retain their deformity" (page 46). The ailment is 
 only the failure of the eyes properly to co-ordinate because 
 of muscular or refractive errors, and the giving up of the 
 struggle to use both eyes together. One only is used, and if 
 the other is constantly neglected through habit or other cause 
 it frequently goes blind. So this ailment, which is quite 
 commonly neglected, should be given special attention in 
 early school life, or before, whenever the nurse or teacher 
 finds such a case among the little children in the homes. 
 
 SomxC cities did not keep separate records of this ailment, 
 and several did not record the ailment at all. There were 
 two cases in Summit among 1,034 children. Waterbury had 
 89 cases in an elementary school population of 12,077, a 
 much larger percentage, but little less than one per cent (.7). 
 
 Yonkers reports 47 cases found by the doctors.* Taking 
 47, we have a percentage of the elementary school enroll- 
 ment of .4. Taking the several cities, and using the nurses' 
 figures for Cambridge and the physicians' in Boston as is 
 reasonable, we have: 
 
 Children. Cases. Percentage. 
 
 Waterbury 12,077 89 .7 (7 in looo) 
 
 Yonkers 12,562 47(25) .4 (.2) 
 
 New Bedford 11,839 221 1.8 (iSiniooo) 
 
 Trenton 12,774 26 .2 
 
 Cambridge 15,445 95 -6 
 
 Providence 31,946 loof .3 
 
 Boston 95,970 173$ -2 
 
 4.2 
 Average .6, or 6 in a 1000. 
 fOculist. ^Perhaps more. 
 
 Leaving out New Bedford with its high figures, we have 
 a percentage of .4, or four in one thousand elementary 
 
 *Our summary of the doctor's reports shows only 25 cases; while 
 the nurse reports 12 cases treated, while our summary of her reports 
 shows only 6 cases. 
 
lyo SCHOOL HEALTH ADMINISTRATION 
 
 school children. Nothing has yet been brought out to show 
 whether the ailments of any kind vary much with place and 
 length of time these medical inspection systems have been in 
 operation. Our estimate is about seven cases in a thousand. 
 
 Very few of these cases are reported as having had treat- 
 ment, operations, or glasses. This is due only partly to ineffi- 
 ciency. Physicians and nurses are frequently not sure that 
 it is necessary or their province to follow-up thoroughly all 
 cases to see that they do obtain the care they need. A later 
 chapter will show that they do not get results amounting to 
 very much without thorough follow-up work, and it is ap- 
 parent that neither tests of efficiency nor adequate knowledge 
 of health facts can be obtained without satisfactory records 
 of the most important matter in all this work, cure and pre- 
 vention. 
 
 (Our estimate is 7 cases in a thousand.) 
 
 8, GLANDS ENLARGED, ADENITIS, TUBERCULAR LYMPH 
 
 NODES 
 
 This is another ailment quite common to children and 
 which may lead to serious consequences, the least of which 
 may be, if Ayres' findings * are true, serious retardation in 
 school, amounting to a loss of 1.2 years in passing through 
 the elementary school. Other causal factors operate, how- 
 ever, with such cases and we are not sure that the retardation 
 may not have been due in whole or in part to poverty, bad 
 heredity or some other associated cause. Verification of such 
 studies lies in the future. 
 
 Malnutrition, bad ventilation, and decayed teeth are 
 named by physicians as causes of this ailment, though they 
 give but little scientific proof of their conclusions. One very 
 clear route of travel to adenitis seems to lie through the 
 following steps : decayed teeth, enlarged tonsils, adenoids 
 and indigestion, then enlarged glands. Frequently the route 
 is also up the eustachian tubes to otitis media, or discharging 
 ears and deafness. The glands may also become tubercular 
 
 *Laggards, page 128, and the 19 13 edition of Medical Inspection 
 of Schools, page 161. 
 
AILMENTS OF SCHOOL CHILDREN 171 
 
 and consumption may follow. The mouth Is the portal. 
 Much of medicine, as of education, is, however, yet a matter 
 of mere hypothesis. 
 
 So few of the gland cases are recorded as treated or 
 cured that a separate column is not given to these data m the 
 table. Something of the frequency of the ailment may be 
 gleaned from the data below : 
 
 ENLARGED GLANDS 
 
 Per- Re- Reported 
 
 Cases. centage. ferred. Treated 
 
 Summit 1,034 Exam'd. ^03 lO.o 
 
 S. Manchester 1,725 Exam'd. 2 .1 2 
 
 Norwood 1,571 El. Pup. 8 -5 » 
 
 Winchester 1,505 El. Pup. 18 2.3 18 
 
 Montclair 3,255 El. Pup. 25 .8 25 
 
 Hoboken 8,773 Exam'd. 5 .0 5 
 
 Schenectady 10,121 El. Pup. 29 .2 
 
 Waterbury 12,077 El. Pup. ^H -9 
 
 Yonkers 3 -O 
 
 New Bedford 11,839 El. Pup. 15 -i 
 
 Trenton 10,587 Exam'd. lO .1 
 
 Cambridge 15,445 El. Pup. 30 -2 
 
 Syracuse 18,016 El. Pup. 39 -2 
 
 Rochester 15,157 Exam'd. 1281 1.2 
 
 Providence 31,946 El. Pup. 70 -2 
 
 Newark 24,310 Exam'd. 4^47 ^-7 
 
 Boston 61,055 El. Pup. 700 I.I 
 
 Average 1.2 per cent for 15 cities. 28.6 percent. 
 
 Here we have percentages of this ailment far below on 
 the average those usually given. In the controlled investiga- 
 tion by Ayres in 1908 previously mentioned, among 7,608 
 children medically examined, a percentage of 40 P^r cent 
 were found suffering from enlarged glands in the six-year 
 group and 7 per cent in the 15-year age group. The per- 
 centage for all is not given. Among 3,304 of those above 
 the age of nine especially studied, over 13 per cent had en- 
 larged glands; and when they were divided into three classes 
 the percentages were as follows: Dull, 20; Normal, 13; 
 Bright, 6. 
 
 None of the figures in these twenty-five cities approach 
 
 10 .1 10 
 
 30 
 
172 SCHOOL HEALTH ADMINISTRATION 
 
 very closely to this average. The conclusions which might 
 be drawn to account for this discrepancy are : 
 
 a. Summit and Newark were the only cities which made 
 very thorough examinations of the children. There is some 
 truth in this. 
 
 b. These cities have not found all the cases. There is 
 also some truth in this. 
 
 c. The New York children are more afflicted with this 
 ailment. I doubt whether there is very much truth in this. 
 
 d. The New York physicians found more cases than 
 there were, or called very slight deviations from the normal, 
 enlarged glands. If there is much truth in the last hypoth- 
 esis, Ayres' findings rest on a very unstable basis. The time 
 is not ripe to be dogmatic in this field. 
 
 In the entire city of New York in the school year of 
 1910-11 among 230,243 children examined, only 483 cases 
 were found, a percentage of .2, the average above given. 
 The 19 1 2 monograph on "The Division of Child Hygiene," 
 of the Department of Health of the City of New York, 
 shows also no great variations by ages, as shown on the 
 chart, part 82. The percentages for 19 10 and 1909 are 
 practically .3. These figures throw more suspicion upon the 
 accuracy of the Ayres' data. 
 
 What general statement of the prevalence of this defect 
 can we derive from the above data ? Some cities apparently 
 found, or at least recorded, no cases at all. One would not 
 expect to find a high percentage of these cases in Summit, 
 it being probably one of the most healthful and generally 
 well-to-do of the cities, a suburban resident town. There 
 seems, however, to be little sociological basis for the varia- 
 tions, the mill towns and others with congested foreign 
 population not standing very high, comparatively. The 
 length of time medical inspection has been in force seems to 
 make no difference. The difference must lie more in the 
 standards, requirements, and interests of the men and women 
 making the examinations and inspections. 
 
 Special studies in England of some 10,000 children place 
 
AILMENTS OF SCHOOL CHILDREN 173 
 
 the percentage of cases below one per cent as in most of 
 the cities in this investigation.* 
 
 The number of cases in Summit was very much smaller 
 the year before the above report, the exact figures not being 
 given; but among 950 pupils examined there are only 91 
 (about 10 per cent) miscellaneous cases of "anemia, mal- 
 nutrition, coughs, colds, nervous affections, glandular swell- 
 ings, etc." Undoubtedly, the percentage was very low; and 
 yet the Ayres' figures for the retarding effect of glands are 
 given in the same report. In the later report studied, 
 1910-11, the doctor says in his report, "Glands — Particular 
 attention was paid to enlarged glands of the neck. These 
 usually accompany decayed teeth and are apt to break down, 
 or become tubercular unless prophylactic treatment is given. 
 There were 103 cases." None were referred according to 
 the following statistical table in the report. This is a glaring 
 example of a point made by the writer on a former page, that 
 physicians find what they give "attention" to, what they look 
 for; and the Summit physician Is quite above the average 
 medical Inspector. 
 
 Discounting, then, very much the Summit percentages, 
 we have Newark to consider. The previous report shows 
 a percentage of 16 for this defect. My judgment is that 
 very slight deviations from type for this defect are recorded, 
 rather than that the children are especially ailing in this 
 particular. Then, too, many children not among the 24,310 
 examined, undoubtedly furnished cases. The probabilities 
 are that the true percentage Is not above four per cent at 
 most. Trenton and Rochester both had physical examina- 
 tions and their percentages are only .1 and 1.2. 
 
 Taking a number of such facts Into consideration we 
 should estimate that the actual number of cases in the ele- 
 mentary school populations serious enough to warrant atten- 
 tion and preventive or curative measures Is around one per 
 cent, as a fairly generous estimate. Not until there is some 
 
 *i9io report of the Chief Health Officer of the English Board of 
 Education, pages 53 and 54. 
 
174 SCHOOL HEALTH ADMINISTRATION 
 
 adequate standardization of reporting this and other ail- 
 ments through the training and supervision of physicians 
 and nurses will there be much correspondence among reports. 
 
 9. HEART DEFECTS, HEART DISEASE, CARDIAC AILMENT 
 
 The 191 1 report of the Board of Education of England 
 above mentioned summarizes the situation here with respect 
 to this ailment, in the following words: "As far as can be 
 judged from the attention bestowed on this subject in the 
 reports of School Medical Officers, it does not appear as 
 yet to have aroused widespread interest or to have formed 
 the basis of many special inquiries" (page 54). We have 
 nothing in America comparable to this report, however. The 
 percentage of children affected seems to be about one per 
 cent. 
 
 Without placing here all the figures, the reasoning and 
 the guessing necessary, we shall give in this and several other 
 cases only the probable frequency of the ailment, with the 
 variabilities. 
 
 Some of the cases are: Summit, .3 per cent; Boston, .2 
 per cent; Rochester, .5 per cent; Newark, i per cent; Tren- 
 ton, I.I per cent; Hoboken, 1.4 per cent. In New York City 
 in 191 1, the percentage is .7. The average for our cities is 
 less than .7. 
 
 Discounting for recording very minor cases, and adding 
 for the cases missed, we judge that the number of the vari- 
 ous kinds of heart defect needing attention and treatment is 
 between .6 and 1.2 per cent, say .9, to name a figure. With 
 better education in this respect, and all examinations made 
 with the pupils' chests stripped, the percentage of real cases 
 will probably rise to one per cent. Most cities do not have 
 the latter necessity for adequate heart and lung examinations. 
 
 10. LUNGS WEAK, NOT TUBERCULAR 
 
 Some children are flat chested, weak lunged and predis- 
 posed to pulmonary troubles, but not yet infected with tuber- 
 culosis. They need good ventilation, physical training in the 
 form of plays and games and probably medical gymnastics, 
 
AILMENTS OF SCHOOL CHILDREN 175 
 
 light work, good food and general care. These are the ones 
 who are anemic and debilitated, and frequently, if not 
 always, profit in an open air school. We can tell little about 
 the frequency of the defect. Depending again largely upon 
 cities that have physical examination, we have an average 
 percentage of about .5 or a half a per cent, five cases in a 
 thousand. This is only a guess because the defect cannot be 
 well defined. 
 
 II. MALNUTRITION, DEBILITY, INDIGESTION, GENERAL CON- 
 DITION 
 
 These ailments are not well differentiated, but they are 
 not separated well in the reports. Debility and indigestion 
 may have little or nothing in common with malnutrition. 
 The latter term is most commonly represented in this col- 
 umn, however. 
 
 The percentages for some of the cities are as follows: 
 Summit, I per cent; Norwood, i per cent; Montclair (many 
 cases of "general condition"), counting 124 cases, 4 per cent; 
 Hoboken, .05 per cent; Waterbury, say 30 cases, .2 per cent; 
 New Bedford, .4 per cent; Trenton, .4 per cent; Cambridge, 
 .1 per cent; Rochester, 5 per cent (these doctors also visit 
 those families who are ill and in poverty; and this may ac- 
 count for the attention given to malnutrition) ; Providence 
 (100 cases), .3 per cent; Newark, 2.6 per cent, and Boston 
 (counting 800 cases), 1.3 per cent. The average is 1.3. 
 The median is 4 per cent. 
 
 There are undoubtedly very many more cases of under 
 and poorly fed children in many of these cities, as could be 
 easily determined on investigation, probably as many as six 
 or seven per cent in some cities with more poor and more 
 foreigners than Rochester. This problem very much needs 
 scientific study, and school systems very much need adjust- 
 ment to the situation as found. England is far ahead of us 
 in this particular. Both the 19 10 and 19 11 English reports 
 mentioned give able treatments of this matter. Among 
 about 200,000 children examined * in counties and urban 
 districts, approximately 20 per cent were regarded "good" 
 
 *I9II Report. 
 
176 SCHOOL HEALTH ADMINISTRATION 
 
 as to nutrition, 69 per cent "normal," 10 per cent "sub- 
 normal," and a little less than one per cent as "bad." These 
 percentages are based upon the medical judgments of the 
 physicians. Attempt at objective standardization of the 
 examination is being made in the relationship to height and 
 weight, pages 27-29. 
 
 A "nutritional index" was worked out, namely: Index 
 equals 100 times the cube root of the quotient of the weight 
 in kilograms divided by the height in kilograms. 
 
 The average value of this index for each year of school 
 age from three to fifteen for 9,166 children examined was 
 determined, and these standards used for measuring the 
 nutritional condition of various groups of children, with fair 
 results. 
 
 The London County Council publishes a book largely 
 given over to the problem of meeting the malnutrition sit- 
 uation (Handbook Containing General Information with 
 Reference to Children's Care, second edition, R. Blair, Edu- 
 cation Officer, London). 
 
 In our own country, and among these cities studied my 
 judgment is that not far from two per cent of the elementary 
 school children are suffering enough from malnutrition to 
 need special care and treatment. In New York City, the 
 percentage is from 2.5 per cent to perhaps 3.5 per cent. 
 
 12. DEFECTIVE MENTALITY, BACKWARD CHILDREN 
 
 Only half of the cities mention this serious defect. Provi- 
 dence has since employed a neurologist for the examination 
 and study of such cases, but further than that there seems 
 to be no specialization of this function as at Cleveland, Los 
 Angeles and other places. 
 
 Some of the percentages of this ailment are as follows : 
 Summit, I per cent; Norwood, 5.4 per cent; Winchester, .1 
 per cent; Montclair, 1.5 per cent; Schenectady (47 cases), 
 .5 per cent; Waterbury, .1 per cent; Trenton, .1 per cent; 
 Cambridge, .1 plus; Providence, .2 per cent, and Newark, 
 1.4 per cent. The average is for these ten cities, .9. This 
 Is practically the number found In Cleveland by the psy- 
 
AILMENTS OF SCHOOL CHILDREN 177 
 
 chlatrist with the help of the Binet tests, but according to 
 the 191 1-12 report, page 3, "falls far short of the total num- 
 ber in the public schools." A distinction is made between 
 the feeble-minded and the mentally defective children, "the 
 epileptic children should also be included in the group to be 
 eliminated" from the schools. This would raise the percent- 
 age for Cleveland (750 cases and 41,514 examined by doc- 
 tors) up to 1.8 per cent. Dr. Holmes of Newark also urges 
 the elimination of all such children from the schools. Dr. 
 Goddard in his investigation of this problem for the School 
 Inquiry Committee, concluded that there are at least 15,000 
 feeble-minded children in the public schools of New York 
 City, about 2 per cent. These are children "so mentally de- 
 fective as to preclude any possibility of their ever being made 
 normal and able to take care of themselves as adults." This 
 is also the percentage found among 2,000 children in the 
 little town of Camden, N. J.* 
 
 Our judgment for these cities is that the actual per- 
 centage of mentally defective children in the elementary 
 schools is not far from one per cent. 
 
 13. NERVOUS AILMENTS, CHOREA, HABIT SPASM, NERVOUS 
 
 EXHAUSTION 
 
 There are a number of ailments of the nervous system 
 which are frequent among children, and important from the 
 educational point of view. These are well treated from 
 the medical point of view by Cornell and Hoag in their 
 books on "Medical Inspection" and the "Health Index." 
 We are concerned here principally with their frequency and 
 administration. Some of these ailments connected with 
 speech, sex, etc., are treated in other columns. The prin- 
 cipal ones here are chorea, or St. Vitus' dance, a nervous 
 twitching of various muscles of the neck, face, head, shoul- 
 ders, arms and legs. Dr. L. D. Cruickshank, in his most 
 excellent "Sixth Annual Report on the Medical Inspection of 
 School Children in Dunfermline," Scotland, says it is "re- 
 
 *See Pedagogical Seminary for June, 191 1, "Two Thousand Chil- 
 dren Tested by the Binet Scale," by Henry H. Goddard. 
 
178 SCHOOL HEALTH ADMINISTRATION 
 
 garded by some as a manifestation of rheumatism and as 
 such requires special care in order that no damage may result 
 to the heart. Children should come under treatment as soon 
 as the choreaic movements are detected. Continuance at 
 school is harmful even when the symptoms are slight in 
 character." 
 
 Nervous exhaustion is found more particularly among the 
 girls in the upper grades and high school. Nervousness, ex- 
 citability, and peculiar nervous habits all come under this 
 list. Epilepsy is included, but would not have been had there 
 been many cases reported (13 in Boston). A few other 
 ailments have very small representation. The chapter by Dr. 
 Cornell in his book, pages 324 to 358, is probably the best 
 school discussion we now have of the trouble. Reports from 
 some of the cities are as follows : 
 
 Summit 8 cases, a percentage of about i per cent 
 
 Montclair 20 cases, a percentage of about .8 per cent 
 
 Hoboken 4 cases, a percentage of about .04 per cent 
 
 Brockton 17 cases, a percentage of about .2 per cent 
 
 Waterbury .... 6 cases, a percentage of about .06 per cent 
 
 Trenton 8 cases, a percentage of about .07 per cent 
 
 Cambridge 14 cases, a percentage of about .09 per cent 
 
 Providence .... 134 cases, a percentage of about .4 per cent 
 
 Newark 77 cases, a percentage of about .3 per cent 
 
 Boston 130 cases, a percentage of about .2 per cent 
 
 3-17 
 Average, .3 per cent. Median, .3 per cent. 
 
 The percentage in Dunfermline is .4 per cent. In New 
 York City, the percentage is also .4 per cent. Better medical 
 examination and inspection in our upper grades and high 
 schools will undoubtedly raise this percentage. My judg- 
 ment for the elementary schools of the cities is that its fre- 
 quency is at least .5 per cent. Dunfermline has more careful 
 work than any public school system in this country, probably, 
 but its examination system is so arranged that all pupils are 
 not examined each year. If the whole school system were 
 covered each year by thorough examinations, the percentage 
 would probably be raised. For serious cases, the percentage 
 is probably less than .2. It can be seen from this that many 
 
AILMENTS OF SCHOOL CHILDREN 179 
 
 cities have not found the cases. When the attention of medi- 
 cal men and nurses is drawn to the importance of this ail- 
 ment and its prevention, the figures will very rapidly 
 climb up. 
 
 14. PALATE DEFECT, CLEFT PALATE, ETC. 
 
 Cleft palate is associated with hare lip. The high, nar- 
 row palate is associated with enlarged tonsils and adenoids. 
 Fortunately, the ailment is uncommon, only seven cities 
 mentioning it, and three of this number with only one case. 
 It might be placed with the Orthopedic defects, or "De- 
 formities." The percentage for Cambridge is .05 ; for 
 Rochester, 1,7; and for Newark, 1.7. It is not mentioned 
 In either Boston report. The average proportion is probably 
 seven cases in a thousand. 
 
 15. SKELETON DEFECTS, ORTHOPEDIC, DEFORMITIES. 
 
 Spinal curvature (scoliosis), round shoulders, and the 
 like, are given separate space in the next two columns (89 
 and 90), because of their importance in school life. In cer- 
 tain cases spinal curvature was given with other deformities 
 and is here included. They should be kept separate. Pigeon 
 breast, caused, like scoliosis, quite largely by rickets in in- 
 fancy, wryneck, webbed fingers and toes, flat feet, and a 
 number of others come in this list. 
 
 The frequency is about .2 per cent, or less. 
 
 In the case of this and the following group of ailments 
 we have the province of medical gymnastics, or therapeutic 
 exercises. In the School Clinic at Dunfermline, previously 
 mentioned, there is a separate division with an expert in 
 charge for all such work. Through massage, carefully 
 guided exercises, and general hygienic regimen much which 
 cannot be surgically or medically cured, can be helped, and 
 Improved. 
 
 16. SPINAL CURVATURE, POSTURE, ROUND SHOULDERS, FLAT 
 
 CHEST 
 
 The lack of sufl^cient medical examiners and the peculiar- 
 ities of public opinion, or public sentiment, are such that 
 
i8o SCHOOL HEALTH ADMINISTRATION 
 
 genuine, all-round physical examinations are not yet being 
 made in American public schools. To discover and study 
 such defects as are here listed means the removal of the 
 child's clothing, or at least stripping to the waist. This is 
 now practiced in the best private and normal schools, and 
 colleges. A very few cities are introducing such examina- 
 tions in the high schools; and some courageous medical ex- 
 aminers go ahead and do their work in a thorough way in 
 the elementary schools. In certain or all cities there are 
 school districts in which anything necessary for scientific 
 work can be done, and in others, generally the richer and 
 supposedly more enlightened, the policy is more that of 
 "hands off." Yet the children of the latter are frequently 
 the ones who need most attention of this kind. 
 
 The frequency in the elementary school population is per- 
 haps not far from .8 per cent, and perhaps one per cent. 
 
 Dunfermline has 2.2 per cent well marked cases of spinal 
 curvature (97 cases and 4-A9'^ pupils examined). Evidently 
 here there were adequate examinations, slight deviations re- 
 garded perhaps, and a greater prevalence than in this coun- 
 try; although we may have more cases than even one per 
 cent. 
 
 Fundamental prevention of this ailment must begin in 
 the child's infancy through the preventing of rickets and 
 such ailments. 
 
 17. SPEECH DEFECTS, STUTTERING, STAMMERING, LISPING, 
 
 LA L LING 
 
 Stammering or stuttering is the commonest of these ail- 
 ments. "The condition is commonly the result of imitation, 
 and this gives rise to a difficulty in treatment, because stam- 
 merers are likely to increase each other's defects when placed 
 in special classes." These words by Dr. Cruikshank may 
 be too strong against class treatment; for pupils imitate and 
 start the habit only when they think it is smart, but when 
 there is a good deal of social disapproval or stigma upon it, 
 the danger of imitation seems to be slight. The new book 
 by Professor Scripture on "Stuttering and Lisping" marks 
 
AILMENTS OF SCHOOL CHILDREN i8i 
 
 an epoch In the scientific diagnosis, treatment and prevention 
 of this distressing ailment. 
 
 Only 433 cases were reported by the physicians in all the 
 cities. 
 
 In Newark, the percentage of such cases among the 
 children examined is nearly 1.7. In Dunfermline, the per- 
 centage is about the same. Exceedingly few cases are men- 
 tioned In the 24 other cities outside of Newark. Probably 
 less than one per cent are affected the country over. We 
 place it .9 per cent, to give it definlteness. 
 
 This concludes physical defects according to our classi- 
 fication. A later table will show the percentages for all 
 the ailments, and the probable number of cases among the 
 elementary school children In all the cities taken together, 
 and comparing them with the cases actually reported. 
 
 There are undoubtedly very Interesting and important 
 individual variations among the cities In the number of cases 
 of the various ailments actually existent; but the personali- 
 ties, standards, equipments, and methods of the workers 
 in the school health service are at present so varied that 
 the real health variations can hardly be disclosed. This 
 remains for the future. Summit, Winchester, Montclair 
 and other cities of a suburban character should show very 
 different findings from Lowell, Hoboken, Jersey City 
 New Bedford and foreign factory cities generally. Such 
 sociological differences do not as yet appear. 
 
CHAPTER SEVEN. 
 COMMON NON-INFECTIOUS AILMENTS 
 
 B. Common Non-Infectious Ailments 
 
 1. ABSCESS^ BOILS, ETC. 
 
 This class of ailments is very infrequent and perhaps 
 should be placed with wounds, sores, etc. If properly cared 
 for by the nurse, boils, carbuncles and other similar infec- 
 tions may easily be classed with the other first-aid treat- 
 ments. Separate place is given here because it is mentioned 
 separately so many times in the reports of 12 cities. All 
 persons who have had these troubles can sympathize with 
 the children and realize that their lives can be filled very 
 full of suffering from such infections. The percentage of 
 cases is very low, probably near .2 per cent. Boston reports 
 314 cases, or .5 per cent of the elementary school enroll- 
 ment. 
 
 2. ACUTE SORE THROAT 
 
 Sore throat is quite common among children and as a 
 term is better than more technical ones. Perhaps both 
 laryngitis and pharyngitis, mentioned practically only by 
 board of health physicians, could also be included in this 
 term, although, in general, accuracy of diagnosis and de- 
 tailed statement mean more scientific procedure. 
 
 Sore throats are so closely associated with a number of 
 infectious diseases that in some towns, such as Montclair, 
 the nurse makes a practice of taking a swab from the 
 throat of almost every child severely affected. The child 
 is first temporarily excluded; the nurse goes to the home 
 with the child, takes the swab, and instructs the mother 
 in the care of the child. When the culture has been made 
 at the drug store or Board of Health office, the nurse knows 
 whether the child should be excluded and turned over to 
 
 182 
 
NON-COMMUNICABLE AILMENTS 183 
 
 the Health Department as a diphtheria or other case. Noth- 
 ing less than this procedure seems to be sufficient to exclude 
 incipient stages of several ailments which may easily become 
 centers of infection, out of school if not within. (The 
 researches of Dr. Chapin at Providence make it doubtful 
 whether there is very much spread of infection at school, 
 191 1 report.)* The frequency of the ailment will prob- 
 ably vary, as will most of the ailments in this class, more 
 than the physical defects, which seem to be remarkably 
 constant, depending more upon the weather, home and 
 school ventilation, and the like. 
 
 The percentage of cases during the school year is prob- 
 ably near .2. Boston has .5 and Newark .05 per cent. 
 
 3. BRONCHITIS 
 
 This ailment is quite infrequently reported or found. 
 Less than half of the cities mention It. Generally the case 
 is not found In school, and Is only reported after the child 
 has returned. It seems certain that an adequate and sci- 
 entific administration of this work will, by the way, neces- 
 sitate fairly complete health histories of the children in 
 school and out. The child who is absent with bronchitis, 
 for example, should be visited by the nurse and Inspected 
 on his return and a record of the ailment made. Common 
 ailments are now much neglected. If the school medical 
 service is ever to develop Into what it should become, a 
 preventive as well as a curative agency, the causes as well 
 as the cases of all these common ailments which so much 
 lower the vital efficiency of children will be matters of 
 careful study. 
 
 The frequency of bronchitis Is as follows : Boston, say, 
 300 cases (for the nurses undoubtedly found a number of 
 new cases), .5 per cent; Lowell, .2 per cent; Trenton, .1 
 per cent, and the others less. 
 
 The frequency is at least .1 per cent. 
 
 *See also Professor Jordan's article in the 1912 N. E. A. report 
 on School Diseases. 
 
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NON-COMMUNICABLE AILMENTS 187 
 
 4. CLEANLINESS NEEDED 
 
 The great enemy of health is filth, and, along with fresh 
 air, exercise, and nourishing food, cleanliness constitutes 
 one of the great preventive methods. Dr. Cruickshank, 
 in his 1911-12 Dunfermline report previously mentioned, 
 adequately sums up the matter (page 109) in these words: 
 
 "On looking through the report one cannot help being 
 impressed by the number of children suffering from dis- 
 eases which ought to be — which indeed are preventable. 
 And when we analyze the causes of the various diseases 
 and defects and seek some common factor operating in 
 every case we find it in the environment. But environment 
 itself is so complex that we must seek for some common 
 factors in it which specially influence the health of tender 
 child life. Of these factors there are several, but the most 
 important are dirt and foul air. hack of cleanliness, per- 
 sonal and otherwise, and absence of fresh air, are probably 
 accountable for more diseases than all other factors to- 
 gether. Frequently they are the direct cause, as in certain 
 inflammations of the eyes and skin, frequently the indirect 
 cause, as in many cases of malnutrition and tuberculosis." 
 
 The schools must fight filth as the arch-fiend. 
 
 The details regarding school baths, compulsory and en- 
 ticed cleaning, and the like will be set forth later. 
 
 Some of the cities do not mention this condition or ail- 
 ment; Boston mentions it in neither the health nor the school 
 department reports. None of the cities are equipped at 
 the schools for providing adequate school cleaning, and it 
 is a waste of energy to tell a child to bathe at home when 
 there is no bathtub there and his parents have never prac- 
 ticed this element of civilization, frequent bathing. Shower 
 baths and swimming pools are essential to the cleanliness 
 of the child population. Rigid treatment will in most cases 
 procure for the children clean underclothing and other gar- 
 ments, and the teacher can look out for faces and hands. 
 Some persons advocate hot and cold water wall-washbowls 
 in each class room not only for the purpose of aftording 
 drinking water by means of a sanitary drinking fountain 
 
1 88 SCHOOL HEALTH ADMINISTRATION 
 
 and water for drawing work and cleaning the blackboards 
 and watering flowers, but also to help develop the personal 
 cleanliness habit. 
 
 Great tact and care is, of course, required of the school 
 nurse and teachers, but the matter can hardly be overem- 
 phasized from the health standpoint. 
 
 Some of the frequencies for uncleanliness are as follows : 
 Summit, 2 per cent; Norwood, 1.3 per cent; Winchester. 
 .5 per cent; Montclair (estimate, 35 cases), i per cent; 
 Yonkers, .3 per cent; New Bedford, .2 per cent; Provi- 
 dence, .3 per cent; Jersey City, .2 per cent; Newark (45 
 cases), .2 per cent. This is an average percentage of .6. 
 
 Considering the fact that many cases are not recorded, 
 and that in some of these cities, such as Providence, the in- 
 spection covered only a part of, or very inadequately, the 
 elementary school population, and that these figures where 
 there were no examinations are based upon enrollment and 
 not average attendance, we should probably find that at any 
 one time from one to two per cent {say one) were in need 
 of immediate cleaning (bathing and clean clothes, not to 
 mention vermin) in order to make them sanitarily whole- 
 some members of a classroom. The physician in Summit, 
 in a first-class suburban city, found a higher percentage of 
 cases, I believe, because he was more sensitive to this condi- 
 tion, took a more energetic attitude toward the treatment 
 of such cases, or kept better records of the work done. The 
 physician who is director of hygiene at Cambridge has de- 
 vised a nozzle for a hose by which he washes down ten to 
 fifteen boys at a time to their and their teachers' delight. 
 
 We give below the summaries of two of the four tables 
 on Cleanliness given in the 1911-12 report of Dunferm- 
 line, Scotland: 
 
 Number of children examined, ages 4 to 14 and over, 
 
 999 boys and 828 girls. 
 
 Per cent. Per cent. 
 
 Boys. Girls. 
 
 Cleanliness, "Good. Above average percentage." 58.15 69.41 
 
 Cleanliness, "Medium. Average percentage." 37-73 29.35 
 
 Cleanliness, "Bad. Below average percentage." 4.10 1.23 
 
NON-COMMUNICABLE AILMENTS 189 
 
 The girls are cleaner than the boys, although, as shown 
 in other tables, with their long hair they suffer more from 
 pediculosis which may also be looked upon as uncleanliness. 
 
 Other tables show that boys are very much dirtier at 
 the age of eleven, than at any age before, while girls grow 
 cleaner. 
 
 Percentage of children marked "bad" as to cleanliness in 
 Dunfermline, Scotland, 1911-12. Children examined, 999. 
 
 Per cent. Per cent. 
 
 Boys. Girls. 
 
 Infants examined for first time, average age, 6 years. ... 1.62 1.22 
 
 Examined entering Senior School, average age, 8 years... 3.1 1.23 
 
 Third examination, 11 years 5.55 i.oi 
 
 Fourth examination, leaving school, 14 years 1.5 1 .... 
 
 The director of hygiene points out the fact, too, that 
 parents, on receiving the notice of, and the invitation to 
 the examination of their children get them in clean condition 
 for it. "Parents receive notice of the intending examina- 
 tion, and frequently prepare the children for it. The figures 
 returned from the School Medical Officer's examination 
 will therefore always show a condition of things better than 
 actually exists" (page 30). 
 
 If physicians and nurses in this country tabulated their 
 findings and made as careful studies of their children as 
 these figures indicate it is very probable that our larger 
 estimate of two per cent of all elementary school children 
 would not be too large. 
 
 5. CATARRH, CHRONIC RHINITIS, COLUMNS IO3-4 
 
 Chronic bad cold and "running nose," resulting from 
 sitting In school with wet feet, bad ventilation at school or 
 home, or some other single or combination of causes, is a 
 more serious and common ailment than Is generally realized. 
 Most of the cities that have much to report at all regarding 
 the health conditions of the children In general, and not 
 merely from one particular aspect, say Infection, report 
 some cases. The number of cases found will depend upon 
 the time of year the examination or the Inspections take 
 
I90 SCHOOL HEALTH ADMINISTRATION 
 
 place since many cases may remain undetected until bad 
 weather or other untoward conditions bring them out. 
 
 The Dunfermline report previously mentioned has this 
 to say regarding catarrhal conditions in connection with 
 adenoids: "Adenoids are clearly associated with catarrhal 
 conditions of the naso-pharnyx. As these conditions are so 
 very prevalent we must continue to expect large numbers 
 of children to suffer from this disagreeable and harmful 
 condition. It is quite probable, however, that pure air in 
 the schools, instruction in the use of the handkerchief, and, 
 when adenoids are suspected, the daily practice of nasal 
 respiratory exercises, would reduce the frequency of opera- 
 tion for this condition to a minimum" (page 35). 
 
 Some of the frequencies are as follows : Trenton, 2 
 per cent; Summit, 7 per cent; Hoboken, only 3 cases re- 
 corded; Rochester, with over 15,000 pupils examined, 
 records no case; Yonkers, i per cent; Cambridge, 2 per 
 cent; Newark records no cases and no other ailment whict^ 
 seems to cover this condition unless it could be placed with 
 adenoids, which is unlikely; Boston (327 cases), .5 per cent. 
 Here we have an average for the cities mentioning the 
 most cases an average percentage of .7. The frequency 
 must be almost that of cleanliness, one or two per cent, say 
 one per cent. How many cases the various cities missed, 
 judging that the actual variations as among cities is not 
 great, can be seen by comparing the figures given, reduced 
 to percentages, with this standard. Boards of Health, as 
 with most other diseases, have a bad showing. 
 
 6. BAD COLDS, CORYZA, COLUMNS IO5-I06 
 
 In this list are those severe, comparatively non-infectious 
 colds which are so frequent among children and which en- 
 tail such severe consequences. Probably all colds are more 
 or less infectious. Hoag, in his "Health Index of Chil- 
 dren," page 50, says they are the most infectious of all 
 ailments: "Colds are probably about the most contagious 
 form of disease we have, yet many, if not most people still 
 
NON-COMMUNICABLE AILMENTS 191 
 
 go on regarding them as due to drafts, getting wet, to 'night 
 air' and similar delusions. As a matter of fact anything 
 which is capable of reducing our resistance makes it easy 
 for cold germs to gain the ascendancy, but the cold is di- 
 rectly due to the germ or germs, and these causes should 
 not be confused with the predisposing factors." 
 
 Since "a cold can always be laid to someone else," as 
 seems probable, it should, perhaps, be treated as an in- 
 fectious disease of the minor group, instead of in this place. 
 We give place here for it, because no city of which I know 
 places it in the infectious group. I leave place for it also, 
 however, along with influenza and grippe. The future will 
 probably bring about a handling of "bad colds" the same 
 as other infectious ailments. 
 
 Nurses mention this ailment in but four cities and the 
 physicians in but one. Both the health and the school de- 
 partments record it as Coryza in Boston. The frequencies 
 are as follows: Norwood (50 cases), 3.2 per cent; Win- 
 chester (33 cases), 2.2 per cent; Montclair (108 cases), 
 2-2 per cent; Boston (400 cases), .7 per cent. 
 
 The average percentage of elementary children is, there- 
 fore, 2.7 per cent. Undoubtedly, the ailment occurred with 
 the same or greater frequency in all cities but was not re- 
 corded. The inadequate medical staffs found that they had 
 far more than they could do with the most serious and even 
 death-dealing diseases, to pay any attention to these minor 
 ones which so frequently bring on the greater. If we are 
 going to make medical supervision what it should be, a 
 means of scientific prevention as well as cure, however, these 
 cases of coryza or bad cold will receive attention and study. 
 
 Our estimate of this ailment, counting only cases which 
 should probably be out of school, or at least receiving care- 
 ful treatment, Is at the lowest, three per cent. It Is probably 
 not less frequent In high school. Rather Infrequent Inspec- 
 tion at the Montclair high school seems to show this. 
 
 These are regarded as separate and distinct cases, al- 
 though we have here an ailment which may come upon a 
 
192 SCHOOL HEALTH ADMINISTRATION 
 
 child more than once in a school year. Perhaps, too, not 
 less than three per cent of the school children are affected 
 with bad colds at some time in the year. Those experi- 
 enced in the classroom would probably place the estimate 
 very much higher. 
 
 7. EAR DISCHARGE, OTITIS MEDIA, RUNNING EAR, OTOR- 
 RHEA, COLUMNS 107-108 
 
 Here we have a serious ailment closely connected with 
 deafness and adenoids. Starting from bad colds and nasal 
 catarrh, along with adenoids and perhaps enlarged tonsils, 
 we get an inflammation which travels up the eustachian 
 tubes and sets up a suppuration in the middle ear which, 
 breaking through the ear drum, pours out along the channel 
 of the outer ear, a most distressing condition. If not cared 
 for the ailment may spread into the mastoid bone back of 
 the ear, making necessary operations for mastoiditis. 
 
 The treatment takes a long time, generally, and nothing 
 short of a first-class school clinic will meet the situation for 
 most children. Sixty-seven cases made 3,074 visits to the 
 school clinic in Dunfermline, Scotland, an average of about 
 46 visits each, and probably not all of these cases were cured 
 at the time of reporting. 
 
 A medical inspection system which neglects this ailment 
 Is either derelict In Its duty, or very far short of what the 
 school medical service should be. 
 
 Seven cities in this group of twenty-five have made no 
 record of such cases, either by nurses or physicians. Jersey 
 City records but 3 cases, excluded. About how many cases 
 there actually were can be estimated from the following 
 percentages : 
 
 Frequency of Ear Discharge among elementary pupils: 
 Summit, .6 per cent; Norwood, .2 per cent; Winchester, 1.8 
 per cent (27 cases) ; Montclair, .3 per cent; Schenectady, 
 2.2 per cent; Waterbury, .2 per cent; Yonkers, .8 per cent; 
 New Bedford (no cases), .9 per cent; Trenton (among 
 10,587 pupils examined only 7 cases) ; Cambridge (69 
 cases), .4 per cent; Providence, .4 per cent; Newark (24,310 
 
NON-COMMUNICABLE AILMENTS 193 
 
 children examined, only 31 cases), .1 per cent; Boston (425 
 cases, counting new cases found by nurses), .7 per cent. 
 Average percentage, .7 per cent. 
 
 Among 1,812 children ranging in age from four to 
 above 14, in Dunfermline, there were 37 cases of "purulent 
 discharge," and 15 cases of "old discharge," percentages of 
 2 and .8. This percentage of 2 seems to be about the num- 
 ber we should find here if we were to have more careful 
 examinations of all children. This will vary with the cities 
 somewhat, undoubtedly, but, I feel sure, much more because 
 of the differences in the doctors and nurses. Many of the 
 cases, moreover, have no actual discharge at all, and yet are 
 serious enough to cause partial deafness. 
 
 The 19 10 report of the Board of Education of England 
 on this subject (page 48) gives the following summary of 
 a table showing the relation of ear discharge to defective 
 hearing and adenoids and tonsils : 
 
 Number children with defective hearing, all ages 44i 
 
 Proportion of these cases due to: 
 
 Middle ear disease with discharge i4-0% 
 
 Middle ear disease without discharge generally associated 
 
 with enlarged tonsils and adenoids 65.7% 
 
 Ceruminous obstruction (ear wax) 20.1^ 
 
 99.8/0 
 
 According to this report, we should judge that about 80 
 per cent of deafness comes from this ailment. We found 
 that the probable proportion of defective hearing was about 
 one per cent. This would show that middle ear disease was 
 more frequent than one per cent. We do not have recorded 
 here the number of cases with no associated defective 
 hearing. 
 
 In the 191 1 report of the same health officer (Sir Geo. 
 Newman, London) we have another summary of several 
 tables, page 44, which throws more light on this ailment. 
 It is a report of the causes of deafness found among 1,265 
 children aged five, and 1,352 aged 12 examined, 2,617 
 altogether: 
 
194 SCHOOL HEALTH ADMINISTRATION 
 
 CAUSES OF DEAFNESS. 2617 PUPILS 
 
 Per cent. Per cent. 
 Age 5. Age 12. 
 
 Due to adenoids 78.4 52.0 
 
 Due to suppurative otitis media (ear discharge) 15.6 38.O 
 
 Due to suppurative otitis media and adenoids 5.8 lO.O 
 
 99.8 100 
 
 This shows a sUghtly different emphasis, showing per- 
 haps that back of it all are the adenoids. Since adenoids 
 are probably enlarged through neglected colds almost en- 
 tirely, we see here a serious chain of factors which must not 
 be overlooked by the school medical service. 
 
 In summary, we should say that this is a very serious 
 ailment, somewhat difficult of diagnosis, very hard to cure, 
 and taking a long time, and existent among from one to two, 
 say 1.5 per cent of elementary school children, more in the 
 the lower grades than in the higher. This is practically 
 Cornell's estimate given in his book, page 589. 
 
 8. EARS, MINOR AILMENTS, IMPACTED CERUMEN OR EAR 
 WAX, EAR ACHES DUE TO SEVERAL CAUSES, BUT FRE- 
 QUENTLY TREATED BY THE NURSES, FOREIGN 
 BODIES IN THE EAR, ETC. 
 
 We have maneuvered our nomenclature to bring otitis 
 media and the other ear ailments together. These other 
 ailments are minor but important. We have seen the influ- 
 ence impacted ear wax has on hearing, producing over 20 
 per cent of the cases according to the investigator quoted, 
 and the persistent earache, foreign bodies and small boils, 
 and the like are no small part of a child's life, meaning, if 
 nothing worse, absence from school or poor attention in it 
 in many cases. Most of the cases are cases of impacted 
 cerumen, although the Boston nurses reported 222 cases of 
 eczema of the ear to 229 cases of cerumen and 40 of foreign 
 bodies. The eczema and boils frequently come from scratch- 
 ing due to pediculosis and dirt, and consequent infection. 
 
 Only six cities mention these smaller ailments of the ears. 
 Winchester mentions only two cases ; Yonkers (say 80 cases) , 
 
NON-COMMUNICABLE AILMENTS 195 
 
 .6 per cent; Cambridge, .4 per cent; Lowell, .3 per cent; 
 Providence, 12 cases only; Boston (229 cases, eczema cases 
 put with eczema), .3 per cent. The average is .4 per cent. 
 These cities did not have physical examinations, so we may 
 understand that only a part of the cases among the entire 
 enrolled elementary school population were found. Half a 
 per cent (.5 per cent) seems reasonable for these minor 
 ailments. Careful records of the whole health history of 
 children will probably increase this percentage. We notice 
 as we go along that those cities having the names of these 
 ailments printed on the report forms get records of such 
 cases, while those that have a few names of ailments which 
 are very uncommonly met, e. g., tuberculosis, do not get 
 them. The medical officers do not look for the ailment, or 
 else fail to write it in. 
 
 9. ECZEMA 
 
 "Eczema is a non-contagious inflammation of the skin 
 caused principally, or altogether, by disturbance in nutri- 
 tion" (Cornell). There are many varieties, and many skin 
 ailments are called by this name which are not true eczema. 
 The ailment is handled chiefly by the nurses, and cared for 
 by them, either in giving treatments or in showing mothers 
 how to give them. In Newark, only the nurses mention this 
 ailment, but they record 9,857 cases as treated. Whether 
 this represents so many children we cannot say. 
 
 Frequencies: Summit, .9 per cent; Norwood, .5 per 
 cent; Montclair (55 cases), 1.4 per cent; Waterbury, .3 
 per cent; Yonkers, .8 per cent; New Bedford, .2 per cent; 
 Trenton, .3 per cent; Cambridge, .2 per cent; Lowell, .1 
 per cent; Providence, .4 per cent; Newark, 45 per cent;* 
 Boston (1,000 cases), 1.6 per cent (on 61,000 inspections), 
 I per cent on 100,000 inspections. 
 
 *A most astounding percentage, and probably meaning cases, with 
 several cases to a child than that not far from half of the children 
 examined had the ailment. The percentage would be also decreased by 
 half when we consider that the nurses covered all the elementary school 
 population, in a way, while the examination reached only about half. 
 Leaving this at 15 per cent would be very far beyond other cities. 
 
196 SCHOOL HEALTH ADMINISTRATION 
 
 The average percentage, excluding Newark, is .6 per 
 cent. The actual number of cases does not probably exceed 
 one per cent. Let lis say .7 per cent. 
 
 10. EYES, MINOR AILMENTS. SORE EYES, BLEPHARITIS, STYES, 
 IRITIS, CORNEAL ULCER, KERATITIS, FOREIGN 
 BODIES IN THE EYE 
 
 Here we have a host of comparatively minor and yet 
 serious cases of eye ailments, mostly of the external eye. 
 Some or most of these can be obviated, perhaps, by proper 
 glasses, thus avoiding eyestrain and lowered resistance. We 
 do not include here conjunctivitis of any kind nor trachoma, 
 since they properly belong in the infectious group, and must 
 receive different treatment. Blepharitis, or common sore 
 eyes, is found more frequently than any other in the group, 
 with styes a close second. 
 
 The frequencies are greater than for any ailment found 
 for some time, and the column showing the nurses' cases is 
 well filled, showing that the nurses have handled a good 
 many of them, and probably found many new cases not 
 found by the doctors. 
 
 Percentages of elementary school population or of num- 
 ber of children examined: Summit, 2.3 per cent; South 
 Manchester, .7 per cent; Norwood, only two cases; Win- 
 chester (16 cases), I per cent; West Orange, no cases; 
 Montclair (26 cases), .8 per cent; Hoboken (53 cases), 
 .6 per cent; Waterbury, .4 per cent; Yonkers (234 cases), 
 .2 per cent; Trenton, .3 per cent; Cambridge (54 cases), 
 .4 per cent; Lowell, 1.7 per cent; New Haven, .7 per cent; 
 Rochester, .3 per cent; Providence (203 cases), .7 per cent; 
 Jersey City recorded only excluded cases; Newark, .7 per 
 cent; Boston (1,116 cases), 1.8 per cent. 
 
 The average percentage is .8 per cent. 
 
 We get our surprises here from the cities that are sup- 
 posed to have physical examinations, much more careful than 
 inspections, but the examination cities excepting Summit do 
 not show up well in this case. Some of the cities report no 
 
NON-COMMUNICABLE AILMENTS 197 
 
 cases and these are either board of health cities or other cities 
 starting the work and not yet well established. 
 
 We should not expect Summit to have the largest pro- 
 portion of cases, since its environment is very good and 
 there is but a small foreign (Italian) section. We should 
 expect these ailments in the mill and factory towns such as 
 Hoboken, Jersey City, Lowell, New Bedford, Providence 
 and Newark. The cases were probably there but were not 
 found. 
 
 The same conservative judgment hitherto exercised 
 would lead us to estimate these ailments as existing in at least 
 1.5 per cent of the elementary children at some time during 
 the school year, and that the percentage of cases would be 
 about two per cent. 
 
 II. HEADACHE, NEURALGIA AND MIGRAINE 
 
 These are symptoms, of course, but they must be treated 
 as ailments by the nurses and often by the physicians because 
 of inability or lack of necessity of giving a thorough diag- 
 nosis. The eyes may be tested, the teeth examined, and the 
 nurse can have a talk with the mother about the child's diges- 
 tion and food, but even then the cause may be untouched. 
 
 Strangely, the physicians report the ailment more than 
 do the nurses, the latter in only three cities mentioning it. 
 Some of the frequencies are as follows: Summit, 1.4 per 
 cent; Winchester, 2 per cent; Montclair, 1.3 per cent; com- 
 paratively few cases in the following cities :Newark, .8 per 
 cent; Boston, .4 per cent. 
 
 The average is about 1.3 per cent. 
 
 For various reasons, we judge this proportion to be 
 actually about 1.5 per cent to 2 per cent, say, at least, 1.5 
 -per cent. Dr. Hoag reports very much higher percentages 
 among the rural schools of Minnesota, but his data are ex- 
 tremely poor, resulting from questioning pupils. 
 
 12. LARYNGITIS 
 
 Only five cities record over one case of this ailment. 
 In Winchester, the frequency is 1.4 per cent; in Mont- 
 
198 SCHOOL HEALTH ADMINISTRATION 
 
 clair, .3 per cent; Cambridge, .1 per cent; Providence, .07 
 per cent; Boston, .25 per cent. 
 
 The average for these cities is .4 per cent. 
 
 The ailment is so bound up with colds, sore throat and 
 the like, that it is bound to be very variable, perhaps. Never- 
 theless, both departments at Boston and a number of other 
 cities give it separate record, and this is probably best. We 
 leave it with an estimate of five in a thousand. 
 
 13. NOSE-BLEED, EPISTAXIS. 
 
 Children frequently have nose-bleed and do not know 
 how to stop it, using various nostrums and superstitious 
 charms instead of effective means for stopping the enervating 
 bleeding. 
 
 The nurses in Boston found 136 cases, a percentage of 
 less than .2 per cent. Perhaps the general proportion would 
 stand near this number, .2 per cent. 
 
 14. PHARYNGITIS, CHRONIC SORE THROAT, COLUMNS 1 2 1-2 
 
 We get our principal notice of this ailment, also, by both 
 departments at Boston. Only three other cities mention it, 
 yet it is a fairly common ailment of childhood. 
 
 Montclair had 12 cases reported, a percentage of .3 per 
 cent; Trenton, .2 per cent; Boston (175 cases, counting some 
 new ones found by the nurses), .3 per cent, or less. 
 
 With little further study, we leave the estimate for future 
 investigations to correct at .3 per cent — the ratio of cases 
 found to the elementary school population when all children 
 are carefully inspected and examined. 
 
 15. RHEUMATISM AND "GROWING PAINS" 
 
 Rheumatism is very serious because of its effect upon the 
 heart, and the so-called "growing pains" should be carefully 
 looked into. The ailment is fortunately not common. Only 
 three cities mention it. The frequencies are also very low. 
 One case in a thousand would probably be above the mark. 
 Closer examinations will probably show, however, that .1 
 per cent is not an overestimate of the actual number of cases 
 among elementary school children. 
 
NON-COMMUNICABLE AILMENTS 199 
 
 Every case should be carefully studied with a view to 
 cure and prevention. Heart disease probably arises in most 
 cases from an attack of rheumatism in childhood; and this 
 is one of the greatest death-dealing diseases, standing only 
 lower than tuberculosis. "It is impossible to cure organic 
 heart disease, but the study of its prevention becomes one 
 of the most important functions of the school medical serv- 
 ice." — Crulckshank. 
 
 16. SEX AILMENTS AND HABITS 
 
 Very few ailments of this character are mentioned, 
 largely because of the lack of searching examinations and 
 careful following-up of cases. Some nurses have done splen- 
 did work in this field of sex education, cure and prevention. 
 Some of the ailments mentioned are: Montclair, 2 cases of 
 masturbation and one of vaginitis found by a physician; 
 Cambridge, 9 cases of masturbation found by nurses in care- 
 ful follow-up work; the same number of cases found in 
 Providence of this harmful habit; and 91 cases of syphilis 
 found by the doctors in Boston. 
 
 These findings speak well for the purity of our children 
 and the homes, even though we may be sure, as is true, that 
 many cases were not reported for personal reasons and be- 
 cause this has not yet been recognized as a part of the duties 
 of the health officers. When we have careful inspection and 
 examinations and thorough follow-up work we shall discover 
 much needed evidence for emphasizing in some manner sex 
 education of the young. 
 
 The syphilis cases were 1.5 per cent of the children in- 
 spected in Boston. Only this one ailment is mentioned. In 
 the other cities, the percentages are less than one per cent. 
 
 Counting all cases actually present among the children 
 and including the habit mentioned, certainly not less than i 
 per cent are affected. 
 
 Cornell (page 554) emphasizes knowledge: "A thor- 
 ough knowledge of syphilis and gonorrhea . . . should be 
 gained by teacher and high school student. Then there will 
 be some hope of preventing these diseases. The salvation 
 
200 SCHOOL HEALTH ADMINISTRATION 
 
 of these weakly, Infected children depends largely upon the 
 recognition of the syphilitic cases by the school inspector."* 
 No prudishness or sentimental false modesty must stand 
 In the way of rooting out such ailments from the lives of the 
 children if possible. According to the old Greeks the wise 
 person is known by his hates and what he fights. Any study 
 of this ailment, brought upon the innocent as portrayed In 
 Ibsen's "Ghosts" and Brieux' "Damaged Goods," will 
 disclose a combatant, one of the most hideous and deadly of 
 civilized life. 
 
 17. MINOR SKIN AILMENTS: HERPES, SEBORRHEA, ACNE 
 (blackheads), SIMPLE RASH, POISON IVY, ETC. 
 
 The serious skin ailments are all given separate mention. 
 Here we have those frequent minor, non-infectious ones 
 which furnish the nurses with so much work In the form of 
 treatment and follow-up. Still certain cities do not mention 
 the ailments of this group at all. 
 
 The frequencies are as follows: Summit, .7 per cent; 
 S. Manchester, .6 per cent; Norwood, 4 per cent; Montclair 
 (27 cases), .8 per cent; Mt. Vernon, .3 per cent; Newton 
 (49 cases), .8 per cent; Hoboken (8 cases), Schenectady 
 (68 cases), .6 per cent; Waterbury, .3 per cent; New Bed- 
 ford, .3 per cent; Trenton, .4 per cent; Cambridge, .9 per 
 cent; New Haven, 3 per cent; Rochester (300 cases), 2 per 
 cent; Providence, .8 per cent; Newark, 1.7 per cent; Boston 
 (2,000 cases), 3 per cent. 
 
 The average Is 1.2 per cent, and the deviation is large 
 as In all cases where certain cities have left out all mention 
 of the ailment. 
 
 What the true percentage of new cases is we hesitate to 
 judge; but leave the very tentative estimate of 1.5 per cent. 
 
 18. STOMATITIS, MOUTH ULCERS 
 
 Boston Is the only city which emphasizes this ailment, 
 
 ^Cornell reports also that in institutions for the feeble minded 
 twenty per cent of the inmates are victims of sj^philis. 
 
NON-COMMUNICABLE AILMENTS 201 
 
 although there are four other mentions of it with only 7 
 cases. 
 
 Counting the number of cases which the nurses saw, 
 120, we have a very small percentage. The nurses of Bos- 
 ton probably covered the entire elementary school population 
 of nearly 96,000 which would give only a .1 percentage. 
 
 We leave the probable true number of cases at this 
 figure^ .1 per cent. 
 
 This ailment might be recorded with minor skin ail- 
 ments, or with malnutrition, but it will probably be best to 
 give it separate mention. McCombs, in his "Diseases of 
 Children for Nurses," page 99, says: "This disease is very 
 common among the poorer class of patients. It is due to 
 uncleanliness and to a spongy condition of the mouth seen 
 in ill-nourished children. There are several varieties named 
 according to the appearance of the lesions in the mouth." 
 
 In most cities the doctors and nurses evidently miss this 
 ailment. 
 
 19. wounds, sores, sprains, chilblains, poison ivy, 
 ^'first aid," dressings 
 
 Here we have a very common group of ailments where 
 the nurses can be of great assistance. Children are always 
 getting cut, bruised, hurt, and the like. Nose-bleed might 
 also go in this group. The nurse shows the child how to 
 apply principles of cleanliness and simple medicine and so 
 not only saves pain and possible infections or worse, but 
 educates the children in a very practical manner. 
 
 It can be seen that some doctors and nurses consider these 
 ailments within their province and some do not. Some also 
 may consider them too trifling to report. However, if 
 they take up time, and are worth doing, they are worth re- 
 porting; and this is the more general custom. 
 
 Eleven cities either give no mention or report exceedingly 
 few cases. Eight are board of education cities and three 
 are board of health. 
 
 The larger percentages are as follows: Norwood, 22 
 per cent; Winchester, 77 per cent; Montclair (187 cases), 
 
202 SCHOOL HEALTH ADMINISTRATION 
 
 5 per cent; Newton, 2 per cent; Hoboken (8 cases) ; Yonkers 
 (3 cases) ; New Bedford, .3 per cent; New Haven, 1.5 per 
 cent; Providence, 1.6 per cent; Newark, 14 per cent; Boston, 
 10 per cent. 
 
 These variations are extreme. Large perceentages mean 
 both a number of treatments of the same case, and real 
 soHcitude and care of the children, most probably. 
 
 The average for the percentages given is 15 per cent. 
 
 This number, taking all facts into consideration, may 
 probably represent fairly accurately the actual number of 
 new cases among the elementary school population in any 
 one year which need the attention of the nurses, and which 
 may come also to the attention of physicians. 
 
 20. URINARY AILMENTS, ENEURESIS, RENAL TROUBLE, FRE- 
 QUENT REQUESTS TO LEAVE THE ROOM, INCON- 
 TINENCE OF URINE 
 
 This weakness of children is quite common but does not 
 receive very frequent mention. Some selected percentages of 
 cities that seem to have had their attention drawn to this 
 ailment are: Montclair, .4 per cent; Cambridge, .2 per 
 cent; Providence, .06 per cent; Boston, .1 per cent. 
 
 For an estimate of little value, we place the average at 
 .2 per cent as the actual number of such cases. 
 
CHAPTER EIGHT 
 
 COMMUNICABLE AILMENTS, PARASITIC AND 
 INFECTIOUS 
 
 II. COMMUNICABLE, OR TRANSMISSABLE AILMENTS 
 
 Here we enter the second grand division of ailments 
 which are of a very serious character because they can 
 rapidly be passed from child to child. Serious doubt is 
 thrown over the old theory, that such diseases as Scarlet 
 Fever and Diphtheria are propagated and diffused princi- 
 pally at the schools, by Dr. Chas. V. Chapin, Superintendent 
 of Health of the city of Providence, Rhode Island (Annual 
 Report for 191 1 and former reports). His data, reaching 
 back to 1885, also throw reasonable doubt over the theory 
 that disinfection and certain forms of exclusion are neces- 
 sary in the case of such ailments. We very much need rigid 
 tests of all these old suppositions by scientific procedure, 
 and the whole subject bristles with unsolved or untouched 
 problems. The number of deaths caused by the more seri- 
 ous of these ailments is given elsewhere, both for the coun- 
 try, page — , and for the cities, table — , columns — .* 
 
 The living organisms causing these ailments are mostly 
 animals, but some are plants, ringworm and favus being due 
 to fungi. The animals vary in size from the large and 
 very common louse down to the itch-mite, almost too small 
 for the naked eye, and thence rapidly down to the micro- 
 scopic and almost undiscoverable germs, or bacilli, so well 
 described zoologically in such books as Hough and Sedg- 
 wick, "The Human Mechanism," and even Ritchie's 
 "Primer of Sanitation." 
 
 *See also the 1912 N. E. A. Proceedings, article by Professor Jor- 
 dan, of the University of Chicago. 
 
 203 
 
204 SCHOOL HEALTH ADMINISTRATION 
 
 A. Parasitic and Minor Infectious Ailments 
 
 For a long time the writer kept only the parasitic ail- 
 ments in this class. They are ailments which it is the 
 special duty of the nurses to drive out of existence as nearly 
 as possible. But conjunctivitis, impetigo, grippe, and ton- 
 silitis all seemed later to belong to this class more than to 
 the serious infectious diseases which may be death-dealing. 
 The advantages of such a classification need not here detain 
 us. Its value will come out by use, and will stand or fall 
 on how well it serves its purpose. 
 
 I. CONJUNCTIVITIS, PINK EYE. COLUMNS I37-8 
 
 The various forms of conjunctivitis are not differen- 
 tiated here. They are very infrequently separated in the 
 reports. The pupil's record card may well contain the 
 specific name, but for general reporting the single term is 
 probably best until the need arises for more detailed report- 
 ing. The most common form is, perhaps, the "pink eye" 
 which frequently plays such havoc with attendance in the 
 primary grades. 
 
 In the case of conjunctivitis, as with most infectious ail- 
 ments, some cities report only the excluded cases. For the 
 serious ailments this will be equivalent to the entire number 
 of suspected or actual cases, but this is not true for several 
 of the minor ailments. The parasitic ailment cases may all 
 remain in school with-proper precautions. 
 
 Some of the frequencies for conjunctivitis are as fol- 
 lows: — The first three cities, only three cases reported; 
 Winchester (15 cases excluded), i per cent; West Orange, 
 3 per cent; Montclair, 3 per cent; only 9 cases in the next 
 four cities; Hoboken, .8 per cent; Schenectady, 2.3 per cent; 
 Waterbury, .8 per cent; Yonkers, .4 per cent; N. Bedford, 
 .4 per cent; Trenton, i per cent; Cambridge, .5 per cent; 
 Syracuse, .9 per cent; Providence, .4 per cent; Newark, 
 1.6 per cent; Boston (1,526 cases), 2 per cent. 
 
 The average is 1.3 per cent. Seemingly, the more care- 
 ful and thorough the Inspection or examination, the closer 
 the percentage comes to two per cent, or more. 
 

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208 SCHOOL HEALTH ADMINISTRATION 
 
 We leave the estimate that nearly three per cent of the 
 elementary school children are probably affected with con- 
 junctivitis in any one school year. 
 
 2. FAVUS, YELLOW SCALP SORES, FUNGUS PARASITE 
 
 This ailment, while relatively infrequent fortunately, is 
 yet very stubborn in resisting cure. Fortunately, also, it is 
 not very infectious. 
 
 One of the best illustrations of the tremendous resistance 
 it offers to curative agents appears in the Dunfermline, Scot- 
 land, report for 1911-12, previously mentioned. Three 
 cases attended the school clinic for treatment during the year 
 283 times, an average of 94 visits each, and even after these 
 we have no statement of cure. 
 
 Some of the other averages for visits given in this re- 
 port for the ailments in this group may perhaps as well be 
 stated here : 
 
 No. of Aver. No. 
 
 Cases. Attendances, of Visits. 
 
 Conjunctivitis 46 455 10 
 
 Phyctenular conjunctivitis 15 320 21 
 
 Ringworm of scalp 26 337 13 
 
 Ringworm of body 7 53 7 
 
 Impetigo 223 1,127 5 
 
 Scabies, itch 22 150 7 
 
 Favus 3 283 94 
 
 The average number of visits of 2,058 cases treated at 
 this school clinic (14,493 visits) was seven visits. 
 
 The English Board of Education reports also point to 
 favus as being the most difficult in point of time of all these 
 ailments to cure. It can be seen that a nurse could treat 
 such an ailment almost every day of the school year, per- 
 haps, before effecting a cure. 
 
 Favus is rather uncommon and the frequencies are low: 
 Yonkers, .3 per cent; Newark (28 cases), .1 per cent. The 
 other cities stand below these figures. 
 
 Our estimate for all cities is .1 per cent, or one case in a 
 thousand. This is practically the percentage, also, for New 
 York City. 
 
COMMUNICABLE AILMENTS 209 
 
 3. IMPETIGO, OR IMPETIGO CONTAGIOSO 
 
 This contagious skin disease, frequently transmitted 
 through towels, perhaps, is characterized by several large 
 flat scabs, or pustules which break early and form crusts. It 
 most frequently appears on the face. 
 
 Some of the frequencies are: Summit, .5 per cent; Nor- 
 wood, 1.4 per cent; Winchester, 4 per cent; Montclair, 2 
 per cent; Hoboken, .4 per cent; Waterbury, 1.8 per cent; 
 Yonkers, .5 per cent; New Bedford, 1.6 per cent; Cam- 
 bridge, .2 per cent; Lowell, .8 per cent; Jersey City, .3 per 
 cent excluded; Newark, i per cent (nurses made 7,389 
 treatments, and perhaps found many more new cases) ; Bos- 
 ton, 2 per cent. 
 
 The average is 1.3 per cent. Impetigo is probably more 
 common than this figure represents. 
 
 The Montclair estimate of 2 per cent seems nearer 
 what may be found on careful examination of all elementary 
 children in each city. 
 
 4. INFLUENZA, GRIPPE 
 
 Boston is the only city which gave very much attention 
 to this ailment. Only six other cities mention it, with very 
 few cases, some of which were excluded from school. 
 
 The Boston percentage is .1 or .2. We cannot tell, for 
 sure. The inspection really covered the entire city, and 
 even the parochial school ailments are included. The num- 
 ber of children was about 90,000 to 95,000. This would 
 reduce Boston's percentages based upon the 61,000 inspec- 
 tions. For the inspected cases were picked out by the teach- 
 ers and nurses as suspected cases from the entire number. 
 
 We leave the probable number of cases actually present 
 in the elementary school population for any one year in 
 the average school system at a maximum of .1. This is 
 only a guess and the figure will very probably be changed 
 with further investigation. 
 
 5. PEDICULOSIS, LICE — BODY AND HEAD. COLUMNS I45-6 
 This is the most frequent ailment found in the schools, 
 with the exception of teeth. It can be said without qualifica- 
 
2IO SCHOOL HEALTH ADMINISTRATION 
 
 tion that no other school ailment takes up so much time 
 and money spent for doctors and, especially, nurses. It is 
 a national disgrace, of course, that this is true ; but it is only 
 by facing such facts that we shall eradicate them. Some 
 cities started medical inspection for the special purpose of 
 ridding the schools of this pest. The President of the Board 
 of Education at South Manchester told the writer that the. 
 plan was started in the hope that one year or two would 
 eliminate the evil entirely. After eight years, the ailment 
 is comparatively common, although reduced in frequency, 
 and limited to a few families. The real remedy for such 
 ailments lies in the homes. 
 
 A girl with long hair suffering from this ailment may 
 be treated and found free from pediculi or their eggs (nits) 
 and called cured, and yet in a week or two be found in- 
 fected again. This makes our number of cases much larger 
 than the number of children affected. Just how much the 
 percentages should be reduced for these considerations, we 
 cannot say. It is probable that a child should be counted 
 but once, no matter how many recurrences there are during 
 the school year. Each of the latter can be counted by the 
 nurse as inspected or treated, or both. 
 
 The percentages for the figures as recorded are as fol- 
 lows : Summit, ii per cent; S. Manchester, 4 per cent; 
 Norwood, 24 per cent; Winchester, 9 per cent; West 
 Orange, 4 per cent; Montclair, 10 per cent; Meriden, 7 
 per cent; Newton, 5 per cent; Brockton, 15 per cent; Ho- 
 boken, 4 per cent; Schenectady, 17 per cent; Waterbury, 
 37 per cent; Yonkers, 4 per cent; N. Bedford, 10 per cent; 
 Trenton, i per cent; Cambridge, 2 per cent; Lowell, 4 per 
 cent; New Haven, 14 per cent; Syracuse, 6 per cent; Roch- 
 ester, 2 per cent; Providence, 13 per cent; Jersey City, .7 
 per cent; Newark, 11 per cent; Boston, 12 per cent. 
 
 The average is 9 per cent. 
 
 The actual number of different elementary school chil- 
 dren afflicted with this ailment in any one school year is 
 certainly not over 5 per cent, or one In twenty, about two 
 pupils to every school room, some time in the year on the 
 
COMMUNICABLE AILMENTS 211 
 
 average. The entire difficulty illustrates the practical im- 
 possibility of getting accurate facts from these reports, as 
 they were then and are still made up. The number of cases 
 is astoundingly large, at any rate, and it is hard to believe 
 that on the average about five per cent of the elementary 
 school children have head lice at some time in each school 
 year. (Body lice are very infrequent.) 
 
 6. RINGWORM, TINEA, BODY AND SCALP 
 
 This is another ailment due to a fungus vegetable para- 
 site, and one which takes time and care to cure. Children 
 under strict supervision and regular treatment may be per- 
 mitted to attend school. The treatment in England, Scot- 
 land and Germany is more efficient than in this country. 
 The chief method of treatment there is by the X-rays. Diag- 
 nosis is made with the help of microscopic examinations. 
 The best reports of ringworm among school children are 
 found in the 19 10 and 19 11 reports of the Chief Medical 
 Officer of the Board of Education of England. 
 
 We may be sure that the ailment exists in every city of 
 any size, although we have cities in this list of twenty-five 
 that have made no mention of It. In Summit the cases are 
 not separated from other skin ailments. Scalp cases are 
 more difficult to cure, and this makes desirable separate 
 records of the two cases. The English report shows aver- 
 age length of exclusions from school for this ailment as 
 high as ten months. At Croyden, England, "the more se- 
 vere cases have been dealt with by X-ray treatment for 
 several years past, and the average time taken to complete 
 the cure of 425 children has been 73 days, I. e., approxi- 
 mately, 10 weeks." Bradford, England, seems to give the 
 best general handling and treatment of this ailment. Eigh- 
 teen cities or urban districts have X-ray apparatus at their 
 school clinics or have portable apparatus. In several places 
 ringworm classes have been established. This gives at once 
 isolation from other children, and a continuance of school- 
 ing. 
 
 In none of the American cities studied in this investlga- 
 
212 SCHOOL HEALTH ADMINISTRATION 
 
 tion has there been any special study and investigation of 
 this ailment, of which the writer has learned. 
 
 Some of the frequencies are : In the first five cities, 
 only lo cases given separate mention, six of whom were 
 excluded; Montclair (33 cases), i per cent; Meriden, .2 
 per cent; Hoboken (36 cases), .4 per cent; Yonkers (14 
 cases), .1 per cent; New Bedford (174 cases), 1.5 per 
 cent; Trenton, only 5 cases reported by one nurse, probably 
 15 in all, .1 per cent; Cambridge, .1 per cent; Providence, 
 .2 per cent; Jersey City (38 cases excluded), .1 per cent; 
 Newark, 3,209 cases excluded and treated by nurses, 13 
 per cent (doctors' cases, 162, or .7 per cent) ; Boston, 504 
 cases, .6 per cent. 
 
 In Newark, the supposition is that 13 per cent does not 
 represent the number of different children affected, but the 
 number of exclusions, many children probably having been 
 excluded more than once. 
 
 The average percentage seems to be near .4 per cent. 
 Any estimate of the actual number of new cases found or 
 to be found in any one school year, not counting any child 
 twice, is precarious. Probably .4 per cent, or 4 cases in a 
 thousand would be near the truth. 
 
 7. SCABIES, ITCH 
 
 The folk term, "slow as the seven years' itch," indicates 
 what has been the character of this ailment In the past. 
 Now, with sulphur ointment and baths and boiling or bak- 
 ing of clothing, the ailment can be killed in a few days. If 
 care is not taken to kill off every itch-mite burrowing along 
 or resting In the skin, the ailment may, however, last in- 
 definitely. In the minds of many physicians the ailment is 
 associated with promiscuous sex relations but, as In the case 
 with venereal diseases, the innocent are not immune and are 
 frequent victims. As with pediculosis, constant scratching 
 and marks of scratches on the body or in the web between 
 the fingers, are common indices. Many cities now keep 
 sulphur ointment for cure and furnish prescriptions, as in 
 the cases of vermin and other parasitic ailments. 
 
COMMUNICABLE AILMENTS 213 
 
 The ailment is even more common than ringworm, and 
 very much more distressing to the children afflicted. Some 
 of the frequencies are as follows: Only 8 cases given 
 separate mention in the first three cities; Winchester (12 
 cases excluded), .8 per cent; Montclair, .4 per cent; Mt. 
 Vernon, .2 per cent; Hoboken, .2 per cent; Schenectady, .2 
 per cent; Waterbury, .1 per cent; Yonkers, .12 per cent; 
 New Bedford, i.i per cent; Trenton, .1 per cent; Cam- 
 bridge, .2 per cent; Syracuse, .3 per cent; Rochester, .2 per 
 cent; Providence (158 cases excluded), .5 per cent; Jersey 
 City, .04 per cent excluded; Newark, .8 per cent excluded; 
 Boston (648 cases), .8 per cent. 
 
 The average number of cases or exclusions is almost .5 
 per cent. The average number of cases among the ele- 
 mentary school population in any one year, counting no case 
 twice, is probably not far from four in a thousand, and per- 
 haps five, say five. The variation is perhaps from about 
 2 to ten in a thousand, although, as we have found it, the 
 variations among physicians and nurses exceeds, and so 
 covers up, the probable variability of cities. 
 
 8. TONSILITIS, QUINSY 
 
 This is generally a rather mild ailment, but may easily 
 be confused with the beginnings of several of the infectious 
 diseases; so it is treated almost as rigorously as if it were 
 a suspected case of diphtheria. The Chicago Board of 
 Health rule is: "Cases of tonsilitis must be excluded on 
 the clinical evidence alone, and throat cultures made for 
 further diagnosis." It is possible for school purposes that 
 the ailment may be placed with "sore throat" cases, since 
 the treatment is practically the same. Where doctors and 
 nurses are sure that the case is tonsilitis and not some other 
 form of sore throat, probably infectious, we have a situation 
 where it is better to have separate mention of the ailment. 
 
 The ailment is an inflammation of the tonsils which may 
 become an abscess. The latter, by breaking while the pa- 
 tient is sleeping, may, according to Dr. Ditman (Home 
 Hygiene and the Prevention of Disease), cause suffocation. 
 
214 SCHOOL HEALTH ADMINISTRATION 
 
 The abscess should be opened by a physician. The preven- 
 tion is along the line of preventing colds, keeping up the 
 resistance, and removing enlarged tonsils. 
 
 A few random frequencies among the elementary school 
 populations are: Montclair, 1.3 per cent; Hoboken, .7 
 per cent; Yonkers, .15 per cent; New Bedford, .6 per cent; 
 Trenton, .2 per cent; Cambridge, .4 per cent; Rochester, 
 .15 per cent; Jersey City, ,06 per cent; Newark, 1.4 per 
 cent; Boston (1,200 cases), 1.3 per cent. 
 
 The average is .76 per cent. 
 
 The actual number of new cases among the elementary 
 school population during any one school year is probably 
 not less than one per cent. This is our estimate. Most 
 cities simply have not found or have not recorded all cases. 
 Less than a half per cent would certainly indicate this. 
 
 We have now completed our survey of minor infectious 
 and parasitic ailments. Mulloscum contagiosum is a very 
 uncommon ailment belonging to this group, but is not given 
 separate mention, only 10 cases having been found in one 
 city, Newark. Hookworm is another serious ailments of 
 this class that should be included wherever the ailment is 
 found, and it seems rather widespread, from reports of 
 Rockefeller Institute. 
 
 B. Infections Diseases 
 
 Here we come to those diseases which started medical 
 inspection by health departments in cities, in the effort to 
 control the causes of death among the young. Beginning 
 here, the study of causes and prevention has led to the dis- 
 covery of a host of previously unrecognized ailments which 
 are only indirectly, if at all, death-dealing. Present studies 
 seem to show that the school is a very slight factor in the 
 spread of infectious ailments, contrary to the long accepted 
 opinion; and, moreover, it is surprising how small a per- 
 centage of the actual cases are found in the schools before 
 they are found and isolated by the parents or family phy- 
 sicians. It must be remembered in this list that many of 
 the cases reported or excluded are only suspected cases, and 
 
COMMUNICABLE AILMENTS 215 
 
 that a further large number of children have been excluded 
 because they lived in the same family or same house as those 
 ill. An interesting and needed study is the comparison of 
 the number of cases reported by boards of health and the 
 numbers found which actually prove to be cases by the 
 school medical service. Another dangerous factor is the 
 disease carrier, a child healthy but carrying and distributing 
 deadly bacilli. 
 
 We should expect that those inspectors and nurses under 
 boards of health would make a better showing in the field 
 we have now entered than the board of education medical 
 workers, for some of them have done little else than look 
 out for and report suspected infectious cases. Let us see. 
 
 In the table, excluded cases are marked X, merely sus- 
 pected cases where so reported are marked with a ?. 
 
 I. CHICKEN POX, VARICELLA 
 
 Summit school health officers found no cases of in- 
 fectious or suspected infectious diseases In the schools dur- 
 ing the year, so far as I could learn from the superintend- 
 ent and physician. Many cases actually occurred, however, 
 and the schools learned of them through reports of the 
 Board of Health. In the writer's opinion, infectious dis- 
 eases are a most important part of school health records 
 whether cases are found in the schools or not. The number 
 of cases of these ailments and the number of deaths of chil- 
 dren of school age in each city are given in the tables. 
 
 Eight children were recorded as having had treatment 
 in Norwood, .7 per cent of the elementary school children; 
 Winchester, 1.3 per cent; West Orange, .7 per cent ex- 
 cluded; Montclair, i per cent; Meriden, .2 per cent; Mt. 
 Vernon, only one case excluded; Newton, .4 per cent prob- 
 ably excluded; Hoboken, .3 per cent; Trenton, with a large 
 medical force, comparatively, and over 10,000 examinations 
 and 8,000 special inspections, and 3,400 inspections by 
 nurses, found only one case of chicken pox in the schools; 
 Cambridge, 1.5 per cent; no cases reported by either Lowell 
 or New Haven, the latter under the Board of Health; 
 
2i6 SCHOOL HEALTH ADMINISTRATION 
 
 Syracuse, .2 per cent; Jersey City, .06 per cent; Newark, .9 
 per cent (better reduced to .5 per cent by using not the 
 number examined but the entire elementary school enroll- 
 ment, perhaps, as explained elsewhere) ; Boston (based on 
 elementary school enrollment, not on number of inspections 
 of special cases, counting 500 cases found by both doctors 
 and nurses), .5 per cent. Several cities have been left out, 
 as usual, because the cases found were so few. They are 
 not representative. 
 
 The average frequency of suspected, or actual, cases 
 found in the schools according to these summaries is .6 per 
 cent. 
 
 This, perhaps, is near the actual number of cases. We 
 cannot tell. Many of the cases found are children who 
 have returned, in the opinion of doctor or nurses, too early. 
 
 2. DIPHTHERIA 
 
 This dread disease is well known, but science is gaining 
 control over it. The most remarkable decreases in fatalities 
 from any disease are shown for this ailment and typhoid. 
 The 19 1 1 Board of Health report for Boston (pages 
 182-3) shows that in 1878 and many years later the ratio 
 of deaths to number of cases was nearly half, and not as 
 low as one out of three dying until 1889. But since 1907 
 the percentages have ranged around 6 per cent, or about 
 one out of fifteen or sixteen cases ill. 
 
 Still there were 2,081 deaths from this disease in 19 10, 
 so it is yet a very real terror. 
 
 Fewer cases or suspected cases of this ailment were 
 found than in the case of chicken pox, 17 cities giving 
 practically no mention of it. The most interesting struggle 
 with infectious diseases in any of the cities during the years 
 studied, was probably that in South Manchester. There 
 were three epidemics; one of diphtheria, one of scarlet 
 fever, and another of measles. The school physician was 
 paid an extra hundred dollars to inspect almost all the 
 children in the school system once a week for six weeks. 
 (See 19 1 1 report.) The health department and the school 
 
COMMUNICABLE AILMENTS 217 
 
 officials did everything possible but the epidemics continued 
 almost as if nothing were being done. Here we have a 
 very severe test of school medical inspection. 
 
 One thousand six hundred and ninety-three days were 
 lost from school by 65 pupils ill with diphtheria, and 1,666 
 by 73 others quarantined because of exposure, a total of 
 3,359 days (number excluded, 138). For scarlet fever 
 other pupils exposed, 2,728 days, a total of 4,731 days. 
 there were lost by 75 children ill, 2,003 days, and for 71 
 Diphtheria occurred in 67 families and scarlet fever in 65. 
 
 In the Inspections, 585 cultures were taken, of which 
 143 were reported positive. Some carriers were found. 
 These tend to show that the number of cases might have 
 been greater had there not been the extraordinary inspec- 
 tion. On the whole, however, it shows the probable limita- 
 tions of school inspection. The schools were not closed 
 during the epidemics, as would be the cases in many cities 
 so stricken. Three children died of diphtheria. At the end 
 of the year it was found that the promoted pupils had lost 
 on an average 32 of the 186 school days, while the non- 
 promoted pupils lost 52 days, a difference of six and ten 
 weeks. How much was due to the absence, or from the 
 absence for any one cause was not worked out. 
 
 The President of the Board of Education, also a member 
 of the State Board of Education of Connecticut, estimated 
 the cost to the schools of the diphtheria and scarlet fever 
 cases at $2,500; these and lesser infectious diseases like 
 measles, at $5,000, all as "ineffective expenditures." And 
 "we cannot estimate the cost to individuals, but assuming 
 that the serious diseases cost the parents even so low an 
 average as $25.00 each, and the milder ones $10.00, the 
 direct burden would be In excess of $5,000. If to this were 
 added the expenses of the health officer, and wages lost by 
 quarantines, we are certainly within the truth in affirming 
 that the sum of the expenses of the town and individuals 
 incidental to contagious diseases was not less than $12,000, 
 and may easily have been $15,000." 
 
2i8 SCHOOL HEALTH ADMINISTRATION 
 
 The Superintendent's reasoning on the cost of these ail- 
 ments is shown in the following paragraph: 
 
 "The total time lost by children who were excluded for 
 the two diseases was 8,090 days. This was equivalent to 44 
 school years for one pupil or 44 children lost one year's 
 schooling. Last year it cost $35.28 to promote one pupil 
 one grade. The 44 years of time lost had a money equiva- 
 lent of $1,552. If to this sum should be added the time 
 lost by the children where parents kept them from school 
 through fear of contagion, and those who were absent sev- 
 eral days awaiting the report of cultures, it is probable that 
 the sum would be about $2,500 in time lost by children 
 absent from school. To this must be added the time con- 
 sumed by teachers in attempts to bring the absent pupils 
 back to grade which always contains an element of loss to 
 the pupil who attends regularly and who loses some portion 
 of the teacher's time expended upon the irregular pupil. 
 . . . There were three deaths from diphtheria, a loss to 
 parents which cannot be computed in money and in which 
 they have the sympathy of the whole community." 
 
 We give a page or so to the Manchester experiment to 
 show the loss of this and other such ailments to a com- 
 munity; to indicate the limitations in even a small city on 
 health control; and to point out a statistical fallacy which 
 has become very frequent in school reports since Ayres' 
 publication of such fiscal studies, also fallacious. 
 
 On the second point, Mr. Cheney urges a contagious 
 hospital for the town, and to the writer suggested the very 
 great need of state-pay for laborers who were quarantined 
 in order that effective quarantine may be obtained. "The 
 infectious ailments spread in the mills, principally, and on 
 the streets, and not so much in the schools," he said. 
 
 This points out one of the most important problems of 
 medical Inspection — that of preventing the spread of infec- 
 tious diseases outside of the schools, on the streets and in 
 the backyards where children play, and also in the mills 
 and stores where children, youths and adults work. It is a 
 nice problem for real investigation. 
 
COMMUNICABLE AILMENTS 219 
 
 The fiscal fallacy Is in computing the cost of retardation 
 and school absence without any regard to the economic laws 
 of diminishing expense. 
 
 Illness, exclusion, and quarantine absence can be rela- 
 tively accurately computed; and, with great care, some 
 notion of the effect these absences have upon retardation 
 can be ascertained; the costs to parents and other such items 
 can be worked out; but the loss to a school system in money 
 from either absence or retardation cannot easily be dis- 
 covered, and has not yet been done. School rooms are not 
 very often used to their full capacity all the time. The 
 pupils of any building who fail in any one year, can usually 
 be accommodated in the same building. Promotions are 
 made somewhat upon the basis of the number of vacant 
 seats to be in the room above. Pupils in the upper grades 
 of crowded districts are frequently sent to other schools 
 where there are uncrowded class rooms. A number of chil- 
 dren fail at each annual promotion, and yet no new teachers 
 are employed for the building, no extra heat or janitor 
 service is used, very little extra is spent for supplies. The 
 cost of retardation or of absence almost disappears in the 
 situation. How much the school system is increased by the 
 damning up process of retardation, i. e., how many more 
 teachers and rooms are necessary, has not yet been dis- 
 covered. 
 
 All the statistical studies of this kind, on the Ayres' plan, 
 go on the assumption that the situation is the same as If all 
 the children failing of promotion each year were put off 
 into separate buildings from the main system. Thus Cleve- 
 land reports (1911 Report) an appalling loss of school 
 money due to retardation. The method Is that of multiply- 
 ing each year of retardation by the per capita cost of the 
 schools. Such figures may have some pragmatic value in 
 obtaining public support, but they are undoubtedly very far 
 from the truth. The law of diminishing expense would 
 show that the "wasted expenditures" were probably quite 
 small. So that we must be very careful In computing the 
 
220 SCHOOL HEALTH ADMINISTRATION 
 
 money cost of illness absence. The most important losses 
 here are other than financial. 
 
 FREQUENCY OF DIPHTHERIA 
 
 South Manchester, 4.2 per cent; none of the other cities 
 have more than one to four cases until we come to New 
 Haven with 164 cases, .7 per cent; next three cities with no 
 more than four cases; Jersey City, .1 per cent; Newark, 
 .1 per cent; Boston (nurses reporting 752 cases), .8 per 
 cent of total elementary enrollment. The total number of 
 cases in the city of Boston in 19 10 was 2,453. 
 
 The average of these cases would be relatively insig- 
 nificant. The general tendency can hardly be told from 
 these figures. The average is, however, .1 per cent. The 
 number of cases, or suspected cases, is very small compared 
 with the total number of cases among school children. 
 
 In New Bedford, for example, in the year 19 10 no sus- 
 pected cases, even, of diphtheria were found in the schools 
 by the medical inspectors, but there were reported to the 
 other division of the Board of Health 96 cases with 24 
 deaths. The inspectors did find 5 suspected cases of measles 
 or children who had returned too early; but there were re- 
 ported to the contagious disease division 697 cases and three 
 deaths. Likewise the school inspectors found 7 cases or sus- 
 pected cases of scarlet fever in the schools, while there were 
 reported to the board of health from the homes 246 cases 
 and 5 deaths. All of these persons with the ailment prob- 
 ably were not school children and ages are not given by ail- 
 ments, but a very large proportion undoubtedly were. We 
 leave it with an estimate of 12 cases in a thousand to be 
 found in a school. All cases among school children should 
 however be recorded on the school card. 
 
 3. MEASLES 
 
 This ailment is very much better reported. The death 
 rate, too, is very much lower; 1,112 cases are reported by 
 doctors and 214 cases by nurses in all the cities, a percentage 
 of the entire elementary school population, counting 1,200 
 
COMMUNICABLE AILMENTS 221 
 
 cases of all the cities, amounting to about .3 per cent. The 
 variations are from zero in seven cities to 5.6 per cent in 
 Meriden. The latter included suspected cases of German 
 
 measles. 
 
 The probable frequency of cases actually present in a 
 school year in an average city is perhaps around .4 P^r cent. 
 
 Any study of reports shows consternation and surprise 
 on the part of superintendents that medical inspection and 
 examination has done so little in controlling this ailment. It 
 simply shows that in this respect as in many others the 
 school must reach out into the home and other phases of 
 life in order best to serve the children. 
 
 Another point is, too, that very little is yet known 
 regarding children's diseases. Medical schools do not 
 emphasize the subject and most medical research has been 
 in other fields. 
 
 4. MUMPS 
 
 Of this ailment only 671 cases or suspected cases are 
 reported by physicians and 1,388 cases by nurses, the Boston 
 nurses contributing nearly all of these, 1,344 cases. (Bos- 
 ton then had 35 nurses and now 46.) The ratio to the 
 entire elementary school population in all cities is (counting 
 1,400 cases) .3 per cent plus, a little more than for diph- 
 theria. 
 
 No city stands out here, except perhaps the nurses' cases 
 in Boston, 1.5 per cent. How many of these were duplicates 
 we know not, since the Boston report gives only bare sum- 
 maries. Some of the other frequencies are: Newark, .2 
 per cent plus; Rochester, .08 per cent; Yonkers, .8 per cent; 
 Hoboken, .08 per cent; Meriden, .3 per cent; Montclair 
 (nurse, 22 cases), .7 per cent; West Orange, .3 per cent. 
 
 The average is about .4 per cent, about 4 cases among a 
 thousand pupils in a school year. 
 
 5. SCARLET FEVER 
 
 The total number of cases in all cities reported by school 
 doctors is 832 and by nurses 676, nearly all of which were 
 
222 SCHOOL HEALTH ADMINISTRATION 
 
 furnished by the Boston nurses. Probably the only places 
 where cases were duplicated by the nurses' reports are 
 Syracuse, Providence and Boston. Subtracting a hundred 
 cases for this and we have left at least 1,408 cases among 
 an elementary school enrollment of more than 414,000, 
 making a frequency of .3 per cent plus. Some of the fre- 
 quencies are: South Manchester, nearly 5 per cent; Win- 
 chester, I per cent; New Haven, 2 per cent; Jersey City, 
 .2 per cent; Newark, .05 per cent on total elementary enroll- 
 ment; Boston, .6 per cent. 
 
 The average for these higher cities is over i per cent. 
 We leave the frequency estimate at .4 per cent as a mini- 
 mum ratio. 
 
 6. TRACHOMA, GRANULATED EYE-LIDS 
 
 Of this terrible ailment, so guarded against at our ports 
 of entry for immigrants, there were reported by the in- 
 spectors 281 cases in all cities, and 104 cases by the nurses. 
 Subtracting 75 cases from the combined sum we have left 
 probably 310 cases, about .08 per cent, not far from one 
 case in a thousand. 
 
 Summit had .2 per cent nearly; Mt. Vernon, over .1 per 
 cent; Yonkers (70 cases), .5 per cent; New Bedford, .1 
 per cent plus; Cambridge, .1 per cent; Jersey City, .07 per 
 cent; Newark (100 cases treated), nearly .2 per cent. 
 
 We leave the estimate at .1 per cent, or one case in a 
 thousand. Cities reporting fewer cases than this conserva- 
 tive estimate very probably haven't found the cases. The 
 cleanest little cities have cases of the ailment. Yonkers, as 
 with almost all the ailments, shows very high percentages, 
 abnormally so in some cases. The indications are that per- 
 haps no city more needs an enlarged force of doctors and 
 nurses. Those in authority have said, however, that Yonkers 
 is such a nice town that much medical service in the schools 
 is not needed. The number and character of the ailments 
 point in the other direction. 
 
 7. PULMONARY TUBERCULOSIS, CONSUMPTION, PHTHISIS 
 
 This ailment is surprisingly uncommon among school 
 
COMMUNICABLE AILMENTS 223 
 
 children when the large number of adults having it are 
 taken into consideration. A number of the cities had, and 
 more now have, open air schools for anemic children and 
 those with tubercular symptoms or tendencies. Probably 
 the most complete reports of such work occur in the South 
 Manchester, Cambridge and Newark reports. The von 
 Pirquet skin test with tuberculin is used in several places 
 to assist the doctors in diagnosis. There was much hope 
 that the Friedman antitoxin would prove a radical remedy 
 and make possible the rapid cure of all such cases. The 
 open air schools would still have their place, however, for 
 weak, anemic, poorly nourished children can best be fed and 
 cared for in such a school. The great need is, of course, 
 more fresh air and outdoor life for all schools. What is 
 good for a few afflicted, is good, and can be provided, for 
 all, so far as air is considered. Open window schools are 
 growing in numbers. A lowering of the temperature of 
 heating coils In the fan rooms, so that air will not be baked 
 and made over-sultry, is also very much to be desired, and 
 will give more nearly outside conditions. Moistening the 
 slightly heated (not much over 60 degree) air, is also neces- 
 sary in forced systems to complete more nearly the supply- 
 ing of the best outside conditions. 
 
 Probably 420 cases of suspected cases of pulmonj>ry 
 tuberculosis were found in the 25 cities, a percentage of 
 .1 per cent. Montclair had about 44 children In her open 
 air school, but the number responding to the tuberculin test 
 is not given. It Is very difficult to tell, and It is not perhaps 
 important to tell exactly, how many children in the schools 
 actually have pulmonary tuberculosis. It is not very hard 
 for the experienced physician or nurse to pick out those chil- 
 dren who run a very great chance of getting it and dying 
 from it before they are thirty years of age. If conditions 
 can be so modified that no actual cases may be found, a very 
 great deal In the essential work of prevention may be done. 
 Here is one of the principal places where the nurse's work 
 for home hygiene counts In the best way. School feeding 
 Is very Important; good home feeding is better If It can 
 
224 SCHOOL HEALTH ADMINISTRATION 
 
 be secured. Home ventilation, cleanliness^ a chance to 
 play out-of-doors, comfortable clothes, no over-work or 
 home study, decent treatment, plain nourishing food, and 
 the remedying of physical defects and ailments : all these 
 come within the province of the modern school nurse in the 
 service of the coming generation. 
 
 8. TUBERCULOSIS OF BONES, JOINTS, AND OTHER PARTS OF 
 
 THE BODY 
 
 Enlarged glands, when they are found tubercular, may 
 be placed in this group. Pott's disease is a common name 
 for tuberculosis of the spine, the ailment which causes the 
 hunch-back. Fortunately this form of tuberculosis is very 
 infrequent, only about 50 cases being reported in all the 
 cities, about .01 per cent. Cambridge reports 27 cases, 
 nearly .2 per cent; and Trenton has a showing of 18 cases, 
 or over .1 per cent. If all the cases existing were actually 
 found the percentage would not be far from .1 per cent in 
 all cities. We leave it as about that sum. 
 
 9. WHOOPING COUGH, PERTUSSIS 
 
 This is quite a common ailment and frequently the cause 
 of death. It is one of the greater /iw^-killers of all school 
 ailments, the period of exclusion being so long. There was 
 a combined number of 693 cases reported in all cities of 
 which probably 133 were duplicates, leaving 560 cases, a 
 frequency of over .1 per cent (.13 per cent). Nine cities 
 do not mention the ailment, five boards of education and 
 four boards of health. It would seem that the latter would 
 give especial attention to this infectious ailment. Some of 
 the frequencies are: Winchester, .6 per cent; Montclair, 
 .7 per cent; Meriden, .5 per cent; Hoboken, .2 per cent; 
 Providence, .07 per cent; Jersey City, .07 per cent; New- 
 ark, .14 per cent; Boston, .3 per cent. 
 
 The higher percentages average ,3 per cent. 
 
 The probable number of children in the schools during 
 the school years is perhaps above even this figure. But we 
 
COMMUNICABLE AILMENTS 225 
 
 leave the probable percentage at .2 per cent of the ele- 
 mentary school children, or two in a thousand. 
 
 SUMMARY OF ALL 54 AILMENTS 
 
 We have now come to the end of a long, hard journey 
 through the ills of childhood. We have tried to look facts 
 in the face and see what these ailments are, how frequent 
 they are, how various cities do their duty by the ailing chil- 
 dren, and we have also endeavored to develop tentative 
 standard percentages which may be the start toward coefi- 
 cients which will prophesy as accurately as insurance tables 
 about how many of these various ailments we may expect 
 in a school population, and how far below the normal vari- 
 ous cities pass. 
 
 The various percentages are collected on a later page. 
 The deaths from these ailments will also be given, as well 
 as a summary of the exclusions. We do not enter into the 
 laborious task of testing each city by these percentage stand- 
 ards to determine its relative standing. If anyone cares to 
 do this the figures are given for it. Rigorous comparisons 
 are perhaps not now needed so much as ideals, norms, and 
 efficient methods of administration. 
 
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CHAPTER NINE 
 
 SPECIAL PHASES OF MEDICAL INSPECTION IN 
 THESE CITIES 
 
 In preceding chapters we have attempted to describe 
 and evaluate the general administration of medical inspec- 
 tion, the work done, and the ailments or disorders found 
 among the school children of these cities, especially those 
 of the elementary schools. In this chapter it becomes our 
 problem to set forth briefly some of the good features of 
 these various medical inspection systems which are some- 
 what in the nature of departures from the simple inspection 
 and examinations by doctors and nurses. Here we shall 
 abandon the method of analyzing the data strictly by cities, 
 and treat the problem on the basis of topics or phases em- 
 phasized. Some of the most important of these phases are : 
 the methods of getting treatments and the starts toward 
 school clinics, the various preventive methods carried on 
 by this department, the examinations of children for work 
 certificates, and the various more or less scientific investiga- 
 tions of the work carried on by the departments themselves 
 or by other school officials. 
 
 I. TREATMENTS AND SCHOOL CLINICS 
 
 The special methods of procuring treatments adopted 
 by medical inspection systems in these cities are both private 
 and public. The schools carry on and pay for certain work, 
 and also encourage or permit a good deal, but not enough, 
 voluntary assistance by private organizations and individ- 
 uals. The ideal towards which the schools seem every- 
 where to be directed more or less vaguely Is that of a first 
 class school clinic accessible to every child and free to every 
 child who wishes, or whose parents wish him to take advan- 
 tage of free diagnosis and treatment, with the further pro- 
 
 228 
 
PHASES OF MEDICAL INSPECTION 229 
 
 vision that every child hi a school system must either pri- 
 vately or publicly be placed in good physical condition, and 
 that there can be no escape from this provision. Com- 
 pulsory education seems absolutely to involve com- 
 pulsory health and the most economical way for a com- 
 munity to provide adequate diagnosis, prevention and con- 
 tinued or immediate treatment is through the instrumentality 
 of the public schools. Why the schools have gone so long 
 with almost utter disregard for the health and normal 
 physical development of their compulsory charges, argues 
 "a certain blindness of human nature" in the teaching 
 profession. This blindness, of course, which is almost a 
 physical defect, comes naturally out of the excessive isola- 
 tion of our public schools and teachers from the real life 
 and needs of our people. When we take the attitude that 
 the problems of the people and the nation set the problems 
 for the public schools, then we shall have a sensitive adapta- 
 tion of our educational systems to the real life of the times 
 and the children to be adapted. 
 
 Some of the essentials of adequate school clinics seem 
 to be the following: 
 
 1. Convenience to the pupils, perhaps for the most 
 
 part and for the ordinary cases, in every school. 
 
 2. Several divisions in the charge of specialists with 
 
 nurse assistants. 
 
 3. These divisions, for a beginning, may be: 
 
 a. Dental, in charge of dentists. They will ex- 
 amine the cases sent in by nurses and doctors 
 and give such treatment as is necessary, and 
 such advice for dental care as seems desir- 
 able, requesting parents, nurse, and teacher 
 to see that they are followed. Small charges 
 may be made where they seem desirable, 
 though this seems as unnecessary as volun- 
 tary payment for the free text-books and 
 other supplies furnished by the schools. It 
 is as much the advantage of the state to have 
 
230 SCHOOL HEALTH ADMINISTRATION 
 
 children in good health as It Is to have them 
 get a certain amount of schooling. And the 
 retarding effect of the various ailments may 
 well cause such waste of time and money 
 as to pay for adequate clinical provisions. 
 
 b. Surgical, in charge of surgeons. This division 
 
 will, with parents present as much as pos- 
 sible (and parents will come out to clinics 
 when they will not come to mere examina- 
 tions), remove such adenoid and tonsillar 
 tissues, and make such other dressings and 
 simple surgical treatments as good judgment 
 provides. Cases of strabismus (cross-eye) 
 and defects requiring operative treatment, 
 may well be handled by this division. 
 
 c. Medical, In charge of regular physicians. This 
 
 division will devote Itself to the diagnosis of 
 referred cases of many ailments not falling 
 to other divisions and the giving of skilled 
 treatments. With scalp ringworm cases 
 needing X-ray treatment, or with discharging 
 ears, favus cases, or any other of a host of 
 ailments which cannot adequately be handled 
 by the nurses, we have cases for this division 
 of the clinic. The Dunfermline (Scotland) 
 clinic has such divisions and the medical di- 
 vision reports a very large amount of work 
 for a small city of about thirty thousand 
 population. 
 
 d. Ocular, for eyes and vision, in charge of 
 
 oculists. This division will handle both the 
 treatment of eye ailments and make careful 
 vision tests of referred cases, furnishing 
 either prescriptions alone or prescriptions 
 with the proper glasses. Providence has al- 
 ready entered this field and every city must 
 undoubtedly follow. 
 
PHASES OF MEDICAL INSPECTION 231 
 
 e. Medical gymnastics division, if this is not cor- 
 
 related with the department of physical edu- 
 cation. 
 
 f. Psychological division, for testing backward 
 
 children.* 
 
 Practically no school system of this country has yet a 
 clinic so well worked out and so paternal as this, although 
 there are a number of approximations to it, and we can 
 see scattered over the country its various elements. We 
 shall begin our further study of the cities with the various 
 means of: 
 
 A. Public School Treatments. 
 
 The work of the nurses consists of assisting the doctors 
 at examinations and making vision and hearing tests. In- 
 specting the children, visiting the homes to help get pre- 
 ventive measures and treatments, taking the children to free 
 dispensaries or to private physicians, and, finally, in treating 
 the children themselves. 
 
 Physicians are, for the most part, prohibited from mak- 
 ing treatments, and the nurses' work In the field of treat- 
 ment ranges In these cities from almost zero up to the large 
 amount of work done In Newark and a few other cities. In 
 some cities, as at New Haven, all the medical supplies and 
 Instruments were carried in the nurse's bag, and consisted 
 of: 
 
 An ear syringe, a sponge, some bandages, two small 
 basins, combs for pediculosis, bichloride tablets, olive oil, 
 zinc ointment, sulphur ointment, scissors, tongue depressors, 
 and a graduated glass. 
 
 From such small beginnings and less, the work ranges 
 upward to finely equipped medical inspection rooms, or 
 school clinics, in many or most of the school buildings and 
 with a large list of medical supplies kept at the central sup- 
 ply department and furnished to schools on the requisitions 
 of principals along with other school supplies. For Boston, 
 
 *Dr. Cornell suggests other divisions in his book. 
 
232 SCHOOL HEALTH ADMINISTRATION 
 
 the requirements for a medical inspection or "nurse's room" 
 are given in the report of the School-house Commission, 
 and the writer got further details at first hand. The plans 
 for the room and the equipment are much the same as those 
 already given in a former chapter for Summit. The same 
 room could be fitted up for the use of one or more of the 
 above-mentioned clinical divisions, of course, if they could 
 work at different times of the week. The medical inspec- 
 tion cabinet and desk combined in use at Boston is the best 
 seen, but a better one was found by the writer in the Depart- 
 ment of School Buildings in the City of New York, The 
 latter is a desk cabinet, with two doors below, and drawers 
 and pigeon holes above which are shut up and covered over 
 by a glass covered door which lets down by hinges at the 
 bottom and makes a writing desk. The top of the cabinet 
 is covered with slate to keep it, like the top of the desk, 
 from being injured by chemicals or medicines. 
 
 Most cities have in one to all of the buildings emer- 
 gency medical cabinets, made up by the nurses or doctors, 
 or sold complete by various medical supply houses. A very 
 small one found in New Bedford consisted of a tin box 
 ten inches square and about three inches deep and containing 
 the following: 
 
 An envelope containing scissors, safety pins, and pincers, 
 a handbook of first aid to the injured, absorbent cotton, 
 gauze, a tourniquet, a package of bandages, six bandage 
 rolls, a box of adhesive plaster, and camphenol ointment. 
 
 Such emergency outfits are, of course, unnecessary where 
 the same materials are kept in an adequate medical inspec- 
 tion cabinet in each medical inspection room in each school. 
 
 The list of instruments furnished physicians and nurses 
 vary very much. In Providence, the school dentist carries 
 with him seventy-five teeth mirrors, so two rooms of chil- 
 dren can be examined at a visit without any disinfection of 
 mirrors. Hoboken has perhaps the longest list of medical 
 tools furnished each school, and the entire list of medical 
 supplies may here prove interesting and suggestive: 
 
PHASES OF MEDICAL INSPECTION 233 
 
 1. Jones' platform scale with 
 
 height standard attached. 
 
 2. Ear speculum. 
 
 3. Nasal speculum. 
 
 4. Head mirror. 
 
 5. Teeth mirror. 
 
 6. Tuning fork. 
 
 7. Stop-watch, one for each physi- 
 
 cian. 
 
 8. Spirit lamp. 
 
 9. Tape measures. 
 
 10. Enamel basins. 
 
 11. Tongue depressors. 
 
 12. Applicators. 
 
 13. Absorbent cotton. 
 
 14. Gauze. 
 
 15. Gauze bandages. 
 i6. Lysol. 
 
 Among the lists found in other cities the following fur- 
 ther items were found: 
 
 Water heaters. 
 
 Paper and cloth towels. 
 
 Aromatic spirits of ammonia. 
 
 Collodian. 
 
 Rubber gloves. 
 
 Medicine droppers. 
 
 Forceps. 
 
 Uniforms for nurses. 
 
 Carrying bags for nurses. 
 
 Clinical and other thermometers. 
 
 Hair brushes. 
 
 Bath caps. 
 
 Tooth picks. 
 
 Graduate glasses. 
 
 Surgeon's needles. 
 
 Bandage jars. 
 
 Adhesive plaster. 
 
 Mercury bichloride tablets. 
 
 Peroxide of hydrogen. 
 
 Disinfectants, sulphur naphol, etc 
 
 Green soap. 
 
 Boric acid. 
 
 Jamaica ginger. 
 
 Ammoniated mercury. 
 
 Creolin. 
 
 Marigold ointment. 
 
 Witch hazel. 
 
 Chamois skin. 
 
 Tongue depressor handles. 
 
 Vaccination shields. 
 
 Enameled table with glass shelves 
 
 Couches. 
 
 Medical cabinet. 
 
 Chairs. 
 
 Floor mats, rugs, and pillows 
 
 Larkspur, for pediculosis. 
 
 Kerosene, for pediculosis. 
 
 Creasol, for pediculosis. 
 
 Sulphur ointment, for scabies. 
 
 White precipitate ointment. 
 
 Iodine. 
 
 Sweet oil. 
 
 Wood alcohol. 
 
 Toothache drops. 
 
 Oil of cloves. 
 
 Argyrol. 
 
 Comp. stearate of zinc. 
 
 Vaselene. 
 
 Comphenol. 
 
 Adreniline. 
 
 Powdered chalk. 
 
 Glycerine. 
 
 Boric acid ointment. 
 
 Vinegar, for pediculosis nits. 
 
 Vitagen. 
 
 Alcohol. 
 
 Muslin. 
 
 Vision test charts. 
 
 Tooth brushes. 
 
 Eye glasses, spectacles. 
 
 Combs. 
 
 Sterilizing outfits. 
 
 A study of the cost of all these items was made in each 
 city, and comparisons made. Cities that have tried to get 
 along by buying an article or two of local druggists when- 
 ever they were needed have wasted a good deal of money. 
 Twenty-five cent hair brushes, for example, have been sold 
 
234 SCHOOL HEALTH ADMINISTRATION 
 
 for $1.50 to the unsuspecting. Changes in certain cities 
 have since been made along these hnes in the direction of 
 having budgets made up each summer for the following 
 year, and then the lists offered for bidders from anywhere. 
 The big supply houses have come into the market and sold 
 all the supplies very reasonably. This is desirable economy 
 in line with other business improvements. 
 
 A list of the medical inspection supplies furnished in 
 quantities at Newark is here appended: 
 
 FOR MEDICAL INSPECTORS 
 
 Absorbent cotton, ^ pound packages, J. & J. Red Cross. 
 
 Alcohol, grain — 95 per cent. 
 
 Tongue depressors, in packages of 100. 
 
 Bandages — 2-inch by 10 yards, J. & J. Linton gauze. 
 
 Bichloride of mercury tablets — yj^ gr. (lOO tablets in a bottle). 
 
 Tincture of green soap, 6-ounce bottle. 
 
 Glass jar, 2-quart. 
 
 Eleven different forms, envelopes, prescription pads, etc. 
 
 FOR SCHOOL NURSES 
 
 Absorbent cotton, ^-pound packages, J. & J. Red Cross. 
 
 Bandages, i-inch by 10 yards, J. & J. Linton gauze. 
 
 Bandages, 2-inch by 10 yards, J. & J. Linton gauze. 
 
 Adhesive plaster, 2-inch by 10 yards, J. & J. "Z. O." 
 
 Alcohol, grain — 95 per cent. 
 
 Plain gauze, I yard long, i yard wide, J. & J. Red Cross. 
 
 Argyrol, 5 per cent. 
 
 Bichloride tablets, 7J4 grains. 
 
 Flexible coUodian. 
 
 Iodine, tincture. 
 
 Lysol. 
 
 Sulphur ointment. 
 
 Sweet oil. 
 
 Stearate of zinc (powder, in boxes). 
 
 White precipitate. 
 
 Zinc ointment. 
 
 Bottles, 4-ounce, with corks. 
 
 Ciliary forceps, No. 1628. 
 
 Clinical thermometer. 
 
 Ointment jars, 4-ounce. 
 
 Tooth picks. 
 
 Three blank forms. 
 
 FOR PRINCIPALS 
 
 Cotton, bandages, adhesive plaster, aromatic spirits of ammonia, 
 and three blank forms, reports on medical inspection. 
 
PHASES OF MEDICAL INSPECTION 235 
 
 FOR SANITARY INSPECTOR 
 
 Formaldehyde. 
 
 Kerosene oil. 
 
 Alcohol, wood. 
 
 Cotton, American Beauty. 
 
 Two blank forms, one a report of sanitary inspection of schools 
 and of disinfection, and the other a report of visits to the homes of 
 quarantined pupils. 
 
 FOR SUPERVISOR OF MEDICAL INSPECTION 
 
 Form 93, a permit for children to attend school. 
 
 Here we have about the best that has been worked out 
 in the way of medical inspection supplies, and this list will 
 probably soon be added to if the efforts for a first-class 
 school clinic are successful. 
 
 PRESCRIPTIONS 
 
 It has been found necessary and desirable to print pre- 
 scriptions in the various languages of the city population for 
 a rapidly increasing list of school ailments. Some of these 
 are at present for: pediculosis (lice), ringworm, impetigo, 
 scabies, caring for the teeth (tooth powders), and home 
 and school advice which amounts to prescriptions for a 
 great variety of other ailments of a simple character. We 
 have not begun to discover what a wide field of health edu- 
 cation of adults exists in the form of well written and illus- 
 trated pamphlets, not to mention lectures, home-visits, etc. 
 A very valuable book for home treatment and prevention 
 of disease has been written by Professor N. E. Ditman, 
 M, D., of Columbia University, entitled "'Home Hygiene 
 and Prevention of Disease" (Dufl^eld & Co.). It is in the 
 form of a small one-volume cyclopedia, beginning with 
 "Abscess" and ending with "Wry-neck," and comprising 
 very practical and scientific advice on practically every phase 
 of health in the home. I wish I had the power to place 
 it in the hands of every parent, intelligent enough to read 
 the newspapers, in America. The book, of course, shows 
 the limitations of home treatment and shows also where the 
 expert skill of medical men is necessary; but it does clear 
 away a great deal of the superstition, inscrutability, and 
 
236 SCHOOL HEALTH ADMINISTRATION 
 
 awesomeness of ill health, and shows plainly and simply 
 each individual's responsibility for prevention and cure. 
 Such knowledge is, of course, essential matter for our high 
 school courses in hygiene, but the pupils there do not get 
 such knowledge or acquaintanceship with such book-tools, 
 because they are so busy cramming comparatively useless 
 information. 
 
 HEALTH LECTURES 
 
 A new departure is the wide range of simple health 
 lectures being given in many cities. Newark has four or 
 five hundred a year, given by specialists or persons well 
 qualified to speak, on a great variety of health topics. The 
 nurses and doctors also give a great number of health talks 
 to the children and teachers of the schools. Stereopticons, 
 tuberculosis exhibits, dental exhibits, budget exhibits, and 
 moving pictures all are, or can, be enlisted to bring to the 
 people the health knowledge which is essential to the 
 saving of many of their lives or, at least, conserving and 
 developing their efficiency in their daily work. Denison's 
 "Helping School Children" (Harper's) is filled with sug- 
 gestions for promoting the health of the school children and 
 their friends and relatives. 
 
 SCHOOL OCULISTS 
 
 We have mentioned the school oculists at Providence, 
 and the splendid work they are doing for getting scientific 
 diagnoses and accurate prescriptions and glasses for school 
 children. The school ocuHst is bound to come. These two 
 oculists at Providence give "two afternoons a week at the 
 Fourth Ward Room for examining eyes," for which they 
 receive an annual salary of $300. Several more are needed 
 more afternoons a week. 
 
 SCHOOL NEUROLOGISTS 
 
 Providence has also the only school neurologist in this 
 group of cities, or had at the time of this study, 1910-11. 
 Neurologists or psychologists for testing mental defective- 
 
PHASES OF MEDICAL INSPECTION 237 
 
 ness and helping with the education of backward and feeble- 
 minded children are, however, to be found in a number of 
 cities (e. g., Cleveland and Los Angeles) in the United 
 States. Their work could hardly be called treatment per- 
 haps, but they are naturally mentioned in this place. 
 
 B. Treatments by Private Organizations 
 
 The great field for private health assistance to the 
 schools has been, it seems, in the field of school dentistry.* 
 We find groups or associations of dentists in many cities 
 volunteering their services. 
 
 The following cities of the twenty-five had more or less 
 of such voluntary work during the years of this study: 
 Summit, Norwood, Winchester, Montclair, Meriden, Wa- 
 terbury, New Bedford, Trenton, Cambridge, Lowell, 
 Rochester, Newark, and Boston. 
 
 In Winchester, the dentists have a schedule of half days 
 on which they will work and give their services, with nom- 
 inal charge of twenty-five cents a case. In Cambridge and 
 Waterbury the school department has purchased chairs at, 
 or less than, $300 each, which are taken from school to 
 school as needed. In New Bedford, the Health Depart- 
 ment spent $600 for a chair and other equipment for a 
 dental room, all of which was placed at the disposal of the 
 volunteer dentists. In Trenton, a very finely equipped 
 dental suite of rooms is furnished by the city in the new 
 city hall. Such volunteer work goes along very well for a 
 time, but it almost invariably breaks down unless a city 
 responds soon and takes the new institution over. No city 
 at this late day really needs to be convinced by volunteer 
 demonstration of the necessity of such clinics or divisions 
 of clinics. The experience of cities the world over is at the 
 disposal of any who wish to meet the vital health problems 
 of the people. 
 
 In Boston, as related, the new Forsythe Dental Dis- 
 pensary, left as a private bequest, is almost extensive enough 
 to handle the dental problem of all the children of Boston 
 
 *Providence alone, also, had a school dentist emploj^ed b)^ the city. 
 
238 SCHOOL HEALTH ADMINISTRATION 
 
 up to the age of sixteen years. It is not thought that existing 
 dentists will suffer by such an arrangement. Rather they 
 will gain through an adult population educated in the 
 realization of the value of good dental services.* 
 
 Other voluntary forms of health and medical service to 
 children are : the provision of clothing brought in by the 
 children and distributed by the nurses, the provision of 
 outings on private bequests, as at Brockton, the provision 
 of free eye-glasses, the various hospital and dispensary 
 forms of treatment offered and given so freely and gen- 
 erously to all that the nurses bring or send, the feeding of 
 the undernourished, the open-air schools, and a great host 
 of other ways almost too numerous to mention but springing 
 into being wherever the school officials or the public or both 
 together are genuinely sensitive to the health needs of the 
 actual children in the public schools and homes. 
 
 The administrative solution of the problem of treatment 
 is to organize it, get it into the hands of skilled and perma- 
 nent workers, and to make the private work become public 
 policy as soon as its value is demonstrated, thus leaving new 
 fields open for private initiative. School superintendents 
 frequently do not see very clearly the health needs or are so 
 engrossed with other matters that they have no time for 
 health essentials. This and a number of difficulties has led 
 the writer to advocate a thorough integration of all health 
 agencies in a school system, in one department of hygiene, 
 and under one physician, physical-educator, or educational 
 hygienist, who will be responsible for the health and normal 
 physical development of the school children. The divisions 
 of such a department may well be, as before stated, and 
 first so listed by Dr. Woods, I believe: Medical Inspection, 
 School Sanitation, the Teaching of Hygiene, Physical Edu- 
 cation, and the Hygiene of Teaching. The salary for such 
 a man will be near $3,000, not less; but ways can easily be 
 devised in many cities for acquiring him with little extra 
 
 *Such dental work in public schools will be found well treated in 
 Gulick and Ayres' Medical Inspection of Schools, 1913 edition, and 
 Cornell's Health and Medical Inspection of School Children. 
 
PHASES OF MEDICAL INSPECTION 239 
 
 expense, and several small cities can go together to get one 
 man as they now do in New England for superintendents. 
 In the country, there can well be a county, or township 
 Director of Hygiene who can examine children, direct 
 nurses and assist physicians, and promote all health phases 
 which are now so terribly neglected in many or most country 
 schools.* 
 
 II. PREVENTION IN MEDICAL INSPECTION 
 
 The principal preventive work of such systems is, quite 
 largely, that of education, finding incipient cases of all kinds, 
 the provision of open-air schools, and the general co-opera- 
 tion with or the correlation of all phases of educational 
 hygiene above mentioned. 
 
 OPEN-AIR SCHOOLS 
 
 Open-air schools were found in South Manchester, 
 Montclair, Schenectady, Cambridge, Providence, and New- 
 ark. Detailed studies of the administration, cost, equip- 
 ment, methods and results were made in all cases, but we 
 cannot here go into the matter in detail. Readers are re- 
 ferred to the excellent reports of some of this work at South 
 Manchester, Cambridge, Providence, and Newark. At 
 Providence the work is in charge of the Board of Health 
 and its enterprising director. Dr. Chapin. Reference is also 
 necessarily made to the valuable little book by Dr. L. P. 
 Ayres on the subject. 
 
 Open-air schools are not filled with tubercular children 
 as many suppose, but with the poorly nourished, the anemic, 
 the delicate, and incipient or potential cases of tuberculosis. 
 The advantages lie in the way of segregation from other 
 pupils of the schools, of special adaptations of work and 
 regimen to individual needs, of the good, fresh air, of the 
 special loving kindness which is the best medicine for some 
 children, of the more natural motor activity, and, especially, 
 of better feeding in many cases. It is hard to regulate the 
 feeding of selected children in a big school system, but it is 
 
 *See the plan for such work in the last chapter. 
 
240 SCHOOL HEALTH ADMINISTRATION 
 
 easy when these children are brought together in segregated 
 groups and all participate In the same activities. 
 
 Open-air schools are not expensive, but are more costly 
 than the usual school system. The expense Is an added one, 
 because many or most of the children leave vacant seats in 
 the schools. But It Is worth all that Is spent on such pro- 
 visions for three reasons, at least: 
 
 a. It shows how necessary fresh air Is in the schools and 
 In the homes for all children and all adults. It gets school 
 officials and parents to thinking of how to provide natural, 
 "uncooked" air to all children at all times. It shows teachers 
 that they do not have to live In a torrid, desert atmosphere 
 to be comfortable and happy. It shows principals and jani- 
 tors that more dependence can be placed upon radiators for 
 heating the rooms instead of raising the temperature almost 
 entirely by overheating or cooking the air before it goes Into 
 the fans and the ventilating flues. It shows that moisture 
 should be added, perhaps in the form of steam pans, and 
 In large quantities, and adequately registered and regulated 
 by accurate humidometers, keeping the air at about 55 per 
 cent saturation, and a temperature In the fan room of about 
 62 degrees and In the school rooms about 65 degrees 
 Fahrenheit. It shows the value of open-window rooms where 
 pupils simply keep on their warm wraps, and breathe di- 
 rectly the outer air, without recourse to an elaborate fan 
 system. But this leads us Into school sanitation In these 
 cities, and that is another chapter. 
 
 b. It shows the importance of nourishment for the de- 
 bilitated children, and a fundamental essential for all chil- 
 dren, besides the fresh air. 
 
 c. The cost is of the nature of a stitch In time saving 
 nine. Most children in open-air schools that have been 
 followed up carefully for some time after such a school has 
 been given up or the children had to leave the school (as in 
 the case of the lamented Dr. Arthur T. Cabot's study and 
 follow-up work in Boston) have either died in early life or 
 Indicated that they had few years yet to live. Long con- 
 tinued open-air schooling for a number of pupils will prob- 
 
PHASES OF MEDICAL INSPECTION 241 
 
 ably raise their resistance enough to make their span of life 
 normal and save to society all the expense incurred in their 
 upbringing. The work can probably be planned so such 
 saving to the school system alone will more than balance 
 the cost of open-air schools. 
 
 It is probable, also, that properly devised systems ot 
 ventilation in the regular schools and proper attention to 
 nourishment, eradicating the coffee-habit, etc., will make un- 
 necessary any elaborate extension of such schools. It may 
 be well to call them open-air hospital schools and provide 
 them for only a few, while placing the greatest emphasis on 
 adequately caring for the ninety-and-nine. 
 
 MEDICAL CONSULTATIONS FOR MOTHERS 
 
 The child-hygiene departments of some of our progres- 
 sive boards of health begin their care of children with con- 
 ception and follow them up in one way or another until the 
 age of the work certificate. This is the boast of Boston and 
 of several other cities. In Newark, the school medical 
 inspection department has provided free medical consulta- 
 tion for mothers with Infants or pre-school children. The 
 development of this work and the good results which have 
 followed show that, without Invading the fields of the health 
 department, the school department, through Its medical In- 
 spection and whole hygiene department, can help to insure 
 the efficiency of the children In the schools long before they 
 set foot In even the kindergarten. Such extensions In re- 
 sponse to genuine community needs can in the long run be 
 only benificent, regardless of the croakings of the wor- 
 shippers of the god of things as they were. 
 
 SCHOOL BUDGET EXHIBITS 
 
 For educational and civic purposes, an annual budget 
 exhibit In which the hygiene department of the schools Is 
 represented, may be of very great value. Hoboken Is the 
 only city having had such an exhibit in the year of study, 
 among the twenty-five cities. The exhibits consisted of 
 charts showing the effects of various ailments on school 
 
242 SCHOOL HEALTH ADMINISTRATION 
 
 progress a la Ayres, the number of children affected with 
 various ailments, the duties of the parents in various direc- 
 tions, and a sample of each kind of the medical suppHes on 
 burlap screens, with the cost of each below. Those desiring 
 to utilize this means of reaching the parents, the tax-payers 
 and the children may well correspond with the New York 
 Bureau of Municipal Research, which has been the father 
 of the movement. 
 
 DISINFECTION OF SCHOOLS AND HOMES 
 
 A good deal of money is spent in this line of prevention 
 of the spread of infectious ailments. Montclair has a sys- 
 tem of sending formaldehyde gas through the vents of the 
 ventilating system, so that a few minutes after an evening 
 audience has used a school auditorium, for instance, the 
 fumes so fill the room that it is impossible for a person to 
 remain in it. Costly paintings hung on the walls of the 
 auditorium visited there, but no damage to them or to any- 
 thing else seemed to follow. However, with all the work 
 and expense, the value of such disinfection is being seriously 
 questioned by medical men. The dependence upon this 
 mode of prevention is waning, and we very much need 
 such studies as those of Dr. Chapin of the Providence Board 
 of Health, those of Kerr in London, and of Professor 
 Jordan of the University of Chicago.* 
 
 EXAMINATIONS FOR WORK CERTIFICATES 
 
 A number of the cities are coming to a realization of 
 the importance of seeing that every child, requesting a work 
 certificate at the age of fourteen, is guarded from going into 
 the struggle of employment with a poor health equipment. 
 Such medical examinations by Boards of Health or Boards 
 of Education frequently get treatments where all former 
 efforts have failed, and in some cases for the first time dis- 
 cover defects that will prove a serious handicap unless prop- 
 erly corrected. Boston seemed to be doing most in this 
 
 *See reports, and the 1912 N. E. A. volume, article by Professor 
 Jordan giving many references, and bringing up a number of these cor- 
 related problems of school infection. 
 
PHASES OF MEDICAL INSPECTION 243 
 
 field in the year of the study, and the writer learned much 
 about the work by watching the examinations, and talking 
 with the examiners afterwards. In only rare cases has it 
 been necessary to refuse such certificates although many are 
 postponed for a time. 
 
 Adequate vocational guidance will of course, in each 
 school system, take this health matter into consideration, 
 relieving the health department of the obligation. Adequate 
 medical inspection throughout school life will greatly lessen 
 the need for such service, as a special piece of medical work. 
 This of course argues power of compulsion in the lower 
 grades, and this is what the New Jersey law grants and 
 many cities in one way or another enforce — that parents 
 may be compelled to place the child in good health condi- 
 tion, or permit the school authorities to do so. Courts, 
 truant officers, and cruelty to children societies all work 
 together for the benefit of the child where any parent or 
 guardian is stubborn in his ignorance. 
 
 HEALTH INVESTIGATIONS BY DEPARTMENTS OF MEDICAL 
 
 INSPECTION 
 
 The work of medical inspection and all health work 
 must be placed upon an adequate scientific basis, commensu- 
 rate with the newer sciences of medicine and education. A 
 city that does not or cannot adequately and accurately meas- 
 ure results in this field is condemned at the start. 
 
 Very few cities have made anything like scientific inves- 
 tigations of what was being accomplished, what ought to 
 be accomplished, or what was necessary to do the work. 
 Boston probably made more investigations during the years 
 studied than all the other cities put together. If this volume 
 does nothing else but show that there are an immense 
 number of problems in educational hygiene which demand 
 Immediate solution by careful inductive methods, its exist- 
 ence will have been justified. 
 
 Some of the problems investigated in Boston were: 
 
 I. The relation of temperature of school rooms to the 
 number of cases of anemia found in the rooms. 
 
244 SCHOOL HEALTH ADMINISTRATION 
 
 2. The relations of ill-health and physical defects to 
 retardation. 
 
 3. The ventilation and temperature of school rooms. 
 
 4. A study of 5,000 choreic children, and their school 
 progress. 
 
 5. An investigation of the number of tubercular chil- 
 dren in the schools, and their environments. 
 
 6. A study of the number of cases of defective vision 
 and hearing in the schools, and the number of children wear- 
 ing glasses, etc. 
 
 These and other studies were made by this one city. 
 Unfortunately none of the studies was carried through to 
 completion by the use of such rigorous inductive methods 
 as would insure accurate and comparable results, so the 
 results of the findings are not here quoted. They were 
 regarded as starts only in the right direction, and have not 
 all been published by the school authorities in public jour- 
 nals, although mention of some of them can be found in 
 the Annual Report of the School Committee for 1910. 
 
 The same could be said for the studies of the relation- 
 ship of ill-health to retardation in South Manchester, Brock- 
 ton, Mt. Vernon, Schenectady, Hoboken, and elsewhere. 
 The field is so new and the problems are so complex and 
 the requirements of adequate investigation are so great in 
 the way of time, labor and ability, or special technique, as 
 well as a number of years of study of results, that we have 
 as yet little definite knowledge of this health work in the 
 schools. And yet there is promise in every study, valuable 
 data possibly to lay by, certain tendencies showing them- 
 selves, and certain skill and interests arising in the investi- 
 gators which are the things to be prayed for if we are to 
 get a science of educational hygiene or a science of educa- 
 tion. We can close this section with no finer thoughts than 
 those expressed by Dr. Cruickshank, now Director of 
 Hygiene for the Board of Education of Scotland in his 
 
PHASES OF MEDICAL INSPECTION 245 
 
 191 1- 1 2 report of medical Inspection in Dunfermline, Scot- 
 land:* 
 
 "It behooves them (the Trustees) to renew their Inter- 
 est and redouble their energies In seeking to establish thor- 
 ough and scientific methods of investigation into the prob- 
 lems which bear upon the numerous ailments and nutritional 
 deficiencies of the school children of their town. It has to 
 be borne In mind that this work Is scientific in the highest 
 sense of the term; that It can be done only by those who have 
 the necessary scientific training; that It entails much diffi- 
 cult and accurate work, and that the results cannot be made 
 Immediately apparent, as is the case with the effects of 
 treatment. It Is, of course, essential that scientific Investiga- 
 tion should both precede and accompany scientific preven- 
 tion. The days of empiricism in medical science are over, 
 and no true progress can be made In the applications of 
 medical science to the problems of education unless their 
 points of contact are subjected to minute and accurate in- 
 vestigation. In all probability medical science, more than 
 any other, will exert an influence on future educational 
 movements." 
 
 BOARD OF HEALTH VS. BOARD OF EDUCATION ADMINIS- 
 TRATION 
 
 Our data are too Inaccurate and too narrow in scope to 
 permit any conclusive statement as whether the boards of 
 education or the boards of health should, in general, have 
 charge of school medical inspection. As we have gone 
 through the various phases of medical Inspection efficiency, 
 we have found a number of Instances where In essential mat- 
 ters the boards of health, even though they are much older 
 In the work, on the average, fall decidedly below the effi- 
 ciency of the boards of education. We have attempted to 
 get data on enough items by which to rate the various cities 
 
 *The writer has recently distributed lOO copies of this excellent re- 
 port bound in boards free of charge to persons in this country known 
 to be interested in school health and working for it, and a thousand 
 more have been promised by Mr. Andrew Carnegie. 
 
246 SCHOOL HEALTH ADMINISTRATION 
 
 and the separate divisions in Boston and New Bedford 
 where both bodies participate. Some of the most essential 
 data we could not get, so the table showing the relative 
 ranking of the cities is merely suggestive of a method. It is, 
 however, interesting to see how the boards of health place 
 themselves at the bottom of the list in the efficiency series. 
 My judgment of the probable true ranking of the cities on 
 all items, i. e., on their general efficiency, need not be ac- 
 cepted.* My best judgment is, however, that, with perfect 
 records and accurate efficiency ratings for all elements, the 
 ranks of any one of these cities would not be raised or low- 
 ered more than five points in the twenty-five. The hardest 
 problem in the ranking was to get and decide upon what were 
 real efficiency data, and the next hardest problem was the 
 relative place of Summit and Newark. The weakness of 
 the latter was in the entirely insufficient number of nurses 
 in comparison with the number of physicians, and lack of 
 provision for high school inspection, while Summit was 
 weak in records and used up a large share of the nurse's 
 time for the work of attendance officer, though the latter 
 is to be commended in general even if it isn't strictly health 
 work. Definite steps have since been taken in Newark to 
 reverse the numbers of doctors (38) and nurses (8), with 
 the doctors to be district supervisors only, while the high 
 schools are now pretty well cared for by male and female 
 doctors, with nurses. 
 
 The medical officers of boards of health are, of course, 
 jealous of their powers, and will not agree with my opinion, 
 nor with my data, perhaps. A good example of their point 
 of view is given in the April, 19 13, American Journal of 
 Public Health in the Report of the Committee on Medical 
 Inspection of Schools and School Children, Dr. S. H. 
 Durgin, probably the first regular school medical inspector 
 of the United States, of Boston, as chairman, and Dr. G. F. 
 Kiefer, of Detroit, as acting chairman. They make a strong 
 stand for board of health control, but present no data in 
 proof and practically no arguments. On other points, their 
 
 *See page 254 for a tentative ranking of the cities on several 
 obtainable items. 
 
PHASES OF MEDICAL INSPECTION 247 
 
 conclusions, based partly on a questionnaire, agree very 
 markedly with conclusions already published by the writer. 
 
 The general impression which one gets in going about 
 from city to city and studying the work of both departments 
 is unstatistical but impressive to the one experiencing it. On 
 the whole there is marked contrast in efficiency, with sev- 
 eral exceptions, between the two departments, in favor of 
 the boards of education. Politics plays a larger part in the 
 work of most health boards, and this seems to vitiate much 
 of their endeavor. 
 
 To summarize many scattered points we give below some 
 of the chief: 
 
 ADVANTAGES AND DISADVANTAGES OF BOARD OF EDUCA- 
 TION AND BOARD OF HEALTH ADMINISTRATION 
 OF MEDICAL INSPECTION 
 I. BOARDS OF HEALTH 
 
 A. Advantages. 
 
 1. They can, if efficient, knit up school health with the 
 
 general health problem. 
 
 2. They can medically inspect parochial and private 
 
 school pupils as well as public school pupils. This 
 Boards of Education can do only where state laws 
 laws force parochial schools to obtain adequate 
 medical inspection. It is then relatively easy, as 
 in Milwaukee, for the boards of education to 
 get control of this important service. 
 
 3. They can employ medical inspectors on full-time, 
 
 giving them other public health work during a 
 large part of the time. 
 
 4. They can keep physicians and nurses in touch with 
 
 all phases of the health problem in the city and 
 community, by having them share in the work of 
 infant-mortality education in the summer, district 
 nursing of adults, infectious disease quaran- 
 tine, etc. 
 
 5. Where there is an efficient, interested superintendent 
 
 of health, not too much engrossed with other 
 health matters, there is a possibility of more ex- 
 pert supervision of school doctors and nurses, and 
 
248 SCHOOL HEALTH ADMINISTRATION 
 
 more progress toward a wide range of curative 
 and preventive measures, than in a school system 
 where the school superintendent has no medical 
 specialist as supervisor of educational hygiene or 
 of medical inspection, and is himself little inter- 
 ested or learned in school hygiene. 
 
 B. Disadvantages. 
 
 1. They seem to be more under the dominance of par- 
 
 tizan politics, and not as efficient as are the boards 
 of education. 
 
 2. They introduce an extraneous element into the 
 
 schools, making it impossible to get the best kind 
 of co-operation on the part of teachers and prin- 
 cipals in health work. 
 
 3. They make impossible the organization of all the 
 
 five divisions of educational hygiene into one or- 
 ganic department. 
 
 4. They do not seem to get the money and the support 
 
 for medical inspection, as well as do the boards of 
 education. 
 
 5. They look upon the school health work in a more 
 
 limited way, generally, e. g., from the standpoint 
 of infectious diseases, or merely that of finding 
 the ailments of children. Curative and preventive 
 measures, and the treatment of the child, his 
 health and his education, as a whole can hardly be 
 obtained, and are little emphasized by such boards. 
 
 6. They seems to be weaker in the way of educating 
 
 the parents through school meetings, medical in- 
 spection, pamphlets, etc. 
 
 7. They very largely omit complete physical examina- 
 
 tions of the children. 
 
 8. They are especially weak in providing an adequate 
 
 number of school nurses, in comparison with 
 boards of education. Counting Boston and New 
 Bedford, and leaving off the first three of our 
 cities, making 1 1 boards of education and 1 1 
 boards of health participating in this work, we 
 
PHASES OF MEDICAL INSPECTION 249 
 
 find the sum of the nurses for the boards of educa- 
 tion is 59, while the sum for the boards of health 
 is only 16. Boston now has over forty nurses and 
 other boards of education have been increasing 
 their numbers. The ratio now would show a 
 greater disparity. Our cities do not well show 
 this tendency because they were selected on the 
 basis of their having nurses. In proportion to the 
 number of pupils and using the data for the entire 
 country given by the Sage Foundation we should 
 have a far greater disparity. The Boards of 
 Health Committee, above mentioned, strongly 
 urges the use of school nurses, however, and rec- 
 ommends as many as three nurses for each doctor, 
 and, at least, one for each 1,500 to 2,000 pupils, 
 and only one physician for each 3,000 pupils, 
 where he gives only part time to the work as they 
 recommend further. 
 9. The best types of medical inspection records, re- 
 ports, and statistics are being devised by boards of 
 education and they are using nomenclature that is 
 more easily understood by the people to whom 
 reports are made than those made by boards of 
 health. However, in these cities we find in two 
 places the ailments of children given in greater 
 detail and in better organized form, than is the 
 case with most of our board of education reports. 
 Cleveland and Newark, on the board of education 
 side, and Providence and Boston on the board of 
 health side would stand out in this one particular. 
 10. Board of health administration of school medical 
 inspection is contrary to the tendencies of the 
 times, most cities taking up the work in recent 
 years putting it into the hands of the school offi- 
 cials, and whole states, with the unfortunate ex- 
 ception of Minnesota, going in this direction, e. g.. 
 New Jersey. The problem evidently will soon be 
 a dead issue except for scattered cities in the east- 
 
250 SCHOOL HEALTH ADMINISTRATION 
 
 When states get general directors or Supervisors 
 of (Educational) Hygiene, as many soon will, we 
 shall have the agencies in the school departments 
 to make board of health administration unneces- 
 sary anywhere. 
 
 11. BOARDS OF EDUCATION 
 
 A. Advantages. 
 
 1. The work can be done by boards of education with- 
 
 out loss to them or to the boards of health and 
 without as great waste of public expenditure. The 
 boards of education can supervise the health con- 
 ditions while individuals are immature and in pub- 
 lic schools with good means of control. Boards 
 of health can do the same for individuals in pri- 
 vate life; and, according to Winslow, in his excel- 
 lent article in the June, 19 13, North American 
 Review, this will soon be extended to factories 
 - , and other institutions where individuals congre- 
 
 gate. In this article also, "Efficiency in the Pub- 
 lic Health Campaign," the day is foretold when 
 most if not all medical work will be public and 
 not private work. This tendency will add so much 
 to the boards of health that the work of the 
 schools will not seem so large in comparison. 
 
 2. Our data seem to show that, in general, these, and 
 
 perhaps most, boards of education take up this 
 work with more energy and general efficiency, 
 with marked exceptions, of course. 
 
 3. The work can be integrated with both the scholastic 
 
 and the general physical development of the pupils 
 better when in the hands of one board, the board 
 of education necessarily, than when the work is 
 divided up. Schools must discover their own 
 health needs in order to do away with the present 
 isolation of parts and to go about physical educa- 
 tion, school sanitation, etc., in a rational manner. 
 
 4. The work can be done more cheaply to the city, not 
 
PHASES OF MEDICAL INSPECTION 25 1 
 
 only because of the greater efficiency of boards of 
 education but because the introduction of super- 
 visors of hygiene as herein planned will make pos- 
 sible several economies and the avoidance of need- 
 less dupHcation of efforts by the two boards. 
 
 5. As is now done in New Jersey, boards of health 
 
 can medically inspect parochial and private 
 schools, leaving to the boards of education the in- 
 spection in public schools. Whether boards of 
 education should take over the inspection in 
 these outside schools is a question. France and 
 Germany exercise a great deal of control over 
 such institutions, making them conform to general 
 state requirements, and it will undoubtedly be 
 necessary to place the inspection of all school chil- 
 dren in the hands of the public educational 
 authorities. 
 
 6. Boards of education seem to get better support from 
 
 the public, although they do not have the powers 
 over the people in general held by boards of 
 health. The schools are closer to the public purse 
 and will be more apt to make the work progress 
 as it should. 
 
 8. They emphasize the ailments which, though not 
 
 directly or immediately death dealing, are, never- 
 theless, very serious in their effects, and yet are 
 largely neglected by boards of health. 
 
 9. The number of part-time doctors with no other 
 
 school health work can be greatly reduced. Super- 
 visors of hygiene and more nurses will help solve 
 the problem, and the time will soon come when 
 the entire medical force in the schools will in some 
 way be made full-time workers like the teachers. 
 Physical education and departmental teaching of 
 hygiene may be mentioned as probable occupation 
 for the time not spent in physical examination 
 each day. With a morning of three hours daily 
 for medical inspection and examination this would 
 
252 SCHOOL HEALTH ADMINISTRATION 
 
 leave only the short afternoons to provide for. 
 Educational hygiene courses, abridging the long 
 M. D. preparation and physical education train- 
 ing, may make possible the introduction of such 
 men at salaries around $i,8oo to $2,000. Full- 
 time workers are undoubtedly to be desired, 
 though we have no data with which to prove it. 
 B. Disadvantages. 
 
 1. At present, lack of competent medical supervision 
 
 of the work of doctors and nurses. 
 
 2. Lack of control over parochial schools, with the pos- 
 
 sibility of uncontrolled infection in these schools 
 spreading to the public schools. 
 
 3. Lack of correlation with the general health prob- 
 
 lems of the community such as the control of mid- 
 wives, milk and water purity, infant mortality, 
 tuberculosis, infectious diseases, and general extra- 
 school health difficulties. 
 
 4. Lack of sufficient police and compulsory power in 
 
 forcing parents and guardians to place their chil- 
 dren in reasonable health condition for school 
 attendance, in most places. 
 
 5. Possibility of under-emphasis of the health factor 
 
 by an institution traditionally specialized for 
 mental and scholastic development. 
 
 GENERAL 
 
 In general, we conclude that while for the present there 
 are a number of cities where this work is now in the hands 
 of excellent men, such as Dr. Chapin of Providence, and 
 may well remain there for a time, and while It Is desirable 
 for cities, rural communities, and states to keep the work 
 In the hands of boards of health for the benefits of variety 
 and testing of these suggestions, still, for the most part, and 
 for all cities and states taking up the work for the first time, 
 and for any localities where it seems quite evident that the 
 work should be taken out of the hands of the boards of 
 health, — In all these places, the administrators of medical 
 inspection of public schools should be the boards of educa- 
 tion. 
 
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PHASES OF MEDICAL INSPECTION 255 
 
 MEDICAL SUPERVISION OF HIGH SCHOOL PUPILS 
 
 As before mentioned, the health of high school pupils is 
 very much neglected and this part of our school system is 
 yet very much of a mere intellectual and academic machine, 
 running by mediaeval and formal-discipline formulae. In 
 preparing the section on The Hygiene of the High School 
 for Professor Johnston's new book on High School Educa- 
 tion, Volume Two, Scribner's, the author has been interested 
 to go more deeply into the health problem of the high 
 school. As I show there, the best data obtainable, from 
 Newark and from Washington, D. C, as well as from my 
 study in Montclair, disclose the fact that there is a surpris- 
 ing amount of sickness and physical defectiveness in the high 
 school population. Carrying through the fifty-four classes 
 of ailments, summarized as to frequencies among a thousand 
 elementary pupils in the last chapter, we find that the high 
 school figures are close up to those for elementary pupils. 
 We are by them reminded of G. Stanley Hall's statement 
 in his volumes on Adolescence that the high school period is 
 a period of a low death rate but of a high morbidity, or 
 sickness, physical defectiveness, rate. 
 
 Our high school pupils are to be the leaders in their 
 respective communities and they should be fitted for efficient 
 leadership by adequate health protection and education while 
 in school. Nothing less that careful, scientific and rigid 
 medical supervision will ever show our high school teachers, 
 too, that pupils of this age are other than disembodied men- 
 talities and book-reading machines. 
 
 I have called attention to valuable statistics on this prob- 
 lem in Professor Johnston's volume. I give here the results 
 of work done by Dr. Thos. Storey with the young men in 
 the secondary and lower collegiate departments at the Col- 
 lege of the City of New York, reprinted from the Pedagogi- 
 cal Seminary for December, 19 12. Dr. Storey has also 
 shown by his records that such medical inspection and ex- 
 amination does not throw an excessive burden upon the free 
 dispensaries and clinics but furnished In the year ending 
 
256 SCHOOL HEALTH ADMINISTRATION 
 
 June, 191 1, patients for 1,100 professional men who re- 
 ceived over $12,000 compensation. (See the Proceedings 
 of the Sixth Congress of the American School Hygiene 
 Association.) 
 
 RESULTS OF DR. STOREY's FOLLOW-UP SYSTEM OF MEDICAL 
 INSPECTION OF HIGH SCHOOL STUDENTS 
 
 The success of this "follow-up" system during the year 
 ending June i, 19 12, may be seen in the following statistics: 
 
 1st term 2d term 
 
 Number of boys given instructional advice 105 1 936 
 
 Number of diagnoses followed up 1542 1409 
 
 Number of conferences necessary to follow up all cases. 2244 1925 
 
 Number of "diagnoses" recorded as "under treatment". 73 158 
 Number of "diagnoses" recorded as having "secured 
 
 treatment" 1298 1093 
 
 Number of "diagnoses" recorded as having "refused 
 
 treatment" 11 10 
 
 Number of "diagnoses" recorded as having "promised 
 
 treatment" , 108 102 
 
 Left college 48 40 
 
 Number of parents refusing to secure treatment 9 8 
 
 Number of individuals warned 328 290 
 
 Number of individuals debarred 71 92 
 
 Number of individuals reinstated 67 85 
 
 Number of individuals that remained debarred 4 7 
 
 Number of dentists consulted privately 273 256 
 
 Number of physicians consulted privately 189 139 
 
 Number of opticians consulted privately 22 16 
 
 Number of dental clinics attended 3 4 
 
 Number of hospitals attended 24 14 
 
 Number of students securing private dental service 320 310 
 
 Number of students securing private medical service... 204 147 
 
 Number of students securing the service of opticians. ... 15 18 
 
 Number of students securing free dental service 8 13 
 
 Number of students securing free medical service 4 5 
 
 Number of students securing free clinical service 
 
 (dental) O 3 
 
 Number of students securing free clinical service 
 
 (medical) 10 II 
 
 Number of students securing service of optician free. . . o o 
 
 Total number securing private service 539 475 
 
 Total number securing free service 22 32 
 
 Total number for whom home treatment was sufficient. 490 429 
 These statistics justify the following conclusions : 
 First. Our medical inspection is effective. It is securing the repair 
 
 of physical defects, and it is correcting unhygienic conditions in over 
 
PHASES OF MEDICAL INSPECTION 257 
 
 ninety per cent of the cases in which such treatment is desirable. This 
 plan of individual instruction in personal hygiene is improving the 
 physiological efficiency of at least a thousand boys every half year. 
 
 Second. Our plan of individual instruction in personal hygiene has 
 met with the support of the parents of practically all our boys. Less 
 than one per cent of the parents refuse treatment. No system can 
 endure without such support. 
 
 Third. It is safe to expect that this continued personal relationship 
 extending throughout the high school period and covering the first two 
 collegiate years will develop permanent habits of personal health con- 
 trol in many if not in most of the boys under our supervision. 
 
 GENERAL CONCLUSIONS REGARDING MEDICAL INSPECTION 
 
 I. The administration of medical inspection in these 
 twenty-five cities is extremely variable and yet there are evi- 
 dences of certain norms or standards toward which progres' 
 sive school systems are more or less slowly evolving. The 
 problem of the dissertation is to discover these standards 
 and to develop others, more scientific and sociological, in 
 order that conscious evolution may soundly abridge much of 
 the tedious process of hit and miss, and avoid great indi- 
 vidual and social waste. This heterogeneity is shown in a 
 variety of ways, not as an intensive study of any narrow 
 phase but sweepingly in the nature of a broad survey in ac- 
 cordance with the nature of the entire study, 
 
 A. The size of the city has little to do with the number 
 of medical inspection agents, although the two largest cities 
 in a number of particulars have almost the same propor- 
 tionate number of units, doctors and nurses, as the smallest 
 cities. 
 
 B. To enable comparison among cities as to number of 
 working units of medical inspection forces, the following 
 factors were added together for a unit: Physicians: aver- 
 age number of hours a day, average number of days a week, 
 average number of weeks in the year, average number of 
 hours yearly actually employed in school medical work, 
 including clerical work, plus the nurse. The quality of the 
 work and the standing of the physicians in their profession, 
 as well as the amount of school time spent in making out 
 records and reports and the amount spent in traveling about 
 
258 SCHOOL HEALTH ADMINISTRATION 
 
 from school to school, could not well be determined. Even 
 the number of days annually in which doctors made school 
 visits could not in all cases be learned. The work varies for 
 physicians from an average of a very few hours a year, 
 probably less than fifty, up to two hours a day for each 
 school day in the year (say 350 hours) , and some give three 
 hours daily though not so regularly, while the nurses' hours 
 are very close to a standard of a five-and-a-half day week of 
 seven to eight hours daily. 
 
 C. The variability is great in the forms of administra- 
 tion and execution of the work. Some cities, like Brockton 
 and Norwood, almost eliminate the physician, while others, 
 like Newark, put the emphasis upon the physicians, although 
 the tendency is strongly toward placing the work more and 
 more in the hands of well trained school nurses. Some cities 
 have the work in the charge of the boards of health, others 
 in charge of boards of education, while others divide the 
 work between the two departments. We have studied cities 
 that have no doctors and others that have no nurses for 
 comparison. Some cities have only inspection systems of a 
 limited kind (for infectious diseases) while others have sys- 
 tems much broader than inspection and including annual 
 physical examinations, cumulative record cards, adequate 
 reporting, and great emphasis upon curative and preventive 
 measures. All-round school clinics are only being agitated 
 as yet. 
 
 D. The variability might also be illustrated by the 
 tables of ailments and the very different proportions for any 
 one ailment from zero to sixty or more per hundred chil- 
 dren. 
 
 II. The cost of medical inspection also varies greatly as 
 shown for salaries. The average salary for physicians is 
 about $400 with great variations, while the salaries of 
 nurses is near $75 a month for the school year, and some for 
 the summer, one or two months. Supervisors' salaries range 
 from $800 up to nearly $4,000. Only one board of health 
 has a special supervisor of this work, and he gets the lowest 
 salary. A city may be paying very small salaries to its school 
 
PHASES OF MEDICAL INSPECTION 259 
 
 physicians and yet be paying more than a city with a large 
 annual salary, when the amounts of time spent during the 
 year in actual school medical work are compared. Other 
 expenditures for medical inspection are as yet very small 
 because of lack of free clinical treatment. The total expendi- 
 tures and relative expenditures are given in the tables. 
 Adequate systems, as here recommended, will cost from one 
 to four per cent of current expenditures. Scientific reor- 
 ganization of many existing systems of educational hygiene 
 as a whole need cost little more than is at present spent for 
 a variety of uncorrected health provisions. 
 
 III. Methods and technique of Inspection are very 
 chaotic, and most reports of the work are so inaccurate 
 and meaningless as to be practically worthless. Little can 
 as yet be said as to what medical inspection Is accomplishing 
 for schools. Record systems need greatly to be simplified 
 so efficiency will be promoted, not discouraged. Medical 
 inspection must be correlated with all other phases of edu- 
 cational hygiene: medical Inspection, physical education, 
 school sanitation, the teaching of hygiene, and the hygiene 
 of teaching. The work has and should broaden out beyond 
 "Inspection" to include annual (physical) examinations and 
 generous curative and preventive measures. Medical Su- 
 pervision of Schools would be a good term to cover all 
 phases, but the writer does not urge its adoption because of 
 the difficulty of getting the name generally used. Health 
 Supervision will not do because this describes the scope of 
 the entire department of hygiene, and may be confused with 
 the city health department. The chief criticism of methods 
 will be found in the last chapter in the form of a plan for 
 doing the work efficiently and well. We have avoided draw- 
 ing deadly comparisons and of showing up as much Ineffi- 
 ciency as possible. Most cities are willing to make desirable 
 improvements when they see that they are Improvements. 
 The final chapter meets this need better than any amount of 
 muck-raking. The tables are largely self-explanatory. 
 
 IV. The no7nenclature and the classification of school 
 ailments and the various phases of medical inspection should 
 
26o SCHOOL HEALTH ADMINISTRATION 
 
 be widely adopted for promoting reasonable uniformity and 
 greater efficiency. The plan of placing the curative work 
 of the nurse in juxtaposition with the cases found by nurse 
 or physician should be adopted. Some of the essentials for 
 each ailment are as follows : 
 
 1. Number of new cases (serious, not minor) found and 
 referred for treatment by (a) the doctor, and by (b) the 
 nurse. 
 
 2. Number of old cases inspected by (a) the doctor, 
 and (b) the nurse. 
 
 3. Number of these cases which were found negative by 
 family physicians and agreed as such by the school physician 
 or nurse. 
 
 4. After subtracting the negative cases (where the diag- 
 nosis has been determined wrong or the child not needing 
 treatment), the total number of new and old remaining^ yet 
 to be followed up until treated and cured. 
 
 5. The number of cases (ailments, perhaps several for 
 some children) (a) treated by the nurses of school clinic, 
 
 (b) treated by other agencies, (c) cured. 
 
 6. Number of children excluded for the various ail- 
 ments, counting only one ailment as causing exclusion, num- 
 ber re-excluded after presenting themselves at the school, 
 and (c) the number re-admitted after illness, exclusion, 
 quarantine, absence of three days or more, and the number 
 admitted for the first time, after the first two weeks of 
 school, i.e., after the routine September room-inspection of 
 all school children. 
 
 7. The number of remaining cases (ailments) not yet 
 (a) treated, (b) cured. 
 
 The classified list of ailments later recommended as a 
 beginning standard should be placed at the left of the page 
 for the report, weekly, monthly or annually, with the above 
 rubrics as headings. Other significant data are given on the 
 alternative recommended weekly report of the nurse for 
 the work of the doctor and herself. This type of report, 
 when well used will balance. 
 
PHASES OF MEDICAL INSPECTION 261 
 
 V. Few of the cities yet have annual medical examina- 
 tion of all elementary pupils; and Boston and South Man- 
 chester, Conn., were the only ones that had done much in 
 the high school field. Medical examination and even inspec- 
 tion reaches but a small proportion of the total number of 
 children in the schools, and, although many cures are re- 
 ported in certain cases, the results in this direction are very 
 meager. Free school clinics are recommended. 
 
CHAPTER TEN 
 
 PHYSICAL EDUCATION AND OTHER PHASES OF 
 EDUCATIONAL HYGIENE 
 
 Following a simple working classification of the various 
 divisions of educational hygiene, we have now completed but 
 one phase or department, that of medical inspection. The 
 short section on Conclusions on Medical Inspection has at- 
 tempted to bring together in succinct form the chief results 
 and principles arising from our study of the health pro- 
 visions in the twenty-five cities chosen for this investigation. 
 There remain yet for consideration and study the following 
 divisions: Physical Education, School Sanitation, The 
 Teaching of Hygiene, and the Hygiene of Teaching. In 
 this chapter we can give but briefly the main data and con- 
 clusions arrived at in the study of these phases in these 
 cities. 
 
 In an investigation of school health provisions, medical 
 inspection naturally comes first, since it, more than anything 
 else, points out those pathological weaknesses of our chil- 
 dren which it is the main business of most of the other 
 divisions to prevent and correct. If the work of doctors 
 and nurses shows that a large percentage of the children 
 are poor in health and bodily efficiency, that they are living 
 unhygienically at home and at school, and that they suffer 
 from a whole host of preventable ailments, then we have 
 clearly laid before the whole school system and all the 
 homes their problem and duty relative to health. Medical 
 Inspection can do much in the finding of ailments and In their 
 cure. It can by no means cover all the fields of prevention 
 In the form of: 
 
 I. Improving the school environment, hygienlcally, 
 through school sanitation; 
 
 262 
 
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264 SCHOOL HEALTH ADMINISTRATION 
 
 2. Promoting normal physical development, vital resist- 
 ance, and certain indispensable health habits and ideals, 
 through physical education; 
 
 3. Giving adequate health education, including knowl- 
 edge, habits, ideals, and appreciations, to the children of the 
 schools and through them to the homes. 
 
 4. Managing and teaching the children in the most 
 hygienic manner, making the methods of teaching and the 
 life of the school such as will promote health and happiness, 
 prevent rather than cause physical defects, and given the 
 nation what Dr. Burnham calls a "militia of health" instead 
 of inefficient and unreliable candidates for the sanitarium.* 
 
 A. PHYSICAL EDUCATION 
 
 A tremendous development of physical education has re- 
 cently taken place in the form of the playground movement 
 and all that it implies, and in the beneficent reaction upon 
 the old, stilted, fatiguing, isolated, and unnatural formal 
 gymnastics inherited from military and autocratic sources. 
 We have shown in a former chapter the tremendous devel- 
 opment of this new form of life and activity for children. 
 Like all of the other new health agencies which have re- 
 cently been crowded into the public schools largely by lay 
 bodies from without, we have here another illustration of 
 a lack of integration with all other health agencies of the 
 schools, of adequate scientific leadership and control, and of 
 proper scientific management and economy. Like many 
 other health provisions, too, the play movement Is still quite 
 largely In the private and voluntary stage of development. 
 
 The principal phases of this form of physical education 
 found by the writer were : 
 
 I. Increased playground space, not only by and near 
 the schools, but In parks, vacant lots and other places, and 
 provided by playground commissions, park commissions 
 and many private agencies. The natural play center Is, 
 
 *See "The Problems of Child Hj^giene," by W. H. Burnham, in the 
 1912 volume of the proceedings of the N. E. A. 
 
DIVISIONS OF HYGIENE 265 
 
 of course, at the school, also the best place for community 
 parks. 
 
 2. Increased school- and factory-made play apparatus in 
 school yards. 
 
 3. Folk dancing in charge of special instructors em- 
 ployed for this work alone at the schools. 
 
 4. School athletic leagues in increasing numbers. 
 
 5. Emphasis upon more democratic and better directed 
 athletics in the high schools. 
 
 6. After school and Saturday direction of play and ath- 
 letics of elementary children by school masters. 
 
 7. Increased number of gymnasiums in the new and old 
 school buildings. 
 
 8. Increased number of physical training teachers and 
 supervisors. 
 
 9. Increased number of evening recreation centers, 
 
 10. Emphasis on the provision of skating rinks for 
 school children in winter. 
 
 11. Increased attention to the educational value of play 
 and to its correlation with other motor activities such as 
 industrial work, especially in vacation schools. 
 
 12. Increased attention to the direction of the recess 
 and other free play periods of school children. 
 
 13. Increased number of summer playgrounds and play- 
 ground instructors and directors. 
 
 14. Emphasis upon swimming and bathing for school 
 children, especially in the summer. 
 
 15. Growing use of play festivals, pageants, and the 
 like. 
 
 It might have been well for us to have carried through 
 rigorously the exact amount of work in all health fields that 
 each city gave during the years studied. Comparisons, how- 
 ever, may be helpful and they may be odious, according to 
 an old saying. We shall be content if we have sketched a 
 method of analyzing the health work of a city, and shown 
 even vaguely how efficiency tests may be applied to them. 
 We studied in some detail the cost, equipment, workers, 
 methods, and results as well as they could be learned of all 
 
266 SCHOOL HEALTH ADMINISTRATION 
 
 play agencies, public and private, in the cities chosen. But 
 we cannot give here all the details necessary for discriminat- 
 ing and comparative work. We do give in the following 
 table the main public school physical education expenditures, 
 including, of course, playgrounds summer and winter. 
 
 Any examination of this table will show that a consid- 
 erable number of cities are doing little or nothing in a spe- 
 cial way for the physical development of the school children, 
 and that it is only in the largest city, Boston, that we find 
 any extended development of physical development agencies 
 that seem at all adequate either in the old Greek or modern 
 sense. Many cities had no physical training teachers, play- 
 ground instructors, or even ten- or fifteen-minute periods 
 during the school days for school room cahsthenics or games. 
 In some schools and cities there has even been a tendency 
 toward cutting out the good, old-fashioned recess, of so 
 much value in a physical way to the children. It is difficult 
 to state a number of these facts by cities, for occasional 
 schools may be held up as exceptions in almost any city, and 
 any general statement, unless favorable, may be resented. 
 
 On the other hand, the general tendency is strongly in 
 the direction of increased health provisions, and a study of 
 the reports of these school systems for the four years from 
 1909 to 19 1 2, inclusive, has shown some almost radical 
 transformations in this direction. Such statements as the 
 following are significant, in the first report (1910) of Dr. 
 Hermann, then Director of Physical Education at Cam- 
 bridge: "We have instituted both a morning and an after- 
 noon recess (italics mine), which are taken out of doors 
 whenever the weather and the yard conditions are favor- 
 able. Without this, only the most active children would get 
 sufficient exercise, and the teachers would not have the 
 opportunity to study their charges while at play." 
 
 Particularly marked development along these lines has 
 taken place in New Bedford, Trenton, Cambridge, Newark 
 and Boston. 
 
 Beginning again with the whole department of physical 
 education, not including play and playgrounds, we found 
 
DIVISIONS OF HYGIENE ' 267 
 
 the following phases, in one or more of the cities, to analyze 
 out and study: 
 
 1. General Director of Department of Hygiene, at 
 Boston only (lacking here only the school physicians, to 
 make the department complete). 
 
 2. Assistant directors of physical education, three at 
 Boston and two at Newark. 
 
 3. Supervisors of physical training or of physical edu- 
 cation, largely the former, having only restricted duties, not 
 having general oversight. 
 
 4. Elementary school teachers of physical training, 
 play, folk dancing, and all that the subject now includes, 
 number and salaries. 
 
 5. High school teachers, or "directors" of gymnasiums, 
 gymnastics, athletics, physical examinations, and the like, 
 number and salaries. 
 
 6. Clerical assistants for several of these departments, 
 number and salaries. 
 
 7. Military drill masters, assistants, and armorers, 
 number and salaries and the work of the cadets. 
 
 8. Number of school gymnasiums, elementary and high 
 schools, including separate drill halls, and the like. 
 
 9. Cost of equipment and maintenance for these. 
 
 10. Number of gymnasiums used for evening recreation 
 work. 
 
 11. Number of swimming pools, shower, and tub baths 
 in elementary and high schools. 
 
 12. Number and salaries of bath matrons, and special 
 janitors for baths. 
 
 13. Number of outside public or private baths open to 
 school children. 
 
 14. Two-minute or ten- or fifteen-minute recreation, 
 play, or callsthenic exercise in the class-room by regular 
 teachers. 
 
 15. Salaries of special repair men for gymnasiums. 
 
 16. School athletic leagues, their hand-books, their 
 membership and expenditures, private and public. 
 
268 SCHOOL HEALTH ADMINISTRATION 
 
 17. Special coaches in athletics in high or elementary 
 schools. 
 
 18. Substitutes in physical education and their manage- 
 ment and salaries. 
 
 19. Number of lectures to pupils on physical develop- 
 ment and general health topics. 
 
 20. Employment of sub-masters for directing play after 
 school and Saturdays, Boston. 
 
 21. Efforts in the field of medical gymnastics. 
 
 Tables when made on the basis of most or all of such 
 divisions, as proved the case for all other phases of educa- 
 tional hygiene, and even for the compact table of school 
 ailments made for medical inspection — isuch tables were 
 pretty much blank spaces, not only because of the hetero- 
 geneity of the work as yet, but also for the reason that 
 many school systems have not yet engaged themselves seri- 
 ously with the problem of physical education. We are still 
 very far from the Greek ideals of harmonious bodily effi- 
 ciency. A revolution must gradually be worked in the idea 
 of public education itself before schools, school curricula, 
 and school administration are adjusted to the health and 
 bodily needs of the children of urban civilization. This will 
 be pointed out more particularly under the hygiene of teach- 
 ing. Much of the promise in the cities here studied lies in 
 the construction of new school buildings, planned, not for 
 disembodied mentalities, nor for rural children getting 
 fairly adequate physical and motor development in the out- 
 of-school life, but for the cooped-up, sedentary, in-door, 
 flat-dwelling children, limited within by the restrictions of 
 apartment-house and school life, and without by the dangers 
 and policemen of the streets. That such a life as is rapidly 
 developing in this country will speedily kill off, through the 
 law of survival, all those unadapted to it and leave a people 
 healthily adjusted to such conditions, may only partially be 
 looked to, for the simple fact of the lower birth-rate in cities 
 and the need of constant replenishment by country folk. 
 Beside this force and possible eugenic control there must be 
 rigorous and radical transforming of the environment and 
 
DIVISIONS OF HYGIENE 269 
 
 education of the rising generations, especially at the schools. 
 Adequate health education may be expected to react upon 
 the health conditions of home and business life, making them 
 in turn more hygienic and healthful.* 
 
 PHYSICAL EDUCATION SUPERVISORS 
 
 Thirteen of the twenty-five cities could be said to have 
 had at this time supervisors or directors of physical training, 
 but in only three or four could these officials be regarded, 
 perhaps, as directors of physical education. A person who 
 merely teaches physical training in elementary or high 
 schools, and who has no general responsibility for or super- 
 vision of all forms of physical education such as mentioned 
 above could hardly be called a director or supervisor of 
 physical education. We should probably put Cambridge, 
 Newark and Boston in this class, and perhaps others. We 
 have listed as supervisors, however, ten others with more 
 limited responsibilities. A person may well be supervisor 
 of physical training or of physical education in the ele- 
 mentary schools or in the high schools alone, but such divi- 
 sion leaves an uncorrected system.* 
 
 The salaries at South Manchester and Winchester are 
 for part-time services. The salaries really range from 
 about $1,000 to about $4,000, the director of hygiene at 
 Boston receiving at that time $3,800, and the assistants 
 about $2,400 each. At Yonkers, no one physical training 
 teacher seemed to be supervisor and no report on physical 
 
 *I do not wish to suggest here that country children are not in 
 need of radically improved hygienic conditions. In making this study 
 the writer traveled over a large portion of New England, New York 
 and New Jersey in street cars, thus coming close once more with coun- 
 try folk; and the most vivid impression of the people met was that of 
 their low physical efficiency. Of course urban and western selection 
 has taken off most of the vigorous, physically superior individuals, as 
 the wars of Europe have cut off its stronger and abler types, but after 
 subtracting this influence we must admit the possibility of raising con- 
 siderably the hygienic conditions of country life. See also Gillette's 
 "Constructive Rural Sociology." 
 
 *See the excellent chapters in Johnston's High School Education 
 (Scribner's) on "Physiology and Hygiene," and "Sex Pedagogy in the 
 High School" and other chapters in Vol. H. 
 
270 SCHOOL HEALTH ADMINISTRATION 
 
 education appears In the 1910-11 annual report. Seven 
 cities, apparently, had no special teachers in this field. In 
 Rochester the supervisor is employed for the work of 
 directing the summer playgrounds, and this is also true of 
 Boston. There, the services of the director are for eleven 
 months. In Boston and Newark, all officials in this field 
 of work are on a salary schedule, with minimum and maxi- 
 mum salaries. This Is highly desirable, as is also, for the 
 most part, the twelve payments a year plan. 
 
 ELEMENTARY SCHOOL TEACHERS OF PHYSICAL TRAINING 
 
 After subtracting the supervisors, so-called, we have 
 but few special teachers of this subject left for the element- 
 ary schools. It is also a problem whether many or most 
 of these cities need many such teachers. In another chapter 
 the author has evolved a plan by which a physician with 
 knowledge and experience in physical education may be 
 employed by a city or several small cities or a country 
 township or county, and given the directorship of all five 
 phases of educational hygiene, thus making possible the 
 elimination of much of the present expenditures for poorly 
 trained medical examiners and physical training supervisors. 
 The present physical directors in the high school gymnasi- 
 ums should be retained, and, If need be, one or more phy- 
 sical training teachers for the elementary schools. If com- 
 petent nurses are employed for about each 1500 to 2000 
 school children they may be given also the present work 
 of the attendance officers; no general directors of summer 
 playgrounds need be employed, except In cities large enough 
 to have assistant directors ; fewer part-time physicians need 
 be employed, as suggested; and in all, for a great many 
 cities, a re-organized and efficient system, correlating all 
 health agencies, may be obtained, even when paying the 
 general physician-director $3,000 or more, for little more 
 annual expense than under the present poorly directed and 
 un-organlzed plans of management. The writer knows of 
 twenty-five available and qualified men for such positions 
 now. More young physicians will take the training neces- 
 
DIVISIONS OF HYGIENE 271 
 
 sary when a demand is evidenced. We probably need 
 more Doctors of Public Health (D. P. H.) rather than 
 so many Doctors of Philosophy (Ph.D.). The possible 
 saved expenditures in this direction for these cities should 
 be subtracted from the estimates of needed hygiene officials 
 given in table XII. 
 
 Besides the ten or more physical training teachers for 
 the elementary schools, Boston had a most interesting ex- 
 periment in the employment of 60 male teachers of the 
 schools (sub-masters) to go out with the boys to the parks 
 and playgrounds after school and Saturday mornings to 
 direct them in their sports. Each teacher is paid $1.25 
 extra for each period, six a week, and the whole scheme 
 has seemed to be eminently successful. 
 
 Instead of giving the amounts expended for such teach- 
 ers and high school directors in the two largest cities, 
 we give only the minimum and maximum salaries, the 
 teachers being at different points in the schedules as was 
 the case of the 35, and now 41 or more, nurses in Boston, 
 and the eight in Newark. Wherever two or more teachers 
 or directors are recorded their combined, and not their 
 separate, salaries are given. Thus the two assistant super- 
 visors at Newark received $1,100 and $1,400 respectively, 
 or $2,500 together (maximum, $2,000) ; and the three 
 teachers at Rochester received a combined sum of $3,300. 
 This would also apply to Yonkers, and also to the play- 
 ground teachers in several places. 
 
 Like the school nurses, the physical training teachers 
 are practically all graduates of special schools or depart- 
 ments for such work. We found only one nurse who 
 had only the qualifications of a regular grade teacher (at 
 Lowell) and we found only one teacher of physical train- 
 ing who had "just picked it up." It is easy today to get 
 superior training in this field, but not in the field of medical 
 inspection, and there are still no schools for the education 
 of directors of hygiene which will abridge the medical 
 course, leaving out much in such special fields as obstetrics 
 and adult treatment as will not function and putting in 
 
272 SCHOOL HEALTH ADMINISTRATION 
 
 much left out by the regular medical course. We are not 
 aware that the University of Wisconsin has provided prepa- 
 ration for this service in its new health department. Teachers 
 and directors can now obtain a good library and can get 
 a good summer course on the medical aspects of their work. 
 
 HIGH SCHOOL TEACHERS OF PHYSICAL TRAINING 
 
 Eleven or more of the twenty-five cities had one or 
 more teachers of physical training in the high schools.* 
 Most of the newer high schools were being supplied with 
 gymnasiums, as well as many of the new elementary schools, 
 and generally we found at each high school thus equipped 
 a man for the boys and a woman for the girls conducting 
 the department. In some cases, as at Montclair and 
 Lowell, outside buildings have been rented or purchased 
 for such provisions. The $500 salary at Lowell was for 
 the part-time services of a drill master for the boy cadets. 
 In this city, Boston, Brockton, and a few other cities, more 
 or less attention is being paid to this form of health de- 
 velopment, largely for high school students. It is much 
 more military in character than the Boy Scouts scheme, 
 and probably not so valuable. The cadets in Brockton, 
 however, take trips somewhat as do the Boy Scouts. Both 
 have uniforms, but with a difference. Of one of these suc- 
 cessful cadet organizations Professor Wm. H. Burnham, 
 the dean of educational hygienists in this country, has this 
 to say: 
 
 "A few weeks ago it was my privilege to witness the 
 parade of the high school cadets of Boston, a parade of 
 two or three thousand school boys. It was an excellent 
 exhibition of the results of careful drill and organization. 
 The cadets did credit to themselves and to their military 
 instructors. But as I observed them as they marched, I 
 noticed how many were sallow in countenance, anemic, or 
 flat chested, or mouth breathers, or apparently suffering 
 
 *See Gulick's study of the "Status of Physical Education in 90 
 Public Normal Schools and 2,392 Public High Schools in the United 
 States." Fourth National School Hygiene Congress. 
 
DIVISIONS OF HYGIENE 273 
 
 from some physical disorder or defect or bad condition; 
 and how few had the ruddy glow and the general aspect 
 of health that the adolescent should exhibit. These were, 
 however, in a certain sense, the pick of the pupils in the 
 public schools. 
 
 "If this is the price that must be paid for education, 
 it is no wonder that parents are dissatisfied and that they 
 ask whether the reward is worth the sacrifice. What man 
 of sense would bargain vigorous health, normal develop- 
 ment, and a few motor accomplishments like those of the 
 Boy Scouts for a little conventional book-knowledge and 
 anemia and ill-health and mal-development?" 
 
 He furthermore recommends* that drill in health habits 
 be substituted in part for the special drill in military tactics, 
 and the development, not of a kind of police force, but of 
 "a militia of health trained to fight the conditions of disease 
 by the methods of modern science." 
 
 This is but one step in the complete socialization of 
 the whole physical education department. With scientific 
 and medically trained people in charge, we may expect 
 studies to be made of the health needs and health problems 
 of the students and the people of the community in order 
 to make education hit the mark. What physical education 
 seems to need is a great deal more of scientific and socialized 
 intelligence, rather than special motor accomplishments. 
 
 We made little or no study of athletics and athletic 
 coaches. The football, basketball, track meets, and all 
 the various forms of outdoor and indoor competitions fur- 
 nish specially acute problems which take special investiga- 
 tion and time in each city. Most of the progressive de- 
 partments are now working for or have attained, athletic 
 fields, stadiums, and all the paraphernalia of the college. 
 With proper re-organization of the high school curricula, 
 throwing out the immense quantities of deadwood that have 
 accumulated for ages of formal discipline theories, and with 
 the introduction of thoroughly essential educational activl- 
 
 *See 1912 volume of the N. E. A., page 1102. 
 
274 SCHOOL HEALTH ADMINISTRATION 
 
 ties, we may expect these health fields and equipment to 
 provide thoroughly democratic and general physical and 
 social development of the old Greek type and better. 
 
 MEDICAL EXAMINATIONS AND EMERGENCY TREATMENT 
 
 In all first-class high school departments of this kind, as 
 in normal schools and colleges, physical examinations and 
 emergency diagnosis and treatment are attempted. The sad 
 fact, however. Is that most high school gymnastic directors 
 are not properly qualified for such work. In asking them 
 for their views on medical Inspection, they nearly always 
 request that the physicians make their heart and lung ex- 
 aminations for those going into athletics because they "do 
 not feel properly qualified"; they do not have a medically 
 trained eye always to notice fairly obvious indexes of phy- 
 sical defects and other ailments; and so, instead of being 
 the health guardians of the high school, able to discover all 
 health Impediments to education and to act as general 
 medical and sanitary Inspectors of the school, we have them 
 occupying a little Isolated niche. Such a lack of medical 
 qualifications. Is, of course, very expensive to the school 
 system that tries to do the best for the hygiene of the 
 school. The male physician-director of the normal school 
 can adequately examine his pupils, with their clothing re- 
 moved, for heart, lung and other examinations, and the 
 woman physician director can also adequately examine and 
 inspect, when necessary, her pupils. Trouble arises when 
 this is attempted by outside or part-time physicians, and the 
 only economical method in the long run will be for these 
 two or more teachers who meet all the pupils perhaps 
 every week, to be physicians, or have special medical knowl- 
 edge, and do the work of medical examination and Inspec- 
 tion. Many illustrations from life could be given of the 
 even fatal results coming from having under-educated health- 
 development teachers in charge of this vitally essential work. 
 
 Boston gets around this difiiculty partly by having 
 qualified persons in the high schools, partly by having special 
 physicians employed for medical examinations in the high 
 
DIVISIONS OF HYGIENE 275 
 
 schools, and partly by having a director of hygiene who 
 is also a physician. The last is a part of the essentials 
 of the plan proposed by the writer in the next chapter. 
 Let us not forget that under the proper kind of a director 
 of hygiene these high school directors may be taught to 
 do this work satisfactorily in many cases. We have in- 
 stances where regular teachers, working with school phy- 
 sicians, have acquired rare powers in this direction. 
 
 GYMNASIUM AND GYMNASIUM BATHS 
 
 At least sixteen or seventeen of the cities had baths in 
 one or more of the schools, elementary and high, but mostly 
 the latter, and both tubs and showers, but mostly the latter. 
 South Manchester each year gives a good report of the 
 school baths, and we find that at one school during 1910-11 
 as many as 12,858 baths were taken. In all modern schools 
 where there are gymnasiums or where there are equipped 
 playgrounds adjacent, we found one or more shower baths 
 for both boys and girls.* We found that about the same 
 number of cities had gymnasiums as had baths, although 
 they are not co-incident. These are relatively modern 
 additions to schools and school boards have not yet been 
 made to realize the truth for school children, many with- 
 out bath tubs or parents with bath ideals at home, that 
 "cleanliness is next to Godliness." 
 
 In a growing number of cities, through the use of bath 
 rooms in schools for summer playgrounds and for evening 
 recreation centers, there is a tendency for public school 
 baths to become general public baths, and there is little 
 reason why this should not become universal, just as much 
 as the tendency for the school to have within it a branch 
 of the public library or any other of the many agencies 
 which are being developed in response to the peoples' needs. 
 Too often our schools are looked upon as absolute, un- 
 
 *For those interested in the various types of equipment for these 
 health features the reader is referred to the excellent reports and adver- 
 tisements in the School Board Journal, published at Milwaukee. 
 
276 SCHOOL HEALTH ADMINISTRATION 
 
 changing and unchangeable Institutions, instead of institu- 
 tions purchased by the hard toil of the many, and sup- 
 plementary institutions, now idle much of the time, for meet- 
 ing the peoples' needs and perplexing life problems. We 
 need scientific sociologists who can discover the needs, and 
 we must have teachers and leaders who can best help the 
 people to meet them through this single public neighbor- 
 hood institution. 
 
 The many other phases of physical training we shall 
 not here discuss. They are sufficient in all for a much 
 needed book. A recent valuable one along this line but 
 more for adults is "Exercise in Education and Medicine," 
 by Professor R. Tait McKenzie, of the University of 
 Pennsylvania. We should have liked to take space for dis- 
 cussing the work of medical gymnastics along the line of 
 mouth breathing exercises, special exercises for spinal cur- 
 vature cases, and the like. Let us turn our attention, how- 
 ever, briefly to the before-mentioned work of: 
 
 PLAYGROUNDS AND PLAYGROUND TEACHERS 
 
 The following interesting and relatively statistical 
 phases of this new movement were given as much study 
 as possibilities of time and available data permitted : 
 
 1. Number of school-yard playgrounds fitted up with 
 play apparatus and the number supervised, summer or 
 winter. 
 
 2. Number of these playgrounds fitted up or supervised 
 by outside agencies. 
 
 3. Number of playgrounds elsewhere provided by the 
 board of education. 
 
 4. Number of other public supported playgrounds, 
 swimming pools, or beaches. 
 
 5. Number of privately supported playgrounds, other 
 than those at the schools. 
 
 6. Expenditures for salaries of playground directors, 
 teachers, caretakers, etc., by the board of education. 
 
 7. Expenditures for playground apparatus by the board 
 of education. 
 
DIVISIONS OF HYGIENE 277 
 
 8. Expenditures for enlarging old or purchasing new 
 playgrounds, grading, and the like. 
 
 9. Expenditures for playground supplies other than ap- 
 paratus. 
 
 10. Expenditures for the rent of playground sites. 
 
 11. Expenditures for tents, shelters, toilet conveniences, 
 baths, etc. 
 
 12. Number, qualifications, and salaries of playground 
 directors or supervisors. 
 
 13. Number of assistant directors, salaries, etc. 
 
 14. Number of playground instructors, salaries, etc. 
 
 15. Number of weeks employed, and daily and weekly 
 time schedules. 
 
 16. Number of instructors for each playground and how 
 selected. 
 
 17. The games, contests, sports, and problems of the 
 work. The writer was once a public playground instructor 
 and realized some of these problems in advance. 
 
 18. Number of regular class-room teachers who by any 
 inducement, such as the $1.25 at Boston, could be gotten 
 out upon the playgrounds with their children to be young 
 again and play. "Come let us play with our children." 
 
 19. Total expenditures for public school playgrounds. 
 
 20. The methods by which the various private bodies 
 realized their aims in getting playgrounds started in the 
 schools. 
 
 These and a number of other problems were first ob- 
 tained in note-book, and other original data form, and then 
 placed on a statistical table for the twenty-five cities. But 
 it was so much a table of gaps, that it could well be used 
 for study only, and not for printing. A few of the many 
 items necessary for adequate knowledge and careful investi- 
 gation appear in the Physical Education table. 
 
 New Bedford and Boston stand out in the writer's mind 
 and data as being typically progressive along these lines, 
 though several other cities such as Rochester and Newark 
 might also have been named. The data were so hard to get 
 that in many cases we have very inadequate facts or none 
 
278 SCHOOL HEALTH ADMINISTRATION 
 
 to present. In other cases we have been able to get all the 
 data we desired. This seemed especially true of New Bed- 
 ford, where a good deal of scientific management seems 
 to pervade the school administration. 
 
 Very few cities outside of Boston have been doing much 
 with the directed and organized play during the day ex- 
 cept in summer. It is difficult to get teachers for their own 
 or the children's good to go out and play at any time, 
 without pay. In most cases they need special training for 
 such work. The many children who come to school, and 
 should come, as early as eight o'clock in the morning and 
 who stay, and should stay (because of bad home or play 
 conditions elsewhere) till four or five in the evening, should 
 have guidance, protection and educative care. The in- 
 creased health efficiency of the teachers and the decrease 
 of teacher-absence through illness, now so great a source 
 of waste in all cities, might easily be sufficient to warrant 
 a city for mere economy to employ, as does Boston, these 
 out-of-school play teachers. Walks, trips, excursions, 
 "tramps," and the like, on Saturdays, have all been tried 
 by the writer as a school principal and were found success- 
 ful, and might easily be added to the above program. The 
 school system of Gary, Indiana, is working out much in 
 the line of the whole day and year school, that many edu- 
 cators have long experienced as a real need of childhood. 
 
 A remarkable thing was the number of privately sup- 
 ported playgrounds. This has recently been a very popular 
 form of private philanthropy, and should be heartily en- 
 couraged and guided. But the goal of it all must be, of 
 course, adequately organized public management of such 
 agencies. It is remarkable how much the leadership of 
 the superintendent of schools stands out in all these fields 
 of enterprise. Some are excellent, old-time scholars, or 
 "hale fellows well met," but they don't see the need or 
 get the results which a modern community may rightfully 
 expect. 
 
 The summer playgrounds are frequently about eight 
 weeks in duration and are often intimately united with the 
 vacation schools, as they should be. The salaries range 
 
DIVISIONS OF HYGIENE 279 
 
 from fifty to two hundred dollars a month. The tremend- 
 ous development of literature in this field makes unneces- 
 sary detailed statements of costs or methods. The National 
 Playground Association of America with its proceedings, 
 and its magazine, the Playground, the books of Bancroft, 
 Mero, Johnson, Perry, Leland, Lee, and many others; the 
 pamphlets, slides, free information, etc., of the Child Hy- 
 giene Division of the Russell Sage Foundation, and many 
 other expert agencies at the command of public school 
 systems desiring assistance have made unnecessary here ex- 
 tended treatment. It may be well briefly to describe the 
 administration in the New Bedford public school play- 
 grounds. 
 
 A skilled playground director was brought from Toledo, 
 Ohio, and the following force employed for six weeks on 
 eight playgrounds in the summer: 
 
 I supervisor at $200. 
 
 8 directors, one for each playground (men).. $600 — $75 a term. 
 
 8 first assistants (women) 480 — 60 a term. 
 
 8 second assistants (women) 750 — 75 a term. 
 
 8 men assistants 800 — lOO a term, 
 
 8 caretakers, or janitors 240 — 30 a term extra. 
 
 The plan was to have four persons on each playground. 
 There were swings, sand boxes, large combination ap- 
 paratus, teeters, slides, merry-go-rounds, rest rooms fitted 
 up with interesting books for the children by the public 
 library and the schools, use of school toilets and baths, 
 trees and benches for the parents and little mothers, and 
 first-class conditions, generally. At night electric arc lights 
 illuminated the grounds and directed play was still carried 
 on, especially basketball and athletic games and "stunts" by 
 the older boys and young working men, I saw no evidence 
 of home-made, or manual-training-made apparatus, which 
 I think should be encouraged and which I have found school 
 boys even below the eighth grade quite able to construct 
 when properly guided, from getting the materials from 
 the mills to digging the holes and painting the constructions 
 bottle-green. All the apparatus was very finely constructed, 
 durable and expensive. It seems that where there is time, 
 
28o SCHOOL HEALTH ADMINISTRATION 
 
 home blacksmiths could make most of the apparatus of 
 playgrounds for which present companies are charging 
 almost exorbitant and seemingly trust prices. The boys 
 should in every case possible be given, also, a chance to 
 show their hand. 
 
 Having reached our space limit for the various forms 
 of Physical Education, let us take a brief survey of one 
 of the three remaining divisions of educational hygiene in 
 these cities. 
 B. School Sanitation. 
 
 Recent surveys of the hygienic aspects of the school 
 environment of our children by the LInited States Govern- 
 ment and other agencies have shown that they are in gen- 
 eral far below the health ideals, knowledge and standards 
 of the present day. One writer has declared that it would 
 be a hygienic providence if half of the vilely constructed 
 and situated school-houses of this country were to burn 
 down, in order to make possible school environments suited 
 to present-day needs and conditions. The writer visited 
 one or more, and as many as ten, school buildings in each 
 city visited, excepting the fifteen not used for this study. 
 Some of the new schools are very close to the best hygienic 
 ideals, and their numbers are fortunately growing. We 
 should have state laws requiring the submission of all plans 
 for school buildings to an expert, up-to-date school architect 
 In the state education department, to help cities avoid the 
 employment of so-called architects who have never planned 
 anything much more elaborate than a sawmill, or common 
 warehouse, and these only by copying imitatively some long- 
 existing structure. 
 
 Our chief method was to learn about some of the more 
 administrative aspects of the school sanitation problem. 
 Some of the features investigated more or less closely 
 were: 
 
 1. The number, kind, cost and efficiency of the various 
 types of sanitary drinking fountains installed. 
 
 2. The kinds, number, cost and efficiency of the vacuum 
 cleaning plants in use, discarded or proposed. 
 
DIVISIONS OF HYGIENE 281 
 
 3. The number and kinds of fan systems of ventilation 
 in use, the attempts to humidify the air, the use of humi- 
 diometers and regulators of temperature and moisture. 
 
 4. The new types of school seats which make cleaning 
 easy, and especially the use of vacuum cleaners. 
 
 5. The construction, location and arrangement of open- 
 window rooms in schools. 
 
 6. The amounts, kinds, efficiency and cost of the floor 
 oils used. 
 
 7. The amounts, kinds, efficiency and cost of dust-ab- 
 sorbing compounds used in sweeping, as well as the use 
 or non-use of the feather dust-raiser. 
 
 8. Paper or cloth towels, number, cost, kinds, and effi- 
 ciency. 
 
 9. Amounts, kinds and use of disinfectants for schools. 
 
 10. The use of individual drinkings cups, and how cared 
 for. 
 
 11. Experiments and investigations in the field of school 
 sanitation. "Re-circulation" has not yet reached the 
 schools. 
 
 12. The general hygienic character of the buildings vis- 
 ited, including fire-proofing, and all the various modern 
 improvements for making cleanliness easily possible. 
 
 13. General management of the cleaning and janitorial 
 service, and how paid, feudally or individually. 
 
 A large amount of data was collected on these phases 
 but the matter makes but poor statistical tables because of 
 the aforesaid lacunas. 
 
 There was some remodeling of the heating, ventilating, 
 toilet, and other sanitary provisions in old schools of a 
 number of systems, Syracuse and New Bedford being espe- 
 cially busy along this line, it seemed. 
 
 Sanitary drinking fountains were found in practically 
 all school systems, but in many, these were only samples 
 sent in by various companies in hopes of an Order. South 
 Manchester, Norwood, Winchester, Montclair, Hoboken, 
 New Bedford, Cambridge, and Boston had them in almost 
 every, or in every school. The Keith bubbler seemed most 
 
282 SCHOOL HEALTH ADMINISTRATION 
 
 used and satisfactory, although a host of other types were 
 being tried out. The writer saw fifteen or sixteen that had 
 been placed over the watering troughs of the boys' play- 
 room in one school in Jersey City. Only one or two were 
 still "in the ring," as the boys said. One or two had been 
 taken off because of the breaking of children's teeth on 
 them in the jostling crowd. The following requirements for 
 such fountains seem to stand out: 
 
 1. They must be very strong and durable, not getting out 
 of repair, nor weak enough in any part to be screwed or 
 pulled off or apart. 
 
 2. They must provide cool water, not warm, in a sani- 
 tary manner, with no part touching the pupil, if possible, 
 that is not immediately washed off. A small leak, or a plan 
 for turning the water on and off by the janitor, or the pos- 
 sibility of running out a large amount of water quickly "to 
 get down to the cool" is necessary. 
 
 3. They must be in batteries and over troughs to pro- 
 vide for many children, without making a flood on the 
 floor. 
 
 4. They must be safe, so no child may be cut, get his 
 teeth broken, or anything of the kind even when pushed 
 about. Good janitor service and training are necessary 
 here also. 
 
 5. They must not be very wasteful of water, although 
 considerable loss is here expected. 
 
 6. They must be placed on every floor, or one in every 
 room, as well as in the basement play-rooms. Plenty of 
 pure water is desirable for children. 
 
 7. They must be relatively inexpensive, although certain 
 cities bought very costly porcelain standards and fountains 
 at great cost. 
 
 8. It should be made impossible for one child to squirt 
 water over an entire group or hall. 
 
 9. If placed out of doors it must not rust and it must 
 not freeze. 
 
 10. It should be self-closing; and the bubble or fountain 
 
DIVISIONS OF HYGIENE 283 
 
 of water should not rise at any time more than one and a 
 half inches.* 
 
 The prices range around three to six dollars apiece, al- 
 though the porcelain standard one, such as used in Mont- 
 clair in a new school, costs about fifty dollars apiece. New 
 Bedford paid $1,093 ^or 117, connected and in place, I 
 believe. 
 
 VACUUM CLEANING PLANTS 
 
 Very few cities were using vacuum cleaning plants in 
 the schools. South Manchester was the only city using them 
 in all schools, and the 1909 report of the superintendent 
 speaks very highly of them. I saw the method of using 
 them in the high school and agreed that they probably were 
 very desirable. The newer schools in Newark are utilizing 
 them. Montclair has a building piped for their use but 
 has not yet put in the apparatus. The piping can be easily 
 done in new but not in old buildings, so putting them in is 
 wise foresight, it seems. Waterbury was tearing up the 
 high school to get pipes in when I was there. Boston had 
 three such plants, two having been installed in the year. 
 Rochester had put a plant in several years before (1908) 
 in a grammar school, but it had proved useless because of 
 the faults of the apparatus perhaps, but more because the 
 head janitor was paid a lump sum, and the women helpers 
 he employed could not manage the apparatus. "It was 
 more bother than it was worth" to them. There are easier 
 and dustier ways. Careful investigation and experiment, 
 careful selection of janitors on other than the feudal sys- 
 tem, probably, careful training of janitors in the use of 
 the apparatus, carefully constructed floor (we need com- 
 position floors that are effective), and careful selection of 
 fewer-legged desks and seats are all necessary for the best 
 use of vacuum cleaners. 
 
 *The School Board Journal above referred to has many advertise- 
 ments and cuts of various makes, and any school system can easily get 
 the chance to try out any number desired. Such experimentation is 
 desirable before purchasing. 
 
284 SCHOOL HEALTH ADMINISTRATION 
 
 SANITARY SCHOOL DESKS AND SEATS 
 
 Real educational school desks will probably be, as in 
 the University of Chicago model school, work benches or 
 combination working desks, movable, adjustable and with 
 movable seats. Such desks are not used. The usual type 
 has four or more legs close to the floor and screwed 
 down. This is the child's stationary stall, for silent, seden- 
 tary, bookish work. It does not meet the needs of the all- 
 around school life. However, there are school desks and 
 seats that have all the disadvantages of being stationary and 
 fixed, and without some of the "new-fangled notions" of 
 combination work-bench-desk, but having, alas, the quality 
 of being adjustable to the child, that can be swept under 
 and kept in sanitary condition. I refer to the oval base, 
 single-pedestal combined seat and desk invented by a Boston 
 janitor and improved upon and sold in the market by a 
 well-known seating firm. Here is only one pedestal for 
 each child in the room instead of four. When poorly put 
 down they become "wobbly," and the boy in front can spoil 
 the writing of the boy behind, but this insecurity is unnec- 
 essary. The Moulthrop movable school chair is also be- 
 coming popular. 
 
 Adjustable desks were used in only a part of the cities 
 and in only a part of the schools. A city may reply to a 
 questionnaire that it uses adjustable desks and have only 
 a few in use. This is a weakness of the investigation re- 
 ported in Chapter Two. 
 
 In Boston, the School House Commission has always 
 been in the lead of most cities in problems of school archi- 
 tecture and sanitation. It has done most in the way of 
 devising the proper kinds of windows in south-exposed 
 rooms, for open-air rooms. It also sent a deputation to 
 Chicago to study open-window and open-air schools there, 
 "with little profit." It has also done most in the study 
 of humidifying the school atmosphere, and the lack of 
 agreement among experts in ventilation consulted has al- 
 most brought matters to a standstill until the problem is 
 less obscure. There are, however, examples of humidifiers 
 
DIVISIONS OF HYGIENE 285 
 
 and regulators that seem to work to great advantage, as 
 at the Horace Mann School, Teachers College, Columbia 
 University. A steam pan is used, and several barrels of 
 water are sometimes used in a day in keeping up a 55 per 
 cent saturation, and a 65 degree class-room temperature, 
 all automatically regulated by wet bulb and dry bulb humidi- 
 ometers by the Johnson Service Company. 
 
 FLOOR OILS 
 
 Floor oils are quite commonly used, and are bought for 
 from ten cents to more than a dollar a gallon. Experiments 
 and analyses at Rochester and try-outs at West Orange 
 seemed to show that there was little difference between oil 
 of the two prices. A city could get about the same oil for 
 the price it wished to pay. We very much need adequate 
 experimental testing of many more or all of the various 
 kinds of school supplies and equipment. We need better 
 use and test of what we get, as well as "more money for 
 public schools." 
 
 Oil carefully put on, left to dry, and then wiped off with 
 cloths, during a two or more days' vacation has in a more 
 or less scientific manner been found very desirable in keep- 
 ing schools clean, and little complaint from women teach- 
 ers about their skirts have arisen. In the writer's own 
 school the women teachers voted to have oiling stopped, 
 but after an experiment of three or four weeks voted to 
 have it renewed. The matter has been tested out in various 
 ways. We need a careful experimental and adequately con- 
 trolled test of the whole method. Some insist on bare floors, 
 others on oiled floors. Differences in floors and jani- 
 tors count, but the matter can be comparatively and experi- 
 mentally proved. 
 
 DUST ABSORBING COMPOUNDS AND SPRAYS 
 
 It is remarkable what a variety of products are used 
 in this field. It is encouraging to see something of the 
 kind used, but again we have little proof of the value of 
 any one kind over others. About twenty of the cities used 
 
286 SCHOOL HEALTH ADMINISTRATION 
 
 damp sawdust or one or more of the various kinds of 
 no-dustos, dustalines, no-more-dust, sprays (Rihac), etc. 
 What must be had is the experimental testing of these 
 expensive theories. Perhaps damp sawdust is sufficiently 
 efficient. Perhaps it would be cheaper to put in vacuum 
 cleaners. Perhaps oil brushes are better. Who knows? 
 
 PAPER VS. CLOTH TOWELS 
 
 Paper towels seem easily to be winning out over the old 
 common cloth towel. Many cities were trying them, and 
 some cities, like New Bedford, Montclair and others, had 
 definitely adopted them for all children. They are now 
 so cheap, so thoroughly individual, so sanitary, and so 
 effective, if well chosen through experimental testing, that 
 there is no longer any excuse for the old, indecent, filthy 
 and generally de-educating lack of proper sanitary neces- 
 sities yet so common. We teach and preach to our children 
 in the classrooms about the dangers of carriers and Typhoid 
 Marys, and then fail to provide conditions which will make 
 possible the acquisition of anti-Typhoid Mary habits in our 
 class and toilet rooms. Every child should have warm 
 water with which to wash his hands, liquid soap for the 
 inevitable grime of the real playground and real boy, good 
 absorbent paper towels, satisfactory arrangements for 
 plenty of good drinking water obtained without danger to 
 life and limb ; clean, well-equipped and sufficient toilet facili- 
 ties, a drying and warming place for himself and his clothes 
 when he comes wet and cold to school (perhaps without 
 breakfast, or one of only coffee and bread) , a place to clean 
 his shoes and insistence on it, a place to hang his clothes 
 that is warm and dry and supplied with hooks that keep 
 the clothing and possible contagion far apart instead of 
 huddled together for the benefit of scarlet fever, diphtheria 
 and very much larger germs. The only kind of health 
 knowledge and hygiene for our pupils is the kind that mill 
 eventuate in adequate health habits, and how many schools 
 even fairly meet the simple essential sanitary standards 
 above named? Entirely too few. 
 
DIVISIONS OF HYGIENE 287 
 
 We must close the report of this division. Better sani- 
 tation is approaching slowly, and for its slowness there is 
 a reason, convincing to the writer, and to be given at the 
 end of the chapter. 
 
 C. The Teaching of Hygiene. 
 
 We meet the same situation in the field of the teaching 
 of hygiene, a form of knowledge, habits and ideals much 
 more important in the modern world than probably three or 
 four entire subjects now tremendously emphasized "for 
 their formal disciplinary value" in our high schools and 
 probably one or two in our elementary schools. And yet 
 the subject is a tail-end subject, little emphasized, and fur- 
 nished with poor textbooks for the most part and very 
 frequently with poor teachers in the grades or high school. 
 Colleges do not generally give credit for, nor demand a 
 knowledge of, this vitally essential subject of health and 
 how to get and maintain it, much to their disparagement, 
 and consequently we find many schools almost entirely 
 neglecting it.* And yet the cadets march by, with sunken 
 chest and defective eye, all but those who have dropped 
 by the wayside through death and illness; and the medical 
 inspectors continue to report their ailments by the thousands. 
 The problems of the people are the problems of education. 
 Health is a prime problem, and health knowledge measuring 
 up to our needs today is one of those alphabetic concepts 
 which every child must have whether he ever sees a gram- 
 mar or an algebra or a Caesar or a geometry or a moderr 
 foreign language in his life. 
 
 Health teaching is in these cities evidently "seriously 
 defective," in the words of the New York School Inquiry 
 Report, and most educators today are realizing it and 
 gradually beginning to introduce pragmatic changes. 
 
 I learned in most cities how much time was given to 
 the subject of hygiene in all grades, elementary and high 
 schools, and the texts used. We shall not repeat here the 
 names of many of the texts. In the older days of logic, all 
 
 *See Johnston's High School Education, volume one. 
 
288 SCHOOL HEALTH ADMINISTRATION 
 
 our subjects began with the anatomy of the subject, the 
 dry-bones, so to speak, the formal grammar, the letters, the 
 parts of a letter in penmanship, celestial mechanics in geog- 
 raphy, the bones of arithmetic, etc. One of the old books 
 on "Anatomy and Physiology for Children," or some such 
 title actually started out with a chapter entitled, "Dry 
 Bones," and all the 206 with their good points were to be 
 learned by heart, with never a mention of how to live 
 healthily and happily in this world. Then came the physi- 
 ology period, when we learned some anatomy and much 
 of the chemistry of digestion and respiration, etc. Today 
 the subject is at last becoming socialized and changed from 
 a logical, abstract science to a vitally essential scientific art, 
 ministering to the health needs of our people. Some of 
 these older texts are still being used in the cities visited, 
 and in very few of the cities in elementary or high school 
 is the subject given the time and texts which its known 
 value warrants and demands. 
 
 The Ritchie Hygiene series and that by Gulick and Jewett 
 seem at present to be in advance of all others. We found 
 them used in but ten cities. In most of the other cities 
 where I had an opportunity to talk with the superintendent 
 on the matter of school hygiene texts, I found books from 
 one of these two suggested series either ordered, about to 
 be ordered, or actually being experimentally tried out in a 
 few rooms. Probably a search of the present book lists of 
 these cities would show better supplies of more modern texts. 
 One subject of great importance but little taught is that 
 of industrial hygiene. Another is sex hygiene. 
 
 Teachers are not adequately trained in this subject in 
 most normal schools and consequently have not the interest 
 In, or such a knowledge of, the subject as Is desirable. 
 Lacking health education, and in their comparative isola- 
 tion from the problems of life, we find that they cannot 
 clearly see "what knowledge is of most worth" to their 
 pupils. The modern world is becoming aware of Its health 
 
 Note. — Colton's new book on "The People's Health" by Mac- 
 millans is a very valuable contribution to upper-grade texts in hygiene. 
 
DIVISIONS OF HYGIENE 289 
 
 heritage and health knowledge now possessed by but a few 
 is rapidly coming to be democratized, so we may expect 
 soon the most rapid changes toward meeting the real needs 
 of real life. Good textbooks are indispensable for the 
 best results for American teachers in general, and their 
 selection, as well as the time allotment, are matters for 
 close study. 
 D. The Hygiene of Teaching. 
 
 This division of educational hygiene is usually called 
 "the hygiene of instruction," but instruction is only a part 
 of the teacher's work and the life of the school. The 
 French are wont to contrast instruction and education. The 
 German or French teacher instructs all his classes all day 
 long. The American teacher gives time for individual 
 study, self-help, and individual guidance, for teaching in 
 the best sense, and so we use the term, the Hygiene of 
 Teaching. 
 
 A teacher may teach hygiene for such long periods or 
 in so dry and dismal a way as to over-fatigue and depress 
 her pupils. She may teach splendidly the subject of tuber- 
 culosis in a school-room with all windows tightly closed and 
 the air so thick and vile that little lungs easily become sus- 
 ceptible to the germs she teaches the children to dread. 
 She would have taught better had she opened her windows 
 in a proper manner. Again she may be teaching quite effec- 
 tively, from the intellectual side, the hygiene of vision, and 
 yet the print of the books she has placed in her pupils' hands 
 may be so atrocious that most children suffer from eye- 
 strain after the study period; or again her curtains may be 
 so arranged that with well printed books and good teaching, 
 she may be injuring her pupils' eyes by bad lighting, while 
 discussing the danger. All these are mistakes in the hygiene 
 of teaching and there are multitudes more which the un- 
 hygienically trained teacher will make continually in any 
 few days of time. 
 
 Other topics in this field, but not studied in the inves- 
 tigation because of the room-to-room character of the work, 
 are : fatigue, school program, one session or two sessions, 
 
290 SCHOOL HEALTH ADMINISTRATION 
 
 recesses or no recesses, rest periods, the type of books, the 
 adjustment of the daily surroundings of pupils to their 
 bodily needs, the health results of marks and examinations, 
 the teacher's responsibility for the increase of defects of 
 vision, for choreic, anemic and debilitated children, the 
 development of healthful habits and interests, and ways of 
 study and doing work; in general, the most harmonious 
 guidance of the school life of the pupil and his fellows, in 
 order that there may be a real hygiene of living, a hygiene 
 that "will make growth more perfect, life more vigorous, 
 decay less rapid, death more remote." 
 
 CONCLUSIONS 
 
 In this chapter we have taken a rapid survey of the 
 last four divisions of educational hygiene as practiced in 
 these cities, and as they should have been practiced. We 
 have found them in a transitional stage and changing in a 
 few years from a more static, isolated attitude toward the 
 problems of school health, to a more socialized, scientific 
 and democratic attitude. Some of the cities will probably 
 be little further advanced in the next decade, but the most 
 of them will before long undoubtably make most of "the 
 things hoped for" an actual realization. 
 
 The principal drawback, as I see it, is neither the lack 
 of money nor the backwardness of the people and the 
 superintendent, but in the gap existing In practically each 
 school system that should be filled by a person specially 
 intelligent, responsive and able in health matters. The 
 ordinary superintendent probably does not give a large 
 fraction of one per cent of his time and energy to the prob- 
 lems of educational hygiene. He and his supervisors and 
 his teachers are otherwise engaged. The intellectual aspects 
 of life are those which absorb his and teachers' energies. 
 He appreciates somewhat the health needs but he does not, 
 or can not, take time for them. The solution of the health 
 problem in the schools will come, as we have seen all along 
 throughout the book, only in the appointment of a thor- 
 oughly qualified man, educated in medicine and school hy- 
 
DIVISIONS OF HYGIENE 291 
 
 giene, and given the entire management and responsibility 
 for the health aspects of education. Only then, I believe, will 
 health become a reality in our schools, and educational 
 hygiene now In Its Infancy become a scientific art. 
 
 The following chapter brings all the suggestions of the 
 book together In the form of a rather detailed and prac- 
 tical plan for reaching this much-to-be-desired goal, in the 
 adequate administration and reorganization of all the divi- 
 sions of educational hygiene. 
 
HEALTH EFFICIENCY THROUGH NOR- 
 MAL EDUCATION 
 
 With the increasing socialisation of education 
 we may look forward toward a more normal 
 mental and physical life for school children. The 
 older methods of sentencing growing children for 
 many years to sedentary book-reading in sta- 
 tionary seats are beginning to pass away. Chil- 
 dren are no longer looked upon by the best 
 teachers and administrators as mere disembodied 
 mentalities, but school life is becoming an all- 
 round life largely consisting of useful, socialising 
 and energising motor work and play. The school 
 grounds are becoming community parks and 
 recreation centers taking the place of the village 
 green of the olden times; the school building is 
 being transformed into a house of childhood ade- 
 quately adapted to the real nature of children and 
 the needs of society; and the old Greek spirit of 
 all-round joyous efficiency is coming by a new 
 birth again into its oivn.. We need many more 
 experimental schools that, like Tuskeegee, Abbots- 
 holme, Inter-laken, and the various consolidated 
 farm schools, ivill lead the way into this broader 
 and less artificial education. Health efficiency 
 through normal living is an actual possibility. 
 
 292 
 
PART THREE 
 
 THE ADMINISTRATION OF MEDICAL INSPECTION 
 
 (Part three may also be had in separate pamphlet 
 torm for the use of teachers, nurses, doctors, etc. The 
 blank forms herein described may be purchased in 
 quantities from the publishers. Teachers College, Co- 
 lumbia University, Publication Department, New 
 York City.) 
 
 293 
 
ENLARGING SCOPE OF THE SCHOOL 
 
 "The complete pedagogy of the future when 
 it comes will he larger than it has yet entered 
 into the heart of any man to conceive. Thus the 
 present situation should appeal to the best young 
 men as education has never before appealed. All 
 the four or five score of child-helping-welfare 
 agencies must and will he correlated with the 
 school and directed from one central bureau, so 
 that each child can be placed just where in the 
 whole system it will get the most good. Each, 
 too, will not only he inspected medically and 
 morally, hut studied for vocational aptitudes." — 
 G. Stanley Hall, in Introduction to "Educational 
 Problems." 
 
 294 
 
CHAPTER ELEVEN 
 THE ADMINISTRATION OF MEDICAL INSPECTION 
 
 A TENTATIVE STANDARD PLAN 
 
 I. GENERAL ORGANIZATION 
 
 A. Each school system able to afford it, and few can- 
 not, should have an organized Department of Hygiene, 
 with a Supervisor of Hygiene, correlative with other super- 
 visory departments in the schools. It should be called the 
 Department of Hygiene to avoid confusion with the depart- 
 ment of health oi the city. It need not be entitled the 
 "Department of School Hygiene" for the same reason that 
 the department of drawing is not called the department of 
 school drawing. Neither need it be called the "Department 
 of Hygiene and Physical Training," nor any other such 
 combination. The word Hygiene is as broad as Health 
 and may be used to cover all health agencies of the public 
 schools, namely: 
 
 1. Medical Inspection. 
 
 2. Physical Education. 
 
 3. School Sanitation. 
 
 4. The Teaching of Hygiene. 
 
 5. The Hygiene of Teaching. 
 
 The function of such a department is to coordinate and 
 make efficient through organization, inspiration, and super- 
 vision all the heterogeneous agencies for the promotion of 
 the health and normal physical development of the school 
 children. 
 
 SCOPE 
 
 A large number of the more or less neglected problems 
 of school health and national vitality would thus come 
 within the scope of this department, among which may be 
 
 295 
 
THE DIVISIONS OF EDUCATIONAL 
 
 HYGIENE 
 
 Supervisor of Hygiene 
 
 MEDICAL 
 SUPERVISION 
 
 SCHOOL 
 SANITATION 
 
 PHYSICAL 
 EDUCATION 
 
 TEACHING 
 HYGIENE 
 
 HYGIENIC 
 TEACHING 
 
 NURSES AND 
 DOCTORS. 
 
 INSPECTIONS 
 AND ANNUAL 
 EXAMINATIONS 
 
 SCHOOL 
 CLINICS. 
 
 HEALTH 
 
 CENSUS. 
 
 DISCOVERING 
 
 HEALTH 
 
 NEEDS. 
 
 CO-OPERATING 
 WITH BOARDS 
 OP HEALTH 
 AND PRIVATE 
 ORGANIZA- 
 TIONS. 
 
 OPEN AIR 
 SCHOOLS. 
 
 LIMITING 
 DOCTORS TO 
 EXAMINA- 
 TIONS, 
 
 SUPERVISION 
 OF NURSES 
 AND WORK 
 IN CLINICS. 
 
 PSYCHOLO- 
 GISTS, 
 OCULISTS, 
 SURGEONS, 
 DENTISTS, 
 PHYSICIANS. 
 
 SUPERVISION 
 OP SCHOOL 
 FEEDING. 
 
 SCIENTIFIC 
 STUDIES OF 
 PREVENTION 
 AND CAUSE 
 OF DISEASE. 
 
 CAREFUL 
 
 RECORDS 
 
 EMPHASIZING 
 
 SERIOUS 
 
 AILMENTS 
 
 FOUND AND 
 
 CURED. 
 
 TRAINING 
 SCHOOL 
 NURSES FOR 
 ALL INSPEC- 
 TION AND 
 EXAMINATION. 
 
 NURSES AS 
 
 ATTENDANCE 
 
 OFFICERS. 
 
 SCHOOL SITES 
 AND ARCHI- 
 TECTURE. 
 
 VENTILATION. 
 
 LIGHTING. 
 
 HEATING. 
 
 DRINKING 
 WATER AND 
 FOUNTAINS. 
 
 SCHOOL 
 CLEANING. 
 
 VACUUM 
 CLEANERS. 
 
 SCHOOL 
 BATHS. 
 
 HYGIENIC 
 
 TOILET 
 
 FACILITIES. 
 
 SCHOOL SEATS 
 AND DESKS. 
 
 DECORATION. 
 
 THE STAND- 
 ARD SCHOOL 
 ROOM. 
 
 FIRE-PROOF 
 CONSTRUC- 
 TION. 
 
 HEALTH, REST, 
 AND EMER- 
 GENCY ROOMS. 
 
 PLAYROOMS 
 AND ROOF 
 PLAYGROUNDS. 
 
 OPEN WINDOW 
 ROOMS. 
 
 SUPERVISION 
 OF JANITORS. 
 
 HYGIENIC 
 CLOAK ROOMS. 
 
 DRYING AND 
 
 WARMING 
 
 SEATS. 
 
 INVESTIGA- 
 TIONS OF RE- 
 CIRCULATION, 
 HUMIDITY. 
 AIR-CLEAN- 
 ING, DISIN- 
 FECTION, ETC. 
 
 PLAY AND 
 PLAYGROUNDS. 
 
 PHYSICAL 
 TRAINING 
 AND GYM- 
 NASTICS. 
 
 MEDICAL 
 GYMNASTICS. 
 
 ATHLETICS 
 AND LEAGUES. 
 
 POSTURE AND 
 CORRECTIONAL 
 
 EXERCISES. 
 
 ASSISTING 
 IN MEDICAL 
 SUPERVISION. 
 
 RECREATION. 
 
 SCHOOL 
 EXCURSIONS 
 AND TRAMPS. 
 
 BOY SCOUTS 
 AND CAMP 
 FIRE GIRLS. 
 
 GYMNASIUMS 
 AND ATHLETIC 
 FIELDS. 
 
 SWIMMING 
 AND BATHING. 
 
 POOLS, SHOW- 
 ERS AND 
 BEACHES. 
 
 POLK 
 DANCING. 
 
 PHYSICAL 
 EDUCATORS 
 WITH MEDICAL 
 KNOWLEDGE. 
 
 HIGH SCHOOL 
 CADETS. 
 
 CLASS ROOM 
 GAMES. 
 
 PAY FOR 
 
 SUPERVISING 
 PLAY AFTER 
 SCHOOL AND 
 SATURDAYS. 
 
 CULTIVATING 
 THE GREEK 
 IDEAL OF 
 PHYSICAL 
 AND MENTAL 
 PERFECTION. 
 
 HEALTH EDU- 
 CATION OP 
 TEACHERS. 
 
 ADVISING 
 CHOICE OP 
 BEST HYGIENE 
 TEXTS AND 
 TOPICS. 
 
 FORMING 
 PERSONAL 
 HYGIENE 
 HABITS. 
 
 PUBLIC 
 HYGIENE 
 STUDY AND 
 CO-OPERATION. 
 
 HEALTH EDU- 
 CATION OP 
 PARENTS. 
 
 FEEDING, 
 CLOTHING 
 AND SLEEP 
 OP CHILDREN. 
 
 HOME HYGIENE 
 IN DOMESTIC 
 SCIENCE. 
 
 VOCATIONAL 
 HYGIENE IN 
 INDUSTRIAL 
 SUBJECTS. 
 
 TALKS BY 
 DOCTORS, 
 NURSES AND 
 SPECIALISTS. 
 
 FIRST AID. 
 
 SEX HYGIENE. 
 
 STUDYING 
 
 COMMUNITY 
 HEALTH 
 PROBLEMS 
 AND METHODS 
 OF IMPROVE- 
 MENT. 
 
 DAILY ORAL 
 QUESTION- 
 NAIRE ON 
 HOME 
 HYGIENE : 
 USE OF 
 TOOTH-BRUSH, 
 COFFEE 
 DRINKING, 
 VENTILATION, 
 ETC. 
 HEALTH 
 KNOWLEDGE, 
 HEALTH 
 IDEALS, 
 HEALTH 
 EFFICIENCY. 
 
 "THE HYGIENE 
 OP INSTRUC- 
 TION." 
 
 FATIGUE, 
 OVER-WORK 
 AND UNDER- 
 WORK. 
 
 THE TYPE OP 
 BOOKS. 
 
 THE HYGIENE 
 OF SCHOOL 
 SUBJECTS. 
 
 INTEREST AND 
 ATTENTION. 
 
 INTER-RECI- 
 TATION RE- 
 CREATION. 
 
 TRANSFORM- 
 ING NEURAS- 
 THENIC AND 
 "CRANKY" 
 TEACHERS. 
 
 MO.TOR 
 ASPECTS OF 
 TEACHING. 
 
 THE GOSPEL 
 OP WORK. 
 
 THE HYGIENE 
 OP JOY IN 
 SCHOOLS. 
 
 PREVENTING 
 PHYSICAL 
 DEFECTS AND 
 PATHOLOGICAL 
 CONDITIONS. 
 
 SCHOOL 
 PROGRAMS. 
 
 PART-TIME OR 
 WHOLE-TIME. 
 
 INFLUENCE 
 OF VACA- 
 TIONS AND 
 HOLIDAYS. 
 
 HEALTH IN- 
 DIVIDUALITY. 
 
 HYGIENIC 
 EFFECTS OP 
 DIFFERENT 
 METHODS. 
 
 THE TEACHER 
 AS MEDICAL 
 GUARDIAN. 
 
MEDICAL INSPECTION PLAN 297 
 
 named: * play and playgrounds, selection of school sites 
 and special phases of school architecture from the hygienic 
 standpoint, pure water, school cleaning, gymnasiums, ven- 
 tilation, heating and lighting, athletics, physical training, 
 summer playgrounds, evening recreation centers, selection 
 of textbooks for the teaching of hygiene, the print of books, 
 problems of fatigue and school programs, home study, 
 proper seating, feeding of the under-nourished, open-air 
 and open-window schools, the work of school doctors, 
 nurses, dentists, oculists, and the school clinics, co-operation 
 with dispensaries, hospitals, infirmaries and private bodies 
 desiring to aid school health work, and, finally, the educa- 
 tion of the public along all lines of educational hygiene and 
 the care of school children. 
 
 B. The Director of Hygiene should be a doctor of 
 educational hygiene, or a doctor of public health (D. P. 
 H.) Lacking training colleges for such men as yet, a 
 physician who is a specialist in children's diseases and who 
 has made a special study of the science and practice of 
 educational hygiene, at least of physical education, and has 
 had successful experience in it, should (by competitive 
 examination) be selected. A number of physicians, qualified 
 fairly well by study and successful experience in school sys- 
 tems, colleges, normal schools, Y, M. C. A.'s and children's 
 hospitals and clinics, are at present available at salaries 
 from $2,000 to $4,000 a year, and the demand will lead 
 to an adequate future supply. Several cities now have 
 such directors. After a brief search the writer has found 
 twenty men qualified and available for such work. 
 
 The health of the children of the schools and nation 
 will not be adequately preserved and protected until such 
 a definite organization and such health leaders are incor- 
 porated in school systems. Efficient leadership furnishes 
 
 *See elaboration of these phases in Hygiene and Physical Educa- 
 tion, for June, 1909, in The Progressive Journal of Education for 
 September, 1909, American Education for April 1912, Education for 
 December, 1912, in School and Home Education for May, 1912, and in 
 The Journal of Education for February 27, 1913. 
 
298 SCHOOL HEALTH ADMINISTRATION 
 
 that scientific management, inspiration, and breath of life 
 necessary in all successful social organization, and the school 
 cannot afford longer to miss its advantages in the funda- 
 mental field of health. 
 C. Scientific Organization with Little Increased Expense. 
 
 The expenditure for such a Supervisor of Hygiene, in 
 cities that already are doing their duty to the children in 
 the line of health, with school doctors, nurses and physical 
 training teachers, frequently may require little or no addi- 
 tion to the present school budget, the work being merely 
 that of reorganization of the various health provisions 
 which have, in various ways and for several years, been 
 coming into the school systems. In all but the largest cities 
 the director can take the place of one or more part-time 
 physicians, and can also do the work of one or more super- 
 visors, or teachers, of physical training in the elementary 
 schools. Money can also be saved by having him direct the 
 summer playground work which now costs a number of 
 cities considerable sums, the school clinic or clinics when 
 started, high and elementary school athletics, evening recre- 
 ation, and a number of other savings which may go to 
 make up his salary. The nurses, when so directed, may 
 take the places of attendance officers in many cities and 
 so save another considerable item. 
 
 The present expenditures in these fields and the reorgan- 
 ized expenditures have been given in preceding chapters 
 and tables. Most cities have not yet caught up with the 
 school health needs; but most cities of average size can 
 secure such departments of hygiene for little over two to 
 three per cent of current school expenditures. In many, 
 the added expense will, as suggested, be inconsiderable. 
 
 For further concreteness, the old and the new reorgan- 
 ized expenditures, for a fairly typical city already possess- 
 ing the elements of such a department, are here given. 
 This city has a population of about 50,000; there are 15 
 schools, a public school average enrollment of 6,000 pupils; 
 and annual current expenditures amounting to about 
 $250,000. 
 
MEDICAL INSPECTION PLAN 299 
 
 OLD, UNCORRELATED SYSTEM 
 
 2 high school teachers of physical training $2,200 
 
 2 elementary school teachers of physical training 1,800 
 
 6 physicians, two one-hour school visits weekly, at $300 i,8oo 
 
 3 school nurses, 44 hours a week, at $750, ten months 2,250 
 
 Total $8,050 
 
 RE-ORGANIZED, DIRECTED SYSTEM 
 
 1 supervisor of hygiene, full time, 11 months $3,000 
 
 2 high school teachers of physical education 2,200 
 
 I assistant physician, two hours a day, ten hours a week 400 
 
 3 school nurses, 44 hours a week, 2 at $825, i at $750 2,400 
 
 Total $8,000 
 
 Here we have the new organized and directed system 
 at less than the original cost. There remain fifty dollars 
 toward more efficient records and blank forms. We have 
 deducted nothing for saved expenditures for attendance offi- 
 cers, playground direction, etc., nothing but five unneces- 
 sary part-time physicians and the two elementary teachers 
 of physical training. Where the latter officials are paid 
 less in the old system and the supervisor $2,500 instead 
 of $3,000, there is another balancing of expenditures. The 
 point is that the added expense need not be great. 
 
 The third nurse may not be added the first year, which 
 would give a further reduction of $750. Perhaps scientific 
 management may make her permanently unnecessary in 
 many cities. 
 
 The supervisor can, with the daily help of one of the 
 two or three nurses, for two hours a day, examine the same 
 number of children as the assistant physician, 3,000; and 
 he can call the teachers together by grades and teach them 
 how to carry on the physical-training work at the schools; 
 and can take part of each day in supervising their work. 
 
 The assistant physician is paid $100 more a month, and 
 gives two full hours in one school daily. With the assist- 
 ance of one of the nurses he can examine during the school 
 year the other half of the school population (3,000 pupils), 
 and can help make such inspections as are necessary. The 
 third nurse, if employed, is left free for individual and 
 
300 SCHOOL HEALTH ADMINISTRATION 
 
 class-room inspections and for follow-up work. Neither the 
 teachers nor the physicians are bothered with vision and 
 hearing tests, the nurses making them; and practically all 
 clerical work connected with medical supervision will also 
 be done by the latter. The physicians will be free for tech- 
 nical medical work, and the teachers will be less interrupted. 
 
 Two of the nurses are paid for an extra month in the 
 summer, one for July and one for August, to follow-up 
 cases not cured at the end of the school year and for neces- 
 sary inspection of children at summer schools and play- 
 grounds. Some of the most valuable work now being done 
 by nurses is accomplished in these summer months; and 
 the number of skin, parasitic, and infectious ailments is 
 very much less at the opening of the next school year. 
 
 The two high school teachers of physical training, one 
 a man and the other a woman, are left at perhaps the same 
 salaries ($1,300 and $900). 
 
 The supervisor of hygiene gives his entire time to the 
 work, not for ten but for eleven months. If he obtains a 
 thoroughly good assistant school-physician, the salary of 
 the latter may be raised from $400 to $500 or more, but 
 not sufficient to make possible the employment of another 
 nurse at the same sum, perhaps. It may be well to employ 
 a woman physician as part-time medical examiner so she 
 may better examine the high school girls. 
 
 The trials and tribulations of the superintendent in 
 trying to get regular and responsible work from part-time 
 physicians and in attempting to direct medical work without 
 medical knowledge, are now at an end. He has a small, 
 compact and almost entirely full-time force. These are 
 essentials. The entire part-time element may yet be elim- 
 inated, but it will mean salaries from $1,500 to $2,000, at 
 least, for full-time assistant physicians. 
 
 Later developments of the system can be made, how- 
 ever, after intelligent study and experience. If another 
 physician is desired he may be obtained, and if, as the city 
 grows, an assistant in physical education for the elementary 
 schools is found necessary, the addition can be made. But 
 
MEDICAL INSPECTION PLAN 301 
 
 these additions are intelligent choices by an expert in edu- 
 cational hygiene, after reasonable investigation. We at- 
 tempt to give here only minimum essentials and suggestions 
 for beginning or reorganizing the work.* 
 
 For the largest cities, such a health reorganization can 
 easily be made, and it is practically possible for many cities 
 
 *At the recent International Congress on School Hygiene at Buffalo 
 the writer was given practically the following facts by a member of a 
 board of education of a typical New England city (about 9,000 pupils) 
 with a request for a plan of efficient reorganization: 
 
 PRESENT "INEFFICIENT" SYSTEM 
 
 12 part-time physicians at $500 $6,000 
 
 nurses 000 
 
 2 truant officers 2,500 
 
 1 elementary physical training teacher i,000 
 
 I summer director of playgrounds 150 
 
 $9,650 
 This system, recognized by the board of education as inefficient 
 and not getting results, is a finely devised machine for getting little more 
 than a collection of pathological statistics of school population. The time 
 the physicians spend in the schools is unknown ; and they have no super- 
 vision nor nurses to follow-up cases and get treatments and cures. 
 There are no public dispensaries for free treatment of children, and a 
 large share of the population is too poor to pay $20 for an adenoid 
 operation, for example, or to provide regular daily or weekly treatment 
 for favus, ringworm, discharging ear, and other ailments. There is enough 
 money being spent, however, to get efficient results in this field. Leaving 
 the high school directors of physical education in their places at the 
 same salaries, we gave for a beginning the following: 
 
 PLAN OF REORGANIZATION 
 
 1 supervisor of hygiene, a physician-physical-educator $2,500 
 
 6 school nurses, 4 at $700, 2 at $770 4.440 
 
 2 part-time physicians, two hours daily, at $500 i,000 
 
 I school clinic, with dental, surgical, and medical divisions 1,000 
 
 I school dentist, with staff of voluntary dentists 500 
 
 New blank forms for records and reports 2I0 
 
 $9,650 
 Here we have a vastly more efficient system at the same expendi- 
 ture of money; we have skilled leadership and supervision; we have a 
 plan which unifies all school health agencies; and we have the emphasis 
 where it belongs, on prevention and cures. Necessary changes can be 
 made after adequate investigation by the hygiene supervisor and super- 
 intendent of schools. 
 
302 SCHOOL HEALTH ADMINISTRATION 
 
 almost as small as eight or ten thousand population. Sev- 
 eral towns may even go together and employ such an expert, 
 as superintendents are now employed in several states. And 
 even rural districts may unite in the same way for the 
 expert services of an educational hygienist and several 
 nurses. The great need is for health experts and for health 
 leadership. The people will respond and act along the 
 best health lines when the health knowledge, now the pos- 
 session of the few, is made the possession of the many. 
 We have suggested here a possible channel for such general 
 health enlightenment. The far-reaching influence of such 
 school health leadership on national health and vitality can 
 as yet hardly be imagined. 
 D. Other Plans for the School Medical Service 
 
 Disregarding as ineffective the physician-alone plan for 
 school medical work, we have two principal alternatives 
 for serious consideration: the physician-and-nurse plan, al- 
 ready suggested, and the nurse-alone plan. For both there 
 is the need of a supervising director of hygiene, unless the 
 superintendent of a small city is exceptionally well qualified 
 medically and has time to devote to the work. We need 
 supervisors of hygiene as much or more than we need super- 
 visors of music, drawing, and such subjects. For both plans 
 we may have either examinations with inspection or only 
 inspection alone. We shall take the stand that routine exam- 
 inations, annually, are important as well as inspections. In 
 the nurse-alone plan the routine inspections, with the use of 
 individual cumulative health record cards, can, at first, take 
 the place of complete medical examinations, by simply 
 adding the vision and hearing tests. 
 
 The nurse-alone plan is, in general, far superior to the 
 physician-alone plan, for a number of reasons, chief of 
 which is that the former gets treatments and cures for a 
 large percentage of the cases, while the latter procures 
 treatment and cure for but five or six to twenty per cent 
 of the cases. Furthermore, the nurses can find most of the 
 cases of all kinds, and can inspect satisfactorily, as proved 
 in New York, for infectious diseases, especially when under 
 
MEDICAL INSPECTION PLAN 303 
 
 supervision (September, 191 1, Report of Bureau of Muni- 
 cipal Research). Cities as small as Canton, Mass., with 
 less than five thousand population, and as large as Oakland, 
 Cal., with nearly two hundred thousand, get good work with 
 only nurses, under supervision. (Reports and letters of 
 Dr. Arthur T. Cabot and of Dr. N. K. Foster, respectively.) 
 Newark with 38 doctors and 8 nurses is reversing these 
 figures by exchanging two doctors for each added nurse. 
 Only five or six doctors will be kept as district supervisors 
 of the nurses. With the general supervisor as before this 
 will greatly increase the eificlency for the money expended. 
 Further, the physicians can work but part-time while nurses 
 devote their entire time to the work. The physicians are 
 irregular and difficult to control in large numbers, while the 
 nurses, with practically no serious competing interests, are 
 easily directed. And, finally, they are less than half, and 
 frequently only one-fifth as costly, hour for hour, and for 
 the year, as physicians. The tables given in former chap- 
 ters show even greater disproportions of cost in a number 
 of cities, when the annual number of daily visits, and num- 
 ber of hours each, are taken into consideration. Good, 
 regular physicians, furthermore, can spare little more than 
 two hours a day regularly and punctually from their prac- 
 tice; and physicians for longer periods must be paid too 
 much and cannot well stand the strain and monotony of 
 long-continued examination or inspection. Diminishing re- 
 turns, with the larger salaries for full-time physicians, bring 
 in the school nurse often much more efficient hour for hour 
 than such physicians as can be obtained. That the 
 nurses need training, before and while in service, and that 
 they must have competent supervision is immediately appar- 
 ent. The plan here outlined, however, places the emphasis 
 upon the nurse and the physician, the physician-nurse plan. 
 Getting full-time work from all school health officials re- 
 mains a nice problem for careful study and local adjustment. 
 The first thing is to get the hygiene supervisor, next the 
 nurses, and finally part or full-time physicians. A very small 
 city unable to obtain, with others even, a supervisor should 
 
304 SCHOOL HEALTH ADMINISTRATION 
 
 start with a nurse rather than with part time physicians if 
 possible. If only a physician is employed the principal and 
 teachers must do the follow-up work. In either case the 
 record and report forms herein given may be used. 
 E. Where to Obtain School Nurses. 
 
 As with all other forms of public service, the success 
 of medical and health work depends very largely upon the 
 character of the persons chosen to carry it on. The greatest 
 weakness of our school systems at the present time is due 
 to the fact that our teachers are quite generally young 
 women novices with a teaching tenure of three to five years 
 only and very largely ignorant of and inexperienced in the 
 real life of the community and nation about them. Edu- 
 cational readjustment must wait upon the improvement of 
 the character of the teaching force. With even the best 
 of supervision and the most scientific plans of management 
 the health service likewise can remain palsied, feeble and 
 inefficient. 
 
 After deciding to obtain officials for the school health 
 work, therefore, the practical problem becomes one of ob- 
 taining high-class health agents. For nurses, we must as 
 yet depend very largely upon the various training schools 
 for visiting nurses, and the visiting nurses' associations. 
 The Department^ of Nursing and Health, under the direction 
 of Miss M. A. Nutting, R.N., at Teachers College, Colum- 
 bia University, in New York City, is at present the only 
 institution in the country which gives instruction and train- 
 ing for school nurses, and the number who can be supplied 
 is at present very small. This is the first source I should 
 recommend. 
 
 Miss E. P. Crandall, R.N., Executive Secretary of the 
 National Organization for Public Health Nursing, 52 East 
 Thirty-fourth street. New York City, and Miss E. L. Foley, 
 R. N., Superintendent of the Visiting Nurse Association, 
 104 South Michigan avenue, Chicago, may also be de- 
 pended upon to advise school systems of graduate nurses 
 who are specially qualified for and looking toward public 
 school work. Miss Fannie F. Clement, 713 Union Trust 
 
MEDICAL INSPECTION PLAN 305 
 
 Building, Washington, D. C, can give valuable informa- 
 tion regarding the Red Cross Rural Nursing Service and 
 persons available as school nurses. The Boston District 
 Nurses Association in affiliation with the Boston School for 
 Social Workers, as well as the Cleveland Visiting Nurses 
 Association in affiliation with Western Reserve University, 
 and, finally, Phipps Institute of Philadelphia are also in 
 touch with most nurses in the country. 
 
 The writer will be pleased to send the names of any 
 persons known as qualified either as hygiene supervisors 
 or as school nurses to responsible persons without charge 
 to either party. Like Albany, N. Y., a city may find in its 
 midst a man qualified both as a physician and a physical 
 educator for such work and good nurses amenable to train- 
 ing in the school service. 
 
 II. THE DIVISIONS OF MEDICAL SUPERVISION 
 
 The various phases or divisions of the work of medical 
 supervision * in this plan and, for the most part, but largely 
 unrecognized, in the best systems now in vogue, are about 
 as follows : 
 
 A. Preliminary clinic, for instruction and standardization. 
 
 B. Inspections. 
 
 1. Pupil Inspections. 
 
 a. September roow-inspection of all pupils by 
 doctors and nurses. 
 
 b. Occasional room-inspections of classes of chil- 
 dren, by nurses. 
 
 c. Individual inspection, by teachers, nurses, and 
 doctors. 
 
 2. Environmental Inspections. 
 
 a. Home hygiene inspection, during home visits 
 of nurses. 
 
 b. Sanitary inspections of the school premises, 
 by any delegated and competent officer. 
 
 C. Examinations, complete physical, annually for all pupils. 
 
 *The term will probably remain medical inspection, even if it is a 
 misnomer in good systems. 
 
3o6 SCHOOL HEALTH ADMINISTRATION 
 
 1. Scholastic: vision and hearing examinations, and per- 
 
 haps others, by the nurses. 
 
 2. Medical: only those technical phases which the nurses 
 
 cannot do well, if any, by doctors. 
 
 3. Anthropological: measurements of height, weight, 
 
 chest-expansion and the like, only if required. Of 
 doubtful value. 
 
 4. Work Certificate : will probably not be needed in well 
 
 conducted systems. 
 
 D. Treatment, Cure and Correction. 
 
 1. By home and family physicians, dentists, or oculists. 
 
 2. By school nurses. 
 
 3. By dispensaries or other free clinics. 
 
 4. By public school clinic, with various divisions. 
 
 E, Prevention. 
 
 By looking for causes, co-operating with other divisions 
 of educational hygiene, and other public and private 
 health agencies, and by placing the emphasis upon 
 preventive rather than merely curative agencies. 
 How to carry on efficiently and economically these dif- 
 ferent phases of the work will be the problem of this 
 chapter.* 
 
 A. The Preliminary Standardization Clinic 
 
 In the typical city for which the reorganized expendi- 
 tures were given, with a proportion of little over three 
 per cent of current school expenditures for the entire 
 department, including medical inspection, we have two phy- 
 sicians and three nurses for six thousand pupils from kinder- 
 garten through high school, three thousand for each phy- 
 sician (one the director), and two thousand for each nurse. 
 For a city of twelve thousand children we should have, of 
 course, twice as many nurses and three assistant physicians. 
 But no matter how large or how small the department may 
 be, even one physician and one nurse, there should be, when 
 they begin to work together, and, if several, at the begin- 
 
 *For relative complete "Outlines of Educational Hygiene," empha- 
 sizing medical supervision, by the writer, see Education for December, 
 1912. 
 
MEDICAL INSPECTION PLAN 307 
 
 ning of each year or oftener, a meeting at which children 
 are examined or inspected, or both, and standards for refer- 
 ring cases to parents, for exclusions, for readmissions, for 
 best methods of doing the work, and the like, are discussed. 
 Teachers and principals may be present at such meetings, 
 and all may take a hand In coming to some common agree- 
 ment, without which there will, In Isolation, develop the 
 greatest irregularity among different workers and frequent 
 injustice to children and parents through conflicting stand- 
 ards and methods. 
 
 This is also the opportunity for the supervisor to outline 
 the work of the year, and to get suggestions from all con- 
 cerned as to its improvement. It is a time for inspiration 
 and education. All need them. Such clinics can be held at 
 one or more of the several schools, if desired, or at teach- 
 ers' meetings, for the purpose of giving the teachers neces- 
 sary elements of child-study of a medical character, which 
 probably never appeared in any course In their professional 
 preparation. 
 
 No city known by the writer now employs this means 
 for making efficient medical supervision, and he hopes for 
 Its speedy experimental testing. Besides these will come, 
 of course, monthly or semi-monthly department meetings 
 which are now quite common in good systems. 
 
 B. Inspections 
 
 I. PUPIL INSPECTIONS 
 
 a. September Class-room Inspections. — Since this plan 
 of administration gives the physician as many pupils as he 
 can examine in the entire year, beginning In September 
 about the third week, and taking pupils In the same order 
 each year, we must provide what many cities have been 
 driven to by hard experience, namely, a preliminary, com- 
 plete, routine, classroom inspection of all pupils. With 
 3,000 pupils, each pair of nurses and physicians will have 
 about 75 rooms, counting 40 pupils to a room. By requir- 
 ing the part-time physicians to spend three hours a day In 
 this first general inspection, and with the nurses all at the 
 
3o8 SCHOOL HEALTH ADMINISTRATION 
 
 same work, counting a classroom, after practice, for each 
 half-hour, and records made, where two work together, 
 we can see that the entire inspection can be made in about 
 two weeks. In the case of the two doctors and three nurses, 
 one nurse would have to work alone at such inspections; 
 and in the afternoons when two of the nurses worked 
 together in each room another would be left to work alone, 
 as she must later in occasional room inspections. In fact, 
 we can be sure of over 20 rooms inspected a day from 
 the small force of five above mentioned, which for the total 
 of probably 150 rooms in the city, would make about eight 
 days. So two weeks would probably be ample with such 
 a system. 
 
 Some doctors lay claim to 250 pupils room-inspected an 
 hour, but these are only very partial inspections, for signs 
 of parasitic or infectious disorders. This first general rou- 
 tine inspection would make a fair substitute for an exam- 
 ination, especially if there were any careful attention given 
 to vision and hearing. It is a general inspection of the 
 child for any serious defects, ailments or conditions which 
 should receive early treatment and care. No vision or 
 hearing tests, as such, are made, but all obvious cases, like 
 strabismus (cross-eye), or inflamed eyes from eye-strain, 
 may be recorded and referred with instructions. 
 
 The principal ailments found will probably be minor 
 skin ailments of a filthy or infectious character, although 
 most ailments will be represented. If there have been 
 nurse-inspections during the summer, fewer cases will be 
 found, but there are always sufficient numbers to warrant 
 rigorous measures for nipping their spread in the bud. 
 
 THE METHOD OF CLASSROOM INSPECTIONS 
 
 The central instrument in all medical supervision (in- 
 spection) is the individual, cumulative health record card 
 of each pupil. On it is recorded the health history of the 
 child during his school years, and in some cases for the 
 years previous to his entering school. The development 
 of the science of educational hygiene and the practical con- 
 
MEDICAL INSPECTION PLAN 309 
 
 trol of health matters must depend very much upon the 
 quality of such individual health histories. Scientific con- 
 trol of living conditions of children, or of any other phe- 
 nomena, rests upon the basis of accurate and carefully se- 
 lected facts. With this principle in mind, and the prog- 
 ress of child and of educational hygiene as a much-to-be- 
 desired practical necessity, by what standards shall we judge 
 such health record cards? Tentative standards used by the 
 author are as follows : 
 
 a. The record must be a separate filing card, not a page 
 
 In a book, nor a loose sheet of paper. The great- 
 est device, or Instrument, for inductive thinking yet 
 Invented is the well-devised card-index system. Pro- 
 fessor Giddlngs well says that Jevons' invention, of 
 a "deductive logic machine," Is but a useless toy com- 
 pared with the modern ''''inductive logic machine," 
 the card Index. 
 
 b. This card must go with the child from room to 
 room, from school to school, and from city to city 
 throughout his school life. The cities that are using 
 cards good for one year only are wasting money and 
 not getting the cumulative history which can al- 
 ways be before teacher, nurse and physician when 
 they study the child from the standpoint of his health. 
 
 c. The record must, as nearly as possible, contain each 
 
 child's entire health history, especially of serious dis- 
 eases, injuries, or defects, winter or summer, and the 
 results of treatments, and dates of cures. 
 
 d. The records must be made by both physicians and 
 nurses, and their records distinguished, say black Ink 
 for the physician and red for nurse. With our plan 
 most of the records will be in red Ink. Examina- 
 tions by specialists, dentists, aurlsts, or oculists can 
 also be recorded on the same card. 
 
 e. Arrangement must be made for recording the chang- 
 
 ing addresses, rooms, and schools of pupils. The 
 telephone number of the parents Is desirable wher- 
 ever it can be obtained. 
 
3IO SCHOOL HEALTH ADMINISTRATION 
 
 f. The results of both examinations and inspections are 
 
 to be recorded. 
 
 g. The card must either have the diseases and defects 
 
 most often found and most to be emphasized printed 
 thereon, or be used in constant connection with a de- 
 tailed and numbered list of such ailments (code), for 
 which only the code numbers need be used, or the 
 code number accompanied by an abbreviation for a 
 special and unusual ailment. The Cleveland card, 
 most carefully drawn up, has a code entirely too brief 
 printed upon it, and has no satisfactory arrangement 
 for recording treatments and cures. The New York 
 city and the cards devised by Burks, Hoag, and Cor- 
 nell have similar or other serious defects. 
 
 h. The card must leave space with each year's record 
 for writing in any general recommendations, sugges- 
 tions to teachers, and the like, which are so individ- 
 ual that they cannot be reduced to code numbers or 
 other signs. Real health records have been prac- 
 tically prevented by attempting to reduce the whole 
 matter to making checks opposite a few ailments. 
 
 i. The signs, or symbols, used to save space and time 
 and for a degree of privacy, if desired, should very 
 probably be printed on each card. The need of keep- 
 ing the children in entire ignorance of their ailments 
 does not appeal to the author's experience. Democ- 
 racy is better. Some of these signs, to be found on 
 the card offered herewith and devised for tentative 
 testing by the author, may well be : — 
 
 X — A cross, for "needs treatment, and should be re- 
 ferred to parents." 
 
 O — a circle around this cross, to be made by the nurse 
 when the ailment is cured. 
 
 O — a circle in the second space, to the right of the X, 
 showing that the ailment has not been cured, but 
 has been improved. No circles will show that the 
 case has not been cured, or improved, or the child 
 has moved away, without his card, or the family 
 
311 
 
312 SCHOOL HEALTH ADMINISTRATION 
 
 has refused treatment, or the family physician has 
 called the case "negative," that is, too minor an ail- 
 ment for treatment or operation. A diagonal line 
 may be drawn through admitted negative cases and 
 deducted from the number previously reported. 
 
 I — a vertical line, to the right of the X or O, showing 
 in red that the nurse, janitress, or school clinic has 
 treated the case, and in black that some other "out- 
 side" agency has made a treatment or series of 
 treatments. Red lines over near the space for re- 
 marks on the same horizontal line, or to the left of 
 this space if desired, may be used to indicate times 
 the nurse has taken the child to dispensary, family 
 physician, or clinic. Home hygiene visits, or sim- 
 ply home visits, may be similarly recorded under 
 that heading. 
 
 P — in the space for the date of the annual medical ex- 
 amination at the top will mean that the parent or 
 guardian of the child has been present at that ex- 
 amination. This is important, for better results fre- 
 quently follow if parents are present, and the records 
 should show it. In general, however, parents attend 
 much better with their children school clinics. 
 
 V — a check, in place of an X, will show that the ailment 
 is too minor to be referred for treatment. Few such 
 checks will be required. Certain incipient ailments 
 must, perhaps, be noticed in this way, however. The 
 discretion is with the supervisor or other officers. 
 Too many very minor cases are now being recorded 
 in many cities. Be conservative. Check cases need 
 not be reported. 
 
 E — will show that the child has been excluded for the 
 ailment marked X. 
 
 R — will show that the child has been readmitted. The 
 teachers will keep a record of the time lost by all 
 exclusion or illness absence and record it at the bot- 
 tom for each term each year. 
 
 Other signs can be devised for other meanings. 
 
MEDICAL INSPECTION PLAN 313 
 
 In the space for remarks, the medical officials will write 
 such facts or suggestions as cannot be given by the system 
 of signs. 
 
 The back of card number one is not here reproduced. 
 Four horizontal spaces at the top may be left for: the pupil's 
 name and addresses, the history of measles, scarlet fever, 
 diphtheria, whooping cough, chicken pox, vaccination and 
 other ailments with spaces for checking or writing in the 
 dates, the nationality if desired, and spaces for changing 
 room numbers or letters. The fourth space may be used for 
 the symbols given on the face, and for others desired. Below 
 the headings, the card may be made up the same as on the 
 face, for three years. 
 
 To the right of these, I have a section for Home 
 Hygiene Inspection, printed in the space for dates of ex- 
 aminations and presence of parents, somewhat similar to 
 the Cleveland and the Hoag cards (see Health Index of 
 Children). Beneath this heading on the 25 lines I have 
 printed (with five vertical spaces to the right) the follow- 
 ing: Grade, Date, Children in school — Boys, Girls, Num- 
 ber of rooms, Number of bed-rooms. Number of beds, 
 Bath tub?. Ventilation, G — F — B (good, fair, or bad), 
 Lighting, G — F — B, Cleanliness, G — F — B, Number of 
 families using closet, Financ. (for financial condition), 
 G — F — B, Nourishment, G — F — B, Children's hours of 
 sleep. Home study opportunity. Mother, Father, Sisters, 
 Brothers, Boarders, Co-operation with the school (i. e., 
 how well they respond to the nurse's and teachers' efforts) 
 and spaces for writing in other data. This matter is, of 
 course, unnecessary on card number two. 
 
 FURTHER SUGGESTIONS FOR USING THE RECORD CARD 
 
 It is relatively unsatisfactory to attempt to place under 
 even twenty-four headings the ailments which physician and 
 nurse must look for and record. One line may be over- 
 crowded while there are left many lines unused, and ailments 
 not printed thereon may be found. To overcome this difli- 
 culty, a space over a half-inch wide has been left for writ- 
 ing in the name, abbreviation, or code number found in the 
 
314 SCHOOL HEALTH ADMINISTRATION 
 
 weekly report for fifty-four ailments and groups of ailments, 
 the term "ailment" referring to all the health disorders of 
 childhood, including physical defects. 
 
 Still further to overcome this difficulty, all names of ail- 
 ments may well be left of the card, the spaces mentioned 
 widened for each year entirely to take up the space where 
 names for ailments are printed, and only code numbers used 
 in the first narrow column for ailments each year. The fig- 
 ure (code number) there would indicate that the ailment 
 had been found, and the signs above mentioned would fol- 
 low as before, on the same horizontal line. Or the card 
 may be entirely reorganized on a freer basis, giving one like 
 the second type here reproduced. 
 
 CARD NUMBER TWO 
 
 The principal disadvantages of the first card are ( i ) 
 that it is impossible to write on it the entire series of efforts 
 which may be necessary to get cured one case, resulting 
 in the overcrowding of one line or two and leaving blank 
 a large part of the card opposite ailments from which the 
 child does not suffer, (2) that since the names of ailments 
 must be general and in only 24 divisions, the code num- 
 bers and the abbreviations or full names of the specific 
 ailments must be written out anyway. Even with a card 
 long enough vertically to make possible the printing of the 
 54 classes of ailments, it would still be necessary to write 
 in the specific name (say, for minor skin diseases). An- 
 other weakness is the home hygiene inspection division 
 separated from the ailment and time of inspection or fol- 
 lowing up of the case. Yet this card has been declared, 
 by a committee studying the record systems of over seventy 
 cities, superior to all in use. Burks' interesting card or 
 slip (Health and the School, page 179) has the same and 
 other defects, his system being devised more for such large 
 cities as Philadelphia, with large central office forces. 
 
 Our card number two of which the face, partially filled 
 in, is given, has been evolved out of all these defects and 
 difficulties. It gives freedom to record essential data not 
 easily placed in a system of rigid symbols, economizes 
 

 
 
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3i6 SCHOOL HEALTH ADMINISTRATION 
 
 space, shows immediately what ailments have been found 
 and what has been done with them, records both inspec- 
 tions and examinations and all dates, and makes possible 
 adequate reporting of follow-up and home hygiene work. 
 Most of it will be filled in (with red ink) by the nurses. 
 Another space may be used for printing in other symbols 
 while the number of lines for the second year may be de- 
 creased to four. The card may be arranged for ten or 
 more years of school life, five or six years on each side. 
 The heading for the back of card i should also be used 
 for this card. No home hygiene space need be arranged 
 as this has been provided for each year. For special cases, 
 the five lines for the first year may be used for a careful 
 health history. 
 
 The card will, of course, be used with the classification 
 and nomenclature of ailments in view as they are printed 
 on the weekly report. 
 
 Interpreted, some of the written-in record has the 
 following meaning: For the first year, 1910-11, enlarged 
 tonsils and adenoids were found at the time of the first 
 (September) routine inspection of all children. We see at 
 once that they were found and cured. They were referred 
 September the tenth, but the family did not respond well; 
 so the mother, a poor widow, was visited on the fifteenth. 
 The latter gave the nurse permission to take the child to 
 the dispensary where her adenoids and tonsils were removed 
 on the twenty-second. The nurse should have seen the 
 child every day or two immediately after the operation, 
 but probably wisely depended upon a responsible teacher 
 to send her for inspection if her wounds did not heal well. 
 On the second of October, however, she did inspect the 
 child, then seven years of age, and found her apparently 
 cured. She could not then state whether the adenoids would 
 grow again' but apparently the child was developing satis- 
 factory nasal breathing, in place of the former mouth 
 breathing. 
 
 For some reason, the child was given her annual exam- 
 ination on September the fourteenth, which resulted in 
 
MEDICAL INSPECTION PLAN 317 
 
 the finding of pediculosis and nits, but her vision was good 
 with her glasses on, and her hearing was satisfactory. The 
 subject of pediculosis was brought up at the first home 
 visit recorded above and the mother promised treatment 
 which she carried out, with improved condition, and twice 
 afterward following notice by the nurse. The examination 
 showed the ailment; it was improved; two inspections 
 showed the ailment later, and it was again improved. The 
 teacher had evidently sent the child to the nurse for the 
 inspections or the nurse had kept after the case and called 
 the child out those two times. 
 
 The next year, 1911-12, the child was again mouth- 
 breathing and the adenoids had probably grown again but 
 the nurse took the child to the dispensary and an operation 
 was spared by the dilation of the child's nostrils. This 
 should have been done, and perhaps continued by the nurse, 
 during the first year. The other items are probably easily 
 read, V equals home visit; T equals teeth; Tr equals 
 treated or treatment; H equals board of health. Any 
 added symbols should be uniform for each city, at least. 
 
 Where a child presents unusual need for treatments, the 
 spaces for two or more years may be used for recording 
 them. A five by eight card should be standard since the 
 smaller ones unnecessarily cramp the work. Our card num- 
 ber two has been reduced for book purposes to a seven-inch 
 length. We have not shown a record of days lost by illness 
 nor a very wide range of home hygiene reporting, although 
 the form admits of it. 
 
 Either of these cards, printed on both sides, and contain- 
 ing the names of the places using them, and the other forms 
 given later, will be sold in quantities by the publishing de- 
 partment of Teachers College, Columbia University, New 
 York. The appearance of the cards will be improved by 
 printing in all words. 
 
 Where a child spends more than eight years in the 
 elementary school system or enters the high school, another 
 card may be clipped to the original card. In fact, for very 
 serious and prolonged cases, the annual spaces with dates 
 
3i8 SCHOOL HEALTH ADMINISTRATION 
 
 above may be turned into term spaces and an additional 
 card added earlier than the ninth year of school life. 
 Whether cards should begin with the kindergarten chil- 
 dren, may rest with the medical director, and superintendent 
 of schools. They probably should' with the exception of 
 the vision test perhaps. Provision for changing addresses 
 may be made by furnishing gummed strips of paper the size 
 of the address space. This is a compromise plan to save 
 space. On the second card the addresses may be written 
 in the first space to the right of the symbol spaces for each 
 year after the spaces at the top have been used. 
 
 Thus we have offered two record cards instead of one 
 for use, adaptation, and criticism. The first has many ad- 
 vantages, but limits seriously the amount of space for re- 
 cording the facts regarding any one ailment; the second is 
 simpler, and gives plenty of space for recording the nature 
 and treatment of any ailment. It also affords more chances 
 for error in using and interpreting the code numbers, per- 
 haps. The second will probably win out after trial. 
 
 These cards (5 by 8 inches in size) may be kept in 
 the teachers' classrooms in small, durable filing cases, such 
 as are furnished in New Bedford, Mass. It is probably 
 not wise to keep all the cards together in the medical in- 
 spection room, for several reasons. At each inspection or 
 examination the child takes his card in a clean piece of 
 paper, or one child carries several of the cards, or some 
 other person, nurse, janitress or principal's clerk, collects 
 them, and takes them to the health officers' room. For 
 room inspections, of course, the cards need not be taken out 
 of the rooms, except as the nurse uses them for making 
 her records and reports. If the health histories are to be 
 used and if teachers are to be educated in health watchful- 
 ness, the cards must be kept before them in their rooms. 
 
 The "parasitic ailments" are favus, ringworm of body 
 or scalp, pediculosis or vermin, scabies, and one or two 
 others seldom if ever found. Where a child has two such 
 ailments, use the space for infectious ailments or for skin 
 ailments in the section above, writing in the name or code 
 
MEDICAL INSPECTION PLAN 319 
 
 number on the right. (No such trouble will arise with the 
 second card presented.) Physical defects are placed at the 
 top as in the weekly reports and the tentative standard 
 classification of ailments. 
 
 THE METHOD OF THE SEPTEMBER ROOM-INSPECTION 
 
 Coming back to the September room-inspection with an 
 understanding of the individual health record cards, let us 
 briefly suggest a workable method. In one of the first 
 plans of this kind drafted by the author in 1908, the 
 doctor and nurse were to go to separate rooms and the 
 teachers were to make the records on the cards for them. 
 If teachers could do this well or if it were thought valuable 
 enough training to take the time to teach them, this would 
 be satisfactory; since the general room-inspection at any 
 time could be done about twice as rapidly as when the 
 nurse and physician work together. Teachers, of course, 
 need such training and knowledge of both the cards and 
 the children. 
 
 However, the nurse frequently needs the doctor's sup- 
 posedly better knowledge and advice, and she can record 
 the matter on the cards very much better than teachers. 
 Doctors who have tried both methods say that the rapidity 
 and ease with which the nurse and doctor working as a 
 team can do room-inspection eliminate all other methods. 
 The nurse, however, cannot see each case so well when 
 she is sitting at a desk busily copying signs; and most values 
 might be gained by having the teacher make the records 
 with the nurse free to watch both her and the doctor. 
 This probably deserves test. It serves to educate the 
 teacher, but leaves the class-room of children to some ex- 
 tent, undirected, although a strong teacher can use the situa- 
 tion as she thinks best, either for continued study by the 
 pupils or for watching the work proceed, and getting an 
 intelligent attitude toward health matters. This is again a 
 matter to be tested. The outcome will probably be that the 
 nurse will record and learn to see the cases too. 
 
 Near the back of the room on the left side of the 
 
320 SCHOOL HEALTH ADMINISTRATION 
 
 pupils will probably be found good light. Here the doctor 
 can take his stand and the pupils by rows of five or six, or 
 boys first and then girls, or in any other convenient way, 
 can file pass him. He may be seated, since it is well, with 
 certain exceptions, to start with the pupils in the lowest 
 grades in both general inspection and in examinations. 
 
 The nurse, let us say, sits at a desk nearby and records 
 the doctor's findings and the disposition of each case. The 
 physician gives a quick, accurate glance at hair, scalp, ears, 
 eyes and eyelids, face, nose, mouth, teeth, tonsils and throat, 
 hands and skin, and quickly sizes up the general condi- 
 tion of the pupil. The doctor does not touch the pupil 
 but has each child open the mouth, show the hands, pull 
 down the eyelids, perhaps, and, in the case of girls, lift 
 up the back hair. Wooden tongue depressors are used for 
 the mouth examination, and no depressor is to be used more 
 than once. Where plant tag-sticks are used for depressors 
 each one may be broken in two and used for two pupils. 
 With increasing skill, all the pupils of a room can be in- 
 spected in a very short time, less than a half hour, and aver- 
 aging, perhaps, two pupils to a minute. 
 
 The standard for the selection of cases for record can 
 be seen in the following question which the doctor must 
 ask himself: May this child remain in the school without 
 injury to himself or to others, and is this ailment one which 
 should have immediate care and treatment, and one about 
 which the parent should be informed? If, in his judgment, 
 and probably with the advice of the nurse, he concludes 
 that it is a sufficiently urgent case of any kind, he gives the 
 nurse the code number of the ailment from the printed code 
 before him, and indicates what shall be done with the case. 
 If he is in some doubt, the child is asked to take his seat 
 or pass elsewhere until after the other pupils are inspected, 
 and may then be taken into the hall or health room for 
 further inspection. In Newark, N. J,, at most room-inspec- 
 tions the pupils go singly into the hall where they are in- 
 spected by the doctor, the nurse, or the two together. This 
 plan has its advantages. 
 
MEDICAL INSPECTION PLAN 3^1 
 
 The doctor should be conservative and practical in his 
 iudgments. Most minor uninfectious cases may wait tor 
 the routine examination when the parent may be present. 
 Further standardization can come with experience, super- 
 vision and standardization clinics. 
 
 EXCLUSIONS 
 
 Doctors and nurses must also be very careful and con- 
 servative about the exclusion of pupils from school. On 
 he average, such exclusions last, for all -Iments neady 
 two or three weeks. Some are unnecessarily excluded for 
 months. Most of the parasitic ailment cases -^ ■-™;;; 
 in school with adequate treatment and control. Where an 
 epidemic of infectious disease is imminent less suspicious 
 cases may be excluded and throat cultures '^^en but con- 
 servative judgment is not even here amiss_ The nu e 
 should take cultures in every case of sore throat. These 
 cultures must be tested and the children readmitted if nega- 
 tive (i. e., if the Klebs-Loeffler baccilli are not found) as 
 
 "° ChddCnISuiring exclusion may be given an exclusion 
 slip at the end of the inspection of that room or imme- 
 diately, if desired. The principal of the school may have 
 such children referred to him, and may mail or send the 
 slip to the parents from his office, besides sending an oral 
 message by the children. Or, the telephone may be used^ 
 The teacher should be notified of the exclusion and of the 
 date fixed for the child's return to school. This may be 
 written on the card protector. . r .■ 
 
 Exclusions may be made for the following infectious 
 ailments: diplheria, or sore throat or tons,ht,s possibly 
 pointing to infection, scarlet fever, whoopng-cougk cincken 
 po.. measles, mumps, traehoma, or any other possibly acute 
 infectious disease, and such parasitic and minor infectious 
 ailments as may be adequately treated over night if strongly 
 called to the parents' attention. Montclair and some other 
 cities have such cases treated in the school by the nurse or 
 janitress, thus saving very much absence. Parents are tried 
 
322 SCHOOL HEALTH ADMINISTRATION 
 
 first, and then, if the home does not adequately eradicate the 
 ailment, permission is gained for the school treatment. 
 Legal compulsion may be required, and should be used with- 
 out fear or favor for the "filth" disorders. 
 
 The nurse may make out the exclusion slip which should 
 be simple, dignified and adequately instructive. If the back 
 can be used for health advice, the chance should not be 
 missed. The seal of the city printed on each as is done in 
 the state forms of Massachusetts and certain cities, will ap- 
 peal in the right way to many parents. The following 
 exclusion form has several advantages in the way of 
 economy : 
 
 MEDICAL SUPERVISION OF 
 SCHOOLS 
 
 Montclair, New Jersey. 
 
 Date , 191. . 
 
 School Room, Grade 
 
 Pupil's name 
 
 EXCLUSION RECORD 
 
 No 
 
 Date , 191. . 
 
 School Room 
 
 Pupil 
 
 Address , 
 
 Cause of Exclusion: 
 
 Readmitted, 
 
 School days lost. . . 
 
 191, 
 
 Home address 
 
 The above named pupil is hereby or- 
 dered to discontinue attendance at 
 school temporarily for the following 
 reasons: 
 
 School Nurse, M.D. 
 (Hand to pupil excluded.) 
 
 over. 
 
 This entire form need not be more than six inches long 
 and two and a half inches wide. 
 
 On the back of the long part, not the stub, should be 
 printed these and any other directions, general advice, or 
 short article from city or state laws: 
 
 The ailment mentioned on the other side of this notice is 
 infectious (contagious), and liable to be transmitted, or "given," 
 
MEDICAL INSPECTION PLAN 323 
 
 to other children. The child should receive prompt treatment 
 by a physician or the school nurse, and should return to school 
 
 , 191 .. , for inspection by the 
 
 school physician or nurse. If found free from infection he may 
 then resume attendance at school. 
 
 Every reasonable effort should be made to give each child 
 the full benefit of every possible day of school attendance. 
 
 A DUPLICATE BOOK FOR DOCTOR AND NURSE 
 
 This form, separable from its stub, should be printed as 
 is a check book, and, whenever desirable, as in the case 
 of acute infectious diseases, will, with small sheets of copy- 
 ing carbon, give four forms, the original for the parent, 
 the stub for the hygiene department, the carbon copy for 
 the board of health as their notification, and the carbon 
 stub for the nurse's or doctor's record. The notice can be 
 sent home in several different ways, depending upon cir- 
 cumstances. One of these exclusion books should be kept 
 in each school, and for its pupils only. 
 
 To avoid conflict of jurisdiction, the city health oflRcer 
 and the director of hygiene, or superintendent, should meet 
 and agree upon a plan of co-operation for readmitting 
 pupils after exclusion or illness absence. The following is 
 the result of such a meeting at Meriden, Connecticut, in 
 the year studied and about a month after the work of 
 medical supervision had begun: 
 
 "It was agreed that the city health oflicer should write 
 permits for returning to school after exclusion for small- 
 pox, scarlet fever, diptheria and membranous croup, and that 
 the school physician only should write certificates for re- 
 turning to school after measles, whooping cough, consump- 
 tion, chickenpox, mumps, sore throat, lice, scabies (itch), 
 and other skin diseases, and other minor ailments." 
 
 And it was furthermore agreed that the school phy- 
 sicians should give no readmission for diseases assigned to 
 the health department and the latter agreed to sign no 
 permits to return for diseases assigned to the school 
 physicians. Practically, then, the school medical service 
 
324 SCHOOL HEALTH ADMINISTRATION 
 
 readmitted pupils for everything except scarlet fever and 
 diphtheria, since small-pox is seldom if ever found. 
 
 Notice of cases of acute infectious diseases like diph- 
 theria, scarlet fever, measles, German measles, perhaps, 
 small-pox, if ever found, and chicken-pox should be imme- 
 diately telephoned to the city health department, the ex- 
 clusion notice being sent later, if necessary. 
 
 The board of health will, of course, notify the schools 
 each day of all children ill with infectious diseases, quar- 
 antined or not, and also when these pupils may be read- 
 mitted. Such ailments whether found in the schools or 
 not should be recorded on the record card and in the 
 reports. 
 
 Conjunctivitis, impetigo, trachoma and the parasitic ail- 
 ments will be handled by the nurse. For trachoma, she will 
 find it best to give instruction rather than treatment. 
 
 Rare cases of tuberculosis should be reported to the 
 superintendent or director of hygiene for special considera- 
 tion. When diphtheria develops it is well to culture the 
 throats of all children in the class to discover possible 
 carriers. 
 
 THE SPIRIT OF THE INSPECTIONS 
 
 Let us remember that we are still in a primary room of 
 a school in our typical city at the work of the September 
 class-room inspection. A great deal will depend upon the 
 spirit in which such work is carried on. Physicians are fre- 
 quently very unpedagogical in their treatment of the chil- 
 dren; and some of the cases of such unpedagogical treat- 
 ment, witnessed by the author in dispensaries and at school 
 inspections and examinations, would appropriately bear the 
 title of "Crimes Against Childhood." Individuals, male or 
 female, found unadapted for this personal, humane work 
 with children should be relieved of it as soon as they can be 
 discovered. The atmosphere of school medical work should 
 be that of health, happiness, and co-operation, not that of 
 so many of our public dispensaries. 
 
MEDICAL INSPECTION PLAN 325 
 
 REPORTING THE ROOM-INSPECTION 
 
 When the class has been room-Inspected, to coin a word, 
 the nurse will take all the cards of ailing pupils to the 
 principal's office or the health room, where they can be 
 reported after the morning's work with the physician. In 
 her case book for each school she will write down the 
 name, address, room and ailment of each defective and ail- 
 ing child and the date. When she sends notices home with 
 the children who are ailing but not excluded and gets no 
 satisfactory results in treatment within three days or a 
 week, the time for a second notice, or for home visiting has 
 come', which may even end with the doctor's visit or that 
 of an officer of the law. After the list of cases has been 
 placed in her book, the cards can be returned to the room, 
 where the teacher will give them a separate place in her 
 file, or mark them with colored clips. At the end of the day, 
 the nurse will record all the work of inspection and the 
 findings in the column for that day's work, on the weekly 
 report form. This daily and weekly report will be treated 
 under "examinations." 
 b. Occasional Room-Inspections 
 
 Occasionally, other room-inspections {special room-in- 
 spection is a good term) must be made by the nurse atter 
 the routine one in September. Very rarely will the doctor 
 be needed for such work. The ailments found, she can her- 
 self record; or, where there are very many cases she may 
 find the co-operation of the teacher very helpful 1 he 
 method can be that of the general inspection described, or 
 she can simply pass along the aisles and mspect the chil- 
 dren The latter can have their hands on the desks, and 
 the nurse, passing along from the rear, can easily note the 
 condition of the hair and scalp, as well as other features. 
 The nurses of Newark made an average of nearly 500 
 occasional class-room inspections each during the school year 
 studied, besides about 21,000 individual inspections and 
 over a thousand home visits each. These room-inspections 
 -are especially valuable in poor, or foreign districts m bring- 
 
326 SCHOOL HEALTH ADMINISTRATION 
 
 ing up the health and cleanhness standards towards that of 
 civilized America. They are also valuable, as suggested, 
 in the case of an impending epidemic. 
 c. Individual Inspections 
 
 Individual inspections are to be made principally by the 
 nurse, but also, if necessary, by the physician in the one build- 
 ing he visits for two or more hours each day. Only urgent 
 cases are to be referred either by nurse or teacher to the 
 doctor. The principal classes of individual inspections are 
 as follows : 
 w. Pupils referred at the time of the nurse's visit, by the 
 
 teachers. 
 X. Pupils entering that school for the first time, any age. 
 y. Pupils who have been out of school for any reason more 
 than three days, especially excluded, or quarantined 
 cases. 
 z. Pupils brought to the attention of the nurse in the homes. 
 
 Where principals are, or become, qualified, a large num- 
 ber of the readmittance inspections may be left to them. 
 The importance of the health training of principals and 
 teachers and the books they can use in study, will be brought 
 out later. A principal who hasn't such a knowledge of 
 children (child-study) needs to "study up." He must, how- 
 ever, beware of cocksureness after little study. 
 
 The usual place for the individual inspections is at the 
 health room or the principal's office. A bell is rung indicat- 
 ing the nurse's arrival. A school janitress or a good prin- 
 cipal's clerk may be of great assistance in getting the chil- 
 dren ready. Each child will come with his health record 
 card in a fold of clean paper, and on this paper may be 
 written the teacher's reason for sending in the pupil. He 
 may be suspected of some ailment, or the teacher has noticed 
 that he is not getting the treatment previously recommended, 
 or for many other reasons, except as punishment. The 
 nurse inspects the child, and, unless he is excluded, sends 
 him back to his room, with a note to the teacher about the 
 case on the same folder-protector of the card. The teacher 
 
MEDICAL INSPECTION PLAN 327 
 
 may clip small memoranda slips on cards of pupils who have 
 not yet obtained treatment, or put these cards in a special 
 part of her file, or she may use the various colored clip- 
 markers for card indexes, each color of which may be 
 given a standard meaning, as before mentioned. 
 
 The symptom chart prepared by Dr. E. B . Hoag and 
 printed in his "Health Index of Children," and separately, 
 or some other set of indices to school ailments, such as are 
 used in Cleveland, or printed by the writer in American 
 Education, or those given by Dr. Wood in his "Health 
 and Education," will be of great assistance to the teachers 
 In locating the children needing referring to doctor or 
 nurse.* Most of the present work of medical inspection 
 is really ^^^c/^^r-Inspection, since most of the cases are first 
 noticed by the teachers and then sent in to the doctors. 
 With all this responsibility the teachers have not been given 
 a square deal in the way of health instruction in the form 
 of lectures, clinics, teachers' meetings, or books, by which 
 to fit themselves for their serious responsibility; and their 
 normal or college courses have never, in most probability, 
 even touched upon such matters. "The child," to their pro- 
 fessional training institutions, was quite largely a disem- 
 bodied mentality, and psychology was the only study of his 
 nature. 
 
 2. Environmental Inspections 
 
 After pupil inspections, according to our outline, come 
 environmental inspections. Home visits, or home hygiene 
 Inspection, by nurses is about their most important work, 
 and the problem of school sanitation will soon come up in 
 any thorough system of medical supervision. The home- 
 hygiene inspections at the time of the nurse's home visits 
 are becoming exceedingly valuable citizen-making institu- 
 tions, and no words here can Indicate the spirit, the pos- 
 sibilities or the methods of that humane and scientific work. 
 
 *See also the bulletin of the U. S. Bureau of Education, No. 524, 
 pp. 130-131. 
 
328 SCHOOL HEALTH ADMINISTRATION 
 
 We arrange for the records of such visits in cipher on 
 each individual record card. Each nurse should obtain 
 Dr. Hoag's or Dr. Cornell's book, and, at least, a book 
 probably now published by the first school nurse of America, 
 Miss Lina L. Rogers, R. N., now superintendent of school 
 nurses at Toronto, and formerly of New York City. Dr. 
 Dresslar's book on School Hygiene is also a desirable volume 
 on the whole field. (Miss Rogers is now Mrs. L. R. 
 Struthers.) 
 
 In certain small cities the experiment has been suc- 
 cessfully tried of making the nurse the attendance officer 
 also (thus saving another salary as related), so that she can 
 go to a home and handle a case of truancy effectively, as 
 any other school "case." The possibilities have not yet been 
 half discovered in this whole field of home visiting. Even 
 where there are attendance officers, the nurse becomes their 
 most valuable assistant. 
 
 School sanitation inspection is more naturally the work 
 of the superintendent, director of hygiene, principal and 
 business manager; but the nurse and the physician should 
 know enough about the subject from such texts as Shaw's 
 or Dresslar's books on "School Hygiene," or the other 
 books mentioned,* to do effective work in calling to their 
 attention as often as is necessary evil conditions of lighting, 
 cleaning, heating, ventilating, the condition of toilets, the 
 necessity for play, playgrounds, and play apparatus, sanitary 
 drinking fountains, the proper kind of dusting, and all such 
 matters. 
 
 The Board of Health of Philadelphia has a special card 
 form, for recording the facts of school sanitation, and Dr. 
 Hoag has a portion of his book and a pamphlet devoted to 
 a "Sanitary Survey of Schools," which is of great assist- 
 
 *Dr. Jesse D. Burks and his wife have published a new book en- 
 titled "Health and the School," and the writer has one under way 
 entitled "School Health," as well as a large volume by a large group of 
 specialists entitled "Educational Hygiene" from kindergarten to uni- 
 versity. The Burks' book is unique, being in dialogue form. Terman & 
 Hoag will soon have out a valuable volume on "Health Work in the 
 School." We need still more volumes — on School Clinics, on School 
 Nursing, on Medical Supervision, etc. 
 
MEDICAL INSPECTION PLAN 329 
 
 ance to the amateur, and which can be had of Whitaker 
 and Ray-Wiggin Co., San Francisco, or Paul Hoeber Co., 
 69 East 59th St., New York City.* Quite frequently the 
 nurse or the school physician will observe unhealthful condi- 
 tions not noticed by teachers or principals, and, then, may 
 be even more successful than they in remedying these condi- 
 tions. It depends upon who has the ability to translate 
 private opinion into public opinion, and private scientific 
 knowledge into public action. 
 
 C. Examinations. 
 
 There is no need of calling these physical examinations, 
 except where the word examination is (badly) used for in- 
 spection. We have suggested that a thorough, routine room- 
 inspection of children for all ailments of a serious character, 
 recorded on the health record cards, is very much like an 
 examination. It is, however, not so individual, so intensive, 
 and so technically diagnostic. Inspections will frequently 
 overlook decayed teeth entirely, and will never include 
 routine vision or hearing tests, nor will they ever require, 
 perhaps, the stripping of each child to the waist, as a mat- 
 ter of routine and without suspicion of some heart or lung 
 ailment. An examination should be a patient, scientific, 
 investigation of a child's health status, regardless of whether 
 he is suspected of an ailment. Such examinations should not 
 be painfully long, and impractical, however, in their min- 
 utiae. Quick, accurate and thorough observation and judg- 
 ment can be developed in this field as in any other. Much 
 will depend upon the physician and the nurse and what 
 they have in their minds as questions and problems regard- 
 ing each child's health condition. 
 
 The examinations should be made in the health, or 
 medical, room. This should be about half the size of an 
 elementary school room (25 by 16), and be well lighted. 
 It should have both hot and cold running water, a toilet 
 adjacent, facilities for a combination tub and shower bath, 
 
 *See also the New Jersey form of 114 points in the U. S. Bulletin, 
 No. 524, pp. 127-9. 
 
330 SCHOOL HEALTH ADMINISTRATION 
 
 a couch, several chairs, an ante-room for those awaiting ex- 
 amination, filing cabinets for case cards (for systems need- 
 ing them), a table or desk or two with drawers, a medicine 
 cabinet, a white enameled iron and glass stand, white enamel 
 wash basins, and the various test cards, medicines, and the 
 like, needed by nurse and physician. Types of equipment 
 and supplies are given in a former chapter. Many schools 
 add to these a platform scale, usually a "Jones," with height 
 standard attached. Its necessity as a matter of general 
 routine for all school children is yet to be demonstrated, 
 however. 
 
 THE METHOD OF THE EXAMINATIONS 
 
 As suggested, it will probably be best for the nurse to be 
 present each day during the two hours or more of the 
 examination, so she can confer with the physician over cases 
 and help in handling the children, making the vision and 
 hearing tests, taking the records, etc., as can best be ar- 
 ranged. Scientific management in business does some of its 
 best work with seemingly minor details of daily practice. 
 There is great opportunity for the practice of its principles 
 in medical supervision and especially in the examinations. 
 This plan, however, must limit itself to bare essentials, in 
 order not to exceed all space limits. 
 
 We have urged that the vision and hearing examinations, 
 once a year or less often, as is found better, be given by the 
 nurse and not by other persons; and that she do this, as 
 much as possible, at the time the physician of her district 
 makes his two-hour daily visit to some one school. One 
 nurse will work with the physician at all times while the 
 extra nurses will devote themselves to inspections and home 
 visiting. 
 
 Here, at the ringing of the bell which indicates the 
 physician's arrival, or before, children suspected of having 
 serious ailments or who for some reason require immediate 
 attention are sent by the teachers or nurse to the health 
 room. At the same time, pupils of the lowest grades, a 
 room at a time, are sent, by threes, to the health or medical 
 
MEDICAL INSPECTION PLAN 331 
 
 (inspection) room. The nurse quickly inspects the serious 
 cases, referring such as are puzzling to the doctor for 
 further inspection, and then disposes of the first group. If 
 desired, they may be examined at this time. 
 
 She then prepares, as may be necessary, a child (of the 
 three mentioned) for the doctor's examination, calling his 
 attention to any ailments or history of the child familiar 
 to her and necessary for him to utilize, and begins, herself, 
 to test the vision and hearing of another child. By the time 
 the doctor is through with his medical examination she will 
 perhaps be through with these two tests, and all can be 
 recorded on the health record card of the pupil, exclusions 
 can be made, or notices to parents regarding serious physical 
 defects or other ailments signed. Each case (name of child) 
 will be placed in her case book, or on a case-card on file in 
 the health room or principal's office. Such cards for de- 
 fective pupils are found necessary in many cities. The one 
 used by Newark is sent to the "department of medical in- 
 spection," when the case is concluded. Cards not sent in by 
 the end of the school term are used for follow-up work in 
 the summer. Whenever a case is concluded, the teacher 
 should be notified. The word "case" is frequently used to 
 mean both a single child and all his ailments at any one 
 time, and again each one of the ailments found, so that a 
 child might be six or more cases at once. If the term is 
 used (and it probably should not), it should refer only 
 to one child with all of his ailments, whether one or many, 
 at any one time. Usually every new ailment he gets will 
 make another case. Then instead of recording the number 
 of "cases," the number of different ailments should be given, 
 and for a large group of children there will always be more 
 ailments than pupils, probably, on the average, two or more 
 to one. 
 
 The time of the examination should preferably be from 
 nine to eleven each day, and each day in a different school 
 during a week or longer, depending upon the number of 
 schools it takes to supply about three thousand children, de- 
 pending somewhat upon the locality, of course. Perhaps 
 
332 SCHOOL HEALTH ADMINISTRATION 
 
 two thousand for the doctor and the same or fewer for the 
 nurse may be found desirable in a poor, foreign district. 
 For small schools the doctor's visits should be distributed 
 over the year. A school with 200 pupils will mean about 
 10 visits, or one every three or four weeks. Compromises 
 may be made here. 
 
 If the nurse and doctor go to the same school, how can 
 we have inspection at other schools each day, someone may 
 ask? This is one of the reasons for the extra nurse in the 
 typical city. She will do this work. Otherwise, the prin- 
 cipals and teachers must use their discretion as they have 
 done for so long, until the nurse can come in the late morn- 
 ing or in the afternoon. Some of these daily inspection 
 visits she can avoid by telephoning to a school and finding 
 whether the teachers have looked and found any urgent 
 cases. On schedule, she will probably get to one or two 
 of these other schools each afternoon anyway. 
 
 THE VISION EXAMINATION 
 
 Whether vision and hearing tests should be made each 
 year is a question. Abroad, all examinations are less fre- 
 quent than here. A modification of the plan of Meriden, 
 Connecticut, commends itself to our judgment, as a tentative 
 hypothesis : that of tests for new children whenever they 
 enter the school above the kindergarten, and every other 
 year thereafter, i. e., the first, third, fifth, seventh, ninth, 
 etc. The three-year interval there practiced would seem 
 too long. 
 
 For the method of the examinations in detail, nurses and 
 doctors should refer to some such book as that of Dr. 
 W. S. Cornell (Health and Medical Inspection of School 
 Children). Whipple's methods given in Monroe's Cyclo- 
 pedia of Education under the topics, "Ear" and "Eye," 
 are also commended. The methods given in Gulick and 
 Ayres' Medical Inspection of Schools, are well chosen. 
 With all their defects as complete tests, the Snelling's or 
 other test types for capacity to read at twenty feet, and for 
 astigmatism, must be, until we get better trained nurses and 
 
MEDICAL INSPECTION PLAN 333 
 
 physicians for this work, our chief reliance. The ap- 
 paratus recommended by Whipple consists of: a test card 
 for acuity, a test card for astigmatism (preferably Ver- 
 hoeff's chart), a simple trial frame into which may be fitted 
 during the examination either one or two minus .75 ^ and 
 one or two plus .75 d spherical lenses (48-inch focus, 
 English system), and one blank disk. Probably better than 
 the trial frame into which may be set the two types of lenses, 
 are cheap spectacle frames fitted up, respectively, with the 
 plus and minus glasses. These are for those, however, who 
 have the interest to go forward and do accurate work, and 
 will probably be used only where there is a director of 
 hygiene. Another instrument, the retinoscope, the shape of 
 a small paddle with a mirror and letters on its face, tests for 
 three types of defects, and is good for quick general diag- 
 nosis for those who learn how to use it. 
 
 But just as important as the test, is the examination of 
 the general condition of the pupil's eyes, whether inflamed, 
 crossed, seemingly strained, whether the child has frequent 
 headaches, how he holds his head, as well as the note by 
 the teacher which she places on the paper in which each 
 child carries his examination card. 
 
 Place the test card in a good light at a distance of 
 twenty feet on the level with the pupil's eyes, and stand the 
 child in such a way as to avoid any reflected glaring light. 
 Children wearing glasses are to be tested with the glasses 
 on, and if normal with them, so recorded. Pupils who, at 
 twenty-foot distance, cannot read the line of letters marked 
 twenty feet should not be counted defective (unless there 
 are other signs of eye strain and ocular defect). Only those 
 whose vision in either eye is 20/40 or less (each eye always 
 tested separately and then, perhaps, both together) should 
 be counted defective, with the exception mentioned. Test- 
 ing with both eyes open has the advantage of showing what 
 the best vision of the child is in ordinary circumstances, but 
 also the disadvantage that it measures principally the vision 
 of the stronger or better eye. As a check, it may be omitted 
 as a routine matter, perhaps, and each child studied as a 
 
334 SCHOOL HEALTH ADMINISTRATION 
 
 separate problem. If both eyes always varied together, 
 mechanical methods, almost, might be employed. Unfor- 
 tunately, the children strain and accommodate their eyes 
 during the test. The best statement of the whole problem 
 here is perhaps that given by the head of the vision de- 
 partment of the school clinic at Dunfermline, Scotland, in 
 the 1911-12 report, distributed so freely by the Carnegie 
 Trust of that place. The following pupils, as a general 
 rule, should be referred as possibly defective and in need 
 of the attention of an oculist: 
 
 a. All pupils showing signs of eyestrain, inflammation, 
 headaches, etc. 
 
 b. All pupils with vision 20/40 or less in either or both 
 eyes. 
 
 English and Scotch reports usually give the following 
 in the report : 
 
 1. Number at different ages with "normal," 20/20, vision. 
 
 2. Number at different ages with "good," 20/30, vision. 
 
 3. Number at different ages with "fair," 20/40, vision. 
 
 4. Number at different ages with "bad," 20/60, vision. 
 
 The data by sexes are, also, frequently given, although 
 probably unnecessarily. Most children are reported to 
 parents who are 20/40 or less. The following for all the 
 pupils of Dunfermline shows either an improvement in 
 visual conditions, or a change in methods by the examiners, 
 or both: 
 
 1910. 1911-12, 
 
 Boys 20/40 or worse 6.4% 5.1% 
 
 Girls 20/40 or worse 12.5% 7.4% 
 
 The duty of the nurse is to get those books which will 
 help her best, and also to obtain help from oculists, and to 
 visit other school systems with good medical supervision 
 systems. No plan can take the place of a live, inquiring, 
 sympathetic intelligence. 
 
 HEARING TESTS 
 
 As the eyes were tested singly so Is the hearing of each 
 ear. The whisper test and the stop-watch tests will be of 
 value. As with vision, the individuality of children is such 
 
MEDICAL INSPECTION PLAN 335 
 
 that the best standard yet is common sense, conservative 
 common sense in this matter. The tragus or projecting por- 
 tion of the ear may be pressed easily into the cavity, and 
 the stop-watch started and stopped and the child, not seeing 
 it, asked if he hears it. What is asked may be whispered 
 quite softly. Numbers and short sentences may be used. 
 The standard may be an ordinary soft whisper at the dis- 
 tance of the vision tests, twenty feet, this probably being 
 the greatest length of the room used. Only a very few 
 children in each school will probably be found with this ail- 
 ment, usually preceded by discharging ears. 
 
 All three or four of the children awaiting examination 
 may be tested at once by standing them with their backs 
 to the nurse and whispering commands, or asking that all 
 who hear the stop-watch at various distances hold up 
 their hands, etc. The difficulty of one pupil imitating an- 
 other may easily be overcome. The growing experience of 
 the nurse gives a norm or standard probably of more value 
 than that of an audiometer, though the development of 
 such objective standards should be encouraged in all this 
 work. The observations of the teacher and parent as to 
 the children's condition should always be sought as a help 
 in examination. 
 
 Both examinations have taken less time, of course, than 
 to read the lines here given in explanation of the work, 
 probably two to five minutes for each pupil, making records 
 and all. 
 
 THE doctor's medical EXAMINATION 
 
 The child having been tested for hearing and vision and 
 the results, if below 20/40, placed on the record card for 
 each eye, or, the numerical record for any degree of de- 
 fect as may seem better, he passes on to the physician who 
 gives him a thorough medical examination, loosening the 
 clothing, removing the coat, or even stripping him as ap- 
 pears necessary for the best examination. The parents of 
 twenty or more children have been notified of the approach- 
 ing examination on this day and it is desirable that as many 
 
336 SCHOOL HEALTH ADMINISTRATION 
 
 come as possible. If a parent is present, all the children of 
 the family in that school should be examined on that 
 morning. 
 
 The doctor looks, not for a few ailments, but for all on 
 the code and report list. Some of the more easily missed 
 ailments, he will give particular attention to, and especially 
 those placed in the upper part of the list of physical de- 
 fects. If a doctor finds few cases of enlarged glands one 
 year and then later learns of their possible harm to the child 
 in his school work, it has been found in our study that he 
 will then begin to find many cases where he had not seen 
 them before. What a man is so sees he, is the law of medical 
 perception. 
 
 The doctor, especially, must be careful to calm the fears 
 of the children and put them at their ease. It is all too 
 customary a habit for children to remain out of school on 
 the days when they know that the doctor is coming. Some 
 teachers use the doctors as disciplinary bogeys, a great 
 mistake. English school physicians may go about with silk 
 hats and frock coats, but many of them carry a bag of candy 
 ("sweets") of which to give to each child examined. One 
 of them who has written a book on the work says it has 
 many advantages. The attitude is the important thing. 
 
 As the doctor makes his examination he records any seri- 
 ous findings needing attention by parents and family phy- 
 sicians on the health record card. The system of signs makes 
 it possible to do this very rapidly and with little waste of 
 time. Here has been one of the greatest leaks, and almost 
 as great as that of having the doctor travel about from 
 school to school every morning on inspection tours, in many 
 of the present systems of so-called "medical inspection." 
 
 Whenever a referable, non-infectious ailment is found 
 in the examination or the inspections, the following note to 
 parents may be filled out from the cards and inclosed in an 
 envelope by the nurse, after the examination is over some- 
 where near eleven o'clock: 
 
MEDICAL INSPECTION PLAN 337 
 
 Medical Supervision of Schools, 
 Montclair, N. J. 
 
 NOTICE TO PARENTS OR GUARDIANS. 
 
 This notice does NOT exclude the pupil from school. 
 
 Date , 191- . 
 
 The parent or guardian of 
 
 is hereby informed that a physical examination by the school physician 
 
 seems to show that this child is suffering from 
 
 You are advised to take 
 
 this child to your family physician or a specialist, 
 
 for advice and treatment as soon as possible, in order that the pupil 
 may be better fitted to do successfully and without injury his school work. 
 
 School Physician. 
 
 This notice may be placed on a card of a certain color, 
 say yellow, and about 55^ by 3/4 inches in size. Some 
 send all such messages by post, but this is in most cases a 
 needless waste. 
 
 On the back of the card may be printed a permit by the 
 parent for the nurse to take the child to a clinic or physician 
 for medical or surgical treatment, and an alternative state- 
 ment that the parent has had a physician and the result of 
 the visit, somewhat as follows : 
 
 PLEASE SEE THAT THIS CARD IS RETURNED TO THE TEACHER. 
 
 This pupil was seen by Dr on 
 
 , 19 .... , with the following result 
 
 Signature of parent or guardian, 
 I desire the school nurse to escort my child to. 
 
 for medical or surgical treatment of the. 
 Signature of parent or guardian. 
 
338 SCHOOL HEALTH ADMINISTRATION 
 
 If the parent does not respond within three days, and an 
 inspection at that time by the nurse shows no evidence of 
 satisfactory treatment, another notice should be sent. 
 
 If this notice is not heeded, and it should be printed and 
 worded in such a manner as to command attention and get 
 results, the nurse may visit the home to help the parent see 
 the need of the treatment or to explain and arrange with 
 her the free treatment at some dispensary, the school clinic, 
 or other similar place. If the nurse is unable to get the 
 treatment, and cannot do it herself, the physician, principal 
 or teacher may attempt the matter. 
 
 So many parents are so poor and so ignorant, and the 
 provisions for treatment are so inadequate or unsatisfactory, 
 that men and women in the school medical service are soon 
 driven to see the absolute necessity of an adequate school 
 clinic, with an oculist to make eye examinations and pre- 
 scribe and, at times, furnish free glasses, dentists for dental 
 service, and surgeons for operative work. The surgeons 
 or the nurses attached, or a school physician, can make such 
 treatments as are necessary — those for ringworm of the 
 scalp with X-rays possibly, for favus, for trachoma, ade- 
 noids, tonsils, etc., and, with the help of the physical educa- 
 tion division, such medical gymnastics as are needed for 
 orthopedic, mouth breathing, and other cases. The need 
 for an open-air school, and outdoor cooler ("uncooked") 
 and moister air in the classrooms, will also soon be made 
 manifest in even the best of cities. 
 
 As the examinations extend through the entire year, 
 and the graduating class of February may not be reached 
 by that time, it will be well to give this class an examina- 
 tion early in the term. Other children who may also be 
 examined out of turn are : the children of a family when a 
 parent has come to the examination, as suggested, children 
 going into athletic contests (very important In some cities), 
 children who are especially referred to the physician by the 
 nurse, or to the nurse by the teacher, and children who have 
 entered school, or that school, for the first time after the 
 pupils of their rooms have been examined. 
 
MEDICAL INSPECTION PLAN 339 
 
 Not only parental visiting at the examinations is desira- 
 ble but also school consultations with nurse or physician, 
 when the parent has neglected treatment for the child, for 
 instance. A notice such as the following may be sent, at the 
 end of the three-day period mentioned: 
 
 DEPARTMENT OF MEDICAL SUPERVISION OF SCHOOLS. 
 
 Date , 19 
 
 To the parent or guardian of 
 
 Public School 
 
 You were notified a few days ago that this child was found on 
 examination by the school physician nurse to be in need of immediate 
 treatment for 
 
 Please call at the school at o'clock 
 
 to confer with the school physician nurse. 
 
 Principal. 
 
 Cross out either "physician" or "nurse" where they are 
 printed for alternative use. This card may be white in 
 color and 3/4 by 5/^ inches in size. Other devices to 
 obtain treatment will be invented by the thoughtful and 
 interested nurse, physician, or principal. Some cities use 
 attendance officers to force children in whom the doctor or 
 nurse will not admit till treated or cured. Notice is also 
 sometimes sent that parents are keeping children out illegal- 
 ly, even though excluded or referred for treatment. 
 
 When the time has come, three days after notification, 
 and the pupil is in school, the teacher sends the pupil in 
 for the nurse's or physician's inspection to see if the cure 
 has been obtained. No record of cure or treatment is ever 
 to be made without such inspection. The teacher's opinion 
 is not enough. Dr. Foster, of Oakland, Cal., has his nurses 
 record cures at the first routine inspection only, and these 
 for ailments found the year previous. Cures take time. 
 
 A further attempt at accuracy, co-operation, and a check 
 on the work of doctor and nurse, is the principal's monthly 
 report based upon his own and the teachers records. This 
 will be described later. 
 
340 SCHOOL HEALTH ADMINISTRATION 
 
 Great care must be taken not to give the impression 
 that the nurse and physician are interested in providing 
 patients for the doctors, dentists and oculists of the town. 
 They are not; and one of the great reasons for the school 
 clinic is to break down this argument not only of the medi- 
 cal fakirs so busy everywhere just now, but also the plain 
 common-sense parents of the children. Dr. Chapin of the 
 Providence Board of Health in his 1910 report and again 
 in the one for 191 1 has met a number of the criticisms 
 of such free treatment, especially that it would injure the 
 pocket-books of private medical people. 
 
 It is probable that if all the children of the nation were 
 given free medical attention and treatment until the age 
 of sixteen, as is almost the case now in Boston since the 
 completion of the Forsythe Dental Clinic, and all children 
 educated in right health habits and the necessity of getting 
 the help of dentist and doctor where their services are 
 necessary, the medical profession as a whole would lose 
 but little, and the nation as a whole would be immeasur- 
 ably improved. Free schools, free text-books, free libraries, 
 free baths, free music in the parks, free postal service, free 
 medical service for old and decrepit already : and why 
 not free treatment where necessary, and rather generously, 
 for the young and plastic, before they lose all their per- 
 manent teeth, perhaps, or the use of an eye, or the hearing 
 of an ear? The bugaboo of "Socialism" hurled in 1828 
 at the speaker for free schools on the court house steps 
 of Philadelphia leading to his arrest, and used so freely 
 ever since, provokes no fright any more in the hearts of 
 those who would minister to the health and happiness of 
 this people. Selfishness will be swept into its deserved 
 oblivion, before this advancing democracy and scientific 
 brotherly love. Compulsory school attendance involves free 
 and compulsory health provisions. These, when established, 
 will point to certain necessary social reforms, of a far-reach- 
 ing character, probably socialistic in tendency. 
 
MEDICAL INSPECTION PLAN 341 
 
 VACCINATION FOR SMALL POX 
 
 No one has yet proved that small pox vaccination is 
 not necessary or desirable for all school children. Many 
 cities are experimentally doing without such requirements 
 in the schools, and the ailment does not seem to get a 
 start in such towns. However, much experience points to 
 its value even if the disease seems to be losing its virulence, 
 and probably the best plan to enforce is that no child shall 
 be admitted to the schools a day without such vaccination. 
 Free vaccination should be provided by the schools or board 
 of health for such purpose, and the work done by the 
 nurse or physician. Re-inspection to observe the effect of 
 the vaccine should be made as in the case of other treat- 
 ments. Here the nurse will often find it necessary to make 
 dressings for the vaccination sores. In Philadelphia, ac- 
 cording to Burks, laxity in the prevention of small pox 
 cost the city in 189 1-2 through an epidemic over $21,000,- 
 000, and another outbreak in 19 12 in Penns3'lvania towns 
 was only checked by wholesale vaccination. 
 
 EDUCATION OF THE PARENTS " 
 
 For many or most of the fifty-four ailments and classes 
 of ailments parents can be given judicious health instruc- 
 tion, as to treatment, reference to doctors and prevention. 
 The book by Dr. Ditman on "Home Hygiene and the 
 Prevention of Disease," by Dufl'ield and Co., or one just as 
 good or better, if any, should probably be in every intelli- 
 gent household. Much of our recently discovered health 
 knowledge has been the almost secret possession of the few. 
 While there is some little danger in home treatment there 
 is no danger in home prevention, and a book along the 
 line of health education in the simple language of the people 
 is necessary to democratize our health knowledge. This 
 latter desire is also back of the simpler nomenclature used 
 in the present system of medical supervision. An examina- 
 tion of the list of school ailments given in the 19 10 or 
 19 II reports of the Boston Board of Health, and other 
 such cities, will show what to avoid in this field. 
 
342 SCHOOL HEALTH ADMINISTRATION 
 
 Do you know, lay reader, what urticaria, verucca, fur- 
 unculus, acne, tinea, scabies, pediculosis, and such names 
 mean? They are respectively: hives, warts, boils, black* 
 heads, ringworm, itch, and head lice. Such terminology 
 for diseases thrown at parents is defended by saying that 
 "it scares them into getting treatments." We say simply 
 that these are the undemocratic methods of persons who 
 do not know how, in the best way, to educate the people 
 into independence and self-respect. Let schools using and 
 adapting this system get close to the people and their needs 
 and their problems, not high in the air above them, or 
 behind some awesome word and mysterious profundity. 
 
 We shall not attempt here to describe all the good 
 methods now being used by schools to reach the parents, 
 or to devise an ideal and general plan. For brevity, only 
 a list of some of the more interesting attempts, and where 
 they can be found, will be listed: 
 
 1. The various colored prescription slips for a growing 
 variety of ailments, to be found in Newark, Providence, 
 New York City, and shown in "Medical Inspection of 
 Schools," by Gulick and Ayres, new edition. 
 
 2. The dental charts showing the location of defective 
 teeth, given out with defective teeth notices in many cities, 
 one form given in the book mentioned; also the various 
 pamphlets such as are given out by the Bath Trustees, City 
 of Boston (on teeth), the Children's Aid Society of New 
 York, the various pamphlets of Dr. E. B. Hoag of Berke- 
 ley, California; the prescriptions for getting compounded 
 very cheaply serviceable tooth powder, by the Board of 
 Health of New York City; the Newton, Mass., Board of 
 Health pamphlet on "Information for the Family in Re- 
 gard to Communicable Diseases," etc., etc. 
 
 3. The health lectures given by school nurses, doctors 
 and principals, and outside specialists, often with the aid 
 of the stereopticon. Newark records 346 such lectures in 
 the school year of 1910-11. 
 
 4. The tuberculosis and other exhibits, stationary and 
 portable. 
 
MEDICAL INSPECTION PLAN 343 
 
 5. The health budget exhibits showing the need for 
 appropriations for medical supervision and other phases of 
 educational hygiene. 
 
 6. Pamphlets on infant and child hygiene for parents. 
 
 7. Pamphlets on sex hygiene. 
 
 8. The remarkable variety of ways described in Elsa 
 Denison's "Helping School Children," showing that "where- 
 ever there is a will there is a way." 
 
 9. The constant and varied use of the newspapers for 
 describing school health needs and what parents can do 
 to help. 
 
 10. The annual health day or health week in the schools, 
 as in Boston. 
 
 11. Above all, the splendid services of the wide-awake 
 and resourceful school nurse going to the homes and help- 
 ing the family in their struggles with the real health 
 problems of life. 
 
 THE WEEKLY REPORT OF DOCTOR AND NURSE 
 
 Our nurse does all the general reporting. Any ade- 
 quate report will always show in juxtaposition the ailments 
 found by both doctor and nurse and what has been done 
 with them, quite in contrast to most of the reports now 
 given out to the public by school superintendents or direct- 
 ing physicians. 
 
 Some of the standards for such a report are: 
 
 a. It must be simple and take up as little time as pos- 
 sible and yet give the facts necessary for the proper educa- 
 tion of the public, and the accurate recording and study 
 of health data necessary for school health control. 
 
 b. It must show the ailments found in detail, if possible, 
 and give the curative results obtained by the department. 
 
 c. It must record the work done by the different mem- 
 bers of the corps and the time they spend in the school 
 service. 
 
 d. It must use some standard classification and nomen- 
 clature of school ailments, not only for the uniformity 
 necessary, and the ease of memorizing a relatively un- 
 
344 SCHOOL HEALTH ADMINISTRATION 
 
 changing outline, but also for dividing the work naturally 
 and emphasizing by position those ailments which play a 
 large part in the success or failure of the pupil in school 
 and life. 
 
 e. It must ehminate as much as possible the writing-in 
 of the names of ailments. A great many reports print only 
 names of ailments which occur with extreme rarity and 
 the doctor and nurse must spend much time in writing-in 
 many ailments or else neglect to report them. The result 
 is commonly neglect, with large numbers of important ail- 
 ments unreported. 
 
 /. The form should be such as will make possible a 
 balancing of figures if possible, somewhat as the monthly 
 reports of teachers and principals are made to balance. 
 This is a difficult matter. Nurses must learn by study how 
 to make out the report, just as they would learn to use 
 any other instrument, say, a typewriter. 
 
 g. It must show the work by days, and by the week, 
 and must record both old and new ailments, making it pos- 
 sible for the superintendent to know at any time of the 
 year how many cases of uncured school ailments there are 
 in the schools and, perhaps, in any school district. "Old" 
 ailments are those found at any time during the year before 
 the week reported. "New" ailments are those found dur- 
 ing the week reported. Daily reporting may be used in 
 large systems, but we are dealing with the more typical 
 cities and rural districts. 
 
 h. It must show the number of new ailments found not 
 only by the doctor but also by the nurse, their sum, the 
 number to be subtracted because "negative," left the city, 
 refused treatment, etc., and what happened to those left. 
 
 i. It must record exclusions, treatment by nurse or out- 
 side agencies, cures found by re-inspection, number read- 
 mitted, and the number "improved but not cured" in a case 
 where cure is a matter of months or years. 
 
 ;. The report will be not only an ailment report, but 
 also a report of the number of examinations, home visits, 
 
MEDICAL INSPECTION PLAN 345 
 
 inspections, pupils taken to the dispensary, etc. If possible, 
 the nurse should report weekly the total number of various 
 ailments to date that have been found, cured, and not cured, 
 with perhaps the number treated and not treated. 
 
 This will greatly reduce the work at the central office. 
 
 k. The report should also give explicit directions as to 
 the way to use it, and should interpret all terms to be used 
 that are shifting in their meaning. All such directions 
 should be printed on the report form itself, if possible. 
 
 /. It should also provide for a report on school sanita- 
 tion, notes and recommendations, record of special cases, 
 and any other data that cannot be given in figures and 
 must be written out. The attempt to put every phase of 
 reports dealing with such intimate and personal matters 
 as these into the squares of report forms by a system of 
 checks or figures easily m'akes for mere routine mechanics. 
 We must have both the form and the spirit, the technically 
 definite and the flexible. 
 
 Instead of printing the large 10x15 report here, we give 
 the headings and other matter necessary to reproduce it. 
 
 THE FORM OF THE WEEKLY AND ANNUAL REPORT 
 
 We give above photographic reproductions of the head- 
 ings of two sides of our tentative and suggestive weekly 
 report. It can be modified as desired. The form is about 
 ten by fifteen inches in size, and should be printed with black 
 and red and with perhaps blue lines to make easily dis- 
 tinguishable the various divisions. The upper half of the 
 face containing the name of the city is the general summary 
 of work done : schools visited, time spent in the schools, etc. 
 The lower half of the face page is divided vertically by a 
 line continuing the line to the right of Wednesday or Thurs- 
 day above. To the left of this line below should be printed 
 specific numbered directions for making out the report such 
 as appear below, while to the right below is the heading 
 "G?bneral Notes to Supervisor of Hygiene," under which 
 is to be written in any notes to supervisor, superintendent, or 
 board of education on such matters as : special cases, recom- 
 
346 
 
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348 SCHOOL HEALTH ADMINISTRATION 
 
 mendations, home hygiene, school sanitation, co-operation of 
 outside agencies, special health needs of the schools, supplies 
 desired, work of open air school, why certain cases are not 
 treated, the chief difficulties, control of epidemics, personal 
 stories of cases for the newspapers, etc., etc. 
 
 On the other side of the report sheet is the "Detailed 
 Report of Ailments," the term ailments covering all affec- 
 tions of children of a pathological character. Vertically on 
 the left are placed the 54 classes of ailments In four divisions 
 with three or four lines left at the end of each division for 
 writing in any special cases that cannot be placed in any of 
 the above divisions. We give only the heading and the side, 
 but the report may easily be duplicated in full by extending 
 the lines. It looks formidable but nothing less, it seems, 
 will keep before physicians and nurses the ailments they 
 should look out for; will make easy the detailed recording 
 of ailments; and will keep a definite unchanging order easily 
 memorized by use. This report will be entirely made out 
 by the nurse in red ink, on Saturday afternoons with the pro- 
 viso that It is to be in the hands of the supervisor or superin- 
 tendent by Monday at nine o'clock A.M. The chief weakness 
 of the report is that it does not entirely separate the data 
 by schools, although this will be done to a large extent where 
 only five schools are visited each week by the medical ex- 
 aminer, Monday being very largely the cases found at one 
 school. Records will, of course, be kept at each school for 
 the year and these may be called In at the end of the year 
 for the annual report. We are not trying here to provide 
 a system for a large city like Philadelphia or even Newark 
 or Boston, but for average cities, around twenty to a hun- 
 dred thousand population. Dr. Burks has met the Phila- 
 delphia type of situation in his new book on Health and the 
 School. The following directions may be printed on the 
 report : 
 
 DIRECTIONS FOR MAKING THE WEEKLY REPORT 
 
 I. This report is to be made out by the nurse at the end of each 
 day's service and summarized on Saturday afternoons for each week 
 just passed. 
 
MEDICAL INSPECTION PLAN 349 
 
 2. It must be delivered at the office of the Supervisor of H\'giene 
 or of the Superintendent of Schools by nine o'clock each Monday 
 morning. 
 
 3. Every effort must be made to make it strictly accurate. No 
 very minor unreferable ailments should be recorded — only those which 
 need serious attention by the schools or the homes or both ; and every 
 reasonable effort should be made to have these ailments treated and 
 cured. 
 
 4. The schools will be numbered in arable numerals and should be 
 so designated on the reports. (For small systems with few schools 
 the names of the schools with their code numbers may be printed in 
 the blank space or spaces at the top of the report under the words 
 "General Summary.") 
 
 5. Time spent in the schools at medical work will be recorded in 
 hours and decimal parts of hours — two hours and a half equalling 2.5 
 hours. 
 
 6. Room inspections should be recorded according to the number 
 of rooms and not the number of pupils. 
 
 7. No pupils should be reported for more than one complete (phy- 
 sical) examination each year. All other physical studies of the pupils 
 will be recorded as inspections. 
 
 8. New ailments are those found during the week reported; old, 
 those previously reported. 
 
 9. Under number of ailments treated "other" or "O" refers to 
 any agencies outside the schools that have treated the pupils. 
 
 10. Under "Remarks" any explanatory information may be written 
 regarding the records to the left. Under "General Notes to Super- 
 visor of Hygiene" any general reports, requisitions, special cases, recom- 
 mendations, or the like, may be written in. 
 
 11. On the back of the report is the "Detailed Report of Ailments." 
 Space is left for writing in the names of ailments not in the classifica- 
 tion. 
 
 12. "Negative, Subtract" refers to ailm.ents previously reported 
 that have since been inspected by a family physician and declared "no 
 case" or not serious enough to warrant treatment or operation. Pupils 
 in any way leaving permanently the school system should also have 
 their uncured ailments subtracted from the previous reports. 
 
 13. The "Grand Total of Number of Ailments to Date" is a brief 
 summary of the year's work to date. In the "Not Cured" column 
 should stand the exact number of ailments in the schools reported on 
 that are not yet cured, so that the school officials may see at a glance 
 just how many adenoid, impetigo, or diphtheria "cases" or ailments 
 exist at the time among the school children. 
 
 14. All ailments of school children, especially the more serious ones, 
 whether found in the schools or not should be here recorded. This 
 applies particularly to "Infectious Diseases." 
 
 1%. If there is an assistant, i. e., one besides the one who works 
 daily with the physician, for this group of children, she should report 
 her work to the first nurse who will incorporate the data in this report. 
 
350 SCHOOL HEALTH ADMINISTRATION 
 
 CLASSIFICATION AND FREQUENCY OF AILMENTS 
 
 We give below our classification of the ailments found 
 in the twenty-five cities investigated with the probable num- 
 ber of these ailments which will be found in any one school 
 year among a thousand elementary pupils, more in the lower 
 grades than In the higher — although we have shown previ- 
 ously that, according to the Newark report of high school 
 ailments, they are much the same and almost as frequent 
 as for elementary pupils. The amount and kind of varia- 
 tion we are not yet ready to estimate. 
 
 Probably the most variable ailments in the list are the 
 infectious ; the frequencies given will for most cities merely 
 indicate the number of actual ailments or carriers that will 
 be found In the schools, and will not be large enough to 
 give the medians for all the actual "cases" in the year. 
 Yet all such cases, whether found In the school or not should 
 be recorded. They cause absence and lowered vitality, and 
 various physical defects such as weakened vision, defective 
 hearing, etc., that are of much concern to the schools. A 
 first-class system will also, through summer nurses and fall 
 Inspections, get records of all serious summer ailments of 
 the children. 
 
 If each physician with one or two assisting nurses has 
 three thousand pupils we can multiply these frequencies by 
 three to see what the totals will be for the year. Very 
 great variations should be investigated, but may be, of 
 course, entirely normal for those pupils. 
 
 There are about 1,419 ailments for the thousand chil- 
 dren if our estimates are anywhere near the true medians 
 for average cities. Later investigations may make possible 
 a statement of reasonable variations from these average fig- 
 ures, and may also show how they vary for different kinds 
 of cities and for different kinds of districts within cities. 
 We have not been able to get very satisfactory data on these 
 problems. Poor and foreign families generally furnish most 
 ailments, especially, perhaps, Russian Jews, South Italians, 
 and Irish, although the native "poor white trash" seem to 
 be in about the same group. 
 
MEDICAL INSPECTION PLAN 351 
 I. NON-COMMUNICABLE AILMENTS. 
 
 A PhvciVal Tiffprte Probable No. Ailments 
 
 A. rnysicai i^etects. per 1,000 Ei. Pupils 
 
 1. Adenoids, nasal obstruction, etc 50 
 
 2. Anemia lO 
 
 3. Deafness, defective hearing 5 
 
 4. Dental, teeth 660 
 
 5. Enlarged tonsils 60 
 
 6. Eyesight, vision 70 
 
 7. Eyes crossed, strabismus, squint 7 
 
 8. Glands enlarged, adenitis lO 
 
 9. Heart defects 9 
 
 10. Lungs very vi^eak, not tuberculosis 5 
 
 11. Malnutrition, debility, indigestion, general condition. 20 
 
 12. Mentality lO 
 
 13. Nervousness, chorea, habit spasm, nervous exhaustion 2 
 
 14. Palate defects 7 
 
 15. Skeleton, orthopedic defects (flat-foot, club-foot, etc.) 2 
 
 16. Spine: curvature, posture, round shoulders, etc 8 
 
 17. Speech: stuttering, stammering, lisping, etc 9 
 
 B. Common Ailments. 
 
 18. Abscess, boils, etc 5 
 
 19. Acute sore throat, cough, etc 3 
 
 20. Bronchitis I 
 
 21. Cleanliness needed 20 
 
 22. Catarrh, rhinitis lO 
 
 23. Colds, bad. Coryza 30 
 
 24. Ear discharge, otitis media 15 
 
 25. Ears: ear wax (impacted cerumen), foreign bodies, 
 
 etc.. Minor 5 
 
 26. Eczema 7 
 
 27. Eyes: "sore," blepharitis, styes, iritis, etc.. Minor... 20 
 
 28. Headache (a symptom), migraine, neuralgia 15 
 
 29. Laryngitis 5 
 
352 SCHOOL HEALTH ADMINISTRATION 
 
 30. Nose-bleed, epistaxis 2 
 
 31. Pharjmgitis, chronic sore throat 3 
 
 32. Rheumatism I 
 
 33. Sex ailments and habits 10 
 
 34. Skin ailments, minor; herpes, seborrhea, acne (black- 
 
 heads), etc 15 
 
 35. Stomatitis, mouth ulcers, "canker sores" I 
 
 36. Wounds, sores, sprains, poison-ivy, chilblains, "first- 
 
 aid," etc 150 
 
 37. Urinary ailments, incontinence of urine, eneuresis. . . 2 
 
 II. COMMUNICABLE AILMENTS. 
 
 A. Parasitic and Minor Infectious Ailments. 
 
 38. Conjunctivitis, "pink eye," etc 30 
 
 39. Favus, yellow^ scalp sores i 
 
 40. Impetigo "contagioso," infectious sores 20 
 
 41. Influenza, grippe, infectious colds of a serious char- 
 
 acter I 
 
 42. Pediculosis, head lice and vermin. 50 
 
 43. Ringworm, body and scalp 4 
 
 44. Scabies, itch 5 
 
 45. Tonsilitis, quinsy lO 
 
 B. Infectious Diseases. 
 
 46. Chicken pox 6 
 
 47. Diphtheria 2 
 
 48. Measles 4 
 
 49. Mumps 4 
 
 50. Scarlet Fever 4 
 
 51. Trachoma, "granulated eye-lids" I 
 
 52. Tuberculosis of the lungs, "consumption" I 
 
 53. Tuberculosis of the bones and other parts of the body i 
 
 54. Whooping Cough, Pertussis 2 
 
 Total 1,419 
 
MEDICAL INSPECTION PLAN 353 
 
 Roughly, I estimate that about one-third of the pupils 
 will be found free from serious ailments (and defects), 
 another third will be found with teeth defects only, and the 
 final third with teeth defects and other ailments. This last 
 third will average about three ailments each. 
 
 principals' monthly reports 
 On the regular monthly report of the principals to the 
 superintendent there should be required a statement as to 
 the general status of the medical service in each school with 
 a statement as to the regularity, punctuality, and fulfillment 
 of the time and schedule requirements of doctors and nurses. 
 The report of principals in Trenton, N. J., is very sug- 
 gestive but defeats itself by its elaborateness, calling for 
 a report for each day of the month on several items and 
 the list of ailments found, cured, etc., etc. This is the 
 proper work for the school nurse and has been provided for 
 in this plan. The principals should be made, however, to 
 feel their responsibility for general oversight and leader- 
 ship of all health measures in their schools and neighbor- 
 hoods. 
 
 CASE CARD SYSTEM 
 
 The blue case cards used in Milwaukee and Newark 
 and the one given in Dr. Cornell's book on Medical Inspec- 
 tion, page 57, are recommended for study and use, if they 
 are found necessary. A book with appropriate headings 
 on each page: room, date found, the ailment, recommenda- 
 tion, results, etc., for each school can more easily be carried, 
 and has some advantages for a small system. See Cornell's 
 Record of Defective Children, page 55. The exclusion 
 books will also give the record of a number of cases. Each 
 school should have its own exclusion-book as well as its own 
 nurse's case book, or card index. The work must always 
 be reported in terms both of the number of children and 
 of the number of ailments. 
 
 THE WORK OF THE TEACHERS 
 
 Teachers and janitors, of course, should be examined 
 prior to their entrance to the school system and every two 
 
354 SCHOOL HEALTH ADMINISTRATION 
 
 to three, or fewer, years thereafter. It is remarkably easy 
 for a tubercular teacher to get a clean bill of health from 
 a physician, and the periodical examination should be 
 made compulsory. Teachers as a class have more than 
 their share of tubercular, nervous, and other ailments. 
 That the teacher be in good health is a prerequisite to the 
 proper health care of her pupils. 
 
 The teacher, also, must be educated for this health work 
 as well as the doctors and nurses after they enter the 
 system. A valuable medical-supervision library has de- 
 veloped in the past four years and each school system 
 should provide its teachers with, at least, one simple well 
 illustrated book on the subject, say Hoag's "Health Index" 
 or CornelPs "Health and Medical Inspection of School Chil- 
 dren," F. A. Davis Co., Philadelphia, as well as the other 
 educative means discussed. Dresslar's "School Hygiene" 
 (Macmillan) is very desirable for the whole health field. 
 In the teachers' hands very largely must remain the health 
 destines of the children, and this responsibility and this op- 
 portunity can never be entirely shifted. 
 
 SUPERINTENDENT'S ANNUAL REPORT ON MEDICAL 
 INSPECTION 
 
 Much in the way of progress, records, and education 
 of the public depends upon the character of this annual, 
 public report. The number of pages of the present reports 
 devoted to this subject varies greatly even by percentages. 
 South Manchester, Conn., probably gives a larger share of 
 its report to these newer health matters than any other 
 city. The plan of coming around to health matters every 
 few years for intensive and comparative treatment while 
 emphasizing certain general features every year is to be 
 commended. Some of the features of the regular report 
 may well be: 
 
 I. The summary of the weekly reports, which have 
 been summarized for the newspapers and for each monthly 
 board meeting during the year, both as to ailments and the 
 general features given on both sides of the report. 
 
MEDICAL INSPECTION PLAN 355 
 
 2. Comparison with the worlc of former years. 
 
 3. Interpretation of the data presented. 
 
 4. Some of the interesting cases handled during the 
 year, to give the intimate personal side, with photographs, 
 if possible. 
 
 5. Emphasis on the percentage of ailments cured. 
 
 6. The principal needs and problems, and what parents 
 can do to help. 
 
 7. Appreciative words for the various voluntary health 
 agencies that have helped during the year, the newspapers, 
 bequests for school clinics, etc. How the various divisions 
 of the hygiene department have co-operated. 
 
 8. A general estimate of the health conditions of the 
 school children. 
 
 III. MEASURING THE EFFICIENCY OF MEDICAL INSPECTION 
 
 SYSTEMS 
 
 The principal efficiency tests are the percentage of the 
 serious ailments existing in the school population that have 
 been found and the percentage of the ailments found that 
 have been cured. The decrease In ailments found from 
 year to year due to prevention and curative measures (not 
 to changes In the standards of inspectors) is a third essential 
 factor. In another place (chapters on ailments, and in the 
 table of ailment frequencies) the writer has given an esti- 
 mate of the approximate percentages of serious ailments 
 to be found In an ordinary school population at the present 
 time with which comparisons may be made. Among a host 
 of other tests of efficiency of this work are the following: 
 
 1. Number of physicians and nurses In proportion to the 
 school population, and the number of nurses in relation to 
 the number of physicians. 
 
 2. The qualifications and the character of the super- 
 vision of these officials, 
 
 3. The percentage of the school population Inspected 
 and examined, and the frequency of these. 
 
356 SCHOOL HEALTH ADMINISTRATION 
 
 4. The quality of the reporting system, whether it em- 
 phasizes essentials, and whether it promotes accurate records 
 with minimum loss of time from other work. 
 
 5. The annual number of hours of work for physicians 
 and nurses, and the regularity and punctuality of attendance 
 upon such work. 
 
 6. The reasonable freedom from epidemics, closing of 
 schools, deaths of school children, large amount of exclu- 
 sion, quarantine, illness, absence and elimination, etc. 
 
 7. The quality of the methods of doctors and nurses 
 to be determined by expert observation. 
 
 8. The amount of state-aid money obtained because of 
 efficiency demonstrated to the State Supervisor of Hygiene. 
 
 REFERENCES 
 
 Some of the literature which will be of value in adapting 
 this system to particular cities or rural regions, and the 
 first four groups now procurable largely for the writing are : 
 
 1. 1911-12 report of the Chief Medical Officer, Dunfermline, Scot- 
 land. 
 
 2. Monograph bulletins on the medical inspection of school chil- 
 dren in: 
 
 Board of Education Cities, such as Celveland, St. Louis, South 
 Manchester, Conn. (1912 report), Milwaukee, Newark, Trenton, 
 Yonkers, Toronto, Canada (Lina H. Rogers), Berkeley, San Jose and 
 Oakland, California, College of The City of New York (Dr. Thos. 
 Storey, on high school medical supervision). State Board of Education 
 of Massachusetts, Boston, etc., Meriden, Conn. 
 
 Board of Health Cities, such as the New York, Chicago, Providence, 
 State Board of Health, Connecticut; State Boards of Health of Vir- 
 ginia and Kansas (Health Almanacs), etc. 
 
 3. Annual Report of the Chief Medical Officer of the English 
 Board of Education, London, England. This gives a list of good city 
 and rural reports. 
 
 4. Annual Reports of the Chief Medical Officer for the London 
 County Council, London, England. 
 
 5. Books: Monroe's "Cyclopedia of Education," five volumes. 
 Health articles. 
 
 Gulick and Ayres, "Medical Inspection of School Children." 
 Cornell, "Health and the Medical Inspection of School Children." 
 Hoag, "The Health Index of Children." 
 Denison's "Helping School Children." 
 
 Wood: "Health and Education," and "The Nurse in Education," 
 U. of Chicago Press. 
 
MEDICAL INSPECTION PLAN 357 
 
 Lina H. Rogers, "The School Nurse," soon to be published. 
 
 Burks "Health and the School," Appleton's. 
 
 Hutt, "Hygiene for Health Visitors, School Nurses, and Social 
 Workers," P. S. King & Son, London, Eng. 
 
 Moll, "The Sexual Life of the Child." 
 
 Hutchinson's "Handbook of Health." 
 
 Ditman's "Home Hygiene and the Prevention of Disease." 
 
 Gillette, "Constructive Rural Sociology." 
 
 Kelynack, "Medical Examination of Schools and Scholars," King 
 & Son, London, Eng. 
 
 Holmes, "The Conservation of the Child." 
 
 Dresslar, "School Hygiene." 
 
 Terman, "The Teacher's Health." 
 
 "Exercise in Education and Medicine," McKenzie, Saunders Co., 
 Philadelphia. 
 
 Shaw^, "School Hygiene." 
 
 Scripture, "Stuttering and Lisping." 
 
 "The Child in the City," by the Chicago School of Philanthropy. 
 
 Putnam, "School Janitors, Mothers and Health," American Acad- 
 emy of Medicine Press, Easton, Pa. 
 
 Marshall, "Mouth Hygiene." 
 
 Hoag and Terman, "Health Work in the Schools," in preparation. 
 
 Hutchinson, "Common Diseases." 
 
 Gulick, "Hygiene Series, "Ginn & Co. 
 
 Ritchie, "Hj'giene Series," World Book Co. 
 
 Colton, "The People's Health." 
 
 Holt, "Diseases of Infancy and Childhood." 
 
 McCombs, "Diseases of Children for Nurses." 
 
 Hoxie, "Practice of Medicine for Nurses." 
 
 "The Public Health Movement," The Annals for March, 191 1. 
 
 Ditman, "Education in Preventive Medicine," Columbia University 
 Press. 
 
 Wile, "Sex Education." 
 
 Woodworth, "The Care of the Body." 
 
 Hough and Sedgwick, "The Human Mechanism." 
 
 Rapeer, "Educational H^'giene" and "School Health," in preparation. 
 
 Lippert and Holmes, "When to Send for the Doctor." 
 
 Sandiford, "The Mental and Physical Life of Children," Longmans. 
 
 Sill, "The Child." 
 
 "Annotated Bibliography of Medical Inspection and Health Super- 
 vision of School Children in the United States for the years 1909-1912," 
 a free bulletin (No. 524) by the U. S. Bureau of Education, Wash- 
 ington, D. C. 
 
 "A Bibliography on Educational Hygiene," by Thos. Wood and 
 Mary Reesor. M. A., Teachers College, Columbia University, 1911, 
 
 "Annotated List of Text and Reference Books for the Training 
 School for Nurses," prepared by the Department of Nursing and 
 Health, Teachers College, Columbia University. 
 
 See also the biblography prepared by the author for his section on 
 
358 SCHOOL HEALTH ADMINISTRATION 
 
 "The Hygiene of the High School" in Johnston's "High School Edu- 
 cation," Vol. n. 
 
 6. Bureaus: The Division of Child Hygiene, Sage Foundation, 
 N. Y. City. 
 
 Bureau of Municipal Research, N. Y. City. 
 
 United States Bureau of Education. 
 
 Reports of the National Education Association, Educational Hygiene 
 Articles. 
 
 The Journal of the American Medical Association, Chicago, re- 
 ports on medical supervision. 
 
 Proceedings of the National and of the International School Hygiene 
 Congresses. 
 
 7. Magazines: Current educational and other literature has many 
 articles on these subjects, all of which can be found in any of the guides 
 to periodical literature found in any public library. 
 
 *See also the bulletin of the U. S. Bureau of Education No. 524, 
 pp. 130-131; and Dr. Dresslar's article on "Typical Health Teaching 
 Agencies of the United States" in the 1912 report of the U. S. Com- 
 missioner of Education, Vol. I. 
 
INDEX 
 
 Abscess, 182. 
 
 Adenitis, 170. 
 
 Abstract of the book, 7-13. 
 
 Adenoids, 141. 
 
 Administration of Educational Hy- 
 giene, 11. 
 
 Administration, general (tables), 76- 
 77. 
 
 Agencies, Health, 56. 
 
 Ailments of School Children, 138 ; 
 summarized, 225 ; tables, 226, etc. 
 
 Anemia, 147. 
 
 Annual Report of Supt., 350. 
 
 Ayres, Dr. L. P., 32, 38. 
 
 Bachman, Dr. Frank, 36. 
 
 Backward children, 176. 
 
 Biggs, Dr., 25. 
 
 Binet tests, 177. 
 
 "Bladder trouble," 202. 
 
 Blepharitis, 196. 
 
 Boards of Education vs. Boards of 
 
 Health, 83, 166, 243, 247. 
 Boils, 182, 
 
 Books on Educational Hygiene, 135. 
 Boy Scouts, 272, 273. 
 Broome, Supt. E. C, 40. 
 Bronchitis, 183. 
 Brubacher, Supt. A. R., 45. 
 Budget exhibits, 241. 
 Burnham, Prof. Wm. H., 272. 
 
 Cabot, Dr. Arthur T. (deceased), 303. 
 
 Case card system, 349. 
 
 Catarrh, 189. 
 
 Chapin, Dr. C. V., 166. 
 
 Checks on Work of Doctors and Nurses, 
 
 95. 
 Chest defects, 179. 
 Chicken Pox, 215. 
 Children's bureau, 57. 
 Chorea, 177. 
 
 Cities, The twenty-flve, 75, 254. 
 Classification of ailments, 135, 352. 
 Cleanliness needed, 187. 
 Clement, Sect. F. F., 304. 
 Clinics, 155, 228, 232, 306. 
 Colds, 190. 
 Colton's "Handbook of the People's 
 
 Health," 288. 
 Common non-infectious ailments, 182, 
 
 184, 185. 
 Communicable ailments, tables, 205-7. 
 Conclusions on Medical Inspection, 
 
 257. 
 Conjunctivitis, 204. 
 Consultations with mothers, 241. 
 Consumption, 222. 
 Contagious ailments, 203. 
 Cornell, Dr. W. S., 98. 
 Coryza, 190. 
 
 Cost of Medical Supervision, 86. 
 Crandall, Prof. Ella P., 304. 
 Cross-eye, 168. 
 Cruickshank, Dr. L. D., 244. 
 Cures, 131. 
 
 Davenport, Dr. Chas. B., 16, 65. 
 
 Deafness, 148. 
 
 Death : causes, 22 ; in the 25 cities, 
 
 207 ; losses, see "Economic." 
 DebiTity, 175. 
 
 Defective pupils, percentage, 129, 352. 
 Deformities, 179. 
 
 Demarest, Supt. A. J., 37. 
 
 Dental defects, 151. 
 
 Desks, school, 284. 
 
 Dewey, Prof. John, 14. 
 
 Diphtheria, 216. 
 
 Directions for making reports, 346. 
 
 Disinfection, 242. 
 
 Doctors and nurses : number, 78-79 ; 
 
 work, 80-81. 
 Doctor's examinations, 333. 
 Dressier, Prof. F. B., 66. 
 Drinking fountains, 282. 
 Dunfermline, 178, 189. 
 Dust absorbing compounds, 285. 
 
 Ear ailments, minor, 194 ; discharge 
 (otitis), 192. 
 
 Economic losses from ill health, 8-9, 
 21-27, 30-33. 
 
 Eczema, 195. 
 
 Educational Hygiene : divisions of, 296. 
 
 Efficiency tables, 253. General effi- 
 ciency, 351. 
 
 Elimination, 34. 
 
 Eneuresis, 202. 
 
 Enlarged tonsils, 157. 
 
 Epistaxix, 198. 
 
 EugenicSj 65. 
 
 Examinations : 100, 102, 113 ; num- 
 ber, 120 ; vision, 123, 327. 
 
 Expenditures for Medical Supervision, 
 299, 301. 
 
 Exclusions : and retardation, 46 ; form 
 and method, 319-320. 
 
 Eyes, minor ailments, 196. 
 
 Eyesight, 122, 161. 
 
 Farr, 32. 
 Favus, 208. 
 Feeding, 175-176. 
 First-aid, 201. 
 Fiscal fallacy^ 219. 
 Fisher, Prof. Irving, 18-30. 
 Flexner, Dr. A., 18. 
 Foley, Sect. Edna L., 304. 
 Foster, Dr. N. K., 303. 
 Fountains, drinking, 282. 
 Frequency of ailments, 226-227, 248- 
 349, 352. 
 
 Giddings, Prof. F. H., 309. 
 
 Glands enlarged, 170. 
 
 Glasses, 167. 
 
 Goddard, Prof. H. H., 177. 
 
 Gorgas, W. C, 54. 
 
 Grippe, 209. 
 
 Gulick, Dr. Luther H., 26, 272, 288. 
 
 Gymnasiums, 275. 
 
 Hall, President G. S., 294. 
 
 Health agencies, 55-60. 
 
 Health record cards, 311, 315. 
 
 Hearing : 148 ; tests, 332. 
 
 Heredity, 65. 
 
 Hermann, Dr. Ernst. 266. 
 
 High School Medical Supervision, 104, 
 
 258-259, 273-277. 
 Hoag, Dr. E. B., 134. 
 Holmes, Dr. Geo. J., 96. 
 Home visits, 325. 
 Howerth, Prof. Ira S., 70. 
 Hygiene of School Room, 61. 
 Hygiene of Teaching or "Instruction, ' 
 
 289, 296. 
 
 359 
 
36o 
 
 INDEX 
 
 Illness losses, summary, 47. 
 
 Impetigo, 209. 
 
 Infectious diseases, 214 ; table, 207. 
 
 Influenza, 209. 
 
 Inspections, 124, 127. 
 
 Investigations, health, 243. 
 
 Itch (scabies), 212. 
 
 Johnston, Prof. Chas. H., 259, 269. 
 
 Keyes, Dr. Chas. H., 33-34. 
 
 Lamson, Dr. W. J., 152. 
 
 Laryngitis, 197. 
 
 Laws on Meflical Inspection, 62. 
 
 Lectures, 236. 
 
 Lice, 209. 
 
 Lisping, 180. 
 
 Locke and Floyd, 23. 
 
 Lungs weak, 10. 
 
 Lubin Vitagraph Co., 57. 
 
 Mackey, Supt. E., 42. 
 
 McKenzie, Prof. R. T., 276. 
 
 Malnutrition, 175. 
 
 Measles, 220. - 
 
 Medical attendance expense, 24. 
 
 Medical Supervision, divisions of, 305. 
 
 Medical supplies, 93, 232. 
 
 Mentality defective, 176. 
 
 Method of inspection, 308, 317. 
 
 Mortality statistics, 19. 
 
 Mothers' consultations, 241. 
 
 Mouth hygiene, 151. 
 
 Mumps, 221. 
 
 National vitality, 21. 
 Nearing, Prof: Scott, 23. 
 Negative cases, 144. 
 Nervous ailments, 177. 
 Neuralgia, 197.' 
 Neurologists, 236. 
 Newman, Sir Geo., 145. 
 Nomenclature, tentative standard, 352. 
 Nose-bleed, epistaxis, 198. 
 Notice to parents, 335. 
 Nurse-alone plan, 302. 
 Nurses : where to get them, 304 ; in- 
 spection by, 127. 
 Nutritional index, 176. 
 Nutting, Prof. M. A., 304. 
 
 Oculists, 236. 
 
 Oils, floor, 285. 
 
 Open-air schools, 239. 
 
 Orthopedic defects, 179. 
 
 Otitis media ear discharge, 192. 
 
 Otorrhea, 192. 
 
 Palate defects, 179. 
 Parental education, 339. 
 Part-time physicians, 303. 
 Pasteur, Louis, 18. 
 Pediculosis, 209. 
 Pertussis, whooping cough, 224. 
 Pharyngitis, 198. 
 
 Physical defects, 134, 141, 352 ; sum- 
 mary table, 184. 
 Physical education, 296 ; table, 263. 
 Pink eye, conjunctivitis, 204. 
 Playgrounds, 64, 276. 
 Posture, 179. 
 Prescriptions, 235. 
 Prevention, 239. 
 
 Preventable deaths, 18,-20, 29-30. 
 Principals' reports, 349. 
 Private organizations, 237. 
 Promotion, 34. 
 Public health,' 17. 
 
 Quarantine and retardation, 46. 
 Quinsy, 213. , 
 
 Ranking of the 25 cities, 254. 
 Reports of doctors and nurses, 341 
 
 and 343-4. 
 Retardation, 34. 
 Reik, Dr. H. O., 158, 168. 
 Rheumatism, 198. 
 Rhinitis, 189. 
 Ringworm, 211. 
 Ritchie Hygiene Series, 288. 
 
 Salaries of physicians and nurses, 87, 
 
 90. 
 Salaries, 75. 
 Sanitary inspection of home and school, 
 
 280, 296, 326. 
 Scabies, itch, 212. 
 Scarlet fever, 221. 
 Schedules, 99. 
 School children, death losses, 28, 29, 
 
 30. 
 School Board Journal, 275, 283. 
 Scientific management, 298. 
 September classroom inspections, 307. 
 Sex ailments, 199. 
 Shoulders, round, 179. 
 Signs for medical inspection reports, 
 
 310. 
 Skeletal defects, 179. 
 Skin ailments, minor, 200. 
 Sore throat, acute, 182. 
 Speech defects, 180. 
 Spinal curvature, 179. 
 Squint, 168. 
 Standardization of medical inspection, 
 
 305-306. 
 Statistical fallacies, 31. 
 Stomatitis, 200. 
 Storey, Dr. Thos., 105, 258. 
 Strabismus (cross-eye or squint), 168. 
 Stuttering and stammering, 180. 
 Strayer, Prof. G. D., 6, 29, 32. 
 Styes, 196. 
 Supplies for medical supervision, 92, 
 
 232. 
 Summaries 7, 47, 64, 107, 257, 290. 
 Supervisor of hygiene 297. 
 Suzzallo, Prof. Henry, 6. 
 
 Teacher's medical inspection, 349. 
 
 Teaching hygiene, 287, 296. 
 
 Teeth defects, 151. 
 
 Tendencies in medical supervision, 84. 
 
 Terman, Prof. L. M., 72. 
 
 Thorndike, Prof. E. L., 6. 
 
 Treatments, 231. 
 
 Throat, sore, 182. 
 
 Time employed in medical supervision, 
 
 94. 
 Tonsolitis, 213. 
 Tonsils, enlarged, 157. 
 Towels, paper and cloth, 286. 
 Trachoma, granulated eye-lids, 222. 
 Tubercular glands, 170. 
 Tuberculosis, of lungs, 222 ; of bones, 
 
 etc., 224. 
 
 Urinary ailments, 202. 
 
 Vaccination, 339. 
 Vacuum cleaning, 283. 
 Verplanck, Supt. F. A., 43. 
 Vision defects, 161, 163, 122. 
 Vision tests, 330. 
 
 Wallace, A. R., 65. 
 
 Wallin, Prof. J. B. W., 48. 
 
 Whooping cough, 224. 
 
 Wilcox, 19. 
 
 Work certificate examinations, 102, 
 
 242. 
 Wounds, sores, sprains, etc., 201. 
 
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