COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX00008516 1 90S j Columbia SIntoettfttp intljeCttptrfltagork College of $f)psicianjs anb burgeons! ittorarp Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/bureauofchildhygOOnewy tr"" A BUREAU OF CHILD HYGIENE GO-OPERATIVE STUDIES AND EXPERIMENTS BY THE DEPARTMENT OF HEALTH OF THE CITY OF NEW YORK AND THE BUREAU OF MUNICIPAL RESEARCH Questions and information from any community will be welcomed with respect to the two subjects dealt with — the medical examination of school children and the instruction of mothers in the care of babies BUREAU OF MUNICIPAL RESEARCH 261 Broadway September, 1908 CONTENTS PA Foreword : by the commissioner of health Introduction : bureau of child hygiene Physical examination of school children Beginnings in New York City Beginnings Growth Notification of parents Progress in method Organization and supervision 9 General organization Supervision Corps of medical inspectors Study of methods and results 11 Period covered Accuracy of examinations Treatment provided An experiment 15 Plan of the experimeut £'' . Children needing treatment Treatment Conclusions Care of babies 27 Reorganization and new plans . . . 31 parate organization Standardizing of service A follow-up system Care of babies Other activities libil I Forms of operative- report and record devised for the bureau of child hygiene Fxhibit 11 Supplementary tables // r A BUREAU OF CHILD HYGIENE CO-OPERATIVE STUDIES AND EXPERIMENTS BY THE DEPARTMENT OF HEALTH OF THE CITY OF NEW YORK AND THE BUREAU OF MUNICIPAL RESEARCH Questions and information from any community will be welcomed with respect to the two subjects dealt with — the medical examination of school children and the instruction of mothers in the care of babies BUREAU OF MUNICIPAL RESEARCH 2 6l B ROADWAY September, T908 FOREWORD By the Commissioner of Health From an economic as well as a humanitarian point of view. there can be no more valuable service rendered to humanity than in the preservation of the health of children. In the pre- vention of premature death and the promotion of normal life, health and happiness, no work can be of greater importance than that which concerns itself vrith children. The depart- ment of health has long, through its several activities, come into close and intimate contact with the children of the city. Owing, however, to a division of forces, the work has not proved as constructively efficient as could be desired. A series of investigations has shown that the desired end can be more readily reached by the grouping of all the activi- ties relating to the health of children under one division or bureau. The department of health has therefore established a bureau of child hygiene, a step which I look upon as potentially one of the most important in the history of preventive medicine. The object of medical supervision over school children is two-fold : first, to prevent the spread of contagious diseases : second, the correction of physical abnormalities, effecting. among its important results, an educational economy to the state by placing the child in a physical condition where mental advancement is possible. The manner in which the work has now been organized will mean a saving of several millions of dollars annually from the standpoint of economy alone, to say nothing of the im- measurable gain in the health of the children of this city. THOMAS DAELIXGTON. M. D, INTRODUCTION In the creation of a division of child hygiene, the depart- ment of health of New York City has made an important ad- dition to the program of preventive medicine. It is the most comprehensive plan yet put into operation by an American city to promote the health of children at all ages, from birth through the period of compulsory school attendance. The in- struction of mothers in the care of babies, the regulation of midwifery, the regulation of the conditions under which babies may be boarded out, medical supervision of school children for both contagious diseases and non-contagious physical defects and the physical examination of children applying for employ- ment permits, are the principal activities now outlined. The methods to be employed are mainly educational, — the educa- tion of mothers in the proper feeding and care of children in their first years, the education of parents to see the necessity for healthful home conditions and for medical or surgical treatment of physical defects when reported to them by medi- cal inspectors and the education of teachers to an alert ob- servation of the physical needs of their pupils. The depart- ment has already successfully maintained for some years a hospital and dispensary for contagious eye diseases, a large proportion of whose cases are school children. The possibilities of such a division, progressively and ef- ficiently administered, are beyond prophecy. A marked re- duction in infant mortality, a higher level of health and vital- ity among children who live and greater efficiency of the school system due to the increased ability of children to benefit by their instruction, — not merely the application of remedies, but the discovery of the causes and methods of prevention of physical defects and low vitality, — these direct results may reasonably be expected and demanded. More remote and less demonstrable results may be hoped for in the way of increased industrial efficiency, of correspondingly decreased poverty and dependency and of decreased truancy and delinquency that now too often lead to wasted or even criminal lives. The establishmenl of the division of child hygiene* fol- lowed upon a series of co-operative studies and experiments by the department of health and the Bureau of Municipal Be- search. A study, conducted in the spring of 1908, of the pre- vailing methods and results in the examination of school chil- dren for non-contagious defects, demonstrated clearly that the accuracy cf the examinations was open to serious question, and thai no adequate methods had been worked out for securing the treatment of children discovered to be defective. Inspec- tors examining in the same schools rendered reports differing as widely as by 100% in the number of children found cle- t'eetive: while of the parents notified that their children re- quired medical attention only 8% reported any action. It was thus made evident that more effective methods of supervision and of follow-up must be devised. To determine to what extent action on the part of parents could he obtained by personal interview and explanation, an experiment in three schools was tried covering the last six week's of the school year 1907-1908. The parents who did not respond promptly to the department's customary postal notifi- cation that their children needed treatment were interviewed either at school or at home, with the result that over 95% either took action or requested the department's nurses to act for them. In three fourths of the cases only one interview was necessary; while the cost in nurse's service per pupil treated was only about sixty cents. Even this figure could be con- siderably lowered in well-established work. A second experiment, during the summer of 1908, w T as concerned with the care of babies. Instead of. as previously, a large cor] s of inspectors and a small number of nurses en- gaged in a house to house visitation for sick children under two years of age, the department of health employed a large staff of nurses and a few inspectors, the former visiting the homes from whieh births were reported and instructing mothers in the care of their babies, the latter visiting sick babies referred by nurses or others and conducting educational lectures and instructions in vacation schools, playgrounds and recreation centres. The results were a substantia] improve- ment in administrative control and efficiency and a strengthened •By resolution of the board of health. August 19, 1008. conviction that the problem of infant mortality is funda- mentally educational and is therefore not merely a summer problem but demands an all the year round service. A per- ceptible, though on the whole not a marked decrease in the deaths of infants occurred, attributable in part at least to the summer campaign by the department of health and by many public and private agencies in alliance with it, whose work was this year especially active. The increased activity of the department of health during the last few years in in- specting the milk supply may also have contributed to the result. These conclusions were held sufficient to warrant the es- tablishment of a new division or bureau. Many problems re- lating to the health of children of course remained untouched by the experiments, such as the vexed questions of free meals and free eye-glasses at school and free treatment generally. These, so far as they come within the field of the new organiza- tion, are for it to solve on the basis of its experience. No apology is offered for presenting plans and purposes as yet unachieved. As plans only, they may prove suggestive to other communities facing similar problems. But more im- portant than that, the account in the following pages describes, in a concrete instance, the method of intelligent self-criticism and experiment which alone enables a public department to keep its service abreast of public needs. PHYSICAL EXAMINATION OF SCHOOL CHILDREN Beginnings in New York City _ . . In 1903, inspectors of the department of health Beginnings examined about 1,000 children for refractive er- rors of vision and for orthopedic defects. Nearly one third were found to have spinal curvature, and about the same pro- portion to have defective vision. Additional vision tests were made in the autumn of 1904, some 12,000 children being ex- amined, of whom over 25% were reported defective. These results indicated clearly enough the need for systematic and thorough physical examination. In April, 1905, therefore, the department of health extended its work, examinations being made for the following defects: malnutrition, diseased anter- ior cervical glands, diseased posterior cervical glands, chorea, cardiac disease, pulmonary disease, skin disease, deformity of spine, deformity of chest, deformity of extremities, defective vision, defective hearing, obstructed nasal breathing, defective teeth, deformed palate, hypertrophied tonsils, posterior nasal growth and defective mentality. This classification remained with few changes until recently. During 1905. some 55,000 children were examined, of Growth whom over 33,000 or 60.6% were pronounced to be in need of treatment. Each year since 1905, an increased num- ber of examinations has been made, as may be seen from the following table: Table 1 PHYSICAL EXAMINATIONS OF SCHOOL CHILDREN 1905 -June, 1908 Borough 1905 1906 • 1907 1908 6 mos. Total Manhattan 55,332 79,085 141,908 59,426 335,751 Bronx 10,943 12,866 23,809 Brooklyn 69,165 62,615 131,780 Queens Richmond 438 26 464 New York City. .55,332 79,085 222,454 134,933 491,804 DIAGRAM I -SHOWING VARIATIONS AMONG MEDICAL INSPECTORS IN FINDING PHYSICAL DEFECTS MANHATTAN - ALL SCHOOLS 40 50 60 PERCENTACE'Or CHILDREN EXAMINED NEEDING TREATMENT „, ,.._ . At the outset, the examinations were in the nature Notification . „ ... of parents rather oi an investigation than a branch of work intended to bring about practical results in the way of treatment. From the start, however, the evidence de- rived from the examinations all pointed to the same conclu- sion, viz., that a large proportion of school children were suf- fering- from remediable physical defects. It immediately be- came clear that examination which did not in some way lead to treatment was futile. The department of health accord- ingly adopted a plan for notifying the parents of children ex- amined in regard to defects needing treatment. At first the notification was enclosed in an envelope and taken home by the child. Later, a reply postal card was employed, the reply being intended to provide the physician consulted by the parent with the means of informing the department of health as to the treatment given. This method has been used up to the present time. In 1907, instead of recording on a separate card Progress in . . . . method each examination and re-exammation, a single card was substituted providing space for the rec- ord of two examinations every year of the child's school life. These cards were not intended to be forwarded to the office of the department of health, as were the former single records. After being summarized by the medical inspector for the pur- poses of reporting, they were left in the schools, usually with the individual teachers. The intention was that by accompany- ing the children from one school and grade to another they should at any time supply teachers with information as to the physical condition of their pupils. These are the only innova- tions of importance since 1905. Organization and Supervision General organization The medical examination of school children, in- cluding that for non-contagious defects, has al- ways been a part of the work carried on in each borough by the division of contagious diseases, under the chief medical inspector. Under the organization hitherto prevail- ing in the department of health, these officials have had no direct dealing with one another. Each reported to the assist- ;mi sanitary superintendent of his borough, who in turn was responsible to the sanitary superintendent of the greater city. The only means of unifying the practice throughout the city has thus been through the sanitary superintendent, who. how- ever, is responsible in the same way for most of the other activities of the department. The organization has been weak because of the" lack of a single chief official, who should be a specialist, in charge of the work throughout the city. In Manhattan an attempt was made to develop Supervision „ . . TT a system of supervising school inspectors. Here, during the past year, three inspectors were assigned to exer- cise, subject to the chief medical inspector, supervision over nearly 100 inspectors. The trial was not comprehensive enough to establish any conclusions. It is unnecessary, however, to do more than point out the impossibility of adequate admin- istrative control over a larg'e staff of medical inspectors with- out supervising inspectors to assist the chief official. Until 1907, the medical examination of school chil- dren and the district inspection of contagious dis- eases were performed by different corps of inspec- tors. In 1907, the system was tried of combining all work in the same staff, each inspector performing both scl 1 and district work. In Manhattan, an increased number of visits followed; but reports from Brooklyn were not favor- able. On the whole, the experience of the department seems in show that the more closely the examination of school chil- dren is allied with the general inspection of contagious dis- eases, the more likely it is to be slighted in favor of the latter. The medjejil supervision of school children has now come to be mainly concerned with non-contagious defects, particularly in their bearing upon education. This is a distinct type of work, and requires special training if it is to reach a maximum of efficiency; il lias as much claim to be administered through a special corps as. for example, the administration of antitoxin. The steps necessary, therefore, to a proper organization of the service were: in DIAGRAM 2- SHOWING VARIATIONS AMONGMEDICAL INSPECTORS IN FINDING PHYSICAL DEFECTS BROOKLYN - ALLSCHOOLS I PERCENTAGE OF CHILDREN EXAMINED NEEDING TREATMENT (1) The separation of school work from the general in- spection of contagions diseases, and its performance by a separate corps of inspectors. (2) The designation or appointment of a single chief of- ficial, with jurisdiction over the entire city, and responsible to the sanitary superintendent for de- veloping and putting into effect a constructive policy and for co-ordinating the service in the different boroughs. (3) The designation of a certain number of inspectors to act as supervisors, reporting to the inspector in charge of each borough, and he in turn to the chief of the division. Study of Methods and Results Early in 1908, a study of the prevailing methods and results was undertaken by the Bureau of methods and ... . . . Municipal .Research in co-operation with the de- partment of health. The inquiry was conducted by the Bureau, while the department of health assigned inspec- tors and nurses as required, and rendered available all its rec- ords and reports. The plan was to scrutinize the methods em- ployed and the results obtained, with a view to devising im- provements. For this purpose, the inquiry concerned itself first with the accuracy of the physical examinations, and sec- ondly with the extent of the treatment actually provided. results The period selected for special study was the latest Period ■. available — the first term of the school year 1907-08, covered . o -i covering approximately the interval from Sept. 1, 1907 to Jan. 31, 1908, when 178,746 children were examined. If physical examinations are to be of value, they Accuracy of bg accurately made ; they must neither fail examinations to find defects that are actually present, nor alarm parents unnecessarily by reporting defects which do not 11 exist or which are too trivial to warrant notice. In order to I Hove the work of the department's inspectors in this respect, several tests were applied. For the two largest boroughs, Manhattan and Brooklyn, a chart was made showing for the period Sept. 1. 1007 to Jan. 31, 1908, the total examinations by each inspector and the number and percentage reported by him to ho defective. The results showed among inspectors a wide variation in percentages found defective, from 100% to 32', in Manhattan, and from 100% to 18% in Brooklyn (Dia- grams 1 and 2; Supplementary Tables 1 and 2). Of this varia- tion a part was, of course, attributable to actual differences among the children examined. That such differences could be so great, however, was hardly to be believed. The next step, therefore, was to select certain schools where more than one inspector had made examinations during the period. It was assumed that conditions in each school are nearly uniform, and that therefore any considerable variations in reports must be due to variations in the inspectors' methods. A chart similar to the former was drawn (Diagram 3; Supple- mentary Table 3), from which it appeared that discrepancies as great as between 32% and 92% and between 43% and 84% occurred in the same schools. In other words, two inspectors examining - different children in the same school reported re- sults differing by 100%. Not only in the total number of children needing treat- ment, hut in the kind of defects found is there room for varia- tion, some inspectors tending to find one or two particular de- fects, other inspectors to find oilier defects. To discover the extenl to which this might be the case, one hundred consecu- tive eanls were taken at random from the file of each in- spector ami a chart was prepared shoAving for each inspector the number of instances reported of each kind of defect (Dia- gram l: Supplementary Table 4). .As may he observed, some inspectors found a few instances of many defects, some found many instances of a few defects, while others found instances in abundance of the whole list of defects. 12 DIAGRAM 3 - SHOWING VARIATIONS AMD N G M EDICAL INS P ECTQRS IN the: same school in finding physical defects SELECTED SCHOOLS-MANHATTAN AND BROOKLYN ! PERCENTAGE OF CHILDREN EXAMINEO NEEDING TREATMENT All of these statements were based on the regular records of the department. To complete the case, the department was requested to assign special inspectors for the purpose of re-ex- amining children who had first been examined by the regular school inspector. The work of 15 inspectors in 15 schools was thus tested, an average of 20 children being re-examined for each. A glance at the following columns reveals the discrep- ancies already mentioned, with one additional — in the indi- viduals reported defective, even when the number so reported was nearly in agreement : Table 2 VARIATIONS AMONG MEDICAL INSPECTORS IN FINDING PHYSICAL DEFECTS Re-examination of the Same Children Pound by Individuals on Defects Original Special whom inspectors inspector inspector were agreed Malnutrition 28 10 10 Anaemia 22 11 7 Enlarged glands 119 126 84 Nervous disease 1 1 1 Cardiac disease 5 8 4 Pulmonary disease 13 2 2 Skin disease 10 7 3 Orthopedic defect 9 12 5 Defective vision 72 • 101 51 Defective hearing 6 9 2 Defective nasal breathing. . 34 20 15 Defective palate 22 16 14 Defective teeth 161 206 147 Hypertrophied tonsils 107 127 80 Adenoids 70 96 49 The conclusion was therefore unavoidable that physical examinations as conducted have been far from uniform and that some plan must be devised for standardizing- them. It is of course to be expected that diagnoses will disagree to some extent even in the face of effort to the contrary; but this dis- agreement must be confined within as narrow limits as possi- ble if the department's reports and notifications are to have a reputation for reliability. 13 For causing treatment to be provided when need- ed, the department has relied, as has already been provided ' ' J stated, upon a postal card notification to parents. This card has been in the following form: "The parent or guardian of is hereby informed that a physical examination of this child seems to show an abnormal condition of the 1 1 < • I n ; 1 1 !: I : Take this card to your family physician for treat- ment and advice." The chief evidence as to the extent and kind of the treat- ment actually provided in consequence of these notifications is afforded by the replies which the physicians who have been consulted are requested to return to the department of health. From nearly 65,000 notifications sent between Sept. 1, 1907, and Jan. 31, 1908, in Manhattan (where the system had been longest in operation) about 5,500 replies were received, or 8.5% of the possible number; in Brooklyn, of 53,000 notifica- tions, 7.6% were heard from. . v n examination was made of over 1,500 replies to ascer- tain what kind of information they present. From less than 5% was it possible to determine whether operative treatment was act rally given or only advised. Similarly, from only 8% could il be Learned that medical treatment was actually given. It is of course not to be supposed that this 7% or 8% represented the total number of children who came under a i hysician's ••arc. nor that only 13% of those who did consult. ;i | hysician were actually treated. It is clear, however, that the method prevailing hitherto is one which leaves tiie depart- ment in ignorance of results as to over 90% of the cases dealt with. The conclusions of the study were therefore (a) that means must be found for standardizing the physical examina- tions, and (b) that a follow-up system must be devised for securing treatment in all possible cases. 14 DIAGRAM 4- SHOWING VARIATIONS AMONG MEDICAL INSPECTORS IN THE DEFECTS FOUND percentage: found, eachdefect* a _ — cai 1 ;-)-Li,'- , -«> 1 "„=< '— o «: r o uj — •*•,. ? § I Q s £ p; s ? > - - i"i^l 5 2^|!^i s 5 < g 5 ° z £ E G > S g p - z S x < S" g 5 p = h | ° s 3 u S= "feg S KSS5: g 2 " S^"fe-S gsS INSPECTOR INSPECTOR JJi Uil X jJliLlJul ^See Supplementary Table 4 An Experiment In order to test the possibilities of a thorough . follow-up system based upon persuasion and per- experiment sona l interviews, the department of health pro- vided for an experiment covering the last six weeks of the school year 1907-08. Three schools were chosen in different parts of Manhattan, with different nationalities predominant. To each was assigned an inspector and a nurse especially selected for their fitness. Though the numbers are not large, less than 1,500 being examined, it has been thought worth while to present in considerable detail the records of the experiment. Where numbers are too small to warrant con- clusions, they may serve to raise questions. Several state- ments are interesting for what they do not show. Where statements appear inconclusive, the form is presented as one which may be employed when more data are available. Each inspector examined about 15 children a day, the total examined by each and by all together being shown in the following table : Table 3 NUMBER OF CHILDREN EXAMINED By Schools School number and location No. 141 462 West 58th St. No. 160 Rivington and Suffolk Sts. No. 168 104th and 105th Sts. near 2nd Ave. Total number examined Prevailing nationality Irish Jewish Italian Grades in which child- ren were ex- amined 2,3,4,5 1,2,3 Number examined 468 516 45S 1,442 These children were not selected; in nearly every instance, each class was completed before another was begun. 15 Children were found to need treatment as follows: Children ^ g^^ Nq ^ g g% treatment I" School No. 160 98% In School Xo. 168 92% The percentages are startlingly high. How far these children may be typical of the school children of the city is. of course, impossible to say. It is sufficiently serious, however, that in any three schools in the city, from 88 c r to 989c of nearly 1.500 children as found in the classes are declared to be in need of treatment. The most important defects needing treatment were those of vision (42%), nasal breathing (59%), hyper- trophied tonsils (39%), anaemia (15%), and teeth (73 %). The reports were tabulated in the form shown in Diagram 5. in order to disclose any divergences that might exist between the sexes or between grades, ages, or normal age and over-age children. Owing to their size, the tables are not published ; detailed information, however, will be gladly furnished on re- quest. The more noticeable points are presented here. School Xo. 160 was reported to have more defective children and more defects per child than the others, and seems to show an especially high number of enlarged tonsils (59.4%). In Schools Xo. 160 and Xo. 168, many children were found with defective nasal breathing (71.3% ; 75.7% ) and defective vision 44.5%: 50.6%). In a single school. Xo. 160. there appeared tu be a considerable difference between the sexes with respect to anaemia, there being 10% among the boys and 20% among the trirls: in all schools together, the figures are 13% for boys and 18% for girls. In other respects, however, there appeared no marked preponderance on the part of either sex. Taking into consideration all defects, there seemed to be a slight de- crease in the number of defects in the older children. This may have been partially due to the replacement of defective firsl teeth by sound permanent teeth: it is possible also that treatmenl may have been provided for the older children. As for grade, defective vision, nasal breathing and hypertrophied tonsils were slightly more frequent in the lower grades. A tabulation was also made (Table 5) of normal age and over-age children, by ages. Contrary to expectation, little difference was discovered between the groups; the numbers. however, are too small to yield any reliable conclusions. The 16 Table 4 CHILDREN EXAMINED AND FOUND NEEDING TREATMENT Summary by School, Age, Grade, Sex and Defects Defects needing School, age, Num- Needing treatment ber ex- treatment Average grade. sex amined Total per child needing No. | % treatment ( School All I All f Both 141 468 412 ss.o 879 2.13 ages 1 grades | sexes 160 516 508 984 1469 2.89 l 168 458 425 92.7 1110 2.61 / Age 1 ! 6 11 11 100.0 31 2.81 i 7 120 115 95.8 334 2.90 ( All ( \ 8 366 350 95.6 946 2.70 All I All \ Both ) 9 409 385 9i.l 1009 2.62 schools ) grades j sexes \ 10 11 254 142 285 132 92.5 92.9 567 311 2.41 2.35 / 12 81 69 85.1 147 2.13 13 • 40 33 82.5 79 2.39 i I 4 16 12 75.0 31 2.58 15 3 3 100.0 q 1.00 . Grade . I 1B 71 • 71 100.0 231 3.25 f \ 2A 261 253 96.9 757 2.99 All I All ) Both ' 2B 447 418 9S.5 1076 2.57 < < \ 3A 410 389 918 945 2.42 schools ages 1 sexes ) 3B 137 114 8S.2 242 2.12 ^ ( / 4A 108 , 92 85.1 194 2.10 1 5A 8 8 100.0 13 1.62 All ( All All ( Sex { j Males 833 784 91 1 2031 2.59 schools ( ages grades ^Females 609 561 92.1 1427 2.54 Total 1442 1345 93.2 3458 2.57 1 At last birthday 17 a •■-I •+■■> c o o < H ft rH P H s O En Q s p H H p a W o 115 ~, -.~. 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OCJ ©J i-H OS CS <=> o rt to HHNC0 COiH COiH 1 ^ 19 form of analysis is offered as a suggestion to others pursuing this line of inquiry. The main positive fact appearing in relation to defects is that from 88% to 98% of the children examined need treat- ment, .1 conclusion which reinforces the already urgent de- mand for attention 1<> the physical condition of school children. The uiaiii object of the experiment was to dis- cover how far treatment could be secured through the method of personal persuasion of parents. It had been asserted that a large number of parents would resent inter- ference and would refuse either to provide treatment or to allow it to be provided. This view was not shared by those directing the experiment; they believed that the principal ob- stacles to be overcome were ignorance or indifference, and that through patient, tactful explanation the great majority of parents could be made to see the reasonableness of treatment. The general methods pursued were the following. The in- spector continued to mail to parents the postal card notifica- tions as previously, at the same time giving to the nurse the record of the physical examination, indicating what defects re- quired treatment. Within a few days, she either visited the borne or requested the parent to come to the school to consult with her. At this interview, having the child's record before her, she explained the nature of the defects from which the child was suffering and the necessity for having them treated. She Hi 'Mi 11 rged the parent to consult the family physician; where ther,e was none and the family claimed to be unable to pay a physician's fee, a dispensary was suggested. Where, owing to their occupation, the parents woe unable even to take their children to a dispensary, the nurse obtained from the parent a written requesl to take the children herself. Tin- belief in the effectiveness of this method was justified bj the result. Only 4.2% of the total number of parents re- fused to act, while 81 % of the total number of children need- ing treatment were actually treated for one or more defects. Thai the lattei figure was not between 00% and 05% was due to the lack of dispensary facilities available to school No. 168. Table 6 shows the results in detail. In two of the three 20 Table 6 TREATMENT PROVIDED Summary by Schools School number Total 141 160 16S No. % Children needing treatment 41 2 508 42 1345 100 Children treated 371 469 255 1095 81.4 For all defects 22 7 385 60 672 49.9 For one or more defects 144 S4 195 423 31.5 Children not treated 41 39 170 25C ) 18.6 Pending 34 2 157 193 14.4 Refused 1 37 13 57 4.2 Defects needing treatment 879 1469 1110 3458 100 Defects treated 581 1222 365 2168 62.6 4-> IDs BB CD 03 CD 0> ■a 03 Eh +-> to a •a 5 CD ™ a 0) e3 Sh Eh % Defective vision 144 85 230 170 .232 31 606 286 47.1 Defective hearing 6 3 5 11 3 — Defective nasal breathing 13S 114 368 324 347 166 853 604 70.8 Hypertrophied tonsils 116 94 307 264 144 72 567 430 75.8 Enlarged glands 3 3 Pulmonary disease 1 2 1 3 1 Cardiac disease 12 9 22 14 2 1 36 24 Nervous disease 1 1 6 7 1 Orthopedic defect 42 22 2 5 49 22 Anaemia 77 42 71 62 75 28 223 132 59.2 Malnutrition 21 11 7 7 1 29 18 Defective teeth 318 200 456 381 238 66 1062 647 60.9 Defective palate 3 6 9 — 21 schools, over 90% of the children with defects received treat- ment; in one, 55% were treated for all defects; in the other, 75%. 31% in all schools who were treated for one or more defects were at the close of the experiment still awaiting treatment for other defects. Had it not been for inadequate facilities for treatment, the greater part of the 14% pend- ing in all schools could have been treated, and the 31% partially treated could have been completely treated. Supple- mentary analyses of various aspects of the experiment were made, but are not of sufficient significance to warrant publica- tion. Neither age, grade nor sex was distinguished for special ease or difficulty as to securing treatment. Of the total children treated, two-thirds of the medical cases came under private practitioners, while operative, dental and eye cases went largely to institutions (Table 7). The tendency was in dental cases to extract teeth instead of to fill them (Table 8). An interesting exception to this practice was found in a re- cently established dental clinic for one of the schools of the Children's Aid Society, where many of the children in School No. 141 were treated. In this school, in only 18% of the cases cared for by institutions was extraction alone employed. Proof has been presented that treatment can be secured by the method of personal persuasion. It remains to show th Mt the method is not prohibited by the amount of work in- volved. Tables 9 and 10 supply the evidence. Of the total children whose treatment followed in consequence of per- sonal interviews, about three fourths (58% -79.9%) required but one personal interview, and the average visits to those treated were only 1.4. The net average result of a day's work by a nurse was the actual treatment of over five children, three of them completely, and two of them for one or more defects. In other words, the cost in nurses' time of securing treatmenl was sixty cents per child. In interpreting these con- clusions, il must be borne in mind that the experiment faced the difficulties of a new enterprise; plans had to be explained and arrangements made; much time was consumed in waiting ;it the dispensaries which would have been turned to account if facilities had been adequate; and the experiment lasted hardly long enough to establish a routine method of work-. In spite of these fads, however, it has been demonstrated that 22 Q H H 6* c; a; c o CD cd + ■d a CD ti fcs <-, a CD O a a o o CD CD CD CD ■d-O CD CD * SS 1 d-d 1 ' CD a, .2"3S + o c e c g _hp_bp ° 'S3 'SiC CD CD CO -CC 03 eHchW Table 7 KIND OF TREATMENT PROVIDED : PRIVATE PRACTICE AND INSTITUTIONS Kind of treatment School number Medical Surgical Dental Ocular 141 160 168 Total 141 160 168 Total 141 160 168 Total 141 160 168 Total Chil- dren treated Treated by- Private physician, dentist or oculist No. %* 70.2 63.2 70.9 66.7 3.7 0.9 0.7 1.6 36.0 19. i 1S.1 21.7 Hospital, dispen- sary or clinic No. 36.8 29.1 33.3 96.3 99.1 99.3 9SJ, 610 80.6 81.9 75.6 59.6 73.3 67.7 71.6 "Based on children treated Table 8 DENTAL TREATMENT: EXTRACTIONS AND FILLINGS Treated by School number Total children given dental treatment Extractions Fillings Extractions and fillings No. % No. % No. % Private den- \ }jl tist or ■{ {60 physician / 16 ° 72 74 12 158 128 307 54 489 200 381 66 C47 21 69 12 29.2 93.2 100.0 616 18.8 99.7 96.3 78.2 22.5 98.5 97.0 718 39 4 43~ 94 1 2 97~ 133 5 2 5J t .2 54 0.0 27.2 73.J, 0.3 3.7 19.8 66.5 1.3 3.0 21.6 12 1 16.6 14 0.0 I Total ^. ( 141 Dispensary J 160 or clinic ) 168 102 24 306 52 13 10 To - 00 1 8.2 7.8 0.0 0.0 ' Total Total ) JjjJ treated "S ^gg 382 45 375 64 2.0 11.0 0.2 0.0 I. Total 484 140 3.6 23 ^ £ OJC2 Hrlffl OO in O m in cvco * +J c o _, OS <» o Q ©5 ~ ~< U5 a *^ "»" ©i OS *H >s o> (0 ■^ ©J to Eh ^ »i >1 Uh ©J c: J- Ol 00 *- ^ CO in o o in in iH 00 00 tH lO'C * r- lO (M OS!£> CD -* -^ £5 C to o o a a W i : C ft< w Q W ft Bl n - 7. ' ft a " r w ° 2 £0 1- PL, "* o o o _ .3 BC d - P u 2 * c « n 7^5?ri| w Ed ai o u 01 5J 4) *-• - fl H ~ O BO o *2 ft [C 1) - d 2 sd ^ 4)

SI* 24 Table 10 AMOUNT OF WORK BY NURSES Children requiring attention of nurse Children treated through ef- forts of nurse Nurse days employed Average children given atten- tion per nurse day Average children treated per nurse day Home visits Dispensary visits School visits Visits of all kinds Average total visits per nurse day Average total visits per child treated School number 141 412 160 168 420 Total 132? 371 454 250 1075 67 60 67 194 6.1 S.2 • 6.2 6.8 5.5 7.5 3.7 5.5 361 3S1 564 1306 29 28 33 90 34 45 31 110 424 454 628 1506 6.3 7.5 9.3 7 7 1.1 1.6 2.5 1.4 25 treatment can be secured and that the amount of work or ex- penditure involved is not prohibitive. „ , The conclusion of the stud}^ and experiment de- Conclusions . ^ ^ scribed in the foregoing pages may be summed up in a few words: (1) The examination of about 1,500 unselected children, of whom from 88% to 98% were declared in need of treatment, argues that the necessity for medical supervision of school children is more serious than has been supposed. (2) The obstacles to removing physical defects are not primarily those of unwillingness of parents. Per- sonal interviews and explanation by school nurses obtained action or permission from 95%. (3) The cost of such a system is not prohibitive. Three- fourths of the children, whose treatment was secured, required but one interview; the cost in nurses' salary was sixty cents per child treated, and this can be reduced. (4) The most difficult problems are those relating to ade- quacy of facilities for treatment. The treatment of children involves much work of a routine nature which has no particular interest for the average clinic physician. Whether working arrangements can be made with dispensaries and clinics for special attention to children remains to be seen. The dental care of school children has as yet received little at- tention in this country. With a single exception, the existing clinics provide for extraction, but for little or no filling. Xo nttempl has been made to solve the question of ''free eye glasses" or "free meals". Both these questions require for their solution more data than have yet been gathered. To the accessary information, the experience of a, staff of nurses in intimate contad with parents and homes of school children should yield ;i valuable contribution. 26 After Operation CARE OF BABIES For many years the department of health has maintained a summer corps of medical inspectors or of medical inspectors and nurses for the purpose of diminishing the death rate of infants from diarrheal diseases. As the infant death rate from this cause reaches its maximum during the summer months, this work has been limited to that period. The method pursued in recent years has been to employ inspectors and nurses in a house to house and family to family inquiry for sick children under two years of age. When such were found, and there was no physician in attendance on the case, the department of health physician or nurse, gave instruction or treatment, revis- iting if necessary. In this way a considerable portion of the tenement sections was covered once during the summer. The report for the summer of 1907 states that in New York City 175,272 families were visited, in which 44,130 children under two years of age were found. Among these, 1,783 cases of diarrheal disease were discovered, of which 688 were at- tended by the department's inspectors or nurses. Revisits were made to the number of 1,080. From this account it appears that on the average 4 families were visited to find 1 child ; that of the children found, 1 out of 25 was sick at the time of visit; and that of the sick children, about three-fifths were already under the care of a private physician. The net result, in other words, of visiting 175,000 families seems to have been, according to the report, the caring for some 700 sick children, each being revisited on the average twice. It is manifestly improbable, however, that such a state- ment presents a fair estimate of the results of the work per- formed. The circulars of instruction distributed year after year and the calls, infrequent though they were, by inspectors and nurses undoubtedly had some influence in directing the thought of mothers to the proper care of their babies. Nevertheless the general method was open to a number of serious objections: (1) The condition of babies undiscovered was entirely un- known to the department, the inspector or nurse being solely 27 dependent upon the chance of the mothers' being at home at the time of the call. (2) As to the babies who were found, the chances were slight that the single visit usually paid by the inspector or nurse during the summer would coincide with the period of sickness. (3) The limitation of the department's efforts to finding sick babies classed its work as mainly remedial rather than preventive. This consideration is most important in view of the frequently sudden onset of the disease. (4) The administrative control over inspectors and nurses by the central office was much lessened by the latter 's being obliged to accept the reports of the former as. to children found in the first instance. (5) In employing a large staff of inspectors and a small staff of nurses the prevailing plan did not secure the greatest economy of expenditure. Inspectors receiving $100 a month for two or three hours of work a day and nurses receiving $75 a month for twice that time were expected to perform practi- cally the same duties. These duties, from their nature, belong essentially to nurses. These and other considerations led the department of health to adopt a new plan for the summer of 1908. A larger staff of nurses and a smaller staff of inspectors were employed, the former for the routine work of visitation, the latter to care for sick children requiring a physician's attention. To each nurse Avas furnished the reports of families in her district in which births had recently been reported to the bur- eau of records. These families were then visited for the pur- pose of instructing the mothers in proper care and feeding, no matter whether the babies were sick- or well. The nurse was expected to eontii her visits until she was ready to report a reasonable assurance thai the instructions had been effective. Whoi she discovered a child in need of medical care and not already attended, she reported it to the department, by tele- phone if necessary, and a medical inspector was sent. Record 28 was maintained in the central office of all such cases, as well as of cases referred by nurses to dispensaries or to other agen- cies. Lectures or talks of instruction, in many instances ac- companied by actual demonstrations, were given by medical instructors at vacation schools, playgrounds for mothers and children, and recreation piers. A noteworthy feature of the summer's program was the effort of the department of health to bring together in a single co-operative scheme all the agencies working to diminish in- fant sickness and mortality. At the call of the commissioner of health, early in the summer, representatives of the depart- ment of education and of over fifty hospitals, dispensaries and charitable agencies met and organized as a conference on the summer care of babies, with several working committees. In place of the many conflicting circulars of instruction previously distributed by various organizations in the city, a single card, attractively lithographed and simple in phraseology, was de- signed, and issued by the department of health. Being dis- tributed by all the members of the conference, this card re- moved a considerable source of confusion in instructions. Plans were formulated for obviating duplication of service. Principally from the fact that the staff of the department of health was inadequate to carry out its program to the full ex- tent originally contemplated, such duplication was not encoun- tered to any considerable degree. A foundation was laid, however, for a closer permanent combination of forces. Full reports of the summer's work are not yet available. The present returns show a decrease from 1907 of two hundred in the deaths of children under one year of age from diar- rheal diseases. To what extent this may have been due to the summer campaign, to a better milk supply, or to other influences, it is difficult to say. It is not improbable that the increased attention given to the health of babies contributed to the result. The summer 's experience established the conviction : (1) That the methods employed should be mainly preven- tive. 29 (2) That the fundamental preventive measure is the educa- tion of mothers in the proper care and feeding of their babies. (3) That an educational campaign, to be fully effective, must not be limited to the summer months but must continue the year round. (4) That the method of visitation pursued not only pro- vides greater administrative control but presents the instruc- tion at the time when most likely to be effective, i. e., soon af- ter the birth of the child. In accordance with these conclusions the department of health is planning to incorporate, as soon as possible, in its regular program of work the instruction of mothers of new- born babies. 30 REORGANIZATION AND NEW PLANS Following upon the foregoing studies and experi- Separate nients, the department of health has reorganized organization its service. At its meeting on August 19th, 1908. the board of health voted to establish a division of child hygiene, with one chief official for the entire city. The division is charged not only with the medical supervision of school children, including examination for both contagious diseases and non-contagious defects, but also the instruction of mothers in the care of new-born infants, the regulation of mid- wifery, the regulation of the boarding out of infants and the examination of children for employment permits. The service of medical inspectors and nurses in the new division will be standardized bv control- ling of service -^ m §' reeor ds devised and already installed for that purpose, and by a system of supervising inspec- tors and nurses. From the records*, the official in charge may see how many examinations each inspector is making daily and how many defects of each kind he is finding. Any unusual variation will be the cause for investigation by a supervisor. Supervisors will make periodical re-examinations of the work of each inspector, and the work of each inspector will be charted every month to reveal departures from uniformity. With each nurse, an account is kept in which she is charged with all cases reported by the inspector to need treatment, and is credited with all cases in which treatment has been provided. From this record the chief officer may read as often as he chooses the number of cases outstanding in the hands of each nurse for treatment. If this number increases from week to week, the nurse either has too much work or is ineffi- cient : if it decreases, she may receive additional assignments. The number of visits, treatments and instructions also appears day by day, so that the amount of work performed is at once evident. The record is designed to systematize, in a form to facilitate administrative control, the reports of inspectors and nurses. To supplement these, a form of report of supervising in- spectors will present independent evidence from the field. It * See Exhibit 1 31 will also be the business of the supervising inspectors and nurses to educate the inspectors and nurses to a higher stand- ard of professional proficiency. It is not impossible that school inspection may assume a technical interest, similar to the service in clinics which confers added professional standing. . , ,. Finallv, to secure actual treatment in as many A follow-up system cases as possible, the follow-up plan of the ex- periment has been adopted. Children reported by inspectors as needing treatment will be turned over to nurses, who will employ personal interviews with parents to urge treatment. No children once pronounced in need of treat- ment will be overlooked. Similar methods will be applied to the care of babies. Care of . .. This activity, hitherto limited to the .summer months, will now, if provided for by appropriation, be maintained the year round. Each nurse will receive from the department office a record of the families in her district in which births have been reported. These are charged to her "case account" until she reports upon them. She is expected to visit and revisit until she has reason to believe that the mothers have learned the essentials of proper care of their babies. Sick babies are referred to inspector's when necessary. Of the other activities included in the plan of the Other . . . ... division, i. e., the regulation of the boarding out of activities P ° babies, the regulation of midwifery and the physical examination of children applying for employment certificates, the first is the only one in which more than a beginning has been made. A permit is required in all cases, previous to the granting of which the home is inspected. Reinspections are made at intervals, or on complaint; permits are revoked when rcuulal ions arc not complied with. 32 Exhibit I FORMS OF OPERATIVE REPORT AND RECORD DEVISED FOR THE BUREAU OF CHILD HYGIENE The record-keeping of the work of school inspection dur- ing the second quarter of 1908 involved the provision for re- cording by the central office of over two million separate items, and of a much greater number by the inspectors and nurses in the schools. In the coming year the work of record- keeping must not only keep pace with an increased field force, but will be complicated by a demand for more detailed statistics of the results of physical examinations. The records of this division must serve a two-fold pur- pose. They must furnish (1) statistical data, and (2) data for the supervision of the force of inspectors and nurses. In form, they must be simple, in order (1) to reduce to a minimum the clerical work of inspectors and nurses, and (2) to eliminate, as far as possible, the chance of error both in original entry and. in tabulation. The following report and record forms have been de- vised : Reports from the field staff Form 1 : Physical examination record Form 2: Inspector's daily report Form 3 : School index card Form 4: Nurse's daily report Office records Form 5 : Physical examination tabulation sheet Form 6 : Physical examination control sheet Form 7 : Contagious diseases tabulation sheet Form 8: Nurse's control and tabulation sheet Reports from the tabulating office For supervision Form 9 : Weekly report of work performed by in- spectors Form 10: Weekly report of work performed by nurses Form 11 : Comparison of the percentages of individ- ual defects found by inspectors 33 For statistics Form 12 : Weekly report to the sanitary superinten- dent of the department of health and to the city superintendent of schools. The same form is used for the published quarterly report. Form 1 Physical Examination Record These records are bound in book form, each blank being separated by perforation into four cards, indicated for convenience as cards 1, 2, 3 and 4, counting from left to right. In order that the department of education may be furnished with a complete physical record of each child, these four cards form two pairs of dupli- cate records, one pair dealing with examination, the other with subsequent treatment. On cards 3 and 4 the inspector marks with crosses on each side of the perforation the defects found that need treatment. On card 3 he makes such recommendations to the teacher or principal as will enable them to make the proper adjustment of seating, exercise, study, etc. Cards 1 and 2 are designed for the nurse. On card 2 she finds the defects by their code number and such re- marks as the inspector thinks necessary for her guid- ance in securing treatment for the child. On this card also, the nurse makes the record of her efforts to secure treatment. When her efforts have been successful or have' met with absolute refusal of the parents to provide or to have provided the proper treatment, she takes the child to the inspector for re-examination and dis- charge. The inspector's signature after such re-exam- ination relieves the nurse of further responsibility. Card 1 is made out by the nurse only after she has se- cured treatment for the child. The card states the ac- tion taken, thus supplementing the facts recorded on card 3. Card 4 is torn off and sent to the department of health by the inspector after the completion of the examination. Card 3 is given by the nurse to the principal. Card 2 is senl in by the nurse to the department of health af- 34 •orm 1 Card 1 Oarrt 2 Depamhent of Health DEPARTMENT OF HEALTH DEPARTMENT OF HEALTH Card 4 DEPARTMENT OF HEALTH Name Name Name Name School Class Address Address Born Date School Class Date School Date School Date For School Principal For Department of Health For School Principal For Department of Health Defects Defects Recommendations Grade Grade Ke-ex Reos | j Remark^ Sex- Sex 1. Age Age g* Remarks I Defective vision 1 Dct'ci/tivi- vision ■2 hrlVudve hi.-aring 2 Defective hearing . r { DHVet, Nasal lni-iiUiitiL!- 8 Defect. Nasal breathing School consultations 4 II \ ] .i'L'1 r. .plii.-d tmisiN ■I H\|"Ttr..|iluVil tonsils Home visits 5 Tubercul. lymph nodes ;'. Tiilj.'ivtil lymph nodes Dispensary visits C I'Hliii'iiini'V discast- Pulmonary disease ~ CiU-di;iL' disi.'iifi 1 7 Cardiac disease 8 Chorea 8 Chorea Orthopedic defect '.) Orthopedic defect 10 Malnutrition 10 malnutrition • 11 Defective teeth 11 Defective teeth Date discharged 12 Defective palate Itf Defective palate 13 Height 13 Height Inspector 14 Weight 14 Weight Nurse Inspector ns|icctur DEPARTMENT OF HEALTH, CITY OF NEW YORK SCHOOL MEDICAL INSPECTOR: DAILY REPORT o TDIE OF 1 s 1 1 s s 1 1 £ , s s8 1 a £ a H I 1 1 1 An'. Cases Dep. Exclusions Ait. Cases Dep. Exclusions Arr. Cases Dep. Exclusions Arr. Cases • Dep. Exclusions Cases Exclusions School NAME ADDRESS DISEASE AGE ACTION TAKEN Exclusions from School i Absentees Visited "3 0) -- s ■p 5 Em O O 0) a CO a T3 .2 ri a a b^ Ph cu S •aiS a en CD o3 Q A cu O b CO - 3^ 03 ft 03 i CO _ a 4) ®« 0) 0. ? ■r. j. - 5 5 3 C 3 3 f 3) ® Q X ^ 7J -z --- - > It 3 « z.s O c - : s - '1 = 01 ft §E : do - re On? 2 5 - I. ii re > si 3 "So re -Z - 0) > ■— re re 1 ft it /. - c3 £ O - v. s. z •3 £ b be C to - — ■J. r - si a 3 - X 'J: a X Jai U 5 0^ 5 CO § - Form S NURSES' CONTROL AND TABULATION SHEET Inspector Instructions' TREATMENTS VISITS From school index card ■ j. z 3 O ■3 1 Ph =3 £ to s - — bj D E EC 3 fa s 3 3 : r'lL v _ •/. - ~- z u Miscellaneous 1 'ontagioiiK cases re s 3 2 = to ml non-contaglous l (ispensary Total DATE g ci << _bt ■7. C Pending DATE t, S eg X P "3 — — V. 1 Form 9 WEEKLY REPORT OF THE WORK OF SCHOOL MEDICAL INSPECTORS NAME OF INSPECTOR c ° m fas £.2 d x ~ S. Exclusions Scarlet fever |a H CD ffi'd bJJ.S EH o ^3 r -1 cc ! Physical examinations During vretk School term bfl C "O 0> ■ £?*> S3 s 5 c Tig CD s £ £ 3 53 c ^ O ffl a fe feS £ i££ Form 10 WEEKLY REPORT OF THE WORK OF SCHOOL NURSES Records for the week Records for the school term 13 © o a w »■£ V. CD g 3 » u 3 CO 3 0) to Eye and skin dis. Phys. def. NAME OF NURSE >> ■Q oS £« so tf.S -e h by 3 Ph . 3 oBo .Sg a> a

as a; CD br •3 CD Ph Form 11 COMPARISON OF THE PERCENTAGES OF THE INDIVIDUAL DEFECTS FOUND BY INSPECTORS IN PHYSICAL EXAMINATIONS NAME OF INSPEC 'OR U > o o be ■■" £ /- 0> K 0> w a o> o co xn to a s rf a 3 c3 O m O CD 1 o Eh EVE AND SKIN DISEASES a 3 c3 co fl S.2 s o S O 3 be o u fee o o to 5 c d 4) 01 s d a > o o o Eh fc H tf 02 fc En Cases found Cases excluded Cases reported cured PHYSICAL EXAMINATIONS TOR NON-CONTAGIOUS DEFECTS -a 11 CD to *£ d« a'? q~ ® d •Si X2 ■3 a O-B a o-c S £ -a 01 a 4) CD 4) > IhB O _ CD 1> 02 Oft 0> O" SS 3 ft ■£$* Number of inspectors Number of nurses . . . tabulation and are sent to the chief of the division, to the chief inspector of each borough and to each super- visor. The names of the inspectors are arranged alphabetically under their supervisors ; those of the nurses, under the inspectors with whom they work. Form 11 Comparison of the Percentages of Individual De- fects Found by Inspectors Form 11 is designed to show the individual variations of the inspectors in finding children who need treatment, and the kind of defects. Periodical charts like Dia- grams 1-4, based upon these forms, will assist the super- vising officials to standardize the methods of physical examination. Form 12. Weekly Report to the Sanitary Superintendent of the Department of Health and to the City Superintend- ent of Schools This form gives the totals for each borough and for the whole city. It also serves for the quarterly statistical report with the change that the physical examinations are divided into the age and sex groups given on Form 5. The quarterly statistical reports will be prefixed with the following summary : Number of public schools Kegistration Number of public schools under inspection Registration Number of other schools under inspection Registration Total number of schools under inspection Registration Number of inspectors on duty in schools Number of nurses on duty in schools 37 Exhibit 2 Supplementary Table 1 SHOWING VARIATIONS AMONG MEDICAL INSPECTORS IN FINDING PHYSICAL DEFECTS * Manhattan — All Schools o R - :r. - 2 o S ■" a £2 7. B - ■:= E . --. B *" ® m o a> P. w S S.SS ■L^ed S8s 1-1 H cue!: " a (UCZ. H Cbe£ . 1 36 100.0 50 670 80.1 99 249 66.3 2 418 99.7 51 466 80.0 100 760 66.0 3 419 97.6 52 456 79.8 101 952 65.9 4 731 97.4 53 164 79.7 102 570 65.8 5 310 96. S 54 670 79.4 103 245 65.3 6 272 95.9 55 630 79.2 104 757 65.1 7 592 93.7 56 282 78.3 105 968 64.9 8 78 93.6 57 702 78.2 106 971 64.5 9 821 93.5 58 519 78.2 107 555 63.9 10 489 93.2 59 649 77.8 108 703 63.8 11 343 93.1 60 472 77.5 109 735 63.1 12 751 92.6 61 1011 77.5 110 631 61.9 13 694 92.5 62 772 72.2 111 724 61.8 14 498 92.5 63 281 77.2 112 400 61.7 15 51- 92.2 64 918 77.0 113 842 61.6 16 598 91.9 65 361 77.0 114 511 61.4 17 336 91.9 66 463 76.5 115 718 61.4 18 774 91.6 67 570 75.8 116 444 61.0 19 753 91.3 68 479 75.3 117 691 60.3 20 548 90.5 69 462 74.7 118 696 60.0 21 1018 S9.3 70 816 74.7 119 708 60.0 22 179 88.2 71 1310 74.4 120 495 59.2 23 76S 88.2 72 1034 74.3 121 126 58.7 24 302 88.0 73 363 74.1 122 895 57.6 25 66 87.9 74 S40 73.8 123 864 57.4 26 536 86.9 75 770 73.6 124 515 57.0 27 1799 86.9 76 364 73.3 125 509 56.5 28 765 86.9 77 550 72.5 126 114 55.2 29 672 86.6 78 1007 72.2 127 352 54.8 30 1149 85.4 79 739 71.7 128 872 50.6 31 899 85.2 80 552 71.5 129 663 50.0 32 857 85.1 81 552 71.0 130 618 49.6 33 735 84.9 82 S54 70.7 131 665 49.0 34 69S 84.6 83 566 70.6 132 783 47.9 35 1000 84.5 84 622 70.5 133 682 44.7 3fi 2sn 84.3 85 379 70.4 134 466 44.6 37 :.s»; 84.2 86 929 69.9 135 513 43.7 38 493 84.1 87 1094 69.7 136 580 43.6 39 362 83.9 88 841 69.6 137 544 43.3 4n 208 83.1 89 652 68.7 138 763 42.4 41 71", 82.8 90 789 68.7 139 795 41.8 42 439 82.7 91 377 68.4 140 757 40.7 43 171 82.fi 92 981 68.3 141 477 40.2 44 815 82.2 93 873 67.8 142 15 40.0 1." 882 82.0 94 582 67.7 143 119 37.8 if. 828 81.4 95 474 67.1 144 914 35.5 47 696 81.0 9fi 935 67.0 145 58 32.7 is 613 80.4 97 87 3 66.7 t'.t 761 98 117 66.6 * Total children examined In Manhattan, Sept. 1, 1907 — Jan. 31, 1908; see Diagram I "• An arbitrary Index number for the purposes of this report; the same in all tables and diagrams 38 Supplementary Table 2 SHOWING VARIATIONS AMONG MEDICAL INSPECTORS IN FINDING PHYSICAL DEFECTS * Brooklyn — All Schools u o o 0) Qi (II a H 05 a S X H O +-> o o> o — 521 o3 l-H H s t^j o - w +j 02 — cfc jesuu joi-ia^soa; e^-eied pauiiojaa 8Ai;oejaa SUIU1139jq IT3S13U 9Apoajaa Sut.iBaq aAijoajaa UOTSIA SAt;39J3a loajap oipadomao asuasip ui>is as^asip XaBUOuipricj asBasip OBipjBQ ■Bajouo spuuiis paSauiug uot;!JjnuiT3j\[ ssSv Xooqos oiiqnj t-'* t O'-INMO WOO"* ^OlOC0OC0i-ITt<-#OTOU5C0i-H,-IC0ce00i--*'C-c-c->«'00-*oo01MMOiNfM M 'OM(M'*N'*Oaifl JMWIONOT r-i CO ^NH^INCeHlO OO O r-» CO r-t i-lj-HrHTHrH>-lT-lrH>Hi-lrH>Hi-l'^THrHrHrHr-lTHrHrHi-Hi-y<'"p T ^ tiotHOOiHOOitDHHlKOIOt-OtOHfKlClHL'-l-MtOO aojjadsui MOt-H51MCl»lO!00tOLOMC,HN lONNH t- IH r-i -* CO ■* M< •* t> O Csl C- 1-1 rH -""-i^rH ^ l-l o tS O O >i ffl cd or l.- co i-H "5f UO ft H*l/l»l'-06OlfflMHaM*iel-5IO1 , O'.l °3 ■§: "O d ° s- s- £ O l, C 0) m £ o 5 'O 5 f- o s- .5 '5 5 ft r. 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