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Attention is called by the committee to the elements of the health conditions in public schools. The health work in the schools consists in: (1) Medical examination of school children for contagious and noncontagious defects. (2) The elimination of children found suffering from contagious diseases. (3) Calling of parents' attention to the defects of their children. (4) Direction of children to physicians and dispensaries. (5) Following the children up to see whether they received treatment. (6) Treatment in schools. (7) Instruction in personal hygiene. (8) Physical training instruction. (9) Segregation of backward and mentally defective children. (10) Sanitary care of schools.

The cost of inspection for the detection of contagious diseases amounted to $0.57 per 1,000 children inspected; the cost of each physical examination amounted, on an average, to $0.097, and the cost of the bome visits of the nurses averaged as high as $0.60 for each case.

School work, 1912. 76 medical inspectors, at $1,200 per annum..

$91,200 172 ourses, at $900 per annum..

154,800 6 additional inspectors, i. e., supervisors, at $1,200 per annum.

7,200 10 additional nurses, i. e., supervisors, at $900 per annum.

9,000 4 medical inspectors (for physical examination of children for employment certificates), at $1,200 per annum..

4,800

267,000 The following is a summary of the reports of four borough chiefs, 15 medical supervisors, and 14 supervising nurses with regard to the present system of medical inspection of school children. The disadvantages of the 1912 system are discussed at length.

" Morning inspection for contagious diseases. The reports are unanimous in disapproving of nurses diagnosing and excluding contagious cases, for the following reasons:

"(1) Their training has not fitted them for it physically or mentally.

" (2) They are overworked and unable, for lack of time, to perform their other duties, especially home visits, which is the essential part of their work. According to the statement of the board of bealth, based on 300 cards selected at random, the amount of time devoted to home visits last year averaged three hours per nurse per day; this year the average is 43 minutes.

"(3) There is a duplication of work, because the inspectors have to visit each case excluded.

*(4) The purses exclude many false cases, thereby causing the inspectors to waste much time in making unnecessary visits. . . . In 100 days they excluded 1,595 cases, or 16 cases a day, for 150 schools, and bu 1912, 17 cases a day for 150 schools. .

"(5) The medical inspector is not able to keep in close touch with the school on account of the infre. quency of his visits, so the 'school physician' no longer exists and the nurse can not take his place. Principals and parents naturally do not have the same confidence in her judgment that they have in the physician's."

"HIGE SCHOOLS.-With regard to medical inspection in high schools the following is a summary of the facts obtained, in answer to a questionnaire sent out to all the high schools of the city, some of which were visited in this connection by the executive secretary of the committee.

"(1) For contagious diseases.-0f the 11 schools reporting medical inspection for contagious diseases, asminations are made by physicians in 5, and by teachers or nurses in the others. In a few instances inspections are made daily and in the others only in suspected cases. Most of the schools keep no records of the number of cases detected. One, however, reports from 25 to 50, and another 31 for last yeu. A number of schools send the suspected cases home, only 2 reporting that the board of health is gotibed. On the whole, responsiblity is left with the class teachers, who are often indifferent and porant in this respect.

"The daily list of contagious sick reported to the board of health is too long for the teachers to go over every morning, and as a rule little attention is paid to it.

*(?) For vision and hearing.–Five schools report that examinations take place either by a physiciun or physical training teachers once a year or once a term. All others report that no examinations are made. Only 3 of the schools reporting examinations keep records, and in them 710 cases were found defective last year. In all of the schools where examinations are made, the pupils are advised to consult a physician, or go to a dispensary. Only three schools require the students to bring from thetr parents an acknowledgment of the school notice as to their defects.

"(3) For defects other than those of eye and ear.-In 7 schools no examinations are made. In 2 only ste general examinations made by a physician. In others they are made by physical training teachers. lo one school the examination applies to candidates for athletics only. In the 12 schools reporting examinations, some inspect the students once or twice a year, some once during the school course. One school reports that examinations are made for teeth; another (Wadleigh), where a physician is employed permanently, inspects for teeth, glands, nose, throat, heart, lungs, back, skin, nervous disorders, digestion, and nutrition. Other schools do not specify the kind of examinations made. No special rooms for examinations, outside of the offices of the physical training teachers, are provided. Records are kept in all but one scbool. Six schools notify the parents of the defects and advise them to have the children treated by physicians and dispensaries. Seven schools give corrective gymnastic exercises.

“The number of remediable defective cases found last year was 764 out of a registration of 7,255.

"Only two schools examine for tuberculosis, and three for parasitic skin diseases. Only one school (DeWitt Clinton) keeps a record of what is being done after the defects are pointed out to the students and their parents This school reports 59 cases of flat foot, 59 cases of scoliosis, 8 cases of hernia, 27 of bad teeth, and 8 miscellaneous ailments rectified.

“NEED OF MEDICAL INSPECTION IN PAROCHIAL AND OTHER FREE SCHOOLS.-There are more than 209 parochial and other free schools existing in this city, which are either entirely ont of the pale of the department of health control, or the control is minimized, owing to the lack of funds for carrying on this work. The Catholic parochial schools alone have, according to the statement of the superintendent of the schools, made at one of the conferences on the health condition of children arranged by the committee, a registration of about 130,000. The schools do not have their own physicians, and the health control existing in them is very unsatisfactory.

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"SUMMARY. “The matters pertaining to the health and comfort of the school children are confided partly to the care of the city health department and partly to that of the department of education. The health department does this work through the bureau of child hygiene: the department of education through a number of committees.

I. The department of health.

"1. The work of the child hygiene division is carried on by physicians and nurses. (1) The duties of the physicians.-- The physicians make physical examinations, diagnose suspected contagious disease cases excluded from school, make absentee and other home visits. (2) The duties of the nurses.The nurses exclude suspected contagious disease cases, make class inspections, and do follow up work in the homes.

"2. The present system differs from the original plan in several particulars: (1) The nurses exclude suspected cases daily, instead of the physicians who used to visit the assigned schools every morning for that purpose. (2) The routine class inspections are made by the nurse once a month instead of by the physician once a term as formerly. (3) The physician visits each school for two days in succession, at an average interval of about 10 days, making physical examinations and visiting the excluded and absentee cases, while last year he devoted only the time that was left after the morning inspections to physical examinations in the school last visited.

"3. Advantages of the present system: (1) It has brought about some economy of money. (2) It has markedly increased the total working hours of the staff by substituting nurses working seven hours for physicians working three or four hours daily. (3) lt resulted in an increase of physical examinations made by inspectors almost double that of last year. (4) The number of treatments for physical defects received by children has increased, due to the better supervision by the increased corps of nurses. (5) The total number of home visits made by nurses has increased, although the average number of visits per nurse has decreased.

"4. Disadvantages of the present system: (1) The dissatisfaction on the part of some physicians, nurses and school principals with the innovation of having nurses exclude children for contagious diseases. (2) The loss of school work occasioned by unnecessary exclusions due to faulty diagnosis. (3) The duplication of work caused by the inspectors visiting excluded cases at their homes to confirm diagnoses. (4) The infrequent visits of the medical inspector to the school instead of former daily visits. (5) The discontinuance of physicians' consultations with parents. (6) The discontinuance of medical examinations for 'working papers' at the school.? (7) The overlooking of cases of tuberculosis by nurses in class inspections. (8) The markedly decreased amount of time devoted to homevisits by nurses. (9) The diminished control of the contagious eye and skin diseases, especially trachoma.

"5. The per cent of New York school children needing treatment for physical defects is over 70, about 40 per cent are found with defects other than teeth, and as large a number suffer from communicable eye and skin diseases.

"6. The proportion of children to one nurse is 3,968, and to one school physician 8,124.
7. The physical examinations are not thorough. The children's clothing is not removed.

This is not actually very great, as during the 5 months, Jan.-June, 1911, 16 cases were excluded daily from 150 schools in Manhattan, while in 1912 during the same period the daily average was 17 for 150 schools, or 1 case to every 4 or 5 inspectors.

? Five and six entail considerable loss in the efficiency of the system.

*8. There is almost a total lack of free dental facilities for poor children.
"9. The cooperation of parents in following the advice of the physicians is fairly satisfactory.
** 10. There is very little cooperation on the part of medical practitioners and dispensaries.

“11. The cooperation of teachers and principals varies greatly, according to the individual school. It is largely a matter of the personal interest of the teachers and principals.

"12. The high schools have almost no medical inspection or supervision for their students.
"13. The parochial and other free schools have no, or very little, medical supervision.
"11. The deperiment education.

"1. The control of the factors affecting the health of school children which are under the care of the
department of education are scattered among a number of committees, so that there is no concentration
al responsibility, which interferes with efficiency of administration.

"2. The various matters pertaining to the health of the school child for which the department of education is responsible are as follows: (1) The sanitary conditions of the school rooms, i. e., cleanliness, light, ventilation, and temperature. (2) Proper janitor service. (3) The detection of and provision for backward and defective children. (4) Intelligent cooperation on the part of the teachers in the detection and correction of physical or mental defects. (5) Physical training.

"3. With the exception of physical training the control of these factors influencing the health of the child is at present unsatisfactory.

**4. Physical training in the schools and the gymnasium equipment may be considered satisfactory.

"RECOMMENDATIONS.

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"1. The present system of medical inspection in the schools by the department of health has not had a fair trial and should be continued for another year at least, before any definite judgment as to its efficacy can be safely reached. Meanwhile the possibility of an arrangement by which the physician, rather than the nurse, could see the suspected cases every day and also have frequent consultations with parents should be seriously considered.

"2. In addition to their present work, the school inspectors should make a routine inspection of every class at the beginning of each term in order that the control of tuberculosis and some contagious eye and skin diseases may be stricter.

"9. The average number of children per nurse and per inspector is too large at the present time. EfSorts should be made to make the budget estimates on a basis of school population. In view of the prevalence of physical defects, the average proportion at the present time should be one nurse to every 2,500 children and one physician to every 7,500.

"1. Physical examinations should be made more thorough and more frequent. The children, or at least the boys at first, should be stripped to the waist at physical examinations. The present plan of examining the child when it enters school, when it graduates and once in the interim should be changed. A child should be examined when it enters school and then every two years. The examination just belore graduation does not have any particular importance.

43. In the nurses' work special emphasis should be laid on the follow up work. The burden of clerical work should be lightened. The unnecessary copying of the nurses' and physicians' record on the class word of the child should be eliminated.

*8. The salaries of the nurses should be graded. Instead of their receiving, as a uniform wage, $900 a gezr, the initial wage should be $800, after a certain period of time increased to $900 and then again to $1,000. The gradation will act as a stimulus to efficient work.

"9. Medical inspection should be instituted in the high schools which are entirely deprived of it at the present time.

**& The city should appropriate money for the enlargement of the force of the child hygiene department Mo as to enable them to undertake the inspection of parochial and other free schools.

*9. The medical practitioners and the dispensaries should be impressed with the importance of this work to the community and be urged to cooperate. Provision for dental clinics should be made, this being done if possible through the existing dispensaries.

"10. In the department of education the responsibility for the conditions affecting the health of the ubool child should be concentrated. An improved organization should be worked out, which would hyping onder the jurisdiction of one committee the sanitary conditions in schools, the instruction of children in physical training and parsonal hygiene, the segregation and treatment of backward and mentally defective children, the instruction of teachers in matters of hygiene, mental defects and the commoner dibers in children, and cooperation with the bealth department which is a condition sine qua non for gocessful medical work in the schools.

" It is suggested that this might be done by extending the scope of the present division of physical training so as to include in it all of these activities, thus forming a special bureau of school hygiene.

"*11. There is an urgent need of a larger corps of physicians in order to extend the facilities for the examination and study of backward children.

Dr. d. A. Knopf inade an investigation of the dental facilities of the dispensaries of New York City for the public bealth committee of the City club. He found that over 16 dispensaries have dental departtoets with tbe average number of dentists in attendance 1-3. In only three dispensaries are special toun sa school children arranged so as not to conflict with school hours.

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“12. An effort should be made to so modify the present system of employing and supervising Janitors of school buildings that the principal of each school should have full authority over and responsibility for

the work of the janitor." New York City. City superintendent of schools. Medical examination of

school children. In his Annual report, year ending July 31, 1911. p. 154–57. tables.

"Only 287.871, or considerably less than one-half of the total number of pupils in average daily attend ance were examined at all. Of the 299,184 defects found, only 152,941 are reported as remedied.

“As I have frequently pointed out in former reports, the medical service rendered to the department of health is inadequate. The figures given above sustain this assertion. Only about one-fourth of the children in the schools derive substantial benefit from this service. The facts fully warrant me in again recommending that legislation be sought to enable the board of education to organize its own burcau of child hygiene. ... Physicians employed by your board should be constantly on hand to advise regarding the school training of children suffering from physical defects, particularly nervous disorders and those resulting from malnutrition, and also with regard to the direction which the education even of normal children should take. The advice of a competent physician as to the physical ability of a boy or girl to accomplish any particular line of school work or to undertake the preparation for vocational

work ... would be of incalculable value to parents, pupils, and teachers.” SCHENCK, Herbert Dana. Medical inspection in schools and its status in New York State. North American journal of homoeopathy, 58: 644–51, October 1910.

“Of the 48 cities in the State outside of Greater New York, 31 sent in answers. Buffalo is the only city of the first class. In the second class are 7 cities, Albany, Rochester, Schenectady, Syracuse, Troy, Utica, and Yonkers, all but Syracuse reporting. Albany made so meager a report ... it cannot be reckoned with, on most questions. Of the other 40 cities having less than 50,000 inhabitants each, comprising cities of the third class, 24 answered the 30 questions sent out by the (American School Hygiene Association of these 17 cities reported 383 schools under supervision. ... Twelve of these cities have an organized system of medical inspection and in 9 the inspection is made for both contagious diseases and physical and hygienic defects, while in 2 others the vision alone is tested. In 2 others, contagious diseases are the only things for which an inspection is made; 12 cities follow up both cases of contagious diseases and of physical defects ... and 6 more follow up only ... contagious disease. In 10 cities it is reported that from 80 to 100 per cent are treated by reputable physicians. The inspection does not average more than one visit per week in most cities. ..

"In 7 cities the parochial and private schools are also inspected for contagious diseases, and in several places for physical defects. ...

“In four places the inspector is required to visit the houses to find out the cause of absence. ...

“In 6 cities the books are fumigated once or twice a year. . . . In 14 of the cities the books and other materials of children ill with contagious diseases or in families where there have been contagious diseases are destroyed and in 14 they are disinfected. ...

"Eight cities provide one or more nurses. ... In 5 cities they perform the duties of a medical inspector in a limited way. In three cities the teachers are expected to do this. In seven cities a permanent (record of the) physical condition of the child is kept; 15 report none.

“The school authorities in 20 of these cities say that medical inspection has improved the hygienic condition of the schools, the efficiency of the children and the attendance. There are none reporting against it."

Summary:

"1. In no sphere has preventive medicine a better field than in correcting the physical and hygienio defects of school children, which are largely undiscovered until school life begins.

“2. The most economical, comprehensive and complete inspection must include examinations by the teachers, by medical inspectors and by nurses in 'follow up'work.

"3. Efficiency and cooperation will be better secured by having physicians employed by the boards of education examine for physical and hygienic defects as well as contagious diseases. As soon as the latter are excluded from school they should fall under the jurisdiction of the board of health.

“4. In New York State medical inspection is rapidly extending and widening its sphere. ...

5. As physicians and citizens it is incumbent upon every member to urge the necessity of comprehensive and accurate medical inspection for defects that impede progress as well as diseases which

endanger others." SHAFER, George H. School medical inspection in New York City. Pedagogical seminary, 18:303-14, September 1911.

Cases of major contagious diseases are at once excluded. The inspector immediately telephones the name and address to the borough office of the division of contagious diseases, and duplicates this by a notice through the mail and again includes the case in his daily report. The division of contagious diseases at once sends a diagnostician, except in case of diphtheria or pulmonary tuberculosis. If the diagnosis is confirmed the case remains under the control of the division of contagious diseases.

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Cases of tuberculosis are referred for treatment to the family physician, or to the department of health clinic and a special report is made to the chief of the division of child hygiene.

A few weeks after school opens in the fall, a general routine inspection of all children is made by the medical inspector. This routine is made at the beginning of each term, and is repeated by the nurse at least once a month.

Contagious diseases are designated according to a certain code as follows: (1) Diphtheria, (2) pedicuJesús, (3) tonsilitis, (4) pediculosis,' (5) acute conjunctivitis, (6) pediculosis,' (7) trachoma, (8) pediculosis,! (9) scarlet fever, (10) measles, (11) varicella, (12) pertussis, (13) mumps, (14) scabies, (15) ringworm, (16) impetigo, (17) favus, (18) molluscum contagiosum, (19) acute coryza.

When the physician diagnoses a case he calls out the code number, and the teacher puts down the name of the child with the code number.

There are three classes of physical examinations. 1. Routine physicals. 2. Work paper physicals. 2. Physicals for athletics.

Esch morning as soon as the inspector has made his tour of inspections, he stops at one of his schools
to make regular physical examinations. These cover the following points: Defective vision, defective
hearing, defective nasal breathing, hypertrophied tonsils, tuberculous lymphnodes, pulmonary disease,
cardiac disease, chorea, orthopaedic defects, malnutrition, defective teeth, defective palate. A meas.
urement of height is also made.

The examinations are made in the following order: First the children entering school for the first time.
Second, beginning with children of the lower grades and proceeding to the higher grades in regular

order.
SMART, Isabelle Thompson. Examination of subnormal children. Women's
medical journal, 22: 57–59, March 1912.

"Medical examination of school children should be included in every city, town and district in the
state, and the special etamination of all children thought to be mentally backward or deficient should be in
esidence everyu here."

Gives some statistics gathered in the course of the author's medical work, 1910-11, as special exam-
iner of the mentally unfit in the public schools of Greater New York.

Of one group, numbering 2,500, there were 204 who needed actual hospital care. There were 627 re-
quiring general medical care; and 90 cases in such poor physical condition as to make an outdoor class
imperative. There were 145 cases of epilepsy, the major number of them of the more serious form known
as grandmal; 147 cases of masturbation; 946 cases of speech defect; cases needing dental care, 1,560.
**The eye defects," says the writer, "were appalling, and ranged ... all the way from a simple, slight
strabismus to congential cataract of both eyes and tuberculosis of the eyeball. . .. I found 1,608 chil-
dren suffering from aural defects; (and] 1,716 cases who had adenoids, or enlarged tonsils. ... Eighty-
one children had chorea, or St. Vitus Dance, while there were 876 cases showing various other forms of
nervous diseases. In addition ... there were 446 hearts in a pathologic state ...

"* Is it any wonder that such children are seldom promoted; that they are reported as nervous and
irritable; that they are with difficulty controlled, and that so many of them become truant?”
SMART, Isabelle Thompson and MACY, Mary s. On the medical examination

of children reported as mentally defective in the public schools. Pediatrics, 23:
665–71, November 1911. tables. charts.

Reprinted.

Data collected in the course of routine examination of 6,245 school children in the public elementary
schools of New York City. The children were all backward.
Result of examination of 6,245 backward children in New York City.

1

Percentage

of examined. Eye defecte..

88.6 Ear diseases or deal.

67.7 Delective teeth.

72. 7 Tons is alone enlarged

32. 2 Adenoids alone enlarged. Tonsils and adenoids. Speech defects. Epilepsy. Chores. Other peuroses.

32.7 Tubercular suspects. Cardiac weakness. Natritional disorders. The repetition of Pediculosis was originally intended to shield the pupil. In the examination the Dapis flle past the physician who calls out the code number to the teacher or nurse as the diagnosis is made. Any one of the four numbers was recorded as pediculosis.” (Letter of author, U. S. Bu. educa.,

29.6 50.1 41.3 6.4 4.4

8.2 17.5 68. 7

Dn.sh. hyg.)

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