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"The location of the clinics is as follows: Borough of Manhattan—341 Pleasant Avenue; Gouverneur Slip. Borough of Brooklyn—330 Throop Avenue; 1249 Herkimer Street; 124 Lawrence Street. Borough oj the Bronz—580 East One hundred and sixty-ninth Street.

"These clinics are open from 2 to 5 p. m. on school days, and from 9 to 12 a. m. on Saturdays. Each clinic has the following service: (1) Eye diseases: (a) Contagious eye diseases; (6) refraction. (2) Nose and throat diseases. (3) General medical diseases. (4) Skin diseases.

"The service at 341 Pleasant Avenue includes hospital wards of 14 beds and facilities for operations on trachoma, adenoids, and hypertrophied tonsils. Similar hospital service will shortly be ready at 330 Throop Avenue, 1249 Herkimer Street, and 580 East One hundred and sixty-ninth Street.

"The children are referred by the school nurse directly to the clinic, a special form of reference card being used. After the child reports at the clinic, the nurse assigned to duty at the clinic follows up the case, making home visits whenever necessary to see that the child remains under treatment until

discharged.” BAKER, Sarah Josephine. The value of the municipal control of child hygiene.

American Journal of obstetrics and diseases of women and children, 65:1061–68, June 1912.

“In New York City since 1908, 727,750 children in the public schools have received a complete physical examination. ... An average of 40 per cent were found to have one or more'associated physical defects ... with or without the most common defect that we find, namely, defective teeth. Thirtyfive per cent of the remainder ... were found to have defective teeth as the only physical defect. . . In the schools alone the efforts of the division of child hygiene have resulted in an immense gain in school time for those children who were affected with contagious eye and skin diseases, the necessary exclusions; . . . for these reasons being reduced from over 57,000 in 1903 to slightly over 3,000 in 1911. ...

“It has been alleged that the assumption by the city of the responsibility for the health of school chil. dren has made serious iproads upon the practice and income of private physicians. In order to ascerta in the exact conditions ... I have had tabulated for . . . 1911 the various sources from which children have received treatment. During that year, of the 65,150 children, 37,986, or 58 per cent, were treated by private physicians or dentists, while the remainder 27,164, or 42 per cent, were under the care of hospitals and dispensaries. ...

“This work in the schools, with its control of the contagious disease situation, with the elimination of the school as the main focus of infection; the physical examination of each child as soon as it enters school, before it is allowed to graduate and as nearly as possible every two years in the interim; the instruction of the parents . . . and the follow-up work. ... was performed during 1911 at a per capita

cost of $0.43.” BLAN, Louis B. Are we taking proper care of the health of our school children? Pedagogical seminary, 19:220-27, June 1912. tables. chart.

Writer records visit made in company with a school physician on a routine round in New York City.

“In ono school, attended by 2,000 pupils, the visiting physician waited patiently for a report of sickness from the various classes. There was not one report of illness or a single case for medical investigation. This seems almost incredible. If this number of children had been previously examined surely some of them would need medical attention. ... In another school ... not one case of cardiac ailment was reported. In point of fact ... two of these children had heart disease.

"In one case ... 'pulmonary trouble' was registered on the health card but no medical attention ... had been given. The case had been recorded three weeks prior. ...

“In none of the schools of New York City has there ever been recorded a complete general history of the child.

"Bronchitis cases are never examined or attended. ...

“There is not time enough to make adequate physical examinations. Each physician covers the ground assigned in less than three hours and is paid little for the work he is doing.

“No complete physical examination of the entering or enrolled elementary school pupils to ascertain the health conditions of their vital organs has as yet been suggested.

“Actual number of deaths among New York City school children between ages 5–15, during year 1910–11 (in part only tabulated):

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9.1

Tubercular disease (pulmonary)..
Cancer..
Nervous (sense organs)
Circulatory (heart)..
Respiratory
Digestive (intestines, stomach, etc.).

132

203

14.5

6 88 127 144 118

8 75 195 169 104

6.1 8.8 10.0 8. 2

5.4 13.9 12.1 7.4

“This pitiful list of victims ... demands serious and immediate attention. All entering pupils should be required to present certificates of medical examination as to the general and specific organic condition of their health, or else be compelled to undergo such examination before they are admitted to school.”

In an emphasizing paragraph to this report, Dr. Luther Halsey Gulick says: “In general the medical inspection of school children in the United States is not having adequate results. A rather wide observation indicates that not one-quarter of the children who need medical attention get it. In most of the cases examinations are made and the diagnosis recorded on a card and filed away for future reference, but nothing actually happens to the child as a result of the examination.” The writer sets forth a number of causes for this trouble In the first place the doctors are young and inexperienced. “In practically all cases, medical inspection is a doctor's secondary interast. ... He has no intention of finding a career in medical inspection of school children. ... The salaries . . . are absurdly small; the mean salary being about $300 per annum. ...

“The work demanded of a medical examiner . . . is not the work for a beginner in medicine. It is the work of a highly trained, long experienced specialist. There are not enough doctors to give either adequate or sufficiently frequent examinations. There are not enough nurses to see to it that the prescriptions of the doctors are carried out. Without school nurses, medical inspection

is of relatively little value.” New York academy of medicine. A Report upon the health conditions in the

public schools of New York City. By the Committee on Public health, hospitals and budget of the New York academy of medicine. Medical record, 82:406-12, August 31, 1912. tables.

Erecutive-secretary, E. H. Lewinski-Corwin. Reprinted Study made: “1. To summarize the present methods of safeguarding the health of school children. ... 2. To analyze these methods and their results from a strictly medical point of view. 3. To enlist the interest and cooperation of the medical profession as a whole in the problem of school hygiene. 4. To give medical advice and assistance to the Departments of health and education in their efforts to solve these problems. 5. To support the reasonable demands of these departments for sufficient city funds to maintain proper health conditions in the public schools."

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Needing treatment..
Found with defects other than teeth

alone..
With defects of teeth as only defect..
With defective vision..
With defective hearing.
With defective nasal breathing
With hypertrophied tonsils.
With defective nutrition..
With pulmonary disease.
With cardiac disease...
With orthopedic defects.
With chorea..
With defective teeth.
With defective palate.
With tuberculous lymph nodes.
Reported treated 2.

75,857 90,511 24,514

1, 491 27,316 34, 639 5, 845

483 1,661 1,190

861 135, 843

85

11.8 15.0 2.5 .2 .7

101, 602
95,062
29, 634

1,519
40, 946
50,012
8,691

656 2,370 1,683

951 164,230

153

15.3 18.7 3. 2

.2 .8 .5

.6 61.6

102, 150
69, 962
30, 408

2,310
43,393
50,934
7,249

744 1,503 1, 461

940 131,747

324

44. 2 30. 2 13.1

1.0 18.7 22.0 3.1 .3 .6 .6

3 58.1

57.0

1

418 65, 150

759 64,861

810 84,968

3 83.0

2 86.0

.2 64.0

Monthly bulletin of the department of health for April, 1912, p. 101. ? These figures do not include children reported with defective teeth as the only defect, whose treatment consisted only of instruction in oral hygiene.

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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. (1) 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 in. spected; the cost of each physical examination amounted, on an average, to $0.097, and the cost of the home 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 nurses, at $900 per annum.

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

7,200 10 additional purses, 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 health, 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 nurses 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 in 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 infrequency 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.”

“High 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.-01 the 11 schools reporting medical inspection for contagious diseases examinations 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 year. A number of schools send the suspected cases home, only 2 reporting that the board of health is notified. On the whole, responsibility is left with the class teachers, who are often indifferent and ignorant 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.

“(2) For vision and hearing.–Five schools report that examinations take place either by a physician 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 their parents an acknowledgment of the school notice as to their defects.

(3) For defects other than those of eye and car.-In 7 schools no examinations are made. In 2 only are general examinations made by a physician. In others they are made by physical training teachers. In one school the examination applies to candidates for athletics only. In the 12 schools report

ing 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 school. 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, & 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 out 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.

“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 formarly. (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 inspec. tions 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) It 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,

1 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.

2 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.
"II. The department of 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 of 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.

“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.

"3. The average number of children per nurse and per inspector is too large at the present time. Efforts 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.

“4. 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 before graduation does not have any particular importance.

“5. 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 card of the child should be eliminated.

“6. The salaries of the nurses should be graded. Instead of their receiving, as a uniform wage, $900 a year, 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.

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

"8. The city should appropriate money for the enlargement of the force of the child hygiene department so 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 school child should be concentrated. An improved organization should be worked out, which would bring under the jurisdiction of one committee the sanitary conditions in schools, the instruction of children in physical training and personal hygiene, the segregation and treatment of backward and mentally defective children, the instruction of teachers in matters of hygiene, mental defects and the commoner diseases in children, and cooperation with the bealth department which is a condition sine qua non for successful 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. 8. A. Knopf made an investigation of the dental facilities of the dispensaries of New York City for the public health committee of the City club. He found that over 16 dispensaries have dental departments with the average number of dentists in attendance 1-3. In only three dispensaries are special bours for school children arranged so as not to conflict with school hours.

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