Medical and sanitary inspection of schools, for the health officer, the physician, the nurse and the teacher

Preface

We realize that the progress of our civilization, the welfare of the individual, and the general good of society are contingent upon the efficiency of the education imparted to the children in the public schools. To take advantage of such opportunities, children must be physically and mentally equipped.

This volume represents an effort to prepare for physicians, nurses, and teachers a guide to the physical examination of school children. The aim is not only to outline plans of what and how such work can be best performed, but also to develop a deeper appreciation of the relations of physical and mental development. Medical inspection of schools has more than justified its existence; it has come to stay, and have an ever-increasing power of service.

In these pages the endeavor is to give definite, rationalized plans to prevent epidemics of contagion in the schools, and to recognize and correct physical defects of school children. Chapters on the sanitation of school buildings have received special consideration. Plans of work have been formulated to meet all requirements for efficiency, time, labor, and money-saving. The author's excuse of ability to write this book is twelve years' experience in the work of medical inspection of school children and three years in charge of the Division of Child Hygiene.

VI PREFACE

In the race, to run over the wrong route is worse than not to run; so the proper thing is to study the course before you start. If these writings prove a trustworthy map to those who undertake the work of medical inspection of school children I shall feel that my labor is fully repaid.

Introduction

Public education is a question which vitally concerns the national government, as well as every State, city and district, and includes within its scope all classes and races. In its general management the problem is identical for every State, city, and town, but the details, depending as they do on surrounding conditions, are chiefly local matters coming under the supervision of the local authorities without outside interference. In the United States, twenty millions of children, or one-fifth of the entire population, are enrolled in the public schools.

The salaries paid to teachers each year amount to more than two hundred million dollars, and the total expenditures on public schools exceeds four hundred million dollars. Besides this enormous annual expenditure there is a permanent investment in public school buildings amounting to over nine hundred million dollars. This requires the levying of a heavy taxation on the people. There is a "general" tax which is levied on the citizens of the State as a whole and a "local" or self-imposed tax levied by each city or town. Four-fifths of the school taxes are of this kind. That this additional burden is cheerfully borne is ample evidence that the people realize the importance of the proper education of children. Not only do the people give willingly of their income, but many of the best and 2

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most influential citizens give their services freely in acting as directors for the management of these institutions. To make this great expenditure for education effective, there must be good teaching, and children physically adapted to take advantage of the education offered.

The progress in medical science, due largely to laboratory research and sociological investigation, has brought to light the causative factors of disease and demonstrated that many are preventable; thus making possible the great advances in preventive medicine, sanitation, and hygiene. Diseases formerly looked upon as visitations of Providence are now known to be almost entirely preventable, and the preservation of health and life by preventive measures has become the watchword of the medical profession. The relation of the schools to these achievements of medical science is of great importance. These endeavors on the part of the medical profession have brought the physician in contact with the school, and have claimed his interest in educational affairs. The physician soon noted the close association between the mental and physical condition of the child. Simultaneously, the teacher outgrew the early educational methods of teaching en masse, and advanced to the modern methods in pedagogy of teaching the individual child. Both teacher and physician noted the marked variations in the mental capacities of different pupils, and recognized the importance of a combined study of the causative factors. To them, therefore, medical inspection of schools owes its existence.

Eighteen years of school medical inspection in America and almost forty years abroad have carried us beyond the question of why such work is needed, and have placed the best and most efficient methods and systems within our reach. There are still a few doubters and disbelievers, but

INTRODUCTION 19

such dissenting voices will always be heard for the same reasons that there are people who are opposed to vaccination and antitoxins, or progress along any line. The value of medical inspection of schools needs no greater endorsement than the fact that many of the State legislatures have passed laws authorizing the establishing of a system of inspection, and in three States medical inspections are mandatory.

The history of medical inspection of schools includes the history of both the school doctor and the school nurse. England was one of the first countries to look after the physical needs of the school child. There nurses were appointed before physicians; in America the process was reversed.

School nursing may be considered as a development of visiting nursing. The latter originated in England about 1860 and reached America in 1877, when a New York City Mission sent the first trained nurse into the homes of the poor. Before 1905 the work was sporadic, but since then it has gained considerable headway.

The school nurse, representing a new idea in visiting nursing, began work in Liverpool in 1887, when nurses paid daily visits to a few schools for the purpose of attending to minor injuries and complaints. They also called at the homes of children who had more serious ailments and urged the parents to obtain the services of a physician. The early school nurses were volunteers, and it was not until 1901 that the London School Board appointed salaried municipal school nurses, with definite duties assigned. They examined the children for contagious skin diseases and excluded all cases found. The nurses did not treat the cases, and consulted only occasionally with the school medical officer. Later the nurse tested the vision and hearing, and kept a record of the physical examinations of the pupils.

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In 1907 a superintendent, and, recently, assistant superintendents were appointed.

The first school medical officer was appointed in London in 1891. His duties were to examine absentees from school who failed to furnish a doctor's certificate. The following year, Dr. Francis Warner published a full report of the examination of fifty thousand school children.

In America, Boston is credited with having established the first system of school inspection, in 1894. New York had a medical inspector. Dr. Moreau Morse, in 1892, but did not establish a system of inspection until 1897. One hundred and fifty physicians were appointed that year by the Department of Health to inspect the school children. These physicians received a salary, of thirty dollars a month, and their duties consisted in visiting the schools each morning, to examine all children sent them by the teachers as suspicious cases of contagious disease. This system was in effect until 1902, when the inspectors were required to give more time to the work, and the salary was increased to one hundred dollars per month. The system was then elaborated to include a routine inspection of all children in the classrooms for the purpose of detecting cases of contagious eye and skin diseases. Home visits were made to absentees to detect unreported cases of contagious disease.

The routine inspection of children in the class-rooms resulted in the exclusion from school of large numbers with cases of minor contagious diseases. It was evident that such exclusions had a limited value, and in many instances had a harmful effect, as the cases were not considered by the parents of sufficient importance to warrant medical treatment. This procedure caused enforced absence from school, and not only interfered with the education of the children, but often made them habitual truants.

IN'TRODUCTION 21

At this time experiments were made with a trained nurse, Miss Lina L. Rogers, who volunteered to do the work. The result showed not only marked improvement in school attendance, but demonstrated that all danger of infection could be controlled, and that the children could remain at school without danger to themselves or their classmates.

As a result of this experiment the first staff of municipal nurses to be employed in the Unites States was established in November, 1902, by the Department of Health of the city of New York. In December, 1902, a hospital and dispensary for the treatment of contagious eye diseases was established by the same department, and in 1905 the medical inspectors began complete physical examinations of all school children.

Notwithstanding these many changes, the results hoped for did not materialize. The physicians and nurses succeeded in obtaining for treatment only 6 per cent, of the physically defective children. The records soon amounted to little more than a mere compilation of statistical data, and very little to show for the work. This resulted in the organization of the Division of Child Hygiene, and a largely increased staff of trained nurses.

Experiments showed the economy and efficiency of placing the control of contagious diseases in schools iii the hands of the school nurse, leaving the medical inspector free to devote his entire time to making physical examinations of the children. In January, 1912, this system of medical inspection was inaugurated, utilizing the services of seventy-four medical inspectors and one hundred and seventy-nine nurses, under the supervision of a staff of supervising inspectors and supervising nurses.

In 1901, the author started a daily class-room inspection of the school children in Philadelphia, and in 1903 inaugurated a system of inspection, utilizing the services of a trained

22 MEDICAL INSPECTION OF SCHOOLS

nurse. The success of this work resulted the following year, in the organization of a corps of fifty medical inspectors to perform the work in the schools and control contagious diseases.

By 1905, fifty-five cities had adopted some form of inspection, and at present there are over five hundred cities and towns in the United States, with medical inspection of schools. The objects of the work include:

1. The detection of contagious diseases, thereby protecting the child and the community.

2. The detection of physical defects which prevent the child from acquiring a full education with the least sacrifice to his physical welfare.

3. To find the capacity of the individual pupil to acquire knowledge in accordance with his mental and physical status.

4. To insure the best possible hygienic surroundings for the child while he is in school.

5. To bring a closer relationship between the school and the home so as to carry out more successfully the oth^r aims of medical inspection and insure treatment for discovered defects.

6. To teach the practice of hygiene and healthful living both in school and at home.