A Radical Proposition: The Brief but Exceptional History of the Seattle School Clinic, 1914-21

A Radical Proposition:

The Brief but Exceptional History of the Seattle School Clinic, 1914-21

Stephen Woolworth

School of Education, Pacific Lutheran University, Tacoma, Washington 98447-0003.
Email: woolworth@plu.edu.

Abstract

This article examines the history of the Seattle school clinic (1914-21) and the efforts of public school administrators to institutionalize a full-service medical program for poor and working class children. At its height, thirty-six volunteer physicians and thirteen partially paid dentists organized within nine departments performed a range of diagnostic and "corrective" surgical procedures, including tonsillectomies, circumcisions, and eye surgeries. These practices were not funded by other public school systems across the United States, almost all of which delineated between prevention and treatment services. This article explains the exceptional nature of the clinic, examines the institutional tensions instigated by the expression of medical authority within the schools, and considers how clinic technologies influenced state-school-child relations.

Keywords
school clinics, school health, child health, school medical inspections, educational history, public health history

The opening of the Seattle school clinic in May 1914 was greeted with little publicity or fanfare. Few in the rapidly growing Pacific Northwest city of a quarter million people seemed to even recognize or appreciate the unprecedented nature of the undertaking. While school administrators across the nation were severing agreements with public health departments and establishing their own health and hygiene programs, a small cadre of [End Page 227] school directors in Seattle had an even bolder idea. They transformed part of the former school administration building in the heart of the city's downtown into a full-service medical clinic. While nurses and medical inspectors in other school systems were inspecting children in the schools and then referring those in need of treatment to private physicians, the school administrators in Seattle went one step further and opened a clinic to treat the very maladies many at the time thought responsible for children's slow progress in school. Soon thousands of poor and working class parents were bringing their children to the school clinic for dental treatment, tonsil or adenoid removal, circumcisions, hernia and eye squint operations, and other procedures deemed "corrective."

The Seattle school directors believed the health of children could be monitored, recorded, and, in many instances, restored to "normal" conditions in a more humane and efficient manner through the schools than under the supervision of the city's influential health department. To prove the point they hired Dr. Ira Brown, a former military physician, to oversee the new school "medical department" and in doing so ended six years of collaboration between the two agencies. The opening of the school medical department—with the clinic as its centerpiece—reflected the tactical shift in school health policy orchestrated by school leaders in Seattle. No longer would health department inspectors comb the schools looking for sick or physically "defective" youth. As Dr. Brown summarily proclaimed at the opening of the clinic, "Heretofore the physician went to the child. We changed that so now the child goes to the physician."¹

The decision to house a comprehensive clinic within the school system was a notable departure from what was occurring across the nation where regulatory practices like medical inspections came to define the prevention focused strategy of public school administrations.² The Seattle school clinic was thus an exceptional case in the history of school health reform in the United States. Its seven-year existence marked one of the only instances a public school [End Page 228] administration oversaw and funded a full-service school medical program. It represents not only a striking example of the medicalization of education within a specific school system, but also stands as a remarkable institutional innovation that cut against the grain of mainstream education and public health policy.³

The Seattle school clinic warrants explanation. Why, for instance, was there such an investment in the power and authority of medical discourse in Seattle during a time when such forces were constrained in other school systems? How did the establishment of a medical clinic influence the exercise of medical authority within the schools? And, why was the clinic in operation for only seven years? This article addresses these questions by first situating school health reform in Seattle within the larger national context and then examining the local factors that led to the initial opening, subsequent operation, and eventual closing of the clinic. It concludes by assessing the significance of the Seattle school clinic within the context of state-school-child relations.

The School Health and Efficiency Movements

School health programs in the United States emerged at the beginning of the twentieth century as part of the larger cultural and scientific rise of medical authority in which the state increasingly acquired the function of population health management.⁴ Beginning in the middle of the nineteenth century, physicians formed medical societies to promote health reform and organized public health boards at the state and local level to institute and regulate practices like the collection of vital statistics and the application [End Page 229] of sanitary science within America's burgeoning cities. The professionalization of public health—as evidenced by the establishment of the American Public Health Association in 1872—occurred alongside the growing role and responsibility of government to safeguard the general health and welfare of the public. However, it was not until the development and eventual acceptance of bacteriology, a laboratory science derived from the research of Robert Koch, Louis Pasteur, and others in Europe who demonstrated that germ microbes were the causative agents behind the spread of contagious disease, that public schools—and the bodies of the children attending them—became one of the primary focal points for health reform.⁵

While health officials first targeted the schoolhouse beginning in the mid-nineteenth century as part of their efforts to control and contain the spread of contagious disease through sanitary inspection of school buildings, the dissemination of bacteriological research—what Nancy Tomes has termed the "marriage of sanitary science and germ theory"—significantly expanded the scope of their disease prevention strategies.⁶ The knowledge that child killers like smallpox, tuberculosis, scarlet fever, and diphtheria were caused by the spread of microscopic pathogenic organisms, not miasma or "bad air," as many previously believed, empowered public health boards to expand their practices in schools from negating environmental hazards through sanitary science and engineering to disease prevention, and the control and treatment of sick children. For example, after an 1894 diphtheria outbreak, Boston health department physicians started entering the schools to examine students for either proof of vaccination or evidence of contagious disease. One year later, children were lining up for medical inspections in the Chicago schools followed shortly thereafter by the establishment of a Division of Medical School Inspection in the health department of New York City. By 1907, school medical inspections were [End Page 230] underway in ninety cities, a figure that rose to nearly five hundred by 1913.⁷

School medical inspections were instituted across the United States as one component of an emergent school health movement driven by coalitions of broad-based reform interests. In northern and midwestern cities, the "drive to broaden the school's responsibility for children's health," writes William Reese, "emanated from narrow-minded advocates of scientific management and business efficiency as well as from grassroots Socialists and liberal reformers."⁸ In the South, reform impulses were expressed through organizations like the Southern Education Board and the Rockefeller Sanitary Commission in their efforts to eradicate hookworm infection.⁹ Extending the mission of the schools to improve the health of children was, for some reformers, a matter of conscience and a means to fulfill the promise of democracy in America's densely populated cities, for others, it was an expression of the ideology of human capital investment, "a response to the allegedly inferior biological makeup of the native poor and certain ethnic groups."¹⁰

Following on the heels of child labor and compulsory school attendance laws, medical inspections represented another form of state intervention into family life at the turn of the century—what Sydney Halpern described as "part of a more general trend toward new forms of societal regulation of childhood."¹¹ School medical inspections were an important development in the overall goal of health reformers to order society according to the knowledge and principles of public health science. In many respects, medical inspections were the quintessential Progressive Era reform because [End Page 231] they combined the knowledge and techniques of applied medical science with the organizational goals of efficiency and the ideology of prevention. It was not long after inspections were started, however, before connections were assumed between the physical condition of children and their intellectual capabilities. As public health historian John Duffy points out, "in the process of checking for contagious diseases, school inspectors uncovered a host of other medical problems among the children, and their reports were ultimately responsible for moving the focus of school health programs well beyond the sanitary condition of school buildings and contagious diseases."¹²

Medical inspections in schools were thus the first regulatory practice to position children—their bodies and their physical and intellectual functioning—as objects of examination in school.¹³ Once physicians entered schools and began examining children, they uncovered a host of untreated conditions and physical abnormalities (e.g., adenoids, enlarged tonsils, squint eye, etc.) in the general school population that led them to broaden their rationale for school medical inspections from disease prevention to the correction of physical and mental defects.¹⁴ Consider, for example, a resolution at the 1904 meeting of the Washington State Medical Association urged physicians to advocate for systematic and careful medical examinations in the public schools because "defects . . . upon the mental, moral and physical development" of children were "not fully appreciated by educators and the public at large."¹⁵

Leonard Ayres' Laggards in Our Schools, the widely read 1909 study of retardation in city schools, further legitimized the efforts of public health physicians to extend their influence beyond disease [End Page 232] prevention in schools to the improvement of student learning. Ayres' study called attention to the problems associated with grade promotions in city school systems. In doing so, his statistical survey effectively merged the concerns of the school efficiency and school health movements. "It is not surprising," Ayres wrote, "that the study of the school records . . . shows a high degree of correlation to exist between . . . marked physical defects and . . . school progress."¹⁶ The publication of Laggards in Our Schools marked what Steven Schlossman, JoAnne Brown, and Michael Sedlak describe as "the final legitimization of the health professional's right of entry into the schools, and the emergence of a new alliance between health specialists and educators in assessing the causes of school failure and planning possible remedies."¹⁷ In fact, by 1910, there were close to two thousand physicians and nearly four hundred nurses working in American schools.¹⁸ One year later the American Medical Association and the National Education Association formed the Joint Commission on School Health Problems as the first step in coordinating school health policies at the national level.¹⁹

While most school medical inspection systems were first initiated by public health departments and boards of health, many school boards had been hiring physicians to work in the role of directors or supervisors of hygiene for over a decade by the time superintendent Frank Cooper and the Seattle school board followed suit in 1914. In most cases, these physicians were given charge of an administrative department with responsibilities that included medical inspection, sanitation inspection, and the teaching of hygiene and physical education. So common was this trend that three-quarters of the 443 urban school districts that responded to a survey item in a 1910 Russell Sage Foundation study on the [End Page 233] supervision of school health reported that medical inspections were under the management of school administrations not public health departments.²⁰ But, as Paul Starr has noted, "School health services lost some of their medical emphasis . . . as they were transferred from local boards of health to boards of education, where by 1911 three of every four cities vested control."²¹

The Opening of the Seattle School Clinic²²

At the time of the clinic's opening in Seattle in 1914, there were approximately thirty-five thousand students enrolled, and over a thousand teachers employed by the public school system. Under thirteen years of Superintendent Frank Cooper's managerial hand, the public school system had become one of the larger bureaucracies in the city with an annual multi-million dollar budget. In the wake of the state's 1903 compulsory school attendance law, Cooper helped develop a system of neighborhood-based elementary schools and he advocated child-centered teaching methods that moved the schools away from relying on traditional practices like rote memorization. He also oversaw the development of a system of special classes and parental schools, industrial and evening classes, kindergartens, a psychological clinic, vocational services, intelligence testing, and an attendance department, all of which reflected the increasing specialization and organizational complexity that accompanied the rise of scientific progressivism in the city's school system.²³

The medical department and clinic were part of this organizational shift toward administrative rationality and what Raymond [End Page 234] Callahan once termed the "cult of efficiency."²⁴ Taken together, they represented an ambitious investment in the power and authority of medical science to solve what were thought to be social and educational problems. At its height, thirty-six volunteer physicians and thirteen partially paid dentists staffed the clinic, which was organized into nine departments. Beyond its organizational features as a specialized subunit within the school system, the opening of the clinic also represented something new and different on the institutional landscape of American education—the marriage of public education and allopathic medicine to support what educational historian Mona Gleason called, "the embodied regulation of children."²⁵ For with the opening of the clinic, the Seattle public school directors took on the work of treating children whose parents could not afford private care and in doing so went further than other school systems in harnessing the disciplinary practices of applied medical science.²⁶

When the school clinic opened in Seattle, it offered a stark contrast to city's overcrowded clinic and hospital where poor children had previously gone to be treated. Located inside the police station, the city clinic was a progressive reformer's worst nightmare. Children were treated alongside adults in an atmosphere far removed from the nurturing and child-centered institutional environment reformers were advocating for in cities across the United States. By contrast, the new school clinic was conceived within the progressive reform spirit as evidenced by the adjoining playground children could enjoy while they waited to see a physician.

According to the publicized protocol at the time, upon entering the clinic, a parent and child were greeted by the receptionist who handed them a number and an envelope and then directed them to the waiting room. There they sat among other families who, like [End Page 235] them, had been directed to the clinic by a school nurse because they were too poor to afford the services of a private physician. When their turn came to see the physician, a nurse escorted the child into a private room where she instructed her to go into the bathroom and urinate in a jar. The nurse then measured and weighed the child, recorded her findings, and instructed her to wait for the doctor.²⁷

The first physician to examine the child was a general practitioner or "General Man," as he was informally known within the profession. He listened to the child's heart followed by her breathing. He checked the child's kidneys and other internal organs, and made note of any physical "deformities" discovered during the course of his examination. The girl was then escorted upstairs for the second exam conducted by the ophthalmologist or eye specialist who assessed her eyes and vision. Had deficiencies been found, the doctor would have ordered a mydriasis and instructed the parent on how to administer eye drops and monitor the dilation of the pupils. An appointment would also have been scheduled within three days time when the child would be given another vision test to determine if glasses were needed.

The ear, nose, and throat doctor inspected the child after the eye examination was completed. He examined the girl's mouth to see if her tonsils were swollen or enlarged, if her teeth or palate suffered from deformations, or if her head shape was altered from the pressure of adenoid growths, all of which according to the ascendant focal infection theory "were major sources of primary infections that then spread to other body organs."²⁸ Like the other physicians, the ear, nose, and throat specialist then recorded his findings on a card inside the envelope given to the mother and her daughter when they arrived at the clinic. When the examination was over, the record was recirculated to the front desk where it was placed in a folder containing the child's name, age, school, and the list of departments in the clinic where she had been examined. Depending on the findings of the physicians, the child was either [End Page 236] sent home or on for additional examinations in one of the other clinical departments (e.g., dentistry, neurological, etc.). If recommendations for follow-up treatment were made by one of the examining physicians, another appointment was scheduled.

While the general protocol described here is all too familiar to anyone born and raised in the culture of modern medicine, for Seattle's poor and working class children in 1914, this was a journey into what must have seemed a strange and alien world. In most instances, the children sent to the clinic had probably only seen a physician for a minute or so during school medical inspections or at the city hospital or clinic, if they had ever been sick enough to be brought there. A visit to the new school clinic, then, was the first formal experience this generation of children had with being medical subjects—of having specialists touch different parts of their body with strange looking instruments, of having their physical features examined and scrutinized, and of having the results of all these activities recorded and compiled into medical biographies whose narratives detailed a timeline of interventions, adjustments, and "corrections." For these children, the new school clinic was thus the beginning of their formal enculturation into not only the norms of modern health and hygiene, and all the able bodied and gender biases contained therein, but also the increasingly technological and atomized practice of allopathic medicine wherein each child was made into an individual case.²⁹

The Establishment of School Clinics

By the 1910s, school and health reformers across the nation opened and operated school clinics to coordinate diagnostic examinations, to determine placements in "open air" schools for students with or at-risk of tuberculosis, and to evaluate whether students warranted placement in the emerging differentiated structure of special classes.³⁰ School clinics symbolized the point of intersection [End Page 237] between the school health and efficiency movements. Through the diagnosis and prevention of physical problems in children, health officials believed they could better keep children abreast of their proper age-graded classification. This, in turn, was thought to prevent retardation and promote the overall organizational efficiency of school systems. It was through the work of clinics, moreover, that reformers sought to diffuse knowledge of health and hygiene as a means of social improvement and uplift. By correcting one individual at a time, reformers believed changes to the collective would follow.³¹

School medical clinics were, in fact, so widely adopted that by 1914 Ernest Hoag and Lewis Terman referred to them as "an integral part of the educational machinery" of public school systems.³² A 1916 survey revealed that out of the hundred largest cities in the United States over three-quarters (n = 77) had some form of school clinic in operation. In these cities, over 70 percent (n = 55) were maintained by charities and philanthropic entities. Either boards and/or departments of health or education administered the others. In most cases, though, clinics only offered free diagnostic services although some went further. Of the 176 school clinics operating in the 77 cities, 59 (33 percent) offered some form of dental treatment, 28 (16 percent) offered eye care, 20 (11 percent) administered ear care, 8 (4 percent) featured nose and throat work, 4 (2 percent) offered orthopedic care, and 3 (2 percent) specifically addressed [End Page 238] tuberculosis. Some 14 (8 percent) clinics listed their treatment services as "general."³³

One of the main reasons why treatment procedures were not more widely authorized in public school clinics was because of the opposition from private physicians who condemned free medical services in schools as a form of socialized medicine.³⁴ In New York City, for example, the city health department run school clinics were closed in 1915, only three years after they were opened, due to the pressure applied by physicians who saw the work of the clinics as encroaching upon their private practice.³⁵ By the second decade of the twentieth century then, public health policies in schools tended to delineate between preventive and curative approaches toward improving and protecting child health.

Medical treatments it was believed at the time further ran the risk of taking schools away from their stated purpose as articulated in most state legal codes and so many school administrators hesitated to pursue the work. "The school has not undertaken forcibly to subject children to surgical operations, nor is there at present any legal method of compelling parents to perform their duty in this respect," Hoag and Terman remarked at the time. Nonetheless, there was a growing belief among some of the more outspoken educational leaders across the country, Hoag and Terman among them, who thought that schools ought to be given more authority over the regulation and correction of children's bodies. They proclaimed the physical growth of the child "stands in need of more expert supervision than the average parent is capable of exercising." For these educational leaders—distrustful of the average parent's ability to care for their children—medical interventions in schools were part of a broader strategy of nation building where children were seen "as the raw material of a new State" with the schools serving as "the nursery of the Nation." Conserving this raw material [End Page 239] then, reasoned the promoters of human capitalism, was "as logical a function of the State as to conserve the natural resources of coal, iron, and water power."³⁶

The administration of medical treatments in schools first began in England after the passage of a national medical inspection law in 1907. Within four years, thirty cities opened school clinics where skin and scalp disease in addition to dental, eye, ear, and throat care were provided.³⁷ However, as noted previously, by the time Seattle's school clinic opened in 1914, only a few school districts were providing any kind of medical treatment and, even then, such provisions were restrained in comparison to the school clinics of England. Whereas some cities like Cleveland operated dental and eye clinics, others like Rochester, Cincinnati, and Philadelphia supported dental clinics only. The city of Bridgeport, Connecticut, opened the first dental hygienist program in 1913 with the goal of preparing practitioners to work in the public schools under the supervision of reformer Albert Fones. The following year, ten of the school's first graduates were hired to "daily inspect and prophylactically treat the teeth, and to instruct the entire first- and second-grade student body in methods of self-care."³⁸

Dr. George Holmes, the head of school medical inspection in Newark, New Jersey, was one of the first leaders in the school health movement to articulate a vision for comprehensive school medical clinics in the United States. Writing in the Journal of the Medical Society of New Jersey in 1911, Holmes suggested that "free public school clinics be established to care for all diseases and defects common to school pupils." Once such a clinic was started, Holmes explained, no pupils were to be treated there unless they could present the "printed slip" proving they not only had been referred by an inspector but also their home had been visited by a [End Page 240] school nurse who found that the impoverished conditions indicated free treatment was warranted. Establishing school clinics, Holmes maintained, would not only prevent students from having to leave school grounds when classes were in session but also would afford school physicians and nurses the opportunity to better educate parents about hygiene."³⁹

In 1913, leading progressive school health reformers Luther Gulick and Leonard Ayres rebuked Holmes's vision of free public school clinics by suggesting few "educational authorities in this country would be prepared to accept so radical a proposition as that of Dr. Holmes." Little did they know that in less than a year a medical clinic would be opened in the public schools of Seattle that, for all intents and purposes, operationalized Holmes's "radical" model.⁴⁰ The two men who would oversee the implementation and subsequent operation of the clinic, and the school medical department in which it was housed, were school superintendent Frank Cooper and public health physician Ira C. Brown.

The Seattle Public School Medical Department

In the years leading up to Brown's hiring, Seattle, like Boston, maintained a shared administrative approach to school health supervision at a time when in most cities the work was consolidated under the authority of school boards and school administrations. School medical inspections in Seattle were first started in 1903, and then in 1908 Superintendent Cooper—then in his seventh year—and Dr. James Crichton, the city's recently appointed health commissioner, designed a system in which the health department physicians administered the medical inspection of students while the school nurses coordinated everything from home visits to medical consultations. The work of the school nurses accorded especially well with Superintendent Cooper's vision of the school as the state's primary child welfare institution, and over time he sought to expand the scale and scope of the nursing corps because he believed their tutelage approach was more effective than the enforcement minded health [End Page 241] department inspectors when it came to protecting and promoting the health of students.⁴¹

Within a few years, jurisdictional tensions between Cooper's school administration and Crichton's health department were evident. While the relative effectiveness of the nurses vis a vis the health department inspectors was the central bone of contention between the two of them, other issues like the health department's fumigation policies, its inconsistent enforcement of quarantines, the content of a controversial article in the health department's school health bulletin, and disagreements about the need for open-air schools all further contributed to the increasing jurisdictional tensions concerning who had controlling authority over the direction of school health policies and practices.⁴² It was not until the health department became embroiled in a series of efficiency investigations that tarnished the reputation of its once highly touted health commissioner, however, that Cooper and the school board asserted their institutional authority as articulated in the 1909 school medical inspector law and hired Dr. Brown to oversee the establishment of a school medical department.⁴³

Before his appointment to the position of "School Medical Inspector" of the Seattle Public Schools in 1914, Dr. Ira Brown served for sixteen years in the United States Army Medical Department where he gained first-hand experience as a public health administrator. His professional experience ranged from the president of the board of health for the city of Porang in the Philippine Islands to the coordinator of disease prevention efforts among soldiers stationed at the Mexican American border. Brown, originally from Genoa, New York, graduated from the University of Buffalo Medical School. He also studied medicine in numerous European cities—Vienna, Berlin, Munich, Paris, London, and Budapest among them. At the time of his appointment, Brown was [End Page 242] fifty-three years old. He had just finished his term of service as a member of the medical reserve corps at Seattle's Fort Lawton.⁴⁴

Brown was paid a salary of $3,600 per year, which alongside the school physician in Houston (who was paid the same amount) made him the highest paid school physician in the nation.⁴⁵ Because Brown's salary was paid by the school board and not the board or department of health like was common in other locales, his high salary reflects the seriousness with which school officials invested in medial work. Brown, though, was also faced with the highest physician to student ratio in the nation (approximately one to thirty-six thousand), but this pressure was alleviated by the corps of volunteer clinic physicians in addition to a sizeable staff of eleven school nurses. Unlike in other cities, the school nurses in Seattle were paid an allowance of $3 per month for carfare to supplement their annual salaries, which ranged from $750 to $925 per year.⁴⁶

Brown's years of military administrative experience guided the manner in which he ran the school medical department. He tirelessly strove not only to integrate the knowledge and practice of medical science with the principles of organizational efficiency, but also to bring the regimentation of military discipline to the work of the school medical department where for the next six years he advanced a medical model of policy and practice within the school system.⁴⁷ [End Page 243]

Brown, with Cooper and the board's support, modeled the school medical department after a typical public health department. At the head of the department was the school medical inspector who, much like a health commissioner, directed departmental affairs. He answered only to the superintendent and school board, just as health commissioners were typically beholden to city councils and mayors. The department included not only a diverse array of specialist physicians and dentists who staffed the dental and medical clinics but a corps of school nurses who visited homes, inspected students in the schools, and taught classes on child care and first aid. Brown's department also oversaw the inspection of school buildings, the distribution of milk, and the implementation of a health curriculum. For all intents and purposes, the medical department reproduced the public health bureaucracy, albeit on a smaller scale, within the institutional structure of the school system.

The centerpiece of the school medical department was the clinic, which was located in the old administration building (once the Central School) in downtown Seattle. The clinic was conceived by Brown and Cooper to provide medical services to the city's poorest families who, under the health department's system of school inspection, either did not go for treatment at the overcrowded city clinic and hospital or experienced problems of some kind once they did (e.g., long waits).⁴⁸ Brown also promoted the clinic as a means to alleviate the problems presented by what he called the "border cases"—children coming from families who had some means but could not "raise enough money to have an operation performed." By opening a school clinic, Cooper and Brown thus hoped to establish a more comprehensive medical and social welfare program that surpassed the limitations of the previous system. Medical inspection "does no good," Dr. Brown commented in his first annual report, unless medical treatment followed.⁴⁹ The addition of the clinic, then, helped establish the schools as the city's total youth institution, which merged reformers' progressive ideals of regulatory social control and benevolent humanitarianism. [End Page 244]

The Seattle School Clinic at Work

The clinic was designed on the hospital model with nine departments of medical specialization. Staffed initially by twenty-nine volunteer doctors and thirteen partially paid dentists, the clinic reflected the technical organization of modern medical science. While there was no residential ward, there were eye, ear, nose, and throat services, a surgical room, a dental section, and clinic clerk who managed the medical records. The nine departments in the clinic included the "General Diagnosis" department where all children went to have their urine checked, their weight taken, and other diagnostic procedures. The General Diagnosis department, Brown once pointed out, worked alongside the Pathological department "in arriving at the correct diagnosis."⁵⁰

The Surgical and Gynecology departments focused in large part on the regulation of sexual development in childhood and adolescence. In addition to tonsil and adenoid removal, physicians in the Surgical Department handled medical procedures pertaining to male children with, as Brown noted, "special attention to sexual organs, the necessity for circumcision," and other "minor injuries (and) malformations." Similarly, the Gynecology Department was organized to examine "all girls sent from the House of Correction and Juvenile Courts, and those girls who suffer from sexual disorders." Before the board hired Dr. Maybelle Park in 1916, Brown asked the volunteer female physicians to engage mothers in the medical supervision of their daughters. At the time of the clinic's opening, Dr. Brown wrote with optimism of the potential good that could be accomplished by the Gynecology Department. "By judicious advice to the mother, by the correction of trivial defects in early womanhood, by education of the children through the mothers," Brown predicted, "many of the future ailments, fears and even calamities will be prevented."⁵¹

The work of the Ophthalmological and the Oto-Laryngological Departments was organized to address the eyes, ears, nose, and throats, while the Orthopedic Department addressed what were considered physical deformities. If a child required a surgical [End Page 245] procedure that was too extensive for the clinic, she was sent to the Children's Orthopedic Hospital where a public school teacher worked to prevent hospitalized children from falling behind in their schoolwork. During the first few years, fewer than thirty students were schooled in the hospital, but over time several more teachers were assigned to the Orthopedic Hospital where they worked three half days per week serving an average daily attendance of twenty students. Eventually, the program came to be called the "Orthopedic School."⁵² The program cost about eleven hundred dollars a year to fund.⁵³

The final two departments within the school clinic included the Neurological and Psychology departments. "One of the problems confronting the school authorities today," wrote Dr. Brown in his first annual report, "is what to do with the nervous children." He hoped the work conducted within the Neurological Department would provide the answers. University of Washington psychologist Dr. Stevenson Smith, who directed the child study laboratory at the university and conducted examinations at the newly established juvenile court, oversaw the work of the Psychology Department. Smith helped introduce applied psychology within the schools, which laid the groundwork for the rise of the Child Study Department. The small number of cases in the Psychology Department between 1914 and 1916 (n = 17), however, suggests his work as department head was minimal.⁵⁴

Brown and Cooper designed the clinic rules and regulations in the spring of 1914. They agreed the clinic would remain open throughout the year to meet the requirements of "diagnosing and treating school children who are unable to secure proper medical attention otherwise." Neither Brown nor Cooper wanted children treated for free until the principals and nurses could make an accurate determination of whether the parents had the financial means [End Page 246] to pay for at least some of the service. When parents were too poor to pay anything, the clinic covered the cost through its operating budget. What funds the clinic did bring in through donations and partial payments (an average of $1,084 per year between the years 1916 and 1921) were deposited with the school board secretary. An emergency fund was then set up, so that a small sum of district moneys was deposited in the clinic's budget each month.⁵⁵

In terms of the actual school monies spent on the clinic, the total amount was small—typically less than 1 percent of the annual expenditures. While no specific budget figures for the medical department or clinic were mentioned in the school board meeting minutes, the annual reports do include expenses related to the "Promotion of Health." In 1915, for example, $11,603 was spent on salaries for Dr. Brown and his corps of nurses while a little more than $4,000 was spent on supplies, bringing the total to just over $15,620 out of more than $2.2 million in total expenditures for the school system. The following year salaries were increased to nearly fourteen thousand dollars, while expenses for supplies and other costs dropped to just over three thousand dollars.⁵⁶

The work of the clinic was extensive considering the small amount of funds devoted to its operation. In its first year, there were nearly eight thousand visits, which suggests somewhere between one-fifth and one-quarter of the student population, although records do not indicate how many were duplicated visits. The majority of procedures involved dental work followed by general examinations, ophthalmological, and then oto-laryngology procedures.⁵⁷ Of the 548 surgical operations conducted in the [End Page 247] clinic's first year, 84 percent (n = 461) involved the removal of tonsils and adenoids. Circumcisions (11 percent/n = 63) were the second most common surgical procedure performed in the clinic.⁵⁸ While there were significantly fewer visits to the clinic during its second year of operation (n = 4,707), the number of surgeries remained more or less the same at 541. Nearly 90 percent (n = 490) of these entailed the removal of adenoid and tonsils followed by circumcisions, which constituted 6 percent (n = 35) of clinic operations. The others included general surgery, eye squint, and hernia operations.⁵⁹

The clinic in Seattle reflected the change in attitudes toward tonsillectomy in American medicine. Focal infection theory—the belief that the teeth, tonsils, and other areas of the body (e.g., nose) represented "portals of infection" where pathogens entered and subsequently spread throughout the body—took root in Seattle as the school clinic became an institutional platform for its application.⁶⁰ Nearly one thousand children had their tonsils and adenoids removed in the first two years the clinic was open. Overall, approximately five thousand dental treatments were performed on children during the first two years which, according to Brown, put the medical department "about 3000 behind" the number of children estimated to be in need of dental work.⁶¹ The most common dental procedures were amalgam fillings (approximately 1/3 or 3,155) followed by temporary extractions (1,437) and then general treatments and examinations. Other work included cement and synthetic fillings, cleanings, permanent extractions, root fillings, acolite inlays, and nerve devitilizations.⁶²

Dr. Brown promoted surgical corrections as a meritocratic intervention—an opportunity for poor and physically defective children to have "an equal chance with the other children" through the judicious application of the rehabilitative and normalizing powers of medical technology. For Brown, the surgeries were also part of a larger nation building strategy similar to the vision advanced by [End Page 248] Ernest Hoag and Lewis Terman.⁶³ Not only were children's bodies being "put in as near the normal condition as scientific medicine and surgery" could make them, Brown once proclaimed, but also these same children could now be included "in the column of the state's greatest assets."⁶⁴ The operations were a form of human capital formation and investment—an ideology that carried powerful subthemes about the role of social institutions and the power of science to produce future servants of the state.

Medical Authority and the Politics of Jurisdiction

The establishment of a medical department and clinic in Seattle initiated a number of jurisdictional tensions and disputes.⁶⁵ Because the clinic positioned the schools as a medical provider for children, its operation led to a number of communications with local physicians and the health department about its policies and management. Specifically, the investment in clinical medicine established a kind of biomedical authority within the institutional structure of the school system. This authority was most visibly expressed through the claims asserted by Dr. Brown as he sought to expand the influence of the medical department over school operations. In most cases, though, Brown significantly overreached in his assertions about medical science curing educational problems and school administrators were not shy about informing him of his miscalculations.

While the clinic had the support of powerful Seattle leaders like Dr. Mark Matthews of the First Presbyterian Church, the most prominent and politically active minister in all the Pacific Northwest who led a congregation of some nine thousand members, it alarmed some members of the city's medical community who were concerned about the potential loss their practices could endure as the result of free treatment offered in the schools.⁶⁶ Unlike in other cities, where this concern rose to the level that it [End Page 249] actually deterred school clinic practices that extended beyond preventative modalities, the members of the Seattle medical community were, for the most part, willing to accept the idea.⁶⁷ "While there has been some criticism of this clinic on the part of the profession of the city," an editorial in Northwest Medicine read a few months after its opening, "it has in reality proven an advantage rather than a detriment to them by reason of the fact that many parents have thus been led to bring their children for needed medical or dental attention which otherwise would have been neglected."⁶⁸ The clinic came to be seen by some physicians as a means to further their professional goals through the socialization of poor and working class parents to their responsibilities instilling the health and hygienic norms of self-care in their children. Still, despite the editorialist's defense of the clinic, suspicion and unease about its operation remained within some segments of the medical community.

Two years after its opening, health commissioner Dr. James McBride and several physicians active in the King County Medical Society complained about the management of the clinic and the handling of several cases. The school board invited the physicians to a meeting where, after some deliberation, a committee of three doctors from the King County Medical Society agreed to meet with Cooper, Brown, and the board president to draft a new set of management rules clarifying certain ambiguities around the clinic's operation—no doubt insuring that only families who could not afford medical care be allowed to use the clinic.⁶⁹

In another instance, the Seattle Dental Society petitioned the school board to ask that students be excused from schools to visit their dentists. The board referred the matter to Cooper who recommended against it. There was a difference, Cooper suggested, between dentists in private practice versus the school dentists who met with students in the clinic. The latter, he wrote, was a "department of the school organization and entirely within school control" because students were diagnosed and recommended for treatment [End Page 250] by the school nurses and sent to the clinic "by or through" the school principals. It was thus a school component and "subject to checks for avoidance of abuses" by school officials. Cooper advised the school board against entering into an agreement with the dental society. In Cooper's view, opening the door to private physicians risked diminishing the discretionary authority of school principals to decide how student time should be spent during school hours.⁷⁰

The establishment of the school medical department and clinic supported the development of biomedical authority within the school system.⁷¹ As the director of this administrative regime, Dr. Brown was not only active in legitimizing and promoting medical work within the schools but also expanding its jurisdictional purview. In overseeing the clinic and other medical department programs, Brown enacted an entrepreneurial style of leadership that reflected his confidence in the diagnostic and corrective powers of medical science. However, the bolder and more assertive his claims became, the more Superintendent Cooper checked his advances.

The first area that Dr. Brown sought to expand the authority of medicine, and that of his department, was the problem of academic failure.⁷² It was here where Brown attempted to position the authority of applied medical science at center of the public schools. Soon after he took office, Brown proclaimed to his staff that "a child who does not keep up in his grade is a medical subject." Brown then went on to insist that the surgical removal of tonsils and adenoids, improvements in student hearing and vision, and dental adjustments all improved student learning and "efficiency" by as "high as sixty five per cent."⁷³ Perhaps because of the results of a survey from the year before that downplayed medical explanations of academic failure among teachers, such a pronouncement was a welcome relief to Cooper because Brown's claim, as [End Page 251] significant and unprecedented as it was in Seattle, went virtually unchallenged within the schools.

These were confident assertions from the new school medical inspector, and they signaled his intention to extend medical authority over teaching and learning. It did not take long, however, before Brown's explanations for poor student performance began to border on the bizarre. For instance, he cited "a lack of harmony of glandular secretion" as the reason why some children fall behind in their grade despite the encouragement of the teacher.⁷⁴ He even suggested that speech defects could be cured through x-ray treatments. These explanations fell outside the norm for medical diagnoses and treatments in schools and they did not go unnoticed by Cooper, who began to realize that he needed to monitor the work of his medical inspector more closely as it pertained to his claims about the power of medical science to improve student learning.

This realization was confirmed for the superintendent when Brown proposed that all students who were absent from school be visited by a nurse within the first day of their absence so that it could be determined whether it was a case of truancy or sickness. When the school board asked Cooper for his opinion of the plan, he immediately pointed to its "impracticability" by noting that over seven hundred students were absent from school each day. That meant each of the ten nurses on staff at the time would, on average, have to make seventy phone calls a day with each call lasting no more than "an average of 6 1/2 minutes." Cooper informed the board "that the principals and teachers exercising careful oversight and properly using the school machinery at their command can and do approximate closely the cause of absence, and cite the medical department to cases requiring consideration by it."⁷⁵

In the fall of 1918, Dr. Brown took his campaign to medicalize school failure to the extreme when he told the board that, based on his experience working with physically deficient men in the army, he thought a system was needed that insured all children had their physical deficiencies taken care of at an early age. In what at the [End Page 252] time was a far-fetched attempt to appropriate the city's schools for public health purposes, Brown then proposed that every child's advancement to the next grade be contingent upon an annual health test or physical examination.⁷⁶ The plan, had it been adopted, would have elevated medical authority, and the work of medical professionals, to the point where they determined how the mission of the public schools was defined, and ultimately, operationalized. For all intents and purposes, Dr. Brown was proposing a medical takeover of the institutional machinery of schooling—an ideological coup d'etat within the public schools that favored physical health over academic achievement.

When the board asked for Cooper's opinion of Brown's plan, he was clearly aware of what was at stake in the proposal and he responded accordingly. Cooper informed the board in no uncertain terms that, "many physical defects can be corrected during youth by proper and efficient educational means." He cited the importance of proper diagnosis, follow-up treatment, and instruction to address the problems Brown was concerned about. While Cooper agreed with Brown that physical defects in children should be addressed in a "far-reaching manner," he labeled Brown's plan to base school promotion on physical exams as unrealistic and inefficient. The idea of convincing students who had done well in school that their children needed to take the same courses again because they did not meet some "physical standard" was enough for Cooper to reject Brown's proposal. From "the standpoint of psychology, if not medicine," Cooper observed, it was better for children suffering from physical problems to be challenged mentally than to deprive them of "needed mental stimuli." Cooper went on to block Brown's proposal by convincing the board to increase the staff in the department of physical education so the schools could do a better job of meeting demands in this area.⁷⁷

In the winter of 1918, Brown wrote to Cooper that there was "nothing so important in connection with school work as the proper care of the children's teeth." He told Cooper that dental [End Page 253] "and other preventative work should have as much time and devotion as any one or more studies in connection with the curriculum." Brown cited the findings of medical research to try and persuade Cooper to go before the board and advocate for more focus on dental work in the schools. The board, Brown suggested to Cooper, might like to know that in the smaller city of Bridgeport, Connecticut, a staff of twenty-four attended to students' teeth. Brown was referring to the school started by Alfred Fones, who was the first to train dental hygienists for work in the public schools. Brown concluded that caring for health was one of those things "the State must do," and even though dental work "is not of great interest to school people, it is of great interest to medical men."⁷⁸ Cooper again resisted Dr. Brown's attempts to broaden the jurisdictional purview of his department by withholding his ideas from the board.

Brown, at one point, tried to reward the physicians who donated their time in the school clinic by having space in each issue of the "School Bulletin" allotted for the doctors to have "an opportunity to have a little legitimate publicity" and publish articles of interest about their work. Brown informed Cooper that the County Hospital had just begun publishing a monthly journal that was "considered legitimate medical advertising."⁷⁹ When the board asked Cooper for his opinion, he said the plan was "entirely commendable" but he felt the purpose of the "School Bulletin" was "best served by keeping its columns entirely free from personal publicity" so as not to risk arousing "resentment" among the local medical fraternity. Cooper concluded that while he "would like to recommend a means of relief for a condition which sometimes embarrasses the 'Medical Inspector,'" he did not think "the proposed plan wise." Again, the board deferred to Cooper's leadership.⁸⁰ [End Page 254]

The most heated disputes involving medical authority in the schools occurred around the mental evaluation and placement of low achieving children in the special schools. For during the same year the clinic was opened in the old administration building, the psychological clinic at the Cascade School was moved next door and renamed the Child Study Laboratory. It was operated under the direction Nellie Goodhue, who was one of a cadre of teachers across the nation who had traveled to Henry H. Goddard's summer institute at the Vineland Training School for the Feebleminded in New Jersey to be trained in the administration of intelligence tests.

In directing the Child Study Laboratory, Goodhue advanced scientific ideas about clinical psychology by integrating the new technology of mental testing into the diagnostic regimen of the child study laboratory. But because established protocol required that low achieving children receive a physiological as well as a psychological examination, Goodhue found herself in the position of having to negotiate responsibility for the evaluation of mental status with Dr. Brown, whom she believed lacked understanding about both the psychological dimensions of mental retardation and the methods of diagnosis.⁸¹ Not surprisingly, Brown and Goodhue clashed over the question of who possessed the scientific and professional authority to oversee the emergent diagnostic and pedagogical enterprise of special education in Seattle. What resulted was a disciplinary turf war between Goodhue and Brown over the respective work of the medical clinic and child study laboratory.

For several years, Brown and Goodhue engaged in a spirited exchange through official memoranda and correspondence to Superintendent Cooper about the respective role of physiological versus psychological diagnoses in the mental evaluation of children thought to be subnormal or, according to the dominant tripartite classification schema of the time, "morons, idiots or imbeciles." These exchanges were the result of a school board request that Brown and Cooper jointly determine which students were inherently uneducable and therefore in need of debarment from the schools.⁸² Together, they recommended that four boys and two girls [End Page 255] be debarred from the public schools. But beneath the surface, their professional orientations were influencing the rationale for their decisions, which reflected the growing fissure between the work of the medical department and the child study laboratory. For example, in one case, Goodhue recommended one boy for debarment while Brown suggested he remain in schools and prescribed thyroid treatment. In another case, Brown recommended a student be dismissed but Goodhue countered that he be retained since he had recently made progress in his work.⁸³

Brown eventually designed a plan to reorganize the examination of children who were following behind in their grades, which positioned the medical department and clinic at the center of the evaluation process. It called for principals to provide the names and addresses of children they thought needed an examination to a school nurse who then determined the extent to which environmental factors were influencing a child's performance in school. If the nurse thought the child should be sent to the clinic, then Brown stated, he would be referred "for such corrective measures as may be done by medical men." The medical department, he concluded, was "the only one sufficiently well equipped to make these home investigations which have a great bearing upon many of these children's conditions."⁸⁴

Brown's plan allotted more time for the medical department to make a diagnosis. According to Brown, the current plan rushed children through the clinic, which led to unreliable diagnoses. Only after the clinic examinations were concluded, Brown proposed, should the principal send the students to the special schools for whatever training was deemed necessary by Goodhue. At the end of the school year, Brown suggested the medical department would collect the names of all students who had failed in their grades from the principals so that they could be physically examined in the clinic during the summer. Brown was confident that once physical defects were corrected, many children would be able to attend the regular classes and relieve the special classes of swelling enrollments. [End Page 256] Goodhue, however, believed that Brown's proposal was not only inefficient but also incorrectly prioritized the physiological basis of mental retardation. "The question of retardation is primarily an educational question and not a medical one," she wrote to Cooper, "Hence the whole problem as to the causes, removal or remedying of the same, the proper placement of each child in the educational system and the best methods for the development of each should be under the direction of the educational department as represented by the Child Study Laboratory."⁸⁵

Brown and Goodhue's disputes were a conflict between two sources of disciplinary authority, the biomedical and the therapeutic. These differences emerged most significantly when Goodhue challenged Brown's assertion that the causation of student retardation was rooted in physiology and therefore a medical problem. "This attitude is not unusual with medical men," she told Cooper, because they are "unfamiliar with the psychological aspects of mental retardation" and are therefore "untrained in psychological methods of determining the same." Goodhue believed the premise behind physical examinations was defeated if all the emphasis was placed on that investigation because parents then erroneously assumed that as with other medical procedures the intellectual level of their child would be normalized. But in most of these cases, Goodhue observed, the medical exam obscured the real cause of the mental condition of these students and undermined the credibility of the teacher if students did not progress after their physical problems were remedied. "Experience has proven to us," Goodhue explained, "that physicians by virtue of their training are apt to make a diagnosis upon the physical condition only and parents as a rule are all too ready to accept this diagnosis" because they do not want to consider that the real cause of the difficulty is lack of mental development. While Goodhue agreed that physical causes were important to consider, she wanted Cooper to know that she would not agree to any plan that prioritized one cause over another before a final diagnosis was reached.⁸⁶ [End Page 257]

Several high profile cases involving the debarment of students, which pitted Brown's expert authority versus Goodhue's would eventually move Cooper to seek outside advice in mediating the interprofessional disputes—a move that in the end favored the rising disciplinary force of applied psychology in education. As Cooper and the board were soon to learn, national trends clearly reflected the emerging dominance of psychology and the technology of intelligence testing in this arena. But before a definitive decision was made concerning jurisdictional authority over mental evaluations, a decision from the Washington State Supreme Court abruptly closed the school clinic and ended Seattle's seven-year investment in applied medical science.

The Closing of the School Clinic

While Seattle gained notoriety for its labor activism in the aftermath of WWI, it was also not immune from the social and political conservatism that swept across the nation as evidenced by the powerful currents of opposition and resistance to public health authority that took root in the years following the war.⁸⁷ Beginning with a backlash against the public health restrictions enforced during the Spanish Influenza outbreak of 1918-19, a growing activism by parents, anti-vaccinationists (e.g., Christian Scientists, etc.), and anti-tax groups took aim at everything from the health curriculum to school medical inspections.⁸⁸ It was thus within a local cultural and political climate oriented toward a less costly, less interventionist and ultimately less socialistic (i.e., "red scare") form of public administration that the school clinic was ordered closed in January 1921.

Less than seven years after it was established, the clinic came under attack by a group of Seattle residents, led by prominent attorney Oliver McGilvra, who were concerned about their tax money supporting medical treatment in the schools. McGilvra sought an injunction in the King County Superior Court to restrain the schools from using public funds to sponsor medical treatment. Initially, after hearing the arguments in court Judge Calvin S. Hall [End Page 258] dismissed their claims. The plaintiffs, however, unwilling to accept the legal reasoning behind Hall's decision, appealed their case to the state's highest court. Then in January 1921, the Washington State Supreme Court, after hearing the case of McGilvra et al. v. Seattle School District, overturned Hall's decision and ruled that a school district could not maintain a clinic, which the court reasoned was more like a "'hospital,'" in one of its buildings. The court ruled that the schools could not operate a clinic "equipped with appliances for rendering of medical, surgical, and dental services in the treatment of the physical ailments of pupils at the expense of the district in substantial excess" of that needed to provide treatment and services to the students in the parental schools, which were residential institutions for troubled and wayward youth. The parental schools were an exception, the court ruled, because students had been removed from "the care and custody of their parents or guardians," and were thus wards of the state.⁸⁹

In its decision, the court reviewed the history of the clinic and the school medical department. The powers of municipal corporations and the school statutes, including the 1919 amendment, which repealed compulsory vaccination, were each reviewed in the court's ruling. Based on these reviews, the court ruled that providing medical, surgical, and dental services in the public schools was "foreign to the powers to be exercised by a school district or its officers, that such power cannot be held to exist in the absence of express legislative language so providing." In reviewing the twenty-two enumerated powers in the school statues, the justices found nothing pertaining to medical practice in the schools beyond sanitary inspection of school buildings and the inspection of students for evidence of contagious disease. The judgment of the King County Superior Court Judge was therefore overruled on appeal, and the school medical clinic in Seattle was declared unconstitutional by the state's highest judicial body.⁹⁰

In response to the court's ruling, the Seattle school board then agreed to support the drafting of a new bill to go before the legislature that would recognize the authority of school boards to manage [End Page 259] school clinics. The members decided the medical department should continue although without an expenditure of school funds in the areas outlined by the court's decision.⁹¹ As it turned out, however, the bill prepared for the legislature did not pass due to a filibuster in the senate. An editorial in Northwest Medicine noted how the bill "succumbed to a combined attack of the Christian Scientists and a group which sought to lower taxes" by minimizing governmental influence in child health.⁹²

Three weeks after the state's high court decided against the Seattle public schools in the McGilvra suit, the school board adopted a new administrative plan for the medical department. It maintained Brown's position and his staff of school nurses whose duties were relegated to reporting instances of contagious or infectious disease (or suspicions of) including their report of home conditions to both the medical inspector and the city health department. Management of the school clinic, however, was turned over to the control of the health department. Brown's role was reduced to the mere supervision of clinic records.⁹³ Eventually, representatives from the Seattle chapter of the American Red Cross—and its child health program, the Junior Red Cross—signed on to coordinate the work of the clinic.⁹⁴

One year after the Red Cross started work in the schools, $6,100 had been collected through membership fees, and proceeds from fundraising activities. Because annual expenses were about double this figure, the Red Cross stepped in to make up the difference. The members of the Junior Red Cross Committee, which was chaired by an assistant school superintendent, agreed that the clinic was "well administered" and was "serving the schools, on the whole, very satisfactorily."⁹⁵ While legal authority to administer medical services no longer rested with the schools, the work [End Page 260] initially continued through the partnership with the Junior Red Cross, although this arrangement turned out to be short-lived.

In addition to the closing of the clinic, other changes diminished the scope of medical authority in the Seattle Public Schools. As Bryce Nelson has described in his history of the Seattle schools, "fiscally and ideologically conservative groups" whose primary goal was "to cut taxes, both by dismantling the schools' social welfare programs and by offering a reduced curriculum" had, much to Cooper's dismay, gained favor with the school board after the 1920 election.⁹⁶ The Tax Reduction Council (TRC), a collection of some fifty civic groups, took particular interest in the operation of the schools in their quest to reduce governmental expenditures. By the end of July 1921, the board, in following the recommendations outlined in the TRC's report on the medical department, eliminated the positions of assistant medical inspector and nurse supervisor, cut Brown's salary, and trimmed the nursing staff from twenty-four to ten. The TRC report concluded that so many nurses in the schools were not needed because of the healthy climate and the "general good health" of the students.⁹⁷

In protest of the board's action, Dr. Brown resigned from his position. The board's budget cuts also eventually pushed Cooper into retirement in 1922 after almost twenty years as the city's educational leader. While Brown would eventually come back to work for the schools on a part-time basis, seven years after the school medical department and clinic were opened in Seattle what was once considered a "radical proposition" had all but disappeared from the institutional landscape of the city. The health commissioner at the time, H. M. Read, tried to persuade the mayor and city council to open a new school clinic "under the direction and supervision" of his department, but it never transpired.⁹⁸ [End Page 261] The Department of Health and Sanitation continued to run neighborhood clinics for infants and young children as part of their Child Welfare Division but to this day—nearly a century later—the court's decision remains in effect in Washington State.

The Case of the Seattle School Clinic

The Seattle school clinic represents a unique case in the history of public school health policy and practice in the United States. During a time when government responsibility for child health was being enacted through state and city health departments, in Seattle that responsibility was assumed in large part by the public school system. Several local level factors contributed to this development, including a history of jurisdictional antagonisms between the public school and public health administrations, strong child health advocacy and leadership from within the schools, a necessary degree of political backing from the local medical profession, and tacit support from parents.⁹⁹

Providing medical treatment in the Seattle schools was an extension of the larger progressive vision of school superintendent Frank Cooper and members of the school board. Cooper saw the schools as the state's primary child welfare agency and so building a comprehensive child service program was wholly consistent with his vision and beliefs as an educational administrator. Cooper's willingness to support such a "radical" undertaking grew out of his frustration with negotiating school health practices with the city health department. Rather than continue with what he believed was an inefficient and moderately effective approach to addressing the health needs of students, Cooper and the members of the board saw an opportunity to work within the spirit of state legislation and build an innovative and comprehensive medical program within the institutional structure of the school system.

The initial hiring and subsequent crusading approach of Dr. Ira Brown in leading the school medical department generated needed [End Page 262] support within the local medical community, which resulted in many physicians and dentists donating their time to the clinic. While this same administrative style would eventually lead Brown into a number of quarrels with Cooper and other school administrators who found themselves having to constantly check his efforts to expand his jurisdictional reach, it did curry favor with many local physicians. This support set Seattle apart from other cities where staunch resistance to what was considered "socialized" medicine in the public schools was significant. In Seattle, these concerns were neither loud nor forceful enough to generate real opposition from the city's medical or dental societies. It was thus the unique combination of a social welfare minded school superintendent and school board, a crusader-like school medical inspector, and a relatively supportive medical and dental community that contributed to the local conditions required for an innovation like the school clinic to emerge.

Explaining how the clinic came into existence in Seattle, however, is quite different from assessing and analyzing its historical significance. The clinic stands as a provocative example of how medical science was harnessed within a large urban school system as part of a regulatory intervention into the lives and bodies of poor children at the beginning of the twentieth century. The case of the Seattle school clinic therefore broadens previous conceptions about the nature of state-school-child relations at the beginning of the twentieth century to include not just corporal regulation as exemplified by school medical inspection and vaccination practices, but an even more encompassing "panoptic disciplining of the person" involving interventionist and corrective surgical technologies.¹⁰⁰ Through disciplinary practices that ranged from circumcision to tooth removal, children's bodies were regulated, normalized, and made useful for the modern social and industrial order.

Informed by the focal theory of infection and fueled by the cultural value bestowed upon surgical therapies as "the cutting edge of medical practice and the symbol of the successes of modern scientific medicine," children's bodies in Seattle became inextricably linked to the construction and legitimation of state authority and [End Page 263] control.¹⁰¹ Through the documentation of each child's visit, medical biographies were constructed—narratives detailing a timeline of interventions, adjustments, and "corrections"—that constituted one means through which children were transformed into medical subjects—or individual cases—as evidenced by the designation of labels (e.g., "mouth breather") and the corresponding documentation of treatment modalities. The clinic functioned—as some of Dr. Brown's far-reaching jurisdictional claims attest—as a demonstration site not only for the near total medicalization of education where everything from grade promotions to the evaluation of intelligence were framed as medical problems and procedures requiring the expert authority of trained physicians, but also the very medicalization of childhood itself.

Ultimately though, the location of clinical medicine within the institutional structure of a school system proved unwieldy as evidenced by the tenacious nature of jurisdictional tensions around the relative authority of medicine vis a vis the competing discourses of education and psychology. While Dr. Brown fought to keep clinic services—and therefore medical authority—relevant within the increasingly specialized and efficiency-driven administrative organization of the school system, the reformist momentum that had launched the medical department and clinic in 1914 had run out of steam as more conservative currents came to dominate the political milieu of the city at the end of WWI. Brown and clinic proponents eventually found themselves fighting a losing battle to maintain legitimacy both inside the school system as medical proposals were met with increasingly less support and outside it as the legal case challenging the expenditure of tax dollars for clinic services moved through the courts.

While the clinic was open for less than seven years, its establishment provided an opportunity for allopathic physicians to compete for the state-sponsored socialization of the child alongside educators, psychologists, and other Progressive Era reformers. The clinic also introduced many Seattle parents to the concept of medical supervision for their children. Much like the more common infant clinics that were opened during the same period by public health [End Page 264] departments in cities across the United States, the school clinic in Seattle was part of a larger health surveillance project that no doubt played a significant role "in generating demand for child health services."¹⁰² As Sydney Halpern has observed, "the example of the clinics . . . rendered child health services attractive . . . to lower-class women," many of who would go on to contribute to the explosive growth in fee for service pediatrics during the 1920s as a result of their prior experiences in public clinics.¹⁰³ The Seattle school clinic's most significant legacy, then, may have been as an institutional site for medical enculturation not just for children but also parents—particularly mothers.

The case of the Seattle School clinic is one that reflected the egalitarian—if not idealistic—spirit of progressive period reformers committed to insuring all children regardless of circumstance would be cared and provided for by the state. But in trying to deliver on that ideal, reformers initiated an institutional platform where the disciplinary knowledge and hence, technological power, of early twentieth-century medicine was inscribed on the bodies of Seattle's school children through procedures like tonsillectomies and adenoidectomies that have largely been discarded as unnecessary, if not harmful, surgical interventions. The case therefore raises some provocative questions about whether the clinic should be remembered more as a bold undertaking to assist and empower the less fortunate, a muscle flexing opportunity for select public health and allopathic physicians in partnership with school administrators, or merely an institutional outlier—or instance of overreach on behalf of professional reformers—during a time of increasing state expansion and intervention into private life.

Funding

None. [End Page 265]