length of line, width of margin, the spacing between lines, it is of fundamental importance that something be done to procure proper textbooks and thus remove the cause of the eye deformity. But for this, the advice of the technical expert is needed. It is not a matter of untrained common-sense-any more than the question of the stress and strain in a building is a matter of untrained common-sense. If the present modes of sitting in the public schools are responsible to any degree for the crooked backs that we sometimes see in children, we should know it, and then change the habits of sitting. This, again, is a matter for the trained orthopedic surgeon. It is not a question of psychology or pedagogy—at least not until after the diagnosis and treatment have been decided upon.

How much home study shall children of a particular age be allowed or required to do? This, also, is not a question of psychology or pedagogy; it is a technical question for the physician. What lessons shall children study at home? This is a question of pedagogy and school administration; but the number of hours for home study, or the time when a child may do his best work—these are biological problems. These are problems that are capable of more or less exact determination.

Such facts as these lead us to believe that there should be, co-ordinated with the other activities of boards of education, a department composed of men who are technical experts on the various questions of health in relation to school life.

The school will make no contribution of permanent value to physical development till it seriously attacks this series of problems with the implements of science.

Is it not obvious: (1) That the detection of contagious disease in the schools, involving daily visits and the power of the law to act, belongs in the nature of the case to the board of health? And further (2) that the care of ventilation, recesses, lighting, seating, exercise, hours of home study, is the business of the board of education?

The general principle involved is that where the object is the protection of the community the board of health is responsible, and where steps necessary to the proper education of the individual are concerned, the Board of Education is responsible. If these propositions are true they leave but one division of the topic open to discussion-namely:

Who should conduct the examination of school children for defects liable to interfere with proper growth and education, such as adenoids, defective eyesight, and hearing?

Whoever does this work, it is further obvious that such records must follow the child from grade to grade and also from school to school; that they must be considered by the class teacher and, most important of all, that each case must be consistently followed up so that in so far as is possible such disabilities may be removed. That is, they are an important part of the school records and must be so made and administered as to be available to the school authorities; so

that the Board of Education must at least be one of the active parties in such a medical examination.

Further than this there is as yet no general agreement. But as an individual it seems to me that this work should be done by the board of education because: (1) it is done for educational purposes; (2) it must be constantly and intimately connected with school records and activities; (3) it does not need to be connected with the other work of the board of health; (4) it differs in kind from the inspection done for the detection of contagious diseases.

III. MEDICAL INSPECTION IN PUBLIC SCHOOLS AS CONTRIBUTING TO HEALTH AND EFFICIENCY.

THOMAS F. HARRINGTON, M.D., DIRECTOR OF DEPARTMENT OF HYGIENE'

PUBLIC SCHOOLS, BOSTON, MASS.

It is now more than sixteen years since Boston started the agitation for the medical inspection of schools in order to harmonize the two great duties which the state owes to its children—namely, education and the preservation of health. Prior to the introduction of medical inspection into the public schools of Boston (1894) every state, having upon its statute books a compulsory educational law, was in the position of compelling by law the children of its province to go directly into the midst of dangers to their health. Unfortunately some states are yet in that same indefensible position. That these dangers are real and a menace to the individual and to the community no one denies today; that they can be almost entirely avoided or removed is beyond dispute. How far medical inspection of school children may contribute to health and efficiency by pointing out the prevalence, the causes, and the means of the removal of those factors tending toward mental stagnation and physical retrogression is the problem which I have been asked to present to this association.

At the beginning of the nineteenth century Peter Frank, of Austria, issued his System of Complete Medical Police, setting forth the duties of physicians to schools. In 1832 the number of lessons was diminished in Sweden for reasons of health, and in the same year France issued regulations concerning medical inspection in schools. Many of the scientific congresses of Europe in the third quarter of the last century discussed the need of medical inspection of schools. School physicians were appointed subsequently in different cities of Sweden, Austria-Hungary, France, Egypt, Belgium, and Holland, as well as in Japan, Chili, Argentina, Switzerland, Russia, Roumania, Servia, Germany, England, and the United States.

The progress was not without opposition. First came the distrust on the part of the teachers that such additional authority established in public schools would give rise to friction, confusion, and over-emphasis of the sanitary and the hygienic factors in school life. Then the argument of the municipal authorities that the financial expenditure involved was not justified by the existing state of health of the school children; the attitude of the medical

profession that the private practice of physicians might be injured thru the measures employed by school inspectors; and lastly the anxiety of parents lest meddlesome interference might destroy the rights and the authority of the home. Then, too, the impatient pressing forward by zealous advocates and the jealous warding off by honest conservatives add much to the confusion and disturbance incidental to the introduction of all new public measures, as well as in changing fixed traditions. Gradually, however, these fears. subsided and the opposition passed into mingled feelings of indifference, incredulity, or ridicule.

Little was then known of the great possibilities in preventive medicine. Tuberculosis was an inherited disease; spinal curvature was due to a "fall;" deaf children were heedless or disobedient; measles and scarlet fever were diseases which every child should have; diphtheria was "quinsy," unless it "turned into croup" from which "no one ever recovered." The child suffering from defective vision was the dunce of the schoolroom until, growing too large for the grade, or driven from school by ridicule and shame, he found peace in the truant school or in the shop and factory where his defects became a menace to limb and life. The many statutes on law books the world over, having for their object the prevention and regulation of child-labor, the enforcement of compulsory education, and the disposition of juvenile truancy and misdemeanors, all find their greatest field of application among children whose discontent at school led to the violation of these laws. Necessity for the wageearning assistance has been, and is, no doubt, often the cause for many parents' sacrifice of their children's education; nevertheless if the voice of those matured today who were forced to leave school at an early age could be recorded, many thousands would, I feel sure, attribute the former rather than the latter as the real cause of their limited schooling.

The idea that medical science had any relationship to the problems of public school life was not entertained prior to the great awakening in preventive medicine during the epoch 1880-90. During this remarkable period Robert Koch discovered the bacillus of tuberculosis; Eberth, the organism of typhoid fever; Klebs and Loeffler, the bacillus of diphtheria; Lavaran, that malaria was transmitted by mosquitoes; Fehleisen, the streptococcus of erysipelas; Kitasarto, the bacillus of tetanus-all discoveries that transferred tuberculosis from the class of diseases supposed to be inherited, and placed it in the category of diseases preventable and curable; that proved diphtheria to be a specific, communicable disease, and not a filth disease; that suggested that skin affections may be contagious, that lockjaw may be epidemic; and that night air is as healthful and as free from disease as day air.

In such a renaissance it was but natural that attention should center upon those affections which for ages had been known to be communicable and most prevalent at the earlier periods of childhood. The legal authority to carry out such an investigation was the board of health; the most likely place to find the facts was in the aggregation of children in school. Thus originated

the first scientific basis for medical inspection of schools. This was at Boston, Massachusetts, in 1892.

The relationship of public-school life to medical science since this introduction of medical inspection is one of interesting evolution. First came the movement to prevent the schools from becoming centers of infectious or contagious diseases; then followed the attention to such hygienic problems as schoolroom environment, proper seating of the children, the lighting, heating, and ventilation of school buildings; next came the examination of each school child in order to ascertain his physical asset for the life mapped out for him and the removal of remediable causes of handicap or a modification in the school program and extra school life of the child in order to avoid possible shipwreck. This was followed by the scientific study of the development of great groups of children in order to obtain accurate data of their physical and mental growth, so that the factors of heredity, age, sex, race, environment, and nutrition might be properly estimated in their bearing on pedagogical progression and racial deterioration. The later stage in this evolutionary process has to do with all those measures tending to the promotion of the physical health and the corresponding growth of the individual child and is embraced in the term "school hygiene." These stages are best considered separately.

I. BOARD OF HEALTH INSPECTION OF SCHOOLS

This was a method inaugurated in this country at Boston, Massachusetts, in 1894, and has been followed more or less closely by the cities in this country and abroad. Briefly, the plan adopted has been as follows: The city is divided into districts and a physician appointed by the board of health has been assigned to each district. These physicians are both agents of the board of health and inspectors of schools. They are all engaged in private practice. They are required to visit each school in their respective districts daily, and to examine all pupils referred to them by the teacher and who in the judgment of the teacher are ill. If any pupil is found to be suffering from any contagious disease, or is otherwise too ill to remain in school, the inspector advises the teacher to send him home for temporary observation by his parents or family physician. The inspector does not prescribe for the child, nor advise or criticize anything beyond that which pertains strictly to the isolation of the child, and he carefully avoids any word or act which might be construed as an infringement upon the rights of the family or the attending physician. He is not required to give a diagnosis even. He is concerned more in the protection of the other children at school than in the treatment of the ill child. In his capacity as agent of the board of health, the inspector receives daily all notifications of communicable diseases reported by physicians and he visits the homes of those so reported residing within his district for the purpose of examining the places and plans of isolation adopted by the family. He reports to the board of health his approval or disapproval of such plans, and he visits the patient as often as may be necessary to inform himself of the con

tinuation of the isolation adopted. No case will be discharged from this quarantine until the inspector certifies that recovery is complete and that all danger of contagion has passed. This plan has been modified somewhat by local conditions, and its administration has been effected by the school authority in a few localities.

Medical inspection under board of health supervision prevails at Buffalo, N.Y.; Camden, N. J.; Chicago, Ill.; Des Moines (west side), Ia.; Detroit, Mich.; Elgin, Ill.; Evansville, Ind.; Hartford, Conn.; Kansas City, Mo.; Milwaukee, Wis.; Minneapolis, Minn.; Montclair, N. J.; Newark, N. J.; New Haven, Conn.; New York, N. Y.; Ogden, Utah; Philadelphia, Pa.; Plainfield, N. J.; Providence, R. I.; Salt Lake City, Utah; Syracuse, N. Y.; Washington, D. C.; Waterbury, Conn.; Indianapolis, Ind.; Baltimore, Md.; Cincinnati, Ohio; Mount Holly, N. J.; Cleveland, Ohio; New Orleans, La., as well as in twenty-three cities and forty-seven towns in Massachusetts where medical inspection of schools is a state law. The board of education appoints the inspectors at Ann Arbor, Mich., at Paterson, Atlantic City, Passaic, Englewood, Orange, and Asbury Park, N. J.; as well as in ten cities in Massachusetts. At Grand Rapids, Mich., and at Jersey City, N. J., the medical inspection is done by nurses appointed by the school authorities. A detailed account of the work as carried on in the different cities of this country has been furnished to me by the several superintendents of schools. I desire to thank these officials for their valuable aid and co-operation in compiling these data.

In many cities the system is in an experimental stage; in a few it has been abandoned on account of municipal financial curtailment; in some places its workings have won commendation; while in other places it has been severely criticized even while its adoption has been urged. These criticisms are against the method and means of administration, not against medical inspection per se, and have given rise to much confusion. An important fact in the method of medical inspection under the board of health is that the detection of cases of contagious diseases among the children is done by the teacher and not by the medical inspector; if the latter confirms the suspicion of the teacher, the child is excluded from school; if the inspector does not agree with the conclusions of the teacher, the child returns to its classroom. Non-agreement is very frequent, and it requires exceptional perseverance for a teacher to hazard the chagrin of a second mistake, yet disastrous consequences might result from such hesitation. In Boston during the year 1905, 21,111 children were referred to the medical inspectors; 9,241 were found free from any disease. In London between 20 and 30 per cent. of the cases submitted by the teachers were not suffering in any way. The greatest criticism against this system of inspection is that it lacks uniformity; that it excludes pupils and does not provide any means of "follow up," nor any guarantee that the child will receive medical care; that the duties of the inspector as an agent of the Board of Health brings him in contact with much contagion in the homes;