supervision of school children there is a difference of opinion. . . . The present tendency seems to be in the direction of a division of the work, leaving to boards of health the control of all matters pertaining to infectious and contagious diseases, and assigning the boards of education those health problems which more vitally concern the educator."

Representative results: Percentages of number examined.

SOBEL, Jacob. The home as a factor in the medical inspection of school children. New York medical journal, 91: 1157-65, June 4, 1910. illus. tables.

Describes the conditions among the poor of New York City.

"The medical inspection at the school is but a mere beginning; . . . the solution of accomplishment lies in the home. . . . There is hardly a single defect. . . found by us in school work, which is not materially influenced by home conditions of the tenement. . . . During the year of 1909, 231,081 children were examined physically, and of these 173,311 were tested for vision, the remainder being in lower grades where vision tests were unreliable and impracticable. Of these 173,311, 17.6 per cent were found defective, 30,408. From my personal observation and examination of several thousand cases I should place the percentage of defective vision as about 30."

Adenoids, malnutrition teeth, etc. Dr. Sobel, in his statements regarding housing conditions and children's growth and welfare, presents Glasgow, Scotland, tables. For which subject, if further reading is desired, see:

Crowley, Ralph H. The physical conditions of school children. School government chronicle, 77: 78-81, January 12, 1907. supplement. tables.

London county council. Report of the Medical inspector, year ended March 31, 1905. School government chronicle, 75: 171-72, February 17, 1906.

Mackenzie, W. Leslie and Foster, A. Report . . . on a collection of statistics as to the physical condition of children attending the public schools of the school board for Glasgow, with relative tables and diagrams. School government chronicle, 78: 145-46, August 17, 1907.

Returns were made for 36,883 boys and 35,974 girls. The mentally defective have been omitted. "The grouping followed is confirmed by the distribution of one, two, and three-roomed houses. . . . "These figures show that the one-roomed child, whether boy or girl, is always on the average distinctly smaller nd lighter than the two-roomed; and the two-roomed than the three-roomed; and the three-roomed than the four-roomed The numbers examined are so larve and the results are so uniform... It cannot be an accident that boys from two-roomed houses should be 11.7 lb. lighter on an average than boys from four-roomed houses and 4.7 inches smaller. Neither is it an accident that girls from one-roomed houses are, on the average, 14 lb. lighter and 5.3 inches shorter than the girls from four-roomed houses.

"This is the most extensive investigation ever undertaken in Britain as to the heights and weights of school children in primary and higher grade schools. The tables and diagrams may legitimately be held to be a provisional standard for future investigations."

STEWART, James. Medical inspection of school children. In National conference of charities and correction. Proceedings, 1910. Fort Wayne, Ind., Press of the Archer printing co. p. 194-200.

"I. As it affects the educational progress of the child. II. As it affects the home and the family. III. As it affects society in general. IV. As it affects the family physician in his practice. V. As to conduct of medical inspection-whether by boards of education or by boards of health." STILES, Charles Wardell. [Hookworm disease among Southern factory and school children] In his Hookworm disease among cotton-mill operatives. Washington, Government printing office, 1912. p. 12; 16-20; 33; 36–37 (the "Typical cotton-mill child") 37-38. tables. statistics. (U. S. [Department of Commerce and Labor] Report on condition of woman and child wage-earners in the United States. vol. XVII)

The various mills and factories, schools, and other institutions inspected, in these States, numbered

177.

"It appears that about 1 in every 4 children under 16, about 1 in every 5 hands from 16 to 20 ... ... came within the suspect class. During the year 1911 microscopic examination of 37.267 children of school age (6 to 18 years) has been made in 87 counties in all by the State boards of health of Alabama, Arkansas, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and Virginia. The percentage of infection by counties ranges from 2.5" to 90.2" (footnote, p. 18).

STILES, Charles Wardell. Some recent investigations into the prevalence of hookworm disease among children. In Child conference for research and welfare, 1910. Proceedings. New York City, G. E. Stechert & co. [1910] 2: 211-15. Observations made in 5 different States, on 2,271 white children.

First series. Of 70 boys and 91 girls, the microscopical examination revealed hookworm infection in 133; before the examinations were made, according to the judgment of local physicians, the apparent age of these children, 29 boys and 28 girls were estimated as underdeveloped from one to eight years each, as indicated by physical development. After the examinations were made, it was found that 49 of these 57 children were infected. Of these 49 infected, underdeveloped children (29 boys and 20 girls) the figures were as follows:

All these children live on farms. Of the total, 161 farm children, 94 are living on farms which have no toilet of any kind; the remaining 67, on farms having the ordinary disease-spreading surface toilet, open at the back. For about 200 different localities, in 6 States, the same conditions are found-records of about 4,645 farm houses show 55.2 per cent having no toilet of any kind.

Second series. Observations made in 4 States, covering 2,110 children in 15 schools and orphanages located in 12 cities, towns, and villages. Of these children, 822 were classed as suspects.

Supplementing the medical inspection come the open-air schools, the better preparation of food, and the playgrounds. "In addition to all the other points thus far mentioned at this conference, the question of the sanitary arrangements in the backyards to the homes in which our children live is a factor second to none that has been discussed, and in those'sanitary arrangements we often find the explanation of much of the sickness and death among our rural, village, and suburban children, the explanation of the underdevelopment of many a child, and the backwardness of many a pupil in our schools."

STOREY, Thomas A. Medical inspection in schools from the standpoint of the educator. Medical review of reviews, 18: 466-72, July 1912.

Reprinted.

Also in American academy of medicine. Bulletin, 13: 432-41, December 1912; and in American academy of medicine. Conservation of school children.

The value of medical inspection when under control of educational authority. "If it is to take a place in the school curriculum it should be under the same responsible control that covers the other members of that curriculum. . . . If medical inspection must follow up cases the 'follow up' must be made through the regular school channels and in the regular way. If medical inspection must have an educational influence upon the hygienic habits of the school child, then its plan of instruction should be pedagogical and under the supervision of the school authorities. It should be a part of the very organization of the school itself.

"From the point of view of the educator, medical inspection carried out in school by a department of the school has a far greater probability of success and efficiency than a system applied in the schools by a department outside the school and without responsibility to a control from the school."

STRAW, Zatae L. Medical inspection of schools. In New Hampshire medical society. Transactions, 1911. Penacook, N. H., W. B. Ranney, printer, 1911. p. 154-66.

A general résumé.

Qualifications demanded in the work of medical inspectors: "1. Skill in diagnosis. . . 2. In no other field of practice is so much general pathological knowledge required. . 3. The medical inspector must have a broad and practical knowledge of hygiene.

"He must have special and technical knowledge with regard to heating and lighting and ventilation-the proper construction of methods of drainage, of disinfectants, of the powers of endurance in the child length of time of safe confinement for it in the schoolroom."

TOWNSEND, John F. Medical inspection of schools and school children. South Carolina medical association. Journal, 7: 334-39, September 1911.

Also in Pediatrics, 23: 410-18, July 1911. Title: Medical inspection of school children. "Medical inspection, to be effective, must embrace in its scope the following:

"First. The relation of the school child to its fellow children as to the communicable diseases, ringworm, pediculosis and various forms of skin diseases.

"Second. The relation of the school child to the community in which it lives, as to the infectious diseases, measles, scarlet fever and diphtheria.

"Third. The relation of the educating of a child to its physical life as to the effect of the school life upon its health, illustrated by the physical wrecks from overstudy, cases of great mental development with physical deterioration, the effects of poor school hygiene on the child's physique.

First. In the promotion of
Third. In the preservation

"Fourth. The school child with reference to its ability to gain an education, or the influence of physical defects upon the educational side of the child's school life. . . . The discovery of these defects and their removal consequently is of supreme importance to the child. "The results of medical inspection have been extremely satisfactory. efficiency in the schools. Second. In the protection of the community. of the lives of the children, and promotion of a healthy spirit among them." United States. Bureau of labor. Retardation, repeating, and elimination. In its Conditions under which children leave school to go to work. Washington, Government printing office, 1910. p. 245-303. tables. (Its Report on condition of woman and child wage-earners in the United States. vol. VII)

Statistical study of six cities: Pawtucket and Woonsocket, R. I.; Columbus Ga.; Columbia, S. C.; Plymouth and Hazleton, Pa.

Number and per cent of boys and girls repeating for specified leading causes (in part, here given).

"Poor health and physical defects [account] for 13.7 per cent. This does not tell the whole story, for in many cases the irregular attendance was probably due to or accompanied by poor health, but it is a sufficiently impressive total as it is."

It is for such children a medical inspector is of vital value.

VAN DERSLICE, James Warren. Medical inspection of public schools. Detroit medical journal, 10: 136-44, April 15, 1910.

Conclusion:

"The medical inspection of public schools is of vast importance to the welfare of the race, and of great economic value if it be properly executed. The controlling body should be a body of physicians vested with the police powers of the State, and to be the final arbiters in all matters of hygiene and sanitation regarding the school child. The medical inspectors should be competent medical men having special training for this work. They should be medical inspection specialists. School nurses should... follow up the cases and aid in carrying out of the work. . . . All notices regarding the physical condition of the child should refer the child to the family physician."

Dr. Van Derslice considers the prominence given to free dispensaries in these notices, to be ill advised. But since the very poor can be reached in this way only, they should be first considered, and not the income of "family physicians."

VAN DERSLICE, James Warren. The status of the school child. Pediatrics, 21: 653-61, December 1909. tables.

Data gathered in 26 cities, from 904 schools.

A statistical study of the school child: Retardation, grades and overage, causes of deficiency, defects according to ages, defects by grades.

"It may be taken as an axiom that the nearer a child is to the normal age for grade, the greater the probability of the pupil's continuance. Thus . . . an overaged child in the fourth grade has 1 chance in 25 of continuing through the eighth grade, while a child of normal age has 1 chance in 3. . . . The number of pupils compelled to leave school because of general ill-health was but 1 in 200 While there

is a loss of 50 per cent between the eighth grade and the high school, the artificial separation of the two is largely accountable for the loss. . . .

"Physical examinations were made of these pupils ...

"These examinations were made by the school medical inspectors and under the rules laid down by the various school boards... The incidence of the commoner infections-scarlet fever, diphtheria, measles-was noted in 6,764 cases. In these it was found that in 78 per cent of the cases occurring as initial cases in the family it affected the school child."

WELCH, J. H. The importance of medical inspection of schools and its present status. Kentucky medical journal, 9: 749-52, October 1, 1911.

General statistical résumé.

"Experience of medical examiners thus far has shown that 7 out of every 10 children are in need of physical examination; 3 out of 10 show defective vision; 2 out of 10 are defective in breathing; and 7 out of 10 have defective teeth.

"What is the penalty for physical defects? Retardation, discouragement, dropping out of school, and annual waste estimated at $12,000,000. If only 50 per cent of these evils could be eliminated by medical inspection, would it not pay? I believe that all school children, teachers, janitors, school buildings, grounds, in all school districts, public, parochial, private, rural and urban should be subjected to examination by experts at least once a year."

WHEELER, R. M. A plea for medical inspection of schools. Journal of the Minnesota State medical association and The Northwestern lancet, 29: 505-509, December 1, 1909.

"It is appalling to note the incompetency of most teachers to assist in this campaign for the betterment of school hygiene. . .

"The plan of a system of medical inspection should.. include the proper education of teachers along the lines of physiology and hygiene. A State commission of medical inspectors should . . . lay down certain simple rules of school hygiene, which should be mastered by every teacher and inculcated into the mind of every pupil. Such lessons might include instruction in bodily and mental cleanliness, personal habits, injurious exercises, proper time of eating and studying, effects of narcotics and alcohol, simple methods of preventing the spread of disease, etc."

Scheme of inspection as outlined to be made by physician, "appointed according to State laws," upon child's first enrollment at school and afterwards; upon the first opening days to be in attendance at school and make a report as to each child's condition, record to be kept at the school. The physician to make, or confirm, all vaccinations; to submit written report to the educational authorities "as to what he considered the existing evils of the schoolroom and building, and make suggestions as to how this part of school sanitation may be improved. Poor lighting, bad ventilation, defective plumbing, dangerous stairways, insufficient heating might all be considered matters which would come within his sphere of supervision."

WILE, Ira S. School lunches and medical inspection. Medical review of reviews, 18:593-98, September 1912. tables.

Also in Journal of home economics, 4:345-52, October 1912.

"Twenty-five per cent of our public school children fail to attend school 75 per cent of the time. . . . Preventable disease is a large factor in this . . . and malnutrition plays no small part in preparing soil for such preventable diseases. . . . The total absence of the term 'malnutrition' in many statistical tables shows that this phase of the problem is entirely omitted in a consideration of medical inspection...

"The relation between school lunches and medical inspection is patent. Medical inspection should be so thorough as to indicate not merely the names of various sypmtoms and conditions, but should suggest whether or not malnutrition could possibly be an underlying factor. Under such conditions school lunches could serve in a curative way to assist in the relief of the conditions reported by the medical inspect.rs. Frequently medical inspectors would also suggest those children not possessing marked

defects, but who are very close to the health poverty line, and for them school lunches could be instituted as part of the preventive measures . . . increasing mental acuity and building up the physical health of our school children."

WILE, Ira S. School lunches. Their relative physical advantages in elementary and secondary schools. New York medical journal, 96:422-25, August 31, 1912. Reprinted.

Résumé of reports: New York, St. Louis, etc., showing the relation between nourished children and undernourished growth, mentality, dentition, and school progress.

"Medical inspection as related to the public school system makes note of many symptoms which are apparent among the children, but all too frequently fails to get down to the factors responsible for them."

WOOD, Thomas Denison. Health examination. In National society for the study of education. Ninth yearbook. Chicago, The University of Chicago press, 1910. Part 1:13-42. tables.

Bibliography: Health examinations, p. 105

The cities in the United States having the best organized systems are: Boston, Chicago, Cleveland, Los Angeles, Milwaukee, New York, and Philadelphia.

"The State cannot afford on economic grounds even, to educate a child who is handicapped by removable obstacles or whose personality or character is being distorted in any preventable manner." WOOD, Thomas Denison. Health problems in education. In American school hygiene association. Proceedings, 1912. Springfield [Mass.] American physical educational review, 1912. p. 125-30.

Also read before the National council of education, National education association of the United States, meeting, 1912; and in U. S. Bureau of education. Current educational topics no. III. p. 13-19 (Bulletin no. 24, 1912)

"There are in the schools of the United States to-day approximately 20,000,000 pupils. Careful study of statistics and estimation of all conditions lead to the following personal conclusions:

"From (1-2 per cent) 300,000 to 400,000 of these have organic heart disease.

"Probably (5 per cent) 1,000,000 at least have now, or have had, tuberculous disease of the lungs. "About (5 per cent) 1,000,000 have spinal curvature, flat foot or some other moderate deformity serious enough to interfere to some degree with health.

"Over (5 per cent) 1,000,000 have defective hearing.

"About (25 per cent) 5,000,000 have defective vision.

"About (25 per cent) 5,000,000 are suffering from malnutrition, in many cases due in part at least to one or more of the other defects enumerated.

"Over (30 per cent) 6,000,000 have enlarged tonsils, adenoids or enlarged cervical glands which need attention.

"Over (50 per cent) 10,000,000 (in some schools as high as 98 per cent) have defective teeth which are potentially if not actually detrimental to health.

"Several millions of the children possess each, two or more of the handicapping defects.

"About (75 per cent) 15,000,000 of the school children in this country need attention to-day for physical defects, which are partially or completely remediable.

"Of essential importance in the health field are the following: (a) Maintenance of sanitary, healthful school environment with clean schoolhouses, abundant light, good air, etc. (b) Hygienic instruction and school management, with particular attention to influence of teacher upon nervous health of pupils. (c) Effective teaching of health and hygiene to all pupils in the schools. (d) Rational supervision and direction of play, games, athletics and all healthful and satisfying forms of physical education.

"Special features . . . which have direct bearing on health include the following: (a) Homes of the pupils. (6) Playgrounds and gymnasiums. (c) Dental clinics and other medical clinics for children. (d) Classes for defectives and cripples. (e) Open-air schools.

"Improvement in school hygiene involves prominently these factors:

"1. Recognition of extraordinary value of work of school nurses, and employment of nurses in the schools.

"2. More comprehensive and thorough training in school hygiene in all normal schools and other institutions for professional education of teachers.

"3. Better technical training for school physicians, school nurses, teachers of hygiene and physical education, and other special officers in this field.

"4. Requirements of tests of knowledge and skill in various phases of school hygiene for teachers in general, and certification of health specialists of different types."