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paying for. We frequently learn of a medical officer in schools inspecting many thousand children during the school year and giving to this work only a portion of his time and receiving for his services a pittance of $200 or less.

To be truly useful, health work in schools requires special training, aptitude, time, and reasonable remuneration. It is a great mistake to regard this work as primarily medical in nature, for it is first and above all else educational. It must aid the boy and girl in health growth and development; it must help the school to adapt its work to individual physical and mental conditions; it must assist in the correction of existing physical defects and in the prevention of others; it must teach the fundamental elements of preventive medicine; it must organize and supervise social-service work in the school community.

In order to indicate some of the best plans for health work in schools and in a measure to furnish standards which may be successfully put into operation, several outlines will be presented. They ore devised to meet varying conditions, such as are sure to exist in different places.

These standards are in a general way indicated by the following outline:

(1) Organization'with a medical officer and nurse or nurses.

(2) Organization with school nurse or nurses only.

(3) Organization by the employment of a simple, nontechnical Health Survey on the part of the teachers only. Such a survey is provided by a series of questions based upon ordinary observation of physical and mental conditions.

(1) SUPERVISION BY A PHYSICIAN AND ONE OR MOBE NURSES.

A physician should be selected who has some special interest in and adaptability for work among school children. In addition to this he ought to make a special study of school hygiene, for medical colleges do not ordinarily include such courses in their curricula.

Whether a physician should give part or all of his time to this sort of work will largely depend upon the volume of work required of him. In school communities where the number of school pupils does not exceed six or eight thousand, it is possible for one welltrained school physician to render satisfactory service by devoting one-half of his time to the work, provided he has as assistants at least two well-trained nurses who possess special adaptability to this kind of work.

In places of from eight to twelve thousand school population it is best to have one physician to give his entire time and an assistant physician to give half of his time. In such places there should be employed at least three school nurses.

In places where the school pupils exceed twelve thousand in number, one may estimate an additional half-time school medical officer for each six thousand increase in the number of pupils and one school nurse on full time for the same number.

For a city the size of Los Angeles this would mean approximately 12 physicians and 12 school nurses.

Many will say that this is an inadequate force for so large a number of pupils, but it must be remembered that school systems have many practical adjustments to make and that this is actually a larger force than schools now employ.

When a city is large enough to require the services of several medical officers in its schools, the following plan is suggested and recommended as an efficient one:

There should be one general director giving his entire time to the work. Instead of employing several half-time medical men as assistants, fewer men on whole time are recommended. The organization might be made as here indicated for a city of, say, 60,000 school children (about 300,000 actual population): One chief health director; 1 general medical officer; 1 eye, ear, nose, and throat specialist; 1 specialist in mental and nervous diseases and experienced in psychological methods; 1 emergency physician, who also would give instruction in hygiene and first aid; 1 woman physician in charge of high-school girls and giving instruction in hygiene.

This number (6) would take the place of 12 physicians under the plan usually in vogue and would result in far better work in every respect.

Such a plan would require a central office of several rooms—one general reception room, one private office for the director, one examin- ing room, one laboratory equipped with medical and psychological apparatus.

There should be a dental and medical clinic, either in connection with the schools (and this is preferable) or, if this seems impossible to arrange, then in connection with some other organization. With this plan in operation, parents of defective children would have the opportunity of taking their children to the general offices for special examinations. The different specialists would keep office hours on different days of the week and could thus give careful and deliberate attention to such school children as required it.

From this office cards of admission to the medical or dental clinics could be issued to those entitled to them.

One special school nurse should be assigned for duty at the central office and should keep the records and assist the physician in charge of the office in the examinations.

There should be one school nurse assigned to each school physician.

The plan proposed presupposes preliminary examinations on the part of nurses and teachers after the manner which will be suggested in the " Outline for the Health Grading of School Children."

This method relieves the medical officers from much purely routine examination of practically normal children and allows them to concentrate their attention on children really needing their expert services. With the methods employed at present, school doctors waste a great amount of time doing purely inexpert work which might far better be done by teachers and nurses. At present most cities are in this way paying experts for inexpert service. This method wastes both time and money and ought to be abolished.

In order to indicate several plans for school health organization which are now in successful operation, the general organization as it exists in four large cities are given below. Several other cities whose organizations are not given ought also to be carefully studied. Of particular importance among those cities whose school health organizations are not here described are the following: Kansas City, Mo., Cleveland, Ohio, Montclair, N. J., Cincinnati, Ohio, Los Angeles, Cal., St. Louis, Mo., Gary, Ind., Boston, Mass., Seattle, Wash., Duluth, Minn., Hibbing, Minn.

Milwaukee, Wis.—The Milwaukee school health department is maintained by the board of education and has the following organization: One medical director; 10 assistant medical inspectors; 1 specialist on diseases of the eye, ear, nose, and throat; 1 full-time dental inspector; 1 special assistant for psychological and anthropological tests; 5 school nurses.

The medical director, dental inspector, and nurses devote their entire time to their work; the remainder of the staff give one-half of each day. A central office is maintained, where the medical director meets parents, conducts special examinations, and carries on the general office work of the department. A dental clinic for indigent children, an outdoor school, and a school for crippled children have recently been added. There are four classes for blind children and four centers for the treatment of speech defects.

The city is divided into 10 districts, 9 of which are approximately equal in size and contain about the same number of schools; the tenth, located in the central portion of the city, covers less area, because the schools are closer together and the conditions met among the pupils are worse than in the outlying sections of the city. Each district is under the care of one assistant medical inspector. For the work of the nurses the city has been divided into five districts, of which the four outlying territories are about equal in size, and the» fifth, in the center of the city, is considerably smaller.

Each school has been supplied with the following materials: An emergency case containing a stretcher, drugs, and dressings; a case for filing the doctor's and nurse's records; a circular for the principal, explaining in brief the purposes of medical inspection, his duties in its accomplishment, and information as to causes and time of exclusions; a circular for each teacher, detailing her duties and giving information as to the early symptoms of contagious diseases; code cards for all teachers on which all diseases of importance are indicated by number; blue cards; psychological examination blanks with circulars of explanation; physical examination blanks.

Complete directions are given to the medical inspectors and nurses in respect to their routine work in the schools. Principals of schools are instructed also in respect to the general plan of health supervision. Indigent children suffering from physical defects are referred to the various city dispensaries. Special attention is given to retarded children, and psychological tests are in constant use.

The Milwaukee system is thoroughly practical and efficient, and excellent results are obtained. It is worthy of careful study. Dr. G. P. Barth is the medical director.

Philadelphia, Pa.—In Philadelphia the examination of school children is conducted by the city health department, but the expense is borne by the board of education. Under ordinary conditions this plan could not be recommended, but it appears to work satisfactorily in Philadelphia. The school nurses are employed and paid by the board of education.

The scope of the work at present includes:

(1) Routine examination of every child once each year as required by the State law.

(2) Sanitary inspection of school building.

(3) The direction and exclusion of children suffering from contagious diseases.

(4) The examination of absentee children for the bureau of compulsory education.

(5) Special examination of mentally deficient children.

(6) Medical supervision of open-air classes for anemic and tubercular children.

(7) Examination of applicants for position of school janitor and other positions in the department or building.

(8) Medical supervision of special classes for blind or crippled children. The supervision of candies and other foodstuffs sold by vendors around the school premises will soon be put into effect.

Oakland, Col.—In Oakland, Dr. N. K. Foster has organized a plan which gives excellent results. The staff consists of 1 medical direct or, 1 assistant medical officer, and 7 school nurses.

Each nurse has her own particular school in which to work. At the beginning of the year a special attempt is made to give attention, first, to those pupils who are urgently in need of it. This is 11562°—13 2

accomplished through the efforts of the teachers and nurses. In this way the worst cases are detected and "followed up" early in the year, a point of much importance. After this preliminary work is finished the nurse examines all of the pupils in her district and senda notices of defects discovered to parents. A visit is invariably made to the home of each child whose parents receive notice.

An interesting and valuable part of the nurse's work consists in simple " health talks " to the individual pupils at the physical examinations, particularly in relation to the defects or disorders from which they suffer. Health talks are also given to entire classes both by the school nurses and school doctors, and special attention is given to instruction in matters pertaining to sex hygiene.

A central office is maintained by the board of education at which the school physicians keep office hours, so that parents may come with their children for special examinations and consultations in respect to further action. The entire department is maintained by the board of education, and the plan works admirably in every respect.

Minneapolis, Minn.—In Minneapolis the work of medical inspection and physical education is combined in the same department. The schools for stammerers, mentally retarded and deficient, the open-air schools, the school gardens, and the truant schools are also under the general supervision of the school health department.

The official organization is as follows: One medical director, 8 assistant medical officers, 18 school nurses, 12 instructors in physical training, 18 playground instructors during the summer montlis, 1 supervising school nurse.

The work of the Minneapolis school health department is maintained by the board of education, and it is highly efficient.

THE SCHOOL NUB8E.1

Medical inspection has rendered the school nurse inevitable. When the doctor was brought into the schools he faced a new and difficult situation. The school doctor's helplessness has been vividly described by Dr. Hayward, of England, as follows:

As a doctor I felt quite stranded in the strange atmosphere of an elementary school, coming into contact not so much with actual illness as with the primaryconditions which produce and foster It—dirt, neglect, improper feeding, malnutrition, insufficient clothing, suppurating ears, defective sight, verminous conditions, the impossibility of getting adequate information from the children or a knowledge of their home conditions, and nobody to whom one could give directions or who could help in examining the children. The only means of approaching the parents was to send an official notice that such or such a condition required treatment. My duties began and ceased with endless notifications, and there it all stopped, as very little notice was taken of them.

1 Part of this section is taken from Hoag and Terman's "Health Work tn Schools," Houghton Mifflin Co.

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