provide the treatment. Experience has shown that some parents will heed printed notices, but that many require a personal explanation, and that some need to be shown how.

This has led to the introduction of the most indispensable factor, namely, the school nurse. The doctor visits for a few minutes, whereas the nurse devotes her entire time to the work. She is the most important feature of the whole plan. Her duties are briefly these: To aid and advise the teacher in her work and to act in emergency cases until the doctor arrives; to follow up children excluded on account of minor contagious diseases, such as scabies, impetigo, pediculosis, and ringworm; to visit the home and confer with the parent, either showing her how to treat the case or influencing her to put the child under the care of a physician.

The nurse is the most efficient link between the home and the school. Her work is immensely important in its direct results and very far-reaching in its indirect influences.

B. MEDICAL INSPECTION IN ROCHESTER.

GEORGE W. GOLER, M. D.,
Health Officer, Rochester, N. Y.

In Rochester we have 12 medical school inspectors, 11 men and 1 woman, working under the direction of the Health Bureau, for the physical inspection of 19.381 school children in 36 public schools, an average of 1,615 pupils to each medical inspector. Each inspector is assigned to a district in which he not only has school inspection work, including the vaccination of all unvaccinated children, but also the care of the sick poor, and the insane examinations in his district. He is assigned to from 2 to 4 schools, according to the amount of the additional work in the district, the size of the school, and the number of pupils. In 1912 the work of each medical inspector averaged as follows: Vaccinations, 450; visits to sick poor, 200; office calls to sick poor, 100; maternity cases, 2; insane examinations, 40.

The medical inspector is also called upon to make a weekly sanitary survey of the school, covering heat, lighting, ventilating, and cleanliness; to make a physical inspection of each child during every school year, and to record his findings on a card, so arranged as to follow up the child from grade to grade, and to present a written statement on one card of the physical condition of the child during its entire school life.

C. MEDICAL INSPECTION IN CITIES OF 100,000 OR LESS.

CLINTON P. MCCORD, M. D.,

Chief Medical Inspector of Schools, Albany, N. Y.

Medical inspection in our public schools is but the opening wedge for the broader idea of health direction. The term "health director" more accurately designates the functions of the officer who is to play a part, constantly increasing in importance, in our educational sys

tems.

Cities of 100,000 population or less offer the fields where the work of health direction can be systematized in the most ideal fashion. These are the cities that in greatest numbers will introduce medical inspection in the next few years, and as the scope of the work broadens, the system may well be expanded toward the ideal plan of health. direction, the beginnings of which we have in Albany.

The health director should be a "full-time," specially trained physician, and should have under his direction a "full-time " medical examiner to direct his energy toward the medical inspection phase of the system, and a corps of school nurses.

The system should be under the board of education, and sufficient appropriation should be made to administer the work in a dignified and scientific manner. The privileges of the family physician must not be disturbed. With the awakening of the general practitioner to his responsibilities will come an increased cooperation with the health director, which is bound to advance the standard of health among children of school age and also may suggest methods of health supervision of children prior to the beginning of school life.

There exist in the public schools five chief highways to health: Medical inspection, school hygiene, personal hygiene, physical training, welfare work. Health direction must take cognizance of them all. The health director should be the officer to keep the physical needs of the child before the public and the educational authorities. He should act as expert to the board of education on questions of school hygiene and to the superintendent of schools upon medico-pedagogical problems. He should pass upon the physical fitness of candidates for the teaching force and should act as consultant to the director of physical training, director of school lunches, and supervisor of special classes. His office should be made the clearing house for "special case" children, where a properly equipped child-study laboratory and a person skilled in the use of psychological tests may aid in properly classifying these children, after which they may be assigned to the proper schools-open-air schools, open-window classrooms, or schools for the mentally deficient.

D. MEDICAL INSPECTION IN MASSACHUSETTS-CORRELATION OF WORK OF SCHOOL PHYSICIANS AND LOCAL AND STATE HEALTH OFFICERS.

W. C. HANSON, M. D.,

Assistant Secretary, Massachusetts State Board of Health.

In a Massachusetts town with a population of about 10,000 inhabitants, including a school population of about 2,000, two physicians are employed by the school committee as medical inspectors, at a salary of $150 per year. To supplement the work of the physicians a school nurse is employed at a salary of $800. Although physicians and nurse are alike responsible to the school committee, they conduct their work in such manner as they deem proper, without any guidance or instructions from the committee. There is, then, no supervision of the work on the part of the school committee. Moreover, neither the physicians nor the nurses are familiar with the work of the local health officials.

The school physician's business is to exclude from the school pupils found to be physically or mentally unfit for work, and those known to have any communicable disease; the local health official's business is to discover the source of infection of any and all cases of communicable disease in the community, within or without the school, and to do all within his power to prevent the spread of infection.

The school physician, so far as he is influenced at all, follows the idea of the school superintendent of carrying out the original course of work that was planned at the beginning of the school year, and does everything that he can to prevent the school's being closed. The local health officer, on the other hand, when there is a case of scarlet fever or diphtheria, acting either with or without the advice of the school physician, closes the school through the power of the board of health to establish quarantine, and often unwisely and unnecessarily causes an interruption of the school curriculum.

Suppose, instead of the school physicians and nurses being in the employ of the school committees and having no official dealings with the board of health, the school and health inspection work is entirely in the hands of the local board of health, what then happens?

In a Massachusetts city with a population of about 104,000, including a school population of about 18,000, there are six school physicians in the employ of the board of health. Two nurses are also employed by the board to follow into the homes many of the children with defects or diseases discovered by the physicians. Each physician and nurse does practically as he or she pleases, visits the schoolhouses and the homes of the pupils, and submits his or her report at irregular intervals to the board of health. The board has issued no printed or written instructions for the guidance of either physicians or nurses. One physician, for example, may and does take a great

deal of interest in his work, the interest carrying him along in it, even for the small salary of $200 per year, so that he does for the city far more than he is paid for doing; whereas another physician does his work in an irregular fashion, taking little interest in it, partly because of the small salary, and submitting his reports only when requested, if at all.

But there is one saving thing about the work as conducted in this city each school physician must report at once to the board of health every case of communicable disease in the school and in the community wherein the school is located, for he acts not only as school physician but as agent to the board of health. He has, however, no idea of correlating the school and health work any more than has the board which employs him.

From what has been said, therefore, it will be inferred that whether the school inspection work is conducted by persons in the employ of the local school committee or the board of health it is not supervised in the great majority of the cities and towns in the Commonwealth. This is a fact.

What is the reason for this lack of definite supervision of the work of school physicians? The answer is, it would seem, the same as applies to all health work: Lack of sufficient interest and appreciation on the part of the public as to the benefits that come from work of this sort if well done, and consequently lack of money to standardize and put the work on a practical basis.

Fundamentally it makes little difference whether school or health officials control the medical inspection of school children. The first essential is a thorough and well-supervised system of school health work on the part of whichever board the local community in question sees fit to appoint. The second essential is a practical correlation of the school and community health work. What is preeminently needed in Massachusetts to-day is the bringing together of the local communities in such a way as to make it impossible for any single community not to know what constitutes, in a place of its size and characteristics, the best practical sort of school-inspection work.

Massachusetts is particularly fortunate in having associated with the State board of health physicians whose chief business it is to assist the local health authorities and to instruct and inform them, if necessary, on matters relating to the prevention of disease. They are, from the nature of their position, their training, and experience, competent to do just that sort of thing which results in bringing together the health authorities of neighboring communities. That was why the Commonwealth wanted their services. Having no autocratic powers over the local authorities, and standing as they do between the municipalities of Massachusettts and the health authorities at the statehouse, they accomplish to-day much in the way of

preventing disease that can not be definitely stated by the words of any written statute.

Into the hands of these men, therefore, whose duties already take them to the cities and the towns, could be put the supervision of the medical school inspection of the State. Just as now they advise with the health officers and boards, investigate conditions and make recommendations, so they could advise with the school physicians, observe their methods and results, and by bringing to them definite experiences of similar communities with similar problems, incite that instinctive desire for high standards which comes so much more surely and vigorously by education than by legislation.

State advisory supervision of school and community health work for the Commonwealth of Massachusetts is in the interest of economy, and is both logical and practical. It will insure local supervision of the medical inspection of schools, regardless of whether that work is controlled by the school committee or the board of health. It will gradually lead to a high and uniform standard of examination of the pupils throughout the Commonwealth; it will preserve local interest and initiative in all health work; it will permit local officials of the school and health boards to have such information in common as each needs, without duplication of work, and it will bring the State educational and health authorities together on a problem that demands combined action in the interest of the public welfare.

III. HYGIENE OF THE SCHOOL BUILDING.

A. THE HYGIENIC CONSTRUCTION OF SCHOOLHOUSES FROM AN ARCHITECT'S STANDPOINT.

W. H. KILHAM, Boston.

So much advance has been made in the general matter of the hygienic construction of schoolhouses that it seems as if the last word must have been said as far as the architects are concerned. No longer is schoolroom air rebreathed by 50 pairs of lungs; the common drinking cup has been replaced by the bubbling stream; dust, once the bugbear of janitors, has fled before the combination of rounded corners and vacuum cleaner; the schoolroom is sunny, well lighted, warmed to a uniform temperature, and, in fact, almost sterilized by the various devices calculated to conserve the health of teachers and pupils. The city schoolhouse of to-day, compared with that of 30 years ago, seems to be almost a perfect structure.

But there is another side. This germ proof, dustless building is also a very costly one. City after city passes large appropriations to provide the "most modern schoolhouse that can be built." With