the number of patients treated and the number of operations actually performed in one year in our dispensaries. It is is misleading in this respect, namely, that the number of discharges does not equal the number of new patients recorded. It does, however, indicate what can be done. It also makes patent this fact, that to claim control that can be attested means that in each year the discharges must approximately equal the number of examinations made, and that the policy must provide for the enforced attendance of the child until discharged.

As for brushing the teeth, we insist upon it as a sanitary measure, as we would the bath, but we do not share the general belief that the toothbrush will prevent dental caries.

Next to adequate nutrition, mastication is the greatest developmental agent. Mastication is also the greatest cleansing agent and only sound teeth will be used. Children's teeth need only to be properly filled and made regular, and even green stain will disappear with this treatment and proper diet.

VI. CONSERVATION OF VISION.

A. SIGHT SAVING AND BRAIN BUILDING.

F. PARK LEWIS, M. D., Buffalo, N. Y.

It is an accepted fact, recognized by ophthalmologists everywhere. that changes occur in the eyes of children during the period of their school life, of which the most prominent symptom is a steadily progressive development of nearsightedness. As definitely formulated by the late Prof. Dufour: (1) In all schools the number of shortsighted pupils increases from class to class. (2) The average degree of shortsightedness increases from class to class. (3) The number of shortsighted pupils increases with the increase in school demands.

This form of myopia is dependent upon a relaxation of the tissues which give form to the eyeball, resulting in a gradual stretching of the globe itself. It is not dependent upon constitutional weakness; neither is it due to bad sanitary environment. It is not merely an abnormal phase of development which is fortuitous in its manifestation. It is a logical sequence of conditions which may be recognized and controlled. Its beginnings are, primarily at least, due to congenital astigmatism and the consequent strain upon the accommodation of the eye in the effort to see. Its development is still further encouraged by the hours of constant daily application in reading and writing at that period in life when the tissues are plastic and easily molded.

There are two obvious and logical remedies: (1) Relieve the excessive focal strain of the astigmatism or other abnormal refractive condition by suitable glasses. (2) Conduct school studies in such a way that close work on books or with pencil and pen is abandoned or reduced to such limited references as would seen to be absolutely

necessary.

We are destroying the eyes of a large number of school children by the burden of continuous near work to which they are subjected. At the first appearance of beginning shortsightedness these children. should be segregated from the others in special classes in which they are taught without books. Measures may be employed for such children in which the building up of the brain, the training of the mind in clear, accurate, and quick thinking, the government of the will, and the development of all of those faculties which we consider to constitute the education of the individual can be accomplished at least as effectively, as rapidly, and as certainly with a far less dependence upon the printed page than has heretofore been considered necessary. In other words, let us have more thinking and fewer books.

B. SCHOOL LIGHTING.

JAMES KERR, M: D., London, England.

Ocular experience is the only final test of illumination. Eyestrain is due to fatigue from overwork or glare. The eye adapts itself to brightness by varying its sensitiveness. Primary glare is due to physical effects on the retina, secondary glare to difficulty in adaptation. One-third of our elementary school children have such defective visual acuity that better illumination is necessary than for normal eyes.

Advances in photometry have made measurement of illumination convenient. Relative photometry in terms of outer daylight is the best for school work. The minimum for any school place should be raised to double Cohn's demand of 10-meter candles. Javal's measurement of sky visible from any place is facilitated by solid angle gauges. The effects of reflection from walls are of importance; cross lighting and top lighting are also advantageous; but accessory illuminating devices require caution.

Artificial lighting for each school place should be not less than 2-foot candles. Blackboards require 60 per cent more. Glare must be guarded against. There should be indirect lighting, soft and shadowless, for halls, semi-indirect and local direct for fine work. The use of gas and electricity is not likely to be decided on hygienic grounds alone.

C. DEFECTIVE VISION FROM THE ECONOMIC STANDPOINT.

LEWIS C. WESSELS, M. D.,

Bureau of Health, Philadelphia, Pa.

In Philadelphia each pupil costs about $35 per year to teach. Under normal conditions a pupil 14 years old should reach the eighth grade at a cost to the State of $280. If on account of defective vision the child only reaches the fourth grade in that time it has still cost the State $280, but with only $140 worth of result, a loss to the State of $140. The loss to the child is considerably more, because at the age of 14 it is likely to be put to work, poorly equipped for the struggle for existence, its earning power curtailed for the want of an education, so that it can contribute but little toward its own support, that of its family, or that of the State. So again the State loses, and all for the want of suitable glasses. While it is quite easy for the medical inspector or teacher to detect defective vision, the recommendation for glasses can not always be carried out on account of poverty or ignorance. These cases can procure free treatment at the dispensaries, but they are too poor or too indifferent to buy the glasses prescribed, and so they continue to struggle along greatly handicapped and fall behind on account of their eyes.

The department of public health and charities has solved this problem in Philadelphia by establishing a division of ophthalmology under the bureau of health, where poor children can be refracted and furnished with glasses free. We are now refracting nearly 2,500 cases a year. If we save each one of these children but one year during its entire school life there will be an annual saving of over $87,000, not counting the child's time and its increased efficiency. So the furnishing of free glasses to school children is not a charity per se, but is a duty and an economic problem. Many children have come to the dispensary wearing glasses bought from some refracting optician or from a 5 or 10 cent store. These glasses were not only unsuitable, but they were positively injurious to the child's eyes.

Few children remain in school after the age of 14, the legal age at which children are permitted to work. This fact emphasizes the necessity of examining the eyes of children in the kindergarten and the first grades. Municipalities should establish their own eye dispensaries for the refracting and the furnishing of glasses free to poor pupils at least. This is an economic problem rather than a charity, as it reduces the cost of education and at the same time increases the efficiency of both the pupil and the teacher.

VII. SCHOOL FEEDING.

A. HISTORY AND PRESENT STATUS OF THE MOVEMENT.

LOUISE STEVENS BRYANT, University of Pennsylvania.

The school-feeding movement is a part of the larger provision forthe child's physical needs, which has grown out of the realization of the dependence of mental progress on bodily condition. It includes first the study of the child's nutritional condition, and then the practical question of providing food at school. As a rule, the term is narrowed to include the provision of warm meals, either breakfast or lunch, at a small sum covering the cost of the food, and its preparation and service.

Considered externally, the movement is quite old, as its beginning antedated compulsory education in Germany, and was associated. with the first constructive attempt on the part of municipalities to meet the social needs growing out of the industrial revolution at the end of the eighteenth century.

In the main, the workers in the school-lunch movement in America are convinced that if the school is to assume responsibility for the feeding of the children, it must be because of the conviction that. warm, nourishing meals, served at cost, are a benefit to 100 per cent and are not merely temporary remedies for acute distress among the 10 per cent that are acutely undernourished.

Five years ago there were four cities with lunch experiments under way in the elementary schools. There are now something over 70 cities with lunches in the regular elementary schools. In nearly all of these the school board assumes at least part of the responsibility. In an increasing number it assumes entire responsibility. Lunches are provided as a regular part of the equipment in nearly all the open-air schools, which are now open in over 100 cities, while the high-school lunch is provided as a matter of course.

Wherever the school feeding movement develops, two things happen: First, in all countries, school feeding-begun by private philanthropy as a relief measure, or by a semiofficial attempt to encourage school attendance, or in some cases to make it possible— becomes gradually recognized, first by municipalities and then by States, as a legitimate extension of the principle of compulsory education; second, as soon as the State begins to take part in the provision of food for its children the meals lose the character of relief measures and become factors in education, with the double result that the suitability of the dietaries is considered with far more care than before, and the hygienic and esthetic aspects of the service receive attention.

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The greatest need of the school-lunch movement is not propaganda-it is going forward with its own momentum. What is needed is the development of technique in medical examinations and in dietetic plans; the application of the principles of efficiency to the administrative system; and finally the constant extension of scientific experimentation in this field, which affords an unrivaled opportunity for the development of the science of nutrition.

B. THE NUTRITION OF SCHOOL CHILDREN.

IRA S. WILE, New York, N. Y.

If we approach the problem of school lunches and medical inspection with a consciousness that they are interdependent and cooperating to secure the same end, we shall better appreciate their educational importance. Both are designed to act in a preventive and curative way in all phases of physical and mental health. Medical inspection seeks in part to eliminate contagious diseases from the public schools, while school lunches aim to increase the resistance of children to contagious diseases. Medical inspection seeks out physical and mental defects; school lunches aim to prevent or relieve physical or mental defects. The common ground of school lunches and medical inspection might well be said to be the prevention, determination, and relief of malnutrition. During the early years of school life nutrition may suffer, owing to incorrect adjustments to school life. A late and hurried breakfast or a rush to school without any food, followed later by a bolted lunch, may be manifested in loss of weight and supervening pallor.

It is most striking that lunches are now being supplied for curative purposes to crippled, anemic, tubercular, and other subnormal children after the medical inspector has called attention to the physical deterioration of the children. These efforts to better nutrition have been accompanied by a reduction in physical and mental defects, together with a marked advancement in mental and moral progress. It is all well and good to supply abnormal children with food and fresh air, as well as mental pabulum, but it seems more rational to give the same opportunity for the preservation of health to the_normal children instead of placing a premium upon ill health. In every community there are many poorly fed children, the inadequacy of whose diet is shown in part in anemia, underweight, enlarged glands, and similar symptoms. Malnutrition is a factor, though, to be sure, not the only one, in the etiology of tuberculosis, adenitis (enlarged glands), anemia, defects in vision, mental defects, chorea (St. Vitus's Dance), protracted convalescence from diseases, and impaired resistance to infections. A second factor in malnutrition to which in