made by the department, with 843 fewer exclusions, and the 15,625 more physical examinations show a pain in amount of work and character of same.

"During 1910-11, 24,310 physical examinations were performed-613 per cent of this number were found to have one or more defects and 383 per cent were found normal.

...

"Were I asked to establish medical inspection in a city .. I would employ first of all, sufficient trained nurses to carry on the major part of the work. The only part of medical inspection that cannot be conducted by nurses trained in school work is the examination of the heart and lungs. . . "I would have these nurses under the direction of a trained physician who should be expected to devote the entire day, from 9 to 5, to school work. Medical inspection should not be carried on in public schools as a necessary evil, but as an indispensable benefit."

LAMSON, William J. The medical inspection of schools. Medical society of New Jersey. Journal, 7: 569–72, April 1911. tables. form.

Duties of a medical inspector, as adopted by the New Jersey State board of education, October 5, 1909, are as follows:

"1. He shall use the same skill in examining pupils as he would in the case of private patients.

"2. He shall arrange his visits to the school to suit the convenience of the school authorities and his own private work. He shall respond to emergency calls as quickly as possible.

"3. He shall make regular inspections: (a) In rural districts at each school at least twice a month; (b) in villages and small towns at least once a week; (c) in towns and cities at least three times a week, and in crowded cities daily.

"4. At the commencement of each school year he shall make a thorough physical examination of each pupil, and record his findings on cards assigned for this purpose: (a) Eyes, for farsightedness or nearsightedness, color blindness, squint and roughly for astigmatism, also the condition of the eyelids; (b) ears, for acuteness of hearing, adenoids, discharge; (c) throat, for enlarged tonsils, adenoids, nasal deformities or discharges; (d) teeth, condition and care; (e) deformities, spine, limbs, etc.; (f) skin, eruption, condition of scalp; (g) when practicable measurements, height, weight and chest measures; examination of heart and lungs.

**5. He shall exclude cases of contagious diseases, and send a written statement of conditions found. "6. He shall from time to time examine into the sanitary conditions of all schools in his district. #7. Any special work, such as frequent extra visits, vaccination or fumigation, shall be arranged for by mutual agreement between the board of education and the inspector."

MACDONALD, Joseph, jr. The object and intent of medical inspection of school children. New Jersey. Journal of the medical society, 9: 231-34, October 1912. To be accomplished

"First. By the appointment of a State medical school inspector as a member of the State board of education.

"Second. By the preparation of uniform blanks by the State board covering individual record cards for yearly examination; recommendation cards for treatment and exclusion cards for infectious or communicable diseases.

Third. By requiring that duplicate reports shall be sent by the school inspectors to the school boards they are serving, and to the State board at Trenton; thus with other essential details . . . a most important department could be built up that would prove not only a great saving in expense to the community, now expended in carrying along physically deficient pupils, but would give us a stronger race of men and women physically and mentally."

Newark. Board of education. Report of Supervisor of medical inspection. In its Annual report, year ending June 30, 1911. p. 211-21. tables.

Comparative table of medical inspection in Newark public schools from 1901 to 1911, inclusive, p. 212.

Inspection of School no. 4: Inspection begun of each child in the first fifteen classes of this school, April 12, 1910. Total number examined, 579.

REBER, C. E. Abnormal school children. School exchange, 3:25-29, October 1908. tables.

A statistical résumé of examinations, 1908, made on various types of school children, both normal and feeble-minded. Discusses chiefly the retarding effects of adenoids upon body-growth, spine, vocal organs, teeth, palate, and mentality-"feeble-mindedness is more likely to be the effect of adenoids, and the causes that bring them about than that adenoids are the effect of feeble-mindedness. . . . Adenoids are a defect of civilization."

Trenton. Board of education. Medical inspection. In its Report, year ending August 31, 1909. p. 45-47.

Begun, January 1909. Six physicians and a school nurse appointed. Each pupil made the subject of a thorough yearly examination. A sanitary inspection of the school buildings, classrooms, grounds once each month.

Reports for six months give the number of examined as 6,346; called to inspect different cases, 3,000.

BAKER, Sara Josephine. Medical inspection and examination of school children... In her The Division of child hygiene of the Department of health of the city of New York. p. 61-93. illus. charts. tables. (City of New York. Department of health. Monograph series, no. 4, September 1912)

Vaccination of school children, p. 89-93:

"The conditions revealed as a result of these physical examinations were of sufficient importance to attract the attention of the health authorities to the necessity of more complete control of the health of the child during its school life. The postal card notifications resulted in obtaining medical care for only about 6 per cent of the physically defective children. It may readily be seen that, while such a system has value in definitely determining the physical condition of the children in the schools, the records soon amount to little more than the mere compiling of statistical data unless some definite and systematized effort be made to see that the children obtain proper medical care.

"It was the recognition of this fact that instigated the studies which resulted in the organization of the division of child hygiene. With its formation, and the appointment of a largely increased staff of trained nurses, it became possible to have the nurses visit the physically defective children in their homes in order to induce parents to provide proper treatment. This system of home visits by the nurses was inaugurated on September 15, 1908. As a result of their efforts, during 1909 83 per cent of the physically defective children obtained treatment, as opposed to the 6 per cent under the former system. The entire system as outlined was carried on with excellent results until January 1, 1912.

Previous to this time it was recognized that, with a visit to each school each day by a medical inspector and a nurse, there was a certain duplication of time spent which might be eliminated with resulting financial economy. Experiments were carried on in two groups of schools during a period of three months in the spring of 1911 to determine the relative economy and efficiency of placing the control of contagious diseases in the schools in the hands of the school nurse, leaving the medical inspector free to devote his entire time in the schools to making physical examinations of the children. The experimental study having shown that such a system was feasible, it was inaugurated on January 1, 1912.

"The complete system of school medical inspection is carried on in 517 public schools with a registered attendance of 684,207 pupils. In addition, 151 other free schools of the city receive a more or less complete series of inspections for the purpose of detecting contagious diseases. Seventy-four medical inspectors and 179 nurses are detailed to the work of school medical inspection under the immediate supervision of the staff of supervising inspectors and supervising nurses in each borough. Each inspector is assigned to duty in a group of schools with an average registration of 9,000 pupils. Each nurse is assigned to duty in a group of schools with an average registration of 4,000 pupils.

"Each public school in the city is visited each day by a nurse, except in certain outlying and sparsely populated districts where visits are made at less frequent intervals. Other free schools are visited upon request, or regularly once or twice weekly.

"Routine inspection.-1. At the beginning of each term each medical inspector makes a routine classroom inspection of each child in the schools under his charge.

"Thereafter the nurse makes a continuous routine class inspection of each child in the schools under her charge, following the same procedure.

"2. All cases of disease found are recorded on a special class index card, with the data in appropriate columns. A card or cards is made out for classroom, and the index kept in an accessible place in each school. Further data regarding each case is recorded on this class index card. Code numbers are used to indicate the kind of disease.

"3. All contagious diseases found are dealt with as described under the heading 'Morning inspection.' 4. When a child is found to be affected with a marked form of physical defect, the particular defect is noted and the child referred to the medical inspector for a physical examination.

"5. All children ordered under treatment are referred to the school nurse and are thereafter controlled as described under the heading 'Morning inspection.'

"Emergency cases.-In the absence of the inspector all emergency cases are treated by the nurse in the school whenever other treatment is not available. Such cases are thereafter referred to the parents for future care.

"THE DIAGNOSIS AND CORRECTION OF NON-CONTAGIOUS UNTREATED PHYSICAL DEFECTS.

"The medical inspector visits each school under his jurisdiction for two successive days. A regular schedule is maintained, and the principals of the schools are thus informed of the dates of the inspector's visits. The principals are requested to instruct the children to report, in small squads, to the inspector for physical examination.

"2. Examinations are made in the following order: First. Children entering school for the first time; Second. Children especially referred by the principals or teachers; Third. Children belonging to the class to be graduated; Fourth. In the regular course, beginning with children of the lowest grades, and proceeding to the higher grades in regular order; Fifth. Classes of the same grade are examined in regular order in each school of the group.

"3. Each child is thoroughly examined for the following conditions: Defective vision, defective hearing, defective nasal breathing, hypertrophied tonsils, tuberculous lymph nodes, defective teeth, malnutrition, pulmonary disease, cardiac disease, chorea, orthopedic defects.

"4. A complete record of each physical examination is made on a special form. If a child is normal, the inspector sends such a report to the borough office of the division. If abnormalities are found, the record form is given to the school nurse.

"A duplicate record of each child's condition is also placed on file with the child's school record, thus affording to the educational authorities the fullest information in regard to the child's physical condition, and enabling them to take advantage of this information in adjusting the individual curriculum. "The nature and results of the treatment obtained for each defect are thereafter noted upon this school record form by the nurse.

"5. Each defective child is given a copy of an appropriate form, properly filled out, to take home to its parents.

"6. If at the end of three days no notice has been received from the parents that the child is under medical care, and if the child shows no evidence of such care, a notice is signed by the principal and sent to the parents.

"7. If the parent calls at the school, as suggested, the inspector or nurse explains the nature of the defect and the need of treatment; if the parents do not respond within three days, the nurse visits the home and explains to the parent the character of the defect, the need of treatment and the beneficial results that may reasonably be expected to result from medical care. Repeated home visits are made by the nurse until treatment is provided or an absolute refusal is encountered.

"8. When parents are willing to have their children treated but are unable to pay a private physician and by reason of home duties or occupation cannot spare the necessary time to obtain treatment, the nurse takes the child to a dispensary, after the parent has signed a request to that effect.

"9. When treatment is obtained or refusal is met, the nurse records on the regular physical examination form and the school record form the character of the treatment. The first form is mailed to the borough office of the division, the second remains on file in the school.

"10. After the child has obtained treatment, it is again examined by the inspector, who records the improvement or non-improvement on the school record form and on the special form forwarded to the borough office of the division.

"Every effort is made primarily to refer those children who require treatment to the private family physician. If there is no private family physician and if, furthermore, the family is unable or unwilling to employ a private physician, the child is then referred to a dispensary or hospital for treatment. "Inspectors and nurses are required to consult with the school authorities regarding the matters pertaining to school environment or the curricula which may have a bearing upon the health of the child. "There are in the city of New York only 19 free dental clinics. Of these, only one is maintained wholly for the treatment of school children. This clinic is supported by a group of philanthropic citizens. The remainder of the clinics are connected with dental colleges or dispensaries, and provide treatment for adults as well as children. Only a few of these clinics fill teeth, and extraction is done in the majority of the cases of children who are able to obtain treatment. . . .

"The need of free dental clinics is acute, and the department of health has asked the board of estimate to include in the departmental budget for 1913 an appropriation suflicient to employ 15 dentists and 8 nurses to allow the establishment of school dental clinics under the supervision of the division of child hygiene.

"Clinics for School Children.—It has been felt by the department that the test of the value of the system of school medical inspection was the character and results of the treatment obtained by the children. In order that the existing need for more facilities for treating the children might be met, and that the character of treatment given and the adequacy of results might be under control, the department has obtained in its budget for 1912 funds for the establishment of six clinics under the supervision of the division of child hygiene, exclusively for the treatment of school children. Statistical data of these clinics can not yet be given, owing to the short time they have been in operation.

"The location of the clinics is as follows Borough of Manhattan-341 Pleasant Avenue; Gouverneur Slip. Borough of Brooklyn-330 Throop Avenue; 1249 Herkimer Street; 124 Lawrence Street. Borough of the Bronz-580 East One hundred and sixty-ninth Street.

"These clinics are open from 2 to 5 p. m. on school days, and from 9 to 12 a. m. on Saturdays. Each clinic has the following service: (1) Eye diseases: (a) Contagious eye diseases; (b) refraction. (2) Nose and throat diseases. (3) General medical diseases. (4) Skin diseases.

"The service at 341 Pleasant Avenue includes hospital wards of 14 beds and facilities for operations on trachoma, adenoids, and hypertrophied tonsils. Similar hospital service will shortly be ready at 330 Throop Avenue, 1249 Herkimer Street, and 580 East One hundred and sixty-ninth Street.

"The children are referred by the school nurse directly to the clinic, a special form of reference card being used. After the child reports at the clinic, the nurse assigned to duty at the clinic follows up the case, making home visits whenever necessary to see that the child remains under treatment until discharged."

BAKER, Sarah Josephine. The value of the municipal control of child hygiene. American journal of obstetrics and diseases of women and children, 65:1061-68, June 1912.

"In New York City since 1908, 727,750 children in the public schools have received a complete physical examination. . . . An average of 40 per cent were found to have one or more associated physical defects... with or without the most common defect that we find, namely, defective teeth. Thirtyfive per cent of the remainder . . . were found to have defective teeth as the only physical defect. . . . In the schools alone the efforts of the division of child hygiene have resulted in an immense gain in school time for those children who were affected with contagious eye and skin diseases, the necessary exclusions; . . . for these reasons being reduced from over 57,000 in 1903 to slightly over 3,000 in 1911. . . . "It has been alleged that the assumption by the city of the responsibility for the health of school children has made serious inroads upon the practice and income of private physicians. In order to ascertain the exact conditions. . . I have had tabulated for . . . 1911 the various sources from which children have received treatment. During that year, of the 65,150 children, 37,986, or 58 per cent, were treated by private physicians or dentists, while the remainder 27,164, or 42 per cent, were under the care of hospitals and dispensaries. . .

"This work in the schools, with its control of the contagious disease situation, with the elimination of the school as the main focus of infection; the physical examination of each child as soon as it enters school, before it is allowed to graduate and as nearly as possible every two years in the interim; the instruction of the parents . . . and the follow-up work . . . was performed during 1911 at a per capita east of $0.43."

BLAN, Louis B. Are we taking proper care of the health of our school children? Pedagogical seminary, 19:220-27, June 1912. tables. chart.

Writer records visit made in company with a school physician on a routine round in New York City. "In one school, attended by 2,000 pupils, the visiting physician waited patiently for a report of sickness from the various classes. There was not one report of illness or a single case for medical investigation. This seems almost incredible. If this number of children had been previously examined surely some of them would need medical attention. . . . In another school . . . not one case of cardiac ailment was reported. In point of fact. . . two of these children had heart disease.

**In one case... 'pulmonary trouble' was registered on the health card but no medical attention ... had been given. The case had been recorded three weeks prior. . . .

"In none of the schools of New York City has there ever been recorded a complete general history of the child.

*Bronchitis cases are never examined or attended. . . .

There is not time enough to make adequate physical examinations. Each physician covers the ground assigned. . . in less than three hours and is paid little for the work he is doing.

"No complete physical examination of the entering or enrolled elementary school pupils to ascertain the health conditions of their vital organs has as yet been suggested.

"Actual number of deaths among New York City school children between ages 5-15, during year 1910-11 (in part only tabulated):