OFFICIAL OR PRIVATE PHYSICIANS AS MEDICAL INSPECTORS.

There is no doubt but that communal physicians intrusted with the charge of medical inspection in schools will make a speedy effort to acquire sufficient practical experience in school hygiene and the necessary training in methods of examination through their own studies and under the direction of official physicians. The opposition advanced in many quarters, that not every certificated physician is able to meet the necessary requirements, is therefore hardly well founded in the majority of cases, and should by no means prove an insurmountable obstacle in the way of introducing school physicians. The fear of a lack of adequately educated physicians is the less justified at the present day, since according to the course of study required in most countries each member of the medical profession without exception can, and in part must, acquire sufficient knowledge in the subsidiary branches which qualify him for undertaking special examinations of school children.

The appointment of female physicians, as has been made in high schools for girls in Paris, Edinburgh, Moscow, and other places, can meet with no objection, if they are admitted to the practice of medicine only after passing the same strict examinations as their male colleagues.

The wisdom of calling official physicians to the duties of public supervision of medical inspection in schools can hardly be doubted; the only objection that can be advanced is the lack of time for the fulfillment of their many obligations. Such an objection is valid only in those countries where public physicians are in charge of extensive districts, or where their whole time is claimed by forensic duties. The claim advanced by the government of Reuss for state medical supervision must be agreed to in the interests of a uniform administration, and for the reason that in most countries the appointment of official physicians is dependent upon the proof of a special knowledge of hygiene.

The minister of education in Bavaria has instructed the trustees of secondary schools to consult official physicians on all sanitary questions. In Austria, according to the provisions of the imperial sanitary law of April 30, 1870, state physicians are required to superintend the sanitary condition of schools; moreover, according to most local laws, each district school board must have a physician as a regular member, who is to give advice on all sanitary matters, to remedy on the spot abuses which come under his notice, to inspect schools, and submit propositions for improvement. Some state school boards have passed explicit resolutions to that effect. The enforcement of these plain legal provisions, however, has as yet been effected only in exceptional cases.

DUTIES OF SCHOOL PHYSICIAN.

Of what nature are the duties of school physicians? It would be altogether wrong to designate the medical treatment of school children in cases of sickness as the business of school physicians. On the contrary, if their position is not to be undermined, and if they are not to come in conflict with various authorities, their labors must, first and foremost, be directed toward prevention of disease. Their duties must be, not to treat sick children, but to preserve healthy children from disease and injuries to body and mind by keeping the agencies which caused them at a distance. The diseases of school children merely give physicians the hint how and where injurious influences are to be sought. If the source of the evil effects has been traced, it will not be difficult for him to make the proper suggestions for moderating or removing the disturbing influence.

The work of physicians should not run in a fixed groove; they must individualize, and above all take local conditions into consideration. School hygiene in cities requires different action on the part of physicians from that in the country.

Though general sanitary conditions are usually better in the country, because of purer air and the fewer restrictions upon the liberty of children, it would be unjust to confine medical inspection to city schools and neglect rural schools. In the same way medical cooperation in the care of health must extend to all public and private schools, as well as to boarding schools, high schools, normal schools, lycées, commercial and industrial schools, and schools for girls (attended exclusively by girls), for it may not be presupposed that the sanitary conditions of these higher institutions are any better than those of elementary schools. On the contrary, thorough and intelligent work from a physician is often especially necessary in such institutions, because, with few exceptions, they lack altogether or have insufficient medical cooperation in their management, though the health of teachers and pupils frequently affords enough occasion for it. It would be superfluous to enumerate instances, as every teacher who does not close his eyes to the simplest requirements of health finds instances enough in his own building. Is it just, for example, that pupils should be kept in schoolrooms with doors and windows closed, while teachers and their companions seek recreation in the halls? Or is it right that a prematurely debilitated teacher should anxiously keep windows and doors closed, preventing the children from receiving a sufficient amount of pure air? How often is it forgotten that fresh air, together with a proper interchange of rest and motion, is the best remedy for headache, anæmia, and mental overfatigue.

Palatial school buildings and hygienic contrivances of all kinds are not sufficient to replace lost freedom and the deprivation of unrestrained exercise in wood and field; certain injurious influences connected with school attendance must be kept at a distance if the health of school children is to be preserved. Disease is not always a result of faulty arrangement of buildings, but is often due to other external agencies.

Kollmann states that the pupils of the old classical school of Frankfort, of which the hygienic appointments were faulty, were examined by a physician before they occupied the new building; after nine years of occupancy of the new building a recent medical examination showed the sad result that, in the meantime, despite the "best sanitary appointments" of the new building, nearsightedness had increased from 26 to 32 per cent. The reason for this is to be found in the increasing strain on the sight in mastering the greater number of studies.

At the 24th meeting of the German Public Sanitation Association, in Nuremberg, Schiller and Schubert formulated the demands of medical school inspection. The duties of school physicians should comprise:

"I. The supervision of the sanitary condition of school buildings and their appointments.

"II. The supervision of the carrying out of regulations concerning the hygiene of instruction and appliances of instruction.

"III. The care of the health of school children and aiding the public physicians in preventing and combating contagious diseases, determining the physical defects of children for the purpose of continuous observation or special consideration during school hours, and the supervision of physical training in so far as it is directed in school."

In the development of school hygiene these requirements might form the skeleton to serve as a foundation for the laws governing the duties of school physicians.

From this state of the case it is readily seen that the professional duties of school physicians group themselves into three classes, to-wit: (1) Supervision of the sanitary conditions of school buildings; (2) influencing as far as permissible the in

struction, and (3) the supervision of the health of pupils. Key has outlined a system of medical inspection and supervision of school hygiene based upon his investigations in hygiene.

Comprehensive and exhaustive regulations for medical inspection were issued in 1885 and republished June 4, 1890, by the council of education in Görz, Gradisca, and Istria, in Austria. Dr. Altschul has drawn up a list of questions, adapted to conditions in the city of Prague, to be used in the sanitary investigation of school buildings and their appointments, as well as in the special physical examinations of pupils, following the form of which a register for schools and pupils might easily be arranged and kept constantly filled out.

The Russian Society for the Preservation of Public Health" has recently arranged a programme for the investigation of the hygienic condition of schools, instruction, and pupils, in which all important points are considered that may come into question in framing instructions for school physicians. Nevertheless, the principle will always hold good that the school physician must “feel” the extent (or scope) of his duties, and that the manner of their fulfillment must be left to the tact of this specialist.

The office of the school physician should be mainly to advise and prevent; least of all to cure.

The advisory sphere of action will include the site and neighborhood of school buildings, materials, plans of construction, division into rooms, and interior arrangement, appliances of instruction, lighting, heating, ventilation, water supply, play grounds, baths, gardens, places for gymnastic exercises, and residences of teachers and pupils. Schools will derive an advantage only when buildings are thoroughly examined once a year by a physician, in company with an architect and the superintendent, and the ways and means for remedying existing evils are discussed.

According to the 31st annual report of the State Board of Medicine in Saxony, all the schools in Dresden have for several years been visited by a commission consisting of an architect, the physician in charge, and the principal of the school, and notes made of the deficiencies noticed. The requirements for school buildings in the canton of Geneva, Switzerland, were defined by the decree of January 28, 1898. In lower Austria the board of health has defined the principles of sanitation to be observed in the construction and maintenance of orphan asylums, educational institutions, and dormitories.

As a preventive measure, school physicians should inspect each class room frequently during the year, examine the eyes, ears, mouths, and spines of the children, and advise the proper authorities of faults noticed; devote their most unremitting energy and attention to locating and fighting contagious diseases and disinfecting schoolrooms and dwelling apartments in the schoolhouse; note down their observations in a book kept in the school, propose measures, adopt their own measures in pressing cases, in anticipation of official approval, and recommend a suspension of school when any danger is threatened. Special attention should be given to faulty speech, bad positions of the body, nervous states, defects of hearing, infectious eye diseases, nearsightedness, and skin diseases; also, when the programme of instruction is under consideration, to call attention to unwholesome features in it or to its hygienic requirements. The examination of pupils at their first entrance into school is of the utmost importance; height, weight, nutrition, constitution, the condition of spine, eyes, and ears, all imperfections, and mental conditions should be accurately determined. It would be most desirable if mothers could be present at the first medical examination, since they could give the best information as to previous illness and could receive suggestions for the treatment and bringing up of children at home. In the mother's presence

children would submit more readily to examination, and more reliable data could be obtained.

Dr. Mangenot maintains that examinations should be exclusively for the benefit of pupils, and that all purely scientific or statistical inquiries, for instance, anthropological, should be forborne for want of time, even though their scientific value was not to be gainsaid. The examinations should be simple, not complicated. When practicable, height and weight should be ascertained. A report should be made twice a year and copies sent to parents. Professional confidence would not be violated, since eye, ear, and nose diseases are inoffensive and would not lead to any faultfinding on the part of parents. Remarks upon syphilis-of rare occurrence among children-could be made apart or entirely omitted; scrofula and rachitis could be indicated by terms intelligible only to the medical profession. Acquainting parents with the results has the advantage of drawing their attention to any evil for which they could seek further medical advice.

Should these preventive measures prove unsuccessful, medical inspection, as has been already said, must extend to the homes of pupils and their manner of life outside of school. In this regard those physicians in the country have the advantage who as family physicians gain an insight into the family relations of pupils. Consequently, they can judge better of the influence of home, food, manner of life, social intercourse with other children, and habits, and can better estimate the consequences of hereditary disease in families, etc., than the school physicians of cities, who as a rule see the children only during a short examination. Disease can only be rightly interpreted and explained when the defective lighting of the homes of pupils, the bad air in sleeping apartments, the damp rooms, the wageearning occupations, and the lack of care of the skin are known to physicians and are considered by them.

SHOULD SCHOOL PHYSICIANS TREAT DISEASED CHILDREN?

It is only in exceptional cases, when children are taken suddenly ill in school, that school physicians should undertake to cure; wherefore the proposition of the medical inspectors of the schools of Paris to provide district schools with an emergency medicine chest containing a small selection of medicines and liniments, and explaining their use to teachers, is not altogether to be ignored. In Austria, in 1895, the supreme board of health indorsed the introduction of medicine chests, with rules for use framed and hung on the wall. Repeated instances of their usefulness are recorded in the country in cases of poisoning by eating poisonous mushrooms, berries, and plants (belladonna, Jamestown weed), as well as in cases of accident during gymnastic exercise.

No one will dispute that physicians alone should have the right to determine when a child shall resume his studies after recovering from illness, or from what studies he should be excused. Children should be examined at once upon entering school, so that defects may be disclosed and further injury to health prevented. It is also of advantage that physicians be sometimes present as silent observers during instruction, so as to watch the children without attracting their attention. It is a well-known fact, in the case of general examinations formally announced, that the subjects often assume forced attitudes of body, give wrong replies in testing their sight or hearing, and so make the results of examinations unreliable. It is a further duty of school physicians to consult teachers on important matters, to explain sanitary measures, in order to remove detrimental influences and supply deficiencies. In this respect it is necessary that physicians hold an equal rank with teachers in their assemblies, that their propositions may not lack a certain authority. On the other hand, physicians should not forget that their posi

tion is a coordinate one, that they must exercise moderation in their claims and not aim beyond their mark.

The sanitary service of school physicians must be permanent, extending over the whole domain of school and throughout the whole year. Great difference of opinion prevails with regard to the frequency of inspection. One inspection a year is not enough, because sanitary conditions change according to the time of day or year, climate, temperature, and the occupation of pupils. On the other hand, one to three detailed examinations of pupils a month must be acknowledged too many.