III. County Machinery

1. Clearing house for facts regarding school hygiene taught and practiced in all schools within county limits; this to be maintained by the county superintendent of schools.

2. Physician and nurse to organize inspection and instruction for rural schools, to give lessons and make demonstrations at county institutes, to show teachers how to interest physicians, dentists, health officers, and parents in the physical welfare of school children.

IV. Town and Township Machinery

1. Teachers intelligent as to physical needs, as to sanitation of buildings, etc.

2. An examining physician, to be salaried where the population justifies; elsewhere to work as a volunteer in cooperation with teacher and with county physician.

3. Physical history of each child from date of entrance to date of leaving school, to be kept up to date by teacher.

V. City Machinery

1. A division to be known as the Department of School Hygiene, headed by an officer who gives his entire time to that department.

2. A subcommittee of the Board of Education.

3. Clearing house for facts regarding school hygiene taught and practiced in all schools within city limits.

4. Specialists to examine applicants for teaching positions, and to reexamine teachers to determine fitness for continuance, for promotion, and for special assignments.

5. A bureau for inspection and control of all hygiene of school buildings, old and new, with power to compel repairs or to reject plans that do not make adequate sanitary provision.

6. Similar supervision of curriculum and of study hours prescribed.

7. A bureau for the inspection and control of curriculum, required home study, exercise, physical training, etc., so far as relates to the health of pupils, and to the physical ability of children to be in certain grades or to be promoted. This will decide the duration of lessons, frequency of intermissions, sequence of subjects, time and method of recess throughout the various grades.

8. Supervision of indoor and outdoor playgrounds, roof gardens, indoor and outdoor gymnasiums, swimming pools, etc.

9. Supervision of instruction in school hygiene.

10. A staff of inspectors for communicable diseases of pupils and teachers, to be subject to the board of education or the board of health.

11. A staff of examiners adequate to examine all children and teachers at least once a year for defects of eye, ear, teeth, nose, throat, lungs, spine, bones, glands, etc., and for weight and height to be under the control of the board of education or the board of health. The expense would not be as great as the penalty paid for omitting such examination.

12. A staff of nurses to assist medical examiners to give children practical demonstrations in cleanliness, to teach mothers the care of children both at their homes and in mothers' meetings, to enlist the cooperation of family physician and neighborhood facilities, such as hospitals, dispensaries and relief agencies, magistrates' courts and probation officers,—all to be under the control of the board of education or the board of health.

Whether inspectors, examiners, and nurses shall be directed by the board of education or the board of health is a question that it is impossible to decide without knowledge of local conditions. So far as state and county organizations are concerned, it is clear that whatever the boards of health may do, it will be necessary for state and county superintendents of education to equip themselves with the machinery above recommended. In cities it is quite clear that a board of education should be responsible for all of the machinery suggested, excepting the three divisions that have to do with work hitherto considered as protection against transmissible diseases, namely, inspection, examination, district visiting. In Cleveland these are school duties. In New York they are duties of the health department. Boston has school nurses and health department physicians. The state law of Massachusetts provides that where health boards do not examine school children, school boards may spend money for the purpose.

As to inspection for transmissible diseases, it seems quite clear that health boards should not delegate their authority or responsibility to any other body, for they alone are accountable to their communities for protection against contagion. It is clear, too, that in the interest of community health, departments of health are justified in pointing out in advance of contagion those children most likely to become a menace. Similar grounds of public interest justify the health boards in sending nurses and physicians to the home as a means of getting things done.

Dr. Biggs feels that responsibility for the physical welfare of school children will strengthen health work in all cities, and, given proper interest on the part of school officials, should make possible universal cooperation in a constructive programme. On the other hand, he believes that division of responsibility between school and health boards will weaken both in their appeals for funds and for support of a constructive programme. I have heard principals and superintendents maintain also that the moral effect of a visit to the school by a representative of the health board vested with powers of that board was much greater than a visit by a representative of the school board. They further allege that a physician coming from the outside is more apt to see things that need correction and less apt to accept excuses than an inspector who feels that he belongs to the same working group as the school-teacher. Because the follow-up work in the homes incident to successful use of knowledge gained at school involves so many sanitary remedies, it is theoretically better organization to hold the health authority responsible.