mistakable in a number of cases, but in many instances masking its presence behind catarrhal symptoms of the air passages, or a suffused condition of the eyes (coryza). The full intensity of this pandemic visitation was probably not felt in the schools until after the close of the service on December 23d, and the evil wrought by it is, as yet, incapable of full estimation. Of the total ailments found, 787, or more than 49 per cent. were affections of the oral and respiratory tracts, and of these tonsilitis and pharyngitis lead the list, the number being respectively 261 and 198, both the acute and chronic forms being included in these figures. Next comes 182 cases of bronchitis in both forms, followed by laryngitis, 51 cases, and rhinitis, 49 cases. These figures serve to show how heavily the brunt of morbid influences falls upon the anatomical tracts under consideration, and what an important part they play in the morbidity and mortality of school life. Diseases of the ear numbered 37 cases, catarrhal and suppurative discharges appearing in 27 cases, while 9 cases of imperfect hearing without visible cause were reported. In affections of the eye, 382 cases were found, 227 of which were returned as being imperfect sight without visible cause. The limitations of the inspection naturally forbade critical examination to ascertain the causes of the defects, or to what extent the statements of the pupils in this respect could be accepted as being trustworthy. The other principal ailments found in this classification were coryza, 67, all forms of conjunctivitis, 34, and strabismus, 20. (It is worthy of mention that many eye cases of a chronic or neglected character were not referred to the inspectors after they had been seen once or twice, in order not to burden unnecessarily the service with multiple visitations from the same individuals.-N. W. S.) Diseases of the skin numbered 45 cases, some of them being of a communicable nature, as tinea in several forms, pediculosis, and impetigo contagiosa. In the class Miscellaneous Diseases, is a total of 274 cases, many of which necessarily rest only upon the statement of the child examined, as headache, neuralgia, gastric, intestinal and urinary diseases, the prescribed scope of the inspection not extending either to the determination of their actuality or cause, if really existent. The principal figures shown here are gastric diseases, 55; headache (habitual) 47; anæmia, 31; intestinal diseases 30, and cervical adenitis, 25.

In reviewing the results of this work it may not be amiss to repeat that its fundamental and controlling purpose was the instant detection of those diseases capable of being passed from child to child, either directly from person to person or indirectly by means of infected things, as books, pencils, toys, clothing, etc. In so far as the medi

cal observation thus exercised extended, it was found that the physical condition of the pupils at the inception of the service was reasonably good, the preceding summer having been not an unhealthy one, and notwithstanding the inclement weather experienced more or less through the fall months, no pronounced tendency toward the development of the more dangerous diseases was observed in the schools. Disorders of the throat and air passages

were, however, very generally noted in the course of the work, which would predispose to and afford favorable conditions and soil for the most malignant diseases of child life, provided the efficient agents of those diseases were introduced. Mention has already been made of the high percentage which diseases of the oral and respiratory tracts hold in the grand total, and in this fact lies a meaning that must be obvious to every medical man. The tonsils and associated mucous surfaces, when irritated or inflamed, constitute a highway for the entrance of diphtheria, scarlet fever, tuberculosis, and probably other infectious disorders; and while such diseases in a severely developed form suffice to detain a child at home, yet there are many cases so mild in character that school attendance is not interrupted, and it is this class that serves to most actively and efficiently spread the disease, while innocent of a knowledge of its dangerous nature; and these walking cases constitute an obstacle to the thorough control of dangerous disorders vastly more formidable than those that are individually of a more severe character. The cases of diphtheria that were found were of this kind, and in their detection and exclusion, as well as in the early recognition of other dangerous ailments, lie the merit and justification of this work as a public health service. The circumstance that local conditions did not concur to develop these maladies to an epidemic intensity, as has been the case here in some other years, does not weigh against this contention. The fact must stand unchallenged that in the public schools are assembled daily the largest numbers of the youthful population anywhere gathered together, comprising all nationalities, classes and kinds, and that here lies the field in which the most strikingly effective public health work on preventive lines can be accomplished. able proportion of ear diseases, with impaired or destroyed hearing and impending dangerous complications, undoubtedly have their origin in disorders of the throat and air passages attendant upon or consequent to measles, influenza, scarlet fever or diphtheria. The results of the inquiries incidentally made into the condition of the eyes and eyesight emphasize the need for expert skill in order to decide, in cases of complaint of imperfect sight, the fact of real visual defect and the proper remedy, or whether the asserted fault was without

A very consider

good foundation. It may, however, be safely assumed that the number of reported cases or habitual headache bears a determinate relation to defective vison among school children; and, indeed, some other ailments may be found to possess such a relationship.3

The following method by which the school inspectors act in harmony with and are agents of the local health board has been found of service in Boston:

"It should be remembered that the boards of health of this State are authorized and required by statute law, to take charge of any case of contagious or infectious disease which may be dangerous to the public health; and while it is preferred that many cases should remain at home and be cared for by the family and the family physician, their isolation at home must be satisfactory to the board of health, and so certified by a medical agent of the board. So also in the discharge of such patients from isolation, the evidence of their freedom from disease, and the safety of their return to school or to the public, must be satisfactory to the board of health and come from its medical agent. For this duty the same medical inspectors are serving as agents of the board of health in the control of infectious diseases which are treated at home. We send to each of the school inspectors every morning a bulletin of the cases of diphtheria and scarlet fever which have been reported during the previous twenty-four hours. Each medical officer selects the cases reported in his district, visits them to see if they are properly isolated, leaves a card for the attending physician informing him of the official visit, and reports his approval or disapproval of the patient's isolation at once to the board of health. If the patient is properly isolated, the inspector places a card on the door of the room to indicate the official designation of the room for the isolation of the patient. If the case is not properly isolated, and it cannot be commanded at home, he reports the fact to the board of health, and such patient is taken to the hospital. He makes another visit to the patient on the question of discharge from isolation, and again reports to the board of health. If it is a case of diphtheria a negative report from the laboratory to the board of health is necessary, and if it is a case of scarlet fever, desquamation must have ceased, and the fact certified by the agent before such patient can lawfully be released from isolation. The agent of the board is thus held responsible for the proper isolation of the patient at home, for recommending the patient's removal to the hospital when necessary, and for the patient's release from isolation. In other words, the board of health is provided with trustworthy information upon which it can act for the

best protection of the schools and the public against the spread of infectious diseases."

It is hardly necessary to state that the so-called infectious and contagious diseases, specific in origin, are communicated in a variety of ways; and that crowded school rooms, common drinking cups, wardrobes, desks and water-closets are ready agents in transferring morbific material. That these conditions are existent to-day in our schools is patent; and that disease is thus transmitted is a logical outcome. What scientific method of disease detection and prophylaxis is in vogue? To our shame, be it said, there is none. That infective material, such as diphtheric virus, may be attached to the ordinary implements and surroundings of school life, has been conclusively demonstrated in the laboratory by Ernst."

KINDERGARTEN DATA.

If there be any one grade that is by its very environment and manner of existence, more productive of disease transmission, than any other, this grade is without doubt that which is ordinarily termed kindergarten. The following reasons suffice to account for this condition:

1. Large numbers within a comparatively confined space.*

*

*

2. Educational material used in common. 3. Tables and chairs used in common. 4. Cleansing agents used in common.* 5. Games demanding intimate contact. 6. Especial susceptibility of the child (at the kindergarten age).

(These facts have been derived from personal observation in the kindergartens in St. Louis and from information secured from competent kindergarten teachers.)

1. A number of children disproportionate to the cubical contents of the room is the rule. One or two rooms, or one relatively large room divided by arches, or two smaller rooms connected by door spaces, frequently contain from 75 to 100 children. The air is noticeably impure, and is kept respirable only by opening the windows during recess. This is the condition in the more favored schools. In the congested districts twice as many children may receive instruction in the same room daily, being divided into sections. Unusual air contamination, and double the amount of incidental personal soil, are thus introduced into the room. It is unfortunately true that in the congested area the index of personal cleanliness is markedly low, and the probability of disease growth and transmission is proportionately greater. 2. The so-called "gift materials" (balls, wooden blocks, beads, sticks, tablets and rings), are used in common; also, rubber balls covered with wool.

*These conditions are also observable in other school grades.

These articles are not characterized by scrupulous cleanliness, sundry wipings by the teachers, after school hours, being the only care afforded. Even these spasmodic cleansings are not obligatory. The vicious possibilities are apparent. Paste and paste brushes are used in common; and the brush that today may be moistened in the mouth of a child in the early stage of a diphtheritic or scarlatinal infection, tomorrow is absent-mindedly lubricated by an innocent neighbor. Modeling clay duly moistened (perchance surreptitiously by the saliva of a tubercular child or molded by the fingers of an infant with impetigo contagiosa, or one harboring pediculi), is also common property.*

3. The tables ordinarily supplied are 18x36 inches and are supposed to meet the needs of two children. These tables are not only common property, but kindergarten teachers are compelled, when the number of pupils is excessive, to place three or four children at each table, thus adding the further element of contagion-crowding. I can find no record that the tables are ever scrubbed. †

4. In some schools the towels are washed every other day; in some schools a weekly cleansing is deemed sufficient. One basin and one towel are passed from child to child, from 15 to 30 children being supplied by the same agents. This is the condition in the more favored localities, and where teachers voluntarily use some individual caution. In other schools it is a prevalent practice to wash the children (total number wrapped in obscurity) upon one dampened towel. Description of the actual condition of said towel, and its possibilities as a disease transmitter, is hardly necessary.

5. The kindergarten system includes various games. These games require more or less intimate contact among the children. The so-called "circle work games" demand clasping of hands, no selection of neighbors, necessarily, being possible. In the "pigeon house" game, a small circle (possibly six feet in diameter) is formed of children. Within this circle two or more children are placed. All the participants are required to pack together as closly as possible. In the "bird's-nest "game, the same compacting process is noticeable, and the parent bird is supposed to be feeding its young (the child imitating the process by opening its mouth, and, in fancy, dropping some food into the open mouths of its playmates), distance between the two mouths from one to six inches.

6. That virgin soil, relatively speaking, invites

*Modeling clay in the St. Louis kindergarten is supplied in abundance, thus avoiding this source of contagion. -Superintendent of Kindergartens.

Later information shows that the tables are occasionally cleaned by the teachers, not under compulsion. There is apparently a distaste for scrubbing, on account of injuring the varnished tops.

infection is true. And when said soil is infected, that relative virulence is manifest is also true. Changing from the abstract to the concrete, it follows that kindergarten pupils, tender in years, comparatively free from subjection to antedatal contagion, are far more liable to infection than those of maturer years, in whom a phase of resist ance, if not immunity, has been established. That this scientific fact is recognized more or less gropingly by the laity, is shown in the conventional statements of mothers, that their children have had none of the diseases of childhood, "as they are still too young to be sent to school; but next year, when we send them to kindergarten, I suppose that they will catch measles and whooping cough, and all the rest." (These facts have been noted by other observers. They are not peculiar to St. Louis, but are characteristic of the kindergarten system.)

No scientific acumen, nor even unusual intelligence is needed to realize that this intimate contact, these compacting methods, common implements and materials, and careless attention to cleanliness and basic hygienic measures, are prolific sources of contagion.*

GENERAL CONDITIONS.

The kindergarten also shares in other unfortunate conditions common to the higher grade. Common drinking cups, water-closets, wardrobes (where clothing is sometimes hung three or four deep upon the walls, or piled in large baskets, there to be placed in contact with all possible unhygienic and contaminating conditions).† School floors are scrubbed but rarely (probably not more than twice or three times yearly, even under a liberal management). It is considered sufficient to use dust brushes and pan. And the janitor, mantled and aureoled in clouds of dust, as he "cleans up after school," is a vivid reminiscence of school life. Walls and ceilings are practically ignorant of any real cleansing.

It is well known that virulent sputum and infectious material exhaled from the lungs, or discarded by the skin (even though in microscopic quantities), are not only actively infectious at the moment

*It may be noted that our local schools are conducted as carefully as could be expected, when due allowance is made for the usual limitations, and that the teachers in control can hardly be presumed to be versed in up-to-date sanitary and hygienic measures. But in the occasional school or school-room, where carelessness obtains, lurks the menace to the child and the general public; and in these cases inspection is especially demanded.

+Among other school habits provocative of disease tranmission, are the interchange of lead-pencils and pens, transferring of chewing gum from child to child, moistening the carbon (in the mouth) of the so-called "lead-pencil," the use of saliva and sponge for cleauing slates, and the tendency toward promiscuous embracing and kissing, noticeable among girls.

of divorce from the host, but, favored by lack of suitable cleansing and other hygienic agents, preserve their malignant power for weeks-the power for weeks-the more resistant bacteria retaining their power for months.

In the light of these well-known facts, the pernicious possibilities of this method of dry cleaning of schools are apparent. That no vast number of cases has been absolutely traced in their infection career to an original contact with contaminated dust, does not militate against the gravity of this cleansing method-or, to be more accurate, this lack of proper cleansing method.

EXAMPLE OF THE EFFICIENCY OF AN INSPECTION SERVICE.

“Numerous instances have come under our observation where a child has been found in school suffering from an infectious disease, by the medical inspector of schools, and sent home; this case has been followed in due time by other cases in children whose only discoverable exposure was that which occurred in the school room. Fresh evidence of such exposure and of its effect has been brought to my attention within a few weeks occurring in the service of Dr. Arnold, one of our school inspectors. An epidemic of diphtheria occurred in a primary school in which there were 40 pupils, 14 of whom were attacked with diphtheria within a period of

Of the 14 cases, 7

18 days, all from one room. were discovered by the school inspector, and 3 of these only by cultures. these only by cultures. All suspicious cases were dismissed from school May 5th, and recommended to the care of their family physicians. The next morning, every pupil was examined and many cultures were taken. The class was then dismissed from Thursday to the following Monday, the room disinfected and cleaned up. For ten days after their return, the throat of all pupils was examined by the medical inspector when they first assembled in the morning, and no pupil who had been absent with any suspicious symptoms was allowed to return until it was proved by a negative culture that there could be no danger. As a result of these measures not a single case of diphtheria resulted. beyond those known to have been infected at the time the epidemic was discovered. A similar experience with scarlet fever occurred in the service of the same school inspector within two weeks, in which 11 cases resulted from the presence in school of one pupil whose illness had been attributed to German measles."

STATISTICS.

The following statistics have been compiled from the annual reports of the Health Commissioner of the City of St. Louis. Unfortunately, an accurate scarlatinal record for the fiscal year 1888-89 could not be procured.

Cases

Deaths

Deaths

Cases

Deaths

Cases

Deaths

Deaths

Cases

Deaths

Cases

52 19 39 16

22 119 31 77 23 132 144 21 67 11 75 14 62

48 17 27 11 26 10 29 96

26 10 21

137 44 89 341

931

111 30 109 33 51 12 62 40 6 44 19 47 16 44

70 23 50 22 24 11 44

50 16 37 16

60 117

Deaths

Cases *** Deaths

38 138 44 117 36

23 144 37 108

29 88 33 64

17 71

78 15 96

68 26

84

15 88 23 55 20 23 101 27 78 28 67 28 63

21

34

18

12

16

31

12

1

9

15 23 193 36 330 60 615 87 583 8 148 28 159 25 190 8 102 13 159 23 259

37 101 26 107 25 48 191 29 185 21 17 71 10 17 130 21 104

From these two tables the following (Table III), which is self-explanatory, has been deduced. Attention is called to the fact that the average school month produces more cases, and a greater actual mortality, than the average vacation month. It is of interest, however, also to note that the average lethal percentage is heavier during the vacation month in both scarlet fever and diphtheria. It would doubtless be immature to state that the monthly school excess over vacation is due entirely to the existing school session. Yet, that the congregation of large numbers of children in our schools during ten months of the year is not only a factor, but probably a very important factor, in disseminating contagion, and thus increasing disease prevalence, can hardly be controverted.

CONCLUDING STATEMENTS.

Many of the unfortunate conditions herewith noted merit attention. But it would be absurd to presume that they would, or in certain instances could, be rectified, on demand, or even after a considerable lapse of years. "The enrollment of pupils for the past fiscal year was 81,917." It is highly improbable that the municipality would furnish to our public school youth 81,917 individual wardrobes, drinking cups, water-closets and toilet requisites; that school interiors would be daily, or even weekly, scrubbed; or that the daily physical condition of every child be certified by a competent medical man. These improbable possibilities are

*It is almost gratuitous to observe that no effort is being made to overthrow the present public school system, nor to shake the confidence of the public therein. Its manifold excellencies are manifest. But like all other "systems," it contains factors with vicious possibilities. Against these do we strive, and toward their amelioration, if not actual removal, are these suggestions made. At best, the inspection service, as outlined here, is relatively inadequate. The public is not yet educated to the plane that will permit appreciation of up-to-date medical and sanitary supervision. The excellent work of Francis Galton in his anthropometric laboratory in the Kensington Museum foreshadows the possibilities of scientific medical control of schools.

21.5 7.67

26.48

3.62

519.2

97.3 22.86

| necessarily not germane to the scope of this discussion; they obscure, rather than clarify, the field of investigation. But daily medical supervision will counteract many unfortunate conditions, will eradicate many more; intelligent and painstaking observance of basic sanitary laws is both possible and feasible; and the public should not condone neglect of these simple and wise policies. The right of the child to truly hygienic surroundings physical, in all that that implies to-day, as well as to truly hygienic surroundings mental, is paramount. Any selfish, partisan, or otherwise narrow-minded act that militates against full fruition in response to this demand-this right-is a crime.*

BIBLIOGRAPHY.

'Durgin: Transactions Massachusetts Medical Society, ‘97. 'Durgin: Transactions Massachusetts Medical Society, '97. Transactions Medical Society of the City Hospital

Alumni, also MEDICAL REVIEW, January 28, 1899. 'Durgin: TransactionsMassachusetts Medical Society, '97. Durgin: Transactions Massachusetts Medical Society, '97. "Durgin: Transactions Massachusetts Medical Society, '97. 'Durgia: Transactions Massachusetts Medical Society, '97. 8Forty-forth Annual Report of the Board of Education of City of St. Louis.

3505 Franklin Avenue.

Treatment of Chronic Catarrhal Otitis by OtoMassage.-C. R. DUFOUR' advises the use of a small electric air-pump, the valves of which are so arranged that the membrana tympani is drawn forward, and the air escapes on the return stroke of the piston, thus allowing the membrana tympani to return on its own accord, and obviating compression.

*It is self-evident that all these statements, applicableto the public schools, are also applicable to other schools, such as the so-called " private" and parochial. From a scientific standpoint medical supervision in these sohools is important in direct proportion to their numerical size, and the relative efficiency of their sanitary equipment.

Journal of the Americun Medical Association, April 15,

1599.