a single small classroom, with two or three children sitting at the same desk. Classrooms lacked ventilation and fresh air, a problem exacerbated by using stoves for heating and gaslights for illumination. These problems continued in New York City even into the early twentieth century, and no doubt the situation was not unique to New York (Duffy, 1974).

The era of school "medical inspection" began in earnest at the end of the nineteenth century (Means, 1975). In 1894, Boston appointed 50 "medical visitors" to visit schools and examine children thought to be "ailing." By 1897, Chicago, Philadelphia, and New York had all started comparable programs, and most of the participating medical personnel provided their services without compensation. The success of these early programs developed into more formalized medical inspection. In 1899, Connecticut made examination of school children for vision problems compulsory. In 1902, New York City provided for the routine inspection of all students to detect contagious eye and skin diseases, and employed school nurses to help the students' families seek and follow through with treatment. In 1906, Massachusetts made medical inspection compulsory in all public schools, a step that ushered in broad-based programs of medical inspections in which school nurses and physicians participated. Legislative mandates became the means of ensuring medical inspections, and legislation continues to this day to be the basis for many elements of school health programs.

Around the turn of the century, the role and advantages of school nurses began to be recognized. In 1902, Lillian Wald demonstrated in New York City that nurses working in schools could reduce absenteeism due to contagious diseases by 50 percent in a matter of weeks (Lynch, 1977). For minor conditions, nurses treated students in school and instructed them in self-care. For major illnesses, nurses visited the homes of children who had been excluded from school because of illness or infection, educated parents on their child's condition, provided information on available medical and financial resources, and urged the parents to have their child treated and returned to school. School nurses began to assume a major role in the daily medical inspection of students, treatment of minor conditions, and referral of major problems to physicians. By 1911, there were 102 cities employing cadres of school nurses. In 1913, New York City alone had 176 school nurses (Means, 1975). This expansion of the role of school nurses freed physicians to spend more time in conducting medical inspections of individual students with recognized needs rather than in inspecting entire classes.

Medical inspections in the early part of the century were no doubt perfunctory and superficial. For example, in New York City in 1904, it was reported that 8,261,733 examinations were given and 515,505 students were treated by school nurses and physicians, yet the total number



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