Copyright }j°_ COPYRIGHT DEPOSIT. "In the schools of Hellas at least one aspect of school hy- giene, namely, physical education, was recognized as a means of developing the ideal citizen — the true function of educa- tion." — Hogarth. "A national school which trained the minds only and neg- lected the bodies of the pupils would have been inconceivable to a Hellene." — Freeman. THE HEALTH INDEX OF CHILDREN BY ERNEST BRYANT HOAG, M. A., M. D. MEDICAL DIRECTOR OP BERKELEY SCHOOLS, LECTURER IN PUBLIC HYGIENE IN THE UNIVERSITY OP CAL- IPORNIA, AUTHOR OP "HEALTH STUDIES." MEMBER OP THE ROYAL SANI- TARY INSTITUTE, LONDON WITH PRBPATORY NOTE BY FRANK F. BUNKER, Ph. B. SUPERINTENDENT OP BERKELEY SCHOOLS SAN' FRANCISCO WHITAKER & RAY-WIGGIN CO. 1910 v3 ^^o^ Copyright, 1910 WHITAKER & RAY-WIGGIN CO. C CIA'^78688 TO MY BROTHER JUNIUS CLARKSON HO AG, M. D. TO WHOSE SKILLFUL, MINISTRATIONS, MANY CHILDREN OWE THEIR HEALTH AND HAPPINESS PREFATORY NOTE. More than two thousand years ago, Plato said that "Med- icine is the science of health," and one of the most common- place of our proverbs tells us that "Prevention is better than cure," yet today it is only with the greatest possible difficulty that the public can be convinced that the prevention of de- fects in school children is better than their cure. It will not be long however, before every school, which makes any claim to progressiveness, is provided with intelligent supervision of the health conditions of its pupils. In the larger places this work will be placed in charge of experts who have been practically trained. Many places, however, are too small to justify the expense of securing experts. In such situations the teacher must be relied upon for services of this character. Indeed even in the larger cities where a corps of trained ex- perts have the work in hand much must be demanded of the teacher if the work be successful. It is therefore important that every teacher familiarize herself with the fundamental things which are now known about the health conditions of the child. An intelligent teacher or parent even though he may not have had technical training, can easily learn to observe the ordinary signs and symptoms which indicate physical defects, for these relate to such points as posture, appearance of teeth, mental activity, colds, deafness, offensive breath, mouth breathing, inattention at home or in the school room, and delinquency in studies. The significance of these symptoms is obvious to the thoughtful individual even though he may never have had the advantage of special preparation. The purpose of Dr. Hoag in this book is to give to teachers and parents a series of suggestions drawn from his own Prefatory Note broad and rich experience, which if carefully apprehended, will lead to intelligent action. Many persons interested in this movement have searched without success for a simple work of this character written in untechnical language. I believe the writer has been happy in making clear and help- ful that which most observers have found confusing. FRANK F. BUNKER, Superintendent of Schools, Berkeley, California. INTRODUCTION. The Health Index of Children. A few years ago a child was considered in health so- long as he did not show the familiar signs of disease. Even doctors often failed to read the plain language of many physical defects because they had not been trained to do so. In most places it is still not custom- ary to regard a child as unhealthy because his upper teeth are prominent, uncovered by his lip, and perhaps crooked. Yet every teacher, parent, and physician ought to know that such a picture presents almost sure signs of adenoids, and that no child with adenoids can be truly healthy. Few school communities even now regard decayed teeth in a child as indicative of poor health, yet it is an incontrovertible fact estab- lished by the highest authorities that no child or even adult with seriously defective teeth can possibly pos- sess good health. We have always been accustomed to certain bad conditions which because of their frequency of occur- rence have never been regarded seriously. Many such conditions in children have, therefore, always existed without exciting comment. They have usually been accepted as incidents of childhood, and their possess- ors as types, deserving no special attention. Now a Introduction cross-eyed child is not a necessary type, nor is an ear- ache a natural incident in any child's life. Both are positive signs of underlying serious causes, and are in themselves only secondary results which might usually have been rather easily avoided. ]\Iany signs of physi- cal troubles among children may be read by anj^one who will take the trouble to learn the language. To this sort of observation Mr. W. H. Allen has given the title, "Reading the Health Indexi." The most valuable asset that any child can possess is good health. This consideration of health as essen- tially valuable in life, is largely a new conception, and is characteristic of the trend of thought of the Twen- tieth Century. AYithout good health no individual can possibly live up to his highest ideals physically, mor- ally', intellectually, or even commercially. He is handi- capped in life's race. The health of the child very largely determines the success of the adult, and what we should be most concerned about in education is the laying up of vital assets for use in the active battle of life. Individual and national vitality are the dominant notes today. "Poor seed yields poor fruitage." In the past this obvious fact has been largely ignored as far as it applies to the health of children, but today the most progressive schools in every country are ser- iously attem])ting to imi)rove the seed from which nations grow, for good citizenship mostly depends up- on the vitality of the seeds from which citizens s])ring. For this reason the development of a sound body is 'Civics and Healtli (Allen). Introduction rapidly becoming the most important function of the School in the education of the child. You cannot properly educate a child who has not good health, so one writer has said, and another prominent school man has gone so far as to say that in the light of recent information relating to the health of school children, a community which neglects the systematic care of its school population is guilty of criminal negligence. We must so educate children that they will possess good health and keep it in after life. ''Education's highest aim is to train us to do the right thing at the right moment without having to think." The right thing in health will be done only when we are so edu- cated that we do not have to think about it. This book is an outgrowth of a series of lectures given to teachers in the Schools of Berkeley and Pasa- dena, to mother's clubs in the same cities, and to my classes in School Hygiene in the University of Califor- nia. The material has, therefore, been pretty well tried out, before being placed in book form. The object of this little manual is to show teachers and parents how to detect easily those ordinary physi- cal defects of the child which bar his progress in school and life, and to suggest means by which such defects may be removed and good health afterwards main- tained. Incidentally it may prove of some value to physicians who are for the first time applying them- selves to this special sort of Public Health work. While most of the material presented here has been drawn from my own rather extended experiences as Medical Officer in schools, I have made full use of Introduction many well known works on Child Hygiene and related subjects. Reference is made to these in foot notes throughout the book. To Professor Alexis F. Lange, of the department of education of the University of California, I am indebt- ed for reading and criticising the proof sheets from the point of view of the University student's need: to Professor Kemp, of the Han Diego Normal School for similar service from the standpoint of the Nor- mal student's requirements. Several Superintendents, teachers and Medical Inspectors of California public schools have furnished valuable suggestions, for which I am si)ecially grateful. The publishers of the author's ''Health Studies," (I). C. Heath & Co.) have court- eously given me permission to use certain extracts from that book. Berkeley, California, October 1, 1910. CONTENTS PART I. THE HEALTH INDEX Diagnostic Table 13 I. The Nose, Throat and Ear 17 II. Defects of Vision • . .31 III. Defective Teeth 39 IV. Contagious Diseases and Scliool Sanitation . . 47 V. Nervous Disorders of Children .... 75 VI. Some General Disorders of School Children . 92 VII. Defects of the Feet . . . . . .98- VIII. Posture .105 PART II. THE CHILD AND HIS ENVIRONMENT IX. Foods for Children 115 X. Health at Home in Relation to School Health . 128 XL The Health of the Teacher 136 PART III. HEALTH ORGANIZATION IN SCHOOLS. XII. An Office System for School Health Departments 153 XIII. A General Plan for Health Supervision in Schools 165 XIV. Some Details of the Physician's Examinations . 177 XV. The Co-operation of School Health Departments With Other Agencies 181 Bibliography 186 PART I THE HEALTH INDEX Diagnostic Table DIAGNOSTIC TABLE Signs of Disorders and their Indications. (To be observed by teacher or parent.) SYMPTOMS. Mouth breathing Prominent upper teeth Loud breathing Nasal voice Catarrh Running nose Frequent colds Sore throat Offensive breath Cough Blank expression Slow mentality Deafness Poor physical development Earache Discharge Inattention Poor spelling Watching of lips Slow progress Headache INDICATIONS. Disorders of Nose, Throat and Ear. (Chapter I.) Sore eyes of any kind Styes Congested eyes Crossed eye Squinting Headache Peculiar postures when reading Holding book too near face Poor reading or spelling Dizziness Bye Disorders and y Defects. ' (Chapter II.) 14 DiAGNOsi'ic Table Decay of teeth Discoloration Crooked teeth Prominent teeth Offensive breath Poor articulation Broken teeth Mal-nutrition Teeth Defects. (Chapter III.) Pallor Flushed face Eruptions Scratching Sleepiness Lassitude Vomiting Headache Cough Running nose Congested eyes Contagious Diseases >- (Chapter IV.) Inability to hold objects well Spasmodic movements Twitching of eyes, face or any part of the body Irritability Fits Bad temper Fainting -Nail biting Undue emotion of any sort Frequent requests to "go out" Timidity Stammering Cruelty Perverted tastes Moroseness Solitary habits Undue embarrassment Undue activity Misbehavior Sex perversions Nervous Disorders. (Chapter V.) Diagnostic Table 15 Pallor Emaciation Enlarged glands in neck Puffiness of face or eyes Shortness of breath Lassitude Perverted tastes (e. g. foods) Slow mentality Peculiar or faulty postures Under development Excessive fat Vicious personal habits Low endurance power Irritability Disinclination to play Fatigue. Walking "pigeon toed" A shuffling, inelastic walk Toeing markedly out Advancing foot by exaggerated knee action Long axes of foot and leg meet at unusually wide angles Shifting from foot to foot Standing on outer edge of feet Locking knees Leaning against wall or desk Shoes run over at either side Front of heel worn down Outer and back part of heel worn down Wearing out of soles ^.syxaetrieally Congestion of the feet Swelling, puffiness Excessive perspiration Callouses Twitching of the foot muscles Nutritional and Gen- > 'eral Disturbances. (Chapter VL) >*Defects of the Feet (Chapter VII.) Incorrect Posture. (Chapter VIII.) Unequal height of shoulders Standing on sides of feet Prominent abdomen Flat chest Curved back Stooping *The teacher should remember always that painful "weak feet" are not necessarily flat and conversely that flat pronated feet may not be painful. No child will present all of the above symptoms. CHAPTER I THE NOSE, THROAT AND EAR. Among the common defects of children those of the nose, throat, and ear probably hold first place and of these, adenoids are perhaps of the greatest interest to a teacher or parent. It is quite impossible to state just what number of school children suffer from ade- noids, but it is safe to estimate the proportion at one in every seven or eight children between the ages of five and fifteen. Adenoids consist of soft vascular tissue forming a third tonsil. It is normal enough until it becomes overgrown. This tissue is found behind the soft palate between the nose and throat. It may completely close this passage and in many cases it becomes so closed when the child takes cold. For this reason an adenoid child breathes part or all of the time with the mouth open. This condition is what is known by the term "mouth-l)reathing." Mouth-breathing is not a bad habit that the child has acquired, but indicates that he cannot secure air in the normal manner through the nose, and must get it by breathing through his mouth. The child does much the same sort of thing that we do when we find the air too close in a badly ventilated 18 The Health Index of Chh.dkex room, we open the window. The child opens the only window he possesses which is his mouth, and thus ob- tains the necessary supply of oxygen. But even under the best of circumstances such a child labors under breathing disadvantages and probably never gets as much oxygen as his body needs. When one considers that many adenoid children spend much of their time in illy ventilated school rooms and sleep in bed-rooms with tightly closed windows, it is apparent that they labor under a con- stant and serious handicap.^ A Sectiou Through the Nose aud Throat Showing- Location of Ailenoirts (Fig. 1.) Adenoids may occur in infants a few months old but are more likely to be first noticed between the 'Of 500 children questioned In the Berkeley schools, it was found that 2'i% of them habitually sleep in totally unventllated bed-rooms. The Nose^ Throat and Ear 19 ages of three to five years. After puberty (12 to 16 years) thej tend to disappear and are seldom found in adults. Because of this well known fact many parents, and unfortunately some physicians, prefer to allow nature to remove the obstruction by her own methods. The child will "out-grow" this, that, and the other difficulty, is a very common expression among such individuals. As a matter of fact there are rel- atively few physical difficulties which children unaided ever "outgrow" successfully. Adenoids, it is quite true, tend to disappear or be absorbed spontaneously, but they leave in their wake a most unfortunate train of results. Usually the teacher and most parents first detect adenoids by means of these unfortunate results. When the symptoms are so pronounced that they are apparent to the rather inexperienced observer, much harm has already been done. Reading the Index of Adenoids. Let any teacher look over her room of twenty or more pupils and she will nearly always discover sev- eral with some or all of the following signs or symp- toms of adenoids : 1. A listless expression (the adenoid face.) 2. A nasal voice. 3. Open mouth (part or all of the time.) 4. An under-developed chin. 5. Prominent and often crooked upper teeth. G. A short upper lip (a relative matter.) 7. A rather heavy expression in the eyes. 8. A pronounced tendency to colds and catarrh. 2U The Health Index of Chh.duen 9. Slow mentality. 10. A pale face. 11. An under developed physique. 12. A contracted chest. 13. Ear ache. 14. A running ear. 15. Deafness. Of these signs and symptoms the most common and apparent are nasal voice, crooked and prominent teeth, earache, deaf)tess, and mouthhreathing. At home it will be noticed that the adenoid child sleeps Avith his mouth open, often snores, and some- times has "night terrors.'' If one looks into the mouth the palate will usually be found very high-arched in- stead of broad as in a normal individual. In the ma- jority of children, the tonsils Avill be found enlarged, and in many of them the lymphatic glands ("kernels") in the neck are swollen. It is apparent then that adenoids produce various deformities which no child will "out-grow" however completely the adenoid tissue itself may disappear. These deformities are chiefly the following: 1. Prominent upper teeth. 2. Crooked upper teeth. 3. Receding or small chin. 4. High arched palate.^ iThe high narrow palate pushes upon the nasal septum caus- ing it to become bent (deflected). This is a common cause of catarrh in the adult. The Nose^ Throat and Ear 21 Children with adenoids usually possess less physi- cal resistance than other children. They fall easy victims to colds and various other contagious diseases, and have little physical endurance or mental vigor, They make slower progress in school and in general are much less buoyant and happy than the normal child.2 Adenoids ought to be discovered before these unfor- tunate results have occurred. This is the duty of the parent and family physician. The first indications of inability to nurse well, mouth-breathing, (while awake or asleep), snoring, and a tendency to colds and catarrh must excite suspicion and the child should then receive a thorough examination by a competent physician. Let no parent trust the individual who tells him that his child will "out-grow" such condi- tions unless he has made a careful examination and has eliminated the possibility of adenoid obstruction. Diseased Tonsils. About one-eighth of school children appear to have seriously diseased tonsils. Most children who have adenoid tissue of sufficient importance to require re- moval, also have enlarged tonsils. This is easy to understand when we recollect that what we call "ade- noids" are made up of a third tonsil and consequently their structure is much the same. Enlarged (hyper- trophied) tonsils when they do occur without the pres- ence of adenoids are seldom easy to diagnose by meth- •It appears from our present investigations and especially those of Mr. Ijeonard P. Ayres that children with adenoids spend nine and one-tenth years in the eight elementary grades. 22 The Health Index of Children ods of siipei'licial observation. However, a child who is subject to frequent attacks of sore throat, one who has offensive breath or a child with a thick voice, ought to be under suspicion of having enlarged or otherwise diseased tonsils. A history of qiiiiisij or tottsilitis nearly always indicates tonsils which are abnormal. It is rare that children who have normal tonsils are troubled with an}' form of sore throat. Acute sore throat always requires the most careful attention. No one can distinguish ordinary tonsi litis from diphtheria unless a culture is taken from the throat and a micro- scopical examination is made. A case of diphtheria which is not recognized early is a very serious matter and often results fatally. This is a fact that teachers and parents ought always to understand in consider- ing the tonsils. ]Many tonsils have small holes or crypts in them which become filled with a white cheesy material. Such tonsils are diseased and retpiire careful attention. Sometimes tonsils are so greatly enlarged that they may be observed by merely asking the child to open his mouth. Remember that normal tonsils are barely risihJe, on each side of the root of the tongue. It ap- pears that pupils suffering from enlarged tonsils re- quire about seven-tenths of a year longer to complete their work in the grades than does the normal child. The Ears. Ear troubles of various sorts are very common among children and they often interfere seriously with progress in school. The commonest troubles with the ears are the following: Thk Nose^ Throat and Ear 23 1. Earache. 2. Ear Discharge. 3. Deafness. Deafness may affect one ear only. It may affect both ears and yet be very slight. It may affect both ears serionsh'. In fact all degrees of deafness are discovered among school children when the hearing is carefully examined. When deafness is discovered it AVill usually be learned that the child has, or has had, adenoids, (see discussion of adenoids). There will usually be a history first of ear ache, followed sooner or later b}' discharge or what the child invariably calls running car. On the other hand, pain in the ears or discharge, or both, indicate that unless promptly treated deafness will inevitably occur in the great majority of cases. Pain, discharge, and deafness are not inci- dental conditions to be rather expected in childhood, as so many parents seem to suppose. They are in reality warning signals of conditions which unless heeded lead to serious and often permanent defects of hearing. "Pain in the ears is almost always an indication that an acute inflammatory process is developing. Ear-ache is of the greatest diagnostic value in all di- seases of the ear, and as a rule is the only (or at least earliest) symptom observed by parents, teachers, and physicians. * * * Ear-ache may be, and as a rule is, the onl.y symptom indicating the development of an acute disease of the middle-ear with all its pro- found and alarming complications, even of the mem- branes of the brain (brain-fever)." * 24 The Health Index of Children In this same article by Dr. Zuill parents are most strongly advised against treating children with ear- ache drops. Such treatment only serves to give a false idea of security and never cures the conditions which are causing the pain. Pain of all sorts is Na- ture's warning signal that something is wrong. It is not a disease but a symptom of disease. It is never right to stop the pain without first attempting to discover its cause. Pain is like a bell-buoy on a danger- ous rock — it points to the place of trouble. One may easily stop the bell from ringing, but the danger- ous rock is still there. The Index of Ear Defects. Resides the symptoms named, pain, discharge, deaf- ness, there are other indications of ear troubles (one or several of which may present themselves,) which an intelligent teacher or parent ought to be able to detect. These include the following: 1. Inattention. 2. Headache. 3. Poor Spelling. 4. Expressionless Voice. 5. Imperfect Articulation (because clear speech is not heard). 0. Irritability. 7. Stupidity of Countenance. Many children learn to spell by hearing rather than by sight, and consequently such pupils if deaf are considerably hampered in this respect. *Earache in Children, Los Angeles Medical Journal, January 1905, Dr. W. L. Zuill, Pasadena. The Nose^ Throat and Ear 25 One ought always to keep in mind tliat catarrh leads to deafness, and in itself indicates the necessity for an examination of the hearing A child with normal hear- ing should hear the tick of the average watch when placed in a line with the ear, about two feet away. In testing the ears the eyes should be shut and one ear closed with a finger of the same side. A loud whis- per with lips turned away from the listener should be heard about 25 feet away. To what extent de- fective hearing interferes with school progress is not at present possible to state exactly. That it does exert a definite unfavorable influence is, however, abundantly proven. The following rather ordinary cases of ear, nose and throat defects taken from a great many others among my experience, will illustrate what may be found in almost any school anywhere. 1. A twelve year old girl showed signs of very poor general physical development. She was stunted in growth, had red eyelids, was slightly deaf, possessed a very slow mentality and suffered from constant colds. The usual physical examination at school showed enormous tonsils nearly meeting in the middle line of the throat. The nose was also obstructed with ad- enoids. As the parents could not afford to pay Tor medical treatment the child was sent by the school nurse to a competent specialist who volunteered treat- ment. Since her operation the child's eyes are nearly well, her hearing is acute, she seldom has colds, and her growth and general mental and physical condition have greatly improved. 2G The Health Index of Children M ^^^^^^r ^^^H ^ ^^1 ^^^H A Type of Child Often Seen in the Sehools (Adenoids.) 2. A little girl of seven years suffered from constant ear-aclie and rnnning ear. For a long time the mother had washed out the ear Avith a strong solution of tea. She said that the child had had ear trouble since she was two years old and supposed she would always have it so saw no need of consulting a doctor. She Avas finally persuaded to bring the child to the clinic where proper treatment, including the removal of adenoids, practically cured the condition in five week's time. 3. A boy fourteen years old had been deaf for nearly a year and ear ache was almost constantly present. He The Nose^ Throat and Ear 27 had never been takeu to a doctor but the well-meauing though misguided mother had carefully poulticed, his ears each uight with Jiot hrcad. It Avas quite im- possible to make this mother understand the harm that this sort of treatment was doing. iVt last, as the boy's condition became much worse, the mother consented to have him sent to a ph^'Sician. An examination showed that both ear drums were ruptured and that there was chronic inflammation of the middle ear present. The boy received the best possible care and at present is at least free from pain. In this case permanent deafness might easily have been prevented by early detection of the trouble and prompt medical attention. As it is the boy's earning power in the world is greatly reduced and he will pass through life with a serious and quite unnecessary handicap. The common habit of putting good food in bad places would be funny if it were not often so serious a matter. Ears are washed with hot tea; sore throats (sometimes diphtheria) are wrapped in hacon; sore chests are cov- ered with stewed onions; boils are poulticed with hread and milk; and various other articles of food are wasted on the outside when they miglit do considerable good on the inside. 4. A young girl of about sixteen jeava of age was employed in an Oakland Market where she worked daily on a wet asphalt floor. Repeated attacks of sore throat and rheumatism affecting many joints, brought her to a physician who at once discovered very large hui-ied tonsils, although an ordinary inspection of the throat showed little evidence of tonsilar disease. A 2S Tiiic Health Index of Children heart murmur was also discovered, iDdicatiug a prob- able infection tlirough tlie tonsils. Immediate re- moval of the tonsils was advised to prevent further in- fection, with more serious heart complication. This advice was however ignored, and one month later the girl died of endocarditis, i. e. inflammation of the heart. This intlammation of the heart was, in this particular case, undoubtedly brought about by direct infection through the diseased tonsils, and prompt surgical attention would probably have prevented the disastrous result which followed neglect of treatment. The close relation which often exists between di- seased tonsils, tonsi litis, rheumatism and certain forms of heart disease is frequently observed by medical men. 5. In looking over a 5th grade one day I observed a child of singularly listless apathetic appearance. She was pale and anaemic; she breathed with her mouth oj>en displaying a set of extremely crooked and decayed teeth. Her voice was nasal and her articulation most imperfect. Her progress in school had been slow and generally unsatisfactory. Upon closer investigation I found an extraordinarily high arched palate and tlie roof of the mouth so contracted that the forefinger could be barely passed in betAveen the up])er teeth of each side. The tonsils were large and adenoids ob- structed the nose. Notification to the parents of the condition present produced no result, nor did a home visit on the part of the nurse. One year later this girl now thirteen years of age, was sent to me again for ex- amination. The second teeth were now erupting in the most irregular manner possible, and the roots of the The Nose^ Tpiroat and Ear 29 first teeth everywhere surrounded them. The deep narrow slit forming the roof of the mouth was filled with erupting second teeth, much delayed by the presence of the persistent but decayed first teeth. Mas- tication had become practically impossible because of ')iial occlusion of the teeth, and the child showed every evidence of j)rofound nutritional disturbance. Her ig- norant parents still think that she is too young to have the condition attended to and that in a measure she will "out-grow" the trouble later. In the meanwhile Mary is very rapidly developing a deformed face and a jaw with teeth more like those of some fishes than a humau being's, for the inside of her mouth is now filled with misplaced teeth ! Resume on Nose, Throat, and Ear Troubles in Children.* An examination of school children shows that many of them suffer from nose, throat, and ear troubles. Probably at least 25% of our children in the schools of the United States have such defects. Why this is so we do not exactly know. Parents are very likely to be unfamiliar with these con- ditions. Often they do not know when their own children are afflicted in this way. No child can do his best work in school if he is suffering from some nose, throat, or ear trouble. The commonest conditions found in such children are enlarged, diseased tonsils, adenoids, earache, ear discharge, and deafness. The tonsils are glands in the throat, one on each side of the root of the tongue. When they are in a healthy con- dition they are barely visible. They often become much inflamed and sometimes there is pus present in them. They may obstruct breathing. Any child with diseased tonsils is likely to be sickly. *The following is published in pamphlet form for distribu- tion in the parent's clubs of the Berkeley schools. • >0 Tiiio Health Ixdiox of Ciiilhukx Any child with diseased tonsils is likely to have many at- tacks of sore throat, or tonsilitis. Diseased tonsils may result in Rheumatism and disease of the heart. Any child with diseased tonsils is very susceptible to con- tagious diseases. Any child with diseased tonsils has an increased tendency toward consumption. No child can be well or do his best work in school with diseased tonsils. Diseased tonsils should usually be removed and should always be treated. The operation is not dangerous. It always improves the child's health. Adenoids are soft spongy growths behind the soft palate, between the nose and throat. A child with adenoids usually breathes with his mouth open. He cannot breathe well through his nose. Mouth breathing is not a habit. Adenoids cause a child to sleep with his mouth open. Adenoids often cause a child to snore. Adenoids nearly always make the teeth come in crooked. Crooked and prominent teeth are nearly always caused by adenoids. Adenoids make a child take cold easily. Adenoids often give a child a stupid appearance. Adenoids often result in actual stupidity, because the child cannot get enough air. Adenoids often cause earache and deafness with some- times a running ear. Catarrh, deafness, earache and dis- charge from the ear, are more often due to some obstruction in the nose or throat than to anything else. Adenoids usually result in delicate health. Adenoids must be removed if you expect a child to be healthy or mentally bright. ■ It is an injustice to children to neglect caring for them when adenoids or diseased tonsils are present. It is very poor economy on the part of the parent to neglect the treat- ment of children so affected. Any child will grow up health- ier, happier, and more useful, if these conditions are taken care of. CHAPTER II DEFECTS OF VISION. Wliile most other defects tend to decrease in num- ber with age and development, defects of vision increase as one passes from tlie examination of the children of the lower to those of the higher grades in our schools. ^ A recent examination in the schools of New York city shows that about 30 per cent of the children suffer from various kinds of ocular defects which are serious enough to require correction. Of 400,000 pupils ex- amined in the schools of Massachusetts, 81,000 had defective ej^esight. iln the schools of Berkeley I have thus far found about 17 per cent with visual defects serious enough to need correction, while in a Poly- technic School in Pasadena, the proportion reached about 35 per cent in my tests during 1908. Eye strain results from various kinds of defective sight and carries with it sooner or later conditions which may seriously affect the nervous system. Many a case of nervous prostration or Neurasthenia has come to an individual in later life from such uncorrected faults of vision. Many a child in every large public school is today stumbling along the educational road, with vision so poor that he cannot read at 20 feet what a child with normal sight reads with ease at 200 feet. In nearly every schoolroom is found one or more chil- dren with "crossed-eye." Test this eye by covering the ^Leonard Ayres has shown that in general "retarded" pupils are less defective than those unretarded, the explanation being that retarded pupils are older. 32 The Health Index of Cphldren straight oue with a piece of card-board aud if the child is over eight or ten years of age, he cannot in the ma- jorit}-^ of cases tell the number of fingers held up at a distance of twelve feet from his face, and often such an eye is practically blind. Yet the early discovery of crossed eye and its complete correction with proper glasses will usually save the sight and often bring the eye around to its normal position. Poor vision not only makes the acquirement of an education a work of great difficulty, but it reduces the earning poiccv of the individual later in life very con- siderably. It is only through our special senses, of which sight is one of the most important if not indeed the primary, that we form anj' notions of the external world. All education in fact is acquired by means of the organs of special sense. Limit any one of these avenues of contact with the world and it is only by means of the over-development in acuteness in some or all of the other sense organs that the defect may be at least in part offset.^ Even then the result is usually quite imperfect and education becomes a difficult prob- lem. Limit or destroy any one of our avenues of con- tact with our environment and a definite receiving area of the brain is dimmed and blurred. Blurred vision for example, may mean a blurred visual area in the brain. Is it any wonder that children with such mental blurs often recpiire a longer period than a nor- mal child to finish a grade or that they complete their work only by the expenditure of an enormous amount of nervous energy? 'The reader is referred to that remarkable and delightful little book by Helen Keller, "The World I Live in." Defects of Vision 33 ^'Education presupposes health." In the past poor vision has never been regarded as an indication of un- sound health. Today we know better. 'The intimate relation betAveen muscle and nerve- center, the functional correlation of every organ with every other, cannot be too thoroughly grasped if a sound theory of training is to be built up." The Index of Eye-Defects. 1. ''Sore eyes," or chronically inflamed eyelids. 2. Styes. 3. Congested (red) eyes. 4. Crossed eye, occasional or constant. 5. Holding book nearer than one foot from the face. G. Inability to read easilj' from the seat the Avrit- iug on the blackboard. 7. Inability after ten years of age to read ordin- ary print at a distance of four inches from the face. 8. Holding the book more than fifteen inches from the face. 9. Squinting or blinking. 10. Reading with the head turned to one side, or sloping the head. 11. Headache. 12. Usually poor readers and spellers. 13. Avoidance of light. 14. Hairless eyelids. 15. Stooping posture. Some interesting and illustrative e^^e cases have come to my attention in the Berkelev and other schools ol The HEAi/rH Index of Children and are brieHy described here because it is evident that siniihir instances will be found in most schools. Only average cases hoAvever have been selected in the follow- ing illustrations. 1. A girl of ten years was very nervous, complained of constant headache, and did very poor work in her studies. The parents were opposed to doctors and refused to allow the child to have her eyes examined or to receive any medical care. The case was reported to the Society for the Prevention of Cruelty to Child- ren and the i)arents forced to let the child have the necessary medical attention. Her eyes were exam- ined, the defect discovered and she was given proper glasses. Since wearing the glasses, her eyes and whole general condition have greatly improved, her headaches have disappeared and her mind is bright. 2. A little boy nine years old had spent two years in the first grade He could neither learn to read nor spell, but he api)eared bright enough and was physi- cally well and strong. An examination of his eyes M'as made and it was discovered that the child could not read ordinary print six iiicJics away from his eyes. He was referred to an oculist at once and given proper lenses to correct his defective vision. In six months time this boy was reading as well as other children of his age, and was able to read some parts of the newspaper to his blind mother. Squint eyes or crossed eyes are found relatively often in our schools, but the seriousness of this defect of vision is rarely realized. Most often the condi- tion is regarded as a Monish, but nothing more. Par- Defects of Vision 35 ents and teachers are astonished to discover that tlie crossed eye after eight or nine years of age and often earlier is sometimes nearly or qnite blind and fre- quently very greatly reduced in powers of sight. 3. I observed tv^^o brothers about eight and ten years of age in one school both of whom had badly crossed eyes. A notice to the father brought him to the oflfice with the remark that he Avas perfectly familiar with the fact that his boj'^s were "cross-eyed" and didn't need a school physician to tell him so. "I would be glad," he said, "if^ my boys had straight eyes and were better looking, but Nature made them that way and I can't afford to spend money beautifying these boj'^s, so I guess they can worry along." This father was a Master Mechanic by trade, but was anxious that his boys should "do something better in life." In his judgment a clerkship was a more desirable position. I demonstrated to him that each of the boys was rapidly losing the vision in one eye and succeeded in showing hira that unless remedied the sight would be lost in the bad eye in each case. I then explained to him about how much this misfortune would reduce the future earning power of his boys. The father listened attentively, the commercial side of the argu- ment appealed to him, and he exclaimed : "Please send me to the nearest oculist, those eyes mvist be saved !" 4. A boy of twelve years of age was reported by his teacher for examination because of a ^'sore-eye." A superficial examination at once showed a corneal ulcer of several da,ys standing, which had been entireh' neg- lected. This boy was an inmate of a high iclass 30 The Health Index of Childuen eliildi-eii's home, yet his condition had never been ob- served by the Matron. Only immediate careful at- tention on the part of the oculist to whom he was re-" ferred saved the sight of the eye. Such oversight of serious i)hysical defects in this children's home was by subsequent examinations of other ])uj)ils from the same place found to be extremely common. Only the ordinary and most evident ailments of childhood re- ceived any attention here, despite the fact that a phy- sician was supposed to care for the health of the chil- dren. This state of affairs exists in most children's homes, as well as in reform schools and other institu- tions for juvenile offenders. 5. A teacher in one of the lower grades had been complaining for a couple of years of extreme nervous- ness and general lassitude No eye symptoms of the usual sort had been observed by herself or by her physi- cian. She had a nund>er of times been on the verge of a nervous collapse and had been almost constantly under medical treatment. A routine examination of the eyes established the cause of the trouble. I'ronounced as- tigmatism existed. When this was corrected with pro])er glasses, all the nervousness and general de- bility disap})eared as if by magic and to her astonish- ment she could read signs and see other common ob jects from the street cars, which formerly she had sup- posed appeared blurred to ever^'one. Defects of Vision 37 Resume on the Results of Uncorrected Defective Eye-tiight.l Defects of eye-sight in school children are very common. Probably at the lowest estimate 20% of the children of our American schools suffer from such defects. These defects not only cause a great deal of trouble in the eyes themselves, but often produce many other serious re- sults, vifhich do not at first seem to be associated with the eyes. The proper treatment of children's eyes will nearly always bring good results. In this way they will often be saved from life-long suffering. A child's education will not be worth much to him if he does not have good eye-sight. The ability to earn a good living depends very largely upon good eye-sight. It is very poor economy to neglect to care for defects in the eyes of children, for sooner or later such children may become bur- dens upon some one. The common defects of the eyes of children are as follows: 1. Near Sight^ — (The eye is too long). This condition is very serious. It not only limits the child's range of vision and prevents his taking part in health giving sports and recreation, but it produces changes in the eyes which often result in practical blindness. 2. Far Sight — (The eye is too short). This condition is more common than near sight. It results in eye strain and often causes squinting, red eyes, headache, nervousness, backwardness in studies, and sometimes digest- ive disorders and poor health generally. 3. At3tigmatism — (Irregular curvature of cornea or lens). This is the most common of all eye defects. It results in blurred vision, headache, nervousness, and other* kinds of discomfort. It may be associated with either near sight or far sight. 4. Cross Eyes or Squint. This is often the result of far sight. It is absolutely neces- •Published in pamphlet form for the use of the parents of the Berkeley school children. o8 The Health Index of Chh.duen sary to have this defect corrected. In children this can usually be done with glasses alone. If the trouble is not cured the vision of the crossed eye will often become poorer and poorer until at last this eye becomes practically blind. 5. Inflamed or Red Eyes. This condition is often caused by a defect in vision, but fre- quently it is due to infection, that is something has gotten into the eyes and carried pus producing germs with it. Serious eye disorders are sometimes "caught" from dirty towels, public bathing pools, dirty hands, or dust. Each child and grown person should use his own towel. Red sore eyes ought never to be neglected. Remember that many cases of sore eyes are contagious and that all such cases need the attention of a doctor. CHAPTER HI DEFECTIVE TEETH. 1 From 50 to 90 per cent of children in the grade schools suffer from defective teeth. ^ Dr. Osier has said that the intelligent consideration of dental hy- giene is of greater importance to a nation than that of the consumption of alcohol, great as that is. In most of our public schools, teachers are attempting to teach Physiology and Hygiene to pupils, the majority of whom possess mouths constantly unhygienic. If the Physiology and Hygiene of the mouth alone were practically and thoroughly taught, it would ac- complish far more good for the child than any amount of the usual perfunctory text book work. Children who recite excellent lessons in Hygiene frequently have conditions present in their mouths which are appalling. Let any teacher who doubts this state- ment examine even superficially the teeth of the pupils in an average grade and she will be convinced of the truth of this statement. Decayed teeth are a constant menace to a child's health. They furnish a lurking place for various sorts of dangerous bacteria. They constantly contain food which has undergone decom- position and which consequently furnishes toxins which are absorbed. Faulty states of nutrition, bad teeth, and enlarged lymph glands in the neck, are ^Por some of the material and forms of expressions in this section the author acknowledges his indebtedness to the ex- cellent pamphlet called "The Why and How of the Teeth." Distributed by the Alameda County Dental Society. 40 The Health Index of Ciih.dren conditions Avliicli usually accompany one another. Bad teeth cause bad digestion, and bad digestion often causes bad teeth. If you have one you are pretty certain to have the other. Many cases of Neurasthenia seem to be due at least in part to diseased teeth. Sir Frederick Treves, the ICnglish surgeon, states that over and over again it would appear as if the want of proper and efficient teeth had been the direct cause of attacks of appciidi- citis. Constipation, says Dr. J. II. Kellogg of Battle Creek, is the most common malady of civilization, ex- cept one — decay of the teeth — and the two disorders often go together. Without good teeth we cannot chew our food pro])erly, and the food is unfit for di-" gestion. The result is indigestion and constipation, poisonous decomposition by bacteria in the intestines, and liability to the whole brood of dangerous dis- eases — such as appendicitis, auto-intoxication, etc. — that come through wrong eating. To have good health we must masticate thoroughly and to masticate thor- oughly we must have sound teeth. One must never imagine that a child's temporary teeth can be safely neglected because a second set comes later. A child rarely has a good set of second teeth if the first have been neglected. It is exactly as important to care for the first teeth both personally and by means of the aid of a dentist, as it is to do the -In the Pasadena and Berkeley Hig-h Schools less than 3% of the students showed uncorrected defects of the teeth." Natural Selection" certainly plays an important part in eliminating the physically unfit from our schools, and to this fact at least in part is due the marked diminution of defects of the teeth in the his?her Schools. Defective Teeth' 41 same for the permanent set. To neglect your chil- dren's first teeth is even a greater crime than to neglect your own, for it stores up endless misery for their later years of life. If systematic examinations were made of the mouths of the children in our public schools and if common sense dental hygiene were enforced, the death rate in this country would be very considerably re- duced, the amount of sickness decreased, and a strong- er race would result in consequence of such rather simple measures. 1 The Index of Bad Teeth. 1. Poor general nutrition. 2. Prominent upper teeth. 3. Inability to keep the mouth closed. 4. Crooked teeth in sight. 5. Decaj^ed teeth in sight. G. Offensive breath. 7. Pallor. 8. Enlarged lymph glands in neck. 9. Tooth ache. 10. Swollen face. 11. Swollen gums. 12. Sore gums. 13. Indigestion. 14. Excessive saliva. 15. Acknowledgment of never having been to a dentist. 16. Acknowledgment of not using a tooth brush. ^Since the opening- of the Berkeley Dental Dispensai'y, an average of eighteen pupils per week have been cared for. 42 The Health Index of Children 17. Dirty looking teeth. IS. Receding gums. 19. Some defects in articulation. 20. Broken teetli.i When no school physician or school dentist is avail- able for conducting examinations, then the teacher or parent ought to observe the points enumerated above and if any of them are noted, consult a dentist at once. Every child ought to see a dentist every six months. "The money spent for one good (dental) house cleaning of one child at fourteen or eighteen exceeds the cost of keeping clean and in repair the teeth of the entire faniily when done systematically every few months." ''The total time required to examine school children for teeth needing attention is much less than the time lost by absence from school or wasted at school on ac- count of toothache." 'S^'ery often the temporary teeth are so badly neglect- ed that serious decay sets in. Under these conditions the roots do not properly absorb, and the second teeth are consequently pushed out of line by the obstruction formed by the roots of the first. This is one of the commonest causes of croolxcd teeth. Sometimes sec- ond teeth are in this way so crowded out of place that one or more appear in the roof of the mouth. A^lienever teeth erupt in a crooked manner they inter- fere with articulation, and sometimes to a very marked degree. Such teeth also seriously interfere with 'Some of these points do not necessarily indicate bad teeth but they are suggestive of dental trouble. Defective Teeth 43 ])ropei' niaslication, and consequently^ with nutrition. If the first teeth decay early and come out, the second teeth will often appear much too soon and before the jaw is sufficiently expanded. This also results in crooked teeth. The effect of adenoids in causing crooked teeth has already been discussed in Chapter 1. ^^KKS^t fl "^^M K^ ^% * * ^# iSm wi^ r ''^M ^ iWI9f/^ p^ ■k itt m ^"^^H ■■■ ^hhiihIh ■l ',MM ^HH flHJHIHH Three Portraits ShoAviiig the Iiin,'ro\ ement in Appearauce Due to Removal of Adenoids aud the Straightening- of the Teetli (By Permission of Dr. A. H. Sug-gett) Particular attention should be given to the sij^th year molars. These are nearly ahvays mistaken for temporary teeth, while as a matter of fact, they are the first permanent teeth. They can be easily recognized by remembering that they are the double teeth which appear in the mouth at the sixth or seventh year. Once lost they will never he replaced. Abscesses of the gums are met with very commonly in School Dispensary work. Nearly every dental case Avhich comes to the Berkeley Dispensary has either 44 The Health Index of Children dead nerves or abscesses present. A dead nerve in time is always followed by abscess formation. In one school girl of fonrteen, twent}^ teetli were found badly decayed, and fonr of the molars were so nearly gone that extraction was necessary. Many of these teeth might have been saved entirely from decay, and the remainder preserved with small flllings if there had not been serious neglect of dental hygiene. It is not at all uncommon to find school dental cases with a dozen or more seriously decayed teeth. Hereditary Syphilis is occasionally observed in the Berkeley Dispensary as indicated by Hutchinsoniau teeth (notched front teeth). Some Cases of Dental Neglect. 1. A child eleven years of age was sent to me for examination because of extremely poor physical devel- opment. An examination of the mouth showed an astonisliingly bad condition. .^lany of the teeth were badly decayed and the gums in several places were discharging i)us. This Avas a case of pyorrhoea due to neglected teeth. This little girl was suffering from constant sepsis, i. e. poisoning from the absorption of pus. The pulse in this case was 125 and the child was very nervous. A notice to the parents yielded no results and indeed produced nothing but offense. In such instances education must begin Avith the parents at home. 2. A girl of about lliirleen was seen in another school, the condition of whose mouth and teeth beg- gared description Fringes of decaged first teeth sur- Defective Teeth 45 rounded the second teeth Everywhere jms was dis- charging from the gnms The second teeth through di- rect infection from the first, were also seriously decay- ed, and fermenting food particles were everywhere pres- ent. Yet the condition of this child's teeth had never been observed by her teacher or by her parents Such a case requires careful attention just as much as does any other case of infection, yet our schools go on com- placently teaching ''Physiology and Hygiene" to hun- dreds of children whose mouths are constantly in nearly as bad condition as in the case Just described. 3. Tn another school the principal sent to me for ex- amination a boy about twelve years of age, because he was supposed to have either an obstruction in the nose or defect of the teeth which interfered with his artic- ulation. It was almost impossible to understand any- thing this boy said and consequently he made very poor progress in school. Upon looking into his mouth I discovered that iiKjst of the hard palate tvas gone. At first I took this for an unusual case of cleft-palate, but further examination brought out the fact that this boy was suffering from hereditary sijiihilis with consequent destruction of the bones of the roof of his mouth. The cavities of the nose and throat opened into each other in such a manner as to form practically one cavity. Neglect of proper medical treatment had brought about this ulceration and final bone destruction of the mouth, most of which had occurred in the last eighteen months. Contrary to the usual opinions of the pub- lic, syphillis is usually curable if taken in time and vigorously treated for an extended period. In this in- 46 The Health Index of Children stauce the child was pkiced under treatment to stop further ravages of the disease and sent to the San Francisco Dental Clinic, where a plate was fitted in his month which ett'ectually closed the great gap into the nasal cavity. The boy can noAv enunciate almost perfectly and will be able to make satisfactory pro- gress in school and later obtain employment, neither of Avhich could he have done in his former sad con- dition without treatment if indeed he had lived. If such various unhygienic conditions of the mouth just described do not offend the health standards of the community, they at least ought to olfeud their aesthetic standards. 1 'I find that about iO'/r of the children in the grades have from fi\'o to ten decayed teetlr CHAPTER IV CONTAGIOUS DISEASES AND SCHOOL SANITATION. As a purely school commercial enterprise the con- trol of contagions diseases and proper attention to School Sanitation is an excellent business investment. iVttention to each of these conditions costs consider- able money, but in the end very much more money is saved for the school, the family, and the community. If one takes into consideration the amount of time lost hj school children through contagious diseases, and the consequent expense for medical attendance, to say nothing of the cost of lowered general vitality to the individual, the money value of sensible hygiene and sanitation in schools is at once evident. Every school ought to keep a very careful record of all its contagious diseases and then estimate how much loss results in appropriation (based upon aver- age daily attendance). As an interesting experiment let the school then attempt to discover about how much money is spent in one year for medical attention in contagious diseases among its school population. The results of such estimates would furnish argu- ments for practical health supervision which could not fail to appeal to the reason of all reasonable people.^ "We can read the index of '^catching' diseases," says Mr. W. H. Allen in Civics and Health, "before the outbreak that calls in the physician. School ex- ^One of my students in the University of California has made a study of this problem in Berkeley. 48 The Health Index of Chh.dren amiuation shows which children have defects that welcome and encourage disease germs. It points to homes that cultivate germs, and consequently menace other homes. To locate children who have enlarged tonsils may prevent a diphtheria epidemic. To detect The Sanitary Driukiiig- Faucet' in September those who are under-nourished, who have bad teeth, and who breathe through the mouth (mouth breathers), will forecast winter's outbreaks of scarlet fever and measles. One dollar spent at this season in examination for soil hospitable to disease germs may save fifty dollars otherwise necessary for cure of contagious diseases. * * * Every teacher can be the sanitary engineer of her own school room or 'The Haws Faucet. Contagious Diseases and School Sanitation 49 school, by co-operating with the school doctor, the town board of health, family physicians, and mothers. * * * First she must know that 'children's di- seases' are not necessary. She should discountenance the old superstition that ever}^ child must run the gamut of children's diseases, that every child must sooner or later have whooping cough, measles, chicken- pox, mumps, scarlet fever, just as they used to think tj'phoid fever and malaria inevitable (in certain dis- tricts). The price of this terrible ignorance has been not only expense, loss of time, acquisition of perma- nent physical defects, and loss of vitality, but, for the majority of children, death before reaching five years of age. * * * The daily inspection of school children for contagious diseases by the school physi- cian (or competent teacher) has, where tried, been found to reduce considerably the amount of sickness in a town. The teacher should be conversant with the early signs of these diseases so that on the slight- est suspicion the child may be sent home witbout waiting for the physician's call (or the late symptoms of the disease). * * * The 'easy' diseases such as measles, whooping cough, etc., cost our communi- ties more than the more terrible diseases like typhoid and small-pox." Except for physicians, knowledge of the details of communicable diseases are rarel}^ necessary. For this reason only some general statements about them and an outline table of their main features will be pre- sented here. It must be understood also that gener- ally only those signs are indicated which appear early 50 The Health Index of Chh.drex in each disease. In this manner confusion will i»e avoided and the way made clear for the teacher or parent to recognize any particular children's disease early in its course. Such early recognition of these diseases of child- hood will in many instances i)revent an cpidoiiir in the school or home and in the end save much time and money and prevent many serious sorts of complica tions, Avhicli often incapacitate the child for his fullest future usefulness and happiness. It will be well to keep in mind the following general facts in regard to children's diseases which are usually little understood, or if understood, very generally dis- regarded. The mouth is more often the place of entrance of con- tagious diseases than any other place. For this, among other reasons, particular attention should be given to the hygiene of the mouth. Decayed teeth undoubtedly favor the contraction of contagious diseases, not only so, but they harbor disease germs which may at any time, and particularly at periods of low resistance, at- tack the individual himself or be conveyed to others by means of coughing, exchanging food, pencils, books, etc. One ought especially to keep these facts in mind with respect to colds. Colds are probably about the most contagious form of disease we have, yet many, if not most people still go on regarding them as due to drafts, getting wet, to "night air'' and similar delusions. As a matter of fact anything which is capable of reducing our resistance makes it easy for cold germs to gain the ascendancy but the cold is directly due to the germ or Contagious Diseases and School Sanitation 51 germs, and these causes should not be confused with the predisposing factors. "A cold can alwaj^s be charged to someone else. How many can be laid to our account? There is one right that is universally not recognized and that is the right of protection from the an open-air class (By Permission of Glen Taylor Private School, Alameda, Cal.) germs showered in the air we breathe and over the food we eat, in the school, street car, and at the restaurant. The chief danger of a cold is to our neighbor, and not to ourselves. A cold which a strong person may throw off in a day or two may mean death to his tuberculous (or otherwise debilitated) neighbor." Sometimes a single child with a cold may infect an 52 The Health Index of Children entire class or all of his family. Before very long we shall no doubt exclude children with ''colds" just as we now do children with diphtheria. "The great preventive measure to be taken for catch- ing diseases — colds, diseased glands — in fact all germ disease, is the repeated cleansing of those portions of the human body in which germs find lodgment — tbe mouth, the nose, the eyes, and the ears." To this should be added that diseased tissues in any of these organs must be cured or removed, for such tis-: sue is a constant breeding place and focus of dissemin-; ation for disease germs. This is one of the strongest; arguments in favor of giving prompt attention to ad- enoids, diseased tonsils, discharging ears, sore eyes and bad teeth. Clean, healthy tissue can rarely if ever be infected with disease germs. Contagious Diseases and School Sanitation 53 ci y, o _ C 0) j: ai a; 01 3 C o o o O J O ^2 • M 03 A i c« -1 1h ft "^ t- ■ r/i ft ' Sh oi 03 Sh <> ' o S ^ S5 0)^ >'-' O -.C ™ 0> -C! Ol— . Q,^ ^ O >.,^ ^■- d to C ^ ^ s « • 03 i>Cm£ fc-M o c S 03 03 c 03 atH 043 d d 03 = « Co5a3aiS 03 M 03 Z os5K^argi;£g;ti 5 cs oj m C ^ ^ ™ o „ fo-M o c S -^twrQ 3 03 r" T„ O 03 02 03 !3 ■ m«0 M - d i; .r-i +-> . P 03 j3 C to rt a 03 S >.mto «J OjrcJ 'Ao? 03 03 03 o "5 03 o-z; ^ mO d rt C to =«^ S to 03 03 OS 03'a dj 03 03 ^« fi ^ ^ 03 C-M cS 43 CO O +Jtd^M 54 The Health Index ue Childuen oil (U >< o OJ ^ a — W (2, t^ cS to o — Six to eight weeks or un- til desquam- ation has ceased. (0 >-. OJ -r When children return, examine head for over- looked spots. All spots should have disappeared before child returns. A mild disease and sel- dom any after effects. Dangerous both during attack and from after effects. Great variation in type of disease. Slight attacks as infec- tious as severe ones. INIany mild cases not diagnosed and many concealed. The peeling may last six to eight weeks. A second at- tack is rare. When scarlet fever is occur- ring in a school, all cases of sore throat should be sent home. HZ 1 to ^^ . rt 3^ ■a ^ oo JO M m O 0) bo Zl " = 55 0)3 o.2^£§ C 4) 3— p, ^ 0) 5 bi3 01'-' +j cS >rt -o^r^-o oS c o ^ £ -'"O •^ S3 o * c O QJ ■ £ P Jos.' a> S.- ^ - nS I CO =^ lij X O C. ^ (0 O to 1* , >^ , 0) to c3 .2E ^ CO rQ d ^ * — OJ ^ - O O ^4) O ro • .C cu - 03 - C "J= S C -.„ tfj^^dCj C rr- C" '^ +J 0) 1 >,!- I , aX ojO c o3 » C •" I O -^ w o < *j o O) a; ojtn .r; d « c ^ J- O 0) .i; QJ C 0) ; "ti o oc, ift'O.^Si C -, dJrrt »-• C Oj^ CO - £=:=«* = _ o^ o£ o 5 S'?.^ c.^ '^ 03'" eo'O c« M S ■ t^ CO 03 I a;'0 •O.^ CO oj !- > ", CO ^^ O m CO , to O ^5 !- Cto oj n P tO' '- O '' *j J= ^ .- I' — ll) : ,n o >, ? ^ ediculosis is most easily detected by looking for the eggs (nits), which are always stuck onto the hair, and are not readily brushed off. The condition is best treated by killing the living parasites with crude petroleum, and then getting rid of the nits. With boys, this is easy — a close hair cut is all that is needed ; with girls, by using a flne-toothed comb wet in alcohol or vinegar, Avhich dissolves the attachment of the eggs to the hair. All combs and brushes must be carefully cleansed. Children with pediculosis should be excluded from school until their heads are clean. In Massachusetts since 1906, parents who neglect or refuse to care for their children in this respect may be prosecuted under the compulsory attendance law. Contagious Diseases and School Sanitation 67 Ringworm. A vegetable parasitic disease of the skin and scalp. When it occurs upon the skin, it yields readily to treatment; but upon the scalp it is extreme- ly chronic. Ringworm of the skin usually appears on the face, hands or arms, rarely upon the body — in vary- ing sized more or less perfect circles; One or more, usually not widely separated, may be present at the same time. All ringed eruptions upon the skin should be examined for ringworm. When the disease attacks the scalp, the hairs fall or break off near the scalp, leaving dime to dollar sized areas nearly bald. The scalp in these areas is usually dry and somewhat scaly, but may be swollen and crust- ed. The disease spreads at the circumference of the area, and new areas arise from scratching, etc. Another disease, somewhat like ringworm of the scalp, is known as favus — a disease much more common in Europe than America. In this disease quite abund- ant crusts of a yellowish color are present where the process is active. The roots of the hairs are killed, so that the loss of hair from this disease is permanent, a scar remaining when the condition is cured. Care must be taken to see that all combs and brushes are thoroughly cleansed, and to prevent children wear- ing each others' hats, caps, etc. Children with ring- worm should not be allowed to attend school. Impetigo. A disease characterized by few or many large or small flat or elevated pustules or festers upon the skin. The condition is often secondary to irrita- tion or itching diseases of the skin (hives, lice, itch), and scratching starts up a pus infection. 68 The Health Ixdex of Ceiildren The disease most often appears upon the face, neck and hands ; less often upon the body and scalp. The size of the s})ots varies very much, and they often run together to form on the face large superficial sores, covered with thick, dirt}^, A'ellowish or brown crusts. The disease is contagious, and often spread by towels and things handled. Children having impetigo should not be allowed to attend school until all sores are healed and the skin is smooth. Contagious Diseases and School Sanitation 69 Sanitation of Schools. The subject of School Sanitation is far too compre- hensive to treat at all completely in a book of the scope of this one ; moreover, there already exists a number of excellent works on this subject which are accessible for teachers. For this reason only some general features of School Sanitation will be j^resented and more es- pecially those which ought to come rather directly under the observation and control of the teacher than of the sanitary oflScer. The whole subject from the teacher's point of view may be profitably presented in the form of a "Sanitary Survey." Such a survey ought to be intelligently undertaken by every conscientious and efficient teacher in a public school. The questions under I (A) should be ansAvered by teachers, the re- mainder by the Principal. Sanitary Survey of a School. 1 I. BUILDING. A. School Room. Yes No 1. Is damp sweeping- practiced? 2. Is" a moist cloth used for wiping- up dust? 3. Has the feather duster been abolished? 4. Is any disinfectant used upon the floors? 5. Are the desks cleaned with a disinfectant? 6. Are the school books disinfected when necessary? 7. Is the common use of articles which might carry infection avoided? Use a check to answer the questions. 70 The Health Index of Children Yes No 8. Has a list of such articles been made up? 9 If a "Plenum" or other system of artificial ventilation is used is it in good working order? 10 Are some of the windows always thrown open if the motor is not in operation? 11. If an artificial system is not used are some ' of the windows always kept open both from the top and the bottom? 12. Are ventilation boards fitted in under the lower sash? 13. Are all the windows thrown open at recess? 14. Have desks been re-dressed within two years? 15. If a stove is used in the room does it have a ••jacket" around it and is there special arrangement for ingress and discharge of the air from the room? 16 If a furnace is used does the air-box con- nect directly with the outer air, and is outer opening kept free from dirt, leaves, snow, etc.? 17. Is some arrangement made to keep the air of the room sufficiently moist? 18. Is the fresh air inlet removed from toilets or other sources of contamination? 19. Is the room free from unpleasant odors at all times? 20. Are dustless crayons used? 21. Are green or brown flat finish boards used instead of glossy black? 22. Are erasers cleaned thoroughly every day out of doors? 23. Are the floors oiled or otherwise treated to prevent dust rising from them? 24. Is the room temperature kept even? 25. Is is kept under 70 degrees and over 60 degrees? Contagious Diseases and School Sanitation 71 Yes No 26. Do the windows have an area equal at least to one-fifth the floor area? 27. Are the desks so placed as never to face direct sunlight? 28. Is the room evenly lighted? 29. Are dark window shades avoided? 30. Are white shades avoided? 31. Are yellow or linen colored shades used? 32. Is the tinting of the walls light enough? 33. Are neutral colors used? 34. Is the ceiling lighter than the walls? 35. Is over decoration avoided? 36. Are the seats adjustable? 37. Are the desks adjustable? 38. Are they adjusted? 39. Are wooden footstools provided where the seats cannot be adjusted? 40. Is a light, dry, clean, ventilated room pro- vided for clothing? 41. Is over-crowding of pupils avoided? 42. Are deaf pupils seated near the front? 43. Are pupils with defective vision seated near the front? 44. Are pupils with skin diseases excluded? The Health Index of Chh.dren Yes No ■ 45. Are pupils with lice excluded? 46. Are contagious diseases recognized early? 47. Is strict exclusion practiced in contagious diseases? 48. Are certificates from physicians required for re-admission? 49. Is successful vaccination required? 50. Are ordinary physical defects looked for and recognized easily? 51. Are parents notified of the presence of de- fects? 52. Are mentally defective pupils excluded? 53. Are children with fits excluded? 54. Are children with St. Vitus Dance excluded? 55. Is there medical supervision of pupils? 56. Is there medical inspection of buildings? 57. Are the windows screened? B. Halls. 1. Are the halls clean? 2. Are floors properly prepared to keep them free from dust? 3. Are halls well lighted? 4. Are they well heated? 5. Is liquid soap provided in hall wash basins? Contagious Diseases and School Sanitation 73 Yes No 6. Are sanitary drinking faucets or fountains provided? 7. Has the roller towel been abolished? S. Has the common drinking- cup been abol- ished? 9. Are the halls well ventilated? 10. Are exits plentiful and unobstructed? " 11. Are stairs wide and straight? 12. Are the halls free from obstructions? C. The Basement. Are the floors clean and dry? 1. 2. Are they of cement? 3. Are wash basins and sinks clean? 4. Are individual towels provided? 5. Are there any shower baths? 6. Are toilets clean and well ventilated? 7. Is the plumbing modern? S. Is the air wholesome? 9. Are toilets well shut off from air intakes? 10. Are sanitary faucets or fountains provided? 11. Is the ventilation and heating apparatus in order? 74 The Health Index of Children Yes No 11. THE GROUNDS. 1. Are the play-grounds large and adequate for the number of pupils? 2. Are they well drained, dry and even,? 3. Is there any play-ground supervision? 4. Is play apparatus provided? 5. Are some open air rooms provided for play, rest, lunch, protection from weather, and for recitations? 6. Are the grounds well separated from un- desirable neighbors? III. GENERAL SANITATION. • 1. Is a lunch room provided for teachers? 2. Is one provided for pupils? 3. Do the lunch rooms have tables? 4. May a hot lunch be obtained? 5. Is there a pleasant rest room for teachers and pupils? 6. Is there an "emergency" outfit provided? 7. Is instruction given on how to use such an outfit? 8. Is practical hygiene taught? 9. Is individual cleanliness insisted upon? 10. Have the teachers been taught how to de- tect ordinary physical defects? 11. Is practical dental hygiene taught by actual observation of the teeth? Nervous Disorders of Children Yes 75 No 12. Is there any personal inspection of pupils? 13. Is school credit given for neatness and cleanliness? 14. Are older pupils taught to make simple sanitary surveys of what they see at stores, shops, homes, parks, dairies, on the streets, etc? 15. Is any inspection ever made of pupils' lunches? 16. Are pupils encouraged to inspect them- selves and their own environment to detect errors? IV. THE ENVIRONMENT OF THE SCHOOL. 1. Is the ground well drained? 2. Are tin cans and other receptacles in which rain water might collect kept picked up? 3. Are other breeding places of mosquitos de- stroyed? 4. Is garbage of all kinds properly destroyed? 5. Is manure and other refuse hauled away as fast as it collects? 6. Are family garbage cans kept covered? 7. Is it thoroughly understood at your school that all refuse of the above sort fur- nishes breeding places for flies? 8. Is the air in the neighborhood of the school clean and free from an excess of gases, dust and smoke? 9. Is your drinking water from a safe source? 10. Does your school understand just how a school drinking water supply may be- come infected with sew^age? 11. Are you relatively free from flies? 12. Are vacant lots kept clean? CHAPTER V. NERVOUS DISORDERS OF CHILDREN. Nervous disorders in school children are no doubt largely of the functional sort but nevertheless they are of the utmost importance and of relatively frequent occurrence. Other and more serious nervous disorders are not very common and yet are to be found to some extent in nearly every large school. A wise, sympathetic understanding of children and their ways is a rather rare quality both among parents and teachers, and it is precisely this lack of intuition in dealing Avith children which so often results dis- astrously for the child. Children are mostly all alike in one respect and that is that they are so different. These differences are often so subtle in character that numy of them are not recognized at all by teacher or parent, yet it is the clear recognition of such dif- ferences and the adaptation of educational and correct- ive methods to them which will result in success or failure for the pupil. Nervous, irritable children in many cases have nerv- ous, irritable fathers or mothers. Often it is quite hopeless to attemi>t to correct these conditions in chil- dren unless the unfavorable home environment can be changed or at least modified. Parents, teachers, and even physicians dealing constantly with children have in the past usually paid too little attention to child Nervous Disorders of Children 77 nature. They have all very generally interpreted chil- dren's ways b}^ the standards of grown-ups. ''It is difficult to understand," says Dr. Leonard G. Guthrie, ''why a subject so important to the welfare of the communit}^ as the study of children should have been so long neglected in this country (England). "P.erhaps the public as well as the medical profession are to blame. For from time immemorial the upbring- ing of children has been regarded from an economical rather than a medical point of view. Many an elab- orate treatise on methods of training children to be healthy, virtuous and brave has seen the light, but has emanated from moral educationalists and not from physicians. In fact, medical men were not supposed to interfere in matters considered to be outside their province. If children were ill or ailing the doctor was called upon to prescribe for their diseases, but advice on their management in general was neither sought nor welcomed. "He was not asked to see a child because it was way- ward, but because it was wasting, not because it was dainty, capricious in appetite, refusing food considered good for it, and craving for all that is unwholesome, but because it had pain in its stomach. Advice was not asked for peevish, passionate children, nor for those who Avere afraid of the dark, and unnaturally timid, absent-minded, or brooding and morose, jealous, spiteful, or cruel, nor for mischievous, untruthful, dis- honest, or immoral children. All such defects were regarded as moral rather than morbid, and were treat- ed as such. It was long before it was recognized that 78 The Health Index op Children a cliild might be dull and stupid in consequence of de- lects of sight or hearing." It is still much the same in our schools today. Schools are largely without medical supervision and the various degrees of peculiarities and so-called mis- behavior among school children are consequently re- garded on the part of teachers from the moral and educational rather than the physical point of view. The nervous disorders ordinarily met in school chil- dren are the following: 1. Chorea, or St. Vitus Dance. 2. Habit Spasms. 3. Neurasthenia, or Nervous Exhaustion. 4. Epilepsy. 5. Hysteria (not common). i). Stammering. 7. Migraine, or Sick Headache. 8. Sex Disturbances. Chorea. It is most important to recognize chorea or St. Vitus Dance early. As a matter of fact, this disorder is rare- ly recognized until it is well advanced. Any child should be suspected of developing chorea, who has the following habits : 1. Kestless. 2. Purposeless motions. 3. Inability to hold pencils, books, knife, fork, etc., securely. 4. Falling down easily and frequently. Nervous Disorders of Children 79 Parents, teachers, and some phj'^sicians often fail to recognize chorea until the spasmodic symptoms occur. These include muscular spasm of various parts of the body, such as contortions of the face, jerking move- ments of the head, shoulders, arms and legs. It is most important to recognize Chorea early as it is often, if not always, closely associated with rheu- matism, and in such cases the heart is very frequently affected. Children with developing chorea are highly excitable and it is therefore most unfortunate that they are so often misunderstood, and perhaps scolded and pun- ished for misbehavior, when in reality they require the most patient and kind sort of treatment. Children with this disorder ought to be removed from school both for their own good and for the good of other pupils, some of whom are very likely to imitate their grimaces and other habits until it becomes a fixed habit in themselves. Children with this nervous affec- tion require long rest, quiet life and the most careful medical treatment. Habit Spasms. Many nervous children develop habit spasms, which are characterized by quick, involuntary, peculiar move- ments. They may be easily recognized by the following description by Dr. Guthrie : "A series of lightning-like blinks or nods or sudden turns of the head aside. The eye-brows may be elevated or corrugated or the upper lids may be raised several times in quick succession as in a munching rabbit, or the nose may be wrinkled and the nostrils expanded or 80 The Health Index of Children contracted whilst half a dozen or more little ineffectual sniff's are produced, or a variety of grunts and queer guttural noises are heard. The characteristic of all these simple tics is that they suddenly come and go, and each form will com- monly give place to another. It is seldom that more than one trick or antic is present at a time." In a more complicated form of habit spasm or tic the child will often perform the most astounding tricks. '"For instance, after spending some days or weeks in repeating apparent efforts to twist his mouth around his nose, the child will suddenly relinquish the attempt and take to elevating his chin and stretching his neck as though his collar were too tight or he will shrug his shoulders or writhe like an eel at short intervals; or, whilst walking will suddenly execute a twirl, a hop, skip or jump, or he will stamp heavily on the ground with one or both feet or strike his head or body vig- orously with his fist. ''One child under observation would at half-minute intervals shut her eyes tightly, show her teeth in a dis- agreeable snarl, and protrude her tongue with vibra- tion like a snake. Children will often lament bitterly that they cannot overcome their "habits,'- and each time they acquire a new one they will mournfully announce the fact to their sorrowing next of kin. Sometimes they occur only when the child knows he is watched, in other cases, only Avhen he believes himself unmolested." The present writer recently observed at a family dinner a parent and four young children all victims of Neuvous Disorders op Children 81 tics or habit spasms in a mild degree. He remembers very Avell that the parent had these habit spasms as a school boy in a much more aggravated form and that several other members of his friend's family including his own father, three brothers and a sister, were all afflicted somewhat. A patient of the writer's some years ago had ac- quired a peculiar form of tic w^hich consisted in sioal- lotving toind and then belching it forth with illy con- cealed but strenuous efforts to avoid detection. These strange, grotesque, subterranean sounds often dis-t turbed the peace of mind of his immediate associates at social functions. The importance of correcting such unfortunate hab- its during the impressionable period of youth will thus be seen to be most desirable. Neurasthenia or Nerve Strain. Nervous exhaustion or neurasthenia is not a disorder enjoj'ed exclusively by the idle rich. While common enough among this class of adults, it affects all classes of people and even children. Many such children have passed through nervous horrors during several years of their lives Avliile their parents and teachers were quite unconscious of any condition existing more serious than "nervousness" or natural ^'perversity." Many neurasthenic children suffer torments yet are entirely unable to explain their situation to relatives or friends or even to appreciate in the least what is the matter with themselves. The writer has a friend who as a boy suffered in this way for at least five years in total 82 The Health Index of Chh.dren silence, and it Avas only as a young man that he finally nnburdened himself to an older and sympathetic brother. This boy progressed normally enough through the first six grades of the public schools. Then at about the age of twelve, the beginning of puberty, he began to develop various signs of nervous exhaustion. Audit(U"y disturbances first afilicted liim. Voices and other sounds seemed often to be hollow, muffled, monotonous, and far away. His own voice sounded the same to him. This condition was often present for days at a time and continued for several years with only slight intermissions. This distressing symptom was almost unbearable and the boy often thought he was losing his mind. In fact by the time he Avas fifteen years old he was (juite fixed in that belief. Sleep was fitful, unrefreshing, and finally at thirteen years of age disturbed with erotic and exhausting dreams which the child could not in the least comprehend. These sexual dreams* which in moderation are nor- mal enough to every growing boy had never been ex- plained to him and constantly preyed upon his sensitive conscience, and this unfortunately reacted in the worst possible manner causing more nervous instability dur- ing the day and increased frequency of the sex dreams at night. He was now more than ever convinced that he Avas losing his mind and the victim of some sort of evil for which in a dim sort of way he considered him- *Thls matter is mentioned here because boys are seldom informed by their parents about such matters and because most of them are greatly alarmed about the occurrence of such dreams until they understand their nature. Sensible instruc- tion about the ag-e of puberty in such matters is absolutely essential to the peace of mind and even health of the average child. Nervous Disorders of Children 83 self responsible. His habits, however, were most ex- emplary and he lived conscientiously to the last degree Of his knowledge. He had indeed a morbid 'iNew England conscience." The child soon fell by the wayside in school. His studies became uninteresting and diflBcult for him. He lost a grade and this filled his cup of sorrow and hu- miliation to the brim. Self confidence began to wane, he took little interest in active sports, his health began to fail, he was anaemic, thin, and always tired. Ring- ing and buzzing sounds added their torments to his other troubles. He was almost constantly disturbed with an excessive flow of saliva and with an almost insane desire to keep swallowing it (a habit of spasm). He became weak, tired, full of indefinite pains, un- happy, apprehensive, miserable. Yet despite all of these afflictions so heavily laid upon his youthful shoul- ders, he managed to present a fair front to his asso- ciates, family and teachers. He did not attempt to avoid company and seek solitude; he took his part as far as he could in boys' games tho' never succeeding very well with them. He was regarded as a delicate, sensitive boy, but not as morose, or melancholy, or the victim of any very unusual troubles. He belonged to the c^ss of neurasthenic children called the '^Re- strained Emotional Type." In this type, as Dr. Guthrie remarks, emotions are very strongly felt, but the powers of control are equally strong. They are (usually) solitary in habit, intro- spective, prone to self analysis, imaginative, with mor- bid love of horrors, and equally morbid dread of them. 84 The Health Index of Children They may harbor various kinds of fears and sometimes develop abnormally conscientious scruples of moral and religious nature. This disposition, Avith its characteristic suppres- sion of outward display of emotions is as exhausting as that of the other type (the unrestrained emotional type) in which emotional excess is obvious, and is associated with many similar complaints. In the case of the boy described it was not until in- creasing years had brought him to the point of seeking advice that his symptoms finally cleared up. For- tunately for him he possessed a father who Avhile en- tirely unconscious of his boy's real sorrows and troubles, yet possessed a wholesome kind of insight and common sense which led him to keep the child out of doors as much as possible. He removed him from school, employed him at light labor part of the time to occupy his mind and aid him in his physical develop- ment, furnished him Avith opportunities for horseback riding, rowing, sailing, camp life, and some traA'el. I^jxcept for this fortunate help from an unusually intel- ligent and kind though medically uninformed parent, this boy might easily haA'e passed, into a mental and I'hysical decline ending A'ery likel}' in tuberculosis or permanent melancholia. As it was he entireh' re- covered at about eighteen years of age. Now the case just described in considerable detail may seem to the reader rather unusual, yet Avitli minor differences it is a certainty that a A'ery considerable number of the boys and girls in our schools are victims of such unhappy disorders caused by nervous exhaus- Nervous Disorders op Children 85 tion. Many pupils like the one just described acquire an amount of self control and reserve which is quite out of proportion to the burdens they bear, and they con- sequently successfully hide from their associates the real troubles through which they are passing. Nervous children need the utmost care both at home and at school. They need a firm but sympathetic hand to guide them. Someone must get their confidence and encourage the unburdening of the little mind so cloud- ed with new and strange thoughts and sensations which the child so little comprehends and so greatly fears. Months or years of untold, unnecessaiw suffering can in this way be prevented, and timid, sufl'ering, unhappy children led into the normal, happy, wholesome life which is the birthright of every child.^ Epilepsy. In this disorder there is loss of consciousness and there may or may not be convulsions. Children who show signs of marked inattention, forgetfulness, dreaminess, great irritability and uncontrolled pas- sions, ought to be kept under observation with the possibility of developing epilepsy in view. Children with early symptoms of epilepsy are also likely to be subject to headaches, disturbed sleep, night terrors and spasms. Sometimes children have an attack of epilepsy which very much resembles fainting. They will grow pale, 'It is important to remember that Neurasthenia, better called Nerve Strain, nearly always has a perfectly definite cause which ought to be discovered and corrected as early as pos- sible, and that a great number of factors must be considered in determining the cause in different cases and various tem- peraments. 86 The Health Index op Children become dazed, stop talking, stand or sit perfectly still, aud lose consciousness for a moment, though the last symptom may not be observed and the child may be quite oblivious of his condition in this respect. In more serious cases the child has a "fit" as it is ordinarily called. He falls down in a spasm, with frothing at the mouth. Following the attack a deep sleep usually comes upon him. Sometimes he will have no recollection of the attack. Nearly every large school that I have examined has had at least one epileptic pupil in it. These cases ought to be recognized by the teacher, aud the pupil ])romptly removed from school. Epileptics have no place in our public school system both for their own sake and the sake of other children who are terrified at the sight of their -fits. Sooner or later chronic epilepsy is likely to result in mental deficiency. Cases of epilepsy in which the attacks are infrequent and do not occur at school often produce results which are attributed to pure perversity and maliciousness. I have lately seen a boy who displays at school, as the only sign- of this disease, general insubordination and slow progress in the school room, and uncontrolled fits of anger with stone throwing and fighting on the play- ground. Considerable mental deterioration has al- ready occurred. Such pupils are sometimes very dangerous com- panions for the other children. In their anger they are likely to seize any object without the least dis- crimination, a rock, a hatchet, a shovel, or the first thing which comes to hand, and hurl it at the innocent Neuvous Disorders op Children 87 but offending child. Special school homes ought to be provided for epileptics in every state.^ Hysteria. This disorder except in very mild forms is not found very commonly among school children. So-called hysterical manifestations, such as undue weeping, laughing, feigned illness, and the like, are not hysteria at all, but indications of a high strung, uncontrolled neurotic temperament. General Nervous Instability. In every large group of children there can always be discovered a considerable number who, while free from any definite nervous disease, yet deviate to a marked degree from the state of the normal child. Such children are restless, inordinately active, busy to no very definite purpose; their emotional natures are often undulj^ developed and under very poor con- trol. Laughter and tears are always near the surface. Affection, anger, sorrow and joy are not very well dif- ferentiated. Tlie}^ are inclined to selfishness, fond of attracting attention, quick to give offense, but quicker to resent it in others. They are usually bright and affectionate, but irritable, passionate and emotionally uncontrolled. Dr. Francis Warner says of this type— "They are the children who are delicate without hav- ing any disease ; who are rarely laid up with any defin- ite illness, but are not strong; they cannot walk far 'Some of the worst crimes on record have been committed by Epileptics. In the criminal code of Ancient Rome the possi- bility of Kpilepsy as a factor in crime received important con- sideration. 88 Tiiio Hi<:altii Index of Ciiilduen without getting tired; the}^ are capricious in appetite, yet sometimes ravenous, but remaining stationary or increasing slowly in weight.^" At home children of this type are usually very badly disciplined and indeed such children often furnish a pretty fair index of the character of their parent or parents. Such parents use little discretion in matters of discipline. They cannot bear to see the child cry. Since the child never meets with resistance, it wishes to possess everything that it sees. It wants every whim and cai)rice satisfied. It knows its strength ; it knows what its tears will accomplish, and as a perfect tyrant it abuses its power to desire everything and to do everything Avhich it should not do. In the end this sort of home training, or rather the lack of it, develops the typicall}^ nervcms, unstable, tyrannical child. He not only becomes a source of annoyance to others, but defeats his own happiness for he never learns the habit of self control. As an adult this type furnishes a large proportion of those who go about in the search for itnearncd happiness, a happiness Avhich they, of course, never secure. Many neurasthenics among adults appear to have passed through a childhood of the sort just described, and indeed their neurasthenia has often resulted di- rectly from their faulty early methods of training. Most "nervous children" need definite, rigid home discipline, and in many instances such training might will begin with the ]>arent. "Such children should be taught to endure pain with some degree of self control. iThe Study of Children (Warner)- Nervous Disorders op Children 89 to respect the rights of others, to obey just commands, to acquire some degree of composure, to live regular lives, to be unselfish and to love the good, the true and the just. This constitutes a strong point in the battle against the conditions which threaten nervous stabil- ity. Love of fellow-man, unselfishness, and a feeling for the welfare of others, a strongly developed feeling of duty — these qualifications fortify one most surely against that egotism which leads to nervousness. Par- ticularly high in these qualities is the love of truth. He who is true to himself and others is rarely over- taken with a disorder whose striking characteristics are ''exaggeration and dissatisfaction." ^ One of the most difficult problems presented for solution in the physical study of school children, is how best to correct the faults which begin at home. After all, it is here that the most essential parts of a child's education should be acquired, and no school has done its full duty to the child which makes no at- tempt to carry education when necessary directly into the home. To illustrate how such home education may be accomplished, some cases from my own exper- ience are related here. Irritability and nervousness among children appear to be constantly increasing, and this is true whether we consider the children of the city or the country; the children of this country or of other highly civil- ized, and therefore complexly organized countries. One of the penalties of life in highly developed society ^Dr. I. A. Atat, in an address entitled, "Nervous Children," re- printed from the Lancet-Clinic. 90 The Health Index of Children is this increased tendency toAvard nervous instability. For this state of affairs parents are to a considerable extent to blame, for the habit of nervous instability is largely acquired in childhood. The child has the right of protection against the constantly increasing wear and tear of complex social conditions, and the right of proper education to enable him to cope with his increasingly difficult environment. Heredity, predisposition, and environnnent .deter- mine the temperamental characteristics of children, and of these environment is perhaps the most impor- tant factor. Many a child with a faulty heredity or distinctly nervous predisposition, has developed into a normal life through the influence of a favorable en- vironment. Environment has much to do in deciding the character and nervous stability of the child. It acts every hour of the day, tending to form the habits, lines of action, and modes of thought. ''Parents con- trol the bodies and minds, hearts and souls of their children, not only through hereditary traits handed down from their ancestors, but also by what they themselves do a(nd think. Example ^and imitation guide the child in thought and action. "^ A bad school environment is capable of doing much harm to any child, but the best of school environments can do little to offset the constant and pernicious in- fluence of an unwisely conducted home. To a very large extent character is formed in a child during his first five or six years of life, so that at the time he ordinarily begins school his nervous organization and 'Development of the Child, (Oppenheim). Nervous Disorders of Children 91 therefore his habits are already pretty firmly estab- lished. It is too much to ask of the school that it re-educate a child whose first five or six years of life have run in wrong channels, or that it correct in a few hours each day the influence of the daily faulty habits of the home. Teachers very soon learn to judge pretty accurately of the character of parents by the conduct of their A School Providiug Sheltered Passag-es for Play in Stormy Weather. Architectural Beauty anil Utility Combined. Kasily Adapted to Out-door Lessons. children. It is a pity that some of the demerits charged to children in the schools cannot be trans- 92 The Health Index of Chh.dren ferred to the parents in the homes. If a child is to succeed at school his pleasures and ainiiseiuents at home must be simple and wholesome. He cannot with impunity be forced or permitted to enter into the social dissipations of adults. The child at home must have regular hours of eating, sleeping, playing; his discip- line must be even and just. "Training should be sys- tematic and constant. It is a mistake to permit some- thing today and forbid it tomorrow. One should not be strict today and tomorrow break all rules by being very lenient. There are few parents who are con- sistent about a child's training. Most are guided by their own caprice." Parents may be too strict, thus stifling all spontaneity in the child, or on the other hand too lenient so that the child never acquires any degree of self control. Children surrounded day after day by a home environment little, or not at all adapted to character formation furnish most of the "nervous" pupils of our schools. CHAPTER VI SOME GENERAL DISORDERS OF SCHOOL CHILDREN. Aside from such disorders as those of the nose, throat, ear, eye, defective teeth, and the usual con- tagious diseases, many children are discovered in the schools who are suffering from more general physical troubles. Of these nutritional disturbances probably head the list. Many a pupil has successfully passed the regular physical examination in schools because no defects of the usual sort looked for have been noted. Nevertheless some of these very children are the ones who are most in need of careful physical attention. The following description of such a child will indi- cate a common type seen in most schools. The pupil is pale, apathetic, thin, maintains a poor posture and often stoops badly. The chest is usually thin and con- tracted, and in some cases the lymphatic glands, espec- ially those of the neck are enlarged. Nervousness is often pronounced. Such an appearance may be ac- counted for in a number of waj^s. First, it may mean that the individual is suffering from malnutrition due to a lack of a proper amount of food, or an improperly balanced ration. Second, it may mean that proper food is being used in a very improper manner. To the latter class belong the children who, because of poor teeth or for other reasons, hahit being a prominent one, 94 The Health Index of Children fail to masticate their food tlioroiiglily and con- sequently never adequately assimilate it. In some instances the condition described results from the physical maladjustments accompanying the period of puberty. xVt this age (twelve to sixteen years) the muscles are often flabby and weak leading to stooping, a slouching gait and general awkwardness. The heart in some pupils of this class is in a very un- stable condition aaid often shows signs of considerable enlargement (hypertrophy). When this is present there is usually some breathlessness on rather slight exertion, a disinclination for exercise or play and a rapid and sometimes irregular pulse. In these cases the phj'-sician often discovers functional It cart mur- murs. Organic disease of the heart is found in perhaps one per cent of most school children. It ought always to be detected in order that the correct advice may be given in regard to exercise and other habits of life. Sometimes the type described indicates incipient tnhcrciilosis. It is very probable that a test of such children by the "tuberculin method," would result in many positive reactions, which otherwise would remain undiscovered until the disease is well advanced. Many children displaying low general vitality con- stantly sleep in illy ventilated bed-rooms and drink coffee or tea in large amounts. The correction of these two physical offenses alone has brought about good results in several of my own cases. (See Chapter VIII). Occasionally the condition is due to extreme nervous- ness (the neurotic type of child), with irregular habits Some General Disorders op School Children 95 of life of various sorts. In many it is caused by lack of outdoor life and sensible physical exercise. Such children never play vigorously and unfortunately are not educated in this respect in their school life. The l)ublic play grounds, with properly supervised play, usually work miracles for children of this type. What- ever may be the cause of poor physical development, its early recognition is one of the most important duties of the teacher, parent, physical director and school physician. These are the types of children who fall by the way- side, who lose grades (the retarded pupils), who become discouraged and who consequently often lose self con- fidence.i To them the teacher owes her best efforts, but unfortunately she often gives them scant attention because they are not as ''interesting" as the healthier and happier pupils. Occasionally the condition described is due to in- ternal parasites (worms) and attention to this alone often leads to excellent results. Such children sleep poorly, grind their teeth in their sleep, and often have ''night terrors." Usually they are nervous, fretful and irritable. Evil sexual habits in themselves do not ordinarily lead to general physical depletion, general opinion to the contrary notwithstanding. Many poorly developed children are greatly misjudged in this respect. The moral effects of such habits are far worse than the phy- sical. The persistent sexual sinner among children is ^Dr. Luther Gulick is of the opinion that when a child of average sensitiveness loses two or more grades, he is usually ruined for life educationally. 96 The Health Index of Children usually a neurotic individual, and liis sex habits form only one of a long chain of other abnormal habits. It rarely does much good to attempt to correct the sex evil alone, and success is only obtained when the whole daily order of life (mental and physical) is changed and is placed upon a healthy, normal basis. Diseases of the Bones and Joints. i All noticeable lameness, whether sudden or con- tinued, may indicate serious joint trouble, or may be due to improper shoes. These cases, as well as curv- atures of the spine, are indicated by habitual faulty l»ostures at the desk or in walking, and should be re- ferred for medical inspection. Spinal curvature should be suspected when one shoul- der is habitually raised or dropped, or when the child leans to the side, or shows persistent round shoulders. Complaints of persistent "growing pains" or "rheu- matism" may be the earliest signs of serious disease of the joints. Diseased Lymphatic Glandts. ■ The lymi»h glands in children are frequently diseased and enlarged, especially those of the neck. AVhen en- larged they are commonly known as "Kernels." The fact that these glands act as sentinels in the body hav- ing the power to arrest or destroy bacteria which gain access to the circulation, makes any involvement of them of serious importance. It is only when they are quite overwhelmed by great numbers of bacteria that these sentinels are themselves broken down by the at- 'From "Medical Inspection," Mass. Board of Education. Some General Diseases of School Children 97 tack of a bacterial enemy. Enlarged Ij'mphatic glands therefore always indicate a diseased condition (an in- fection) Avhicli must not be ignored. Such enlarged glands occur in the acute contagious diseases of child- ren. They are also very commonly affected when the teeth are badly decayed. The very close relation be- tween diseased teeth, poor nutrition and enlargement of the lymph glands of the neck, is most noticeable in ex- amining school children. Among the first 800 school children examined in the schools of Berkeley these three defects, viz. bad teeth, enlarged glands, and mal- nutrition headed the list. This condition of the glands is also very commonly present with diseased tonsils and adenoids. The extent to which the involvement of the glands occurs depends upon the severity of the cause, whether from bad teeth, diseased tonsils, or other causes, and upon the natural resisting j^ower of the individual. In general a child with considerable involvement of these glands has low powers of resistance, and indeed it may be said that this condition is an index of a low physical state. Really healthy children do not show any indication of enlarged lymph glands. When the glands remain enlarged for a considerable period of time one must always consider the possibility of a tuberculous condition. Where this is present the glands are at first hard and elastic. Later they become tender and painful and the skin over and around them is red. At last the gland softens and breaks down with considerable discharge. "Certain observers claim, and advance strong testi- 98 The Health Index of Children mouy to prove, that Avlien enlarged glands in children persist and finally lung tuberculosis occurs, the infec- tion is conveyed from the glands to the lungs. Seventy or eighty per cent of enlarged cervical glands may be said to be tuberculous." CHAPTER VII. DEFECTS OF THE FEET.l In a general way the public is now awakening to the importance of proper shoeing, and the medical profession is being made aware of the real signifi- cance of defective feet. It has been shown that while some feet present symptoms which point directly to flat foot, other defective feet may have no local mani- festations; instead they produce remote symptoms which are usually associated with other and grave disorders. For example, defective feet which did not ache nor tire easily nor swell, nor in any way attract attention to themselves have been shown to be the cause of pain in the knees, in the thighs, in the hip- joints, of a whole category of backaches and a painful affection of the end of the spine. Some of these (no- tably the backaches) are symptoms of other disorders which when present, may demand operations. How important it is then that in observing these symptoms the possibility of defective feet as an indirect cause should be borne in mind. Because of the gravity of the results should such a condition be overlooked or mistaken, this subject cannot too often be given pub- licity. Particularly is this so since in the vast ma- ^For most of the material in this Chapter the author is in- debted to Dr. Jas T. Watkins, orthopedic surgeon to the San Francisco Hospital and Polyclinic. 100 The Health Ixdex of Children jority of instances defective feet are not congenital bnt acquired, and therefore preventable. It is be- lieved that the following discussion will throw light upon the cause of this condition and indicate how it may be prevented. In studying the human foot it should be regarded as a mechanical contrivance especially devised for weight bearing and progression in an upright individual in somewhat unstable equilibrium. Not only are the feet of individuals unlike, but traces of distinct racial t^'pes may be noted ; the negroid, flat and flexible; the Semetic, with the flat expanded fore- foot of desert dwellers; and the short coupled, rela- tively high-arched foot of the Caucasian. Among American school children are many whose feet, because of their ancestry, show a disposition to follow one or the other of these types. It is a matter of comment, though as yet unsupported by statistics, that a relatively large proportion of children of the second group suft'er from defective feet which present symptoms — such as pain, weariness, stiffness, or swell- ing of the ankles. To comprehend the factors to which are principally due the almost universally defective feet of school children, some slight understanding of anatomy and physiology of normal feet is essential. By normal feet are meant feet of children which have not been distorted nor cramped by wearing defective shoes. As mechanical appliances of a well recognized type, it should be appreciated in what parts of the feet cer- tain actions take place and what structures partici- Defects op the Feet, 101 pate in the performing of these actions. Once this is done the ph^^sical environment which is essential to the complete performance of a foot's function will be appreciated. That is, the several features wiill be recognized which must be incorporated in a shoe if the latter is not to prove harmful. A comparison, feature by feature, of such a shoe with the kind of foot wear to which children are habituated from infancy will, it is believed, throw light upon the most patent cause of defective feet. To such a discussion a his- tory of footgear, though interesting, is not essential. Suffice it that man would seem to have shown a dis- position to decorate his feet and to modify his foot- gear to the prejudice of the former's usefulness as soon as he found that the unencumbered use of them was not indispensable to success in the struggle for exist- ence. Evidence in support of the view that physical de- fects acquired after birth are as a rule not hereditary is seen in the fact that despite the distortions to which its parents' feet have been subjected the average baby's feet are normal at birth. Viewing such a foot as a whole it will be seen to represent in general a longitudinal arch, high and un- stable at the inner side, Ioav and well braced at the outer side; and a traverse arch, which in the fore- foot exists only when raised, and disappears there the moment weight is put upon it. The forefoot as it slopes gradually forward, ex- pands and is made up of numerous small bones. Its function is manifestly that of balancer and shock 102 The Health Index of Children absorber. On the other hand the back part of the foot is made up of massive bones, few in number, which descend steeply. This part is manifestly adapt- ed to bearing weight. The comfort experienced by many shoe- wearing wo- men when they adopt so-called high French heels is due to the fact that part of the muscular effort neces- sary to raise the heel from the floor is dispensed with and that the heel of the shoe is so devised as to bring it more directly beneath the arch of the foot, thereby diminishing the strain put upon the ligaments which hold the several bones of the foot together. Up and down motions of the foot on the leg take place in the joint formed by the leg bones with the ankle bone. The range of motion in this joint varies with peoples and individuals. For example, it has been noted that dwellers in the Tyrol and Swiss Alps, who wear half shoes and stockings which do not in any way impede the motions of this joint, show very remarkable joint motion. Again the feet of young children show a much greater range of motion in this joint than the feet of adults. The conclusion is, there- fore, inevitable that the relatively limited up and down motions in the ankle joints of the latter are to be at- tributed to the restrictions imposed by the ''uppers'' of high shoes upon growing and adult feet. It will be recalled that during fast walking or run- ning, toeing inward is marked and involuntary. In- deed it is not possible to walk fast nor run for more than a moment without toeing in. This is then the attitude of muscular strength and is known as adduc- tion. Defects op the Feet 103 If the reader will place one hand palm downward upon the table and then without moving the base of the palm, crowd tlie fingers as far inward as possible •with the other hand, it will be noted that the hand which was flat has become arched with the highest part of the arch at its inner border, and that the at- titude assumed by the fingers is analogous to that assumed by the forefoot in turning in. This position is seen to shorten the foot and to raise the arch and keep it raised. Conversely turning out (the attitude of rest) lengthens the foot and lowers the arch. The objection to walking with the feet turned out in the usual way is thus seen. In a properly constructed shoe for a normal foot the heel should be broad and low; instead of tapering to a point it should remain unchanged or even be slightly flanged, thereby increasing the firmness of its tread. The shoe should grasp the wearer's heel firmly. The shank should be flexible and very short. If the narrow shank is long it will bind the foot and prevent the side to side motions essential to turning the foot inward. The sole should have a straight inner edge and permit of the foot's assuming the in-turned or adducted posi- tion. In this position a line drawn through the mid- dle of the heel will pass to the outer side of the little toe. It should have very little "spring" or rocker, because this, like a high heel, causes the toes to be bent upward. It should be flat from side to side and not convex downward as is customary in most factory-made shoes. The "upper" should be deeper and more roomy at the inner side over 104 The Health Index of Children the high inner arch than at the outer side. Half shoes (low shoes) are preferable to shoes with high uppers, because the latter restrict the up and down motions, of the foot. Finally, because feet vary as much as other physi- cal characteristics, much care must be taken in select- ing that combination of features which are peculiar to the individual. Whenever it is possible shoes should be made over individual lasts. Resume on Fiat-Foot. 1 The particular defect of the feet known as "tlat-foot" is the one of most interest to those whose business it is to observe school children. It results from a dis- proportion between the strength of the foot and the weight it has to bear. Excessive strains, general mus- cular weakness, or any condition which weakens the foot has a tendency to produce fiat-foot. One of the most important factors among children is, perhaps, the use of impro})er foot-wear. Most shoes force the foot outward and in this position the weight from above has a tendency to break down the arch. The symptoms of most cases of flat-foot start at or about the time of puberty and one of the earliest of these is cramps in the calves of the legs. Later there is loss of the arch and of the concavity on the inner side of the foot. It is very important to remember that before much loss of the arch has occurred there may be a great deal of pain in the calf muscles, in the foot itself, and in the back. ^The Resume on Plat-foot is largely taken from an article by Dr. Edward H. Ochsner of Chicago. Defects op the Feet 105 The foot finally loses a good deal of its range of motion, especially the ability to turn inwards. The outward turn of the foot becomes prominent, and the ankles have a tendency to bend inwards. It is most impor- tant to teach children with flat-foot to walk properly. To this end they must learn to walk with the feet nearly parallel. Children with flat-foot or broken arch should receive treatment as early as possible in order to prevent serious results. Such treatment can ordinarily be given only by orthopedic surgeons who have made a specialty of physical defects of this character. CHArTER VIII. POSTURE.l Posture exerts a far greater iiilliieiice upon health tlian is ordinarily recognized. We commonly value it for its aesthetic effect, but this is in fact of relatively little importance as compared with its influence upon health. Nor must we forget the effect of posture upon character. A well poised body gives to others the im- pression of a Avell balanced mind, Avhile the constant habit of good carriage reacts to the advantage of the individual himself. To a great extent we can he what icc act. We can, says Dr. Luther Gulick, assume the bodily positions and movements and manners and tones of voice that belong to the emotional state we desire. "Our muscles can be made to express the positive, the constructive, the joyful attitude * * * * ^ye be- come the thing we act; and if we always act the best thing that we have within our power, we are on the road to actually becoming that thing."^ In the schools of Germany and some other European countries the cultivation of a good posture is con- sidered a very essential part of a child's education, 'Without the aid of Dr. Joel E. Goldthwait's paper on "The Relation of Posture to Human Efficiency and the Influence of Poise upon the Support and Function of tlie Viscera," this chapter could not have been satisfactorily presented by the writer. Dr. Goldthwait's paper was read at a meeting of the Boston Medical Library in 1908. ="Mind and Work," Dr. Luther H. Gulick. Posture 107 For this reason few German students are seen who do not carry themselves well. In this country it is very different. The cultivation of a fine carriage is con- sidered a luxury, an accomplishment, but not an es- sential factor in education. The other day I watched the children of a large school assemble in the halls pre- paratory to marching out for recess. In the long lines hardly a single child assumed an easy, graceful, health- ful posture. Some stood on the outer side of one foot (one indication, by the way, of a weak arch), others stood with heads forward and shoulders stooped ; some stood with abdomen forward and shoulders back; some with one shoulder much lower than the other (some- times an indication of spinal curvature) ; they slouched and moved about restlessly in many uncouth ways. It occurred to me then that these children were not only lop-sided in bodies but were perhaps developing lop-sided minds as Avell. We are largely what we act, and a slovenly mind is apt to go with a slovenly body. One rarely sees a suc- cessful business or professional man of very slovenly posture. The orderly habit of mind which brings suc- cess is usually associated with an orderly habit of body. Dr Gulick gives us one of the secrets of such success, a secret so simi)le that he who runs may read. "If you are walking along the street and wake up to the fact that you are carrying yourself poorly, take the mental attitude of standing straight, as well as the physical one. Look at the men you meet and imagine that each one of them owes you a dollar. Put even a suggestion of arrogance into your position. Hold your 108 The Health Index of Children Greek Statue of the Sixth Century Sho^viii^- a Perfect Staudiug- Posture. liead well back; this will not only give the impression to others that you possess the power that you want, but it will actualh' tend to bring the power to you. Posture 109 Flat chest, flabby muscles, jelly-like abdomen do not make for what we call a strong personality. Keep the neck against the collar." Now children cannot acquire this bodily habit of success too early. To be of much use it must become instinctive, automatic. The muscles of the child must do the right thing at the right time without his having to think about it. But muscles must be taught and taught early, if such useful automatic action is to ever be successfully acquired, for after all education as a whole depends for its success upon learning how to do most things Avithout having to think. The thinking faculty must largely be reserved for purposes of co- ordination; it should be spared the petty details of purely mechanical functions. But even more important than the mental effects of posture are the purely physical effects. No one has more thoroughly or beautifully explained this than Dr. Joel E. Goldthwait, of Harvard University. In speaking of the collection of casts from Greece in the period of 500-600 B. C. in the Museum of Fine Arts in Boston, Dr. Goldthwait says : "There is not a single cast or reproduction that did not show the body so poised that the greatest eflSciency of the organism would be possible." Of one male figure in particular he says : "The head is erect and in such balance that all of the muscles must be in easy contraction, making- possible any movement, forward, backward, sidewise or with any combination with the greatest ease and with the least possible waste of energy. The chest is high, allowing the fullest freedom of action of the 110 The Health Index of Cihldhen thoracic organs. The shoulders are erect, in which position all the muscles are in eas^- contraction, read}' for immediate function with the least effort. The trunk is so balanced that no group of muscles or part is St. Gnudrii's StJitue of liiiieolii IIIiistratiuK- Posture strained, but action with the minimum of waste is possible, Avliile the visceral ( internal organs of abdo- men), supi)ort and function is maintained with the Jeast effort. So also, of the legs, there is no strain, Posture 111 but every part is ready for full duty with the least waste in either time or energy. The greatest amount of general fitness is suggested by the figure, and this applies not only to that which is physical, but to the spirit or the purpose of the individual. In every part, the body, the mind and spirit, the figure suggests readi- ness and efficiency * * * * * * * in modern times it is not difficult to find equally satisfactory types. Nothing can be finer than the St. Gauden's figure of Lincoln, which is quite remarkable in that even though the figure is depicted in repose, with one knee relaxed, the trunk is perfectly erect so that the poise of the head is free from strain and the visceral function, or support can in no way be disturbed." The evil effect of incorrect posture upon the internal organs are rather easily explained. In the inclination of the body forward or the drooping position, which one is apt to assume when fatigued, the breast bone is depressed at the upper end. This results in decreasing the space in the chest from before backwards, and so interferes with the free action of the lungs and some- times of the heart as well. In this drooping posture there is considerable "increase in the downward in- clination of the ribs." This results in a flattening of the upper part of the chest under the collar bones at the sides and consequently in a restriction of lung space at this place. Tuberculosis frequently begins at just this point. The organs of the abdomen are affected by the drooping or fatigue posture even more than those of the chest. In general the effect is to shorten the abdominal cavity and crowd the contents 112 The Health Index of Children downward. This often results in serious disorders either of the abdominal organs or the organs within ihe pelvis. The latter condition explains many of the disturbances from which women especially are apt to suffer. Children often assume bad postures in school, es- pecially while reading, writing, or resting at their desks. To correct this as far as possible, the child's feet must reach the floor, the width of the seat must be great enough to come rather close to the knees, and it must have a slight backward slope. The desk must be so arranged that the child may /arc it with arms and hands upon it. The desk must come as near the pupil as possible without touching him. This prevents leaning forward too far. ''If this posture is taken, the head will be erect, the arms will offer a support, the chest will be easily filled, the shoulders will be on a level, the back will be straight, and the position can be maintained for some consider- able time without fatigue.''^ By maintaining correct posture one avoids a very considerable part of the struggle for existence which confronts those who have carelessly or ignorantly al- lowed their bodies to assume faulty postures. Correct posture places the individual in the position of great- est physical efficiency. This posture is assumed when '^the body is held so that it is made as tall as is possible without raising onto the toes. In this position the head is erect, the shoulders are thrown back so that their center is back of the center of gravity, the chest ^The Physical Nature of the Child, (Rowe). Posture 113 is liigh, the abdomen is flat, and the spinal curves are slightly convex backward in the middle part of the back and convex forward in the lower part." Elaborate systems of gymnastics are neither enjoy- able nor desirable for the average child or adult, nor are they in the least necessary for the acquisition of a correct posture. All that is required either for health- ful exercises or learning good posture habits are sim- ple exercises jjracticed daily until the muscles easily and naturally hold the framework of the body in the positions desired. In school the teacher must not only know how to teach correct postures, but ought to be herself a constant example of what she wishes to inculcate in the minds of her pupils, for no amount of teaching however good will ever offset a bad example. 114 The Health Index of Children PART II. THE CHILD AND HIS ENVIRONMENT. CHAPTER IX. FOODS FOR CHILDREN. 1 In considering- the question of how best to feed school children, it must not be forgotten that the period of school life extends over a number of years, and that in the school house we invariably find children of dif- ferent stages of growth and development, and children with very widely different needs. It Avould be impos- sible for any directions however lengthy, to properly or adequately cover the requirements of all children, even at the same stage of their lives, Avith their widely vary- ing tastes and idiosynocrasies, and their special consti- tutional tendencies. No diet list however carefully chosen could be used with good results for all children of any one age — much less for children of all ages. The only hope of a proper solution to this many- sided problem, lies in creating in the minds of those people who have the catering in charge, an intelligent understanding of the uses of the various foods and trusting the rest to their discrimination. Many rules of dietetics are only of service when applied by the person who has had experience with the particular child in question, and possesses a thorough understanding of its special needs. Only wide general principles are univer- sally applicable. The scientific principles which underlie the proper 'Prepared for this book by Mrs. Dr. Jaffa. Foods for Children 117 selection of foods are few and easily understood. Chemical analysis has shown us that all foods, no mat- ter how simple or how complex they may appear, con- tain only four classes of materials. Each class has many subdivisions containing an infinite variety of chemical compounds. But nothing has been found that cannot be classified under these four heads. Two of these are mineral matter and water, which are not necessary to consider in our present discussion. That leaves us only two main classes of nutrients to under- stand and to deal with ; the nitrogenous group and the non-nitrogenous. The question is naturally asked, "Of what use is this classification? In what way does it help?" The ans- wer is at once plain when we consider that these two classes have entirely distinct and separate offices to perform in the body. The protein or nitrogenous group builds tissues; the bones, muscles, nerves, in- ternal organs, etc. It supplies material both for the building if new tissues, as in growth, and for the repair of the old. The non-nitrogenous group furnishes heat to keep the body warm and energy or power with which to perform our work. This material may be stored up in the body for future use in the form of fat, but can never be used to build real or deep tissues. Fat in the body is like coal in the basement, ready to be converted into heat and energy. Our need of it after we have accumulated enough fat to round out our frames is in direct proportion to the weather and to the amount of energy we expend in both voluntary and involuntary functions. The little girl who sits in a warm room and 118 The Health Index of Children reads and sews, does not need as much as her brother wlio phiys ball in the cold winter air. That brother is the best example of a healtliy crea- ture in need of plenty of nourishing food, that we could well find — especially if he is in his teens. There, is every kind of a call for food that could be found under normal conditions. AVho else in the family is growing so quickly, who else lengthening out and widening every bone and tissue of the body? The baby of the family may be doing that, but she is not studying or exercising, neither is she under nerve strain. The father may be using his brain in his work and may be under nerve strain, but he is not growing and may not be exercising overly much. Rarely indeed do we find a human crea- ture, whose demands for food materials are so many and so urgent as those of the boy in his teens. If the problems involved in the proper feeding of a growing boy be solved first, the results may be modified for other children, up and down the line, according to their ages and conditions, and their individual needs. We have come to know a great deal about the food for the first period of rapid growth, that of infancy, since the chemical analysis of mothers' milk has furnished us with a perfect model upon which to base our selec- tion of substitutes when the natural food fails us. But the second period that comes early in the *'teens" is not 3'et so generally' understood. During these 3'ears of adolescence, when Nature is making every efl'ort to develop and round out the per- fect individual, she needs all the help we can give her. She can not build if we do not supply her with material, Foods for Children 119 but she can, and often does, build one part at the ex- pense of another. It is a common thing to hear a mother say, with reference to a child, that he "outgrew his strength." Translated, that expression means that the child did not get, or was not able to use, sufficient food material to supply all the needs of the entire organism. It is the second and last chance that Nature has, to remedy defects in the constitution, and she makes a desperate effort to accomplish it. The results of im- proper feeding at this time can not be easily remedied. It is often a case of "now or never," and the work that is not done in this second formative period of life may not be done at all. Weak spots in the building will alwa^^s remain weak spots, and Ave should not run any risks at this time. Many of the nervous symptoms usually observed during the period of adolescence are not necessary or normal. The nerves suffer from in- sufficient and improper nourishment, as well as from other wrong and unhygienic conditions during the early "teens." (See Chapter V). When the importance of proper nutrition is once fully realized, the first question asked is, "How can we supply it — what kind of food does the child need?" The answer is very plain. He needs All Kinds, and in sufficient quantities. He should be fed not only from the different classes of foods, but from the various sub- classes, as well. Fortunately for us, most foods con- tain some nutrients from each. When we classify foods we place them according to the largest amount or importance of some ingredient that they contain, but 120 The Health Index of Children that does not mean that they do not contain any other. The following table illustrates this jioiut. Some of our common foods are placed under the class to which they belong, while in parenthesis are indicated what important nutrients of the other class they contain. Verv small amounts are not so indicated : Foods for Children 121 > ^ So trt +-> be iH (TQ -i-j O (1) O +J ■*-> o o fe m o > rH S^ CO -^ LO CO ,-^ ^ Q 3 o3 ;I^ CO O O L. U. a 3 O m bD a 3 O L. C5 .5 'i-i to 03 03 bfl to to' to *3 fa O z o „• K- < o u. CO CO < O w 3 O E (U O) s "z '3 m o a> :;3 03 M bJ3 be

01 a o K CO 01 01 03 bi) o Z ffi _, pi _I p^ rH c4 CO ■^ LO ?d c-^ 00 oi o g 'g o u ft fl B o X2 o o o p PI O o o to XT bD iH to 01 CO '3 o y CO -u CO 4J P! to to PI rlS el Pi PI 13 < 03 o O o o o 01 CO 0> 03 02 o to "cS M o CO o CO "S o o CO 13 to 01 o -l-J Ol o "cd -i-j o Ph 0> 03 -u 0) bB 01 > PI 05 o o O CO 13 to 0> Ol O o3 O 01 o Pi 01 en o '3 u fa rH im' CO ■^ LO (6 t>^ 00 122 The Health Index op Ciiildken It is important also that we should not ignore the subdivisions. While the sugars, starches, and fats belong in one large class, and apparently perform the same office, they vary greatly in other ways. Starch must first be converted into sugar, in the digestive tract, before it is absorbed and used. Therefore, it would be much more difficult for the body to obtain all of its carbohydrate from starchy food, rather than from starch and sugar both. Again, fat is worth two and one-fourth times as much as either starch or sugar for producing energy. The Esquimaux and Lap- landers realize this when they eat their tallow and blubber during the long and severe Arctic winters. The boy's instincts, too, will lead him to choose the all-round diet that he needs, provided he has an oppor- tunity for selection. He can not choose what is not there, and his instinct will rarely be strong enough to cause him to demand what he does not see. To limit his choice to a few articles is to tempt him to over use the one that appeals to him the most. To regulate his diet according to the taste or fads of the grown-ups is to hamper him most cruelly. It is not necessary to weigh or measure or count it out. It is only necessary to see that he is provided with some food materials from each important group. Protein, or nitrogenous food, he needs, of course, in large quantities, to furnish the huilding material with which Nature is to develop the frame of the child into that of the man. It is not well for him to get it all from meat — that puts too much strain on the organs of elimination. The "meat substitutes" should be kept Foods for Children 123 in mind and provided for the non -meat meals. He should be given milk and eggs or nuts, cheese, beans, lentils, etc., and he will not crave meat as inordinately as most bojs do. His need of building material will thus be partially satisfied but it should always be re- membered that he requires more protein than an adult until he has his full growth. The non-nitrogenous foods are in great demand as well, to furnish the body heat and the energy for all his work and his "sports," and to round out his frame. But he should not be expected or allowed to get all he needs of it from starchy foods. They are very bulky and would prove an unnecessary strain on the organs of digestion. Do not be afraid of sugar as part of a meal. Candy is an excellent dessert for active grow- ing children — and nut candy — properly chewed is es- pecially nutritious. Remember that Mother''s milk contains five per cent of sugar and is the ideal food for the growing body of the infant. It contains protein, sugar and fat but no starch. Fat is a most important element in the dietary. While its office in the body is the same as that of the other non-nitrogenous foods, its digestion is different, and it is worth more than twice as much in furnishing heat and energy. No child should be allowed to go without fat simply because meat fat or butter are dis- tasteful or do not agree. One kind after tlie other should be tried — cream, ham or bacon fat, nut oils, vegetable or fish oils — until the right one is found. When fat is not tolerated with one kind of food, it often will be tolerated in a different combination. 124 The Health Index op Chh.dren Some concentrated nonrishnient should be used at each meal in connection with the more bulky foods, so that the proper amount may be taken without crowd- ing the digestive apparatus. The sugars and fats are the most concentrated foods — ^and meat, cheese, eggs, etc., next on the list. This means that there is less water and waste material in them. At first glance it may appear that no real directions have been given for the dietary of a growing child. ''Feed him everything. He eats everything now." But perhaps a second and more careful glance will disclose errors. True, there is no one great radical change advocated; but it is the accumulation of all the little things that makes the real difference. Nature works slowly. In order to help her we, too, must work slowly and patiently with carefully thought-out meals, con- scientiously persisted in for years, if we expect to see results. Some apparently slight change made in each meal three times a day for 3G5 days in the year would make a great difference in the end. Suppose for instance, it were decided to add "grow- ing material to the dinner'' other than the meat. Sup- pose the meat soup were replaced occasionally by a bean or pea soup or by one of the various milk soups ; and that on other days the potatoes were replaced by rice or macaroni and peas used more frequently than other vegetables; and that on others, the pie were re- placed by custard or soft home made candy — would not that alona make considerable difference at the end of the year? And if for breakfast, oatmeal were used instead of Foods for Children 125 wheat or wheat foods — breakfast cheese for those who do not eat meat or eggs, milk or cocoa instead of colfee — milk toast instead of dry toast, etc., would not the sum total of the year's breakfasts count? The meal that usually requires the most radical re- construction is the lunch. Between the children that rush home and swallow a hasty bite of unsuitable material and hasten back for fear of being late, or else to play with the other children, and those who carry a cold lunch composed of food that would not furnish very much nourishment, even if it were not diflflcult to digest — there remain probably, only a small percentage of children whose lunches are suited to their needs. This is a great drawback in many cases, for it is often the one meal where individual requirements can be most easily attended to. To slight one meal out of three is to slight a very large portion of the child's opportunities for nourishment. The lunch can never be considered alone. It must of necessity depend largely upon what is given for the other meals of the day. It is really not a difficult task to make one meal complimentary to the others when the habit of mind is once established. Having acquired a permanent mental picture of the food groups, and having the special requirements of the child, it becomes an easy matter to arrange a lunch of nourishing ma- terials not supplied by the other meals. Does he eat heartily of meat at night and perhaps has some for breakfast? The lunch should contain "non-meat protein." Does he prefer the vegetables and dessert at dinner? Give him meat at noon. Do the 126 Tub Health Index of Children other members of the family object to oil or fat? See that the growing boy gets peanut butter or mayonnaise sandwiches, etc., for his lunch. Is his breakfast light? His lunch should then be very hearty. Is he tired at dinner time, and sleepy? His most nourishing meal should be at noon. Does he refuse eggs for breakfast? He may relish and digest them Avell for lunch, and thus it goes. It would be impossible to cover the ground of the various elements involved in the decision. In general, the lunch, as well as the other meals, should be as simple as possible in order to supply the required nourishment. The work of handling the quan- tity and kind of food, needed to build up the physical frame, and keep the organism in good running order, is (juite enough strain on the digestive organs, without hampering them with unnecessarily complicated or difhcult dishes. As a rule, made dishes, fried food, "warmed overs," smoked and salted meats, thickened gravies, etc., should not often be given even to the healthy child, and uerer to one whose digestion is weak. Food that is difficult of digestion may often be handled jierfectly on occasions, Avhen frequent repeti- tions would cause disastrous results. It must never be forgotten, in this connection, that "what is one nmn's meat is another man's poison," and careful ob- servation is the only sure guide. The main points to keep in mind may be summarized as follows: Be persistent in using foods from each group. Be sure to use plenty of "growing material"" without going to an extreme with meat. Foods for Children 127 In iisiug meat subKstitutes remember: (a). — That milk is tlie most valuable one to use if it agrees, and that skim milk is just as rich in growing materials as whole milk. (b). — That eggs come next in order. (c). — That nuts must be ground or very icell chewed in order to be properly digested and assimilated. (d).— That soup meat has all the growing material left in it, and none of the deleterious elements (uric acid-forming materials, etc., that are in the soup), and is a cheap and excellent food, and can be made into appetizing dishes for breakfast or lunch. (e). — That oatmeal, macaroni, rice and gluten flour have more growing material than potatoes or wiiite flour. f). — That in using nuts, cheese and beans, the ques- tion of individual digestion must dictate the choice. Do not forget that in pushing nourishment, some concentrated foods should always be used witli the more bulky ones. Fruits and vegetables have a hygienic and a medic- inal value, but after this purpose is well served, they are expensive food materials. In comparing the prices of the different foods, we should consider the amount of nourishment they con tain as well as the price per pound. Eating between meals should only be allowed where it is prompted by hunger and not by a desire for goodies. Only easily digested foods as crackers and fruit, etc., should be given at such times. The nourishment should be fairly well distributed 128 The Health Index of Children among the three meals, and not crowded mainly into the dinner. The weekly dietary shonld contain considerable va- riety, but the single meal, not too great a mixture. Study the effects of combinations before discarding any food from the diet list. Never crowd nourishment nor risk indigestible food on occasions of excitement or fatigue. After indulgence in an unusually heavy or taxing meal see that the next one is uuusuall}' simple. When protein is added to the dinner for the sake of the children, the '"growu-ups" may eat less of the meat. The necessity for careful mastication is a lesson that children can not be taught too early. When the ''what's, the why's and the wherefore's" of feeding the growing boy in his teens, are well under- stood, it becomes an easy matter to cut down and mod- ify his dietary to suit the cases of the younger or the older children, the fatter or the leaner, the more active or more sluggish, the thriving or the poorly nourished. It is only necessary to keep in mind what the foods do in the body, and the special needs of an}' nornml child may be easily met. Those who are suffering from weakness or disease should be under the care and direction of a physician. CHAPTER X. HEALTH AT HOME IN RELATION TO SCHOOL HEALTH. The school is often criticized for results which really originate in the home. It has become a common habit now-a-days to find fault with our school system in nearly every particular. Some of this present day criticism is just, and is therefore accomplishing much good, for our schools are rather keen to give heed to fair complaints. But much of the complaint is mereh^ destructive in nature and is often based upon misconceptions of actual existing con- ditions. Our present school methods undoubtedly do produce many physical defects and contribute to others orig- inating elsewhere, but the fault is just as often to be found in various abnormal home conditions, and in ignorant or careless physical neglect. School health and home health are interdependent, and an oversight of this plain fact often leads to many errors. 1. Not long ago I noticed a little girl of twelve years in one of the best Berkeley schools who appeared sin- gularly nervous and queer. The usual physical exam- ination revealed nothing of particular importance. Eyes, ears, nose, throat, teeth, heart, lungs, and the like, all seemed healthy enough. Yet that the child was far from normal in some respects was apparent in her 130 The Health Index of ('hh,l)I(ex general appearance and nervous demeanor. A home visit from the school nurse revealed at once the nature of the difficulty. The mother while by no means indigent considered that her circumstances were too straightened to justify her in purchasing milk for her child to drink. She therefore kept the cott'ee pot constantly on the stove and permitted the little girl to help herself as often as she wished. The result was that this child was drink- ing a pot and a half of strong coffee daily. The mother thought that coffee was a food and a cheaper one than milk, so she ignorantly made use of it. The child's condition in school was thus easily and quickly explained. A few simple explanations on the part of the school nurse soon set this mother right, and one less school child was from that moment a victim of the coffee habit. 2. In another school a boy of ten years was observed who appeared illy nourished, pale and apathetic. There again the physical examination revealed no defects of the usual sort, but the nurse's visit to the home ex- plained the trouble. The boy slept in a very small bed-room opening out of the kitchen. In both the bed-room and kitchen the windows were kept care- fully and conscientiously closed at night, and during the day the air was never Avholesome. A simple lesson on the hygiene of ventilation given on the spot by the tactful nurse worked wonders. A few weeks of sleep in the same room with the windoAvs thrown wide ojjen at night jjroduced a very different looking boy. Health at. Home in Kelation to School Health 131 The little girl in the first case was coffee jmisoned — the little boy in the second case was air poisoned. These instances just related are by no means excep- tional, but fair types of many such cases met by care- ful physical examiners in the schools. Of over 500 children in the Berkeley Schools, in the grades from the third to eighth inclusive, it was dis- covered that 53 per cent use tea or coffee or both daily, and in this respect these schools are not exceptional. This habit deserves more serious consideration on the part of parents and teachers than is usually given to it. Disguise it as one may, this is a mild drug habit and while not necessarily of great importance in its effects upon healthy adults, it certainly has seriously bad effects upon children. It is high time to teach temperance in all tilings instead of unduly focussing attention almost exclusively^ upon tobacco and alcohol. Many school children live in homes of more or less constant unstable nervous equilibrium. An irritable mother or father can hardly fail to produce an irri- table child. An irritable child at school rarely makes good pro- gress, and is frequently scolded and punished by the teacher. The child Avho leaves home for school in a state of nervous excitement from any cause must not be blaiued for capriciousness, irritability, or misbe- havior in the school room. The influence of environ- ment is greater than that of heredity. TJie daily home environment very largely determines the child's conduct in school. Let the tactful teacher or nurse investigate the home conditions of her nerv- 132 The Health Index of Childuex oiis, misbehaving children and she will nearly always discover the exciting cause of the child's actions. Conditions of malnutrition are very frequently ob- served in school children. This condition is by no means always due to poverty at home. The fact is that relatively few families in this country are too I)oor to furnish their children with nutritious food in pro{)er quantity. The counnon explanation is ig- norance of what sort of food the child really requires for good health. Children are most often allowed to make their own selections of diet. The whim and the caprice of the child are too fretiuently encouraged. Children and adults can with very few exceptions eat Avhat is placed before them when the food is intelli- gently selected and well itreparcd. 3. I re<-ently noticed two children, brother and sis- ter who had a singular pallor and appeared jioorly nourished. Their work in school was of low grade. A visit to the home brought out the interesting inform- ation that the breakfast of preference with these child- ren consisted of pic, pirllcs and coffer, and this pre- ference was not infrecjuently indulged. It was with great difficulty that the mother (a fairly intelligent Norwegian i was persuaded that no child can thrive upon such an atrocious morning meal. 4. I once found a little boy of eight in the schools another city whose sluggish motions, pallor, and ema- ciation were apparent to any observer. A few direct questions elicited the information that his breakfast usuallv consisted of strong cotfee and bread without Health at Home in Relation to School Health 133 buttei-. For limcli lie usually had some bread and butter; for supper some soup and bread. His parents were Ignorant, shiftless, and poverty stricken. A wholesome lunch of good variety was provided for this boy and the parents instructed about the necessity for a properly balanced ration. The result was that the child soon grew strong and healthy in appearance and improved greatly in his daily school work. 5. It is not altogether uncommon to observe cases of absolute home neglect among school children. The folloAving case will serve as an illustration. A boy in a second grade asked his teacher to excuse him from the usual physical exercises in school, which she I)roraptly did. He said, "it hurts me to do those things." Upon examination I discovered a large tuber- cular abscess in the groin. This abscess was discharg- ing and yet had never been dressed nor had it received any kind of attention. It was with difficulty that the j)arents were made to understand the seriousness of the condition. Proper surgical treatment cured the case in a few weeks. 6. Another boy in the same grade had a peculiar walk which the careful teacher had noticed. He was very delicate looking and had once fainted on his way to school. Investigation demonstrated tliat this child was suffering from chronic appendicitis, which the parents had evidently neglected. I insisted upon the child being removed from school and being placed under a physician's care. In two months he returned a well and relatively strong boy. 7. A third boy in this grade breathed so loudly 134 The Health Index of Children through his mouth that all the pupils in the room were disturbed. He was apathetic and stupid looking and he made no progress whatever in his studies, yet his par- ents had not observed much that Avas wrong with him. These parents Avere notified that adenoids were present and an Operation was advised and done. When I next saw him one year later he was scarcely recognizable as the same child. His whole appearance had changed, he breathed quietly, his facial expression was bright, he had improved in physical vigor, and was doing as good work as the other children in his grade. 8. Sometimes the most evident principles of home hygiene are violated to the serious detriment of a child. My attention was called by a teacher to a boy in a fourth grade who was constantly giving her trouble. He was sullen, irritable, refractory, quarrelsome, and misbehaved generally. His physical appearance was extremely bad. Upon examination I found plain evi- dences of lung disease. He had a constant cough and it was said that there had been some sort of a hem- orrhage some time before. The school nurse discovered that this was a case where the father was tuberculous and that this boy had slept in the same uuventilated room Avith his sick jtarent. No attention Avas given to a reasonable diet in this home and the household Avas in general A'ery badly ordered. Against the wishes, and indeed Avith the absolute disapproA^al of the parents, the boy was taken out of school. Some sensible hygienic instruc- tions AA'ere giA'en by the nurse and an out-door life ad- vised for the boy. Some months later I saw him on the Health at Home in Relation to School Health 135 street, and to all appearances he Avas well on the road to recovery. 9. The neglect of the practice of dental hygiene is the rule rather than the exception among school child- ren. For this state of affairs the home is of course pri- marily to blame. The plain fact that clean teeth do not decoy had not as yet sunk into the inner consciousness of most parents, nor do they understand that various serious disorders originate in neglected teeth. A par- ticularly striking instance of such dental neglect is furnished by the case of a boy whom I examined in a Pasadena school. He was reported to me because of his poor general physical appearance, but the teach- er had not noted any trouble with the child's teeth. An inspection of the mouth revealed the whole dif- ficulty at a glance. The teeth were in a horrible state of decay. One tooth in particular was badly ulcer- ated, the gum had receded and most of the root on the cheek side was exposed to view. Some of the tissue was evidently tuberculous. Strange to say, the father offered the greatest possible opposition to having the teeth properly cared for, believing as most parents do that first teeth are meant by nature to decay and that it is not worth while to interfere with nature's beneficent methods. The older brother of this child was at the same time suffering from en- larged and discharging tuberculous lymph glands in the neck. Both children were miserably nourished, nnhapi)y in appearance, and making no progress in school. After repeated efforts on the part of the school phy- 13G The Health Index of Chu.duen sician and the Principal of the school, the fathei* at last consented to have these boys placed under proper treat- ment. One year later I met them as I was driv- ing one afternoon in the country. Their vigorous appearance and exuberant spirits were in such marked contrast to that of a year before that at first I did not recognize them. They had been visiting an aunt in the country, and were now walking home, a distance of six miles, and the smaller and formerly less vigor- ous boy was pulling the. other one in a wagon ! Two boys like these saved from misery and perhaps death and made happy and useful, justify, the ex- pense of a School Health Department. Yet some ])eo- ple still doubt the advisability of health supervision of children in the schools! CHAPTER XI THE HEALTH OF THE TEACHER. Ver}^ few schools in this country pay any serious attention to ttie health of their teachers. Even in the matter of vaccination, although usually required of all pupils, teachers are ordinarily exempt. Not only is this true of teachers, but few Normal Schools in- sist upon any adequate physical examination of their students. The result of all this is that some teachers are employed who are constant menaces to the pupils entrusted to their care. Tuberculosis, although rather common, is not the only disease from which teachers suffer and which may react seriouslj^ upon their pupils. When we consider the amount of time which a child spends under the care of a teacher and the intimate relations which exist between them, it is evident that the teacher is only second in importance to the mother herself. Despite these self evident facts the teacher's l)hysical condition rarely receives consideration, either for her own good or for the good of the child. Books on School H,ygiene or on Medical Inspection of Schools seldom discuss the subject of the teacher's health at all, or if they do, the topic is treated most inadequately. Of all physical disorders, nervousness in its various phases is probably the one of greatest importance loS The Health Index of Chh.uken among teachei-.s. Public school teaching is of necessity (according to our present rather irrational sj'stem) a nerve racking occupation, even to those teachers who begin work with well balanced nervous organizations. AMiat may we expect then of those individuals in the teaching profession who never have possessed much nervous stability ? Nervous Disorders Among Teachers. One of the strongest arguments, among many others, in favor of a greater proportion of men teachers in the upper grades of our public schools is the fact that women by nature possess as a rule far less nervous sta- bility than men. All of these facts are, however, large- ly ignored in the selection of teachers in our schools, and we go on complacently placing our sensitive child- ren during the most important formative periods of their lives, under the care of teachers who may be a con- stant daily source of injury to them. The writer remem- bers very vividly one of his own teachers in a third grade who had so little self control that she was regard- ed with the greatest fear by her pupils. The slightest childish indiscretion was sufficient to send her into fits of uncontrolled anger, during which she would grab the unhappy victim (most often the present writer) by the scrutf of the neck and whirl him about, red in the face and choking, until his feet struck the to])s of the desks and the life was nearly shaken out of him. This teacher never smiled, she was always sour, unhaj)py, despondent, ill-natured. The influence up- on sensitive children of a year si)ent under such a The Health ob^ the Teacher 139 termagant cannot be estimated, and the memory of it can never be entirely effaced. Later in life this wo- man's actions were easily explained to the satisfaction of her chief victim. Her mother and one sister became violently insane. This teacher possessed an extreme neurotic type of character which she had undoubtedly inherited, and, was no more fit to deal with young- children than are many of the inmates of insane asylums. Violent uncontrolled tempers and other ill natured actions are not the only or chief manifestations of nervousness in teachers. Many estimable, good na- tured, conscientious individuals possess little sense of composure. Sometimes teachers of this type are es- pecially gay, vivacious, affectionate, ;dem;onstrative. Their very over-indulgence in these estimable qualities often unfits them to fulfill their duties properly. Such teachers are constantly solicitious for the welfare of their charges, they are all "dears and darlings"; they are coddled or severely disciplined by turns, and with little discrimination. I have seen some women teach- ers of this type who had succeeded in disorganizing the entire school through such manifestations of nerv- ous instability. Repose with them was never practiced and therefore repose was an unknown quantity among the children in their schools. Children in such schools dread the visits of the school nurse or physician because they have been told over and over again that "the doctor isn't going to hurt you," or "the nurse won't carry you away," or given similar unwise suggestions which in themselves 14U The Health Index of Children intimidate the child. Such teachers, like some par- ents, are likely to threaten certain children with an "examination by the doctor, to see why they don't behave." Under snch circumstances the child of course comes to look upon the doctor as he does upon the "Policeman" or other bugaboo, of which some fond teachers and parents make constant use, to secure easy obedience. Teachers, of all people, need to acquire a good sense of repose and must learn to administer discipline with wisdom and judgment. Next in importance to the ill-tempered or over-so- licitous types of teachers, come the depressed and mel- ancholy types. These individuals rarely bring light and joy into the school room. They inspire awe but never love; they obtain "discipline" but never obe- dience. To this type, teaching is usually a necessary evil, and pupils are regarded as unfortunate incidents in their daily work for a livelihood. No school room should ever be clouded by the presence of such brood- ing sfonii centers. Children require a cheerful, happy environment, and if they do not secure it their lives are always blighted, for they are sensitive little human plants reacting to the slightest human frost. Then there is the intoisvli/ and ahnormaUy active teacher. This type is never at rest. Every common duty is performed with a wearisome strenuosity which leads the child in time to long for an opportunity to just once explode and relieve the tension. Finally there are the victims of hah it-spasms of one sort or another, which some children so readily and skillfully acquire by imitation. The Health of the Teacher 141 The writer i-einembers one such teacher whom he had in his extreme youth. She constantly twitched and Avrinkled her nose as if she smelled something un- pleasant. It was not long before half the little boys in the class, with this ever present example before them, were going about sniffing the air like young colts. One eye-hlinking teacher will sometimes set half of the girls and some of the boys to winking their eyes furiouslj^, while any other peculiar nervous habits ' of the teacher, such as nervous laughing, raising the brows, stammering, nail biting, coughing, and the like, are soon reproduced with avidity by several of the apt pupils. All of these types usually represent varying degrees of neurasthenia, or an unstable nervous equilibrium, which in itself if uncontrolled, ought to debar their possessors from the serious responsibility of training children. Indigestion. Next to nervousness, indigestion in its various phases is probably the commonest complaint among teachers. For this state of affairs there are many reasons, but most of them fall into a common group, viz, lack of exercise, worry, insufficient mastication, improper prep- aration of food. There is no better way to keep healthy and happy than by learning the importance of careful habits of eating. Most of our headaches, "fits of the blues," and depressed feelings come from the abuse of food. People tvith healthy digestions are rarely sick. Unless we take good care of the digestive organs, we 142 The Health Index of Childuex cannot expect to have niucli resistance against disease. Tlie digestive organs naturally' secrete juices which are antagonistic to many disease germs. Abuse of these organs weals:ens their powers of defense. INIauy colds are fallen because of disordered digestion. De- cayed teeth are more often caused by indigestion and bad nutrition tlian by anything else. It is no disgrace to be sick when we cannot prevent it, but ignorance of how to keep well is rather worse than any other sort of ignorance. I have seen many teachers of Physiology and Hygiene who as practical examples of the observance of the kiAvs they taught, were very sad failures. One may be justly proud of vigorous health, especially when it is the result of careful study and obedience to nature's laws. I'robably more sickness is caused by the improper use of food than by any other one thing. Most people eat too much food. Overeating easily becomes a habit. When the stomach is overloaded, digestion is retarded and some of the food is sure to fer)ue)it. Gas forms and also certain other products of fermentation. The gas causes bloating, Avith uncomfortable sensations. Sometimes the stonuich pushes up against the heart and causes pali)itation. Many persons imagine they have heart trouble, when indigestion is really the cause of the symptoms. The fermentation products are ab- sorbed by the blood and circulate in the body. Some of these are poisons. By overindulgence in food, which may in itself be harmless, a person may thus poison himself, just as if he had swallowed actual poison. This is one of the commonest causes of headache. The Health of the Teacher 143 The state of the mind has a great deal to do with how our different organs do their work. Pleasant company, good cheer, and attractive food all stim- ulate the organs of digestion to do their best work. Unpleasant surroundings, unattractive food, or worry may cause an attack of indigestion. People hardly ever suffer from indigestion after a pleasant banquet, even when they overeat. But the most frugal meal with a bad temper or other unpleasant conditions may actually stop the process of digestion. Many persons suffer from chronic dj^spepsia simpl}^ because they imagine that their food will disagree Avith them. ^Vlien the mind is directed into cheerful and healthy channels and common sense is used about eat- ing habits, dyspepsia usually disappears. Dyspeptics generally form the habit of thinking too much about themselves and of resorting to -drugs from which they appear to expect miracles. A healthy person has a good appetite and enjoys eating. But such a person does not form unnatural food habits. One should not be fussy about food. It is easy to get into the habit of thinking that one can- not eat this or that particular kind of food, but with few exceptions, we can eat any wholesome food. The less one worries about his food, the better. Fads in regard to food and peculiar diets oughc to be studiously avoided. These fads seem to be the par- ticular obsessions of teachers. We hear much of fruit diets, vegetable diets, nut diets, the no breakfast cure, and the like. One needs only to remember that experi- ence has proved, and science has demonstrated, that a 144 The Health Index of Chh.dren mixed diet taken three times dailij is best for the aver- age man or woman. The diet question is very easily and very satisfactorily settled by remembering that thoroiigh mastication of all sorts of common sense, well prepared food will preclude the danger of over-in- dulgence, and if one will thoroughly masticate or "Fletcherize" one may forget most other rules of eat- ing with irapunit3^ Headache. 1 Headache is a distressing symptom from which many teachers suffer, and Avhich materially decreases their happiness and usefulness in school. It ought to be kept clearly in mind that headache is a symptom, and not a disease in itself. It has many causes, among Avhich may be mentioned the following: eye strain, nervous exhaustion, men- strual irregularities, poor nutrition, indigestion, jaun- dice, catarrh, rheumatism, neuralgia, and had ventila- tion (air ])oisoning. ) Eye strain, consti})atiou, indi- gestion, bad ventilation and nervous exhaustion are by far the commonest causes of headache. One ought always to attempt to discover the cause of a headache before trying to treat it. Such causes are usually not hard to find, and once known, the treatment is usually successful. If the cause is not easily discovered and remedied, medical attention is necessary, for headaches should never be neglected. The common method of resorting to "headache powders" and other drugs, Avithout nnu-h thought as to 'Most of the material on headaches, dyspepsia and colds is taken from the author's Health Studies, D. C. Heath Co., Pub- lishers. The Health op the Teacher 145 the trouble, cannot be too severely condemned. Most headache powders advertised as cures contain coal-tar products, such as acetanilid, which if used without the advice of a physician, are likely to injure the heart and do much other harm. Such remedies never re- move the cause, thej merely afford temporary relief and deceive the senses. Some deaths have been at- tributed to the use of headache patent medicines. Eye Strain. So much has been Avritten about eye strain and knowledge of its consequences is now so general, that little need be .said on this subject here. The common symptoms of eye strain in adults are — headache, dis- inclination to continued reading, nervousness, indi- gestion and blurred vision. Sometimes the only or chief symptom present is nervousness. Many cases of nervous breakdown among teachers have been due to this cause alone. The writer knows a prominent teacher who for three years suffered from extreme neurasthenia and was finally obliged to spend several months in a Sanatorium, only to discover at last that the entire trouble was caused by muscular uribalance which produced constant eye strain, or what is more exactly the fact, nerve strain. Many most unexpected results have been produced by this defect. The teacher who feels special interest in this subject is referred to the "Biographic Clinics" of Dr. Gould, in which it is shown very conclusively that undetected and therefore uncorrected eye strain has been the chief cause of the misery suffered by such 146 The Health Index of Children noted men as Charles Darwin, Thomas Henry Huxley, Carlyle, Wagner, and many others. The ability to read ordinary print at the usual dis- tance does not prove that e^'e defects may not be pres- ent, for some such defects are at least in part overcome by an unconscious nervous effort on the part of the individual. Slight degrees of astigmatism often pro- duce worse results than more serious forms of eye trouble, because the individual overcomes the defect through constant but unrecognized nerve strain. If the defect were more noticeable to the individual it would probably be recognized earlier and corrected by the aid of glasses. The most common uncorrected and often unnoticed eye defects are astigmatism, muscular unbalance and far sight, (hyperopia). Colds. Every teacher must have noticed how easy it is to take cold when very tired or exhausted. Anything Avliich reduces the resisting powers of the body makes one more susceptible to disease of any kind. It is because the bacteria of colds are nearly always l»resent and because most people do many unwise things which weaken their natural powers of defense against them that colds are so connuon. Those who learn how to live normal lives hardly ever suffer from colds. On the other hand, many people eat too much, overdress themselves, live in badly ventilated places, or do other unhygienic things — and then wonder why they are constantly subject to colds. There are many other reasons to account for a tendency to colds. For example diseased tonsils and The Health of the Teacher 147 obstructions in the nose, such as turbinates and certain other groAvths, render an individual an easy victim. Other indirect causes which make one liable to take cold are usually one or more of the following: poor nutrition, exhaustion, constipation, exposure to dust, indigestion, bad ventilation, improper methods of clothing the body, which usually result in keeping the skin surface damp, and improper care of the feet. Once knowing the causes of the disease we call a cold, the prevention is fairly easy. Any one who is not in delicate health can learn to avoid colds. No one can afford not to do so. Cool daily bathing increases the resistance of the body. Such baths train the blood vessels of the skin to dilate and contract quickly. This is desirable in order that we may promptly meet sudden changes in temperature by increasing or checking perspira- tion. The practice of cool bathing is beneficial be- cause it trains the nervous system which directly con- trols the capillaries. The use of heavy underclothing which keeps the sur- face of the body constantly moist is to be avoided. Linen and cotton mesh are better than wool; the ma- terial must be such as to allow evaporation of per- spiration. The habit of bundling up the neck with furs or other wraps is a bad practice, except when one is exposed to very cold weather. Eubbers and over- shoes should never be kept on long at a time, and heavy stockings need never be worn. Bedrooms must be well ventilated with open win- dows, and the bedclothes should be warm but light in 148 Tub Hkaltii Index of Ciiilduen weight. The practice of sleeping out of doors is de- sirable when the climate aud siirroundings permit. Teachers particularly should be careful that the air of the school room is not too dry, as is apt to be the case in steam-heated schools. Air that is too dry takes up moisture from the nose and throat and is almost sure to result in catarrh. Sudden chilling should be avoided as far as possible. Sensible care of the di- gestive apparatus and attention to the bowels are most essential. When one does come down with a cold despite pre- caution, it should never be neglected. The best method of cure is to go to bed for a day or two in a well- ventilated room, take plenty of hot drinks, eat little food, and use some simple cathartic. Washing out the nose and throat with weak hot salt water and soda is frequently of great benefit. The results of frequent or neglected colds are often serious. Many teachers are constantly having colds, and one result of this is chronic catarrh. Much mucus is secreted from the nose and throat, and often the bronchial tubes become involved. This means that intiammation is always present and that certain harmful bacteria never cease their labors. Teachers who suffer in this way are likely to have a decided tendency toward tuberculosis. Sometimes these ca- tarrhal conditions travel back through the eustachian tube connecting the throat with the ear, and serious trouble in the ear follows. Most cases of deafness are due to neglected catarrh. The usual "catarrh remedies" are either worthless The Health of the Teacher 149 or only temporary in the relief they give. Catarrh always needs careful attention from a skillful physi- cian. No one can be constantly subjected to colds and not suffer seriously, for though a single cold may seem trivial, repeated attacks predispose to catarrh, tuber- culosis, and probably to pneumonia. The various physical disorders of teachers must of necessity react upon their pupils in at least two ways ; first, through general unfavorable influence; second, through the direct transmission of disease. A teacher with tuberculosis may easily infect numbers of her pupils, and tuberculosis is not infrequent among teach- ers, especially in California and the South, where cli- mate attracts the invalid. Even a cold may bring ser- ious sickness to one or several of the pupils of the teacher affected. Colds, as Mr. iVllen says, "can always be charged to some one else. . .the chief danger of a cold is to our neighbor." When our neighbors are chil- dren, the danger is doubly great, for mere colds may lead by indirect methods to pneumonia, tuberculosis, or even diphtheria. One teacher with a cold may easily infect a whole class, and in some of the pupils the re- sult is pretty sure to be serious. Sometimes "colds" affecting either teachers or pupils will be regarded as much a cause for exclusion from school as the more serious diseases such as scarlet fever, measles, and whooping cough now are. The splendid effect upon pupils of exuberant health in the teacher can never be over-estimated, but the deadly depressing effect on the young of ill-health is rarely appreciated. The delicate or sick teacher is 150 The Health Index of Children nearly always fatigued. ''Fatigue begins at the top and works down." The nervous teacher is fatigued all of the time. Often that is why she is nervous. The dyspejitic teacher is fatigued, for dyspepsia, mal-nutri- tion, and fatigue are inseparable companions. Fatigue, as ordinarily expressed in lowered vital activity, means fatigue poisons in the blood. Disease, over-work, vit- iated air, social dissipations, anger, and other undue emotional uncontrol all result in fatigue poisons which sooner or later reach the nerve cells of the brain inhibit- ing clear thinking and muscular activity. Fatigue re- duces the powers of self-control. The fatigued teacher is a fussi/ one, frequently she is an angry one also. Cunnilative fatigue, as Dr. Gulick well says, reduces the whole personality, mental, moral, physical to low- er and cruder levels. ^ Fatigue leads to crooked think- ing and "crooked thinking by a teacher leads to crooked thinking by a pupil." Fatigue accompanies all dis eased conditions in time and the degree of it is directly proportional to the degree of physical disarrangement in the system. Frequently the ill-health of teachers is a direct result of the maladjustments of the school systeuL "Teachers no less than pupils, have a heaven-ordained right to work so adjusted that the highest possible physical con- dition shall be maintained automatically.'' Teachers, as well as pupils, have the right to a healthful environ- ment, and reasonable teaching requirements are as mm'h due them as are reasonable lessons due her pup- ils. i"Mind and Work", (Gulick). The Health of the Teacher 151 Trustwortli}^ certificates of physical fitness ought to be required of teachers at the opening of every school year. In my own experience as Medical Director of Schools I have time and again observed teachers afflict- ed with tuberculosis, asthma, deafness, defective vision, neurasthenia, deformities, malnutrition, anaemia, heart disease, and a number of other disorders. The schools which have introduced medical supervision of pupils, only have done but half their duty. Teachers must not only be physically sound Avhen thej'^ begin the year, but they must themselves habitually obey the common laws of health. Disobedience of these common laws by the teacher means ineffective teaching of them. From every teacher with abundant vitality and force- ful personality, there radiates an influence for good which far transcends mere mental capacity, however great that may be. PART III. HEALTH ORGANIZATION IN SCHOOLS CHAPTER XII. AN OFFICE SYSTEM FOR CITY SCHOOL HEALTH DE- PARTMENTS. There are certain fundamentals underlying modern office systems, these being simplicity, brevity, and ac- cnrac3\ Some form of card index most fully satis- fies these requirements. Even if the system adopted is small enough to be housed in a few desk drawers, it is well from the beginning to establish a number of divisions of the department.- The following cover practically every field of activity in the modern school health department. Department of Hygiene. 1. Division of Sanitation. 2. Division of Health Education. 3. Division of Medical Examination. 4. Division of School Nursing. 5. Division of Relief. 6. Division of Epidemiology. 7. Division of Statistics. The designation '^'Department of Hygiene" is used to avoid confusion with a probable '^Department of Health," existing as part of the city government. Correspondence. In general any communication from the office of the Medical Director of schools, ^Prepared for this book by Dr. John N. Force. 154 The Health Index of ('hha)Uen .slioiild be typewritten on standard sized paper bear- ing an official letter head. It should be numbered and a carbon co^n' retained and filed. Clippings should be filed in envelopes under a subject in- dex, and magazine or book references may be recorded on the outside of these subject envelopes, l)irislu)i of ^anitatioiL All matters pertaining to the sanitation of the school buildings belong to this division. In order to acquaint himself with existing conditions, the Medical Director should make, or cause to be made, a careful sanitary- survey of each building. This record is kept in his office, and alterations made as conditions improve. There are many forms for this survey of school buildings. Al- len's "Civics and Health" gives one, and there are sev- eral in (Jerhard's ''Guide to Sanitary Inspections." Insanitary conditions should be innnediately reported to the sui)erintendent of schools by letters describing Ihem, and suggesting remedies. Division of Health Education. If the Medical Di- rector conducts lectures for parents, he should have announcements of the course printed for dis- tribution. If he Avishes to give information in se- lected cases he may prepare a series of health leaflets. Suggestions for these can be found in the circulars issued by many state and local boards of health. As examples of these may be mentioned the cards used in the schools of Everett, Massachusetts for cases of skin disease. These cards combine information with a i)resciMption which ma}^ be torn oft' and taken to a pharmacist. The same principles will apply to the Office System 155 training of teachers in reading the health index, main- taining sanitary room conditions, and teaching hy- giene. "Suggestions to Teachers and School Physi- cians Kegarding Medical Inspection" is the title of a pamphlet issued by the Massachusetts Board of Educa- tion, which contains many excellent ideas. ''Health Studies" D. C. Heath & Co., is an example of a gram- mar grade text in hygiene on absolutely modern lines. Kecord of lectures delivered, and printed matter dis- tributed should be kept in the office of the Medical Director. Division of Medical Examination. From this divis- ion originally developed all the others and it is still the most important. Man}^ forms have been advocated for this work, from separate cards for each physical examination to a complete health record extending over the whole school life. After study of these the one herewith submitted has been developed. This card includes in the health record of each pupil a complete "follow-up" system. The other side of the card maj- be used for the attendance and scholarship record for the whole period of school life. A practical point in print- ing cards on both sides is to pattern after the im- pressions on coins. The back of a card may then be read without removing it from the filing drawer. This form may be filed in duplicate. One copy in the cus- tody of the Principals follows the changing fortunes of the child from grade to grade. The other is filed alphabetically in the office of the Medical Director to await the next annual examination of the child. At 15G The Health Iadex of Children the time of exaniinatiou, some form of notice islioiild be sent to the parents of each defective child. One system advocates a different card for each of the com- mon physical defects. This is an absolnte Avaste of printing and a needless increase in red tape. The second notice is sent Avlien the teacher reports lack of attention to the first within a stated time. If both notices are disregarded, the division of school nursing is called into action. Once a mouth the Trincipal notes on his individual record cards, defects which have been corrected since the last monthly report. He then reports these corrections and the uncorrected remainder to the Medical Director. The latter from this report may then bring his card records up to date. V>y use of a "code" for indicating defects and their corrections the whole work is mucli simi)litied. lUrisioii of ScJiool Xiirsiiif/. The School Nurse is the medium of comunniication between the Medi- cal Director and the family. The work of school nurses has been well described in a recent article on the school nursing system of (iermany. "They are to visit the homes of the parents of such school chil- dren as receive no medical treatment in spite of the re- peated messages, and to endeavor to induce the par- ents to follow the advice of the school physician. If a child in the school is noticeable for its uncleanliness, or insufficient clothing or poor nutrition, the nurse is to inform herself regarding the economic status of the parents, and the housing and nutritive condition of the child.'' Office System 157 In many places the school nurse treats the com- mon skin diseases, and does minor surgical dress- ings. The advisability of this in a city Avith proper dispensary facilities is questionable. The nurse needs as much training in social service, as in nursing. She should make a weekly report of visits and a social survey of each family visited, and maintain a card file of these surveys at the office of the Medical Director, noting changes as they occur. Division of Relief. Allen in "Civics and Health" commends our American way of "getting things done" in contrast to the foreign way of "doing things." It is better, he maintains, not to care for our indigent defectives in the schools, but to refer them for medical, dental, or social attention to exist- ing relief agencies. Record should be kept of such references, and the agency should be asked to report back to the Medical Director a memorandum of the relief afforded. Division of Epidemiology. The conduct of this division is determined to some extent by the man- ner in which contagious diseases of school children are supervised by the local Board of Health. If the report of a case is received from the health depart- ment, at the office of the Superintendent of schools by telephone, the operator should make out duplicate exclusion cards, one for the information of the Princi- pal of the school, and the other for the Medical Direc- tor. By having these forms bound up alternately paper and card, carbon sheets may be used. The paper to the Principal includes a detachable notice 158 The Health Index of Children to the parents of the child excluded, aud the dupli- cate record on the card can in the same manner be divided to send as a notice to the health department, and retain a stub for the file of the Medical Director. The notice to the health department serves as a check on the telephone message, or as an original notice if the case Avas discovered at school. Note should be made when the child is readmitted. From his card record the Medical Director can make up his ''pin map." A pin map is a powerful public health object lesson if displayed on the walls of the Medical Direc- tor's office. A map of the city is ruled oif into school districts, and for every case of contagious disease a jjin is placed in the square where the child resides. If the common black-headed pins are dipped in differ- ent colored sealing wax, the distribution of each di- sease can be determined and many useful facts de- duced therefrom. Division of Statistics. If the preceding card files and reports have been carefully kept, the labor of the monthly statistical report of the Medical Director to the Superintendent of schools, will be minimized. Summary of Forms. 1. Letter head. 2. Sanitary Survey of School Building. 3. Educational Pamphlets. (a) Announcement of lectures for parents. (b) Announcement of lectures for teachers. (c) Health leaflets. (d) Pamphlets on school hygiene. Office System 159 4. Individual Health Record Card. 5. First Notice to Parents. 6. Second Notice to Parents. 7. Teacher's or Principal's Monthly Card Report of Defectives. 8. Social Survey Card. 9. Nurse's Weekly Card Report of visits. 10. Card Request for Relief. 11. Exclusion Card. 12. District Map of City. 13. Medical Director's Monthly Card Report, (made in duplicate.) In this system all forms requiring to be filled out and filed, with the exception of the sanitarj^ survey of school building, are on cards five by eight inches. They can therefore be housed in uniform filing draw- ers. The retained stub of the exclusion notice can be filed in a drawer which has been partitioned length- wise. Four forms only require duplication, and only eight require writing, four by the Medical Director, one bj' the Medical Director and Principal, one by the Prin- cipal alone, and two by the nurse. There is one an- nual form, two forms used monthly, and one Aveekly. The others are filled out as occasion arises. Foes of red tape who see too much detail in this system, will notice that Providence, Rhode Island uses twenty- five forms in her medical inspection of schools. z III o J^ S 1 H - < a. O X J- ■1 u ^ (d i o B 1 < '5 z z Z ^« ," j3 < 1 s ii-s s u s OS u Q i^i " J Z o ^i O CJ Ui ;^ ;« 03 00 « eo c ■o e « •s o H i J Z *o bJ *© q: Si < 73 « _j a. Q u • Q. — ^^ ■ b. o en 12 § a < 11 1 < t*s , S3 ^ili a: Q ". "-Ir 5 V dz I < (d u a z • o> ^•a; < o " « Hi > 5 O. a. < 1 c o 3 z 3 g 1 = i ° II " ■^1 Q X (J z g < 2 d •s ,3 z u. ■3 u. 1 u3 1 z J ■£ H X ^ d z 1 3 r*) Im Q 3 O u o a >>t^ «t3 o o X u 2 o o-S 03 5tJ 2 l« £ h §3 o o O II, CO O O I" o 2 a '^ =3 ^- ^ u ^ 3 2 CO Z 2 " .SP-o as S 2 -S "O a c <« 2 -a be c « u CO a. c •a Q S 73 U3 2 :S ^ '^ z < « [i a u 1 < V, z f J :3 ^ ! Z M D i £ > w Id i a: ( H 0. ' K ' s ? < K H Qi > < z PQ ^ >t 0, >i 1 5 z c Z Q ^ I ■r- Z < a 0^ i J < £ X 2 X £ J >i g a: g je >. 1 u 55 >• b. s S i b 1 U 1 •3 CU 1 t- X Q. — s I — E ^ — — — — - 0. t c ■0 3 c c 1 s „ 1 •0 b X oS c c 1 1 M ^ In b s u £ •a t_ a 5 c X ■5 ^v I d "5 g V c a c ■0 * S a - I J > 2 < m > V- a: X S < U — — — •a — — — - t> g g j^ ^ g c o C (0 1 1 1 a E CU ■5 S 3 1 '■5 •a 7: > 3 3 C iS G > ti 1 1 at 1 r H b Q 1 ' 1 ■« -T— — "1 — >. 1 1 ' 0. 1 ■"pnii "o 1 "oio* ■5 1 "•W K » -"' 'I JOIlt dn3 >o Allt BUO, «N mj a JO S3BI d JO A au., N IS J i CHAPTER XIII. A GENERAL PLAN FOR HEALTH SUPERVISION IN SCHOOLS. The necessity for careful supervision of the health and development of school children is no longer open to argument. In the best towns and cities of the United States the people themselves are demanding such supervision as one of the most vital functions of the public school system. No school can any longer claim a place in modern educational progress which ignores or neglects the health conditions of its pupils. A child to be properly educated must have good health. Organization Plan. Medical inspection, or as it is better called, health supervision of schools, is provided for by methods which will vary all the way from desultory volun- tary services to the complete, well jjaid, methodical plan of New York City. In general it may be safely stated that schools get just about what they pay for. One does not usually expect satisfactory service from a voluntary or poorl}^ paid superintendent or teacher. Whatever sort of public service is worth having is usually worth paying for. Health officers in schools should, therefore, be regarded as any other employees of the school system. We frequently hear of a school medical officer inspecting several thousand children JG6 The Health Index of Children in a year, or even less time, while giving to this work onl}^ a portion (and usually a small one) of his time, and receiving for such work a pittance of |200 or less. Now such a piece of work as this is sometimes worth just about what is paid for it, but more often its value is much less. No inspector can possibly cover several thousand cases yearly in a few hours per week, and do valuable work for the schools. Buch a nuin is just what his name implies, an ''inspector." He inspects^ it is quite true, but he never studies nor adjusts. To be truly useful, health work in our schools re- quires training, aptitude, time, and reasonable recom- pense. Except in cities where the health department is organized on a large and complete plan with its var- ious departments in charge of well-qualified directors, the medical supervision of schools ought to be under the direct control of the Board of Education. This is true because medical work in schools naturally forms an essential part of our general educational system. It is a great mistake to think of such work as first of all medical, for it is first of all educational. It must aid the boy and girl in healthy growth and develop- ment; it must help the school to adapt its work to individual physical and mental conditions; it must assist in the correction of existing physical defects and in the prevention of others; it must teach the fundamental elements of preventive medicine; it should superintend in a general way the teaching of physiology and hygiene. Parents Not Always Wise in Health Matters. If all parents were sufficiently wise in health mat- General Plan for Health Supervision 167 ters, it would probably be quite unnecessary for schools to make any special study of the physical con- dition of the children entrusted to their care. All that could then be fairly required would be the guar- antee of a healthful school environment, including such things as good ventilation, correct methods of lighting and heating, sanitary plumbing, the elimina- tion of contagious diseases, frequent recesses, sufficient attention to physical education, and the proper kind of health instruction. But it is a fact and not a theory that not all, or even most parents, are wise in matters pertaining to the health conditions of their children. It becomes, therefore, the plain duty of the school department to furnish not only a healthful school environment, but also a careful guardianship of the personal health of its pupils. If medical supervision were synonymous with medi- cal inspection, from which our present health work in schools originated, it would be very easy for one phy- sician to inspect ten or more thousand children per year but with careful medical supervision the number examined will usually be far less. Medical inspection as it was ordinarily carried out merely contemplated the superficial examination of pupils for the detection of skin diseases and signs of the ordinary contagious diseases of childhood. Medical supervision includes far more than inspec- tion. It means the health study in a broad sense, of the children in the schools, with an attempt to ad- just them to their physical environment. It means a study of the conditions of sight and hearing, an ex- 1()8 The Health Index of C'hh.drex amiuation for evidences of nasal ob.strnction, diseased tonsils, seriously defective teeth, disorders of nuti-ition and development, nnbalauced nervous organizations, for signs of early heart or lung disease, for enlarged glands, skin diseases, as well as syni])toms of children's A Group of Childrcu Awaiting' Physical Kxamiiiatiou. common contagious diseases. The careful physical study of school children has, therefore, supplanted the early and inadequate method of inspection, and has shown clearly that there is an intimate relation between the child's physical condition and his mental progress and future success. General Plan for Health Supervision 169 A Practical Working Plan For a City. In order to discover those pupils who most need physical attention, a plan can be devised whereby the teacher makes the first selection and refers the pupils selected to the examining physician. A convenient method is to furnish a card about 8x10 inches, having printed on one side of it, twenty-five arbitrary signs and symptoms of physical defects. lUiese are ex- pressed in terms which any teacher can understand and use. For example terms such as the following may be used: (See page 154). Posture, nutrition, endurance, mental activity, ap- pearance of teeth, mouth-breather, frequent absences, inattention, delinquency in studies, squinting or other signs of eye trouble, deafness, nasal voice, colds^ offensive breath, signs of contagious diseases, condi- tion of skin, cleanliness of person, vicious habits, home conditions, nervous symptoms. Reading the Health Index. Any intelligent teacher can observe points such as these among her pupils if she tries. This is what is called reading the "Health Index." A set of cards is given to each teacher by the principal. The teacher fills in the parent's name, pupils name, age grade, and home address, at the top of the card, and then simply makes a check opposite the sign or symp- tom she has observed, as for instance, "nasal voice." She may perhaps fill out ten or twelve of these cards in a room of twenty-five or thirty pupils. These cards are then handed to the principal, who in turn gives 170 The Health Index op Children them to the school physician when he calls. The phy- sician then calls these pupils to the principal's oflBce one at a time. Here they are carefully examined and the results are recorded on the reverse side of the pupil's cards. This examination includes the eyes, ears, nose, throat, heart, lungs, skin, teeth, general physical appearance, and indications of any contagious or nervous disease. The teacher receives the cards belonging to her room after the examinations have been made of her pupils, follows the cases as far as possible and makes a monthly report to the physician. If this is not done the school physician soon loses all knowledge of the cases he has examined. When teachers are aware of the physical embarrassments of their pupils, they are then in a position to treat them more intelligently in their daily school work. AMienever the examining physician discovers physical conditions which need attention, a notice is sent to the parent of the child suggesting further examination and advice from the family physician, dentist or specialist, as the case may require, and offering the opportunity for further advice at his office. The Work of the School Nurse. The school nurse should accompany the school phy- sician on his visits to schools. When home visits are advisable for purposes of personal advice, explana- tion, or for other reasons, the nurse can note this fact during the physical examination and call at the home as early as possible afterward. These personal calls are productive of much good and are nearly always received with manifestations of interest and with con- General Plan for Health Supervision 171 sideration. Sometimes the nurse can show parents how to construct a cheap sleeping porch for a child much in need of fresh air. This has accomplished much good in many of our Berkeley homes already. Sometimes the nurse can give suggestions about proper food for a child and demonstrate how it ought to be cooked. Sometimes the nurse can provide means for attention to medical or dental conditions which would otherwise be neglected. Among the very needy, the nurse can personally dress any minor accident cases, take care of some contagious diseases and care for simple eye inflammations. The nurse often discovers conditions of home en- vironment which explain many of the defects found by the physician in his examinations in the school. The relation of home health to school health is in many ways an intimate one, and the school nurse is indis- pensable in studying this relation and in providing means for the proper adjustment of many of the un- favorable situations she is able to detect in her per- sonal visits. Of the one hundred and fifteen different house visits made by the Berkeley school nurse during the fall term of 1909, practically ninety per cent of them were pro- ductive of good results. Of the first seven hvmdred and fifty children referred to the school physician by the teachers in Berkeley, nearly seventy per cent were found to be in need of m'edical or dental attention. Of these the greatest number showed defects of nutrition, enlarged lymph glands, and badly decayed teeth. 172 The Health Index of Children Following the Cases Needing Attention. Without an adequate system for following cases which have been found to need medical or dental at- tention, very little good can be accomplished by any method of health supervision. The following plan will be found to work satisfactorily, but no doubt other ideas would serve the purpose equally well. After a pupil has received his physical examination and the case has been recorded, send his card back with him to his teacher. P^ach teacher will thus have in her possession the record cards for those of her pupils who have received an examination. From time to time she must attempt to discover what attention the notice to the parent has received and record this on the pupil's card. Where no attention has been given to the case, the physician can be notified and a second notice sent home together \vith an invitation to bring the child to the office for further examination and advice. In many cases it will be found necessary to pro- vide medical or dental service for these cases in order to get anything done for the child. If possible some sort of a medical and dental school dispensary should be established. If this cannot be accomplished, then arrangements can usually be made with individual physicians and dentists to care for such children at their private offices. Pure charity service ought usually to be avoided, but arrangements for very small charges must be made. An advisory health committee composed of several physicians and dentists will be found to be of very great service in any school health department. It is very desirable in some schools to General Plan for Health Supervision 173 have the pupils' school standing, attendance, etc., on one side of the card and the physical record on the other. By this method it is often possible to explain retardation, slow mentalitj^, nervous manifestations, etc., hj the physical conditions found present. The school nurse should keep a careful card record of all her home visits and from time to time should inform the examining physician of the results she has ob- tained. For this purpose a special card must be used. The question often arises as to whether a doctor ought to give all of his time to school health super- vision in cities of some size. Arguments of value can be made on both sides of this question. The discussion usually adjusts itself however, as few places are at present willing to pay salaries which justify effi- cient physicians in giving up all their time to this kind of medical specialty. It is the writer's opinion that men or women who devote only half of their time to health work in schools will usuall}^ give the best service. By this method better physicians can be in- duced to undertake the work than where all of their time is demanded. It is also true that physicians who are in touch with a variety of medical cases will gener- ally prove more valuable to the schools than those who confine themselves to strictly school medical work. Health work in schools is of necessity very monotonous and extremely limited in medical scope, therefor© the best service cannot be expected from physicians who are not in touch with a large variety of cases out- side of those found in schools. In time the medical officer who gives his time exclusively to health work 174 The Health Index of Children will almost inevitably fall into unfortunate ruts through the very nature of his routine occupation. It is sometimes possible to employ a school health officer who is also teaching Hygiene or a related sub- ject in a University or other institution of learning, or who is a city or county health official. In these in- stances the combination works quite satisfactorily even though the individual may not be engaged in actual private practice. A competent physician in the schools should be well paid. The office can never be one of dignity if he is not. In general it may be said that such an official should receive the same salary for one half of his time as is given to the best paid principal in the same city for his full time. On this basis the best of medical talent can be obtained, but on any other salary basis efficient service will rarely be secured. This plan is self adjusting, small places paying small salaries and larger ones proportionately larger salaries. The real danger of a school health position degenerating into a political job must never be forgotten. A Plan for Small Communities. In small towns and in the country it will often be found quite impossible to organize a school health department on anything except the simplest basis. Sometimes it Avill be found quite hopeless to employ either an examining physician or a school nurse. In such instances the teacher herself must learn how to read the Health Index of her pupils and advise the parents what children ought to be taken to the General Plan for Health Supervision 175 family pliysician, dentist, or specialist for a thorough examination. Many times it will be possible for the Principal of the school to make it his particular duty to read the Health Index of all the pupils in his school. In small communities it is sometimes feasible to em- ploy a physician to spend a very limited amount of time in the schools where he may co-operate with the Principal or the teachers in making physical examina- tions and aid them with expert advice. It will usually- be found best for teachers to confine their work to gen- eral inspection, calling in the physician to confirm their observations by more careful examinations. Voluntary medical service is frequently offered, but it is rarely advisable to accept it for reasons that are self-evident. Even the smallest places can afford to pay for a limited amount for medical advice in schools. At least twice each year a physician ought to make a careful health survey of the sanitary conditions of all school grounds and buildings and this should be under- taken only by a doctor especially qualified for such work for many good physicians have never had experi- ence or training in school sanitation. In small coun- ties it may be possible to employ a physician to super- vise the health of all schools in the county. If select cities such as Pasadena, where four hun- dred and twenty-one of the first seven hundred and six pupils examined were found to be in need of medical or dental attention, and about sixty per cent of the first seven hundred and fifty examined in Berkeley were found in the same condition, it would appear that there can be no argument against the necessity for medical supervision in less favored places. 170 The Health Index of CHn^DREX GENERAL HEALTH SURVEY TO AID THE TEACHER IN DETECTING DEFECTIVE PUPILS, School Grade Teacher Pupil Age Address 1. Do you drink tea? How many cups? 2. Do you drink coffee? How many cups? 3. Do you drink cocoa or chocolate? How many cups? 4. Do you drink milk? How many glasses? 5. Do you eat your lunch at school? 6. Do you ever come to school without breakfast? How often? 7. Do you ever go without lunch? How often? 8. What time do you go to bed? 9. What time do you get up? 10. Do you do any work out of school hours? 11. Do you study any out of school hours? Plow much? 12. Do you have headache very often? 13. Does the print blur w^hen you read? 14. Can you read writing on the board easily? 15. Can you always hear the teacher easily? 16. Do you ever have ear ache? 17. Do you ever have ruiiiiiiig; ear? 18. Do you ever have tooth ache? 19. Have you ever been to a dentist? 20. Do you own a tooth brush? 21. Do you use a tooth brush every day? 22. Do you have your bedroom window kept open or closed at night? 23. Are the windows in your house screened in summer? 24. What school work do you like best? 25. What school work do you like least? HEALTH SURVEY OF PUPILS WHO HAVE BEEN EXAM- INED BY THE SCHOOL PHYSICI.\N. 1. Names of pupils who have received a Physical examination and whose card shows one or more defects. 2. Character of defects. 3. Has any attention been given to case? 4. Will attention be given soon? 5. Special suggestions about any case. ILLUSTRATION: John .Jones, Washington School, 5th grade. Adenoids; no attention. Teeth; attention. Eyes; will receive attention. Nurse ought to visit home which is at 2526 University Ave. HARRIET SMITH, Teacher. CHAPTER XIV. SOME DETAILS OF THE PHYSICIAN'S EXAMINATION. In examining the throat, wooden tongue-depressors, which may be used once only and then discarded, are absolutely necessary. In testing eyes, no special light apparatus is necessary. All that is required is the Snellen Test Type Card and good daylight. In test- ing the hearing a stop-watch is desirable because the answers of children are often very deceptive. Each eye and each ear must be tested separately. It is well to test the color sense while testing the eyes, and for this purpose colored discs or yarns may be employed. Experience is required in testing the eyes of children because they often transpose, misread, or omit letters. Many children find some difficulty in reading the 20|20 line, and for practical purposes I believe that the abil- ity to read the 20|30 (oculists' opinions to the contrary notwithstanding) should be considered satisfactory unless other signs of eye trouble are present. The ordinary star shaped astigmatism test-card is valuable in routine eye tests. Special care should be directed to the squint or "cross eye." Very few people understand that the squint or cross eye nearly always becomes T)lind unless it receives early care. It is im- portant for parents to know that cross eye can very often be corrected by the early use of proper glasses. 178 The Health Index of Chh.dren The ''near point" of reading nnist be observed. In children over ten years of age it is about four inclies. Inability to read at this distance suggests hyperopia. The importance of seeing that parents take their children to oculists and not to opticians can not be over-stated. Many parents of school children patron- ize the "doctor" in the rear of a jewelry store unless they are carefuly instructed to the contrary. The importance of observing crooked and prominent teeth must not be overlooked. This condition as is well known to careful examiners, is usually due to adenoids. Adenoids can indeed usually be diagnosed by the facial expression, the appearance of the teeth, and the Jti(jJi arch of the hard palate. An examina- tion with the finger is rarely advisable or necessary. The relation between deafness, earache, discharging ear, and enlarged tonsils on the one hand, and adenoids on the other must always be kept in mind. Rather large tonsils are common in young children even when no diseased condition is present, and, as is well known, this condition tends to disappear of itself. Unless the enlargement is excessive I do not believe that such tonsils always indicate the necessity for medical or surgical treatment. It is often a part of a general lymphatic enlargement. An ordinary nasal speculum used without special artificial means of illumination is all that is necessary in routine work on the nose. Even the speculum may usually be dispensed with. Polypi are very easily di- agnosed from symptoms of obsti*uction and nose bleed. Enlarged turbinates in school children are in my ex- perience rare. Some Details op the Physician's Examination 179 The examination of the heart is very important. With a Bowles Stethoscope or a phonendoscope, the necessity for the removal of the clothing is avoided. A skilful examiner can always detect murmurs in this way. When they are discovered a more complete ex- amination with the chest bared can be made to deter- mine the presence or absence of hypertrophy or dilita- tion. Murmurs on the left side in the second inter- space are so commonly found as to be negligible. They are practically always accidental or functional. A cer- tain amount of enlargement of the heart during the rapidly growing age, especially near the age of pu- berty, we all know to be common and of no great con- sequence. In this condition, however, boys and girls ought to be cautioned about athletic strains or excess- ive exercise of any sort. Functionally w^eak hearts among children are often encountered, and appropriate advice ought to be given in these cases. Such hearts are found more espec- ially among girls of the high school age. Students of this age also need careful examinations for incipient tuberculosis. Unless there are special indications for it, a careful examination of the lungs is rarely necess- ary in grammar grade pupils. Such examinations are indeed quite impossible unless the clothing be removed, which is not often advisable. An important matter of technique, however, is a rough test of the ability to expand the lungs and chest. It is truly astonishing how few pupils know how to breathe properly. This they must be taught. More important perhaps than all else is a careful ex- 180 The Health Index of Children amination of the teeth. The neglect of the first teeth is practically imiversal, and even the second teeth need attention in probably sixty per cent of the children of most schools. As a matter of routine, an examination of the lymph glands of the neck is important. Enlarged glands are often associated with bad teeth, tubercular condi- tions, and general malnutrition. It is my observa- tion that really healthy children rarely show even mod- erate enlargement of these glands. Kough tests of muscular control, co-ordination, etc., may always be made quickly and easily. Incipient chorea (St. Vitus Dance) will often be noticed in this way. Sex examinations, however desirable they may be, are not to be recommended at present except with the consent and presence of the parent, and at his request. Lastly the general posture, state of nutrition, color, and cleanliness, of these little folks must be taken in at a glance by the examiner. After completing the cards from a given room, the physician visits the room himself and observes the pu- pils at work. He will probably detect some cases which the teacher has overlooked. He will also ob- serve the conditions of temperature, light and the gen- eral sanitary surroundings of the pupils. By this plan of office examination and personal inspection, the phy- sician gradually covers every room in the building. It is needless to say that tact and understanding of children are most essential in this work. CHAPTER XV THE CO-OPERATION OF SCHOOL HEALTH DEPART- MENTS WITH OTHER HEALTH AGENCIES.l Medical supervision of schools is rapidly becoming an increasingly important factor in modern education. The necessity for such careful supervision of the health and development of school children is no longer an open question. Only the most unprogressive communities now op- pose this sort of work, and only careless communites fail to avail themselves of its advantages. No school can today claim an important place in modern educa- tional progress which ignores or neglects the health conditions of its pupils. Like most other new devel- opments, school health supervision methods have evolved from very small, unorganized beginnings. As in most other projects, one community learns very little from others, but each attempts to work out its own problems, thereby falling into the same errors, confronting the same difficulties, and wasting about the same amount of energy. We have today no stan- dardization of methods^ and endless useless discussion results from this fact. In the light of the experience of many progressive cities such standardization in essential matters might now be rather easily estab- ^A paper read by the Author at the St. Louis meeting of the American Academy of Medicine, 1910. 182 The Health Index of Chh.drex lislied, thus saving an enormous amount of time and energy to towns and cities whieli wisli to inaugurate this work. Most communities have in existence one or several sorts of health organizations but few of them have at- tempted to correlate the work of the various health agencies. A concrete example of what may be accom- plished by such useful correlation is furnished by the city of Berkeley, California, and for this reason this is presented as typical of what may be done in many other places. Berkeley is a city of about forty thousand people. It is a suburb of San Francisco and is the seat of the University of California. Health supervision was only organized here recently and the usual difficulties have had to be met. A reasonably expert Board of Health was of course in existence and it employs a Health Officer who devotes part of his time to the city work, receiving for this service the moderate compen- sation of about a thousand dollars a year. Since the great San Francisco fire of 190G a small medical clinic or dispensary has been in operation under the direction of three physicians. For several years the Berkeley Charity Organization has also been in operation, under a Board of Directors which em- ploys a Secretary and visiting nurse. The medical dispensary was situated on the west side of the city near the manufacturing district and conse- quently among the homes of the foreign element. The Charity Organization was situated near the busi- ness center. Co-operation 183 The Medical Director of Schools was elected by the Board of Education at a reasonable salary to devote the entire school day (from 9 a. m. to 3 p. m.) to the health work of the schools, and was given a suite of offices in connection with the rooms of the Board of Education. An arrangement was made whereby the Charity Organization Nurse should devote one half of her time to that agency and one half to the city schools. It soon became clear that the four health agencies in Berkeley, viz. the City Board of Health, the Berke- ley Charitj^ Organization, the West Berkeley Clinic, and the School Health Department were wasting con- siderable time, energy and money. To correct this condition the following plan was carried into effect. 1st. The rather inadequate Clinic was, after much discussion, and Avith some difficult}^, re-organized into a dispensary with a staff made up of fifteen represent- ative physicians, instead of the former small and somewhat exclusive staff of only three. 2d. The Charity Organization was induced to Join hands with the new Berkeley Dispensary. To this end a large dwelling house near to both the school and city health departments was rented, and these two rival health organizations established under one roof, thus saving much money in rent, much time and energy, and resulting in common rather than separate efforts toward raising means for support. 3d. The Alameda County Dental Society now or- ganized two Dental Dispensaries, one for Oakland and another for Berkeley. By means of a theatre party and through private contributions of the dentists them- 184 The Health Index of Children selves sufficient means were secured to completely equip in the most modern fashion these tv\'o dental dispensaries. The Board of Education at once offered co-operation with the Berkeley Dental Dispensary by placing at its disposal offices in connection with those of the Medical Director of Schools. 4th. The City Health Department has closely as- sociated itself with all of the above health agencies and is co-operating in every possible manner. The result of the combination thus described is that all of the health agencies, including: The School Health Departnifent, The City Health Department, The Charity Organization, The Medical Dispensary and The Dental Dispensary are now located within one block of one another and are combined under three roofs instead of five. A city Charity Commission has recently been ap- pointed by the Mayor and is closely associated with the agencies just named. The local Chapter of the Red Cross has united its etforts Avith the others. Within a few months Berkeley therefore has succeed- ed in uniting toward one common end the efforts of the following health agencies : 1. The School Health Department. ± The City Health Department. 3. The Charity Organization. 4. The Medical Dispensary. 5. The Dental Dispensary. 6. The City Charity Commission. 7. The Red (^ross. What has been done on a small scale in Berkeley, Co-operation 185 the State Board of Health and State Medical Societj- have done on a much larger one. The ^'California Public Health League" has been formed, and this will as far as possible unite the efforts of every organized health agency in the State, including "The Society for the Prevention of Syphilis and Gonorrhoea." The School Health Department in Berkeley feels that its efficiency has been increased many fold through the co-operation just described. It has de- vised a system of records which is simple, yet complete. Every school case cared for by a.nj one of the health agencies is reported by card to the office of the Medi- cal Director of Schools. The school nurse keeps an accurate card record of every school home visited. No case is entitled to medical or dental treatment which is not first recommended by the Charity Organization. An advisory Health Committee of fifteen physicians has been appointed by the Board of Education to aid the school physician in his work. A lecture Staff of six physicians, dentists and nurses has been organ- ized to give lectures on various health topics at three different centers for the benefit of parents and school children. A woman physician has been added to the Health Department of Schools who teaches Hygiene in the High School and has general supervision of the health of the High School girls. What has been rather easily accomplished in Berkeley by the School Health Department and other health agencies in less than a year can be done in almost any other city with tjie expenditure of a little time, thought and energy. 18() The Health Index op Children BIBLIOGRAPHY. This list is not intended to be even approximately complete, but it does furnish a working basis for those interested in Child Hygiene and School Sanitation. For a more extended list of books, magazines and pam- phlets, on various phases of Hygiene, Public Health, etc., the reader is referred to the Bibliography in the author's Health Studies, D. C. Heath & Co. Child Hygiene in General. *Physical Nature of the Child (Rowe) Macmillan Co. *The Development of the Child (Oppenheim) Macmillan Co. *The Study of Children (Warner) Macmillan Co. *Civics and Health (Allen) Ginn & Co. * Youth (Hall) D. Appleton & Co. Bibliography of School Hygiene (Burnham) (contains 436 titles) found in the Proceedings of the N. E. A., 1898. The Nervous System of the Child (Warner) Nev^^ York, 1900. ♦Fatigue (Mosso) New York, 1900. The Psychological Clinic — Philadelphia. Journal of the Royal Sanitary Institute — London — 90 Buck- ingham Palace Road. Journal of Educational Psychology — 2427 Yorke Street, Bal- timore. Medical Inspection — Massachusetts Board of Education. The Doctor in the Schools (Dr. Hackworth Stuart) — H. K. Lewis, 136 Gower St., W. C. London, (1908). Various Publications of the Bureau of Municipal Research — New York City. Various Publications of the Russell Sage Foundation Fund — (Dept. of Child Hygiene). The World's Work. McClure's. Good Housekeeping. Journal of the American Academy of Medicine — Easton, Pa. Bibliography 187 Bulletin of the California State Board of Health (Especially February, 1910.)- Bulletin of the Michigan State Board of Health. Bulletin of the Massachusetts State Board of Health. Bulletin of the North Carolina State Board of Health (Es- pecially for September, 1910), (Teacher's Edition). *The Survey — New York. Medical Inspection of Schools. *Medical Inspection of Schools — (Gulick and Ayres) Char- ities Publishing Co., New York, (1908). Medical Inspection of Schools — (Hogarth) Oxford Medical Publications, London, (1909). Medical Inspection of School Children — (Mackenzie) Wm. Hodge & Co., Edinburgh. Guide Practique du Medecin-Inspecteur Des Ecoles — (Dr. L. Dufestel) O. Doin & Son, Paris, (1910). School Hygiene. Hygiene Scholaire — (Dr. L. Dufestel) O. Doin & Son, Paris, (1909). *School Hygiene — (Dr. Ludwig Katelman) C. W. Bardeen, Syracuse, N. Y., (1899). School Hygiene— School Hygiene Publishing Co., 2 Char- lotte St., London, W. School Hygiene — (Shaw) Macmillan Co. *School Hygiene — (Porter) Longmans Green & Co., New Yorki (1906), (An excellent practical book). *International Archiv fur Schulhygiene — (Otto Gmelin), Munich. (This is one of the most important publications in School Hygiene to-day. Extracts of articles are printed in French, German and English). Handbuch der Schulhygiene — '(Dr. Leo Burgenstein and Dr. Aug. Netolitzky) Gustav Fischer. ISS TUK HlOALTII IXDKX OF ("HILDIJEX Medical Text Books and General Reading. Commoner Diseases of the Eye — (Wood and Woodruff) iiJnglehard & Co., Chicago, (1909). Diseases of the Eye — (May). Manual of Otology — (Bacon) Lea Bros. & Co., Philadelphia. Diseases of infancy and childhood — (Holt) D. Appleton & Co. Tuberculosis — (Bridge) W. B. Saunders & Co. Instinct and Health — (Hutchinson) Dodd, Mead & Co., New York. Mind and Work — (Gulick) Doubleday, Page & Co., New York. *The Efficient Life— (Gulick) Doubleday, Page & Co., New York. Outdoor Schools — (Ayres) Doubleday, Page & Co., New York. Hygiene of the Mind — (Clouston) Dutton & Co., New York. Health Studies— (Hoag) D. C. Heath & Co., Boston. *National Vitality — Document 419, (Irving Fisher) Govern- ment Printing Office, Washington. (Contains exhaustive ref- erences to subjects in Hygiene, Public Health, and all related topics. Should be in the hands of every teacher). Magazines, Pamphlets, Reprints, Etc. *Health Pamphlets for Schools — (for teachers and parents). (Dr. E. B. Hoag) Whitaker & Ray-Wiggin Co., San Francisco. 1. The Nose, Throat and Ear. 2. The Eye. *The How and Why of the Teeth — Alameda County Dental Society, Oakland, Cal. The Care of the Teeth— (Dr. R. C. Ohmsted) Board of Education, Pasadena, Cal. Tuberculosis in Children— (Dr. Langley Porter) San Fran- cisco, Cal. *Titles marked with an a.sterisk are particularly recom- mended to teachers. DEC 30 1910 One copy del. to Cat. Div. BK SG mo