Copyright^ . COPYRIGHT DEPOSIT. RIVERSIDE TEXTBOOKS IN EDUCATION EDITED BY ELLWOOD P. CUBBERLEY PROFESSOR OF EDUCATION LELAND STANFORD JUNIOR UNIVERSITY RIVERSIDE TEXTBOOKS IN EDUCATION EDITED BY ELLWOOD P. CUBBERLEY RURAL LIFE AND EDUCATION. By Ell- wood P. Cubberley, Professor of Education, Leland Stanford Junior University. #1.50 net. Postpaid. THE HYGIENE OF THE SCHOOL CHILD. By Lewis M. Terman, Associate Professor of Education, Leland Stanford Junior University. $1.65 net. Postpaid. THE EVOLUTION OF THE EDUCATIONAL IDEAL. By Mabel Irene Emerson, First Assistant in'Charge of the George Bancroft School. Boston. $1.00 net. Postpaid. HEALTH WORK IN THE SCHOOLS. By Ernest Bryant Hoag, M.D., Director of School Hygiene for the State Board of Health for Minne- sota, and Lewis M. Terman. $1.60 net. Postpaid. Other Volumes in Preparation HOUGHTON MIFFLIN COMPANY BOSTON NEW YORK CHICAGO U"il||| |||li">l|||l III"""!!!"""!!! Ill Ill I|l"""l|l Ill ni"" , l||l" , "l|ni""l|JI» ,, n||| llll 1 '""!!!'""'!!! Ill Nil l||B" | l||n l "?| B-jllliiillllliiiillllliiiillll (Ill Ill flllliiiillillmillllliiiillll ill IllimJl Ill llli Ill Mil ill ill ilil lIlHiiillil iL-E HEALTH WORK IN THE SCHOOLS BY ERNEST BRYANT HOAG, M.D. Director of School Hygiene for the State Board of Health for Minnesota LEWIS M. TERMAN Associate Professor of Education, Leland Stanford Jr. University HOUGHTON MIFFLIN COMPANY BOSTON NEW YORK CHICAGO Stfte ftitoersibe $re?'g Cambcibfle §=- ,l> I||I"'H||| |||l»'il|j| ||| |||H"ll|||ll"i|||| ||| i||l ||| j 1 1 j I il|||l"'ll||||i"ll||| |I|I'"U||| |||l'"H|||lt»U|j=-§ iuillll lIliiiiiillliiiiiillllmiillliiuiilllnniilllh.ullllliMillllunilllhu.illlllhiHlllliMiilll llliiiidilluiulllllinillll Ill illllutiilil lllii»iillliiiuillliiiii3 V COPYRIGHT, I914, BY ERNEST B. HOAG AKD LEWIS M. TERMAN ALL RIGHTS RESERVED CAMBRIDGE . MASSACHUSETTS U . S . A AUG-Si9l4 ©CLA376928 TO HENRY M. BRACKEN, M.D. SECRETARY OF THE STATE BOARD OF HEALTH FOR MINNESOTA EDITOR'S INTRODUCTION Educational Hygiene has four chief divisions: (1) The Hygiene of Physical and Mental Growth; (2) Health Supervision in the Schools, including methods of health observation and teaching; (3) the Hygiene of Instruction; and (4) the Hygiene of the School Plant. The first of these divisions has been treated by one of the authors of this book in The Hygiene of the School Child, which has appeared as an earlier number of this Series, and the third, by the same author, is in preparation. The fourth division is to be covered by another author, and is also in preparation. The present volume deals with the problems in- volved in health supervision, health examination, and hygiene teaching, — in other words, with the second of the above divisions; and it is hoped that it will con- tribute materially to the standardization of health supervision and to the broadening of its scope. Every one must realize that a great amount of what goes by the name of "medical inspection of schools" can be called health work only by courtesy. All along the line, among superintendents, teachers, school nurses, school boards, and even school doctors, education is needed which will lend a broader vision to the purpose and possibilities of genuine health supervision. Special emphasis has been given by the authors to i viii EDITOR'S INTRODUCTION the part played by the teacher in school health work. To this end, two chapters have been prepared (v and vi) for the purpose of assisting teachers in the observa- tion of general health conditions among children, and three others (ix, x, and xi) for the purpose of acquaint- ing them with the most important facts regarding those transmissible diseases which concern the school. Three additional chapters (xv, xvi, and xvn) are devoted to suggestions for the teaching of hygiene in the grades, and another chapter (xvm) discusses health conditions among teachers. It will be seen, therefore, that the book has been planned primarily for the use of the grade teacher, and with her needs especially in view, though it is hoped that it may also serve as a handbook for the guidance of superintendents, school nurses, and boards of education. It is seldom that we have presented, by authors of such extended practical experience and large technical knowledge, a book on such a technical subject written in such simple language and presented in so attractive a manner. Stanford University, Cal., May 6, 1914. CONTENTS CHAPTER I Social Responsibility for the Health of School Children 1 The spread of school medical work. Physical defects among school children. Parental guardianship of children's health not sufficient. The responsibility of society. The rela- tion of the school medical service to private medical practice. Other functions of school health departments. The reaction of school health work upon the home. Opposition to school medical work. References. CHAPTER II The Scope and Administration of Health Super- vision 15 Stages in the development of school health work. The divisions of educational hygiene. Outline of the scope, procedure, and administration of medical supervision. Method of control. Division of power. Records. Schools and publicity. References. CHAPTER HI Plans for Organization for Health Work . . 37 State versus local control. Examples of state departments. City organization of school health supervision. Plan (1): Physician and nurses. The cost of health supervision by Plan (1). CHAPTER IV The School Nurse: including Suggestions for Health Supervision by the "Nurse Alone" Plan 48 Spread of school nursing. Nurses necessary for follow-up work. School nurses reduce absence. Other functions of the CONTENTS school nurse. Influence of school nurses upon the home. Number needed. Equipment needed by school nurses. A plan for the health supervision of schools by nurses alone. Selected references. CHAPTER V The Health Grading of School : Children by Teachers 62 The general importance of the teacher's cooperation. Teachers versus physicians. An outline for the health grading of school children by teachers. Health survey. Sug- gestions for using the outline for health grading. The signifi- cance of the answers to the questions. Some results secured by the outline for the health grading of school children. References. CHAPTER VI A Demonstration Clinic for Instruction in the Observation of Defects 90 Verbatim report of a demonstration clinic. A summary of clinics held at sixteen cities. CHAPTER VII The School Medical Clinic 109 Difficulty of getting results from medical inspection. What the school clinic is. Typical school medical clinics of England. Cost, equipment and management. Why free clinics are necessary. The opposition to free school clinics. To protect the health of children is a social obligation. Summary. References. CHAPTER VIII School Dentistry 125 Historical. Dental clinics should be free. Preventing dental decay. References. CONTENTS xi CHAPTER EX Transmissible Diseases 133 The school as a factor in the spread of contagious diseases. The school as a means of controlling contagious diseases. Newer ideas about modes of infection. Danger of the com- mon cup, common towel, etc. Air not a common source of infection. Isolation of "carriers" versus school closing. Ages at which transmissible diseases most often occur. CHAPTER X Transmissible Diseases (Continued) 148 Measles. Scarlet fever. Diphtheria. Whooping-cough. Mumps. Chickenpox. Smallpox. CHAPTER XI Transmissible Diseases (Concluded) 175 Tuberculosis. Hookworm disease. Poliomyelitis (Infan- tile paralysis). Epidemic Meningitis. Contagious eye diseases. Contagious diseases of the skin. General sum- mary. Selected references. CHAPTER XII Open-Air Schools 198 Recent spread. Program. Results. Pedagogical results. References. CHAPTER XIII School Housekeeping • . . . . 209 School dust and its dangers. Prevention of dust by means of floor oils. Method of cleaning. Other ways of preventing dust. Standards of cleanliness. Professional training for janitors. References. xii CONTENTS CHAPTER XIV The Teaching of Hygiene: The First Six Grades 221 Inculcating health habits. Health instruction in the first five grades. Personal hygiene inspection by teacher and pupils. Inculcating food habits. Vital topics of hygiene study for grades three to five. Teaching hygiene in the sixth grade. Hygiene lessons dramatized. Outline of scheme for teaching hygiene in the sixth grade. CHAPTER XV The Teaching of Hygiene: Seventh and Eighth Grades 236 Early instruction must deal with the concrete. Focus attention upon health rather than upon disease. Practical instruction in bacteriology for the seventh and eighth grades. Teaching hygiene by means of "sanitary surveys." Helps for the teaching of hygiene in the grades. CHAPTER XVI The Teaching of Hygiene: Education with Ref- erence to Sex 252 The problem. Need of safeguarding school children. The school's relation to sex-education. Special considerations relating to sex education. Methods and content of instruc- tion by stages. Divided responsibility of the home and school in sex-education. Selected references. CHAPTER XVII The Teacher's Health 270 Mortality rate and physical morbidity. Premature super- annuation. Tuberculosis among teachers. The teacher as neurasthenic. Health suggestions for the teacher. The hygiene of character. How to prevent mental fixation. The responsibility of the normal school. Vocational guid- ance for teachers. References. CONTENTS xiii chapter xvrn What the World is doing for the Health of School Children 285 England. Germany. France. Switzerland. Sweden. Den- mark. Norway. Scotland. Ireland. Canada. Australia. Japan. Other countries. The United States. Conclusion. References. APPENDIX School Health Organization in Various Cities of ,the United States 305 Milwaukee. Minneapolis. Philadelphia. Oakland. New York. Suggestions for a Teacher's Private Library in School Hygiene 315 GLOSSARY 317 INDEX 319 Note: The authorship of the chapters of this book is as follows: Dr. Hoag — Chapters III, V, VI, IX, X, XI, XIV, and XV. Prof. Terman — Chapters I, II, IV, VII, VIII, XII, XIII, XVI, XVII, and XVHI. p •N / LIST OF ILLUSTRATIONS Facing School nurse recording pulse and temperature in an open-air class _, . . 54 ^Testing vision 96 Adenoids . . . 98^ Crossed eye and obstructed breathing 99 f Testing hearing . 100 ^' Teeth examination . . . . . . . . . . . 101 v Chronological and physiological age 106 / A school dental clinic in Rochester, New York .... 130 / Crooked teeth 131 \/ Open-air schools 200 »/ An open-air class in mid-winter, Chicago ...... 206 ■,/ Chicago open-air classes 207 " The Muroscroll 216 v LIST OF FIGURES 1. Percentage of recommendations acted on in Philadelphia . 50 2. Teeth diagram 79 3. Weekly average of deaths from measles in London, England 134 4. Curve showing number of cases of diphtheria in Halle, Ger- many 135 5. Curve indicating average seasonal occurrence of all chil- dren's diseases in the Berkeley schools 145 6. Showing the average weekly gain or loss in weight of children attending the Bradford Open-Air School .... 200 7. Haemoglobin tests, Providence Open- Air School . . . 202 8. Curves showing changes in haemoglobin during school year . 203 HEALTH WOKK IN THE SCHOOLS CHAPTER I SOCIAL RESPONSIBILITY FOR THE HEALTH OF SCHOOL CHILDREN The spread of school medical work The health supervision of schools is not a passing fad. The conservation of the child is a problem which, like that of world peace, is bound to take possession of the minds of all humanitarian people. To the ethical principle of humanitarianism is added the stern counsel of biological laws, which teach us that an elaborate scheme of mental culture which proceeds without regard to the needs of the body is but a house built upon the sands. It is significant for the future of the movement that with minor exceptions all civilized countries have almost simultaneously taken it up. Its universal de- velopment is inevitable. Progress has been remarkably uniform in different countries, though naturally there are some differences in the details of procedure and in the points of emphasis. Germany has forged ahead with her dental clinics and open-air schools; France, with her school lunches and vacation colonies; while England has set the whole world an example in the 2 HEALTH WORK IN THE SCHOOLS earnest way in which she has undertaken to ameliorate the evils which medical inspection of schools has revealed. Our own country, on the whole, is behind most of the nations of Europe in the practice of school hygiene, but is making progress rapidly. But the doctor has not been brought into the school without opposition, and it is therefore desirable to inquire further into the justification for this new assumption of responsibility on the part of organized society. Physical defects among school children Serious defects of eyes, ears, nose, throat, lungs, teeth, glands, nutrition, heart action, nervous co- ordination, and mentality have been discovered with surprising frequency wherever they have been looked for. Statistics on these matters have been so indefi- nitely extended and (when we make allowance for cer- tain differences in procedure) have given such uniform results, that we can safely say that in any school sys- tem, no matter where it may be located or to what social classes its patrons belong, from 50 to 75 per cent of its pupils are suffering from one or more physical defects serious enough to require skilled attention. 1 While it is not claimed that all this defectiveness is produced by the school, some of it undoubtedly is, and in the case of still other pupils the school is at least a partial cause. At any rate, it is well known that defec- tive pupils are present in the schools in large numbers, 1 Lewis M. Terman, The Hygiene of the School Child, chapter I. Houghton Mifflin Co., 1914. SOCIAL RESPONSIBILITY 3 and that the defects are often unfavorable to a normal physical and mental development. Although many of the defects are curable or preventable, as a rule even intelligent parents and teachers either do not observe them or else they underestimate their seriousness. Parental guardianship of children's health not sufficient If all parents were wise in regard to health matters, it would not be so necessary for schools to make a special study of the physical conditions of the children entrusted to their care. All that could then be fairly required would be the guaranty of a healthful school environment, including such things as good ventila- tion, correct methods of lighting and heating, sanitary plumbing, the control of contagious diseases, frequent recesses, sufficient physical training, and the proper sort of health instruction. But it is a fact and not a theory that not all parents possess the special knowl- edge which is necessary for the hygienic supervision of physical and mental development. Even intelligent parents may be unable to detect the early symptoms of physical disorder, just as they may be unable to decide upon the best methods or texts for teaching history or geography. They do not see the defects in their own children because they are used to them. Many are so superstitious as to prefer to treat adenoids by sugges- tion, others so ignorant as to interpret pediculosis capitis as a sign of good health. Plainly, therefore, it becomes the duty of the school department to furnish 4 HEALTH WORK IN THE SCHOOLS not only a healthful school environment, but also a health guardianship over its pupils. The responsibility of society The children of to-day must be viewed as the raw S material of a new State; the schools as the nursery of the Nation. To conserve this raw material is as logical a function of the State as to conserve the natural resources of coal, iron, and water power. To investi- gate exhaustively the evils which exist and to remedy all that may be remedied without transgressing unduly upon the jealous precincts of parental responsibility is a plain matter of duty. Theoretically, it matters little how the State performs this duty, whether by a house- to-house census of the children, or in some other way. Practically, however, there is no effective or conven- ient way except to do the work in connection with the public schools. In many of our best towns and cities the people themselves are demanding such supervision on the principle that it is one of the important func- tions of the public school system. The argument that the health supervision of schools invades the rights of the home has exactly the same value as the corresponding argument against com- pulsory school attendance and prescribed courses of study. The school does not claim anything more than the right to make an examination of the child's physi- cal and mental condition in order that the work of the school may be properly adjusted to his health and growth needs, and, further, to notify and advise SOCIAL RESPONSIBILITY 5 parents regarding such defects as are found to exist. This is not an unwarranted assumption of power. The responsibility for remedial action is left entirely with parents. The school has not undertaken forcibly to subject children to surgical operations, nor is there at present any legal method of compelling parents to per- form their duty in this respect. We can invoke the law for wanton neglect of a broken bone, but there is no way to punish the neglect of discharging ears, adenoids, or astigmatism, any one of which may prove more serious in the long run than a fractured bone. It is interesting to conjecture how far present prac- tice in this respect is likely to be modified. Compulsory public education itself is so recent that only a few dec- / ades ago it was considered by a majority of people as a species of meddlesome paternalism. According to the old conception the child was the parents' child; if they questioned the value of an education there was no recourse in the child's behalf. There are a million or more illiterate adults in the United States to-day who are victims of this mistaken social theory. The theory, happily, has been discarded. We now know that the interests of society demand an elaborate scheme of educational processes under social control. Some time we shall understand, just as clearly, that the child's physical growth also stands in need of more expert supervision than the average parent is capable of exercising. 6 HEALTH WORK IN THE SCHOOLS The relation of the school medical service to private medical practice It is sometimes contended that all medical work should be left in the hands of the family doctor, and that the employment of school physicians is both an ^ impertinence and a needless expense. The practicing physician himself often takes this stand, just as for- merly private teachers resented the intrusion into their domain of teachers who were paid at public expense. The two situations are strikingly similar. There were private schools which afforded excellent educational opportunities, but unfortunately they did not reach all the people and they were excessively expensive. Similarly there are families who know enough about health and the causes which are likely to undermine it to seek the frequent advice of high-priced, skill- ful physicians. On the other hand, a large majority of families can hardly be said to have a family physician, and when they do his function seldom goes beyond the treatment of acute disease or physical injury. Under present conditions the family doctor institution hardly touches the rich field of preventive medicine with which it is the business of the school physician to deal. In the vast majority of cases, if the child's physical needs receive no expert oversight in the school, they will receive no expert attention at all. It is, therefore, not at all a question of relieving the family physician of any of the functions he has been accustomed to exercise, but of doing the work he has SOCIAL RESPONSIBILITY 7 left undone. The practicing physician is not always present when needed. As a rule he docs not appear on the scene until an emergency occurs. He has no com- mission to go out in quest of disease. He has little op- portunity so to order the lives of his clients that they will escape emergencies. We refuse to pay him except to cure our diseases; it is unfair as well as absurd, therefore, to expect that his chief interest will be in the prevention of disease. The wonder is that the disparity between the physician's interest in disease and his in- terest in health is not greater. It is to the credit of the profession that the better class of practicing physicians almost unanimously indorse the work the schools have undertaken in child hygiene. Other functions of school health departments Apart from its contribution to national vitality, the health supervision of schools is entirely justified by its influence upon the efficiency of the school itself. For one thing, it appreciably affects regularity of attend- ance, which, as Ayres has shown, is one of the im- portant factors in retardation. It does this by elimi- nating some of the causes of illness, and by treating in the school certain parasitic diseases and other slight ailments which otherwise would require exclusion. Ringworm and pediculosis, especially, have in the past caused a great deal of needless irregularity of attend- ance. Chronic physical defects, particularly of breath- ing and of nutrition, have a retarding effect on school progress, even when they are not of such a nature as to 8 HEALTH WORK IN THE SCHOOLS cause absence. To the extent that health supervision of schools is successful in securing the medical or sur- gical treatment of defects, or in ameliorating environ- mental conditions in the home, it cannot fail to con- tribute to the solution of the retardation question. In the prevention of epidemics the school depart- ment of health renders invaluable assistance to the local non-educational board of health. The latter is usually given authoritative control in such matters as closing the schools, granting permits to return after illness, etc., but the closer contact of the school health officer with the pupils often enables him to sound the alarm and in many ways to become a necessary ally in preventing the spread of infectious diseases. Not the least important function of the school health department is that of cooperation with the school architect and sanitary engineers. Of the mil- lions of dollars expended annually in the United States for school buildings, a large part, from the point of view of school hygiene, must be considered as almost wasted. School buildings erected earlier than twenty years ago belong usually to discredited types of architecture, and are being replaced rapidly by new and still more expensive plants. Unless these embody the very best ideas in sanitation and hygiene, they, too, will soon have to be replaced. There is no reason why the better class of school buildings erected to-day should not be well preserved and for the most part hygienic in the year 2000. It would be hard to over- estimate the injury that may be wrought in three SOCIAL RESPONSIBILITY 9 quarters of a century by a poorly lighted, ill- ventilated, or unsanitary school building of twenty-five rooms. Within that time many thousands of children will have been subjected to its unwholesome influence. The re- sulting sickness, ill health, and death would appall us, if it were possible to estimate it. The health department will also give immediate returns in the hygienic supervision of school activities. Competitive athletics, for example, are always danger- ous without such control, particularly below the col- lege age. Likewise the hygiene of instruction presents a promising field of research that can best be carried on by official investigation supported by the school itself. There is hardly a limit to the number of hygiene re- searches which it would be feasible for the school to undertake. Furthermore, the department of health would give valuable assistance to the teaching corps in hygiene teaching. At present hygiene is one of the least taught, i and probably also the worst taught, of all the branches of the curriculum. This is largely because the teachers themselves have been poorly instructed in the subject., The work of the health department in this respect is twofold: (1) It will give the teachers themselves sys- tematic instruction in the hygiene of physical and mental development, so that they may cooperate in- telligently with the work of the department; and (2) it will aid the teachers in the choice of subject-matter and in the methods of presenting hygiene lessons in the schools. 10 HEALTH WORK IN THE SCHOOLS Finally, health supervision in the schools will con- tribute to the conservation of the teacher's health. This has been fully presented in chapter xvm, and need not be dwelt upon here. The reaction of school health work upon the home But, supposing that all defects have been discovered, and that school life goes on without aches and pains, must we go all over the work next year and the next, forever? Is the social mill to go on, indefinitely, grind- ing out diseased and crippled children by the thou- sands? The most hopeful approach to this problem lies in the schools themselves. By all means let us remedy defects when they exist, but, in addition, let us en- deavor to prevent defects from occurring. The school must investigate the home conditions of defective pupils. It must know more of the child's habits, what time he goes to bed, how long he sleeps, how much he works, how much he studies at home, what he eats, what he drinks, where and under what conditions he sleeps, and what the home environment is in every particular that concerns the child's health. If we read the lesson of the health index aright, it means not only sick school children, but sick school buildings and sick homes as well. The health of the child reflects the health of the community in which he lives. The surest means of increasing community health are: (1) by increasing the health of the child through improved school conditions, and by attention to his physical defects; (2) by teaching the child sensible, ap- SOCIAL RESPONSIBILITY 11 plicable health lessons; (3) by carrying the influences of this health improvement and health instruction into the home. The public school has not fulfilled its duty when the child alone is educated within its walls. The school must be the educational center, the social center, and the hygienic center of the community in which it is located, — a hub from which will radiate influences for social betterment in many lines. Opposition to school medical work Thus far the opposition to health supervision in the schools comes from three chief sources. One of these is the misconception as to the purpose of the work which is likely to be entertained by the more ignorant people of a school community. At first such people are likely to become panic-stricken with the foolish notion that their children may be subjected to some strange kind of violence, forcible surgical attention, hypnotism, etc. As the school health officer becomes a more familiar figure about the school premises, and as his kindly in- terest in the children becomes known, this fear always disappears. The two other sources of opposition are harder to eradicate, because founded on prejudice rather than ignorance. These are the Christian Scientists, and the League for Medical Freedom. The tenets of the former are so well known that they need not be discussed here. It is well to note, however, that the attitude of Christian Scientists toward school 12 HEALTH WORK IN THE SCHOOLS health work is not always unfriendly where the purely advisory capacity of the school doctor is understood. On the other hand, where the school authorities, in their communications and notices to parents, are at all insistent in their efforts to bring about the correc- tion of defects, the enmity of this religious sect is likely to be aroused. Notwithstanding certain hygienic principles in Christian Science, its sweeping warfare against medicine must be viewed as the conflict of an absurd superstition with the welfare of the State and its children. Superstition has had to yield to quaran- tines and to state laws which punish parental neglect in case of acute and immediately dangerous diseases. Here, also, it will have to adjust itself as best it can to the march of science, which, at last, is beginning to question the right of either parental or religious au- thority to interfere with the health or safety of the child. The League for Medical Freedom is a less worthy, but a more active and dangerous, opponent of child hygiene measures. This is a recently founded and vigorous organization composed largely of "sectarian" physicians, quacks, and patent-medicine vendors, whose main purpose seems to be to oppose all social restraints on medical practice and to preserve the divine right of all kinds of practitioners, regular and irregular, to prey upon the gullibility of the people. In the short time since it was organized, it has in several cases successfully opposed the extension of school medical inspection, and has defeated progressive legis- SOCIAL RESPONSIBILITY 13 lation on matters relating to hygiene and medical practice generally. Its methods are always and everywhere the same — to prejudice the minds of those not alive to the real issue by the cry of "medical tyranny," "political doc- tors," "sacred rights of the family," etc. Teachers will not be deceived by catchwords of this sort, enlisted in the cause of the patent-medicine industry and quack schools of "healing." Teachers are intelligent enough to scent the insincerity in the argument that medical inspection is being fostered for the special benefit of a particular "school" of medicine, — the allopathic versus the hydropathic, homoeopathic, osteopathic, naturopathic, etc. It is well for teachers to understand that real medical science is not torn asunder by sepa- rate schools, any more than is the science of chemistry or physics. There is only medical science on the one hand, and quackery and superstition on the other. All such opposition will gradually be dissipated, or at least silenced. Medical inspection, enlarged to in- clude all phases of school hygiene, will soon be looked upon as a mere matter of course, — the logical and necessary correlate of compulsory education. REFERENCES (The most important references are indicated by a *) 1. Allen, W. H.: "A Broader Motive for School Hygiene." Atlan- tic Monthly, June, 1908. 2. Blan, Louis: " Are we taking Proper Care of the Health of our Children?" Ped. Sem., 1912, pp. 220-27. 3. Burnham, W. II.: "Health Inspection in the Schools." Ped. Sem., 1900, pp. 70-94. 14 HEALTH WORK IN THE SCHOOLS *4. Dresslar, F. B. : " The Duty of the State in the Medical Inspec- tion of Schools." Bull. A96, U.S. Bur. of Ed., 1912. 5. Fisher, Irving : " Public Responsibility for the Health of Infants and Children." Fed. Sem., 1909, pp. 395-402. 6. Gorst, Sir John E.: The Children of the Nation. (Chapter iv, pp. 50-66.) *7. Gulick and Ayres: Medical Inspection of Schools. 1913, pp. 224. (Chapter i.) 8. Gulick, Luther H.: "Constructive Community and Personal Hygiene." Science, 1910, pp. 801-10. 9. Cronin, John J.: "The Doctor in the Public School." Review of Reviews, 1907, pp. 433-40. 10. Forsyth, David: Children in Health and Disease. 1909, pp. 360. (Chapter vi.) *11. Hall, G. Stanley: "The Medical Profession and Children." Red. Sem., 1908. *12. Hogarth, A. H.: Medical Inspection of Schools. 1909, pp. 360. (Chapters in to vin, inclusive.) *13. Moore, Benjamin: The Dawn of the Health Age. Liverpool, 1910, pp. 204. 14. Osier, Dr. William: "Medical and Hygiene Inspection of Schools." Rept. Inter. Cong. Sch. Hyg., 1907, pp. 465-68. *15. Terman, Lewis M.: The Hygiene of the School Child. 1913. (Chapter i.) , See Collier s Weekly, June 3, 1911, for an expose of the " League for Medical Freedom." See all standard works on school hygiene or medical inspection of schools. CHAPTER II THE SCOPE AND ADMINISTRATION OF HEALTH SUPERVISION Stages in the development of school health work The health supervision of schools presents three clearly defined stages in its development : — (1) Its original purpose in almost every case was the detection of contagious disease. The work was merely an extension of that of the local board of health, and was designed to protect the community from epidem- ics. The value of such inspection immediately became evident. (2) The second stage is represented by the extension of the scope of the work to include examinations for non-contagious physical defects. The early surveys of the Danish and Swedish commissions had dem- onstrated an enormous prevalence of defectiveness among supposedly normal children of both sexes and of all ages and classes. It was discovered that many of these defects have a bearing upon the child's school progress, and upon his physical development. It was observed, moreover, that many of them are easily curable or removable. About two hundred cities in the United States, mostly the larger ones, have under- taken to give their school children complete examina- tions for all kinds of physical defectiveness. 16 HEALTH WORK IN THE SCHOOLS (3) The third stage passes beyond "medical inspec- tion," as such, and becomes a distinct field of preven- tive medicine. A suitable name for it is "Health and Development Supervision." Its keynote is the cultiva- tion of health and the prevention of defectiveness by the hygienic supervision of all the, school activities. This phase of child hygiene, the most important of all, is just in its beginning. Health supervision has been too narrowly conceived, but we are coming to realize that almost everything which contributes to the conservation of the child belongs within its scope. The schools, instead of causing sickness and defective- ness, must be made to preserve the child from many kinds of morbidity, repair his already existing defects, and combat his hereditary predisposition to illness and the unfavorable conditions of his social environ- ment. In order to prosecute the work intelligently hun- dreds of researches will have to be made; researches to which the public schools must be freely thrown open, and for the support of which public funds should be appropriated. Out of the data from such investiga- tions there will rise, gradually, a new science of educa- tional hygiene which will go as far beyond the usual poverty-stricken courses in "school hygiene" as medi- cal science now transcends the teachings of the eight- eenth-century medical school. 1 The broad scope of educational hygiene is made clear in the following outline, which is a modifica- 1 See Popular Science Monthly, 1912, pp. 289-97. SCOPE AND ADMINISTRATION 17 tion of the comprehensive suggestions of Louis W. Rapeer. 1 The Divisions of Educational Hygiene I. School sanitation. A. School sites, hygienic aspects. B. School arelfftecture, hygienic aspects. C. Ventilation and humidification. D. Lighting. E. Heating. F. Drinking-water and fountains. G. School baths. H. School cleaning. I. School toilets. J. Seating. K. Decoration. L. The standard schoolroom. M. Janitor service. n. Physical education. A. Playgrounds and play. B. Athletics and "leagues." C. Physical training. D. Correctional exercises. E. Posture. .F. Recreation. G. School excursions, "tramps." H. Physical development examinations. I. Gymnasiums and gymnastics. J. Swimming and bathing. K. Medical gymastics. L. Social center work for adults. III. Health teaching. A. Choice of hygiene texts. B. Health instruction topics. 1 The authors are indebted to Dr. Louis W. Rapeer for permission to include this valuable outline in the present volume. No one else has made such a thorough study of efficiency in school-health serv- ice as Dr. Rapeer. 18 HEALTH WORK IN THE SCHOOLS C. Health habits. D. Public and personal hygiene. E. Health education of parents. F. Feeding and clothing of children. G. Health education of teachers. H. Home hygiene, in domestic science. I. Industrial hygiene, in industrial work. J. First aid and avoidance of accidents. K. Talks by doctors, nurses, and specialists. L. Pupil's cooperation in medical supervision. M. Health leaflets. IV. The hygiene of instruction and of mental development. A. Fatigue. B. School program. C. Home study. D. Examinations. E. Type of books. F. Motor aspects of teaching. G. Cheerfulness and calmness. H. Part time or whole time. I. Vacations and their influence. J. Teaching through play. K. Attention and inter-recitation recreation. L. Preventing pathological conditions. M. The hygiene of discipline. N. The hygiene of classification, promotion, and gradation. O. The hygiene of mentally exceptional children; the nervous, the feeble-minded, etc. P. The hygiene of the learning process, habit forma- tion, etc. V. Medical supervision. Each of the above divisions should have its special texts, and its special courses in teacher's colleges and normal schools. Space is lacking to show in detail the contents, aim, and procedure for each division, but SCOPE AND ADMINISTRATION 19 this will be done for Division V, Medical Supervision. The following outline, based upon Rapeer's conclusions from his valuable comparative study of medical su- pervision in twenty-five American cities, reveals the scope and procedure for one of the five divisions given above: — Outline of the Scope, Procedure and Administration of Medical Supervision A. Officials. 1 . General director of the department of hygiene. 2. Medical examiners. 3. Nurses. 4. Oculists, dentists and surgeons at school clinics and dispensaries. 5. Teachers, principals, and superintendents. 6. Physical-training teachers. 7. Board of health. 8. Sanitary inspectors. 9. Health lecturers. B. Phases of work of medical supervision. 1. Preliminary working together of all doctors and nurses, with teachers present as much as possible for standardization. 2. Inspections. a. September room inspection of all pupils. b. Occasional room inspection by nurses. c. Individual inspection by teachers and nurses, teachers to refer suspicious cases with help of symptom chart. Nurse to inspect, also, all pupils absent for three or more days, and entering pupils. Doctor to make individual inspection of urgent cases. d. Home-hygiene inspection by nurses. Re- corded on pupil's health-record card. e. Sanitary inspection of school. By superin- tendent of school or representative: doctor, 20 HEALTH WORK IN THE SCHOOLS nurse, principal, business manager, or sanitary inspector. 3. Examinations — Complete physical, annually, for pupils. a. Medical — only such phases by the doctor as the nurse cannot do well. 6. "Vision, hearing, teeth, scalp, skin, — by the nurse. c. Height, weight, chest-expansion, and other measurements, if required — by nurse, physi- cal trainers, or principals. 4. Cure and correction. a. Treatments by the home through school advice and family physicians. b. Treatments by school nurses and clinics. c. Follow-up work in getting or keeping up treat- ment. d. Prescriptions for simple, common ailments, so far as safe, in the language of the people. e. Getting cooperation of dispensaries, boards of health, etc. /. Testing efficiency by cures and improvements. g. Health-budget exhibits, and other means of health education. 5. Central office where parents may bring children for special examinations and for consultation, includ- ing psychological tests. 6. Prevention. a. Good ventilation, fresh-air or open-air rooms or schools. b. Summer inspection by nurses, at playgrounds and summer schools. c. Special inspections, to prevent epidemics. d. Improved instruction of pupils and parents in hygiene. e. Cooperation with health and recreation agen- cies. /. Daily inspection, by nurses. g. Testing efficiency by decrease of ailments and defects. SCOPE AND ADMINISTRATION 21 h. Efficient supervision of doctors and nurses. i. Limiting medical inspectors largely to examin- ations. j. Coordinating all phases of educational hygiene. k. Continued home-hygiene inspection. C. Records and reports. 1. Individual, cumulative health-record card. a. The central instrument of medical supervi- sion, as nurse is the central agent. 6. Should provide for entire health record, includ- ing inspections, examinations, and records of cures and improvements. c. Should have the good features of the Cleve- land, Ohio, the Meriden, Connecticut, and Dr. W. S. Cornell's cards (and, perhaps, those of the New York City card for both health and scholastic record). d. May be kept in the classrooms for teachers' constant reference and carried by pupils to inspection or examination. e. Doctor's findings on the twenty or more exam- ination cards daily should be left for the nurse to report, before cards are returned, to the rooms. Doctor may be relieved of most clerical work, if results are supervised, thus saving time. /. To distinguish, nurse should make records on cards in red ink, doctor in black. g. State or national cards should be adopted. 2. Nurse's daily or weekly report. a. The best type is probably that of the weekly report of the nurses in the Philadelphia schools. b. Nurse reports number and results of doctor's examinations, as well as her own. c. Reports should be summarized weekly, and printed in newspapers. d. A standard classification of school ailments should be used. e. Simplest classification is, infectious and non- 22 HEALTH WORK IN THE SCHOOLS infectious, using common names in alphabetical order. The former may be divided into para- sitic and infectious diseases, the latter into physical defects and common ailments. Gen- eral divisions, such as communicable and non- communicable diseases, are desirable. 3. Annual report to the people. a. Should be detailed, and yet comprehensible to the public. b. It should show how many cases were found, how many cured, improved, found not needing treatment by family physician, and by what agencies cared for. The number, not cured, treated, or improved, is a most necessary part of efficient reporting. Adequate reporting in this field has not been worked out by any city. 4. Other records, notices, reports, exclusions, etc., need be little different from those in vogue. (Rec- ords should lead to a frequent health invoice.) D. Standardization. 1. Examinations. a. Medical, by the doctor (medical examiner) if there is one. X. Number, 7 to 10 an hour, say twenty in a two-hour day when there are no excep- tional cases, or about one hundred a week. Y. Depending upon the district and the amount of consultation by nurse and in- dividual inspection of referred cases, the doctor can examine medically from 1500 to 2000 pupils in the 180 days of the usual school year. (Minimum.) Z. In the nurse-alone plan, one nurse can examine from 800 to 1200 pupils in the year and do her other work of home visiting and inspection, varying greatly with nurses and communities. b. Scholastic or anthropological. SCOPE AND ADMINISTRATION 23 X. Vision tests, about three minutes each. Snellen's charts. Vision less than twenty- twenty referred only when there are bad symptoms of eye-strain, otherwise twenty - forty. Strabismus (cross-eye) should always be referred for treatment. Y. Hearing tests, about two minutes each — twenty an hour, at least. By nurse or physical trainer. Stop-watch and whis- per tests. Common sense about the only standard yet. Z. Height, weight, and chest-expansion measurements, if required, about three minutes each. Of little value as usually taken. Rarely used, even when well taken with pupils stripped. 2. Inspections. a. September room inspections, — about forty an hour, nurse and doctor working in separate rooms with help of teachers. 6. Nurse and doctor should be conservative about referring cases and excluding pupils, even in case of threatened epidemic. c. Sanitary inspection of school, standardized by a special report card such as used by the Philadelphia Board of Health (devised by the Bureau of Municipal Research). d. Nurses and doctors should be given schools in groups, or along good lines of travel. 3. Efficient supervision, and occasional working to- gether on a number of referred cases by all doctors and nurses, highly desirable for purpose of stand- ardization. E. Expenditures. 1. For nurse: five and a half days a week (8.45 to 5 each school day), with the responsibility of inspec- tion, not less than $70 a month, preferably for twelve months. 2. For doctor: two hours spent in a single school each 24 HEALTH WORK IN THE SCHOOLS day, making a reasonable number of careful medi- cal examinations, forty hours a month, about $60 to $80 a month for ten months. Where more is paid it is a question whether it would not be better to use the money for a good nurse on full time. Physical examinations cannot be carried on more than two or three hours a day, because of the physical strain. Neither can physicians be taken for long from their regular practice each day. To employ all for full time is out of the question. Diminishing returns bring in the nurse, often more competent for the simple school troubles to be referred to parents and family physicians, than is the school doctor. 3. Supervisor of the Department of Hygiene : $3000 to $4000 a year, for full time. 4. Supplies : depending upon conditions, although cer- tain standard supplies can be designated. Newark, New Jersey, has a good list. This phase of the work varies greatly in different cities. 5. Free treatment: Amount of free treatment is rapidly increasing in the larger cities. While using care, this work must be greatly extended. School medical inspection still suffers from lack of standards. Too often a narrow view prevails regarding the opportunities and responsibilities which the work involves. As stated by Rapeer, "the public demand for more attention to the health of school children has often been met by such temporizing sedatives as the hiring of some doctors to look into the school buildings occasionally when they have time; having manufac- turing companies send in a few samples of sanitary drinking-fountains or adjustable desks; or permitting the park department to station a young woman with a see-saw and a swing on some school-yard 'playground' during the summer." SCOPE AND ADMINISTRATION 25 It is with the hope of broadening the scope of health work in the schools and contributing to the standardi- zation of its methods that the above outline has been presented. The authors believe that it cannot be too carefully studied, either by school boards, superin- tendents, school doctors, or teachers. Method of control This was one of the earliest questions to arise. Medi- cal inspection everywhere began as an extension of the work of the already existing board of health. However, the more the scope of health supervision has been ex- tended, the greater the tendency has been to doubt the wisdom of this method of control. Three leading objections have been made : — (1) The board of health is almost certain to place the emphasis too much on the mere prevention of disease. Insidious defectiveness and the causes leading up to it are likely to be overlooked; (2) The board of health is not in a position to make such adjustments of the educational processes as may be necessary to minister to the health and growth heeds of the pupil. Attempts to do so inevitably lead to conflict between the board of health and the educa- tional authorities, or at least to misunderstanding with consequent failure to cooperate; (3) When the work is administered by the non- educational machinery, the interest of the teacher is not so easily enlisted. The bifurcated educational aim which has wrought such havoc in education for hun- 26 HEALTH WORK IN THE SCHOOLS dreds of years becomes through this system of divided responsibility more strongly intrenched than ever. The school looks after the child's mind, the board of health after its body. Everybody forgets that the child is a psychophysical organism and that any dual system of educational control is sure to violate this unity. It cannot be too often repeated that the examination of pupils for contagious disease is a relatively unim- portant part of the health supervision of schools. Statistics show that as a rule not more than 4 per cent of the pupils of a school system need to be excluded in one year. On the other hand, 60 per cent of the pupils suffer from non-contagious defects which need con- stantly to be taken into account by the educational authorities. Moreover, the physical welfare of every child is more or less jeopardized by the sedentary occu- pations, indoor life, and nervous strain of the modern school. The task of the school department of health is so to direct the educational processes that the child's native heritage of vigor and health may be fully at- tained, and his hereditary deficiencies, in so far as pos- sible, made good. This is an educational problem. It is one that is not likely to be effectively dealt with except through the administrative authority of the school. On the other hand, communities so conservative as to be content with the earlier type of "medical inspection" may very well leave the work to non-educational authorities. 1 By 1911 over three fourths of the cities in the United SCOPE AND ADMINISTRATION 27 States supporting health supervision had lodged the administration with the board of education, so that we may now consider educational control one of the standard requirements of health supervision, and the best guaranty of broad and effective cooperation along all lines of child hygiene in the schools. It cannot be denied, however, that in a few in- stances splendid work has been carried on in the schools by the board of health, and in a few instances narrow, unsatisfactory work by the educational au- thorities. Much depends upon the man behind the system. If all officers of public health had an adequate comprehension of the strictly educational and preven- tive aspects of hygiene in the schools, there would be less to choose in the matter of control. But as the situa- tion now stands, there can be no question that, gener- ally speaking, the health supervision of schools in this country ought to be conducted by educational depart- ments of health. There should be such departments in every city school system, in every county also for the benefit of rural and town schools, and above all a State department for the coordination and standardization of the work. Division of power Granting that such a department of health exists, what relations shall it sustain to the superintendent and to the teachers? Shall it act only in an advisory capacity, or may we safely charge it with a certain amount of administrative authority ? To be concrete, 28 HEALTH WORK IN THE SCHOOLS let us suppose that the health department decides that a given pupil cannot safely attend school more than three hours per day. Let us suppose also that the superintendent of schools and the child's teacher dis- agree with this opinion. In such a case whose judg- ment should legally prevail? Similar questions are likely to arise occasionally in regard to excusing a pupil from gymnastics, and in regard to the segregation of children in special classes for open-air treatment, etc. It seems clear that the decisions of the department of health should at least not be subject to reversal by any other authority than the board of education or superintendent, and it is an open question whether the superintendent should have this power. School hy- giene is a technical field, where only expert opinion is reliable. Because the hygienic affairs of the school require expert direction, the board of education creates the health department for this purpose, just as it creates other offices for the supervision of instruction. The expertness of the department should, therefore, be respected. Deficiency of a child's blood in oxygen- carrying material, or a retarded condition of his skeletal development as indicated by the Roentgen rays, or an excessive predisposition to fatigue, — these are matters which call for expert diagnosis and expert treatment no less than measles or diphtheria. Practically, however, there ought to be few cases of conflict, wherever the ultimate control is vested. The sensible medical director will find that he must work through the superintendent and the teachers. If he SCOPE AND ADMINISTRATION 29 conscientiously gathers his data and cautiously bases his recommendations upon a reliable body of ascer- tained fact, and if he presents these recommendations with reasonbale tact, there will ordinarily be no diffi- culty in securing favorable action on the part of super- intendent and board of education. On the other hand, if the medical director is incautious or unscientific in his recommendations, if he is intemperate in his con- demnation of current school practices, or if he meddles unduly with the work of instruction, the efficiency of his department is certain to be impaired. The school department of health should have no place for the man or woman who is temperamentally unable or unwilling to cooperate harmoniously with other educational authorities. Records The practical value of the work of the department of school hygiene depends intimately upon its book- keeping methods. Too often the methods in use fail to give us the information we need. The following are some of the faults which have helped to render the statistics of medical inspection confusing, contradic- tory, and sometimes misleading : — (1) Stating the absolute number of defects found without indicating the number of children furnishing them. What a community wants to know is not that School A has fewer defective eyes than School B, but the relative percentage of defective eyes in the two schools. 30 HEALTH WORK IN THE SCHOOLS (2) We should also be informed what the percentage is a percentage of; whether of total enrollment, or of a representative portion of the enrollment, or of a por- tion specially selected by teachers or nurses for sus- pected defects. (3) Another common mistake is to fail to distin- guish between the number of examinations made and the number of children examined. Since many chil- dren receive frequent examinations, the two sets of facts do not even approximately correspond. (4) Still more serious is the failure of the general report to differentiate sufficiently among kinds of defects. The common and the extremely rare, primary and secondary, curable and incurable, chronic and temporary, the very grave and the unimportant are all lumped together. This leaves us without data for arriving at reliable conclusions as to the influence of the various kinds of defectiveness upon mental devel- opment or upon the child's school progress. In such an ill-considered system of records, a slightly decayed temporary tooth, about to be replaced by a permanent one, counts for just as much as an extreme case of myopic astigmatism or a discharging ear. Hunchbacks and boils are not distinguished. Again, one defect, by counting all its symptoms, becomes three or four. By one system of records a child may be accredited with two defects and by another system with eight or ten, without necessarily implying any essential difference in the expertness of the examinations themselves. Defects which are plainly temporary should be care- C5 « ■- CO - H fc- pa pa o pa pa 10 pj H **< M pa Hi m a C3 pa pa -H pa K < w hi O o w o W H P 09 pa pi a E < M pa 00 pa P c a a G B 8 A Bi «< *3 n e i o a 3 SB OJ •a a p 3 p p> g 03 w D el H H H 3 c q w en tit ■8 | (9 o OJ IB g o S .3 a o 3 H d 5 1 OJ o o t>> 4) « 32 HEALTH WORK IN THE SCHOOLS fully distinguished in reports from those which are chronic; likewise the curable from the incurable. These factors help to determine what action the school shall take regarding notification of parents, and in adapting the work of the school to the child. What we most want to know is how the many kinds of defec- tiveness are related to each other, to school progress, to age, and to mentality. (5) The pupil's individual record card is not less important than the general report, and is subject to much the same faults. It should be explicit and not vague. In recording a defective ear, for example, it should distinguish between partial deafness and a dis- charge. Eyes should be recorded separately, and ob- jective tests for eye-strain should be listed, apart from general symptoms. If glasses are worn, the fact should be noted, together with the date of their pur- chase and with record of the visual acuity with them on. Squint should be designated explicitly. Explicit- ness should be the rule. At the same time the record should not be encumbered and rendered misleading by the over-conscientious insertion of data pertaining to slight and unimportant ailments. (See page 31.) (6) Having an ideal individual record card, what shall we do with it? Some medical directors bury their work alive by riling it away in a distant central office. If a teacher wants to know the facts about the health of one of her pupils, she will have to make a trip to this office. Needless to say, under this kind of system, teachers and supervisors cannot be expected to know SCOPE AND ADMINISTRATION 33 much about the health conditions of their children. The card should always accompany the pupil through- out his course by being transferred to each of his suc- cessive teachers. If the central office can afford to have a copy, well and good. If there is only one card, there ought to be no question as to where it belongs. Schools and publicity The school does not always court full publicity. School reports give little information as to the real efficiency of a school. They are too likely to give all the lights and none of the shadows. They are some- times shameless advertisements of the superintendent or the school board. The private individual who shows an interest in facts not officially revealed may be accused of enmity and suspected of acting from per- sonal motives. The following are some of the matters concerning which American school authorities do not give sufficient information : — (1) The amount of retardation and elimination in all the grades. (2) The intra-school and extra-school causes of such retardation and elimination as exist. (3) The efficiency of the school, as measured by its actual grade performances. Here, instead of any at- tempt at stating objective facts, the board of education may lay claim to having the "most efficient school system in the State." In the West this is changed to the "best in the United States." (4) The hygienic imperfections of its school build- 34 HEALTH WORK IN THE SCHOOLS ings are seldom plainly and explicitly stated. When the evil is too crying to permit absolute silence, such statements as are allowed to appear lose all flavor of truthfulness either through vagueness or fragmentari- ness. The schoolroom which has one third the stand- ard amount of light, and which investigation would probably show to have an excessive amount of eye defect among its pupils, will at most be reported as "somewhat deficient in light," etc. School authorities do not tell us what school buildings are supplied with air dryer than the air of Sahara. They do not tell us anything about the relation of colds, influenza, etc., to the ventilation and warming of school buildings, nor do they enlighten us very materially in regard to the methods of sanitation which they employ. (5) Lastly, as we have already seen, they tell the public very little about the physical conditions of the children, and still less about the relation of one defect to others or to school and social environment. Not even schools can remain permanently exempt from publicity. For the very reason that public educa- tion is the institution of most vital concern to the entire population, those who control it are morally obligated to afford publicity of all the facts which con- cern it. The more intimate or unpleasant the facts the deeper is this obligation. Sooner or later, this ideal is certain to take possession of us. The campaign for pub- licity in matters of public concern will not stop at the threshold of the school, and we shall do well to prepare SCOPE AND ADMINISTRATION 35 ourselves for it by studying a little the methods of scientific management. REFERENCES (Only references relating to the scope and administration of medi- cal inspection are included here.) *1. Allen, W. H.: Civics and Health. (Chapter xxx, "School and Health Reports"; chapter xxxiii, "Organization of School Hygiene in New York City"; chapter xxix, " Official Machin- ery for Enforcing Health Rights.") *2. Ayres, Leonard P.: Medical Inspection Legislation. 1911, pp. 54. Bull. 99, Russell Sage Foundation, New York. 3. Cornell, Walter S. : "Good and Bad Forms of Record Keeping." Proc. Am. Sch. Hyg. Assoc., 1911, pp. 65-72. 4. Cornell, Walter S. : " The Need of Improved Records of the Physical Conditions of Children." Psychological Clinic, 1909, pp. 161-63. 5. Cornell, Walter S.: The Health and Medical Inspection of School Children, 1912. (Chapter I.) 6. Crowley, Dr. Ralph H.: The Hygiene of the School Child, 1909. (Chapter v, " Medical Inspection of the Child in the School. The Parent and the State.") *7. Gulick and Ayres: The Medical Inspection of Schools. 1913. (Chapter vi, "Making Medical Inspection Effective"; chapter x, "Controlling Authorities"; chap, xi, "Legal Provisions.") *8. Hoag, E. B.: The Health Index of Children. 1910, pp. 188. (Chapter xn, "An Office System for School Health Depart- ments"; chapter xm, " A General Plan for Health Supervision in Schools"; chapter xiv, "Some Details of the Physician's Examinations"; chapter xv, "The Cooperation of School Health Departments with Other Agencies.") *9. Hogarth, Dr. A. N.: The Medical Inspection of Schools. 1909. (Chapter vn, " The General Principles and Aims of Medical Inspection"; chapter vn, "The Organization of a Central Department"; chapter ix, "Local Organization"; chapter xm, "Administrative Routine"; chapter xvi, "Common Diseases affecting School Life.") 10. Hope, Dr. E. S.: "Correlation of the School Medical Service and the Health Medical Service." In Kelynack's Medical In- spection of Schools, chapter i, pp. 1-10. 11. Howcrth, Dr. W. J.: " Organization and Administration of the Medical Examination of Scholars." In Kelynack's Medical Inspection of Schools, chapter in, pp. 34-62. 12. Mackenzie, Dr. W. Leslie: The Medical Inspection of School Children. 1909. (Chapters i to vi.) 13. Porter, Charles: School Hygiene and the Laws of Health. Lon- 36 HEALTH WORK IN THE SCHOOLS don, 1908. (Chapter xxn, " The Medical Inspection of Schools and School Children.") *14. Rapeer, Louis W.: School Health Administration. 1913, pp. 360. 15. Snedden, David S.: "Problems of Health Supervision in the Schools of Massachusetts." Proc. Am. Sch. Hyg. Assoc, 1912, pp. 18-26. 16. Storey, Dr. Thomas A.: "Medical Inspection in Schools from the Standpoint of the Educator." Medical Review of Reviews, July, 1912. *17. Newmayer, Dr. S. W.: Medical and Sanitary Inspection of Schools. 1913, pp. 318. (Part I.) CHAPTER III PLANS FOR ORGANIZATION FOR HEALTH WORK State versus local control Although the development of health work in the schools has been very rapid, much remains to be done to make it as effective as it ought to be. Its greatest weakness lies in the absence of standardized direction and procedure. With regard to it the most divergent beliefs and practices prevail. The logical place for the oversight of such work is the State, though almost everywhere in the United States city action has preceded state action. For the State to assume general responsibility for school health work would only be in line with other extensions of the State's interest in the welfare of its children, in- cluding state laws for vocational education, state uni- formity in textbooks and courses of study, state sup- port for secondary schools, etc. State action in matters relating to school hygiene is desirable for two important reasons: (1) it sets standards for the conduct of the work which insure that it will be, on the whole, much better done than is the case when each community is left to work out its own methods blindly; and (2) it is the best and only guaranty that backward communities will not neglect 38 HEALTH WORK IN THE SCHOOLS such matters altogether. In the absence of manda- tory state laws, rural schools almost never enjoy the requisite hygienic oversight, either as regards school buildings or the children themselves. By 1912 some twenty States had passed laws pro- viding for the medical inspection of schools, but in only nine cases are the laws mandatory. Even where the law is mandatory, the details of method and pro- cedure are too often left to the initiative of the city, county, or school district, so that most of the benefits which would accrue from responsible state depart- ments of health supervision are not enjoyed. Examples of state departments In August, 1912, the State of Minnesota organized, for the first time in the United States, a "State Divi- sion of Health Supervision of Schools. " The work was undertaken by the State Board of Health, with the cooperation of the State Department of Public In- struction. A Director of School Hygiene was appointed whose duties were as follows : — (1) To visit towns and cities desiring aid in the promotion of school health work. (2) To maintain a clearing-house of information in matters pertaining to school and child hygiene, at the offices of the State Board of Health. (3) To offer lectures on general topics of school and child hygiene to teachers' institutes, and other or- ganizations desiring them. ORGANIZATION IN THE SCHOOLS 39 (4) To conduct short courses on child hygiene at each of the State Normal Schools. (5) To carry on investigations in matters pertain- ing to school and child hygiene. (G) To publish and circulate information to schools, pupils, and parents on subjects relating to the pro- motion of health among school children. (7) To maintain an exhibit of school hygiene, at the offices of the State Board of Health. (8) To maintain a bureau of information in respect to available school medical officers and school nurses. The general program of the director at each place visited was as follows : — (1) A general meeting with all the teachers of the local school system, at which were explained methods for the physical observation of school children. At these meetings practical demonstrations (or school clinics) were given, with one or more grades of school children present, usually a fourth or fifth grade. (See chapter vi for a stenographic report of one such clinic held.) (2) Individual demonstrations in various grades in different schools. (3) Examination of special cases, including mentally defective children. (4) A second meeting with all the teachers for the purpose of discussing the results of the examinations. (5) An open meeting devoted to the interests of parents of school children. 40 HEALTH WORK IN THE SCHOOLS (6) Sanitary inspection of school buildings and premises. (7) Organization of the study of mentally deficient children. (8) Recommendations for health promotion ad- dressed to the board of education, and adapted to the conditions discovered. The University of Virginia, in cooperation with the State Board of Health and the State Department of Public Instruction, has organized a plan somewhat similar to that of Minnesota, and it is safe to say that in a comparatively short time state organization and standardization of school and child hygiene will be undertaken by most of the progressive States of the Union. However maintained, provided only the work be vigorously and sanely prosecuted, the State Depart- ment of Child Hygiene is sure to be of incalculable benefit. It hastens the progress of health supervision not only by persuading school authorities to establish it, but also by standardizing the procedure so as to insure efficiency. By influencing legal and educational control it would in many cases save years of needless and discouraging experimentation. Such a depart- ment should organize and prosecute State-wide in- vestigations of child hygiene, in the broadest sense, including infant mortality, mental retardation, juve- nile criminality, the hygiene of mental activity, etc. In the organization of such departments it is de- ORGANIZATION IN THE SCHOOLS 41 sirable that the work be broadly conceived, so as to bring within its scope as many aspects of child hygiene and child welfare as possible. Research should be vigor- ously prosecuted along all lines of mental and physical deviation, and should look especially toward methods of amelioration and prevention. There should be sub- departments for the hygiene of instruction, mental retardation, preventive mental hygiene, etc., each with specially trained assistants in charge. City organization of school health supervision Most of the larger cities of the country have taken up the work in some fashion or other, without refer- ence to state action. By 1898, Boston, Chicago, New York, and Philadelphia had inaugurated systems of medical inspection. About 90 cities had followed the example by 1907, 337 by 1910, and nearly 500 by 1913. This wave of activity has resulted in (1) a few well-developed City Departments of School Hygiene; (2) many partially developed undertakings; and (3) a desire, on the part of many smaller cities, to undertake some kind of health supervision in an inexpensive way, without the employment of school physicians. In order to indicate some of the best plans for health work in schools, and in a measure to furnish standards which may be successfully put into operation, three distinct plans of organization for school health work are here set forth, devised to meet varying conditions, 42 HEALTH WORK LN THE SCHOOLS such as are sure to exist in different places. The three plans are as follows : — (1) Organization with one or more medical officers, and a nurse or nurses. (2) Organization with a school nurse or nurses only. (3) Organization by the employment of a simple non-technical health survey on the part of the teachers only. Such a survey is provided by a series of ques- tions based upon ordinary observations of physical and mental conditions. In the present chapter, Plan (1) is set forth in a general way, and in the appendix the organization in five typical cities is described. Plan (2), supervision by nurses only, is described in chapter iv; and Plan (3), health grading by teachers^ in chapters v and vi. Plan (1): Physicians and Nurses A physician should be selected who has some special interest in and adaptability for work with school chil- dren. In addition to this he should have made some special study of school hygiene, since medical colleges unfortunately do not usually include such courses in their curricula. Whether the medical officer shall give part or all of his time to this work will depend largely upon the duties required of him. In communities where the number of school pupils does not exceed 4000 to 6000, it is possible for one well-trained school doctor to render satisfactory service by devoting one half of his time to the work, provided he has as assistants at ORGANIZATION IN THE SCHOOLS 43 least two well-trained nurses who possess special adaptability for this kind of work. In places of from 8,000 to 12,000 school population, it is best to have one physician give his entire time, and an assistant physician give half-time. In such places there should be employed at least three or four school nurses. In places where the school pupils exceed 12,000, one may estimate an additional half-time school medi- cal officer and from one to two full-time school nurses for each 6,000 increase in the number of pupils. For a city the size of Los Angeles or Indianapolis, this would mean from twelve to twenty school nurses. Many will say that this is an inadequate force for so large a number of pupils, and gauged by absolute perfection this may be true. But it must be remem- bered that school systems have many practical adjust- ments to make, and that this is actually a larger force than schools now employ. The plan presupposes preliminary examinations on the part of nurses and teachers, after the manner sug- gested in chapter v. This method relieves the medical officers from much purely routine examination of practically normal children, and allows them to con- centrate their attention on children really needing expert services. With the methods employed at pres- ent, school doctors waste a great amount of time doing purely inexpert work, which might far better be done by teachers and nurses. At present most cities are in this way paying experts for inexpert service. 44 HEALTH WORK IN THE SCHOOLS When a city is large enough to require the services of several medical officers in the schools, the follow- ing plan is suggested and recommended as the most efficient one : — There should be one general director, giving his entire time to the work. Instead of employing several half-time physicians as his assistants, fewer men on whole time are recommended. The organization might be made up as here indicated for a city of, say, 60,000 school children: — One Chief Health Director. One General Medical Officer. One eye, ear, nose, and throat specialist. One specialist in mental and nervous diseases, who is also experienced in psychological methods. One emergency physician. One woman physician in charge of high-school girls. One dental specialist. This number (seven) would take the place of the twelve physicians under the usual plan in vogue, and, with appropriate increase in the number of school nurses, would result in better work in every respect. Such a plan would require a central office of several rooms; namely, one general reception-room; one pri- vate office for the director; one examining-room; one laboratory equipped with medical and psychological apparatus. There should be a dental and medical clinic, either in connection with the schools (and this is preferable), or, if this seems impossible to arrange, then in connection with some other organization. ORGANIZATION IN THE SCHOOLS 45 With this plan in operation, parents of defective children would have the opportunity of taking their children to the central office for special examinations. The different specialists would keep office hours on different days of the week, and could thus give careful and deliberate attention to such school children as re- quired it. From this office, cards of admission to the medical or dental clinics could be issued to those en- titled to them. One special school nurse should be assigned for duty at the central office, whose duty it would be to keep the records and assist the physician in the examination. 1 The cost of health supervision by Plan (l) The expense of a system providing for competent health supervision of about 50,000 school children would probably fall somewhere between $18,000 and $25,000 annually for equipment and for salaries of physicians and nurses. If the scope of the work is enlarged by the addition of one or more psychologists, and by extensive use of clinics for free treatment, the cost would be proportionately greater. The importance of adequate salaries deserves special emphasis. We frequently hear of a medical officer giving half-time, examining thousands of children 1 For the benefit of those specially interested in school health organization, the plans of health supervision in five representative cities of the United States are presented, in some detail, in Appen- dix I. Special attention is called to the organization in Milwaukee. See also Rapier's School Health Administration for work in twenty- five representative cities. 46 HEALTH WORK IN THE SCHOOLS in a school year, and receiving for his services a pit- tance of $200. It should go without saying that what- ever public service is worth having is worth paying for. Until salaries of health supervisors are placed on a better footing it is useless to expect the kind of serv- ice that is most needed. Costs are large or small relatively to other costs. The annual money loss to the people of the United States due to their ignorance and carelessness of the laws of hygiene has been conservatively estimated at not less than $2,000,000,000. It is probably a good deal more than that. The annual cost from tuberculo- sis alone is not less than $500,000,000. Our calcula- tion takes no account of impaired efficiency due to alcoholism or other vicious habits, undue fatigue, minor ailments, and general lack of expert direction of the human machine, nor does it try to place a money value upon grief and moral suffering resulting from preventable sickness or death. If the kind of health supervision here suggested were established in every city and county of every State in the Union, the annual cost would not exceed $5,000,000 to $10,000,000, or less than half of one per cent of our annual loss from sickness, physical in- efficiency, and premature death. In passing we may also note that this sum is about equal to the cost of one warship; to one sixtieth of the money cost of the alcoholic beverages consumed annually in the United States; or to one fortieth of our annual ex- penditure for tobacco. ORGANIZATION IN THE SCHOOLS 47 It is, of course, not claimed that child hygiene in the schools can prevent all of the losses due to pre- ventable sickness, but there can be no doubt that it would save many times more than half of one per cent of them. Through education its effects would become cumulative. It is not unreasonable to suppose that in the long run the annual returns would amount to fifty times the annual cost. Compared to other ed- ucational expenditures the cost cannot be consid- ered large. The elementary and secondary schools of the United States are supported by an annual ex- pense of nearly $450,000,000. If ideal health super- vision were made universal, this amount would have to be increased only to the extent of about one or two per cent. Stating it in another way, the public at present is willing to expend, and does expend on an average, about $35 annually in the mental and moral education of one of its children. If it also undertook the hygienic supervision of the child's growth and development the amount would be about $35.50. Health supervision for the child's whole elementary school life would be about $3 to $4. A progressive city of 300,000 people and 45,000 school enrollment expends over $125,000 for salaries of superintendents, assistant superintendents, and supervising principals, who themselves do no teaching. It could at least afford to expend one fifth of this amount for health super- vision and hygiene investigations. CHAPTER IV THE SCHOOL NURSE: INCLUDING SUGGESTIONS FOR HEALTH SUPERVISION BY THE "NURSE ALONE" PLAN Spread of school nursing One of the latest and best additions to our educa- tional forces is the school nurse. Perhaps no other educational movement, not even excepting medical inspection itself, has spread with more rapidity or has met with such unanimity of support. School nursing had its beginning in England. In 1894 a district nurse was asked to visit a London school attended by poor children, to help to relieve their ills. In 1898, a voluntary "School Nurses' So- ciety" was founded with the idea of extending the work, as a result of which three nurses were appointed. In 1904, when the work of the London School Board was taken over by the London County Council, and reorganized, the number of nurses was increased to 12, and still later to 50. Other cities of England, large and small, speedily followed the example of London, and school nursing is now being carried into the rural districts. In the United States it was not until 1903 that the movement can really be said to have begun. In that year New York appropriated $30,000 for the purpose, THE SCHOOL NURSE 49 and appointed 27 nurses to assist the Board of Health in the medical inspection of schools. By 1907, eight cities in the country had school nurses, and by 1910 nearly eighty. Of these 71 per cent are located in the Northern States. Boston, with its force of 25 school nurses, supported at an annual expense of $25,000, is an excellent illustration of what progressive Ameri- can cities are doing in this line. New York City, at the time this is written, has 176. In all parts of the country the number is increasing with great rapidity. Special provision for the employment of school nurses is now made in the medical inspection laws of several States. Nurses necessary for follow-up work Medical inspection rendered the school nurse in- evitable. When the doctor was brought into the schools, he faced a new and tremendously difficult situation. The school doctor's helplessness has been vividly described by Dr. Hayward, of England, as follows : — As a doctor I felt quite stranded in the strange atmosphere of an elementary school, coming into contact, not so much with actual illness, as with the primary conditions which produce and foster it. Dirt, neglect, improper feeding, mal- nutrition, insufficient clothing, suppurating ears, defective sight, verminous conditions, the impossibility of getting adequate information from the children or a knowledge of their home conditions; and nobody to whom one could give directions or who could help in examining the children. The only means of approaching the parents was to send an official notice that such or such a condition required treatment. My duties began and ceased with endless notifications, and there it all stopped, as very little notice was taken of them. 50 HEALTH WORK IN THE SCHOOLS This has been the experience everywhere. Without an effective follow-up service, conducted by visiting nurses, medical inspection is ineffective. Until 1908, New York City relied upon a postal card notification sent to parents of defective children, and was able to secure action in only 6 per cent of the cases where treatment was recommended. Immediately upon placing the follow-up service in the hands of school nurses the percentage increased to 84. This brought treatment to nearly 200,000 additional pupils. The following chart shows the difference in the results of recommendations acted on in Philadelphia. THE SCHOOL NURSE 51 obtained by a given medical inspector in Philadelphia after the addition of a school nurse to his staff. In each case the height of the first column shows the percentage of recommendations acted upon by the parents before the employment of the nurse; the second column after her employment. In a majority of cases parental neglect spells igno- rance. The postal card notification is a poor educa- tional device. The nurse goes into the home and by tactful presentation of the child's case effects what no other agency could accomplish. She not only secures action in the case at hand, but she becomes a permanent advisory influence in the homes where she visits. She does what the iron hand of law could not do. We can hardly imagine any kind of legal machinery, devised for compelling parental treatment of children's defects, which would succeed in as large a percentage of cases as does the school nurse. School nurses reduce absence In the second place, medical inspection without school nurses is always a costly tax on attendance. Children with scabies, impetigo, pediculosis, etc., are sent home by the thousand, to mingle on the street with other children after school hours, beyond the control of the school and without effective treatment. Where diseases of this kind are either treated by the nurses at school or by the parents after her instruc- tion, exclusions are usually reduced to 5 or 10 per cent of the number previously necessary. In New 52 HEALTH WORK IN THE SCHOOLS York City the reduction was from about 10,000 to about 1000 per month. In a quarter of a school year exclusions were enforced in New York as fol- lows : — Measles 18 Diphtheria 140 Scarlet fever 13 Whooping-cough 61 Mumps 13 Chickenpox 172 Trachoma 12641 Pediculosis 3994 Skin diseases 661 Miscellaneous 1823 Nearly all these exclusions preventable by school nursing. Over 95 per cent of the above exclusions would have been prevented by the school nurse. By her ministra- tions and instruction in the home these diseases of filth and neglect are almost eliminated. As expressed by Jane Addams : * — The best of medical inspection succeeds only in sending the child home; they say that such and such a child would have a bad effect on the other children, and therefore he is sent back to the family physician for treatment. In most cases a family physician is not called in, because, in the words of ArtemusWard, "there ain't none"; and therefore the child is kept out indefinitely, and the public school, so far as that child is concerned, is doing nothing, and the child continues to play in the alley and on the street or sit in the doors of the tenement with the rest of the children. This is the whole idea — that medical inspection was succeeded and almost transposed by the addition of the visiting nurses. The med- ical inspection got the child out of school, and the visiting nurse got the child back. It seems almost foolish to have medical inspection without the visiting nurse. 1 Am. J. Nursing, 1908. THE SCHOOL NURSE 53 Other functions of the school nurse By virtue of her room to room visitation and her opportunities for observation, the school nurse also becomes the ideal sanitary inspector. She notes tem- peratures, ventilation, seating, cleanliness of room, toilets, blackboards, and the clothes of children. Her hospital standards of sanitation tend to follow her into the schools. In special schools for the tuberculous, crippled, or anaemic children, the school nurse is indispensable. She records body temperatures, supervises the diet, the sleep, and the play of the children, and advises continually with parents, teachers, and doctors. In some such schools her constant presence is as neces- sary as in the hospital ward. Again, the school nurse becomes an invaluable as- sistant in the teaching of hygiene to pupils. Every pupil ought to have more expert instruction on such subjects as home-nursing and first aid in emergencies than the average teacher can be reasonably expected to give. This deserves a special place in the seventh and eight grades. In the matter of sex hygiene, too, the school nurse can give much personal advice and instruction to the older girls. As has been pointed out by Miss Stewart, 1 the nurse, more than almost any other social worker, sees the dreadful havoc wrought by ignorance of the laws of sex. She becomes vividly 1 Ninth Year-Book of the National Society for the Scientific Study of Education, p. 5. 54 HEALTH WORK IN THE SCHOOLS impressed with the necessity of such teaching as will supply to young girls the power and motive for self- protection. Girls are willing to consult her the more readily because they realize that this is an everyday subject with her. Influence of school nurses upon the home The school nurse, like the municipal district nurse, is first and last a social worker. Important as are her duties in the school, her ministrations and educative influence in the home are more valuable still. She instructs ignorant but fond mothers in the best methods of feeding, clothing, and caring for their children. She is received in their homes as no other official visitor could possibly be. Mothers are quick to detect the genuineness of her interest in their chil- dren, and are often ready to follow with blind faith any instructions she has to offer. At her advent in a tenement or street, the mothers not infrequently crowd eagerly around her, plying her with questions and bringing their babies for inspection. The school nurse is thus a potent factor in diminishing infant mortality. In short, Dr. Osier does not overstate the case when he says that the visiting nurse is " a minis- tering angel everywhere. " In many a family she be- comes a spiritual adviser, not only pointing out in- adequate sanitation which keeps them sick, but also educating them on the folly of cut-throat chattel mortgages, unnecessary furniture purchased at ruin- ous prices on the installment plan, the short-sighted THE SCHOOL NURSE 55 policy of taking children prematurely out of school to work, etc. All of this is especially important in the Ameri- canization of the more ignorant foreign-born popu- lation. As stated by Dr. Darlington, of New York City: — In all large communities, the poorer element of the foreign- born population presents the greatest problem encountered in municipal health work. Diversified in their habits, often superstitious and resentful of any interference with their mode of life, oppressed by poverty, frequently ignorant or neglectful of the simplest sanitary requirements, their assim- ilation as citizens of their adopted country comes only as result of education — persistent, inclusive, and never-end- ing. In public health work this education is brought about by various means. Lectures, printed instructions, and pub- licity in all its forms are used, but the most valuable and effective form is found in individual instruction in the home. Personal efforts, advice, instruction, and demonstration offer the most practical and effective means, and we have found the employment of trained nurses for this purpose of ines- timable value. That the visiting nurse is a good economic invest- ment is evidenced by the fact that some of the large insurance companies, such as the Metropolitan Life of New York City, find it to their advantage to em- ploy a number of them to visit the homes of policy- holders for the purpose of giving instruction in mat- ters of hygiene. Department stores and factories also find it good business to employ nurses to look after the health of their employees and to teach them personal hygiene. The visiting nurse is a "health nurse. " 56 HEALTH WORK IN THE SCHOOLS Number needed The number of school nurses needed varies some- what according to social conditions, and according to the range of duties expected of them. We find all the way from 1,000 to 10,000 children under the care of one nurse. In New York City each nurse has from two to seven schools, with a total attendance of about 4000 children. In Philadelphia five schools and about 5000 children are usually allotted to one nurse, while in Boston the proportion of nurses is almost twice as great. Nor is it at all demonstrated that the point of diminishing returns has yet been reached in the num- ber employed. It is not improbable that the ratio will be increased until it reaches an average of one nurse for each 1000 of the school enrollment. If there were one nurse for every 2000 pupils, about 10,000 would be required in the entire United States. A nurse's room, completely equipped, is coming to be regarded as one of the essentials in every school build- ing of eight or more rooms. Thus far the institution of school nursing has not spread to rural communities in the United States, though it has done so to a certain extent in England. This cannot be attributed to any lack of need, but only to the greater expense and other obstacles inci- dent to a more scattered population. As our country districts become more densely populated, and as they resort more often to school consolidation, the nurse will here, also, become a necessary part of the school force. THE SCHOOL NURSE 57 Equipment needed by school nurses With such an extensive scope of duties, oppor- tunities, and difficulties, it at once becomes evident that both the personal qualities and the professional training of the school nurse are matters of great im- portance. She must be quick to understand every class and condition of people, patient, sympathetic, and tactful. All agree that tact is absolutely essential. She must be simple, direct, concrete, forceful, con- vincing. Her business is not to entertain, but to get things done, and she must therefore be persuasive as well as pleasing. On the professional side, besides having a good high-school education and a complete course in a nurses' training school of recognized standing, she should have had some months of additional experi- ence in a children's hospital. She must also know something of education, child psychology, general hygiene, nutrition, infant mortality, child-welfare movements, domestic sanitation, and certain legal matters. If she has had previous experience as a dis- trict nurse or as a teacher, so much the better. Good health and willingness to work are of course taken for granted. With the rapid multiplication of school nurses the desirability of special professional training for them will become more obvious. Teachers College, Colum- bia, has already introduced a one-year course for this purpose, designed to follow the usual two-year train- 58 HEALTH WORK IN THE SCHOOLS ing for nurses. Courses of this nature will no doubt be established at an early date in other teachers' colleges, and perhaps also in connection with medical schools. The school nurse has proved her worth to the most skeptical, but her usefulness can be greatly enhanced by the requirement of a professional train- ing which gives special attention to problems of school hygiene. A Plan For the Health Supervision of Schools by Nurses Alone x This plan is adapted to places which are unable, or think they are unable, to procure expert medical service in schools. It has been amply demonstrated that well-trained nurses are able to accomplish ex- tremely useful results, even without the direct aid of medical supervision. The plan has been in success- ful operation in Alameda, California, since 1911, and is soon to be established at Ely, Austin, Cloquet, Owatonna, and a number of other towns of Min- nesota. Properly trained nurses are able to detect most of the physical handicaps of school children. Such nurses have no difficulty in discovering common defects of the nervous sytem, eyes, ears, throat, teeth, skin, and lymph glands of the neck. They can usually detect the presence of adenoids and note disorders of nutrition, as well as observe defective postures. About 1 This is the second plan for school health supervision, mentioned on page 42, chapter in. THE SCHOOL NURSE 59 the only points of importance which they ought not to attempt to cover in their examinations are those which pertain to certain special conditions requiring exact diagnosis. These would include the heart, lungs, special diseases of the skin and nervous system, and some of the unusual contagious diseases of childhood. Certainly more than 90 per cent of the usual defects of school children will be observed by the rightly trained school nurse, and this plan will inevitably justify itself and gradually lead to more thorough organization with medical service. According to Dr. R. C. Cabot, of the Harvard Medical School, the school nurse comes to excel the young doctor in detecting the first symptoms of in- fectious disease. The results of nurse inspection in Boston prove her efficiency in this line. Under the inspection of doctors and teachers the average number of cases of scarlet fever discovered annually in the schools was 14. In 1908, the school nurses found 1000 cases. Where the doctors and teachers had found an annual average of 86 cases of measles, the school nurses discovered 2285! This disparity in efficiency, however, is in reality a disparity between nurses and teachers, as previous to the introduction of nurses the physicians had examined, for the most part, only those children sent to them by the teachers as suspects. The following communication is from Louis W. Rapeer, who has made an exceptionally thorough study of the results of medical inspection in about forty American cities : — 60 HEALTH WORK IN THE SCHOOLS I have come to the tentative conclusion that many schools do not need physicians, and that a great deal would be gained, and little or nothing lost, by employing experi- enced school nurses for each group of 1000 to 1800 pupils. New York City, as well as other cities, has proved that school nurses can inspect for contagious diseases. Canton, Massachusetts, also has shown that only the nurse is needed. 1 Physicians for less than one hour a day cost about half what nurses cost for full time, five and a half days a week. A school nurse when trained, one who has the study habit, can also make the physical examinations and record the findings on a history card for each pupil, especially for defects of ears, eyes, nose, mouth, throat, skin, scalp, malnutrition, and ner- vousness, — about 97 per cent of all. Nurses very much les- sen professional jealousy among the doctors; get far better response from children and from parents ; get cures, the great object of medical supervision; open the eyes of teachers to the symptoms of ailments and defects; follow up better the children they themselves examine; cooperate better with women's clubs, dentists, dispensaries, and oculists; get back the truants and absentees; keep down impetigo, lice, and infant mortality in the summer; distribute literature on the cure and prevention in the homes; and in general are on the job all the time as a life-work, not as a perfunctory side issue. Three hours each morning for inspection and 20 exam- inations ; afternoons for inspection and home visiting — about 1000 to 1800 children. Occasionally physicians object to allowing school nurses to make health examinations or to treat cuts, bruises, sores, and the like. The tendency, however, is to the extension rather than the restriction of their duties. There is no reason why physicians should view this with apprehension since the nurse's work 1 See Dr. Arthur Cabot's article in The Physicians and Surgeon's Journal for May, 1911, and the September, 1911, report of the Bu- reau of Municipal Research, 261 Broadway, New York. THE SCHOOL NURSE Gl finds its natural limitations without any need for arti- ficial restriction. In every instance where nurses are employed to make the examinations of pupils, one or more physi- cians ought to be available for special consultation in questionable and unusually important cases. The hearty cooperation of teachers will also be required in this scheme and they ought to make use of an outline of health grading, such as that presented in chapter v. SELECTED REFERENCES (Only the most important references are given here. A complete bibliography will be found in the Ninth Year-Book of the National Society /or the Study of Education, referred to below.) 1. Allport, Dr. Frank: The School Nurse. *2. Cornell, W. S. : Health and Medical Inspection of School Chil- dren. 1912, pp. 76-89. 3. Crowley, Ralph H.: The Hygiene of School Life. 1910, pp. 181- 83. 4. Forbes, Duncan :" The School Nurse. " See Kelynack's Medi- cal Inspection of Schools. 1910, chapter xvn, pp. 264, 274. *5. Gulick and Ayres: Medical Inspection of Schools. (Chapter v. "The School Nurse," pp. 62-71.) *6. Hogarth, A. H. : Medical Inspection of Schools. 1909, chapter xii. pp. 172-86. 7. Leipoldt, C. L.: The School Nurse. London, 1912. *8. Newmayer, Dr. S. W.: "Evidences that the School Nurse Pays." Proc. of Fifth American Cong. School Hygiene, 1911. pp. 44-51. 9. Nutting, Adelaide: "The Nurse in the Public School." Rept. of U.S. Bureau of Education, No. 1906, chapter viii. *10. "The Nurse in Education," being the Ninth Year Book of the National Society for the Study of Education. 1911, pp. 72. 11. Poelchau, Dr. G.: "Bericht liber die Tatigkeit der Schul- schwestern in Charlottenburg in Schuljahre 1909-10." Inter. Mag. Schulhyg., 1911, pp. 263-79. CHAPTER V THE HEALTH GRADING OF SCHOOL CHILDREN BY TEACHERS 1 The General Importance of the Teacher's Cooperation The cooperation of the teacher The effectiveness of any system of health super- vision in the schools depends in large measure upon securing the intelligent and willing cooperation of the teachers. The more prominent the preventive aspect of the work done, the more important this becomes. A large part of the doctor's advice has to be acted upon finally, if at all, by the teacher. She is the only person in constant attendance upon the pupils. She has even larger opportunity than the school nurse to detect the first symptom of contagious disease in the school. It would be well if normal schools afforded to young teachers a more satisfactory training in school hygiene. They would then be able to cooperate more intelligently in the management of all kinds of atypical children, — the precocious, the mentally de- fective, the incorrigible, the physically defective, the timid, the quarrelsome, the stuttering, the neuras- thenic, etc. 1 This is the third plan for the health supervision of schools men- tioned on page 42, chapter in. HEALTH GRADING 63 The teacher's part in molding the health habits of pupils is equaled by that of no other agency. It de- volves upon the teacher to cultivate habits of posture which will prevent spinal curvature and myopia, and habits of physical activity which will help to counter- balance the effects of sedentary life and ward off disease. It is her duty to impart the knowledge of hygiene and ideals of correct living which will func- tion throughout life as the cheapest form of health insurance and the most effective protection against immorality and vice. The responsibility of the school for the child's health does not cease with the close of school life. Besides assisting the physician, with records and other routine work, teachers are also frequently charged with the testing of vision and hearing. This practice has become especially common in the United States. At present legal enactments in many States, including Colorado, Connecticut, Indiana, Maine, Massachusetts, Minnesota, and Utah, provide that sight and hearing tests be made by the teacher, and such tests are the custom in probably a majority of American cities. To a less extent this has been done also in England and Scotland. Teachers vs. physicians Physicians sometimes oppose this extension of the teacher's work into a field which they regard as one that should be reserved for a higher degree of ex- pertness than the average teacher can be expected to 64 HEALTH WORK IN THE SCHOOLS possess. Some of the best oculists and aurists in the country, however, have taken the other view. In- deed, it has been largely due to the influence of such specialists themselves that these routine examina- tions have been so generally entrusted to teachers and nurses. In 1906, when the legislature of Massachu- setts was considering a mandatory provision by which vision and hearing were to be tested by teachers, sittings were held during which a mass of evidence as to the feasibility of the plan was offered by some of the best-known specialists of the State. Tests of the kind here referred to can be made by any one who is competent to teach. It is not claimed that the teacher can assume the expert functions of the oculist or aurist, and the making of sight and hearing tests does not require that they should do so. It is claimed, and is now fairly well recognized, that they are at least as capable of making tests of the special senses as is the physician who is not also a specialist. It should be stated, however, that, wherever this policy is fol- lowed, the intention is to have examinations made by specialists in all cases where defects are apparently revealed by the teacher's test. Teachers should have special instruction and prac- tice to aid them in reading the health index of the child for all the common diseases and defects. The contribution that can rightfully be expected from teachers in all these lines depends in part upon the size and efficiency of the school nursing corps. In general, the more nurses the less it will be neces- HEALTH GRADING (i5 sary to require of the teachers. This applies especi- ally to the detection of contagious diseases and physi- cal defectiveness, first-aid work, follow-up service, etc. But the responsibility of conducting the activi- ties of the school in such a way as to transgress as little as possible the fundamental laws of hygiene is one which the teacher can never wholly shift. Any scheme of medical inspection or health supervision which does not succeed in enlisting the interests and enthusiastic support of the teachers fails in one of the most fundamental requirements. An Outline for the Health Grading of School Children by Teachers Health supervision of schools, must in many places, at present, be delegated largely or entirely to teachers, a fact which we cannot ignore. For this special work, however, very few teachers, or even nurses, have received adequate training. In order to help meet this condition as it exists in the schools, the following Outline for a Health Survey of School Children is suggested. Its use will succeed not only in largely removing the usual obstacles to health supervision in a community, but even where such obstacles do not exist, the plan when put into operation will, it is believed, greatly assist those engaged in the health care of children in the schools. The plan consists of two parts : — I. An outline for a partial health survey to be made 66 HEALTH WORK IN THE SCHOOLS by the aid of the pupils themselves, or, in the case of young children, by the aid of parents. II. An outline for a more extensive health survey on the part of teachers (or nurses). Whether a medical officer and nurse are employed, or not, does not much affect the plan; although, of course, any scheme for health supervision in schools will succeed best where competent, specially trained professional service is available. The answers to these questions on the part of pupils or their parents will furnish some very definite in- formation in respect to physical and mental condi- tions, and prove valuable to every teacher. The answers under Part II will stimulate and encourage observation on the part of the teacher and will also supply a very considerable amount of useful informa- tion which may serve as a basis for practical hygiene teaching. With the employment of this survey, no school need wait for the appointment of a medical officer before beginning some effective health work with school children. In making the survey the teacher may take her own time. If it is completed in a room of twenty to forty pupils in a month or six weeks, it will be quite satis- factory. Any teacher will be able to accomplish it without feeling that she is imposed upon. After a pupil's health survey is made, a notice should be sent to the parents in those cases where physical difficulties appear to exist. This notice may be very general and noncommittal in character, and should always be HEALTH GRADING 67 signed by the principal of the school. Such a notice has been successfully employed in the following form: — To the Parent of The teacher of this child has reason to believe that he is suffering from physical defects, serious enough to need attention. An examination by your family physician or dentist is, therefore, advised. For further details you are invited to call at the office of the Principal at any time you may find it convenient. Very sincerely yours, Principal of School. A health survey carried out in the manner suggested will result: — (1) In overcoming most of the prejudice against physical examinations of school children. (2) In educating the public in matters of child hygiene and preventive medicine. (3) In largely solving the question of expense. (4) In the discovery of probably 90 per cent of the urgent cases of physical defects. (5) In considerably decreasing the wear and tear on the teacher. (6) In considerably increasing the children's health, happiness, and efficiency. (7) In serving as a useful preliminary examination for a medical officer of schools so that he may know where to concentrate his attention. (8) In giving positive information in respect to the kind of hygiene teaching which is most needed. The significance of all the answers obtained by the 68 HEALTH WORK IN THE SCHOOLS use of the questions in the health survey may not at first be appreciated by the teacher or other person without medical training, but experience and a little study will gradually make this matter plain. Part I of Health Survey Questions to be answered by pupil or parent, or by pupil with aid of the teacher Name. ./. School Date % Question 1: How old are you? Answer: 9> Question 2: What grade are you in? Answer: ^.ir£. Question 3: Have you ever had any serious sickness? What was it? Answer: ; Question 4 : What do you usually eat for breakfast? Answer: Question 5: Do you eat breakfast every day? Answer: Question 6: Do you eat a noon meal every day? Answer : Question 7: Do you drink coffee? How much? Answer : Question 8: Do you drink tea? How much? Answer : Question 9 : Do you have your bedroom window open or shut at night? Answer: Question 10: Have you ever been to a dentist? Answer : Question 11: Do you own a toothbrush? Answer : Question 12: Do you use a toothbrush? Answer: ; Question 13: Do you sometimes have toothache? Answer : HEALTH GRADING 69 Question 14: Do you have headache often? Answer: jH.0 Question 15: Can you read easily what is written on the blackboard? Answer : Question 16: Does the print blur in your book? Answer: Question 17: Do you often see double? Answer: rH^rf Question 18: Do youever have earache? Answer: IA-& - Question 19: Do your ears ever run? Answer: j^y([/0 Question 20: Can you hear easily what the teacher says? Answer : Question 21 : Is it hard for you to breathe through your nose? Answer: .'...'■ Question 22: Do you have sore throat often? Answer: Question 23: Do you tire easily in school? Answer: Question 24: Do you work any out of school hours? Answer : Question 25: What kind of work? Answer: Question 26: How much? Answer: .' ! .'. / .' Additional optional questions Question 27: What time do you go to bed? Answer : Question 28: What time do you get up? Answer : Question 29 : Does any one else use your toothbrush? Answer : Question 30: Do you eat candy every day? Answer : Question 31: How often do you bathe? Answer: Question 32: Do you often take cold? Answer : 70 HEALTH WOKK IN THE SCHOOLS Part II of Health Survey Questions to be answered by the teacher or nurse 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. A. General appearance Is the child healthy appearing? Is his color good? Is he physically well developed? Is he free from apparent deformities? Has he a good standing posture? Has he a good sitting posture? Are the shoulders even? Does the child walk normally? Are the two sides of the shoe heels worn evenly? Is the physiological age of the child appar- ently equal to his chronological age? B. Mental conditions Is the child normally advanced in school? . . Is he mentally alert? Does he answer ordinary questions intelli- gently? Does he play normally? C. Nervous conditions Is the child good-tempered? Is he free from abnormal emotion? Does he have good powers of muscular coor- dination? Is he free from spasmodic movements? Is he free from the nail-biting habit? Does he speak without stammering? Is he free from pronounced peculiarities such as irritability, timidity, embarrassment, cruelty, moroseness, fits, general misbe- havior, etc.? Is he apparently free from bad sexual habits? Yes No HEALTH GRADING 71 9. Is he free from so-called "bladder trouble" (requests to "go out")? 10. Is he usually free from headache? D. Teeth 1. Are the teeth clean? 2. Are the teeth sound? 3. Are the six-year molars in good condition? 4. Has the child been to a dentist within six months? 5. Are the teeth regular? 6. Does the child use a toothbrush every day?. 7. Are the gums free from abscesses? 8. Are the gums healthy-looking? 9. Are the upper teeth straight (not prominent) ? 10. Have decayed teeth been filled? E. Nose and throat 1. Does the child breathe with the mouth closed ? 2. Is he free from chronic nasal discharge? 3. Is he free from "nasal voice"? 4. Has he a well-developed face? 5. Has he a well-developed chin? 6. Has he straight, even teeth? 7. Is the child mentally alert? 8. Is he usually free from sore throat? 9. Is the hard palate wide (not high and narrow) ? 10. Is the hearing good? 11. Does the child breathe quietly? F. Ears 1. Does the child usually answer questions without first saying "what"? 2. Is he fairly attentive? 3. Is he fairly bright appearing? 4. Does he have a voice which is not monoto- nous and not "expressionless"? 5. Does he spell fairly well? Yes No 72 HEALTH WORK IN THE SCHOOLS 6. Does he read fairly well? 7. Is he free from earache? 8. Does he hear a watch tick as far as the aver- age child? 9. Is he free from ear discharge? 10. Is he free from any peculiar postures which might indicate deafness? G. Eyes 1. Are the child's eyes straight? 2. Is he free from chronic headache? 3. Does he do his work without fatigue? 4. Is he free from squinting or frowning? 5. Is the child free from postures which might indicate eye defects, such as leaning over too near the desk, holding the head on one side, etc.? 6. Are the eyes free from corneal ulcers or scars? 7. Are the eyes free from redness and discharge? 8. Are the eyelids healthy-looking? 9. Can the child read writing on the board from his seat? 10. Have the eyes been tested separately with the Snellen Test Type? H. Communicable diseases of the skin 1. Is the head free from any signs of disease (lice, ringworm) ? 2. Is the skin of the face, hands, wrists, fore- arms, and chest free from red, somewhat cir- cular patches (ringworm) ? 3. Is the skin of the face, hands, and forearms free from infected spots with crusts and pus (impetigo) ? 4. Is the child free from red, scratched lines and spots on the hands, wrists, forearms, chest, and between the fingers (itch) ? Yes No HEALTH GRADING 73 /. Eruptive children's diseases The following points often indicate the early signs of trans- missible diseases in children. They will not ordinarily be observed, of course, at the time of making this health sur- vey:— 1. Flushed face 2. Lassitude 3. Vomiting 4. Eruptions 5. Congested eyes 6. Discharging eyes . . . 7. Nasal discharge 8. Persistent coughing 9. Scratching 10. Aches and pains. . . . 11. Sore throat 12. Headache Yes No 74 HEALTH WORK IN THE SCHOOLS BLANK FOR SUMMARY Physical Development Nervous System Nutrition Mental Condition Eyes Ears Nose i. . . . Throat Teeth Skin Eruptive Disease Food Ventilation of Bedroom Coffee Habits Tea Habits Home Habits , HEALTH GRADING 75 ABBREVIATED CARD FORM OF A TEACHER'S HEALTH SURVEY OF THE SCHOOL CHDLD Name School Grade Age. Date Yes No 1. Have you ever been in a grade more than one year? 2. Have you ever had any serious sickness?. 3. Do you feel strong and well now? 4. Do you eat breakfast every day? 5. Do you eat a noon meal every day? 6. Do you drink coffee? 7. Do you always have your bedroom win- dow open at night? 8. Have you been to a dentist within a year? 9. Do you have toothache often? 10. Do you own a toothbrush? 11. Do you use your toothbrush every day?. . 12. Do you have a toothbrush of your own? . 13. Do you have much trouble with headache? 14. Can you read writing on the blackboard from your seat? 15. Does the print in your books run together or look dim or crooked? 16. Do your eyes hurt after reading a good while? 17. Do you sometimes see two letters or two lines instead of one? 18. Do you often have earache? 19. Do your ears ever run? 20. Can you always hear the teacher? 21. Do you go to bed by nine o'clock? 22. Do you go to bed by ten o'clock? 23. Do you bathe at least once every week?. . 24. Have you ever been vaccinated? 25. Have you ever had smallpox? 76 HEALTH WORK IN THE SCHOOLS Remarks : — This child has had the following diseases at the age indicated below: — Chickenpox when years old Whooping-cough when years old Diphtheria Measles Tonsillitis Mumps Scarlet fever Pneumonia Typhoid fever Smallpox Tuberculosis Infantile paralysis HEALTH GRADING 77 Suggestions for Using the Outline for Health Grading 1. Call the pupils, one at a time, to the desk. Begin with Part I, and ask the questions as they appear in the Outline and write the answers yourself. One can get a great deal of information by noticing the manner in which the pupil answers the question. Mistakes in answers may often be corrected in this way, when they would not be observed if the pupil were to answer the questions himself in his own writ- ing at his seat. Do not suggest the answer. 2. In asking questions about headache and ear- ache, or any other questions where the word "fre- quent" appears, use the word " frequent " as meaning once a week or oftener. 3. Be perfectly sure that the pupil understands the question, and test his answer in a number of different ways where you have any reason to doubt the reply given. 4. It is desirable to have the Outline for Health Grading completed for every pupil in your room be- fore the arrival of the visiting physician. 5. After the completion of the health grading in your room, make a list of the pupils who you think ought to receive further examination by a phy- sician or nurse. Where only the minor difficulties are discovered it is not necessary to call the atten- tion of a physician to these points, although it may sometimes be necessary, by means of the blank no- 78 HEALTH WORK IN THE SCHOOLS tice, to inform the parents of what you discover. Do not place any pupils on the list to be examined by a physician unless you have a definite reason for doing so. 6. Make a list of all the retarded pupils in your room, and of this number indicate those whom you suspect of being mentally deficient. The Significance op the Answers to the Questions op Part I op the Outline The answers in Part I will furnish information on the following points: — 1. Retardation. 2. Influence of previous sickness on present condition. 3. Relation of home habits to individual health. 4. Condition of the teeth. 5. Condition of the eyes. 6. Condition of the ears. 7. Condition of the nose. 8. Condition of the throat. 9. Amount of work done out of school. 10. Food habits. Defective teeth If a child in the third grade or above has never been to a dentist, it is presumptive evidence in most cases that his teeth are defective. Testimony of aching teeth always indicates defective teeth; sound teeth never ache. In nearly every room it will be noted that several pupils make use of a family toothbrush. Nothing could more effectually spread disease than this practice. "ST O Ck a g o •v^ M ■ t> ^ tffcksj*' 3 - o < >H 9 — > O) 3 a cv. O a o 3 o 2 us i 1 1 a a 5 3 3 o P .2 8 § 1 i '-3 a o 1 o H 5 $ ? 1 < U O P H « 80 HEALTH WORK IN THE SCHOOLS Practically every school disease that we know about is spread by the secretions of the nose and throat. This clearly indicates the danger from the use of the common toothbrush. Chronic- headache Chronic headache in school children is usually caused by one of the following conditions: — 1. Eye-strain. 2. Indigestion. 3. Constipation. 4. Auto-intoxication, or absorption of the products of fermentation from the intestines. 5. Decayed teeth. 6. Bad ventilation at home, or at school, or both. 7. Malnutrition. 8. Adenoids. While there are some other causes of headache, they are so infrequent as to be negligible here. Of the above causes given, eye-strain, constipation, and auto-intoxi- cation are probably the most common. Eye-strain Blurring of the print always indicates some form of visual defect and is, therefore, positive evidence of eye-strain. It is always well to ask if the pupil habit- ually sees double; also if he notices spots before the eyes, if the letters appear to move, etc. Earache Chronic earache always indicates more or less seri- ous trouble. It means that inflammation is present HEALTH GRADING 81 in the ear. In many cases earache is due to the pres- ence of adenoids, and frequent earache always indi- cates either adenoids or some other abnormal con- dition of the throat. If not corrected, earache very frequently leads to more or less permanent deafness. Discharging ears This condition is more serious than earache, and indicates that the disease process in the ears is ad- vancing rapidly. The condition should always be treated at the earliest possible time. Always test the hearing of pupils who have earache or ear discharge by means of the watch tick or whispered words. As a check in this test always test children with normal hearing at the same time. Test each ear separately. Difficult nasal breathing Children who complain of constant difficulty in breathing through the nose usually have adenoids. Sometimes the obstruction is in the nose itself and in this case is due to enlarged turbinates or to polypi. Many children with adenoids will say they can breathe easily through their noses simply because they have never breathed normally, and do not, therefore, know what nasal breathing means. Inquire if the child's mouth is usually dry when he wakes in the morning. Frequent sore throat This condition nearly always indicates diseased tonsils, and should always receive prompt attention. 82 HEALTH WORK IN THE SCHOOLS If the tonsils are much enlarged, adenoids will nearly always be found present. On the other hand, adenoids are often found present when there is no enlargement of the tonsils. Rheumatism is often associated with diseased tonsils. So-called "growing-pains," stiff- neck, and tender, aching joints are common symptoms of rheumatism. The Significance of Answers to Part II General appearance There are many reasons for poor general appearance. The most common is probably general malnutrition, due commonly to insufficient food, the wrong variety of food, or the wrong use of food. Some other causes are the following: — Adenoids. Diseased tonsils. Bad ventilation. Very rapid growth. Tuberculosis. A recent sickness of some kind. Very defective teeth. Peculiarities in posture, walk, etc. These conditions may be explained in general by weak muscles, due to rapid growth; spinal disease (often tubercular); flat-foot or weakened arches; rick- ets; tuberculosis of knee-joint or hip-joint; paralysis, from some serious disease, such as infantile paralysis, meningitis, or diphtheria. HEALTH GRADING 83 Mental conditions A child who is two years or more retarded in school, who does not play normally, or who is not mentally alert, should always be suspected of being mentally deficient. He should be tested by the Binet method. 1 It is necessary to distinguish between merely dull and mentally deficient children. Many mentally deficient children show none of the physical signs of such a con- dition, and may be the best-looking children in the class. Be careful not to overestimate the intelligence of the old, mature child who is two or three years re- tarded, even though he does fairly good work in a class of much younger, less mature children. He must be judged by the ability of children of his own age, and not by children younger than himself. Nervous conditions Stammering is nearly always a nervous condition, and is not usually due to physical defects. Nail-biting is almost never a mere habit, but is caused by an un- stable condition of the nervous system. Spasmodic movements should always be carefully observed, as they often indicate St. Vitus' dance or habit-spasms. True hysteria is very seldom observed in school chil- dren. General nervousness is indicated by a lack of repose, too much emotion, inability to keep quiet, etc., and may be due to any of a large number of causes. Sometimes the home conditions will offer the 1 See p. 105. 84 HEALTH WORK IN THE SCHOOLS explanation. Often the child is from a nervous family. Sometimes the trouble is due to bad sexual habits, but more often the sexual habits are due to an unstable nervous system. So-called "bladder trouble" is practically always a sign of general nervousness, and usually has nothing at all to do with the condition of the kidneys. Nose and throat Adenoids are usually indicated by a nasal voice, frequent colds, crooked and prominent teeth, mouth- breathing, and mental dullness. Not all of these con- ditions are always present, but some of them are. Adenoids and enlarged tonsils are usually associated. Ears Never forget the relation between adenoids and earache, discharging ears, and deafness. Eyes Children with crossed eyes nearly always have a defect of vision, and the crossed eye will in time usu- ally become blind, or nearly so. These children should have properly fitted glasses at the earliest possible moment. This will often straighten the eyes and save the sight. Defective eyes are often indicated by red lids or red eyes, blurred vision, double vision, etc. The teacher should test the sight of each child by using the Snellen Test Type. 1 1 The Snellen cards, together with directions for their use, can be secured from any book-dealer for a few cents. A set should be kept in every schoolroom. See chapter vi, p. 95. HEALTH GRADING 85 Skin Any sudden eruption should always be noted as possibly indicating a contagious disease, such as measles, chickenpox, scarlet fever, and the like. No sort of skin disease should ever be ignored; its cause must be discovered. Examine the teeth of the children yourself Stand in a good light, have the children file past you and open their mouths as widely as possible. Take a quick look at all of the teeth and make a note of each child who has defective teeth. It is not neces- sary to note the number of such teeth, for every de- fective tooth ought to receive immediate attention. Some general observations Try to discover what children always have coated tongues. This is most always due to constipation. Try to correct this condition among children, as it is extremely common and usually receives very little attention at home. Attempt to learn the home habits of the children under your care. You will be surprised to learn how many keep very late hours. Try to learn the cause for this. Try to learn how many children eat candy every day. Talk to them about bathing habits, and learn what their habits actually are in this respect. Make a list of the children who live in families where there 86 HEALTH WORK IN THE SCHOOLS is chronic sickness, and discover what the sickness is. Always be on the alert for signs of children's conta- gious diseases when they first manifest themselves. Use the information obtained by the Outline for practical teaching in matters of hygiene, in your parti- cular room. This will furnish a more effective basis for useful health teaching than anything else. Part III: Some Results secured by the Outline for the Health Grading of School Children In order to test the usefulness of the method for health grading of school children, and also to demon- strate to teachers actual conditions in their rooms, thirty-three grades were questioned on Part I of the Outline. In obtaining the answers, the physician asked the questions, one at a time, of the entire roomful of children, their answers being indicated by rising. 1 At this time no individual names were recorded. The tabulated results which appear below are remarkable not only as indicating the number of physical handi- caps which may easily be discovered, but also in re- spect to the uniformity found in different schools of the same and widely separated towns and cities. No one can possibly read these results, so easily obtained, and remain unconvinced of the seriousness of the de- 1 To avoid suggestion it is better to secure the data by question- ing each pupil privately whenever time permits. If this is impossi- ble, the pupils should be urged to state the exact facts, without pay- ing any attention to the answers given by other children. HEALTH GRADING 87 fects from which at least 40 to 50 per cent of school children suffer. The accompanying table summarizes the answers to " survey " questions in ten cities and towns of Min- TABLE I Answers to "Survey" Questions Addressed to 3215 Minnesota Children Name of Town or City 2 a < IH o a © 2 M M O 'A 9 .9 3 u asis of the number of p upils questi oned in eacl i case. TABLE II. SCHOOL CLINIC A SUMMARY OF CLINICS HELD AT SIXTEEN CITIES Date .... Grades . . . Number present No ventilation of bedroom .... Own a toothbrush Daily use of toothbrush Use of common toothbrush .... Never have been to a dentist . . . Frequent toothache Frequent headache Blurred vision Frequent earache Running ears Frequent sore throat Adenoids Diseased tonsils No form of proteid food for breakfast No fruit for breakfast Daily use of coffee . Adrian May 7 3-8 inc. 95 Luverne May 7 3, 4, 5 44 26 39 10 4 19 9 13 16 6 1 x 6 3 19 40 25 Dawson April 23 3, 4, 5 107 83. Winthrop April 20 2-5 inc. 87 57 82 14 10 x 41 37 19 13 4 5 6 96 Madison April 24 2-5 inc. 119 Benson April 11 4, 5 & 7 113 40 104 15 104 3-5 inc. 91 32 Morris April 8 4&5 22 Granite Falls April 16 April 22 April 18 3&4 4&5 3, 4, 5 65 89 95 X 5 39 57 80 84 22 40 19 X X 2 X X X 17 20 28 13 X 26 7 20 16 16 12 13 3 4 4 6 X X 3 ■ 4 6 4 X X 16 X X 50 X 84 33 40 54 Pipestone Albert Lea 4, 5, 6 114 3 102 22 30 28 37 19 7 36 3, 4, 5 85 65 36 7 3 57 17 8 16 5 x 7 5 17 67 68 3, 4, 5 31 94 37 12 46 91 3, 4, 5 52 31 38 18 3 26 14 13 12 14 Average per cent 37 81 19 9 50 28 25 22 13 3 4 X 15 X 6 X 5 20 33 41 82 40 71 x Blank spaces indicate that the question was not asked, or examination was not made. The percentages in the last column are, of course, estimated on the basis of the number of pupils questioned in each case. CHAPTER VII THE SCHOOL MEDICAL CLINIC Difficulty of getting results from medical inspection Dr. H. H. Hogarth, assistant medical officer of Education for the London County Council, has made an observation in his excellent book on the Medical Inspection of Schools to the truth of which all experi- enced school doctors will assent. "Every school doc- tor," he says, "goes through the same process of reflection and education. At first he enters the school as a novice, recognizing that his duty is to inspect, not to treat ; that his own position is open to attack on the part of his brother practitioners; that he may be inter- fering with the rightful responsibilities of parents. He is so absorbed in the new work, the new ideas; so inter- ested in the children, the educational system, and the teachers, that as soon as he has notified parent and teacher that a child is suffering from some particular disease, leaving them to take whatever further action may be necessary, he considers he has done his part. It is not until he returns a year later that he realizes how completely his advice has been ignored. Then he begins to think." As has already been emphasized, medical inspection in the beginning was little more than inspection. The early New York inspectors found that ninety-four per 110 HEALTH WORK IN THE SCHOOLS cent of their notifications failed to bring results. In England, likewise, where poverty is more widespread than with us, the results were so disappointing as to awaken everybody concerned to a realization of the futility of any system of inspection which takes no steps to ameliorate the evils it discovers. Casting about for means to accomplish this end, school authorities have discovered a number of reme- dies of various degrees of effectiveness. One of these is the system of school nurses, already discussed. An- other remedy, supplementary to school nursing, and of even greater portent for preventive medicine, is the school clinic. What the school clinic is The school clinic is a clinic controlled by the educa- tional authorities, and supported at public expense for the purpose of permitting a more thorough examina- tion, and in some cases also treatment, of defects re- vealed by the routine inspection. In many cities the work of the clinic is confined to the first of these func- tions. The school doctor on his rounds finds children whose condition merits a more thorough diagnosis than can be given in the preliminary and rather superficial survey. The parents of such children are asked to bring them to the clinic for special examination and advice. If grave defectiveness or disease is found, the parents are urged to secure the necessary treatment from the family physician, or in case of extreme pov- erty the school doctor may arrange with local hospitals THE SCHOOL MEDICAL CLINIC 111 or dispensaries for gratuitous service. Clinics for this diagnostic and advisory purpose have everywhere rapidly followed the introduction of medical inspec- tion. In cities above 15,000 or 20,000 population they are fast coming to be looked upon as a standard re- quirement of any system of school medical service. The main purpose of this chapter, however, is to describe a somewhat different type of school clinic, already becoming numerous in England and not un- known in the United States, — a clinic designed to afford more or less treatment as well as diagnosis. Typical school medical clinics of England Dr. Lewis Williams' account * of the school clinic at Bradford, England, gives an excellent idea of the sig- nificance of this new medico-educational institution. Bradford is a manufacturing city of about 300,000 population. The school clinic was opened about two years ago, in the hope that it would make possible the treatment and cure of that large percentage of children who, because of indigence or parental neglect, had received no benefit from the inspection of their defects. The staff consists of three physicians, one dentist, two nurses, and two clerks, all on full time. Treatment is free, except that parents, when able, are required to pay the actual cost of eye-glasses. Although attend- ance is voluntary, objection to treatment is very sel- dom met with. The reason for this lies partly in the absence of expense, but perhaps still more in the psy- 1 See reference 5, at the end of this chapter. 112 HEALTH WORK IN THE SCHOOLS etiological difference between persuading parents to do something and merely securing their consent to have it done. The former violates the principle of human inertia; the latter takes advantage of it. The following table shows what the Bradford clinic accomplished in 1910: — Number treated Defective vision 650 External eye disease 576 t>. f of head 623 Ringworm | ofbody ^ Verminous heads 360 Scabies and impetigo 419 Ear discharge 285 Defective teeth 450 Stammering 150 Infectious disease 1052 Of the 5000 who secured free treatment at the clinic, certainly very few would have received any other atten- tion whatever. Ringworm of the head was treated by the X-ray method, one exposure being sufficient in over 92 per cent of the cases. At a cost of from 30 to 65 cents each, 559 pairs of glasses were supplied. A spe- cial teacher was employed to give breathing exercises and other treatment to stammering children. In 1908, a clinic was opened in the Poplar School, London, organized by Miss Margaret MacMillan and endowed by Mr. Joseph Fels. This is interesting as showing what can be accomplished by a small clinic, drawing its cases from only about 1000 children of a single school. 1 During the two years from December 1 See article by Dr. Tribe, in School Hygiene for May 1911. THE SCHOOL MEDICAL CLINIC 113 1908 to December, 1910, 450 pupils came under treat- ment in this clinic, or nearly half the total enrollment of the school. An analysis of 210 of the 450 cases shows a number of interesting facts. Twenty-three cases were treated daily for ear discharge, until cured. On the average, the number of months required to cure a discharging ear about equaled the number of months the ear had been neglected. The clinic recommended 35 cases of adenoids or enlarged tonsils for operation, and out of this number met only two refusals. Fifty- five children were treated for anaemia or debility, of whom 32 were either cured or distinctly improved. Of the 210 cases analyzed, cure was effected for 94, 21 were improved, 67 were still under treatment when the report was made, 8 had been transferred to a hospital, and 9 had left school. All of this was accomplished with no interference in attendance, and at slight ex- pense. Similar school clinics have been established in Eng- land in many other cities. Cost, equipment and management Hogarth estimates that $7500 will usually suffice to build and equip a clinic for a city of 20,000 population, counting $2500 for equipment and $5000 for building. It should provide five or six rooms, as follows: One large and one small waiting-room, two consulting- rooms (for physician and dentist), a dark room, and a nurse's room. For a large staff more room will be re- quired. The staff should include an oculist, a general 114 HEALTH WOEK IN THE SCHOOLS physician, a dentist, nurses, and assistants. In small cities the staff is usually composed of regular practicing physicians, who receive official appointments to devote from one to three half -days per week to the work. The customary remuneration is about $5 for each half- day of work. Some of the larger clinics, like that of Bradford, employ all the physicians on full time. Dr. Williams thinks full-time employment preferable, wher- ever it is feasible. The physicians become more inter- ested in their work, and come to see more clearly its educational bearings. Another practical advantage of this plan is that it is less likely to create friction between the school physician and local practitioners. When the school physician also engages in practice he is likely to be suspected of using his office to secure patronage for himself. Why free clinics are necessary The policy of free medical and dental clinics sup- ported by public taxation differs in no respect from the universally accepted principle of public education. The latter, in effect, presupposes the former, inasmuch as children with neglected physical defects cannot re- ceive in full the benefits which the school has to offer. It would be folly to permit any a priori social theory to blind us to the essential facts. At the risk of repetition let us review some of the obstacles encountered in the process of education and of medical inspection which have led to such an unfore- seen and radical departure from our ancient moorings. THE SCHOOL MEDICAL CLINIC 115 The most important and common defects and dis- eases revealed by medical inspection are defective vis- ion, discharging ears, adenoids and hypertrophied ton- sils, tuberculosis, enlarged glands, carious teeth, and malnutrition. The purpose of medical inspection being to combat racial degeneracy and to conserve vitality, its sole justification lies in the contribution it makes to this end. This may sound trite, but it is fundamental. The following are illustrations of the difficulties met in the accomplishment of this purpose. Discharging ears, as has been shown, present a con- dition of great seriousness, and need in most cases to have daily attention, such as syringing, washing, etc. Now experience proves that usually parents will not, even when urgently and repeatedly advised by the school doctor or nurse, secure for the child so afflicted the proper medical care. As a rule they lack the knowl- edge of hygiene and medicine which would enable them to appreciate the situation. Others, and these are very numerous, canot afford the services of expert oculists or aurists at current rates, and are reluctant to accept as charity what they have not the means to command. Even when the aurist is consulted for a discharging ear, the tedious treatment which ensues, often lasting many months, is seldom carried out by parents with the needed regularity and carefulness. Physicians find that in most cases it is simply folly to expect a cure by this method. The only assurance of success in this direction is for the child to be taken daily to the physi- cian's office or to the hospital for the necessary treat- 116 HEALTH WORK IN THE SCHOOLS ment. Aside from the question of expense or the preju- dice against charity, it is useless to expect that this will be done. Each visit may consume from two to four hours of time. Whether rich or poor we are too busy and impatient to submit to such a tedious ordeal. The result is that nine tenths of the cases of ear discharge among school children have been neglected. Theorize as we may about the danger of tampering with parental responsibility by the support of school clinics for free treatment, we are confronted by this fact of neglect. With the inauguration of the school clinic the entire problem vanishes. The child goes daily to the near-by clinic, often in the building where he attends school, and receives the necessary treatment at the hands of nurse or doctor. There is no waste of time, no loss of school attendance, and a mere bagatelle of expense. Best of all, the treatment brings cure. Most of the other forms of defectiveness offer, with greater or less variation, the same problems and the same solution. In the case of defective vision, for example, to secure parental action requires, in about 50 per cent of the cases, from two to four home visits by the school nurse. In the case of 15 to 30 per cent, nothing is ever accomplished. Many who respond do so by seeking the inexpert advice of opticians. Now and then a parent buys a pair of ten-cent goggles from a street peddler and thinks that in this sacrifice he has paid due homage to Hygeia. A small minority take their children to a reputable oculist and have them cor- rectly fitted with glasses, at an expense of $5 to $30 THE SCHOOL MEDICAL CLINIC 117 each. Only a very small minority, be it said to the credit of humanity, seek for or permit assistance through laws for relief of the poor. The sum total of results is disappointing, notwithstanding the cost in time and energy. Upon the establishment of the school clinic of the English type the situation is com- pletely changed. When a child is discovered with de- fective vision, instead of hounding the parents with arguments and pleadings, the child is sent to the clinic and is tested for glasses. The clinic even secures for the child necessary lenses and frames at special rates, arranged for by the school authorities with a reliable optician. The cost ranges from 30 to 60 cents, and is met by the parents, if they are able; if not, by the school board. In English cities, such as Bradford, about 80 per cent are paid for by the parents. But the important points are that the eyes actually receive treatment, that the treatment is skillful, and that the cost is inconsiderable. In like manner, enlarged glands, tuberculous ten- dencies, throat occlusions, and many other defects re- quire either more expert or more constant attention than they are likely to receive from the family doctor. The X-ray treatment for ringworm is a good illustra- tion of the efficiency that may be secured by the intro- duction of wholesale methods into medical practice. Only a few practitioners have the equipment for treat- ment; those who have it charge high fees, while the disease is common only among the poor. Left to such a combination of circumstances the disease would flour- 118 HEALTH WORK IN THE SCHOOLS ish indefinitely. The properly equipped school clinic practically eradicates it from a middle-sized city within a few months, and at an expense which is almost neg- ligible. By the old way everything had to be done with a maximum of inconvenience, resistance, and leakage. The chief obstacle always was human inertia, the most characteristic trait of mankind. If the success of any cause is contingent upon a general abandonment of the way of least resistance, that cause is already lost. An issue may have the passive favor of all the people and yet fail of fruitage through neglect. The old system tried to persuade the parents to do something; the school clinic only asks their assent. The school clinic attains the desired results and does it without friction. The opposition to free school clinics The opposition comes chiefly from practising physi- cians, some of whom look with apprehension upon every social movement which seems to point toward an ultimate socialization of their profession. The issue, however, becomes clear if we only remember that dis- ease is to be conceived as an evil to be eradicated, not as a resource to be conserved for the benefit of any profession. Partly by his own fault, and partly for social and economic reasons, the family doctor has failed to keep the people well. The family doctor insti- tution need not be abolished, but it must be supple- mented. What it has not done at all, or what it has done only with huge waste of effort, presents a legiti- THE SCHOOL MEDICAL CLINIC 119 mate field for organized social endeavors. There is no likelihood that any considerable portion of physicians will oppose the general introduction of the school clinic, though organizations like the League for Med- ical Freedom may be expected to do so most vigor- ously. A committee of physicians commissioned by the local medical association to inquire into the bearing of the Bradford clinic upon private medical practice reported as follows: "Your committee consider that the school clinic as carried on at Bradford has not hitherto proved detrimental to the interests of practi- tioners of that district." ! What the school clinic ac- complishes is pure gain. To protect the health of children is a social obligation It is hardly necessary, interesting as it would be, to speculate upon the final outcome of the school clinic. Whether it will lead to the complete socialization of medicine and dentistry, just as education has been socialized, is a question it is impossible to answer. It is certain, however, that social regulation and control over matters pertaining to the health of children will be extended in the future rather than limited. Intrin- sically there is nothing more radical in the principle of free medical and dental treatment than in the Ameri- can scheme of public education and free textbooks. From the beginning the cry about weakening parental 1 Quoted by Dr. Lewis Williams in his article on " School Clinics, " in School Hygiene for March, 1911. 120 HEALTH WORK IN THE SCHOOLS responsibility has been raised against both. Gradually we are learning that it is less a question of parental responsibility than of children's rights. Private enter- prise has done too little for the health of our children to justify any claim to a monopoly of the business. It matters little what social procedure we adopt to insure that our children grow as nearly as may be into their full heritage of health and strength, as long as the end is accomplished. Least of all need we prematurely be frightened by the specter of socialism. To protect the bodies of children from defective development is not a question of socialism, but of humanity and of common sense. The school clinic is effective from the mere fact that it is an integral part of the educational machinery. It works in the closest relations with teachers, attendance officers, and nurses. The presumption is all in favor of the child. His case will be watched from day to day. The more it comes under the observation of the school physician, the greater is the probability that needed modifications of the curriculum will be made. In the words of Dr. Lewis Williams, "inasmuch as those very diseases which chiefly affect school children and play such havoc with school efficiency and school attend- ance are the very ones most neglected by parents in spite of medical inspection, the school clinic plainly becomes the only method of dealing with the diffi- culty." As forcibly stated by Hogarth, "to secure an improved physical condition for the next generation, to obtain a higher standard both of school attendance THE SCHOOL MEDICAL CLINIC 121 and of education, to give a fair chance to thousands who are now hopelessly handicapped before the race is well begun, are aims which cannot be lightly set aside." Summary We may summarize the benefits of the school clinic as follows : — (1) It gives opportunity for a more thorough exam- ination of serious or puzzling cases than is possible in the ordinary routine of medical inspection. This bene- fit is derived from all school clinics and has no neces- sary connection with any scheme of free treatment. (2) It is the function of the school clinic to render the final decision in regard to segregations in open-air schools, special classes for the deaf and dumb, or schools for mentally defective children. (3) The bacteriological department of the school clinic regulates authoritatively and conveniently exclusions for contagious disease, and readmissions upon recovery. A certificate of freedom from contag- ion issued by the practising physician is often worth- less. The latter may have neither the bacteriological training nor the laboratory equipment to enable him to make scientific determinations of the presence or absence of pathogenic bacteria. Hogarth found that out of 240 certificates, issued by Bradford physicians, of freedom from scabies (itch), 234 were incorrect. (4) The school clinic alone is in position to maintain the close relations with the school and with the indi- vidual pupils which will insure the constant attention 122 HEALTH WORK IN THE SCHOOLS necessary to the successful treatment of chronic de- fects. This is especially true of discharging ears, mal- nutrition, tuberculosis, etc. (5) In all lines of defectiveness the English type of school clinic brings results which it has not been pos- sible to secure by any other means. Through its work, eye defects are corrected, discharging ears are cured, adenoids are removed, teeth are repaired, verminous conditions are eradicated. The logical issue of diagno- sis is adequate and skillful treatment. This is what the school clinic insures. (6) The introduction of systematic and wholesale methods in preventive medicine, and the consequent saving of time, energy, and equipment, puts the whole matter upon a different economic basis. Adenoid oper- ations, eyeglasses, X-ray treatment of ringworm, and the like, are reduced to a small fraction of their former cost. Vaccinations by the school physician at the rate of twenty-five cents per child are just as effective as when performed by the practitioner for two dollars. 1 (7) The school clinic should not be conducted as a semi-charitable institution. The practice of restricting treatment to such cases as have been investigated and recommended by local charity organizations is inde- fensible. To make a certificate of indigency the badge of admission is to brand those who accept its benefits 1 Under the recent state law of compulsory vaccination at private expense Californians have been compelled to expend annually for vaccinations alone an amount of money large enough to support an efficient system of medical inspection for half the schools of the State. THE SCHOOL MEDICAL CLINIC 123 with the stigma of pauperism. In protecting the lives and fostering the health of children it must be remem- bered that we are not conferring a charity, but per- forming a duty. (8) All the stock arguments against the operation of school clinics prove on examination to be untenable. To oppose the principle on which the institution rests is to deny the right and duty of society to engage in organized effort to conserve the raw material of the coming State. (9) The school clinic affords to the school doctor much-needed relief from the monotony of routine inspection. The importance of this point cannot easily be overestimated. Experience proves that after the novelty has worn off the work of inspection, the physi- cian is almost sure to become restless and discontented. He feels that he is not making any professional growth, as, indeed, is too likely to be true, considering the limi- tations and restrictions of his duties. Permission to give treatment both broadens his professional outlook and satisfies a legitimate and natural desire to accom- plish objective results. (10) The school clinic should be enlarged to include a psychological branch, in addition to the medical and dental work. REFERENCES *1. Crowley, Dr. R. H.: The Hygiene of School Life. 1910, pp. 167- 83. 2. Elder, Dr. M.: "The Deptford School Clinic." School Hygiene, 1911, pp. 580-88. *3. Terman, Lewis M.: "School Clinics, Dental and Medical." The Psychological Clinic, 1912, pp. 271-78. 124 HEALTH WORK IN THE SCHOOLS 4. Tribe, Dr. R.: "Results of Treatment at the Poplar School Clinic (London.") School Hygiene, May, 1911. *5. Williams, Dr. Lewis : " School Clinics. " In Kelynack's Medical Inspection of Schools and Scholars, 1910, chapter xin, pp. 218- 31. 6. Williams, Dr. Lewis: "School Clinics." School Hygiene, March, 1911. CHAPTER VIII SCHOOL DENTISTRY Historical School dentistry had its beginning in Strassburg, Germany, in 1902. The undertaking was due entirely to the enthusiastic efforts of Dr. Ernst Jessen, whose name therefore deserves an honored place in the his- tory of school hygiene. The Strassburg clinic is sup- ported at public expense, and is open without charge to the school children of the city, rich and poor. Al- though attendance upon the clinic is entirely volun- tary, the patronage has been very gratifying, as the following table will show. TABLE III No. treated No. available for treatment Total cost. 1st year 2d " 3d " 4th " 2666 4967 6828 7491 17,119 17,054 18,073 18,607 $1355.00 1685.00 2135.00 2250.00 At first, more than half of those who offered them- selves for treatment were impelled by toothache, but the number coming for other purposes rapidly in- creased. A pupil seldom refuses to attend, when urged by the teacher. Results were evident from the beginning. After the repair of their teeth many children improved in health, 126 HEALTH WORK IN THE SCHOOLS absence from school noticeably decreased, and in some cases discipline became easier. In Strassburg the clinic has the loyal support of the teachers, medical in- spectors, and a large majority of the parents. One of its most valuable results is the influence it exerts as a con- stant object lesson in hygiene to both pupil and parent. Before long the school authorities at Strassburg were overwhelmed with inquiries from every part of the world. By 1907, thirty-three cities and towns in Ger- many had instituted school dental clinics, and by 1909 the number was about fifty. They are now quite gen- eral in the larger cities, and traveling clinics for rural schools are coming to be popular. In the smaller cities there are usually two or three school dentists, working on part-time. Wiesbaden, with 8000 school children, has six. Other cities, taking Strassburg for their model, employ full-time dentists, and admit them to pension rights on the same footing as teachers. The cost for salaries, materials, and up-keep of clinics is sometimes met entirely by public taxation, and sometimes in part by private philanthropy; but in either case the treatment is free to the pupil. The per capita expense in Germany is ridiculously small. As shown by the above table, the cost in Strassburg is less than twenty-five cents a year for each child treated. Of forty-nine cities reporting in 1909, the cost per child was greater than this in only four. 1 1 Other cities in Germany, such as Mannheim, Stuttgart, etc., prefer to send the child to a private dentist of his own choice and to SCHOOL DENTISTRY 127 In England, school dentistry has had a rapid devel- opment, though the sentiment there is less favorable to the free treatment of children whose parents can afford to pay. The Cambridge Dental Institute for Children, one of the best known of England's school clinics, was organized in 1907 at private expense, and was taken over after two years by the Borough Coun- cil. Before the work began in 1908, the average num- ber of unfilled carious teeth per Cambridge child was 1, 2, 3, and 4 for the ages 6, 7, 8, and 9 respectively. After three years the number had fallen to .3, .6, 1.5, and 1.6 for the same ages. In 1908, 24 per cent of the children accepted treatment; in 1909, 25 per cent; and in 1910, 39 per cent. By this time 72 per cent of the children had sound, or artificially sound, teeth; before the work began, only 33 per cent. Of those urged to take treatment the first year, and refusing, 40 per cent accepted treatment later. 1 The greatest problem in Cambridge has been to get parents to bring the chil- dren, even though the treatment is absolutely free. Experience in other English cities proves that even a nominal charge dooms the school dental clinic to failure. One point in the Cambridge plan deserves special mention; namely, the concentration of effort upon the younger children. When the funds available are inade- quate to the task of putting in order the teeth of all the children, the Cambridge plan insures the greatest good pay the expense of the dental work done, rather than to employ a school dentist. Of course it matters little who does the work so long as it is really done. 1 See Wallis, School Dental Clinics. (Reference 6.) 128 HEALTH WORK IN THE SCHOOLS to the greatest number. The average cost of keeping a child's teeth in repair throughout its school life, begin- ning with the first year, is probably less than the aver- age cost of one treatment for the older child whose teeth have been neglected, and the good accomplished is proportionately greater. When this is done with every entering class the total expense involved is not large, and the teeth may thereafter be easily kept in satisfactory condition with but slight annual repairs. 1 In the United States, dental clinics have been estab- lished in New York, Chicago, Philadelphia, Cleveland, Los Angeles, and in nearly all of the other large cities. Many of the smaller cities are following the example. Boston is fortunate in the establishment of the For- syth Dental Infirmary, made possible by the generos- ity of John Hamilton and Thomas Forsyth. The insti- tution is housed in a magnificent building and is en- dowed with $1,000,000 for maintenance. The gift is entirely for the benefit of Boston children under the age of sixteen years. Practical instruction in mouth hygiene is given, a dental museum is supported, and a room is available for public lectures. The institution also supports a research fellowship for the investiga- tion of dental diseases. Dental clinics should be free For the most part, the school clinic in the United States is conducted for the benefit of indigent, or semi- 1 The same plan is being followed in West Newton, Massachu- setts. SCHOOL DENTISTRY 129 indigent, children. It is frankly a charitable institu- tion, belonging in the same category as orphanages, poorhouses, etc. It is also different in that much of the dental service is rendered gratuitously by local dental associations. In those cases where the dentist receives pay for his school work the expense is usually borne by charitable organizations, and not by the school. The objections urged against the public support of free dental clinics are the same as those urged against school feeding, and precisely the same as those urged a few generations ago against free public schools: namely, that the people would be pauperized, that parental responsibility would be lessened, and that the income of private practitioners would be jeopardized. Experi- ence proves that the first two objections are ground- less. Parental responsibility is created rather than destroyed, and pauperization is no more caused by free school dentistry than by free textbooks and tui- tion. It is not even probable that the income of private dentists would be sensibly affected. The universal care of children's teeth in the schools would soon make the dentist habit universal, so that in a few years all persons beyond school age would be patrons of the private dentist, instead of the present 10 or 15 per cent. Moreover, many of the wealthier classes who now pa- tronize private dentists for their children would con- tinue to do so, even if free school clinics were estab- lished. The larger part of the work which is done by the free dental clinic would otherwise not be done at all. The good it accomplishes is clear gain. 130 HEALTH WORK IN THE SCHOOLS Anyway, it is the welfare of the child which is sought, not the aggrandizement of a profession. By the whole- sale methods used in the schools, the cost of dentistry is reduced to about one third of what it would amount to if done by private dentists. There is no reason why society should neglect the teeth of children in the inter- ests of private dentists, any more than it should yield up their bodies in the interest of the private manufac- turer who fattens on child labor. We seem, indeed, to be on the eve of a great dental crusade, — a crusade which promises to make the public-school dentist as familiar a personage as the superintendent himself, and fully as indispensable. There is no alternative to the German method. In order to expedite his work, the school dentist stands in need of an assistant, just as the school doctor must have his nurses. Laws need to be enacted legal- izing the profession of the school dental nurse. The dental nurse, on proper certification, by examination or otherwise, would be permitted to examine teeth in the schools, clean them, and apply local treatment to allay pain. A large share of the school dentist's time would thus be saved. Preventing dental decay At least 80 per cent of the children in our schools have seriously defective teeth. In the upper grades, to be sure, many of these dental disabilities have been repaired. But a repaired tooth, after all, is only a makeshift. It is always in danger of a functional or organic breakdown. 69 a Orthodontia restores the jaw to normal Teeth like these can be made straight. CROOKED TEETH SCHOOL DENTISTRY 131 Modern dentistry is preventive in nature, and teaches that teeth need not necessarily decay at all. With a few exceptions, such as those found in certain cases of general faulty development, or conditions re- sulting from acute diseases, teeth may be kept from decay by the simple device of keeping them clean. The toothbrush cannot be relied on for this purpose. Not over twenty children out of a hundred use a tooth- brush with needed regularity, and hardly any of these know how to use it correctly. Most of them brush with a crosswise stroke instead of with an up-and-down motion. Even when correctly used the brush does not insure that every part of the tooth surface, inner as well as outer, will be kept clean. The latest and best method of insuring complete cleanliness, and thus guarding against decay is as follows: — As soon as the child has cut his first set of teeth, an attempt is made to remove placque formation as rap- idly as it occurs. Placques are deposits in and under which acid-forming bacteria find lodgment. Decay of teeth is due primarily to those bacteria of the mouth which produce lactic acid. This decay takes place under the placques. Consequently prompt removal of this deposit insures the teeth against decay. To detect the placques, which are often invisible to the eye or even the touch, the teeth are swabbed with a "disclos- ing solution" made of the tincture of iodine and a little glycerine. After the teeth are washed with water, the solution leaves the placques stained brown, while the rest of the tooth remains white. The brown spots or 132 HEALTH WOEK IN THE SCHOOLS placques are now rubbed with a moist silica prepara- tion, and dental ribbon which is treated with the same material is run between the teeth. This procedure repeated about twice a month keeps the teeth relatively free from placques. It is necessary, however, to visit the dentist at least every six months for a more thorough treatment than can be given by the parent at home. This method followed conscien- tiously will prevent decay, give the enamel a beautiful luster and save at least seventy-five per cent of the usual expense for dental repairs. At best, dental repair is a purely mechanical process which gives evidence to the world of previous dental neglect. In only a restricted sense is it a hygienic mea- sure. The method just described, combined with the proper care of the gums and surface of the tongue, as- sures a degree of oral cleanliness which defies the as- saults of the bacteria of the mouth. REFERENCES » 1. Jessen, Dr. Ernst: Die Zahnpflege in der Schule vom Standpunkt des Aerztes. 1909, pp. 67. 2. Jessen, Dr. Ernst: " Schulzahnpflege u. Schule." Proc. 2nd Inter. Cong. Sch. Hyg., 1907, pp. 495-502. 3. Jessen, Dr. Ernst: "Kostenpunkt einer Stadtischen Schulzahn- klinik." Inter. Mag. Sch. Hyg., vol. iv, 1908, pp. 432-36. 4. Jessen, Dr. Ernst : " Die Zahnarztliche Behandlung der Volkschul- kinder." Inter. Mag. Sch. Hyg., 1907, pp. 205-22. 5. Schlegel, Dr.: "The Reading (Pa.) Free Dental Dispensary." Psych. Clinic, February, 1910. 6. Wallis, C. E.: School Dental Clinics: Their Foundation and Man- agement. London, 1913. 7. Wimmenauer, Dr.: "Schularzte u. Schulzahnhygiene. " Zt f. Schulges., 1911, pp. 882-93. 1 On problems relating to the growth and care of children's teeth see Lewis M. Tennan's, The Hygiene of the School Child, chapter xi. Houghton Mifflin Co., 1914. CHAPTER IX TRANSMISSIBLE DISEASES The mortality in the United States from measles, scarlet fever, whooping-cough, and diphtheria amounts every year to more than twice the loss of life on the field of Gettysburg. On the basis of the knowledge which we now have regarding the causes of these dis- eases and the modes of their transmission, probably more than half of this loss should be looked upon as absolutely preventable. The annual needless mortal- ity from this cause, therefore, exceeds the slaughter in most of the bloodiest battles of the world's history. Thousands of other deaths result from complications following children's transmissible diseases. The school as a factor in the spread of contagious diseases For some of this loss the school is directly respon- sible, particularly in the case of measles and diphtheria. Statistics collected from many parts of the world have established this beyond doubt. When society forcibly brings children together in the public school it is mor- ally responsible for the sickness and deaths which result from such compulsory contact. Thus Korosi found that for a large number of Ger- man cities, taken together, the average number of cases of measles per month, over a period of eighteen 134 HEALTH WORK IN THE SCHOOLS years, was less than one sixth as great during vacation as for the school months. Dr. Schaefer found similar differences for Hamburg, though the vacation decrease for scarlet fever and diphtheria was much less marked than for measles. In Chicago, for the two years 1899 and 1900, the average monthly frequency of both scar- let fever and diphtheria was more than twice as great during the school months as in vacation. The following curve shows the average monthly mortality from measles in the city of London for the Jan. Feb. Mar. Apr. May. Jun. Jul. Aug. Sep. Oct. N*ov. Dee. 60 55 50 45 40 35 30 25 20 15 10 5 FIG. 3 Weekly average of deaths from measles in London, England, summed up for ten years, 1900-1910. See influence of vacation. (Fairfield.) O o © 8 r-C •«= •c — — ' As "**, ^ ^ 1- 35 i s S s s a a . — 8 -A s a 3 o -t* 136 HEALTH WORK IN THE SCHOOLS years 1900 to 1910, averaged together. Attention is called to the marked influence of even the short vaca- tion there given. Fig. 4 shows a similar influence of the school on the prevalence of diphtheria in Halle, Germany, for the years 1906 to 1912 taken together. The school as a means of controlling contagious diseases However, in spite of the dangers which the school involves for the spread of contagious diseases, it affords at the same time unexcelled opportunity for their con- trol and prevention. Everywhere the medical super- vision of schools has accomplished much in this way. In the year 1906-07 medical inspectors discovered the following cases of contagious diseases in the public schools of Massachusetts : — TABLE IV Diphtheria 238 Scarlet fever 313 Measles 637 Whooping-cough 973 Mumps 367 Chickenpox 548 Influenza 276 Syphilis 36 Tuberculosis 115 Scabies (itch) 1054 Pediculosis (head lice) 7691 Impetigo 1568 Conjunctivitis 779 Ringworm 715 Other skin diseases, mostly contagious 1170 TRANSMISSIBLE DISEASES 137 These cases were all discovered among children present at school, and their immediate exclusion must have prevented a vast number of infections otherwise inevitable. Since medical inspection was instituted in Boston, diphtheria in that city has decreased 65 per cent and scarlet fever 15 per cent, and both are now less com- mon in school months than during vacation. In other words, by vigilance the school department of hygiene can more than offset the increased danger of epidemics incident to school attendance. When we remember that 90 per cent of all deaths from these diseases occur before the age of 10 years, the importance of their prompt and efficient control through the school ma- chinery readily becomes apparent. Our ideas on the transmissible diseases of children are rapidly changing. Instead of waiting for these dis- eases to make their appearance, we now attempt to dis- cover those conditions which favor them, in order that we may remove the soil most favorable to their growth and dissemination. 'Newer ideas about modes of infection Recent studies of the contagious diseases of child- hood have brought about a radical change in our view- point in regard to their modes of infection. In the past it was the custom of both school people and medical officers to concentrate their attention upon the various objects (fomites) which had been in rather close con- tact with the sick person, as the probable sources of 138 HEALTH WORK IN THE SCHOOLS infection. Within the meaning of this term were in- cluded a great many articles, such as bedding, books, toys, clothing, furniture, letters, desks, pencils, money, etc. At present the best informed medical men are paying less attention to fomite infection, and more to infection through personal contact. In other words, attention is now being fixed on 'persons rather than things as the sources of infection. Modern bacteriological investiga- tions have pretty conclusively demonstrated that in the majority of instances diseases are spread directly from one individual to another, rather than through an intermediate object of some sort. With the old theory of fomite infection, a great amount of time, energy, and money was expended on methods of disinfection, all to very little purpose. To-day far more efficient results are obtained by discovering, isolating, and con- trolling the individual carrier of the disease. Trans- missible diseases are, of course, transmitted only by means of living, active, micro-organisms of some sort. We are fast learning that these living organisms, or germs, which are either plant or animal in nature, cannot ordinarily live long outside of their particu- lar host. For this reason we believe less to-day than formerly in dust infection, air infection, book infection, infection through clothing and the like. Danger of the common cup, common towel, etc. Contact infection is undoubtedly the commonest and by far the most certain mode of infection. But TRANSMISSIBLE DISEASES 139 contact infection does not exclude infection by means of various objects which may carry fresh material from the infected individual. Thus, diphtheria germs may easily be carried from the mouth of a sick child to the mouth of a well one by means of a pencil, provided the pencil has very recently been in the mouth of the child ill with diphtheria. Similarly a handkerchief used in common by a well child and one sick with measles easily carries the infection to the well child. What is said in this connection is not to be construed as a vindication of the common drinking-cup, which is always dangerous. Davison, who made bacteriological examinations of a large number of public drinking-cups, found that nearly all harbored dangerous germs, and that 37.5 per cent bore the tubercule bacilli. Bensel's experiment of allowing diphtheria patients to drink once from a glass sterilized for the purpose demon- strated that germs of the disease were deposited in from 25 to 40 per cent of the cases. Measles, scarlet fever, whooping-cough, tuberculosis, and syphilis are known to be transmitted frequently in this way. The common drinking-cup in public places has been legislated out of existence in more than a dozen States since Kansas set the example in 1909. By 1911, more than forty rail- roads in the United States had substituted individual cups. 1 The common cup and the common towel will both have to go. The best substitute for the former is a 1 Common drinking-cups on inter-state trains were prohibited by federal regulation in 1912. 140 HEALTH WORK IN THE SCHOOLS rightly constructed drinking-fountain, of which several are on the market. Individual cups are usually not kept clean, and are too often "borrowed." The com- mon towel should be replaced by absorbent paper tow- els, which are used once and then discarded. It has been shown also that books are capable of transmitting diseases, though the likelihood of their doing so has probably been exaggerated. At any rate, guinea-pigs have been inoculated with tuberculosis and other diseases by preparations made from library books. The danger from this source is probably suffi- cient to justify city boards of health in making daily reports on contagious diseases to public libraries, and books known to have been recently used by infected persons should be disinfected by the moist, hot air method. This requires exposure of the books for about thirty-two hours in an atmosphere of 80° C. (176° F.) and 30 to 40 per cent humidity. The method is said not to be injurious to the most delicate book. The modes of transmission just mentioned are in reality to be classed with contact infections. What is meant, then, by contact infection is contact with the virile specific germ of the disease, either directly through the patient or indirectly by means of an object which carries fresh material from the patient. It is not denied that infection by air or by fomites does some- times occur, but the evidence to-day is all against these modes in the great majority of cases. TRANSMISSIBLE DISEASES 141 Air not a common source of infection It is not unnatural that air should have been so long considered one of the chief vehicles of infection, for it has been relatively few years since the germ principle of disease was discovered. Chapin says, "Until this germ idea was well established as a fact, the infective material was supposed to emanate from the surface of the body and from moist soil and decomposing matter of all kinds. Contagious diseases were known to arise without any apparent connection with other cases, and what could be more natural than to assume that the invisible, imponderable materies morbi is mixed with and carried by air? " Even to-day one finds some educated, as well as many ignorant, individuals and some entire communities believing that stagnant pools of water breed typhoid, that "sewer gas" may give rise to diphtheria, that drafts of air may cause pneu- monia, that air from marshes gives rise to malaria, etc. These and many similar delusions persist, despite the fact that we now possess abundant evidence to the con- trary. While it is possible that air may at times carry the germs of some diseases, it is now acknowledged by those most entitled to an opinion that air does not often carry germs in a condition capable of producing infection. That diseases are often spread in street- cars, trains, churches, schools, theaters, and other crowded places is, of course, a matter of common knowledge and experience; but these instances are sat- isfactorily explained by the fact that a large number of 142 HEALTH WORK IN THE SCHOOLS individuals are here associated in close personal con- tact. It is easy under such conditions for infection to spread from one individual to another by means of the fine spray produced by coughing, sneezing, laughing, and the like. Isolation of "carriers" versus school closing The practical abandonment of the old idea of fomite and air infection, except in rather rare and exceptional instances, has resulted in an entire change of procedure in respect to the control of contagious diseases in schools. The time-honored method of closing and dis- infecting a school during an epidemic of measles or diphtheria is based on the theory of fomite and air infection in the school. This habit, still in practice in most places, results in loss of school time and expense to the school department. Worse still, many infected pupils are allowed to play about the streets among well children, and thus constantly spread the infection. The modern practice, which gives far better results, is to isolate the sick children and those believed most likely to be capable of carrying infection, while the school is kept in operation. It is now well understood that individuals who are not themselves sick may often carry the germs of cer- tain diseases in their bodies. This is true of diphtheria, typhoid fever, meningitis, pneumonia, influenza, tuber- culosis, and probably of scarlet fever, measles, whoop- ing-cough, mumps, and some other diseases. Such persons as carry in their bodies the germs of a dis- TRANSMISSIBLE DISEASES 143 ease without themselves being sick, are known as "carriers." Dr. Chapin has remarked that probably the most important discovery bearing on preventive medicine, since the demonstration of the bacterial origin of dis- ease, is that disease germs frequently invade the body without causing disease. Where the throats of school children have been examined by the culture method during an epidemic of diphtheria, from 10 to 40 per cent of apparently well pupils have often been dis- covered who were carrying diphtheria bacilli in their throats, and were quite capable of giving the disease to others. In an epidemic of diphtheria which occurred in Berkeley, California, in 1906, Dr. George F. Reinhardt found 25 per cent of the well pupils to be carriers. Prompt isolation of both the sick pupils and the car- riers resulted in the control of the epidemic. Of 4526 contact cases among wage-earners, exam- ined in Providence, Rhode Island, during a diphtheria epidemic, 14.4 per cent were found to have the diph- theria bacilli present in their throats. It was signifi- cant in this instance that women were infected much oftener than men; the explanation being that women are in more constant and intimate contact with sick children than men are. The subject of contact infection cannot be dismissed without reference to atypical cases of transmissible diseases. Formerly it was supposed that most if not all diseases exhibited definite, characteristic symp- toms, and that mild atypical cases either did not exist, 144 HEALTH WORK IN THE SCHOOLS or occurred infrequently. Now we know that many such atypical cases occur, and that, because of the fact that they often pass unrecognized, these cases are frequent sources of epidemics. Many such atypical cases have been observed in diphtheria, influenza, scar- let fever, smallpox, and typhoid fever, and there is an evidence of such cases in most other infectious diseases. The problem to-day is as much one of discovering mild, atypical diseases and carriers of diseases as of locating the ordinary cases. With the recognition of all or most of these carriers and atypical cases the con- trol of epidemics becomes a relatively simple matter. As long as mild, unrecognizable cases and carriers are allowed to go about freely, no possible good can result from the closing of schools. With the recognition and isolation of these cases, the closing of a school (with few or no exceptions) is not only unnecessary but posi- tively undesirable and even harmful, for the unrecog- nized, mild, atypical cases and carriers may then freely spread disease among other children. In epidemics of infantile paralysis, epidemic menin- gitis, and possibly a few other diseases, it may occas- ionally still be necessary to resort to the closing of schools, but if this procedure is unaccompanied by isolation of the exposed as well as the sick it can result in little good. As regards smallpox the prompt vaccin- ation of all unvaccinated children during the earliest days of an epidemic offers so perfect a protection to the well that closure of schools becomes an entirely unnec- essary and even harmful procedure. TRANSMISSIBLE DISEASES 145 Ages at which transmissible diseases most often occur It is most important for schools to make accurate collections of data in respect to transmissible diseases, and to exhibit this so far as possible in a graphic form by means of charts and the plotting of curves. By this FIG. 5 Curve indicating average seasonal occurrence of all children's diseases in the Berkeley Schools for the years 1906-1910. Note that the curve reaches its height in March. method, information can be instantly grasped and the problem of control can be more easily solved. The value of this procedure will be evident from the follow- ing study, made in the schools of Berkeley, California. 1 A simple but instructive curve plotted from the average monthly reports of all transmissible diseases in Berkeley from 190G to 1910 shows that the curve 1 Hoag and Hall, "A Preliminary Report on Contagious Diseases in Schools." Bulletin, American Academy of Medicine, 1911. 146 HEALTH WORK IN THE SCHOOLS reaches its maximum in March. This clearly indicates, then, that March is the sick month of the year in this community. This period is coincident with the worst weather, when windows at home and at school are kept closed and pupils are at the same time in close personal association with one another and thus offer abundant opportunity for direct infection by contact. Plotting a combined age-curve for chickenpox, diph- theria, mumps, measles, scarlet fever, whooping-cough, typhoid, and tuberculosis, it appeared that 42 per cent of the diseases occur between the ages of 5 and 10 years, and only 16 per cent between the ages of 10 and 15 years; 79 per cent occur between birth and 15 years; only 13 per cent after 20 years. In other words, 68 per cent of the diseases in question occur in children of school age. Another 21 per cent occur in children too young to attend school. Of the reported cases of measles, 28 per cent occur under 5 years; 48 per cent between 5 and 10 years; 13 per cent between 10 and 15 years; or a total of 89 per cent under 15 years. With mumps, only 6 per cent of the cases oc- cur under 5 years; but 50 per cent occur between 5 and 10 years, and 26 per cent between 10 and 15 years. In chickenpox, 61 per cent occur between 5 and 10 years, and 14 per cent under five years; while 18 per cent occur between 10 and 15 years, and only 7 per cent occur after 15 years. In scarlet fever, 40 per cent occur between 5 and 10 TRANSMISSIBLE DISEASES 147 years, 28 per cent between 10 and 15 years, and 15 per cent under 5 years. Diphtheria gives 23 per cent for children under 5 years, 35 per cent from 5 to 10 years, and 18 per cent from 10 to 15 years, the cases rapidly diminishing from this age on. In whooping-cough we get a different sort of result, as 52 per cent occur under 5 years of age, 39 per cent between 5 and 10, and only 5 per cent after 15 years. Typhoid exhibits no claim as a children's disease, as only 11 per cent occur under 10 years of age, and only 3 per cent are reported in children under 5 years. In respect to tuberculosis, very few cases were re- ported among children; but we must remember in this connection that many latent general cases as well as some glandular and bone cases often fail to be re- ported. CHAPTER X TRANSMISSIBLE DISEASES (Continued) 1 The most frequent diseases of children of school age are: — 1. Measles. 2. Scarlet fever. 3. Diphtheria. 4. Whooping-cough. 5. Mumps. 6. Chickenpox. 7. Smallpox. 8. Tuberculosis. 9. Hookworm disease. 10. Infantile paralysis. 11. Epidemic meningitis. 12. Eye diseases. 13. Skin diseases. These diseases will be discussed in the order named, and such symptoms and complications will be given as will be useful to the non-medical reader. Further details concerning the transmissible dis- eases of children may always be obtained in a useful form from the various state boards of health, as well as from the city boards of health of the larger places. Some of these the reader ought to procure on account of their practical descriptions and their readily applic- 1 The writers acknowledge their debt, in the preparation of this section, to Dr. James Kerr's Transmissible Diseases. TRANSMISSIBLE DISEASES 149 able methods to school needs. The following Boards of Health publish particularly important and interesting bulletins and reports : — California State Board of Health — Sacramento. Minnesota State Board of Health — St. Paul. Indiana State Board of Health — Indianapolis. North Carolina State Board of Health — Raleigh. Michigan State Board of Health — Jackson. New York State Board of Health — Albany. 1. Measles Measles is the most infectious disease of childhood, as well as the commonest. Practically every child who is exposed takes it the first time of exposure. It is most common during the first five years of life, but is often contracted between five and fifteen years, and occas- ionally during adult life. It rather rarely occurs during the first six months of life, but occasionally infection takes place before birth when the mother is suffering with the disease. While measles is not ordinarily regarded by the pub- lic as a serious disease, yet it is safe to say that it has a general mortality of not less than 4 per cent. Under bad hygienic conditions this mortality is often higher and may reach 10 to 40 per cent, while under very favorable conditions the percentage may be very low. The highest death rate is reached in the first and second years of life. In Aberdeen, Scotland, the statistics for twenty years show that of children under 3 years contracting measles 1 in 12 died, while the average rate for children 150 HEALTH WOEK IN THE SCHOOLS over 3 was 1 death in 120 cases. The mortality was highest in the second year, 1 in 9. The importance of postponing the disease is, therefore, obvious. An epi- demic of measles in the kindergarten or lower grades should always be regarded with apprehension. The mortality from measles is always higher in cases in which other diseases exist, such as tuberculosis, syphilis, general malnutrition, etc. Complications. The mortality and serious morbidity of measles are not usually due to the toxins of the dis- ease itself, but to complications accompanying the dis- ease. The most important complications are those which affect the respiratory organs, such as bronchitis, broncho-pneumonia, and tuberculosis. Other less seri- ous complications are those of the eyes, ears, nose, and throat. After effects. The most serious after-effect of measles is tuberculosis. This occurs in a considerable number of cases, and for this reason the child should always receive the best possible hygienic care after recovery from the acute stages. Symptoms. Those who are intimately concerned with children ought to be familiar with the com- mon symptoms of children's diseases. The following are the usual and most evident indications of measles: — 1. Catarrh of eyes, nose, throat. The child seems to have a cold. 2. General lassitude. 3. Fever. 4. Eruption. TRANSMISSIBLE DISEASES 151 The child usually begins to sneeze and blow his nose; his eyes soon become red and watery; often there is considerable cough; sometimes there is a chill; bluish- white spots surrounded by a red area are usually seen on the mucous membrane of the mouth, opposite the double teeth. These spots make their appearance be- fore the rash comes out. The rash usually shows about the fourth day of the disease, and begins on the face, neck, and head most frequently, and soon extends to the trunk, arms, and legs. The eruption begins as pa- pules, or small reddish spots, occurring in groups which have tendency to form irregular crescents. The papules do not form vesicles (small blisters), or pustules. Prevention. The great infectivity of measles, and the fact that it is most infectious before it can be easily recognized, make its prevention a matter of extreme difficulty. While compulsory notification cannot have the results which have been obtained with other infec- tious fevers, with our modern methods of medical inspection in schools much good ought to be accom- plished. Closure of schools has been found a very unsatisfac- tory method, and is productive of an enormous waste of school time. To secure a really efficient method of protection it will be necessary for the medical officers of schools to acquire an accurate knowledge of the health history of the school children. This may be ac- complished by keeping a list of all the diseases which the children have had. Provision should be made for this on the child's "Physical Record Card." 152 HEALTH WORK IN THE SCHOOLS If during an outbreak of measles it is discovered that certain children have already had the disease, they need not be excluded from school. When a case of measles occurs in a class, all children who have not had the disease should be at once excluded. Rules on this point have been formulated for the London County Council, by Dr. Thomas, as follows: — (a) A child attending other than an infant school, who has already had measles, need not be excluded. (6) A child attending other than an infant school, who has not had measles, must be excluded until the Monday follow- ing the expiration of fourteen days from the occurrence of the first case. (c) A child attending an infant school, whether or not it has measles, is excluded for the same period. Disinfection. Disinfection of rooms at school or at home, as ordinarily carried out, probably has little or no effect, and is consequently a loss of time, energy, and money. Ordinary airing and cleaning will accom- plish all that is necessary, especially if the rooms are exposed to bright sunlight. Bedclothing and personal clothing should be thoroughly washed and aired. Willful exposure. Children should be protected as long as possible against infection with measles. It must not be forgotten that in any case, whether young or old, complications, such as tuberculosis, pneumonia, meningitis, ear disease, and eye troubles, may occur. The individual who willfully exposes a child to measles (a procedure which is far from infrequent) is guilty of criminal ignorance. TRANSMISSIBLE DISEASES 153 2. Scarlet Fever Scarlet fever is one of the most serious of the diseases which affect children, and its after effects are particu- larly to be dreaded. It occurs at all seasons, but in epi- demic form is most likely to occur during the fall and winter months. Very little is known concerning the relation of tem- perature and climate to this disease, but like other eruptive diseases of childhood it is usually less severe in warm than in cold climates. Age occurrence. Scarlet fever is most common in children between 5 and 10 years of age, and more cases occur at the age of 6 years than at any other. Under 1 year and over 15 years of age relatively few cases of scarlet fever are observed. The disease occasionally manifests itself in adult life, but out of 167,840 cases recorded by Ford Carger there were only 77 in indi- viduals past 50 years of age. There exists a great differ- ence in the degree of susceptibility of individuals toward this disease, some being practically immune, while others exhibit a high degree of predisposition to infection with it. Modes of infection. As with most other diseases, we now know that scarlet fever is most often spread by direct contact. Although the specific organism causing the disease has not yet been positively identified, it is probably present in the secretions of the nose and throat. There is reason to believe that the organism, whatever it is, may under some conditions be spread by 154 HEALTH WOKK IN THE SCHOOLS carriers. Epidemics sometimes occur through infected milk supplies. Air infection plays little or no part in spreading this disease, and there is no evidence that water ever carries it. In respect to fomites, Kerr remarks that these may play considerable part in the dissemination of infec- tion. He further states that the clothes of a patient are highly infectious, and may remain so for a long period. It is difficult, he says, to accept without some reserve the tragic stories, so frequently related, of infection clinging to clothes or toys for over twenty years and then breaking out when the articles are disturbed. There can be little doubt, however, that clothing, books, letters, toys, and bedding can retain the virus alive for months, especially if they are excluded from light and air. 1 Chapin, however, is disinclined to place much reli- ance in the various alleged cases of f omite infection in any of the transmissible diseases, and says that the amount of disease caused in this way is relatively very small. We have no need for such a theory and a much more satisfactory explanation is at hand. 2 This explanation Chapin finds in the existence of healthy carriers and atypical cases. He also points out that if infection from fomites really occurred as often as has been supposed, transmissible diseases would be much more prevalent than they are. There is no good epidemiological evidence that diseases are spread by 1 Kerr, James, Infectious Diseases. 2 Chapin, C. V., Sources and Modes of Infection. TRANSMISSIBLE DISEASES 155 fomites except in cases due to spore-forming bacteria. In schools, scarlet fever is not spread as readily as mea- sles or diphtheria. Duration of infectiousness. The patient is capable of transmitting the disease from the time his symptoms are first noted and until the catarrhal stage has disap- peared. As long as there is any inflammation in the nose or throat, or any discharge from the ears, the individual is infectious. It is also probable that infec- tion spreads from suppurating glands in the neck. It has always been supposed that the desquamating (peeling) skin was highly infectious, but to-day this is regarded less seriously than formerly, although the possibility of infection from this source cannot yet be entirely ignored. On an average, a child will be a possible source of infection for about six weeks, but each individual case must be judged by the disappearance of the catarrhal symptoms of the nose and throat, the ear discharge, the discharge from the lymphatic glands, and last, and probably of least importance, the disappearance of peeling. After exposure, a susceptible individual should be isolated for about ten days, as a matter of precau- tion. Period of Incubation. The symptoms of scarlet fever develop rapidly, the period of incubation in the major- ity of cases not exceeding seven days. More often it is not more than four days, and it is probable that most cases do not require over two or three days before they exhibit symptoms of the disease. 156 HEALTH WORK IN THE SCHOOLS Early symptoms. For the guidance of the non-medi- cal reader the following early symptoms of scarlet fever are given: — A. General B. Specific Fever. Quick change from good health to Sore throat. sickness. Headache. Abrupt rise of temperature. Vomiting. Rapid pulse out of proportion to Chilliness. fever. Malaise. Sore throat. Of these symptoms the first four are the most signifi- cant in children. Vomiting and sore throat are almost invariably present. The rash usually appears in about twenty-four hours from the time of the appearance of the first symptoms. It usually appears first in the neck and chest, gradually spreading downward to the arms, trunk, and legs. The rash consists of minute points on a surface somewhat less red. The points are very closely set together, are no larger than half a pinhead, and are not much raised, at least not sufficiently to be felt by the finger. The appearance of the tongue is often somewhat characteristic. At first it is heavily coated and white. Later it has a "white strawberry" appearance. This is succeeded by a "red strawberry" stage. Mortality. Scarlet fever has not a very high mor- tality. In England it is said to be from 2 to 5 per cent. This varies greatly, however, with the age of the pa- tient. For children under 1 year of age it may reach as high as 21 per cent, and for children between 1 and 2 TRANSMISSIBLE DISEASES 157 years of age, 16 per cent. In general, the younger the patient, the higher the death rate. From 10 to 15 years of age is said to be the period of fewest fatalities. Complications. Scarlet fever has associated with it more serious complications than has any other of the eruptive diseases of childhood. Of these complications the following are the most important: — 1. Nephritis (Bright's disease). 2. Arthritis (articular rheumatism). 3. Heart disease : — (a) Endocarditis. (6) Pericarditis. 4. Adenitis (inflammation of the lymphatic glands). 5. Otitis media (inflammation of the middle ear). 6. Rhinitis (inflammation of the nasal passages). 7. Tonsillitis. 8. Broncho-pneumonia. 9. Meningitis. 10. Diphtheria. Nephritis, or Bright's disease, is not rare in cases of scarlet fever, even in mild cases, and sometimes it per- sists as a permanent organic disease of the kidneys. It is not as yet clear whether this complication is caused by the toxin or by the germ of scarlet fever, but it is probable that both play an important part. After 10 years of age nephritis is rarely encountered as a complication. On the other hand, when Bright's disease occurs in children under ten, scarlet fever ought to be thought of as a possible explanation, as it may be present in a mild, unrecognized form. Kidney compli- cations probably occur in not less than 10 per cent of the cases. 158 HEALTH WOKK IN THE SCHOOLS Arthritis, or rheumatism of the joints, is said to occur in about 4 per cent of all cases, and in more than half of all these it appears in children past 10 years of age. Muscular rheumatism also appears in some scarlet fever cases and is probably caused by the toxins of the disease. Heart complications are not very common, but when they do occur they are most often coincident with rheumatism. Of 22,096 cases of scarlet fever observed, endocarditis — inflammation of the lining of the heart — appeared in only 0.58 per cent of the entire number. The commonest complication of all in scarlet fever is otitis media, or inflammation of the middle ear. Usu- ally about 12 per cent of cases are observed to be thus affected. The germs setting up the inflammation may be carried either through the eustachian tube from the nose and throat, or by means of the blood. The discharge which takes place from one or both ears may be transient in character, or may last for months or years. This condition may, of course, pro- duce more or less permanent deafness, especially in cases which do not receive proper treatment. It seems very probable that discharging ears may be the cause of scarlet fever infections in many cases. Sometimes a mother will attribute a case of scarlet fever in the family to the fact that some clothing or toys which were not completely disinfected at the time of occur- rence of a previous case, perhaps years before, had been recently unpacked and handled. An investiga- tion in such cases often demonstrates the presence of a TRANSMISSIBLE DISEASES 159 discharging ear in the previous case, which has per- sisted since the time of the scarlet fever attack. It is far more reasonable to attribute infection to such a source rather than to any organisms remaining active for a long period in clothing. Diphtheria, following scarlet fever or associated with it, is often observed. This may in part be explained by the fact that the child may have been a diphtheria car- rier and that the germs have become active during the attack of scarlet fever, or that the resistance has be- come reduced because of it. Until antitoxin was em- ployed, this complication was the cause of a fearful mortality, but with its early and general use the danger has been greatly reduced. 3. Diphtheria Diphtheria is one of the few diseases for which a specific treatment has been discovered. The use of antitoxin has not only greatly reduced the mortality from the disease, but has also decreased the seriousness of sickness incident to it. The bacillus which causes diphtheria was discovered by Klebs in 1883, and much of the modern treatment of germ diseases dates back to this period. Age. Diphtheria occurs most frequently during the first ten years of life. Under 1 year of age it is not com- mon, but it is met more frequently during the period from 2 to 5 years than at any other time. After 12 years of age it is relatively uncommon. Modes of infection. Direct contact explains satisfac- 160 HEALTH WORK IN THE SCHOOLS torily the greatest number of cases, although indirect contact, from the common use of such articles as pen- cils, handkerchiefs, towels, common eating-utensils, and the like, may account for a good many cases. Some epidemics appear to have originated in infected milk supplies. Carriers are very common in diphtheria, and the con- trol of the sick cases and carriers is usually all that is necessary to stop an epidemic of this disease. Chapin thinks that perhaps 1 or 2 per cent of the population carry the germs of diphtheria constantly in the nose or throat. Among those that have been in close con- tact with diphtheria cases the percentage of carriers is usually pretty high; 10 to 15 per cent is not an un- usual proportion under such conditions. In schools where there have been epidemics of diphtheria it has not been uncommon to discover that from 25 to 50 per cent of the well children are carriers of the bacillus, and are therefore capable of spreading the disease. It often happens that atypical cases of diphtheria occur, cases which are so mild in character that they may even be overlooked by physicians. From mild cases of this type serious cases and even epidemics may result through the infection of susceptible individuals. Every case of definite sore throat ought to be regarded as a possible case of diphtheria, until proved not to be one. The only possible way to determine the facts is by use of the culture method; i.e., the throat must be swabbed and the bacteria grown on an artificial culture medium for twelve to twenty -four hours, and then TRANSMISSIBLE DISEASES 161 examined bacteriologically. Every competent health officer now has facilities for such diphtheria examina- tions, and the public ought to make free use of the opportunities thus afforded. It should never be forgotten that diphtheria and scarlet fever are often associated. Therefore, in scarlet fever, cultures from the throat should be taken as a matter of precaution. The old idea that diphtheria may be spread by defec- tive drains, "sewer gas," stagnant water, "bad air," and the like needs only to be mentioned to be con- demned as a superstition. Fomites play no more im- portant part in spreading diphtheria than they do in most other transmissible diseases. For infection to be carried in this manner the infective material must be relatively fresh. The domestic cat sometimes suffers from diphtheria, and there is sufficient evidence to lead us to believe that this animal may infect human beings who come into direct contact with it. Diphtheritic patches and ulcers sometimes occur on the udders of cows, and a few milk epidemics have been traced to such sources. It is not possible to state just how long it takes the disease to develop in a suceptible person after exposure, but there is good reason to believe that it sometimes appears as soon as twenty-four hours. On the other hand, the germs may be carried in the nose or throat for days, weeks, or months, before any symptoms ap- pear, while in other instances, as we have already learned, a carrier may show no symptoms of sickness at 162 HEALTH WOEK IN THE SCHOOLS all. Ordinarily about two or three days will be required for the disease to develop. Symptoms. The prominent and common symptoms of diphtheria are as follows : — Fever. Headache. Malaise. Chilliness. Lassitude. Rapid pulse. Loss of appetite. Sore throat. Patches of whitish membrane in the throat. Complications. Broncho-pneumonia may occur and is always a very serious complication. Inflammation of the middle ear (otitis media) is not rare, and some- times the discharge contains diphtheria germs. Paralysis of various parts is not uncommon, and is due to the toxins of the disease. Paralysis of the heart is the cause of many of the sudden deaths in attacks of diphtheria, or during early convalescence. In some cases the muscles of the eyes are affected; in others those of the legs, arms, throat, face, or the muscles of respiration. Sometimes the paralysis occurs in several parts of the body. Mortality. Before the use of antitoxin, the death rate from diphtheria was very high, often reaching 25 or 30 per cent of the cases, while 25 to 40 per cent was not unknown. With the early use of antitoxin this terrible mortality has been reduced to from 3 to 14 per cent, depending upon the severity of the epidemic. If a TRANSMISSIBLE DISEASES 163 diphtheria case is treated with antitoxin serum the first day, death very seldom occurs; but every day of delay adds to the risk. It should be understood that antitoxin also affords protection against diphtheria in the cases of exposed persons, and it is especially important to administer it in the case of those who carry the germs in the nose or throat. Control of an epidemic of diphtheria. A matter of prime importance in the control of diphtheria is to recognize the cases early, and isolate them. Next in importance is the discovery of carriers, and the isola- tion of these also. Last of all, no cases of either class should be allowed to mingle with other children (or adults) until examination proves that the germs of the disease have entirely disappeared. It is probably never necessary for a school to be closed if the precautions just described are carefully observed, though it is, of course, necessary to clean and disinfect the desk and personal belongings of the chil- dren who are known to have been infected. Conclusions from the investigation of an epidemic in a Berkeley (California) School 1 The existence of an epidemic of diphtheria in one of the schools of Berkeley afforded an opportunity to make an exhaustive trial of the control of diphtheria by strictly laboratory methods. The local health authorities first became alarmed 1 Abstracted from a Report by Archibald A. Ward and Margaret Henderson. 164 HEALTH WORK IN THE SCHOOLS about diphtheria in Berkeley early in November. In October five cases were reported, four of them from the Lincoln School District. In the first half of November ten cases were reported, nine of them from the Lincoln School District and two of them resulting in death. Besides these reported cases, there were un- official rumors of many others. A great clamor arose among the inhabitants of the region, and those of other parts of Berkeley who heard of the epidemic, insisting on the closing of the school until the diphtheria should be over. But it was deemed wiser to keep the school open, excluding all children who showed diphtheria bacilli in their throats. If the school closed, all children would go out of the control and observation of the health officer. If it were open, they would remain segregated, new cases would be easily traced, and old cases more easily kept quaran- tined until free from infection. It was, therefore, de- cided to examine every child in the school, excluding all those showing diphtheria bacilli, and readmitting infected ones only after two negative cultures had been obtained from them at an interval of at least a week. The school was then closed for the three days neces- sary to examine the cultures, and when it was reop- ened, those children showing diphtheria bacilli were sent home, together with their sisters and brothers. No attempt was made to disinfect the school at any time during the epidemic. The principal undertook to see that the desks of the children found to be infected TRANSMISSIBLE DISEASES 1G5 were washed in a 4 per cent formalin solution, and that their books and pencils were sent home with them. Be- yond this nothing was done in the way of disinfection at any time. About 475 children were examined, and 27, or about 5 per cent, were found positive. There was no attempt to quarantine these children; they were merely ex- cluded from the school. The first examination did not stop the epidemic and it was decided that the second one must be made more stringent. Various changes were made, for this reason, in the technique. Cultures were taken from the throat, as before, but, in addition, cultures were also made from the nose, on the same tube of blood serum. In this second examination, 77 of the 550 children, or 14 per cent, were found to be harboring diphtheria bacilli. This meant the exclusion from school of a total of 125 children. Conclusions (1) The epidemic was due to three factors: (a) Exist- ence of mild cases of diphtheria which, because of the lack of bacteriological examination, had gone un- recognized as diphtheria; (b) the insufficient length of quarantine in clinical cases; (c) germ cases following exposure and never showing clinical symptoms (car- riers). (2) Attempts to isolate all infected children had no effect on the course of the epidemic, so long as throat cultures only were made. When both nose and throat 166 HEALTH WORK IN THE SCHOOLS cultures were made and all the children showing posi- tive cultures were quarantined, the epidemic stopped. (3) It is extremely important, in times of danger from diphtheria, that every sore throat, no matter how far it may seem to be from diphtheria, be regarded as suspicious until a bacteriological examination has proved it to be otherwise. (4) It is such a frequent occurrence to have a posi- tive culture follow a negative one that at least two negatives should be demanded for release from quaran- tine. No case should be released on clinical signs alone. (5) It is possible to stop epidemic diphtheria in a public school by regulation of attendance by means of bacteriological findings. 4. Whooping-cough Until recently the organism of whooping-cough was unknown. Now it is generally recognized as an influ- enza-like bacillus called the "Bordet Bacillus." Whoop- ing-cough is very largely a disease of infancy and early childhood. If a child can be protected against the dis- ease until he is five or six years old, his chances of tak- ing it are very greatly reduced. The greatest number of cases probably occur in the fourth year, but the disease is common in children under 1 year of age, and some- times occurs in babies less than 2 months old. After 10 years of age, whooping-cough is relatively rare, but occasionally adults are affected, and, in rare cases, the aged. Mode of transmission. Whooping-cough is trans- TRANSMISSIBLE DISEASES 167 mitted very largely, if not exclusively, by direct or indirect contact. The disease is extremely contagious, although not as much so as measles. The period of in- fectiousness extends from the earliest catarrhal symp- toms, which first appear as an ordinary cold, until the cough has ceased. One attack of whooping-cough prac- tically protects for life against reinfection. Not much is positively known about the period of development of whooping-cough, but this probably varies from one or two days to two weeks. If, after exposure, the disease has not appeared within fifteen days, there is little or no danger that it will appear at all. Symptoms. It is highly important to understand that whooping-cough usually begins much like an ordi- nary cold, with cough, and that it is often if not usually unrecognized for a number of days. Generally the cough becomes progressively more severe, and by the end of the first or second week the paroxysmal charac- ter of the cough makes the case a clear one. This paroxysm associated with the cough may occur a few or many times during the twenty-four hours. The child coughs violently in quick succession and is unable to get his breath; his face becomes very red or even purple, and he presents a rather alarming appear- ance. At last the breath is drawn in with a "whoop," which may or may not end the particular spasm. Vomiting usually occurs at the end of the "whoop," but sometimes precedes it. Duration. One of the many unfortunate features of 168 HEALTH WORK IN THE SCHOOLS whooping-cough is its long duration. On the average this covers a period of five or six weeks. The "whoop " may persist for a much longer period than this, and sometimes it continues for several months, or even for a year. Complications. Whooping-cough should be regarded seriously for several reasons. First of all, it keeps the child out of school for several weeks or months; second, it causes a tremendous strain of the heart and lungs; third, it has many possible complications. Among these are: — Hemorrhages in the eyes, nose, bronchial tubes, and occa- sionally in other localities, including the ear, skin, and brain. Digestive disturbances. Hernia (rupture). Broncho-pneumonia. Nervous complications of various kinds, such as convul- sions, and, in rare cases, paralysis. Heart strain not infrequently occurs in severe cases. This may result in permanent injury, but more often it is of tem- porary character. Tuberculosis often follows long attacks of broncho-pneu- monia, and is much to be dreaded in such cases. Control. Whenever there is an epidemic of whooping- cough, every child with a suspicious cold and cough ought to be excluded from school and kept under ob- servation for about two weeks. Such a precaution will greatly reduce the number of cases in a school. Chil- dren who develop the disease should be isolated for a period of about six weeks, and it is unsafe to allow them to mingle with other children until the "whoop" has disappeared. A slight cough without the "whoop" TRANSMISSIBLE DISEASES 169 may ordinarily be ignored, as this often persists long after all danger of infection has passed. A bacterio- logical examination for the presence of the specific germ of the disease will of course settle the question of the infectiousness of a case. All expectorations should be carefully destroyed by disinfectants, or by burning. Disinfection of articles which may carry infection ought to be practiced as a matter of precaution, although there is probably rela- tively little danger of infection from such sources. Children from families in which there is whooping- cough need not be excluded from school, if they them- selves have had the disease. If they have not, unless over 10 years of age, they should be excluded for at least two or three weeks. After this they may return, but should be carefully watched for symptoms. 5. Mumps Mode of transmission. While the specific germ of mumps has not been discovered, there is no doubt as to the existence of such an organism. Some regard the dis- ease as a septicaemia, or general infection in the blood. Season has little to do with the occurrence of mumps, but age is a factor of much importance. The disease is not common in the very young, or in those past middle life. It most often occurs between the ages of 5 and 15 years. In the Berkeley, California, investigation (Hoag and Hall), 50 per cent of the cases occurred between 5 and 10 years, and 26 per cent between 10 and 15 years. We are rapidly learning that most infectious diseases 170 HEALTH WORK IN THE SCHOOLS are spread directly or indirectly from the secretions of the nose and throat, and in this respect mumps appears to offer no exception. Mumps may be called a school disease. Epidemics in high schools and colleges are not uncommon, and they often appear also in barracks. The disease is not very contagious, the susceptibility of children to it being much less than in the case of other transmissible dis- eases of childhood. It is contagious from the time of the appearance of the earliest symptoms, and probably usually remains so for several days after the disappearance of the swelling. The period of incubation varies considerably, but is usually from three days to three weeks, with an average period of about twenty days after exposure. Symptoms. Often the swelling of the parotid glands (at the angle of the jaw) is the first symptom. In some severe cases there may be headache, pains in the back and legs, and vomiting and fever for about one day before the appearance of the glandular swelling. Pain often precedes the swelling of the parotid glands, and the glands may swell on one or both sides of the neck. Usually the swelling reaches its limit in two or three days, and then remains stationary for a few days, when it slowly decreases. Ordinarily the swelling completely subsides in a week or ten days from the beginning of the process. Other glands of the neck are occasionally affected, but in any event the course of the disease is nearly always mild and uneventful. As a complication, swelling of the sexual glands (tes- TRANSMISSIBLE DISEASES 171 tides or ovaries) occasionally occurs. This is rarely observed before puberty, but after this period it may appear in either sex. Other complications are not often met with, and need not be mentioned here. Control. In the majority of cases the symptoms will not appear until at least a week after exposure. Con- sequently an exposed child who has not had the disease need not be isolated during the first week. After that it is well to practice isolation for a period of about two weeks. Second attacks are possible, but are so infre- quent as to be negligible. Disinfection, except of desks and the personal belongings of the child, need not be practiced. 6. Chickenpox While chickenpox is usually mild and harmless, yet this is not always the case, and in exceptional instances some severe complications may arise. A point of par- ticular importance is that it is frequently confused with smallpox, every physician having seen cases of beginning smallpox diagnosed "chickenpox." At one time it was supposed that chickenpox was a mild form of smallpox, but since about 1870 there has been no controversy in regard to this point. Varicella, or chickenpox, originates through infec- tion only, but just how this comes about we are still in doubt. Most authorities doubt if this disease is ever carried by a third person or by fomites. It is also doubtful if air transmission plays any part in the spread of the disease. 172 HEALTH WORK IN THE SCHOOLS The contagiousness begins as soon as the eruption appears, and probably continues until all crusts have fallen from the skin. It is rare that an individual ever has more than one attack, but this does occur occasionally. Chickenpox is a universal disease, and is rarely altogether absent from large centers of population. It occurs most often in the epidemic form, soon after the opening of schools. Chickenpox is so rare in adults that every such case ought to be very carefully distinguished from smallpox. The early symptoms are: — Fever. Loss of appetite. Restlessness. Malaise. Vomiting. Nosebleed. The eruption usually comes out in from one to four days after the appearance of the first symptoms, but sometimes the noticeable symptoms and the eruption seem to occur simultaneously. The eruption begins as small papules (little red spots), which soon change into vesicles (little blisters). These vesicles soon dry and in a day or so leave scabs, which usually fall off after two or three days. All stages of the eruption may be observed on the body at the same time. Complications. Complications are very rare, but do occur in a number of different forms, as follows: — Nephritis (kidney disease). Arthritis (rheumatism). Paralysis. TRANSMISSIBLE DISEASES 173 Chorea. Infections. Gangrene of skin. Control. The child should be excluded from school from the time of the earliest symptoms until the scabs have disappeared. 7. Smallpox An exact knowledge of smallpox is important, be- cause in mild cases it is easily confused with chicken- pox. It not infrequently happens that a case of small- pox is so mild that it does not even present the slight symptoms common to chickenpox. Onset of the disease. In smallpox there is always some fever for a period of about three days before any other marked symptoms appear. With fever there is associ- ated headache, general malaise, and often such symp- toms as occur with a slight influenza. After the third day from the beginning of the symptoms the eruption comes out, and the person thereafter feels better for a time, or indeed does not again feel sick at all. "There is no other eruptive disease in which such experience as this can be noted; it is peculiar to this one." The distribution of the eruption. On the third day, with subsidence of the fever, the eruption appears. It appears first on the face; later on the back of the hands and wrists. In chickenpox the definite onset which character- izes smallpox is lacking. The early symptoms in chickenpox are usually insignificant, and the fever does not subside with the appearance of the eruption. 174 HEALTH WORK IN THE SCHOOLS The red spots (papules) are not so hard in chickenpox as in smallpox, and they quickly form blisters (vesicles). The eruption is most abundant on the trunk and es- pecially on the upper part of the back, while the face is fairly free. Vaccination affords almost perfect protection against smallpox. The literature on this subject is so exhaus- tive that merely to mention the titles of the most im- portant articles is out of the question. For a concise and conclusive argument, however, in favor of vaccina- tion, the reader may be referred to Vaccination: What it is; What it does; What its Claims are on the People, issued by the New York State Department of Health. Every individual ought to be protected against small- pox by vaccination, but in any event vaccination must be practiced at the time of any appearance of this dis- ease among school children. CHAPTER XI TRANSMISSIBLE DISEASES (Concluded) 8. Tuberculosis The subject of tuberculosis has been fully discussed in the volume of this series called The Hygiene of the School Child, and it is, therefore, unnecessary to enter into any extended details at this point. 1 "Open" and "latent" tuberculosis. "Open" tuber- culosis, by which is meant tuberculosis in the trans- missible form, such as is found in unhealed tuberculous conditions of the lungs, is rarely met by school health officers in their routine work. Evidence of former bone tuberculosis is seen not infrequently in the form of de- formed spines (kyphosis) or a shortened leg, usually caused by hip-joint disease. Scars in the neck most often represent former tuberculous lymph-glands which have either ruptured spontaneously or have been lanced. Occasionally one observes discharging lymph- glands of tuberculous nature in the neck or the groin, and, less often, abscesses in the back. Also, in relatively rare instances, cases of active pulmonary tuberculosis are found. In the main, however, tuberculosis in school children is of the latent type, discoverable chiefly by use of the Von Pirquet test. 1 See also chapter xu of the present volume, "Open- Air Schools." 176 HEALTH WORK IN THE SCHOOLS That a very large number of children are afflicted with latent tuberculosis there is no possible doubt, and modern investigations point to the fact that most tuberculosis is acquired in childhood, even though it may not become evident for many years. It is the con- viction of one of the writers, who has personally exam- ined more than 100,000 school children, that most of the type which we call "malnourished" are in reality cases of latent tuberculosis. This opinion is shared by some others who have had wide experience in dealing with children. For the reason just stated, if for no other, cases of malnutrition should receive prompt and careful attention. Not nearly so many instances of malnutrition as we imagine are really caused by insufficient food. If this were the fact fewer such cases would be observed among the children of the well-to-do. Malnourished children always greatly improve by treatment in open- air schools where feeding, fresh air, and rest are skill- fully combined. An attempt should always be made to discover the nature of home conditions in these cases, for in some instances tuberculosis will be found present in one or more members of the family. One ought to suspect the possibility of tuberculosis in children who show some or all of the following signs: — Delicate constitution. Tendency to tire out easily. Pallor. Flushed face at certain periods. Capricious appetite. Enlarged cervical (neck) glands. TRANSMISSIBLE DISEASES 177 Adenoids. Diseased tonsils. No delicate child should be neglected. The time to control tuberculosis is at the beginning, when the dis- ease may be indicated only by some such general signs as those just mentioned. The teacher's health must receive attention, partic- ularly in respect to tuberculosis. One tuberculous teacher of careless or uncleanly habits has opportunity to infect the 40 or 50 children in her classroom, and through them to send infection into as many homes, ex- posing in the end 200 or 300 individuals to the chance of infection. As stated by Dr. Langley Porter, "when we consider the contact of child with child, a contact maintained for hours daily, often in an ill-ventilated room, we realize that the danger here is very real. A proper school inspection will mean the elimination of the actually tuberculous pupil and teacher from con- tact with healthy pupils and instructors." Prevention. To summarize the means of preventing tuberculosis in school children we may mention the following essential points: — (1) Elimination of the tuberculous teacher. (2) Segregation of the tuberculous school child. (3) Building up the health of all anaemic, nervous, and weak school children. (4) Short school day for young children. (5) Well-ventilated schoolrooms. (6) Sanitary schoolrooms. (7) Open-air schools. (8) Low temperature schools (temperature not to exceed 60° to 68° F.). 178 HEALTH WORK IN THE SCHOOLS (9) Common-sense physical training, out of doors. (10) More careful health observation on the part of teachers. (11) Systematic health inspection of schools. (12) Home visits by nurses. (13) Knowledge of the nature of the food which school chil- dren receive. (14) Common-sense, applicable, hygiene instruction. 9. Hookworm Disease Hookworm is not often seen in the school children of this country, except in the Southern States. The dis- ease is also common among the Japanese, Hindus, Porto Ricans, and in some of the countries of southern Europe. In the tropics the disease is said to be "the greatest enemy of the human race." In the United States hookworm has been found common from Vir- ginia to Florida and Texas. In a few other States it has been observed rather infrequently. It is estimated that at least 2,000,000 people of our Southern States are infected. Mode of transmission. The commonest cause of in- fection among school children is the habit of going barefooted. The disease commonly gains entrance in one of two ways — first and most commonly, through the skin; second, and less frequently, through the mouth. Dock * states that the reproductive stage is reached only in the intestinal canal; that the species infecting man does not infect other animals; that the eggs do not hatch in the intestinal canal; and that the larvae are not infectious until they are at least four or five days old. The real source of infection is, therefore, 1 Dock and Bass, Hookworm Disease. TRANSMISSIBLE DISEASES 179 found in the body wastes of individuals who are in- fected with the disease. The usual sequence of infection is as follows: The eggs from the worms in the human intestines reach the soil with the faeces, often as many as 1,700,000 eggs being passed in a single stool; the eggs hatch into larvae in the soil; the larvae pass through the skin (commonly through the feet) and reach the intestines; in the intes- tines the larvae develop into adult worms; the adult worms produce eggs, which in their turn are passed out of the body with the faeces. The general effect of the disease, when it is severe, is to produce an extreme degree of anaemia, with conse- quent loss of energy and mental alertness. In children growth is interfered with, so that a young man of 20 years who has been infected since childhood is often no more developed than a boy of 12 or 13 years. In many of these cases of delayed development X-ray pictures of the hands show the same slow development of wrist bones and the ends of the long bones of the arm as that found in cases of retarded development due to other causes. Prevention. The all-important matter in hookworm disease is prevention. This is best carried out by the following procedures, as given by Dock: — (1) Stopping the danger of infection by exterminat- ing the mature worms in the bodies of human beings, in order to check the supply of eggs at the source. (2) Preventing the growth or existence of larvae in the places where they develop. 180 HEALTH WORK IN THE SCHOOLS (3) Preventing infection by larvae that have devel- oped notwithstanding the efforts mentioned under (1) and (2). Fortunately it has been found an easy matter to cure this disease, and, after a preliminary treatment with "salts," a few doses of thymol usually completes the cure. 10. Poliomyelitis (Infantile Paralysis) Little need be said in this book about this disease of childhood, for two reasons : first, it will rarely or never be identified at school; second, it fortunately affects children of school age less frequently than infants. Mode of transmission. Evidence is now available which indicates that the disease may be spread by the stable-fly. On the other hand, some investigations throw considerable doubt on this point. At any rate, the fly is a menace to health, whether of the stable or domestic variety, and should be eliminated from civilized communities. The secretions of the nose and mouth of infected children carry the disease, a fact to which attention has been directed in respect to most contagious diseases of children. Control. There is a division of opinion as to whether schools should be closed during an epidemic of infantile paralysis. Many modern hygienists claim that such a procedure is quite unnecessary and useless, while some others insist upon the prompt closing of the schools. In any event, absolute isolation is necessary. We know rather less about this disease than any other from which TRANSMISSIBLE DISEASES 181 children suffer, and it remains to-day one of the mys- teries which medical science is attempting to solve, but one which, like most other disease mysteries, will no doubt soon yield to painstaking scientific investiga- tion. 11. Epidemic Meningitis As epidemics of meningitis have occurred rather fre- quently in this country, teachers, nurses, and others who deal with school children ought to have some knowledge of it. It has been recognized in the United States since 1805, and at various periods since that time there have been many definite epidemics of the disease. According to Osier, epidemic meningitis is most pre- valent in winter and spring. The disease is primarily one of childhood, but young adults are sometimes affected. Contagion. While epidemic meningitis is distinctly transmissible, it does not spread in the same manner as does scarlet fever or measles, but more after the man- ner of pneumonia. In general it may be said that it is chiefly communicated through the secretions of the nose, mouth, and eyes. The organism causing the dis- ease has been known since 1887. Symptoms. The attack in the majority of cases is sudden. Sometimes there is abrupt severe headache, with fever, vomiting, and a fast pulse, followed by rig- idity of the neck and unconsciousness. Very acute at- tacks often begin with sudden dizziness, followed by 182 HEALTH WOKK IN THE SCHOOLS vomiting and headache, after which fever occurs, and even delirium. While there is great variety in the mode of onset, it may be said that in the main the characteristic points are: — Suddenness of attack. Headache. Dizziness. Vomiting. Fever. Unconsciousness. Rapid pulse. Retraction of the head. Oscillation of the eyes. Sometimes an eruption. Complications. Infection of the ear is very common, and deafness often follows. Inflammation of various joints (arthritis) is common. Accumulation of fluid in the ventricles of the brain (hydrocephaly) sometimes results, causing permanent feeble-mindedness. Treatment. Flexner's serum is the only form of treat- ment for epidemic meningitis which offers much hope. Every case of this disease should be diagnosed early and given the Flexner treatment. 12. Contagious Eye Diseases 1 Attention has been called to the fact that children of school age are especially susceptible to general contag- ious diseases. This is also true of diseases affecting the 1 In the preparation of this section the authors are indebted to Whitaker and Ray-Wiggin Company for permission to use certain material from Dr. Hoag's The Health Index of Children. TRANSMISSIBLE DISEASES 183 eyes. The early recognition of these eye troubles is of very great importance, not only to the child afflicted, but also to his intimate associates. As a rule, a teacher is justified in excluding any child, or at least in insisting upon a certificate from a physician, whenever such child is found with evidence of discharging eyes, gluing of the eyelids, or reddening of their inner surfaces, accompanied with any marked sensitiveness to light. To assist the teacher, parent, or any one else who has not had the medical experience, to distinguish the different contagious diseases of the eye, the following brief description of their essential characteristics may prove useful. (a) Pink-eye (acute catarrhal conjunctivitis) This disease is of frequent occurrence among chil- dren, and spreads in a school rapidly. It is commonly carried by means of the common wash-basin, or towel, borrowed handkerchiefs, and the like. The child com- plains of smarting eyes, sensitiveness to light, and a sensation as though sand were in the eyes. The eyelids stick together at night, and there is often some visible discharge in the corners of the eyes between the lids. The small blood vessels in the white part of the eyes (sclera) and of the lining of the lids (conjunctiva) are very prominent. This results in very noticeable red- dening of the eyes. The disorder usually lasts from ten to fourteen days, but it may persist a much longer time. The trouble is easily cured if it is attended to at once. 184 HEALTH WORK IN THE SCHOOLS (6) Gonorrheal conjunctivitis This serious disease of the eyes is often found in new- born children, but it may also occur in children of any age or in adults. It is caused by the germ of gonorrhoea. Indications of this disease are: — Intense inflammation of the eyelids. Profuse, thick, purulent discharge. Lids red and swollen. Usually intense pain. Marked aversion to light. Profuse flow of tears. This form of eye disease is most serious in its conse- quences, often causing blindness. It is highly contag- ious. For these reasons it ought to be recognized early, and receive immediate and skillful treatment. Fortu- nately, it is not extremely frequent among school chil- dren. The disease usually lasts from four to six weeks, but sometimes very much longer. The child must be kept carefully away from other children, and every precaution used to prevent contagion by means of tow- els, handkerchiefs, wash-basins, the fingers, etc. (c) Diphtheritic conjunctivitis This disease is due to the same germ as that which produces diphtheria in the throat or nose. It is very dangerous, but rather infrequent. Contagion is very easy, and therefore its early recognition is of the ut- most importance. The essential characteristics of this disease are: — TRANSMISSIBLE DISEASES 185 Severe pain in the eyes. Eyelids tense and dark-colored. Discharge at first thin and scanty, later thick and puru- lent. A thick, tenacious, grayish membrane forms upon the inner surface of the eyelids which is very difficult to remove. The disease demands the same treatment as diph- theria of the throat, and the periods of exclusion and quarantine are of great importance. (d) Trachoma This is one of the most serious of all diseases of the eyes, being highly destructive and extremely likely to produce blindness. Trachoma is prevalent in certain foreign countries, especially in the Orient. In Califor- nia trachoma is most frequently found among Indians and Mexicans, sometimes, also, among the Japanese. It is extremely common among the Indians of Minne- sota. In the large cities of the East and Middle West the disease often occurs among the children of other nationalities, largely in the slums or poorer districts. As many as 17,000 cases have been discovered in the New York schools in one year. Children suffering from the disease must be imme- diately isolated, and kept so until recovery is complete. The principal characteristics of trachoma are: — Inflammation. This is not very intense, but there is con- siderable swelling of the lids, an aversion to light, and flow- ing of tears. The outer surface of the eyeball becomes roughened. The inner surface of the eyelids becomes covered with 186 HEALTH WORK IN THE SCHOOLS small granules, not unlike boiled sago grains in appearance, and this produces what is called granular eyelids. The disease is extremely contagious through the dis- charge from the eyes. Towels, basins, handkerchiefs, etc., are the chief means of conveyance, but uncleanly habits, unhygienic surroundings, poor food, poverty, and the like, favor its development and spread. Strict quarantine against this malady must be established, and continued until all signs of discharge have ceased. Laboratory examinations should be made in all cases of suspected trachoma. Conclusions (1) All contagious eye diseases need to be recognized early. (2) Removal from school of children with such diseases is necessary. (3) Great care must be exercised to prevent contagion through — The common towel; The common basin; Handkerchiefs ; Dirty fingers; Bedclothing; Public bathing-suits, and, possibly, swimming- tanks. TRANSMISSIBLE DISEASES 187 13. Contagious Diseases of the Skin 1 (a) Scabies (the itch) A contagious skin disease, due to an animal para- site which burrows in the skin, causing intense itching and scratching. The disease usually begins upon the hands and arms, spreading over the whole body, but does not affect the face and scalp. Between the fingers, on the front of the wrist, at the bend of the elbows and near the arm -pits are favorite locations for the disease; but in persons of cleanly habits the disease may not show at all upon the hands, and its real nature is deter- mined only after a most thorough and careful examina- tion. There is great variation in the extent and sever- ity of this disease, lack of personal care and cleanliness always favoring its development. Scratching soon brings about an infection of the skin with some of the pus-producing germs, and the disease is then accom- panied by impetigo, a pus infection of the skin. Itch is very common, and, because of the great vari- ation in its severity, mild cases are often mistaken for hives, eczema, etc. All children who are scratching or have an irritation upon the skin should be examined for scabies. It is very important that all infected members of a family be treated till cured, else the disease is passed back and forth from one to another. It is also impor- 1 With acknowledgments to a pamphlet on Medical Inspection by the Massachusetts Board of Education, and one by the Cincinnati City Board of Health, called Suggestions to Teachers. 188 HEALTH WORK IN THE SCHOOLS tant that all underclothing, bedding, towels, and other things that come in contact with the body, be boiled when washed. All cases of scabies should be excluded from school until cured. (6) Pediculi capitis (head lice) An extremely common accident among children, either from wearing each others' hats and caps, or hanging them on each others' pegs, or from combs and brushes. No person should be blamed for having lice — only for keeping them. The irritation caused by vermin in the scalp leads to scratching, which in turn causes an inflammation of the skin of the neck and scalp. The skin then easily be- comes infected with some of the pus-producing germs, and large or small scabs and crusts are formed with the dried matter and blood. Along with this condition the glands back of the ears and in the neck become swollen, and may be very painful and tender. The condition of pediculosis is most easily detected by looking for the eggs (nits), which are fastened to 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 fine-toothed comb wet in alcohol or vinegar, which dissolves the attachment of the eggs to the hair. All combs and brushes must be carefully cleansed. The best way to eradicate lice from a school is to TRANSMISSIBLE DISEASES 189 have the school nurses give the necessary treatments. This can be done at school, without any exclusions. If there are no school nurses, then children with pedicu- losis should be excluded from school until the heads are clean. In Massachusetts, parents who neglect or refuse to care for their children in this respect may be prosecuted under the compulsory attendance law. (c) Ringworm A parasitic disease of the skin and scalp. When it occurs upon the skin it yields readily to treatment; but upon the scalp it is extremely chronic. Ringworm of the skin usually appears on the face, hands, or arms — rarely upon the body — in rings of varying size. 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 crusted. The disease spreads at the circumfer- ence 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 abundant crusts of a yellowish color are present where the process is active. The roots of the hairs are killed, so that the loss of the hair from this disease 190 HEALTH WORK IN THE SCHOOLS 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 of the skin may be treated at school by school nurses. Ringworm of the scalp was formerly dealt with by exclusion, or by segregation of the children in special classes. By the earlier tedious methods of treatment attendance at the "ringworm class" was sometimes necessary for many months, or even years. The new X-ray method is so much more expeditious that where this method is used the disease no longer presents any serious problem. (d) Impetigo A disease characterized by a few or many, large or small, flat or elevated, pustules or festers upon the skin. The condition is often secondary to irritation or itch- ing diseases of the skin (hives, lice, itch), and scratch- ing starts up a pus infection. The disease most often appears upon the face, neck, and hands; less often upon the body and scalp. The size of the spots varies very much, and they often run together to form on the face large superficial sores, cov- ered with thick, dirty, yellowish, 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. TRANSMISSIBLE DISEASES 191 General Summary Any of the following points ought to suggest the pos- sibility of some form of transmissible disease in chil- dren : — Flushed face. Persistent cough. Lassitude. Scratching. Vomiting. Sore throat. Eruption. Aches and pains. Red eyes. Headache. Watery eyes. Fever. Nasal discharge. Loss of appetite. 192 TABLE V. COMMON TRANSMISSIBLE Principal early signs and symptoms Method of Infection O Begins like cold in the head, with feverishness, running nose, in- named and watery eyes, and sneezing; small crescented groups of mulberry-tinted spots appear about the third day; rash seen first on forehead and face. The rash varies with heat; may almost disappear if the air is cold, and come out again with warmth. Illness usually slight. Onset sud- den. Rash often first thing no- ticed; no cold in head. Usually have feverishness and sore throat, and the eyes may be inflamed. Rash something between measles and scarlet fever; variable. Sometimes begins with feverish- ness, but is usually very mild and without sign of fever. Rash ap- pears on second day as small pimples, which in about a day be- come filled with clear fluid. This fluid then becomes matter, the spot dries up, and the crust falls off. May have successive crops of rash until tenth day. The onset is usually sudden, with headache, languor, feverishness, sore throat, and often the child is sick at the stomach. Usually within twenty-four hours the rash appears, and is finely spot- ted, evenly diffused, and bright red. The rash is seen first on the neck and upper part of the chest, and lasts three to ten days, when it fades and the skin peels in scales, flakes, or even large pieces. The tongue becomes whitish, with bright red spots. The eyes are not watery or congested. Forced exhalation and discharges from nose and mouth. Forced exhalation and discharges from nose and mouth. Forced exhalation and crusts on the spots. Forced exhalation, and discharges from nose and mouth, par- ticles of skin, and dis- charges from supurat- ing glands or ears. Milk especially apt to convey infection. DISEASES OF SCHOOL CHILDREN 1 193 Remarks Period of exclusion recom- mended After effects often severe. Period of greatest risk of infection, first three or four days, before the rash appears. May have repeated attacks. Great va- riation in type of disease. Often fatal. After effects slight. When children return, examine head for overlooked spots. All spots should have disappeared before child returns. A mild disease and seldom any after effects. Dangerous both during attack and from after effects. Great variation in type of disease. Slight attacks as infectious as severe ones. Many mild cases not diagnosed and many concealed. The peeling may last six to eight weeks. A second attack is rare. When scarlet fever is occurring in a school, all cases of sore throat should be sent home. Four to five weeks. Three weeks. Till all scabs have dis- appeared. Six to eight weeks, or until desquamation has ceased. > With acknowledgments to The Health Index 0/ Children (Hoag). 194 COMMON TRANSMISSIBLE DISEASES •c Onset insidious; may be rapid or gradual. Typically sore throat, great weakness, and swelling of glands in the neck, about the angle of the jaw. The back of the throat, tonsils, or palate may show patches like pieces of yel- lowish-white kid. The most pro- nounced symptom is great debil- ity and lassitude, and there may be little else noticeable. There may be hardly any symptoms at all. Begins like cold in the head, with bronchitis and sore throat, and is a cough which is worse at night. Symptoms may at first be very mild. Characteristic " whooping ' ' cough develops in about a fort- night, and the spasm of cough- ing often ends with vomiting. Onset may be sudden, beginning with sickness and fever and pain about the angle of the jaw. The glands become swollen and tender, and the jaws stiff, and the saliva sticky. Begins with feverishness, pain in head, back, and limbs, and usu- ally cold in the head. Illness is usually well marked and the onset rather sudden, with feverishness, severe backache, and sickness. About third day a red rash of shot-like pimples, felt below the skin and seen first about the face and wrists. Spots develop in two days, then form little blisters, and in another two days become yellowish and filled with matter. Scabs then form, and these fall off about the four- teenth day. Forced exhalation and discharges from nose, mouth, and ears. Forced exhalation and discharges from nose and mouth. Forced exhalation and discharges from the nose and mouth. Forced exhalation and discharges from the nose and mouth. Forced exhalation; all discharges, and parti- cles of skin or scabs. OF SCHOOL CHILDREN.— Continued 195 Remarks Period of exclusion recom- mended Very dangerous both during attack and from after effects. When diphtheria is occurring in a school, all children suffer- ing from sore throat should be excluded. There is great variation of type, and mild cases are often not recognized, but are as infectious as severe cases. There is no immunity from further attacks. Membrane may occur in nose only. After effects often very severe, and the disease causes great debility. Relapses are apt to occur. Second attacks rare. Specially infectious for first week or two. If a child is sick after a bout of coughing, it is most probably suffering from whooping-cough. Great variation in type of disease. Seldom leaves after effects, tious. Very infec- Excessively infectious. After effects often very serious and accompanied with pros- tration and nervous disability. Is peculiarly infectious. When small- pox occurs in connection with a school or with any of the children's homes, an endeavor should be made to have all per- sons over seven years of age vaccinated. Cases of modified smallpox — in vaccin- ated persons — may be, and often arc, so slight as to escape detection. Fact of existence of disease may be concealed. Mild or modified smallpox as infectious as severe type. Six weeks, or until all diphtheritic germs have disappeared from cultures taken from throat. Two months, or until cough and vomiting cease. About a month. About three weeks. Till all scabs have dis- appeared. 196 HEALTH WORK IN THE SCHOOLS SELECTED REFERENCES (Chapters ix, x, and xi) 1. Bernhard, Dr. L. : " Zur Diphtheriebekampfung in den Schulen." Beiheft with Zt. f. Schulges., August, 1912, pp. 198-207. 2. Bridge, Dr. Norman: Tuberculosis. 1912, * 3. Burgerstein u. Netolitzsky: Handbuch der Schulhygiene. 1912, pp. 421-62. 4. Carruthers, Dr. A. : " Epidemic Poliomyeletis in West Suffolk." School Hygiene, 1912, pp. 94-101. * 5. Chapin, Dr. C. V.: Sources and Modes of Infection. 1910, pp. 399. * 6. Cohn, Dr. M.: "Schulschluss u. Morbiditat an Masern, Schar- lach u. Diphtherie." Zt. f. Schulges., 1913, pp. 64 ff. * 7. Cornell, Dr. Walter S.: The Health and Medical Inspection of School Children, 1912, pp. 524-64. 8. D'Ewart, John: "School Infectivity." The Child, 1912, pp. 162-67. 9. Dock and Bass: The Hookworm Disease. 10. Dregalski, Dr. V.: "Bekampfung der ubertragbaren Krank- heiten in den Schulen." Beiheft with Zt. f. Schulges., August, 1912, pp. 739-48. 11. Eberstaller, Dr.: " Masern u. Schule." Inter. Mag. Sch. Hyg., vol. in, 1907, pp. 1-20. *12. Fairfield, Dr. Letitia: "School Influence on the Mortality from Scarlet Fever, Diphtheria and Measles." School Hygiene, 1911, pp. 549-53. *13. Gilmour, A.: "Measles and Child Welfare." The Child, 1913, pp. 352-60. *14. Gulick and Ayres: The Medical Inspection of Schools. 1913. (2d edition.) 15. Harmon, N. Bishop: "Concerning Dirt." School Hygiene, 1910. pp. 74-81. 16. Herrman, Charles: "Prevention of the Spread of Contagious Disease in Public Schools." Inter. Mag. Sch. Hyg., 1909, pp. 1-16. 17. Hill, Dr. Charles: The New Public Health. Minn. St. Board of Health. *18. Hoag, Dr.E.B.: The Health Index of Children. 1910. (Chapter IV -) 19. Hoag and Hall: Bulletin of American Academy of Medicine, 1911. 20. Hogarth, Dr. A. H. : The Medical Inspection of Schools. 1909. (Chapter xm.) 21. Hopf, Dr.: "Hygienische Bedeutung des Handewaschens." Zt.f. Schulges., 1906, pp. 154 ff. 22. Hutchinson, Dr. Woods: Preventable Diseases. 1909. (Chapters x and xi.) TRANSMISSIBLE DISEASES 197 23. Jacobi, Dr. A.: "Contagious Disease." Report of Fifth Congress of Am. Sch. Hyg. Assoc, 1911, pp. 51-58. *24. Kerr, Dr. James: (and others): "The Control of Measles." School Hygiene, 1913, pp. 131-69. 25. Laser, Dr.: "Das Nagelbeissen der Schulkinder." Zt. f. Schulges., 190G, pp. 219/. *2C. Matheny, W. A.: "The Common Drinking-Cup." Ted. Sem., 1911, pp. 205-14. (Contains bibliography of twenty-three titles.) 27. Meylan, G. : " The Hygiene and Sanitation of Summer Camps." Report of Sixth Congress of Am. Sch. Hyg. Assoc, 1912, pp. 71- 76. *28. Nice, Leonard B.: "The Disinfection of Books." Ped. Sem., 1911, pp. 198-204. (Contains bibliography.) *29. Oker-Blom, Dr. Max: "Zur Bekiimpfung des Scharlachs in den Schulen." Inter. Mag. Sch. Hyg., 1912, pp. 516-28. 30. Osier: Modern Medicine Series. 31. Petruschky, Dr. J.: "Der Diphtherieschutz der Schulkinder." Beiheft with Zt. f. Schulges., August, 1912, pp. 177-88. 32. Porter, Dr. Charles: School Hygiene and the Laws of Health, pp. 224-38. 33. Pottenger, Dr. F. M.: Tubercidosis. *34. Poelschau, Dr. : " Ueber die Bekampfung der Masern durch die Schule." Beiheft with Zt.f. Schulges., August, 1912, pp. 162-77. 35. Porter, Dr. Langley: Prevention of Tuberculosis in Children. *36. Rosenfeld, Dr. S.: "Schulbesuchsdaueru. Morbiditat." Zt.f. Schulges., 1906, pp. 472/. *37. Schulz, Dr.: "Ueber Klassenepidemien von Diphtheric" Beiheft with Zt. f. Schulges., August, 1912, pp. 188-98. 38. Sequeira, Dr. J. H.: "The Treatment of Ringworm." School Hygiene, 1912, pp. 155-61. .39. Shaw, E. R. : School Hygiene. 1901. (Chapter xn.) *40. Von Sholly, Dr. Anna: "Trachoma; Its Prevalence and Treat- ment." Report of Sixth Congress Am. Sch. Hyg. Assoc, 1912, pp. 115-24. 41. Toledano, Dr.: "La revaccination des enfants des ecoles." La Midecine Scolaire, 1912, pp. 113-25, and 162-76. *42. Williams, Dr. Lewis: "The Control of Contagious Diseases through the School Clinic." School Hygiene, May, 1910. *43. Newmayer, S. W.: Medical and Sanitary Inspection of Schools. 1914, pp. 318. See also the Proceedings of the various International Congresses of School Hygiene, especially of 1913. CHAPTER XII OPEN-AIR SCHOOLS Recent spread The phenomenal spread of open-air schools during the last few years constitutes one of the most signif- icant developments in modern education. 1 The first open-air recovery school was that of Charlottenburg, Germany, in 1904. England's first school of this type was opened in 1907; America's first, in 1908. Since then, open-air schools for tuberculous or pre-tuber- culous children have been established in nearly all of the large cities of every country. There were open-air schools in forty -four cities of the United States in 1912. No city which has undertaken the work has subse- quently abandoned it. The school department of Boston has adopted the plan of building one or more open-air classrooms in each new school building to be erected. About 5 per cent of Boston's school population will attend these classes. In some of the cities and countries of Cali- fornia a majority of the school buildings now being erected are constructed on a plan which permits all the rooms to be converted in a moment into open-air rooms. This is done by means of hinged windows, 1 For a comprehensive and interesting account of this entire move- ment, including data regarding management, cost, etc., the reader is referred to the admirable booklet by Leonard P. Ayres. OPEN-AIR SCHOOLS 199 which reach from floor to ceiling, and which occupy practically all of the space of one or more of the walls. The open-air school has been conducted in the main for the benefit of tuberculous or pre-tuberculous chil- dren. Here such children are watched over by school nurses or medical attendants, fed from one to five meals of nourishing food per day, and given a daily program which resembles very little the study pro- gram of the ordinary school. The book work is usually reduced to two or three hours per day and the re- mainder of the time is devoted to manual work, play, meals, rest, and sleep. Program The following program of the Bradford (England) open-air school is typical : — 9 A.M. Breakfast. 9.45 to 10.45 Ordinary school work. 10.45 to 11 Play. 11 to 12 Ordinary school work. 12.30 to 1 Dinner. 1 to 2 P.M. Rest and sleep. 2 to 3 Play. 3 to 4.30 Outdoor lessons (nature study, geography, etc.). 5 Tea. 5.30 to 6 Play. In some of the open-air schools of Germany as many as five meals are served per day ; in the United States, more often from one to three. In some cases the amount of time devoted to instruction is less than that at Brad- ford, and the period for sleep proportionately longer. 200 HEALTH WORK IN THE SCHOOLS Results Tuberculous children who attend open-air classes seldom fail to show immediate and rapid improvement in weight, appetite, blood-count, mental alertness, and freedom from colds. At the Bostall Wood School (London), children gained on the average six and a Lbs. A.ug Sept. Ocfc Nov. 4 S c shoo osec 1 3 2 1 ** *"' *'* .'" ^** _,*'' .+' .**. ."' >" *'• *"' .-*" -*"' FIG. 6 Showing the average weekly gain or loss in weight of children attending the Bradford Open-Air School in 1908. The dotted line shows the average in- crease which takes place in the case of children under ordinary conditions. Mid-winter sun-baths at Leysin Hospital for children with tuberculosis of the bone. Pivot windows. Open-Air School. George Bancroft Building, Minneapolis. OPEN-AIR SCHOOLS OPEN-AIR SCHOOLS 201 half pounds during the thirteen weeks the school was in session. The Charlottenburg school brought a similar increase in weight. In the first open-air school of Chicago the average gain per child was three and three quarter pounds during the first month. These gains are all much in excess of the normal. As a rule, the rapid gain in weight continues only so long as the school is in session. When vacation comes, and the child is thrown back upon the resources and regimen of the home, his progress toward recovery is checked or thwarted altogether. In the school year 1910-11, the children of Open-Air School Number 21, New York City, lost during the Thanksgiving, Christ- mas, and Easter vacations an average of 1.72 pounds per child. This was 49 per cent of the average gain per child during the entire year. In one of the Cleve- land open-air schools (1910-11) the pupils made an average gain in weight of more than four and a half pounds between December 12 and January 9, while the pupils of a similar school, in the same city, required to be indoors during the same period on account of building repairs, suffered an average loss of one and a half pounds, notwithstanding the continuance of special feeding. The improvement in the condition of the blood is also very marked. Children who are placed in open-air classes are usually found to have a haemoglobin con- tent of about 70 per cent. Sometimes it is as low as 50 or 60 per cent. Under the combined influence of outdoor instruction, feeding, decreased book-work, 202 HEALTH WORK IN THE SCHOOLS and increase of rest and play, the haemoglobin seldom fails to mount rapidly to 80 or 85 per cent. This is within 5 or 10 per cent of normal for children of school age. At Bradford the average increase of haemoglobin during nine weeks was 10 per cent. For Open-Air School Number 21, New York City, the average gain per child from October to May was 13.75 per cent. Haemoglobin records, like those of weight, demon- strate the superiority of the open-air school over the average city home. This is clearly revealed in figure 7. /o 84 82 80 78 76 74 J 3 J3 ° " ^ © t» P *1 ._• • .. . o S . ® / \ f \ \ } i \ \ \ \ t % C ~\ \ \ \ \ 1 \ FIG. 7 Haemoglobin tests, Providence Open-Air School, 1908-1909. Average for class. Note falling off during vacation. OPEN-AIR SCHOOLS 203 Except for vacation disturbances, therefore, the haemoglobin improves under the open-air regimen throughout the school year. The gain is usually very rapid at first, then becomes somewhat slower as the normal condition is approached. It is interesting to compare with this the haemoglobin curve of normal children in the ordinary indoor class. Such a comparison was made in New York City, in 1910-11, between 27 normal children of the regular 90 89 88 87 86 85 84 a 83 2 82 1 81 1 80 *S 79 as 78 77 76 75 -74 T8 -72 _. Jl rare — Oct. Nov. Dec. ■ran — Jan. Feb. Mar. Apr. May June 8 *»., ^ ■ ^ £<% ° 1 •. ■■ ^iinn ■ \< «■ Hirot ■m BB&- ■■ ^~^™ ■ VT iy ;|pi re \ 9 jM r fr \ Hra ' ■ y Kt^m ■ i IBP i%vl«w^ v! F zzagj^ ? •' vrgjw ^i.^Jl ■l . .... -' 5 4 I ' £| " a S I ^ I S a. ^ >> S5 A The monthly examination by the physician in charge. Complete relaxation on the cots. CHICAGO OPEN-AIR CLASSES From Kingsley's " Open-Air Crusaders," by permission of United Charities of Chicago. OPEN-AIR SCHOOLS 207 lief maps are constructed in the sand showing the configuration of the surrounding country. The action of running water, the formation of deltas, the causes of floods, the modes of irrigation, etc., are all made clear by objective instruction. The habits of plants and animals, fundamental facts relating to the de- composition of rocks, soil formation, weather condi- tions, etc., are easily imparted and made intimate possessions of the child's mind. Open-air schools have so fully proved their superi- ority as to warrant their extension to include a con- siderable proportion of the school population. At least ten or fifteen per cent should be looked upon as def- initely predisposed to tuberculosis. Nor is there any valid argument for limiting the advantages of open- air schools to children who are sickly. Schools which accomplish so much for the latter could not fail to be of benefit to normal children. It is foolish to deny a healthful environment to all except those whose health is already impaired. REFERENCES ON OPEN-AIR SCHOOLS 1. Austin, Gertrude: "Heliotherapy for Tuberculous Children." The Child, 1912, pp. 839-45. *2. Ayres, Leonard P.: Open-Air Schools. 1910, pp. 171. 3. Baginsky, Adolph: "Ueber Waldschulen u. Walderholung- statten." Zt.f. piid. Psych., Path., u. Hygiene, 1906, pp. 161-77. 4. Bienstock: "Die Waldschule in Mlihlhausen." Zt.f. Schulges., 1908, pp. 219 ff. *5. Bruner, F. G.: "The Influence of Open Air and Low Tempera- ture on the Mental Alertness and Scholarship of Pupils." Proc. N.E.A., 1911, pp. 890-98. 6. Clark, Ida: "Open-Air Schools in England and Germany." Kgn. Rev., 1910, pp. 462-09. 208 HEALTH WORK IN THE SCHOOLS 7. Crowley, Ralph: The Hygiene of School Life. 1910. (Chapter XIV.) *8. Curtis, Elnora: "Outdoor Schools." Ped. Sem., 1909, pp. 169- 94. 9. Godfring: "Die Waldschule f. Schwachbefahigte Kinder." Zt. f. Schulges., 1907, pp. 236 ff. *10. Haberlin, Dr. : " Die Blutarmut u. Skrof ulose der Kinder; ihre Folgenu. ihre Behandlung." Zt.f. Kinderforsch., 1911, pp. 1-8. 11. Henderson, C. H., "Outdoor Schools." The World's Work, January, 1909. *12. Kingsley, Sherman C: Open-Air Crusaders. 1911, pp. 109. *13. De Montmorency, J. E.: "School Excursions and Vacation Schools." Special Rept. by London Board of Education, 1907, pp. 71. 14. Spencer, Mrs. Anna: "Open- Air Schools." Rept. of Inter. Cong, of Tuberculosis, 1908, pp. 612-18. 15. Taylor, D. M.: "Residential Open- Air Schools for Delicate children." The Child, 1912, pp. 846-54. 16. Warner, Allan: "Open- Air Schools by the seaside." The Child, 1912, pp. 826-38. *17. Watt: W. E.: Open Air. 1910, pp. 282. 18. Williams, Ralph: "The Sheffield Open- Air Recovery School." School Hygiene, 1910, pp. 136-43. CHAPTER XIII SCHOOL HOUSEKEEPING School dust and its dangers Schoolrooms have too long been prisons for the incarceration of children and dust. Until recently, a school without its eternal cloud of dust was as in- conceivable as a school without children. However, with the advance of physiological and bacteriological science our ideals are undergoing a rapid change, and the modern canons of school hygiene are ever becom- ing more strict in regard to methods of insuring clean- liness. School cleanliness means chiefly the avoidance of dust. To carry on a constant warfare against this enemy of children we employ janitor service amount- ing to the full time of 30,000 or 40,000 men and women. Their monthly wages amount to more than the wages paid to our standing army. The enemy they fight is infinitely more menacing to our national welfare than the military forces of other nations. Directly and indirectly, dust probably causes greater destruc- tion of life in the United States every year than was accomplished by battle in any year of our Civil War. All nations employ naval and military experts at liberal salaries to study scientifically the means of defense and destruction in order that the forces of war may 210 HEALTH WORK IN THE SCHOOLS be managed effectively. But nations do not employ dust experts. Few people know what constitutes efficient janitor service, or care enough about it to find out. Would not a national training school for janitors contribute more to humanity than do mili- tary and naval academies? Dust is of two kinds, organic and inorganic. Dust of some kind is omnipresent. On lofty mountain-tops or over the sea the number of dust particles per cubic centimeter of air may be as low as 150 or 200. In a garden near the center of Paris the number was 160,000 per cubic centimeter. The air in a room where the Royal Scientific Society of Edinburgh met was found to contain 275,000 particles per cubic centimeter be- fore the meeting and 400,000 after an hour and a half. Near the ceiling there were 3,000,000 particles per cubic centimeter. But not all dust is injurious. If not metallic or gritty, inorganic dust particles may be breathed in great numbers without injury. Apart from germ- bearing particles, it is the gritty mineral dust that is most to be feared. Mineral dust produces its injury in two ways : (1) Numerous small particles lodge in the lungs and excite by their presence the formation around them of a fibrous tissue which replaces the true lung tissue; and (2) they produce lacerations of the throat and lungs which serve as lodging-places for disease germs, especially the tubercle bacilli. Laborers who grind pottery, and inhale thousands of sharp-edge dust particles with every breath, die with SCHOOL HOUSEKEEPING 211 six times the normal frequency from tuberculosis. For the same reason, glass-workers and stone-cutters have a mortality from tuberculosis several times the normal. Mineral dust is abundant in all but the best-kept schoolrooms. It is (1) blown in by the dust-laden air from streets or roads; (2) carried in on the shoes of children as dirt and gravel, later to be ground and pulverized on the floor; and (3) manufactured in large quantities by the inordinate use of chalk and black- boards. Dust from all these sources is so dangerous that relentless warfare should be waged against it. Organic dust is dangerous principally as a germ- carrier, although air-borne germs do not play as great a role in causing infectious diseases as they were formerly thought to play. Nevertheless infections sometimes occur in this way, and hygiene demands that we should keep the number of organic dust parti- cles as low as possible. The amount of germ-carrying dust in a room is tested by exposing to the air, for a given time, a gela- tin plate of standard size and material, which catches the floating germs and acts as a culture medium for the development of bacterial colonies. The plate is then examined microscopically, and the number of bacterial colonies counted. The number collected on a plate is found to vary from none in purest mountain air to many hundreds in the worst ventilated dwellings, shops, and schools. In a children's drawing-room the number in a short 212 HEALTH WORK IN THE SCHOOLS time was multiplied eight times by the dancing of twenty children. In railway coaches, bedrooms, schools, etc., the number increases rapidly the more persons there are crowded together, the more actively they move about, and the smaller the intake of pure air. The investigations of Camelry, Haldane, and Ander- son show that the number of germs carried by school- room air averages about ten times as great in the worst ventilated as in the best ventilated schools. Children are often exposed for six hours a day to an atmosphere which is five times as thick with germs as the ordinary bedroom in a middle-class home. It was found that the number of bacteria per liter of air in a Dundee high school could be raised from 10 to 150, by having the pupils stamp on the floor. The number is always enormously increased by calisthenic exercises in the room, by the movements of children at recess, and by dry sweeping. Even a well- ventilated schoolroom, if dirty, has been found to contain more bacterial colonies than a one-room city dwelling, kept clean. Prevention of dust by means of floor oils Many experimental tests have demonstrated that floor oils are extremely effective, if applied correctly and often enough. The floor should first be cleaned thoroughly, the oil should be spread thin, and after drying the unabsorbed oil should be mopped up. Treatment should be given at least three days before SCHOOL HOUSEKEEPING 213 the room is to be used, and should be repeated at least two or three times yearly. The following table from Dr. Lambert, 1 which is a fair sample of numerous experiments of this kind, illustrates very well the effect of floor oil on the num- ber of germs in schoolroom air: — TABLE VI Colonies of bacteria Plates exposed Floors treated with oil Floors not treated 5 minutes in still air 2 38 11 6 1 7 30 minutes in still air 12 5 minutes during sweeping 456 5 minutes just after sweeping 5 minutes beginning 10 minutes after sweeping 5 minutes beginning 15 minutes after sweeping 79 62 31 Dr. Butler's tests (quoted by Lambert) show that the bacteria are no more numerous over an oiled floor after four weeks than over an untreated floor two days after scrubbing. In fact, the oil is very effective for twelve to fifteen weeks after its application. Other tests have shown that an old, worn floor is more hy- gienic when oiled than a new and well-laid floor un- treated. Oker-Blom has demonstrated that if a floor is properly treated with oil the amount of dust in the air after sweeping is less than is the case after the chil- dren have been permitted to run twice around the room in physical exercises. 2 1 See reference 10 at the end of this chapter. 2 See reference 12 at the end of this chapter. 214 HEALTH WOEK IN THE SCHOOLS Against the use of oil it has been argued that it darkens the floors, makes them slippery, and causes the soiling of girls' dresses. These arguments have little weight. The darkening can be partly prevented by properly cleaning the floors before the oil is applied, and by wiping them every week with wet cloths. The floors will not be made slippery if the excess of oil is removed, nor will they, after the first few days, spot the dress very considerably. With the shorter dresses now worn, the skirt and the floor seldom come in con- tact. Pupils should be taught, anyway, that it is better and cleaner to have a little dirt on the dress than to mix it with the food which is given to the lungs. Method of cleaning The number of dust particles and germs also depends on the method of dirt removal. The least effective method is that of sweeping the dry floor with the old- fashioned straw broom. Only the coarse dirt, which, of course, is harmless because it could not reach the lungs, is removed in this way. The fine dirt, the only kind that can injure us, is mixed with the air. The bristle brush far excels the broom as an instrument of cleanliness, and is especially effective when used with dampened sawdust or other materials of like nature. Still better is the oil brush, an ordinary brush furn- ished with a small tank for kerosene. The kerosene slowly feeds down from the tank upon the bristles, keeping them slightly moist. When the floor is kept SCHOOL HOUSEKEEPING 215 well oiled and brushes of this type are used, the dust practically disappears. It seems probable, however, that vacuum cleaners are destined to supersede all other methods in the care of schoolhouses, as they have done for office buildings, hotels, apartment houses, etc. Some hun- dreds of school buildings are already equipped with them, with a resulting noticeable decrease in sickness and improvement of attendance. Where primitive methods of sweeping are employed, dusting becomes an important feature in the care of the school building. The feather duster and the old- fashioned broom were fit companions in crime. Both have been driven from our city schools, but both continue their nefarious business in the rural dis- tricts. They should be outlawed relentlessly. The feather duster moves the dust, but does not re- move it. The only way to get rid of the dust which settles on the school furniture is to wipe it up with a damp cloth. No other dusting deserves the name, and any other kind is worse than none at all. Other ways of preventing dust We have already seen that floating dust is many times increased by the marching, stamping, and play of children in the room. Calisthenic exercises should be given out of doors, and, except when it cannot be avoided, children should not be permitted to remain indoors at recess time. Open windows let the fresh 216 HEALTH WORK IN THE SCHOOLS air blow in and the dust blow out. The windows should be kept open during all recesses. As a rule, blackboards are used much more than is necessary. "Dustless" crayons are not quite dustless, but should replace the soft plaster-of-Paris chalks still so generally used. Better than chalk and black- board is the " muroscroll, " a paper surface which rolls in a wooden frame and is used with wax crayon. It is inexpensive, convenient, and while not rendering the blackboard entirely unnecessary, it can replace it for most purposes. Dust can be further prevented by proper cleanliness of the children in shoes, dress, and body. The schools should be provided with doormats of both the wire and fiber varieties. Special effort should be made to keep the gym- nasium clean. Children breathe more deeply there than in the classroom. Mats and other dust-gathering paraphernalia should be discarded. The windows should be kept open, and cleaning should be thorough and frequent. If the school building employs mechanical ventila- tion, care should be exercised to keep the fresh-air supply free from dust. The intake should not be near a street or a dusty playground. In many cases it is necessary to screen the air at the intake by letting it pass through a cloth filter, which is kept damp by the dropping of water upon it. The basement also deserves special mention, partic- ularly when it is used as a substitute for playgrounds. M 1 * , 1 H mmm THE MUROSCROLL SCHOOL HOUSEKEEPING 217 It is almost always poorly ventilated, and is usually filled with fine mineral dust produced by the move- ment of children over the cement floors. If a real play- ground is impossible, it is often better to use the halls than the basement for this purpose. Chicago has re- cently abolished basement play, and other cities are rapidly following the example. The moral argument against the basement playground is as strong as the hygienic. Standards of cleanliness The low standard of cleanliness still prevailing in the care of the school is well brought out in an in- vestigation by the Russell Sage Foundation in 1911. By means of a questionnaire sent to our 1200 cities, reports were secured from 758 on this point. The main results are summarized in the table given below. It TABLE VII Frequency Daily Once in 2 days .... Once in three days. Weekly Once in 2 weeks . . . Once in 3 weeks . . . Monthly Once in 2 months. . Once in 3 months. . Once in 5 months. Once a year As needed Never Cities reporting Floors Floors Windows washed swept washed 1 574 1 1 49 1 3 86 36 6 22 27 2 8 8 5 135 2 117 50 1 84 140 139 115 2 111 57 31 68 10 139 44. 5 218 HEALTH WORK IN THE SCHOOLS will be noted that less than one half wash the floors as often as once in three months, and that nearly 10 per cent do not sweep oftener than once in three days. It is very probable that if data could be secured from the cities which failed to answer the questionnaire the figures would be still more shocking. The school cannot be kept sanitary unless it is thoroughly swept and dusted each school day. The sweeping should always be done with windows open and after the close of the school day. The dusting should be done in the morning, at least half an hour before the pupils assemble. If the floors have not been oil-dressed, damp sawdust or some other preparation should be used in sweeping. Untreated floors should be varnished once a year, and all cracks should be kept filled. In addition, the floors and all the furniture need to be thoroughly washed every few weeks. Win- dows also should be cleaned several times a year, to keep them more transparent. Copenhagen requires that the school furniture be washed at least once every fourteen days, the windows eight times a year, and the inside of the desks once a year. The floors must be cleaned daily, and dry sweeping and dry dusting are prohibited. These measures were instituted chiefly for the purpose of combating tuberculosis. Janitor service should not ordinarily be done by the pupils, but in case this cannot be avoided, only pupils of good physical constitution, and those who come SCHOOL HOUSEKEEPING 219 from families untainted with tuberculosis, should be permitted to do the work. Professional training for janitors Efficient housekeeping in the school should be sub- stituted for our present haphazard janitor service. The school should be kept as clean as our best hospitals. Before this can be brought about, janitors will have to be better trained for the work they have to do. Too often janitors have nothing to recommend them except "poverty or political pull." The position of janitor is really a responsible one. No other individ- ual about the school building, unless it be the princi- pal, has so much influence over conditions which affect the health of the pupils. At present even the better class of janitors usually do this work by rule-of-thumb methods. This is be- cause they have received no instruction as regards the scientific principles which relate to their work. Instead of merely being able to operate a fan, etc., mechanically, the janitor ought to know why fresh air is needed. He should not only be willing to sweep and dust according to rules, but he should appreciate the dangers arising from bad methods of school housekeeping. He should not only be able to run the ventilating and heating apparatus when it is in order; he should also have the mechanical skill to make certain repairs and to locate defects. Such knowledge and skill do not come of themselves. Professional training courses are needed, along the 220 HEALTH WORK IN THE SCHOOLS lines suggested by references 6, 8, and 13 at the end of this chapter. Courses of this type do not cost much in time or money, and the results are out of all pro- portion to either. It is vain to expect in janitors a love of cleanliness or a conscientious adherence to the rules laid down for them, if they do not appreciate the dan- gers of uncleanliness and the reasonableness of the rules. 1 REFERENCES *1. Ayres, Leonard P.: "What American Cities are doing for the Health of School Children." Annals Am. Acad. Polit. and Soc. Sci., March, 1911. *2. Burgerstein, Leo: "The Main Problems of Schoolroom Sanita- tion and School Work." Ped. Sem., 1910, pp. 15-28. 3. Burrage and Bailey: School Sanitation and Decoration. 1899. 4. Burmeister, K.: "Ueber die Verwendung von Staubbindenden Fussbodenolen in Schulen." Inter. Mag. Sch. Hyg., 1905, pp. 185-217. 5. Cooley, R. L.: "The Vacuum Cleaning of Schoolhouses a Spe- cial Problem." Am. Sch. Board J., July, 1911, pp. 18-19. *6. Dresslar, F. B.: School Hygiene, 1913, pp. 344-63. 7. Engels, Dr.: " Staubbindende Fussbodenole." Zt. f. Schulges., 1903, pp. 349-72. 8. Frost, W. D.: "Our Short Course for Janitors." Proc. N.E.A., 1911, pp. 990-92. 9. Furst, M.: "Ueber die Reinigung der Volkschulklassen." Zt. f. Schulges., 1903, pp. 441-47 and 545-67. *10. Lambert, John: "Preparations for the Prevention of Dust in Schools." The Child., January, 1912, pp. 279-89. *11. Macfie, R. G.: Air and Health. 1909, pp. 161-91. 12. Oker-Blom, Max: "Diirfen die Schulkinder beim Kehren der Schulraume behilflich sein?" Inter. Mag. Sch. Hyg., 1912, pp. 477-90. *13. Putnam, Dr. Helen: School Janitors, Mothers, and Health. 1913, pp. 201. 1 See reference 6 for an ideal set of instructions for the use of janitors. CHAPTER XIV THE TEACHING OF HYGIENE: THE FIRST SIX GRADES Inculcating health habits Those who are interested in the subject of hy- giene and sanitation in schools, whether as students, teachers, or principals, ought to possess some def- inite knowledge of the fundamental ideas underly- ing the successful presentation of health principles to children. These principles of health are in fact relatively simple, but unfortunately almost no other subject in the public schools is so inadequately taught as hygiene. This condition is to be explained in part by the fact that teachers are themselves ordinarily poorly instructed in the subject; in part by the fact that the subject-matter is not directly applied to the real life of the pupil, and is therefore ineffective. There is a vast difference between instructing a child about principles pertaining to his health and inducing him to put such principles into action. The teacher's problem is mainly the latter one, and any method of instruction which fails in this respect is a failure altogether. We hear much about the health supervision of schools, physical education, and the like, but how often are these ideas associated with the proper methods of school sanitation and with efficient instruc- 222 HEALTH WORK IN THE SCHOOLS tion of pupils in matters pertaining to personal health? The truth is that the various health problems in schools have not been sufficiently correlated, and therefore much waste of time and energy have re- sulted. The problems of school hygiene will never be solved in a satisfactory manner until the closely related factors entering into them are clearly apprehended and properly associated. Of these factors, that of hygiene teaching is one of the most fundamental. How shall health instruction be made efficient in the different grades, and to pupils of various ages and of different home conditions? It would seem self-evi- dent that the first requirement is that the instruction must be adapted to the pupil's powers of compre- hension, but this is the very requirement most often lost sight of. The adaptation of the subject-matter to the intellectual and social development of the child has been strangely, and one might almost say per- versely, neglected. Miniaturing a subject adapted to an adult mind does not necessarily bring it within the range of the child's comprehension. In the lowest grades, say from the first to the fifth inclusive, little formal instruction is necessary, but health habits must be established at this stage of the child's development. This can be successfully accomplished by regarding such habits as an im- portant part of the child's everyday life at school, and as far as possible in the home. From the time a child enters school, until he is about ten or eleven THE TEACHING OF HYGIENE 223 years of age, it is a mistake to suppose that he is much influenced by explanations and reasons. His habits of life during this period ought to be largely auto- matic. Children of this age who learn successfully do so mostly by imitation and constant repetition. This is the age during which environment exerts its greatest influence, for the young child becomes a part of all that surrounds him. A child's character in most fundamental particulars is usually pretty well established by the time he is seven or eight years of age, if indeed not earlier. It is of the utmost impor- tance, therefore, to place young children in a proper health environment. This must find expression in the schoolroom, in the personal habits of the teacher herself, in the school associates of the child, and in the general conditions of the child's home. The rather common practice of attempting to in- struct very young pupils in such subjects as the effects of narcotics and stimulants, the physiological uses of food, the structure of the body, the functions of organs, the chemistry of the air, the nature of the blood, the growth of bacteria, and the methods by which they are spread, and the like, is so absurd as to seem past belief. Yet these are some of the many topics to be found mentioned in most courses of study for children in the lower grades, and in part required by the laws of the State. The young child's mind never fully grasps such abstract ideas. Information at this period, to be of value, must be concrete, def- inite, capable of being expressed at once in action, and 224 HEALTH WOKK IN THE SCHOOLS stated in terms with which the boy or girl is already perfectly familiar. The child must be instructed how to do the right thing in health, rather than why to do it, just as the aim of moral education 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 by children only when they are so educated that they do not have to think about it. It is of no possible use to tell small children that dirty finger-nails may harbor disease bacteria, or for us to talk about germs at all. These little pupils may successfully repeat what is said to them about such matters, but such conceptions are never really grasped by the young child. The habit of clean hands and nails at school must be acquired by the child, not primarily because of the possible danger from disease germs on dirty hands, but because clean hands are arbitrarily desirable. And the same may be said of habits pertaining to clothing, shoes, the hair, the teeth, and various other personal matters. The kind of knowledge which is desirable at this age is that which expresses itself in useful action. It is not essential that young pupils, or most older ones, should learn much about the structure or anatomy of the body; nor is it necessary or desirable for any but relatively mature pupils to understand how the body does its work (its physiology). But even the very youngest children in the schools are not too young to begin to learn some simple but fundamental prin- ciples in respect to the care of the body, about some THE TEACHING OF HYGIENE 225 of the things which interfere with its best action, and how to avoid them. This is true hygiene. The complete study of the human body is one of the most difficult of all subjects. No piece of ma- chinery, however complicated it may be, can compare with the body in this respect. But without attempt- ing to study any but its most obvious features of struc- ture and action, even very young children can under- stand enough about this human machine of ours to learn how to take the best care of it. It should be the purpose of hygiene instruction in schools "to help young people, who will be men and women before very long, to know the truth about common living, and to act on such knowledge." Health instruction in the first five grades As has already been indicated, no formal methods of instruction need be presented before the sixth grade. Instead, teaching effort ought to be concentrated upon the inculcation of health habits. One of the easiest and most effective methods for helping the pupil to form health habits at this time is that of "personal inspection." This need never prove embarrassing, either to the pupil or to the parent, and when properly conducted will be regarded, first, as a source of entertainment, and second, as a matter of personal pride, until at last health habits have become an inseparable part of the child's life. Children are not dirty because they prefer to be so, but because they are not taught the pleasure of cleanli- 226 HEALTH WORK IN THE SCHOOLS ness. Nearly all the rooms of the lower grades in our grammar schools are offensive to the sense of smell, at least to the individual who has not had his olfactory sense perverted through constant abuse of it. This offensive odor is due in large part to dirty, neglected bodies and clothes. The first requirement is, there- fore, to inculcate the love of personal neatness and cleanliness. It goes without saying that the teacher herself must embody this principle before she attempts to impart it to her pupils. In some rare cases, however, the lesson will have to begin with the reformation of the personal habits of the teacher. Personal hygiene inspection by teacher and pupils The personal inspection of pupils must be adapted to the peculiar needs of individual conditions, but in the main may follow the method outlined below. The pupils themselves may be easily taught to take part in this inspection by the teacher appointing the one passing the best inspection to act as inspector of the rest of the class, for a given time. The complete inspection need not be introduced at once, but the pupils may be led very gradually into it, so that their interest will be aroused and their fears or prejudices overcome. Other points not mentioned in the outline here given may be introduced, at the discretion of the teacher, and in order to meet local requirements. Some points may, of course, be omitted for the same reason, but in general the plan here suggested will be found fairly satisfactory in the majority of schools. THE TEACHING OF HYGIENE 227 It should be noted that in this personal hygiene in- spection the questions are asked so that the negative answers indicate the number of undesirable conditions existing. Daily inspection of pupils in the first five grades 1. Are the hands clean? 2. Is the face clean? 3. Is the hair clean, well brushed, and cared for? 4. Are the nails clean and neat? 5. Do the teeth look clean? 6. Has the toothbrush been used? 7. Are the ears clean? 8. Is the clothing neat and clean? 9. Are the shoes neat, clean, and well fitting? 10. Does the child have a handkerchief? Additional information to be obtained by the teacher, at intervals 1. Is at least one window kept open in the bedroom at night? 2. Does the child drink coffee? How much? 3. Does he drink tea? How much? 4. Does he always have breakfast? 5. What does he usually eat? 6. Does he always have lunch? 7. What time does he go to bed? 8. What time does he get up? 9. Is he suitably clothed? 10. How often does he bathe? 11. Is he required to do any work for pay? What sort? 12. Are the bowels evacuated daily? 13. Has the child apparently any bad sex habits? 14. Does the child use an individual toothbrush? 15. Does the child visit a dentist at least once every year? In the grades one to five, inclusive, little need be done in the way of health instruction beyond the con- stant inculcation of health habits. In grades one and 228 HEALTH WORK IN THE SCHOOLS two the simple daily inspection will be about all that will be necessary or indeed successful. Inculcating food habits Beginning with the third grade, when the average child will be about eight years old, some very simple talks about foods may be introduced. It will be pos- sible to discover what the child usually eats at each meal, what he brings to school for his lunch, etc. It will be possible to teach these little people that they must have a mixed diet, and to explain in common words what this means. Peculiar and undesirable food habits may be dis- covered and corrected at this time. The child of this age can be taught how properly to masticate his food . A visit to the domestic science department may be made, and the children instructed how and what to eat by means of some actual meals eaten there under obser- vation. Simple health stories will prove useful at this period in the child's education, such as may be found in Hall's Primer of Hygiene. These stories ought to be read and explained by the teacher, and not set as les- sons to be recited by the little pupils (a method which never accomplishes any good). Proper eating habits may be rather easily acquired at this time. If the child in the third grade learns how and what to eat, his in- struction in hygiene will have been quite satisfactory. Here again the explanation, or why, is entirely unneces- sary, and has little or nothing to do with the formation of good habits. THE TEACHING OF HYGIENE 229 Other health habits may, of course, be formed at this age, and the teacher must use her judgment about what is most necessary to include under particular and peculiar conditions. This will depend largely upon the social status of the average pupil in her class. Vital topics of hygiene study for grades three to five The following tabulated suggestions are offered as helpful in instructing pupils from 9 to 12 years of age: — 1. Make lists on the board of what a considerable number of pupils had for breakfast. 2. From this make a list of the good foods, and another of the bad foods. 3. Include in the desirable foods such things as milk, cocoa, well-cooked cereals, bacon, eggs, toast, bread and butter, cornbread, crackers, and fruit, — particu- larly baked apples and stewed prunes. 4. Include in the undesirable foods such things as coffee, tea, hot breads and biscuits, doughnuts, and hot cakes of all kinds when used to the exclusion of other foods. 5. Make a list of breakfasts which fail to include a suffi- cient variety of foods. 6. Make a list of breakfasts which include a good variety of foods. 7. Note how many children report breakfasts principally made up of coffee and bread; coffee and doughnuts; coffee and crackers; bread and syrup; or breakfasts which include only starchy foods, or exclusively meat foods. Learn how many have butter. Note how many children eat no breakfast. Find out what time the meal is eaten ; how long the child spends at breakfast ; whether the child sits at table when he has his breakfast. 8. If necessary, try to get in touch with the parents of children who have inadequate or otherwise undesirable breakfasts. This may often be accomplished by the 230 HEALTH WORK IN THE SCHOOLS school nurse, who sometimes works miracles in home reform. 9. Simple talks on the care of teeth may now be introduced . They ought to be based upon actual conditions discov- ered in the class by the teacher in the daily and other inspections. 10. Simple lessons on the value of good air may be intro- duced in the third grade and carried through the other grades. The young child is not interested in the mechan- ical processes of ventilation, but may easily be taught to value fresh air and to form a dislike for foul air. Teach the child at this time how to detect bad air by the sense of smell, and encourage him to observe in this way the conditions present at school and at home. Proper breathing habits may be profitably taught now, and the teacher will be surprised to discover how few children know how to breathe in the right way. 11. The cleanliness of the schoolroom must be dwelt upon, and the children urged to take part in keeping it free from unnecessary dirt. If during the first five grades the daily personal and the general inspection at intervals be observed, and knowledge of good food, fresh air, and cleanliness of environment be insisted upon, the child will have formed the most fundamentally important habits of health. But the teacher must never forget that what she is teaching is not "lessons," but habits, and that, therefore, she must never fail to relate each and every part of her instruction to the daily life of the pupil. To sum up what the average pupil ought to have acquired by the time he has reached the sixth grade, we will say: — 1. He ought to appear at school with reasonably clean hands, face, ears, and body. 2. His clothes ought to be neat, and free from avoidable dirt. THE TEACHING OF HYGIENE 231 3. His shoes ought to be reasonably clean, and well enough fitting to avoid injury to his feet. 4. He must have acquired a love for fresh air, and an antipathy toward bad air. 5. He must have learned by experience the value of a well- ventilated bedroom and schoolroom. 6. He must have learned to eat properly, and to know in general what to eat and what not to eat. 7. He must have learned to value not only cleanliness of person, but cleanliness of immediate environment. 8. He must have learned how much to sleep, what time to go to bed, and what time to get up. 9. He must have acquired the habit of evacuating his bow- els daily. 10. He must have learned to value a clean mouth and clean teeth, to use his toothbrush daily, and to visit a dentist at least once a year. Teaching hygiene in the sixth grade Beginning with the sixth grade, the character of hygiene teaching should be considerably changed from that given in the earlier grades. One of the best meth- ods for presentation to children of this age (about 11 or 12 years) is that which has been employed with re- markable success by the Health Department of New York City in its "Little Mother's League." Hygiene lessons dramatized Under the guidance of a skillful woman physician and school nurse, little girls of 10 to 12 years of age are taught simple, practical lessons in home hygiene, including such things as the care of milk, foods for babies and young children, the general care of babies, keeping the home clean, the value of fresh air, and 232 HEALTH WORK IN THE SCHOOLS other useful lessons on the health of the home. Fol- lowing a lesson on a subject such as, for example, the care of milk, certain children (usually two) are ap- pointed to write a little drama and present it before the other members of the League. This method in- terests the children tremendously, and impresses the subject upon their minds more effectively than any- thing else could. One of the writers of this book wit- nessed such a play given by a division of the " Little Mother's League," of New York City, in the summer of 1911, and was greatly impressed with the value of this sort of health instruction. No attempt is made by the teachers to correct the phraseology of the actors in the play, but they are allowed to present the subject exactly in their own way. The only requirement on the part of the teach- ers is that the subject-matter shall be essentially cor- rect. This means that children teach other children in words of their own, an innovation in teaching which accounts for the wonderful and instant success which the method met as soon as it was introduced. This method may be easily adapted to classes in the public schools, and to mixed classes as well as to little girls alone. It seems rather remarkable that the most suc- cessful method ever devised for teaching useful health lessons to children of this age should have originated, not in the public schools, but in a great city health de- partment which has not ordinarily been looked upon as responsible for teaching of any sort. This is another illustration of the fact that some of the best methods THE TEACHING OF HYGIENE 233 of teaching originate outside of school systems, and is in line with the growing demand of to-day that teach- ing methods and lesson materials be in touch with the real life of the everyday world. The efficient and conscientious teacher will at once grasp the wonderful possibilities of this kind of in- struction through play, and easily adapt it to all the practical needs of pupils of the sixth grade. 1 Reading material may be employed at this time, if desired, although this is not in the least an essential requirement for any but the teacher who is devoid of initiative and interest in her subject. The writers would mildly protest against any required text for pupils of this grade, but would recommend supple- mentary reading, of which there is now fortunately available an abundance of the best sort. Outline of scheme for teaching hygiene in the sixth grade The following is a list of subjects from which selec- tions for discussion may be made by the teacher, and followed, in some cases, with appropriate supplement- ary reading by the pupils: — 1. Care of milk. 2. Handling of food at home, in bakeries, stores, markets, etc. 3. Preparation of food. 1 The Louisa Alcott School of Boston has carried this idea still further by the use of models of all kinds, which the children make. The exhibit of this school at the International Congress of Hygiene at Washington in 1912 was most impressive. 234 HEALTH WORK IN THE SCHOOLS 4. Preservation of food. 5. Eating habits. 6. Disposal of garbage. 7. Pure water supplies. 8. Disposal of sewage. 9. Water and purification. 10. Flies and their control. 11. Mosquitoes and their control. 12. Fresh air. (a) At home. (b) At school. (c) In factories, stores, theaters, churches, etc. 13. The skin. 14. The teeth. 15. The eyes. 16. The ears. 17. The nose and throat. 18. Colds. 19. Headache. 20. Personal habits. (a) Clothing. (6) The bowels. (c) Play exercise. (d) Sex habits. (e) Sleep. (/) Bathing. (g) Work. (h) Food. (i) Coffee, tea, tobacco, alcohol. Following the discussion and supplementary read- ing of the subjects indicated in the list given, pupils should be asked to make personal observations, re- port personal experiences, and in general should be encouraged to take an active part in the lessons. Technical explanations should be diligently avoided, and memory work discouraged. The teacher may now encourage the preparation THE TEACHING OF HYGIENE 235 and presentation of health plays on certain profita- ble topics. For advice on this subject teachers are rec- ommended to correspond with the Division of Child Hygiene of the New York City Board of Health, requesting details as to the management of the "Lit- tle Mother's League." l 1 For references, see p. 251. CHAPTER XV THE TEACHING OF HYGIENE: SEVENTH AND EIGHTH GRADES Early instruction must deal with the concrete When the pupil has passed into the seventh grade he is ready to begin the formal study of hygiene. Un- til this period he should have been occupied primarily in establishing proper health habits. If he has been led along the right educational paths he will have accomplished this object. It will now be possible to pay less attention to matters of personal health, and to concentrate attention more particularly upon matters of environment. At this time it will be possible and desirable to begin to instruct the pupil definitely about bacteria — what they are, what they do, how they are carried about. To attempt to do this before the child is about 12 or 13 years old will result in little real good. The young pupil must be confronted only with con- crete ideas, ideas rather closely related to his daily experiences. To attempt to present a subject which deals with the invisible world, as does the study of bacteria, is to violate one of the commonest principles of pedagogy, namely, that the child must be led gradually from the concrete to the abstract, from the known to the unknown. Beginning with the seventh grade, however, simple demonstrations, illustrating THE TEACHING OF HYGIENE 237 the relation of germ life to the various processes of human life, may be successfully introduced. Focus attention upon health, rather than upon disease The teacher cannot, however, be too careful to avoid focusing attention too much upon disease. The whole object of hygiene in the schools must be to teach health, not disease. How to keep well and strong is the desired object at this time. The avoidance of dis- ease will naturally follow when the pupil is properly instructed in the simple principles of health. Several of our otherwise useful modern texts on hygiene for the schools err in this respect, with the result that a sensitive child is more likely to be impressed with the morbid rather than the wholesome in daily life. Some hygiene texts, in their laudable attempts to escape the errors, platitudes, and gross exaggerations of the older texts, have done nearly as much harm in too severely adhering to the pathological scientific discoveries of the day, while at the same time ignoring the fact that the child has not acquired any true per- spective which will enable him to view things in their proper proportions. People may be easily frightened by too much truth, or rather by truth presented at too acute an angle. All that is necessary and essential in matters pertaining to disease may, if done at the right time, be easily presented without in the least frightening the child. When taught in the right way, and opportunely, modern ideas of hygiene and sani- tation need never alarm any one. 238 HEALTH WORK IN THE SCHOOLS Learning how to meet his environment constitutes, as Professor Huxley long ago said, a liberal education for the child. It is never ignorance, but knowledge, which leads to health, and therefore to happiness. Man has always been most afraid of those things which he does not understand. One need fear dis- ease far less when one really understands its nature and how easily it may usually be avoided. Before beginning the study of bacteria, the young student will do well first to observe some of the re- lated forms of life with which he is more familiar. For this nothing can serve a better purpose than common yeasts and molds. Every child knows what these are, but few know just how they grow and what they do. Practical instruction in bacteriology for the seventh and eighth grades For further suggestions and definite explanations the teacher is referred to Professor Conn's Bacteria, Yeasts, and Molds. None of the experiments given require any special training or technical skill, and therefore no teacher need feel discouraged from at- tempting to carry out the directions given. Apply the knowledge gained in the experiments on bacteria, yeasts, and molds to the keeping-power of various foods; to the condition of the air of various rooms; to the cleanliness of hands, etc. 1 1 If the teacher is in California, she should apply to the State Hygiene Laboratory at Berkeley for a set of demonstration plates, illustrating the growth of bacteria. In connection with this topic the teacher should read Conn's Bacteria, Yeasts, and Molds (Ginn & Co.). THE TEACHING OF HYGIENE 239 The teacher must make it very clear to the pupil that bacteria, yeasts, and molds are true plants, and therefore dependent upon similar conditions for their growth as plants of a higher nature. She must also let the pupil understand that, while most bacteria are perfectly harmless plants, disease bacteria are spread about in the same way as the harmless variety. Have the children note how colds spread in a room at school, and ask them to offer explanations. Apply the knowledge of colds to other forms of sickness. Ask for suggestions on the prevention of the spread of diseases. The value of general cleanliness, pure air, sunshine, clean food, pure water, and milk must be emphasized at this time. Let the pupil try to answer the following questions after having completed the study indicated in this section: — 1. What is yeast? 2. How does it get into food? 3. What kind of food does it need for growth? 4. How does it grow? 5. Why does it make bread rise? 6. What effect does heat have upon yeast? 7. Why will yeast not grow in preserved fruit? 8. What is required for the growth of molds? 9. On what sorts of things do molds grow? 10. How may the growth of molds be prevented? 11. Where do molds come from? 12. Where are bacteria found in greatest numbers? 13. Why does boiled milk keep longer than raw milk? 14. What sort of milk has the largest number of bacteria? 15. What is a good test of clean milk? 16. How do bacteria get into food? 17. What kind of air has the greatest number of bacteria in it? 240 HEALTH WORK IN THE SCHOOLS 18. What kinds of things carry bacteria? 19. How may food be kept from spoiling? 20. How are disease bacteria spread from one person to another? Teaching hygiene by means of "sanitary surveys" Following a general study of bacteria, in the manner outlined in the preceding section, the pupil may now be interested in making "sanitary surveys" in his immediate neighborhood. The plan which follows is not given from the idea that it ought to be strictly followed, but merely for its suggestive value. Teachers must use their judgment in adapting it to varying school conditions. In some instances it will be neces- sary to simplify the questions; in other instances they may be considerably amplified. Schools in rural districts must have surveys ar- ranged for them which will meet the particular prob- lems of the country: city schools will present very different sorts of problems to solve. The object of these surveys is to get the pupil in touch with his own particular health environment, to induce him to be observant of actual conditions as he will find them on the way to and from school, at home, on the city streets, in the country, in the school building, at the dairy, and in the market or grocery store. People endure unsanitary conditions because they have never been taught anything better. Just as soon as they become really observant, they become intoler- ant of whatever is unwholesome. Sanitary education is of vastly more importance than sanitary legislation. THE TEACHING OF HYGIENE 241 Pupils in school do not become interested in health through reading about it, any more than they suc- ceed in acquiring an interest in language through the study of technical grammar. Whatever the pupil acquires that is really worth while he gets by actual observation, practice, and action. Knowledge, to be of any value, must be put to use. The teacher who will make use of the survey plan, as suggested here, will be astonished at the results obtained, both in respect to the information gained and interest aroused in the pupil, and to the bene- ficial results reacting on the whole community. Such a plan recognizes the fact that the pupil is an embryo citizen, and seeks to prepare him for efficient citizen- ship in his own town or city. The following sanitary surveys are presented as generally suggestive of the possibilities in the study of a pupil's health environment : — 1. Sanitary survey of a home. 2. Sanitary survey of a market. 3. Sanitary survey of a school. 4. Sanitary survey of a bakery. 5. Sanitary survey of a dairy. Sanitary survey of a home I. Location. 1. Drainage. a. Is the house on raised ground? b. Is t he drainage carried oft' on all sides by natural or artificial drains? Yes No 1 These surveys are lo be made with the aid of the teacher, and, if possible, the parents. 242 HEALTH WORK IN THE SCHOOLS Sanitary survey of a home c. Are the grounds kept free from stag- nant water? II. Sunlight and ventilation. 1. Has the house good exposure to the sun? 2. Has it good exposure to the air? 3. Are the rooms most used on the sunny side of the house? III. General interior. 1. Upon entering the house does the air seem fresh and odorless? 2. Is the house free from flies? 3. Are there at least two outside windows to a room? 4. Have they screens? 5. Is the heating arrangement adequate for the size of the house? 6. Does it furnish fresh air for ventilation? 7. Is the number of occupants consistent with the size of the house? 8. Is the plumbing modern and open? 9. Are the lights placed so as to avoid a glare? 10. Can the floor coverings be removed and easily cleaned? 11. Has the feather duster been discarded? 12. Are useless hangings and decorations avoided? 13. Are the floors clean and smooth? 14. Do the toilets have an outside window for light and ventilation? IV. Sleeping apartments. 1. Are there fewer than three occupants to a room? 2. Do the rooms receive sunlight, at least part of the day? 3. Is the exposure such as to admit the most and best air? 4. Are the windows open from the top and bottom at night? Yes No THE TEACHING OF HYGIENE 243 Sanitary survey of a home 5. Is the bed placed in the air currents? 6. Are rugs used in place of carpets? 7. Are bed coverings frequently aired and cleaned? V. The kitchen. 1. Are the windows well screened? 2. Is there a cooler-closet or an ice-box? 3. Is the stove well ventilated? 4. Are the sink and drain-pipe kept per- fectly clean? 5. Is the food kept under cover or screen? 6. Is the source of milk supply known? 7. Is the source of water supply known? 8. Is the source of food supplies known? 9. Is the filter cleaned out every day? 10. Is the floor kept clean, and the floor and walls painted frequently? 11. Is there a light dry room in which per- ishable articles of food may be stored? 12. Is the ice-box frequently cleaned? 13. Are there proper toilet facilities con- nected with the kitchen? 14. Are clean hand-towels provided? 15. Are the eating utensils of sick persons boiled? VI. The back yard. 1. Are breeding-places for flies avoided? 2. Are breeding-places for mosquitoes avoided? 3. Is the yard kept free from rats and mice? 4. If there is an outside privy, is it kept in a sanitary condition? 5. If there is a cesspool, is it cleaned out when necessary? 6. Are wells and cisterns protected from drainage from contaminated sources? 7. Is the drinking-water known to be safe? 8. Is the ground kept free from slops and all refuse and filth? Yes No 244 HEALTH WORK IN THE SCHOOLS Sanitary survey of a meat market 1. Is the market in a sanitary location? 2. Is the building well constructed? 3. Is the cellar rat-proof? 4. Are the outhouses and stables sufficiently removed? 5. Is barnyard refuse and market refuse fre- quently removed? 6. Are the general premises clean? 7. Are the meat scraps kept in metal cans? 8. Are the premises free from rats? 9. Are the floors of concrete, or other imper- vious material? 10. Are the doors made to swing? 11. Are windows and doors screened? 12. Is the place free from flies? 13. Are counters made of marble, or glass, or hard wood? 14. Are they screened to prevent handling of meat? 15. Are the refrigerators clean? 16. Are clerks clean and healthy -looking? 17. Are they well protected with clean aprons? 18. Is all meat protected from flies and dust? 19. Are tables, trucks, racks, refrigerators, refuse boxes, floors, and tools cleaned daily? 20. Is the source of meat known? 21. Is it federally inspected? 22. Is it city inspected? 23. Is the meat delivered in covered wagons, and kept carefully wrapped until it reaches the purchaser? 24. Are the carcasses kept carefully wrapped while being transported to the market? 25. Are the wagons clean? 26. Are the refuse wagons covered? Yes THE TEACHING OF HYGIENE 245 Sanitary survey of a bakery I. Location and construction. 1. Is the building in a sanitary location? 2. Is it a sufficient distance from stables and outhouses? 3. Is barnyard refuse frequently removed? 4. Is the cellar rat-proof? II. The salesroom. 1. Axe the doors screened? 2. Are they double-hinged (swinging) ? 3. Is the food kept covered under glass? 4. Is the store clean and free from flies? 5. Are the clerks protected by clean aprons ? in. The bakery. 1. Is the dough mixed by machine? 2. Are the floors of the bakery clean and dry? 3. Is the bread wrapped before sending it out on the wagon? 4. Has the baker or any of his employees tuberculosis, or any other contagious disease? 5. Are they clean and careful in personal habits? 6. Are pet animals kept out of the bakery? 7. Is there night-work in the bakery? 8. Is the ceiling free from dirt and cobwebs ? 9. Is the ventilation good? 10. Are there windows enough? 11. Are the storage facilities good? 12. Are there toilets? 13. Are they properly located? 14. Is there a place for people to wash their hands? 15. Are individual towels used? 16. Is the bakery free from cockroaches and other vermin? 17. Are utensils and machines kept clean? 18. Are flies kept out? 19. Is garbage kept covered in metal cans? 20. Is it frequently removed? Yes No 246 HEALTH WORK IN THE SCHOOLS Sanitary survey of a school I. Ventilation. 1. Are the rooms well ventilated? 2. Does the air smell clean and fresh? 3. Is there some method for humidifying the air? 4. Are the rooms well aired at recess? II. Lighting. 1. Are the rooms evenly lighted? 2. Is the window area at least one fifth of the floor area? 3. Are the desks so placed as never to face direct sunlight? 4. Are dark window-shades avoided? 5. Are yellow or linen-colored shades or Venetian blinds used? 6. Is the tinting of the walls light? 7. Is the ceiling lighter than the walls? 8. Is over-decoration avoided? 9. Does all the light come from one side, the left? 10. Is there eight feet of space between the front wall and the first window? 11 . Does the light enter the room from the east or west? 12. Do the windows reach within a foot of the ceiling? 13. Are the seats in the darkest side of the room no farther than twenty-four feet from the windows ? DH. Temperature. 1. Is the temperature kept over 65 degrees, and less than 70 degrees? 2. Is there a thermometer in each room? 3. Is a daily temperature chart kept in each room? IV. Cleaning and sweeping. 1. Has the feather duster been discarded? 2. Is a damp cloth used for cleaning up dust? Yes THE TEACHING OF HYGIENE 247 Sanitary survey of a school 3. Are the windows washed at least three times a year? 4. Has dry sweeping been abolished? 5. Is oiled sawdust used on the floors when sweeping is done? 6. Are the floors oiled at least twice a year? 7. Are the floors free from sticky oil? 8. Are the rooms well aired at the time of cleaning? 9. Are the desks and all articles of furniture kept constantly clean? 10. Are desks re-dressed at least every two years? 11. Are desks washed with a disinfectant when necessary? 12. Is the common use of articles which might carry infection avoided? V. The pupils themselves. 1. Are pupils required to keep their hands and faces clean? 2. Is the clothing of the pupils reasonably clean? 3. Are pupils with poor eyesight seated near the front? 4. Are deaf pupils seated near the front? 5. Are pupils with skin diseases excluded? 6. Are pupils with any contagious disease excluded. 7. Is there any health supervision of pu- pils? Is there a school nurse? Do the teachers make any physical examinations of pupils? Is hygiene taught? How is it taught? Are the desks adjustable? 12. Are they adjusted to the pupils? VI. General sanitation. 1. Are paper towels provided? Yes No 8. 9. 10. 11. 248 HEALTH WORK IN THE SCHOOLS Sanitary survey of a school Yes No 2. Is liquid soap provided? 3. Are there any shower-baths? 4. Are drinking-fountains provided? 5. Is the common drinking-cup abolished? 6. Has the roller-towel been abolished? 7. Has the common hand-towel been abol- ished? 8. Is there a comfortable lunch-room for pupils. 9. Is there a comfortable rest-room for teachers? 10. Is there a "first-aid " emergency outfit supplied? 11. Does anybody know how to use it? 12. Are toilets clean? 13. Are toilet-rooms well ventilated? 14. Are toilets kept flushed? 15. Is the basement light and clean? 16. Are the school grounds kept perfectly clean? 17. Is the drinking-water safe to use? 18. Has any investigation of the water been made? 19. Are ventilated coat-closets provided? 20. Is fire drill practiced frequently? Sanitary survey of a dairy I. The barn. 1. If made of wood, are the walls fre- quently whitewashed? 2. Are walls and ceilings kept clear of cobwebs? 3. Are windows so located as to prevent direct drafts on the animals? 4. Is the barn well ventilated? 5. Are floors made moisture-proof? 6. Are gutters (preferably of cement) provided behind the stalls? THE TEACHING OF HYGIENE 249 Sanitary survey of a dairy Yes No 7. Do they drain properly? 8. Are the stalls kept clean? 9. Are ceilings dust-proof? 10. Is a clean wash-room provided for the milkers? 11. Are paper or individual towels fur- nished? 12. Is the roller-towel abolished? 13. Is liquid soap provided? n. The milk-house. 1. Is there a milk-house separated from the barn, and used for no other pur- pose? 2. Is it clean? 3. Is it screened? 4. Is it provided with a cement floor? 5. Are flies kept out? 6. Is it cool? 7. Is the milk kept covered? 8. Is the milk cooled to at least 50 de- grees? HI. The utensils. 1. Are all utensils kept clean? 2. Are pails, cans, and bottles and other utensils steamed or boiled before using? 3. Are all utensils which have been ex- posed in a house where there has been a contagious disease carefully sterilized? 4. Is the patent milk-pail with cover used? 5. Is the milk milked through gauze? 6. Is the gauze always boiled and dried before using? IV. The premises. 1. Is manure removed at least once a week? 2. Are domestic animals kept away from the premises at the time of milking? 250 HEALTH WORK IN THE SCHOOLS Sanitary survey of a dairy Yes No V. The surroundings. 1. Is the barnyard clean and well drained? 2. Are outhouses well removed from the vicinity of the barn and milk-house? 3. Are sheds provided for animals? 4. Is the water supply safe? 5. Is the well (if any) so situated that no contamination can occur from a privy or other source? 6. Is all sewage contamination of water supply avoided? 7. Are garbage and manure prevented from accumulating? 8. Are breeding-places for flies avoided? VI. The animals. 1. Are the cows kept clean? 2. Are the cows tuberculin-tested? 3.' Are all the cows with any suspicion of disease kept away from the others? 4. Are cows kept away from sewage- infected streams? vn. The milkers. 1. Do milkers wear clean, special milk- ing-suits? 2. Do milkers keep their hands clean? 3. Are all milkers in good health? 4. Are milkers who have been in associa- tion with cases of transmissible dis- eases kept away until danger is past? VIII. The "bunk-house." 1. If a house for milkers is provided, is it kept clean? 2. Is it well ventilated? 3. Is there a suitable wash-room? 4. Are the beds clean? x 1 It is not expected that every dairy, and especially those in rural districts, will come up to the ideal suggested here, but they should approximate it in all essential matters. THE TEACHING OF HYGIENE 251 HELPS FOR THE TEACHING OF HYGIENE IN THE GRADES Allen, William: Civics and Health. 1909, pp. 411. Ginn & Co. Denison, Elsa: Helping School Children. 1913, pp. 352. Harper & Bros. Hoag, E. B.: Health Studies. 1909, pp. 223. D. C. Heath & Co. Hoag, E. B.: Health Pamphlets for Schools. Whi taker and Ray- Wiggin Co., San Francisco. Hutchinson, Woods: We and Our Children (for teacher and parent). Houghton Mifflin Co. Hutchinson, Woods: Hutchinson's Health Series. Houghton Mifflin Co. Putnam, Dr. Helen: Report of the Committee on the Teaching of Hygiene in Public Schools. Bulletin of American Academy of Medicine, 1905, pp. 1-64. Easton, Pa. Ritchie and Caldwell: Primer of Hygiene and Primer of Sanitation. World Book Co. Tolman and Guthrie: Hygiene for the Worker. American Book Co. Wood and Reesor: Health Instruction in the Elementary Schools. 1912, pp. 140. Published by Teachers College, Columbia Univer- sity, New York City. See also: Bulletin of American Academy of Medicine, October, 1912. A symposium on the teaching of hygiene. (Several excellent pa- pers.) Easton, Pa. CHAPTER XVI THE TEACHING OF HYGIENE: EDUCATION WITH REFERENCE TO SEX The problem Every teacher should have a true conception of the frequency with which ignorance of the laws of sex is responsible for sickness, misery, and death, indus- trial inefficiency, the infection of the innocent, and life-wreckages of many other kinds. The economic losses accruing from such ignorance doubtless exceed many millions of dollars annually in the United States alone, while the more important ethical and moral losses are of course not measurable at all. An ade- quate discussion of this aspect of the problem would lead us beyond the limits of the present chapter, and the reader is accordingly referred to the judicious treatments of the subject by Stanley Hall, Dr. Prince Morrow, and Professor Henderson. 1 As a rule even intelligent, well-educated persons are not well enough acquainted with either the moral or the hygienic im- portance of the problem. 2 1 See references at end of this chapter. 2 Searching investigations made by our most reliable authorities have revealed the fact that the prevalence of social diseases is far greater than most of us have believed. It is estimated that at least 60 per cent of the males in this country have contracted the "red plague" (gonorrhoea) at least once, and that 2,000,000 of our people, EDUCATION WITH REFERENCE TO SEX 253 Need of safeguarding school children Another aspect of the problem, touching the school even more directly, is the question of improper sexual conduct among children in the upper grades and high school. In even the best regulated, coeducational high school there is almost always a greater or less under- current of interests and events which are unwhole- some even when they are not positively immoral. Sometimes only a very few of the pupils are involved, many of them innocent women and children, are victims of the "black plague " (syphilis). Over one third of these are innocently infected. Reliable statistics indicate that each year about 10 per cent of the entire adult male population of the large cities are treated for one or the other of these diseases. In a city like New York this amounts to almost a quarter of a million cases annually, or more than seven times as many as the number of cases of diphtheria, scar- let fever, smallpox, measles, and chickenpox combined. Morrow estimates that 20 per cent of the venereal infection is acquired before the twenty-first birthday. Of the million boys who arrive at puberty annually in the United States, not far from half are venereally diseased within a few years. These conditions are not peculiar to the United States, but are common to practically the entire civilized world. Thus, in Germany, of the 8,500,000 persons included in the industrial insurance regula- tions, 500,000 each year receive sick benefits from this cause. This is about 6 per cent of the enrollment. The proportion for waitresses rises to 13.5 per cent, for young salesmen to 16.4 per cent, and for university students to 25 per cent. For a study of the moral condi- tions in American colleges the reader is referred to Birdseye. (See reference 3 at end of this chapter.) It is now quite well known that about one third of all blindness, and 80 per cent of congenital blindness, is due to ophthalmia neona- torum, or venereal infection of the child's eyes during birth. The social diseases are responsible also for about one half of the internal surgical operations which women undergo, for perhaps half of the ster- ility, and for about 15 to 20 per cent of the admissions to our insane hospitals. 254 HEALTH WORK IN THE SCHOOLS sometimes many; children from the "best homes" hardly less often than others. Teachers and school officers too often rest in strange ignorance of things which pass before their very eyes. Often they are indignant if the problem is even called to their attention, blind, it would seem, to the very existence of this most imperious and most pervading of all human instincts. But when overt immorality among their pupils stands unmistakably revealed, these same persons are the ones most likely to turn with heartless severity upon the offenders, to banish them from the school as "degenerates. " In such cases one or two pupils are made the scapegoats and ex- pelled, as though to vindicate the honor of the school and to reestablish the self-respect of those who are responsible for its reputation. The inhuman and un- sympathetic treatment sometimes meted out to such offenders, who may be mere children and sinned against rather than sinning, would be impossible in any man who had not completely forgotten the storm and fire of his own adolescense. 1 We should avoid alike the folly which ignores the evils and the cruelty which combats them with heart- less punishment and other summary measures. We must consent to face honestly and without prudery or 1 " Of all cultivated classes, educators alone remain timid and in- active. . . . Teachers, who have the rarest opportunity to observe, have learned nothing and ignore the truth." (Stanley Hall.) " The very persons to whom to-day we have to look to effect the sexual enlightenment of children are themselves, to a great extent, also in need of enlightenment." (Albert Moll.) EDUCATION WITH REFERENCE TO SEX 255 hypocrisy the actual situation : the fact that in most boys and in many girls the sexual emotions do not lie dormant until the traits of will and character have developed sufficiently for their proper control; the fact that very few boys and not all girls reach manhood or womanhood without at least for a time falling vic- tims to reprehensible practices or conduct; the fact that many children from homes otherwise admir- able have been so poorly instructed that their ideas of sexual matters are sufficiently grotesque and dis- torted to render almost any kind of conduct on their part pardonable and pitiable. The entire world is at last awakening to the serious- ness of the problem. In almost every civilized coun- try active organizations have been effected for the purpose of combating the evils by means of social, penal, and industrial reforms, and by more thorough- going enlightenment of the young. The school's relation to sex-education The relation of the school to the entire problem of sex-education is fairly well indicated by the expres- sions of belief regarding the following propositions, submitted in 1012 by the American Federation of Sex Hygiene to leading educators, physicians, and public men in various parts of the country. About one hundred replies were received, for the most part from just those persons who by virtue of their interest and experience are best entitled to a respectful hearing on the subject. The propositions and votes thereon are as follows: — 256 HEALTH WORK IN THE SCHOOLS Proposition I The well-known facts concerning the widespread igno- rance, misunderstanding, and misuse of the human sexual function point clearly to the need of special instruction of young people in the scientific principles of sex. Affirmative, 91; negative, 0; doubtful, 5. Proposition II As it is well established that few parents are both quali- fied and willing to give their children this vital instruction, it is necessary that such instruction be given in the public schools, both elementary and high, in colleges, and in other organized educational agencies. Affirmative, 73; negative, 7; doubtful, 11. Proposition III The scientific basis of sex-instruction should be laid in the biological nature-study of elementary schools and the bio- logical courses of higher schools and colleges. Beginning with the nature-study lessons of the primary grades, life- histories of living things should be emphasized. In the ad- vanced nature-study of the grammar grades and the biology courses of the high school there should be a gradual presen- tation of the leading biological facts of animal and plant reproduction. It should also be incorporated in courses in hygiene and in ethics. Affirmative, 80; negative, 3; doubtful, 3. Proposition IV Specific instruction applying the biological facts to human life is needed, preferably at the end of the biology course in the early years of high school. Affirmative, 75; negative, 1; doubtful, 2. Proposition V Since numerous pupils never reach the high school, there is need of some definitely organized instruction relating to human life for pupils of grammar-school ages. This is the most difficult problem now apparent. Affirmative, 73; negative, 6; doubtful, 9. EDUCATION WITH REFERENCE TO SEX 257 Proposition VI Provision should be made for sex-instruction in evening schools, in forms adapted to the needs of various types of students. Affirmative, 72 negative, 1 ; doubtful, 2. Proposition VII In order to appreciate the problems and cooperate with special teachers all teachers should know the fundamental biological, hygienic, and ethical facts relating to sex-proc- esses. To this end, teachers' training-schools should offer courses of biology and selected reading which give the needed knowledge. Affirmative, 82; negative, 0; doubtful, 8. Proposition VIII While the nature-study and biology classes may be coedu- cational, as abundant experience has proved, the special application of biological facts to human life should be in separate classes. Affirmative, 82 negative, 0; doubtful, 5. Proposition IX Special lectures under the auspices of clubs, churches, and other associations interested in general education should be established in order that the sex-education movement may reach parents and young people who are not connected with schools. Affirmative, 86; negative, 0; doubtful, 0. Proposition X The above propositions refer to instruction in normal sex- processes. Such instructions should obviously be made basal. But, at the proper time, instruction should be given also as to: (1) the danger of unnatural and unhygienic sex-habits; (2) licentious or irregular sexual indulgence; (3) and later, the impressive facts relating to the dangers of social diseases, and the consequences to themselves and others. Instruction in regard to the last two should be given only to the upper classes of the high school and to students in college, by care- 258 HEALTH WORK IN THE SCHOOLS fully selected instructors, preferably by those with, special training in medicine or physiology, and at the same time pos- sessing tact and skill; but all teachers should be prepared to help individual students who may need advice. Affirmative, 85; negative, 3; doubtful, 2. Proposition XI While instruction concerning abnormal conditions is largely a problem relating to adolescents, some direction of individ- uals is sadly needed by many children in the two or three pre- adolescent years; and it is to be hoped that every school will finally have one or more competent persons (principal, nurse, doctor, or teacher) able to deal effectively with the individ- uals needing help. Affirmative, 81; negative, 0; doubtful, 5. Proposition XII The introduction of sex-instruction into the public educa- tional system should be made carefully, and with due regard to local conditions, such as the attitude of school officials, public opinion, and the availability of specially trained teachers. Nothing could be more undesirable than precipi- tate introduction of sex-instruction by propagandic legisla- tors, or by over-zealous school officials. Far better results are to be expected if the teachers and parents interested in each school are first awakened to the need of special instruc- tion; and then the work should be developed gradually, quietly, conservatively, and on a sure foundation. Affirmative, 90; negative, 0; doubtful, 4. As to the need of some kind of education of the young with reference to sex perhaps every reader will agree with the authorities quoted. We cannot, even if we would, keep the child long in the innocence which rests upon ignorance. The child's interests in matters of sex are far more precocious and far more intense than appears on the surface. If the information which is sought is not gained from sources that are reliable EDUCATION WITH REFERENCE TO SEX 259 and pure, it will be found in sources that are less desir- able. There is no third possibility. The "conspiracy of silence" has always and everywhere proved an utter failure. Special considerations relating to sex education The points on which disagreement arises have mainly to do with (1) the proper place for the instruction to be given, whether in the school or at home; (2) the content of such instruction; (3) the method of ap- proach; and (4) its appropriate time in the life of the child. These questions can be answered only with an understanding of their relations to each other, and in the light of certain general principles. The subject is too difficult to make dogmatism safe. The following, however, are important considerations: — (a) The purpose of sex-education should not be too narrowly conceived. The end cannot be attained by a few "sex-talks," stating bluntly the facts of the sex- life and painting in lurid colors the evil results of trans- gressions. The purpose of such education is much farther-reaching, and involves, indeed, the gradual shaping of the child's attitude toward fundamental ethical values, the patient molding of a whole char- acter. (6) We must clearly understand also that knowl- edge, alone, does not meet the requirements of this kind of education. Mere information, however exact, does not insure right conduct. The problem is less one of enlightenment than of moral education. The will 260 HEALTH WOKK IN THE SCHOOLS must be made the master of the instincts. To rein- force the will, the "thou shalt not" needs to be re- placed by the uplifting power of inspiring ideals, intel- lectual enthusiasms, and wholesome respect for the integrity of body and mind. The life needs to be filled so full of good work and wholesome play that super- fluous energy will not seek improper outlets. The sexual instinct is not to be so much repressed as sub' limated; its energies directed to secondary channels and transformed into higher values. (c) The school needs to lay greater emphasis upon the broader relations of moral education, which should be interpreted to include training in social cooperation, acquaintance with social and civic responsibilities, the inculcation of habits of personal hygiene, respect for the body and pride in its capacities, love of outdoor life and sports, notions of chivalry, preference for good literature, a taste for music and art, etc. Nor can the school itself be an effective agent in moral education until its own moral dangers are frankly recognized. To overwork the device of emulation; to lay the stress upon getting ahead of others; to neglect the multi- tudinous opportunities offered by the school for prac- tical training in social duties and responsibilities; to divorce the teaching of history and civics from all ref- erence to modern social and industrial environment; to herd adolescent boys and girls promiscuously in crowded schoolrooms and narrow hallways where inti- mate physical contact is possible or unavoidable; to neglect the careful chaperonage of school children on EDUCATION WITH REFERENCE TO SEX 261 social occasions, school picnics, etc. ; to induce conges- tion of blood in the pelvic regions by five or six hours of sedentary work, unrelieved by physical activity; to treat all reference to sex problems with prudery and repression: — all of these mistakes lay a burden of guilt upon the school which it cannot without hypoc- risy deny. When the school has cleared itself from all blame in these particulars, and has set a thoroughly wholesome environment for the adolescent boy and girl, it will be in better position to campaign for the cooperation of parents for the sex-education of chil- dren. (d) Sex-pedagogy differs in one fundamental par- ticular from the pedagogy of any other subject; it must not seek to create special interest in the material presented. For this reason, vague allusions which excite curiosity, and pictures, charts, or diagrams which center attention upon the physiological proc- esses of reproduction, are to be avoided. Some of the booklets prepared by well-meaning but unpedagogical enthusiasts, and designed for the use of the pupil, are thoroughly vicious in this respect. (e) Wherever the special instruction is given, whether in the home or the school, timeliness must be observed. Too early instruction may create the vices it seeks to prevent. The greater danger, however, is that the instruction best suited for each period of de- velopment will be unduly delayed. 1 1 "Better a year too early than an hour too late" has been the slogan of the reformers. 262 HEALTH WORK IN THE SCHOOLS On account of the age element, mass instruction in sex-hygiene by school grades is always indefensible. A fourth-grade class will usually be found to contain children all the way from 8 to 13 years of age. A sixth- grade class may range from 10 to 15 years, or an eighth- grade class from 12 to 17. For sex-instruction chil- dren should always be classified by ages, not by grades. (/) It is questionable whether mass instruction by means of "sex-talks," unrelated to other lines of in- struction, should ever be permitted, even when the pupils are classified on an age basis. Children of the same age may differ very greatly in physiological ma- turity, in the amount of sex-information they already possess, in innocence, and in their emotional reaction to the instruction given. The sudden presentation of the brutal facts of sex is almost sure to prove a nervous shock to some children, in whom it may give rise to morbid ruminations, phobias, etc. (g) Just here lies the great danger in exaggerating the evils of solitary vices. The views commonly held by teachers and other intelligent people on this point are colored by the extravagant exaggerations depicted in the literature disseminated by quack doctors. If the teacher learns that a feeble-minded or weakly or incorrigible child in her class is guilty of such practices, she is likely to conclude that the defect or perversity is due solely to the bad habit. It is now universally admitted by the best medical authorities that the evils of solitary vice are in most cases confined prin- cipally to their indirect effect upon morals, self-respect, EDUCATION WITH REFERENCE TO SEX 263 etc., and to the resulting shame, worry, and other morbid ruminations. Nothing but evil can come out of scare-literature or scare-instruction. Quartering people alive in the sight of the public did not stop crime, nor will the horrible and essentially untruthful depictions of the evils of impurity lead children into paths of morality; what it will do is to drive a good many of them to the verge of insanity. Methods and content of instruction by stages Much experimentation will be necessary to deter- mine the proper content and the most effective meth- ods of sex-education. Our present knowledge and ex- perience, however, justify the following tentative out- line, which is offered purely for whatever suggestive value it may have: — One to six years. No instruction is necessary in the first half of this period, but habits of cleanliness should begin. Sleep, diet, bathing, etc., are very important. Care should be exercised with regard to choice of nurse. Male infants should be circumcised. Innocent habits of unnecessary touching and handling should be guarded against. At this period the trait of frankness may become deeply implanted in the child's nature, or its growth may be prevented or delayed. Extreme punishments breed cowardice and destroy confidence. As soon as the child's curiosity awakens regarding the origin of babies, he should be told the truth, in language simple and unevasive. This will usually occur about the age of 264 HEALTH WORK IN THE SCHOOLS four or five years. The instruction at this point need not include the facts about paternal relationship, because the child has not yet begun to wonder about this. Six to twelve years. In the first half of this period the teaching of nature-study should acquaint the child gradually with the processes of reproduction in plants. The function of flowers, pollen, and seed, and the method of fertilization should be made thoroughly familiar. The program for the second half of this period should include similar study of typical animals below mammals, — fish, birds, insects, etc. Nature-study, in the broad sense, should be given a liberal share of the program, and the instruction above suggested could be related in such a way to the general processes of nature, and so gradually and opportunely intro- duced, that the needed information will be assimilated without attracting morbid attention to sex as such. Indeed, the child will not be consciously aware that he is receiving sex-instruction. Sometime during this period, probably between the ages of seven and ten, the child will need to be in- formed, in a general way, regarding the relation of father to offspring. The exact time and the exact ex- tent of the information needed will depend entirely upon the child's spontaneous curiosity. Indiscriminate warnings against improper habits should not be indulged in, but children known to have formed bad habits should receive private instruction. Here, as elsewhere, the idea should be to make virtue EDUCATION WITH REFERENCE TO SEX 265 attractive by instilling ideals of cleanliness, strength, manliness, chivalry, etc. Twelve to fifteen or sixteen. The biological and hy- gienic phases of the nature-study program may now receive still further emphasis. The study of animals may be extended to include mammals, the function of the ovum, modes of fertilization, etc. The broader ethical implications should be stressed, the necessity for care of the young, the evolution of mother love, the significance of family life for the species, etc. As before, this will be incidentally woven in with the rest of the course, though its applications to human life can be made somewhat more explicit than in the earlier stages. Because of the prevailing attitude toward sexual mat- ters it may be advisable, where possible, to present mammalian zoology to boys and girls in separate classes. More special sex-instruction at this period is also of prime importance. Well before the phenomena of puberty make their appearance, both boys and girls should know the natural developments that may be expected and their appropriate hygiene. It is shame- ful and inexcusable that so large a proportion of chil- dren reach maturity without any such instruction whatever. This, no doubt, helps to account for a fact which several studies have reliably established, — that from 25 to 50 per cent of women suffer from menstrual disorders. With boys, emphasis should be placed upon the absolute normality of emissions during sleep, and upon the normality and healthfulness of continence. 266 HEALTH WORK IN THE SCHOOLS Fifteen, and beyond. The teaching of biology should here be amplified to include the chief laws of heredity, human physiology with special reference to hygiene, the bacterial origin of disease and the modes of trans- mission, eugenics, etc. For the first time full particu- lars may be given regarding the consequences of ven- ereal infection, with special emphasis on the dangers to which innocent women and children may be exposed. The education of adolescent girls should everywhere include extensive training in household science, and in the hygiene of physical and mental development. Education for motherhood should be its conscious and avowed purpose. Summarizing, we may say: — (1) That sex-education should be individualized and adapted both in method and content to the child's stage of development and to his expanding curiosity. (2) It will be mainly of two kinds; general and spe- cial. The general includes the broad foundation laid by the extensive courses in nature-study and biology. The special includes the direct instruction about sex- ual phenomena, both normal and morbid. These two types of instruction will not necessarily be kept entirely separate. Indeed, the value of the special instruction will depend largely upon the degree to which it is made an integral and logical part of the whole process of biological enlightenment. (3) Sex-education must never be considered as an isolated problem, but as one related to the whole ques- tion of moral educatioD. Its success will always depend EDUCATION WITH REFERENCE TO SEX 267 on the degree to which it is supported by high ideals, wholesome enthusiasms, and a right attitude toward the social world in general. Divided responsibility of the home and school in sex-education We are now in better position to say where sex-edu- cation belongs. It is obvious that the instruction we have designated as general, the biological founda- tion, should be given in the school. It belongs ther,e because the average parent has neither the time nor the equipment necessary to give it. The school has the time and can equip itself for the work by the in- troduction of laboratory methods into the elementary school, and by extending the training of teachers in hygiene and biology. It is equally evident that the instruction designated as special belongs partly in the home and partly in the school. The more personal and intimate its nature, the more such instruction becomes the proper function of the home. However, a great deal even of the special instruction can and should be woven in with the school work in nature-study and biology, and when parents are known to be entirely neglectful of their duties in this respect there is no alternative but for the school to assume the entire responsibility for the child's sexual enlightenment. The school should make every effort to enlist the cooperation of parents by means of popular lectures to parent-teacher associations, conferences with parents 268 HEALTH WORK IN THE SCHOOLS in special cases, etc. Rightly prepared pamphlets ex- plaining the need of sex-education, indicating what such instruction should include and when it should be given, etc., would, no doubt, perform a great service. It is strange that this method has been so little used in this country. Finally, the complexity of the problem should re- mind us of the many-sided cooperation which will be demanded for its satisfactory solution. We may men- tion, for example, its relation to the alcohol question, to the social control of prostitution, to industrial methods, to poverty, to public recreation, to religion, to law, to housing, to newspapers, to divorce, to child- dependency and child-labor, to the reform of medical practice, to coeducation, school retardation, feeble- mindedness, etc. SELECTED REFERENCES (Recent literature on this subject is voluminous. Only a few of the most important references are given here.) *1. Addams, Jane: A New Conscience and an Ancient Evil. 1912, pp. 219. 2. Bell, Sanford: "A Preliminary Study of the Emotion of Love between the Sexes." Am. J. Psych., 1902, pp. 325-54. 3. Birdseye, C. F. : Reorganization of Our Colleges. 1909, pp. 410. (See pp. 118-45.) 4. Cabot, R. C: "The Consecration of the Affections." Fifth Cong. Amer. Sch. Hyg. Assoc, 1911, pp. 114-20. *5. Eddy, Walter H.: "An Experiment in Teaching Sex-Hygiene." J. Ed. Psych., October, 1911, pp. 451-58. 6. Eliot, Charles W.: "School Instruction in Sex-Hygiene." Fifth Cong. Amer. Sch. Hyg. Assoc, 1911, pp. 22-26. *7. Ellis, Havelock: Studies in the Psychology of Sex. Vol. vi. (See especially chapter n, "Sexual Education"; and chapter in, " Sexual Education and Nakedness.") 8. Foster, W. S.: "School Instruction in Matters of Sex." J. Ed. Psych., 1911, pp. 440-50. EDUCATION WITH REFERENCE TO SEX 269 9. Freud, Sigmund: Three Contributions to the Sexual Theory. Nervous and Mental Diseases Monograph Series, no. 7, New York, 1910, pp. 91. 10a. Hall, W. S. : From Youth to Manhood. *10b. Hall, Stanley: Educational Problems. 1911. (See vol. i, pp. 388-539. This is the broadest and most scholarly treatment of the subjects yet published.) *11. Henderson, Charles R.: "Education with Reference to Sex." Eighth Year-Book of the Nat' I Society for the Scientific Study of Education. (Part i, "Pathological, Economic and Social As- pects," pp. 74. Part n, "Agencies and Methods," pp. 89.) 12. Hodge, C. F.: "Instruction in Social Hygiene in the Public School." Bull. Amer. Acad. Med., 1910, pp. 506-17. (See other papers of the symposium in same number.) 13. Jung, C. G.: "The Association Method." Am. J. Psych., 1910, pp. 201-69. 14. Kongress der deutschen Gesellschaft zur Behdmpfung der Ge- schlechtskrankheiten, Sexualpadogogik. Leipzig, 1907, pp. 321. 15. Mckeever, William A.: "Instructing the Young in Regard to Sex." Home Training Bull., no. 8, Manhattan, Kansas, pp. 16. *16. Moll, Dr. Albert: The Sexual Life of the Child. Translated by Paul, 1912, pp.339. (See pp. 179-219, " Importance of the Sex- ual Life of the Child "; and pp. 246-325, "Sexual Education.") *17. Morrow, Dr. Prince: Social Diseases and Marriage. 1904. 18. Parkinson, W. D.: "Sex and Education." Ed. Rev., January, 1911, pp. 42-59. 19. Putnam, Dr. Helen: "Education for Parenthood." Education 1911, pp. *20. Report of the Special Committee on the Matter and Methods of Sex Education; Amer. Federation for Sex Hygiene, New York. 1912, pp. 34. 21. Schmitt, Clara: "The Teaching of the Facts of Sex in the Public Schools." Ped. Sem., 1910, pp. 229-41. 22. Smith, P. A.: "Sex-Education in Japan." J. Ed. Psych., 1912, pp. 257-S3. 23. Smith, Nellie M.: The Three Gifts of Life. 1913, pp. 138. 24. Zenner, P.: Education in Sexual Physiology and Hygiene; A Physicians Message. Cincinnati, 1910, pp. 126. CHAPTER XVn THE TEACHER'S HEALTH 1 The teacher's health is an important though neg- lected aspect of school hygiene. If the teacher is tuber- culous the children are directly exposed to contagion at a very susceptible period of life. If she is neuras- thenic, nervously unstable, querulous, or discontented, the effects upon the suggestible, sensitive child may be still more unfortunate. The welfare of children is so deeply involved that it is no longer justifiable to make the profession a haven for those of delicate con- stitution. There is little reliable information about the health conditions among our half-million teachers. We do not know definitely their mortality rates from vari- ous diseases, what class of material enters the pro- fession, to what extent health is injured by the work, or what measures would contribute to the conserva- tion of this most important body of public servants. Mortality rate and physical morbidity Balliett's health questionnaire, submitted to 159 teachers, indicated that persons of average physical 1 For a more extended discussion of this subject see The Teacher's Health, by Lewis M. Terman. Published by Houghton Mifflin Co., in The Riverside Educational Monographs, 1913, 136 pages. THE TEACHER'S HEALTH 271 constitution suffer distinct impairment of health within five to ten years after entering the profession. Of five hundred New England and Middle West teachers questioned by Dr. Burnham, 37.4 per cent stated that their health had been injured in greater or less degree by the conditions of their work. The factors blamed were, in order of frequency, poor ven- tilation, bad lighting, nervous strain, standing, noises, overcrowded classes, chalk-dust, and too long periods of unbroken work. In Europe more extensive data are available. Sigel examined all the teachers of Leipzig, and found 42.8 per cent definitely diseased. Karup's and Gollmer's statistics, from 12,381 German teachers, showed a low mortality rate from all causes combined, but a high susceptibility to tuberculosis and nervous diseases. Statistics from the National Provident Society of English Teachers, including 18,000 members, show a high morbidity rate from throat and chest troubles, influenza, nervous complaints, and gastro-intestinal disorders. Each year about 12 per cent of the entire number of teachers in this society receive sick bene- fits. Records of retirement under the English Super- annuation Act credit one third of the breakdowns to "neurasthenia," "nervous prostration," and "nervous debility." By virtue of an admirable Swedish law, granting sick allowances to teachers who have been ill one month or more, we have had, since 1906, complete morbidity records from all the 18,000 teachers of that 272 HEALTH WORK IN THE SCHOOLS country. An average of 4 per cent of the male ele- mentary teachers and nearly 9 per cent of the female elementary teachers are out one month or more each year. The average period of disability is 4.9 months for the former and 5.6 months for the latter. Nervous troubles were responsible for 31.2 to 36 per cent of the illnesses, tuberculosis for 6 to 9.3 per cent, other re- spiratory troubles for 13.7 to 17.9 per cent, anaemia and general debility for 5.5 to 12.7 per cent, and in- testinal troubles for 7.6 to 8.9 per cent. We are also informed that 2.5 per cent of the active teaching staff of Sweden are sufferers from neurasthenia of "a pro- nounced type," and further that 1.17 per cent of the Swedish female teachers are tuberculous. If these figures hold for the United States our neu- rasthenic teachers would number about 12,500, and our tuberculous teachers about 5000. The former are teaching a full half-million children, the latter some two hundred thousand. Premature superannuation Teachers become prematurely superannuated. After the age of 45 or 50, new positions are not easily ob- tained. At an age when the lawyer, physician, min- ister, or man of affairs is at his zenith, the teacher is looked upon as passee. English teachers are retired on pension at an average of 53 years for males and 51 for females. The average age for superannuation of male teachers is 49.1 years in Saxony, and 51.7 in Hesse and Bayern. THE TEACHER'S HEALTH 273 Tuberculosis among teachers The mortality of teachers from tuberculosis is especially high. In Saxony this is 60 per cent higher for the years 20 to 29 than for the general male popu- lation, and 23 per cent higher between 30 and 39. In the Netherlands for the ages 25 to 35 the rate is 60 per cent higher than for lawyers, and 30 per cent higher than for physicians. For Switzerland it is 10 per cent higher than for the general population between 20 and 39 years, and 30 per cent higher be- tween 40 and 49 years. From a careful study of the prevalence of tuberculosis among the 3187 teachers of Paris, it was estimated that about 3 per cent of the French teachers in service are tuberculous. In Ontario, 57 per cent of the deaths among female teachers and about 30 per cent among male teachers are caused by tuberculosis. The corresponding figures for stone-cutters are 65 per cent, for lawyers, 25 per cent, and for farmers, 16 per cent. Official returns from the United States Census Bureau show that for ten of our large cities, averaged together, 39.6 per cent of the deaths among female teachers are caused by tuberculosis, 39.1 per cent among stone-cutters, 26.8 per cent among saloon-keepers, and 13.9 per cent among farmers. For the entire census registra- tion area of the United States the following facts hold with great constancy and uniformity: (1) That for both male and female teachers the mortality rate from tuberculosis ranges from 19 to 26 per cent above 274 HEALTH WORK IN THE SCHOOLS that for persons of the corresponding sex in other occupations; and (2) that for female teachers the rate is from 39 to 43 per cent higher than for male teachers. Mortality rates, after all, do not tell the whole story. Teachers belong to a highly selected class, both physically and morally, and ought to show a relatively low mortality rate. They also suffer from many minor complaints which do not greatly affect longev- ity, but which are destructive to efficiency and to the joy of living. The teacher as neurasthenic Few teachers of ten years' experience have escaped a nervous breakdown. Probably from 3 to 5 per cent of all our teachers are definitely neurasthenic. All the studies emphasize the exhausting nature of the teacher's work. Of the 305 German teachers reply- ing to Wichmann's questionnaire, 78 per cent suf- fered nervous troubles, the leading symptoms being morbid anxiety, 45 per cent; fixed ideas, 35 per cent; headaches, 71 per cent; heart palpitations, 58 per cent. These, however, are not average conditions, since the questionnaire no doubt elicited a disproportionate number of replies from those who were ill. The teacher's short day is more apparent than real. The conscientious teacher usually begins her duties nearly an hour before the class is assembled, and re- mains at the post until long after the close of the after- noon session. The teacher who can manage to limit THE TEACHER'S HEALTH 275 her school day to less than seven hours, exclusive of evening work, may consider herself fortunate. In most cases evening lessons will consume one or two hours additional. Many teachers work nine or ten hours a day. The teacher's work cannot be adequately measured in terms of hours and minutes. She must work al- ways under full steam. An hour of teaching is prob- ably equivalent, from the standpoint of fatigue, to two hours of ordinary study, done in quiet without the necessity of speaking. Four hours of actual teaching thus represent about eight hours of ordinary office work. Add to this two hours for correcting papers, preparing lesson plans, supervising plays, etc., and the four-hour day has grown to one of ten. When teachers are overworked they must resort to the friendly protection of mechanical methods. Teachers who are sweated cannot do creative think- ing. Overworked teachers degenerate to the plane of lesson-setting and lesson-hearing. Emotional strain is added to intellectual overpres- sure. Many a teacher is constantly haunted by a vague fear of unpleasant conflicts with parents, pupils, or the school authorities. Most trying of all is the neces- sity of working under a school administrative regime which hedges the teacher about with unnatural re- straints and destroys her individuality. Other factors are overwork in the normal school, overcrowded classes, and the presence of exceptional children in the regular classes. Pupils who are incor- 276 HEALTH WOEK IN THE SCHOOLS rigible or backward contribute more than their share to the worries of the conscientious teacher. The investigations prove that it is the beginning teacher who runs the greatest risk of pathological nervous exhaustion. With 47 per cent of Wichmann's neurasthenics the nervous troubles appeared in less than five years, and within fifteen years for 87 per cent. The reason is probably threefold: (1) the new teacher is more prodigal of energy from excess of en- thusiasm and because she has not learned the neces- sity of mental economy; (2) she lacks the experience which would enable her to work with the least ex- penditure of effort; and (3) the early years act as a sieve to eliminate all but the strongest. Whatever the relative shares of these factors, it should be under- stood that the first years of employment are critical for the teacher's health. To ignore the laws of physi- cal or mental hygiene at this period is to sow the seeds of lifelong nervous affliction and premature super- annuation. School administrators can aid in averting this danger by lightening the burdens of the young teacher, by instructing her in economical methods of work, and still more by patient sympathy, kindly criticism, and frequent encouragement. Salaries and tenure should be improved. The aver- age salary of the American teacher is about $450. It takes $800 for a small family to live in any of our larger cities in the style of a common laborer. Teachers' incomes are as little conducive to physical efficiency as to soul expansion. When teachers have worn them- THE TEACHER'S HEALTH 277 selves out or become ill in the public service, they should not be turned out to subsist upon the charity of friends, but should be granted retiring allowances. Health suggestions for the teacher The teacher should learn the value of the "factor of safety" in mental economy. She is always in danger of short-sighted prodigality of energy. To live up to the last foot-pound of nervous energy daily is to fall into nervous bankruptcy at the first emergency. The teacher should find the safe limits for her day's work, and abide well within them. Sleepiness and the feeling of fatigue are the twin guardians of the "factor of safety." If their warnings are not heeded, insomnia, worry, and nightmares are pretty sure to follow. The eyes are the "weak link" in the health of many a teacher. Probably from 10 to 20 per cent suffer from unrelieved but relievable eye-strain. For the teacher to carry on "correspondence courses" with her pupils is to invite disaster. To face a light for several hours a day, as many teachers do, is alone sufficient to break down a good nervous system. When the eyes "go bad" the best oculist in reach should be consulted. If the teacher would be healthy, she should take varied daily exercise, preferably of the play type. Hobbies such as nature-study, horseback riding, tennis, golf, etc., are to be commended. Collateral work of sedentary nature is to be avoided. Vacation should be employed in such a way as to 278 HEALTH WORK IN THE SCHOOLS rid the teacher's brain and muscles of the accumu- lated clinkers of a school year. If she belongs to the well-known variety pedagogia ancemia, she should carry to her schoolroom in September many millions more red corpuscles than she could have boasted on the previous commencement day. For the teacher to spend her entire vacation in professional study is intellectual as well as physical suicide. The vacation is preeminently a time for striking a new balance. No one has more reason than the teacher to know something of dietaries and food-values. Constipa- tion and indigestion drag innumerable teachers along the retrograde path to professional incapacity and premature superannuation. Habits of living and eat- ing which produce costiveness should be blacklisted. The deadly cold lunch, eaten in solemn silence, should be forsworn. Thanks to the thermos lunch-bottle and basket, the cold lunch is no longer a necessary evil. The pedagogical voice is expected to be anything but pleasant. "Teachers' nodes" are more common than "clergyman's sore throat." The teacher has five "voice days" per week, the clergyman but one. The teacher should therefore guard her voice as some- thing more than an instrument of communication. Success or failure may hang upon its quality. There is the voice which irritates and provokes, and another which inspires quiet and instills respect. In short, the teacher's voice is more important than her grammar. She can preserve it and improve it by learning how to use it and when to remain silent. THE TEACHER'S HEALTH 279 The hygiene of character The teacher's work is likely to have certain reactive influences upon her character. The social instincts tend to atrophy. Teachers traditionally are bookish and unpractical, out of touch with civic and political affairs. Living an individualistic existence, they are always in danger of developing provincialism of in- tellect and character. The teacher should associate with people outside of her profession, and should keep one foot in the living, throbbing world. The social instincts of the teacher are also subject to perversions. We refer here particularly to male teachers, who so often are characterized by effemi- nancy, extreme docility, obsequiousness, and lack of manly force. Not a few superintendents and princi- pals become dictatorial, overbearing, and tyrannical toward their inferiors. The classroom teacher, also, may become dogmatic, exacting, and meddlesome in her relations to the chil- dren. Looking always after their faults and mis- takes, she tends to lose sympathy and generosity. She develops into a "Citizen Fixit. " Her rules be- come categorical imperatives. She forgets the value of the personal touch, fails to utilize the leverage of the child's natural instincts of suggestibility, loyalty, and hero-worship, and becomes prosy, prodding, and vexatious. Other dangers are method-cult, pedantry, and the didactic habit. Verbalism, rules, definitions, and pre- 280 HEALTH WORK IN THE SCHOOLS ciseness of form tend to replace substance. The "rit- uals," called parsing, and the petty exactitude some- times required in the formal statement of arithmetical solutions, are good illustrations. Every slightly dif- ferent way of doing a thing comes to be labeled with a name of its own. Teachers are prone to overesti- mate the value of what they teach, some of which is obsolete fact, misapplied half-truth, or useless pedan- try. The result of all this is likely to be premature mental decay. The constant contact with little minds may dwarf the teacher's own mental growth. By dint of so many times doing the same thing in the same way she falls a "victim to fixed modes of interpretation." It is hard to be spontaneous, fresh, and inspiring at the hundredth repetition. New categories become less and less possible. The personality becomes " shut in. " When this state supervenes, intellectual progress comes to an end; firm, rigid lines settle in upon the soul — it is habit-bound. How to prevent mental fixation An important antidote is to reserve certain hours each day for a vacation from professional habits. This is recreation, which therefore should become the teacher's religion. It should involve play, the very es- sence of which is its creativeness and the relaxation from habitual routine, and it should be seasoned with constructive mental activity in some field of art, lit- erature, science, etc. This will foster the attitude of THE TEACHER'S HEALTH 281 the learner, without which early decay is certain. The daily recreation will need also to be reinforced by va- cations spent in travel or in non-professional study. The teacher should cultivate the faculty of "doing the usual thing in the unusual way." The artist tem- perament should be her ideal, for the true artist abhors exact duplications and always endeavors to transvalu- ate all his experience. In every possible way variety should be mingled with the day's routine. Within cer- tain limits the teacher might be shifted from one grade or one department to another, or, where this is not feasible, a new position should be sought occasionally. To escape the danger of a premature mental arrest, every possible source of life and enthusiasm should be utilized. The responsibility of the normal school As regards the first of these points, there is reason to believe that the intense strain of the normal course directly contributes to the human wreckage which lit- ters the profession. Hardly any one will deny that normal-school students are as a rule overworked, but the overpressure is frequently justified on the plea of necessity. We may ask, however, whether it would not be wiser to lengthen the course a little instead of defy- ing the laws of nature in the effort to crowd three years of work into two, or four into three. In the second place, normal schools could contribute to the hygiene of the profession, and at the same time to the protection of the public, if they would conscien- 282 HEALTH WORK IN THE SCHOOLS tiously undertake a selection in the admission of their students. Before entering upon the training course all candidates should be required to undergo a thorough physical examination made by experts employed by the school itself, — the physically unfit to be rejected. The examination should be repeated each year after entrance, and again when the candidate enters upon regular employment. In most other countries such examinations are given as a matter of course. In the third place, in order that teachers may be placed in a position to protect themselves from those risks to health and happiness which are sure to be encountered in the practice of their calling, as well as also for the sake of fitting them to act as the health guardians of their pupils, the subject of school hygiene should be raised from its present neglect and given the right of way in the normal-school curriculum. Instruc- tion in the subject should escape its present absurd limitation to the traditional (and sometimes obsolete) laws of heating, lighting, and ventilation, and ground itself upon the newer and infinitely broader conceptions of its bearing and scope. Finally, the normal school could contribute to the hygiene of the profession by conscientiously refusing to place its stamp of approval on candidates who are careless, ugly -tempered, cynical, and void of sympathy for children. The public is not in position to protect itself against poor teachers who have once been brev- etted with the school's diploma. We must stop the stream of undesirables at its source. THE TEACHER'S HEALTH 283 Vocational guidance for teachers The normal school could also profitably engage in the work of vocational guidance of its students. Here the effort would need to go beyond the mere exclusion of the unfit, and include the direction of each candidate into that type and grade of teaching where her strong- est qualities would be most effective, and where her weakest would least imperil her success. Such work will have to be grounded upon a positive body of facts and principles, as yet largely unknown, relating to the psychology of teaching success. Its aim will be to distinguish fundamental traits of teacher- personality necessary for success in various lines of teaching. It will endeavor to place the teacher where she can do the most effective work; in the right grade, in the right subject, with the right sex, and in the most suitable environment generally. A by no means negligible product of any well-directed effort toward vocational guidance in the normal school will be the cultivation in the young teacher of a spirit of self-study and self-criticism, which throughout her career should point the way to self-improvement, to increased success, and to a wholesome spiritual attitude toward the inevitable vexations of the profession. REFERENCES » I. The Teacher's Physical Health *1. Burnham, W. H. : " A Contribution to the Hygiene of Teaching. Ped. Sem., 1904, pp. 488-97. 1 For a complete bibliography see book by the writer, The Teach- er's Health. 1913, pp. 136. Boston: Houghton Mifflin Co. 284 HEALTH WORK IN THE SCHOOLS *2. Hoag, E. B.: The Health Index of Children. (Chapter xi, pp. 136-52.) 3. Hulbert, H. L. P.: "The Care of the Teacher's Voice." Proc. Second Inter. Congress Sch. Hyg., 1907, pp. 862-66. 4. Lowden, T. S.: "The Teacher's Health." Education, vol. xxix, pp. 30/. and 153/. *5. Oldright, Dr. William: "The Schoolroom as a Factor in Tuber- culosis." Proc. Second Inter. Congress Sch. Hyg., 1907, pp. 686- 92. 6. Schmid-Monnard, Dr.: "Die Ueberbiirdung der Lehrer an hoheren Lehranstalten." Zt. f. Schulges., 1899, pp. 701-06. *7. Small, W. S.: "The Hygiene of Teaching." Proc. American School Hygiene Assoc, vol. i, pp. 142-52. 8. Steenhoff, Dr. G.: "The State of Health of Teachers in the Infant and Elementary Schools of Sweden." Inter. Mag. School Hygiene. 1911, pp. 564-66. *9. Terman, Lewis M. : The Teacher's Health : A Study in the Hygiene of an Occupation. 1913, pp. 136. *10. Van Tussenbroek, Dr. Cathrine: "Hygiene des Lehrkorpers." Rept. First Cong. Sch. Hyg., 1904, vol. iv, pp. 323-62. *11. Wichmann, Dr. R.: "Zur Statistik der Nervositat bei Lehren." Zt.f. Schulges., 1903, pp. 626, 696, 776; 1904, pp. 304, 543, 713. 12. Williamson, Dr. R. T.: "The Medical Examination of School- Teachers." (Chapter xvm in Kelynack's Medical Inspection of Schools, 1910; same article in the Proc. Third Inter. Cong. Sch. Hyg., 1910, pp. 351-58. II. The Teacher's Mental Health and the Hygiene of Character 13. Adams, J.: "The Dullness of Schoolmasters." Ed. Foundations, 1911, pp. 350-67. 14. Benson, Arthur C: "The Personality of the Teacher." Ed. Rev., 1909, pp. 217-30. 15. Burk, F. D.: The Withered Heart of Our Schools." Ed. Rev., December 1907. *16. Hall, G. S.: "Certain Degenerative Tendencies among Teach- ers." Ped. Sera., vol. xn, pp. 454-63. 17. Hughes, Edwin Holt: "The Reaction of the Teaching Profes- sion." Educator-Journal, 1906, pp. 223-30. 18. Terman, Lewis M.: "The Teacher Psychosis." Scribner's Mag., November, 1908, pp. 505-08 (published anonymously). *19. Zergiebel, M.: "Zur Psychologie des Lehrers." Zt. f. Ped. Psych., 1911, pp. 471-83. CHAPTER XVIII WHAT THE WORLD IS DOING FOR THE HEALTH OF SCHOOL CHILDREN The purpose of this chapter is to give a brief review of the progress of school health work in various coun- tries. It is hoped that it may convey at least a general impression of the breadth and profundity of a move- ment which with us, as elsewhere, has developed so suddenly that even intelligent people who happen to be uninformed of its scope and fundamental purposes are likely to conceive of it as only another airy decep- tion to add to the already long list of American school fads. England Medical inspection in England was not a growth, but rather a sudden national awakening to the fact of racial deterioration. As late as 1902 there was no ade- quate system of medical inspection anywhere in the country; now it is universal. England's interest in physical education and other problems of child hygiene received its first great im- pulse from the disclosures of the results of conscriptions during the Boer War. The fact that about half of the army volunteers had to be rejected for physical unfit- ness touched deeply the national pride of England, and 286 HEALTH WORK IN THE SCHOOLS brought a keen realization of the dangers of national decay through the physical degeneracy of the people. Numerous investigations, both governmental and pri- vate, were soon launched for the purpose of ascertain- ing the extent of physical deterioration and of suggest- ing means for its amelioration. In 1907 an Education Act was adopted which pro- vided for a compulsory system of medical inspection in all the public elementary schools of England and Wales, a system probably unsurpassed in any other country. The aet became effective in January, 1908, and within a year nearly all the 307 educational dis- tricts of England and Wales had complied with it. The important provisions of this act are two in num- ber: (1) medical inspection is made compulsory, and (2) the duty of executing it is specifically imposed upon the education authority. It is provided, however, that the education authority may, if it sees fit, arrange to have the work carried on under its supervision by the public health machinery already in existence. Prac- tically it makes little difference which course is pur- sued, since it places the responsibility for the conduct of the work upon the education authority. As interpreted by the Central Board of Education, the aim of the English Education Act is not primarily the medical inspection of children, but their physical and mental improvement. The subject of school hy- giene is related in every possible way to the public health work, and is viewed as an integral factor in the health of the nation. Doctors, teachers, and nurses WHAT THE WORLD IS DOING 287 work together in the closest cooperation. The aim is not merely to improve the health of the children who are weakly or ailing, but in the broadest sense to con- serve the health of all children by adapting and modi- fying the system of education so as to make it fit their needs and capacities. No other nation, unless it be Japan, has adopted a school medical service with a more rational conception of its true purpose. In her school medical clinics Eng- land has boldly undertaken the free medical treatment of her ailing children, heedless of the criticisms of the medical profession. Her school physicians are as a rule full-time officers, highly trained and well paid. The leading organ of school health in England is the Journal of School Hygiene, published since 1910. Germany Germany's first school doctor was appointed in 1883, at Frankfort-on-the-Main. By 1905, 100 cities had a total of 598 school doctors, and by 1908, the number had risen to over 400 cities and 1500 doctors. In Germany, medical inspection of schools has not become a national movement, each of the several states composing the empire acting upon its own initiative. Thus far only two states have a state-wide school med- ical service for town and country alike, but everywhere there is lively agitation looking toward an extension of the work to rural schools, secondary schools, and pri- vate schools of all grades. German school doctors are nearly always part-time 288 HEALTH WORK IN THE SCHOOLS officials. Even those who are employed for full time may supplement their salaries with private practice. The pay of the whole-time doctors ranges from $1750 to $2750, with pension rights. School nurses are not very commonly employed, and the effectiveness of the service suffers greatly in consequence. There are many dental, but few medical, clinics. The school doctor never undertakes to give treatment, and all suggestions in this line meet with vehement opposition on the part of the practicing physicians. As stated by Fiirst, " med- ical inspection in Germany has gone only a little way toward its real goal of medical supervision." In this respect Germany is, with certain exceptions, distinctly behind a number of other countries. The Wiesbaden plan of medical inspection, which has become the model for many German and American cities, deserves special mention. It provides essenti- ally as follows : — 1. A superficial examination of all new entrants. 2. Following this a thorough physical examination of new entrants takes place within six to eight weeks after the open- ing of school. The results of the examination are recorded for each child upon an individual "health schedule," a card which contains spaces for the entries of health data secured from all the examinations made during the entire school life of the child. If a child requires continuous medical super- vision, the doctor inserts the words "Medical control" at the top of his schedule. 3. Reexaminations of the same nature occur in the sec- ond, fourth, sixth, and eighth years of school life. 4. The school doctor visits each school at least once a month, and each classroom at least once each half-year. 5. All cases of infectious disease coming to the notice of WHAT THE WORLD IS DOING 289 the head-master must be reported at once to the school doctor, who calls and inspects the class to which the patient belongs. All suspects are sent home, and kept under ob- servation for a few days. Orders for school closure, disin- fection, etc., must be sent by the school doctor to the local sanitary authority. The German method of making the medical examin- ation is of special interest because of its thoroughness, and might well be recommended to American school doctors. As described by Dr. Fiirst, it takes place as follows : — A teacher assists the school doctor by writing on the health schedules at his dictation. The children, who have been previously weighed and measured, approach the doctor in turn, stripped to the waist (including the younger girls). Their general condition is noted, then the chest measure- ment taken; the neck is palpated, and glandular swellings, enlarged thyroid, etc., are noted. The mouth is inspected, and the condition of the teeth and tonsils, and the presence of adenoids noted. The nasal and aural openings are super- ficially inspected and, if suspicious appearances present themselves, a more thorough examination of these is made. The back is now inspected, particular attention being paid to the spine; then the head and hair are looked at. Where appearances of illness present themselves, or the child com- plains of pain, etc., a more thorough physical examination is made, cases which cannot be satisfactorily diagnosed in the presence of the more or less fidgety class being reserved for private examination after the others have been dis- missed. In other ways than by medical inspection Germany affords us admirable examples of what schools can do for the health of their children. Swimming instruction is often obligatory, and school shower-baths are be- coming extremely common. In case of serious spinal 290 HEALTH WORK IN THE SCHOOLS curvature, physical exercises of a corrective nature are prescribed by the school doctor, and carried out under his direction. Half-holidays and school journeys are common. Over two hundred cities supply from one to three daily meals to all necessitous school children, municipal grants supplementing private benefactions for this purpose. In the matter of special schools for defectives, Germany leads the world. Up to 1908 such schools had been established in about two hunded German cities. The open-air recovery school, already noted, is only one of the many types of special schools in Germany. In the amount of productive research, the number and value of its manuals and texts, and in its high-class scientific journals, Germany has contributed far more to the cause of school hygiene than any other country. The following are some of the most prominent German periodicals devoted to school hygiene and related sub- jects : — Zeitschrift fiir Schulgesundheitspflege. Monthly. Founded 1888. Internationales Archiv. filr Schulhygiene. Quarterly. Founded 1905. Das Schulzimmer. Quarterly (1903-10). Eos. Quarterly. Founded 1905. Zeitschrift fiir Kriippelfiirsorge. Quarterly. Soziale Midizin und Hygiene. Monthly. France Medical inspection began in France as early as 1834, when a school doctor was appointed for each boys' school in Paris. The service was extended to girls' WHAT THE WORLD IS DOING 291 schools in 1843. The first school doctors, however, re- ceived no salary, and did little real inspection. It was not until 1879, when Paris organized an extensive sys- tem, that medical inspection in France could really be said to have begun. From that date the movement spread rapidly to other cities. By the Education Act of 1886 the legal position of medical inspectors was fully established, and at present practically all the cities have a system based more or less intimately on that of Paris. For many years the work in France was confined almost entirely to sanitation and the prevention of contagious diseases. Only a few cities — such as Nice, for example — have undertaken the careful individual examination of all of their school children, though the attention of French school doctors is rapidly turning to the fundamental problems of child hygiene. Other notable activities conducted by French edu- cational authorities are school feeding and "vacation colonies." The latter have recently become extremely popular, so that it is not at all rare for the wealthier communes (districts, or wards) of cities to purchase large estates in the country for the special use of vaca- tion colonies for school children. In choosing the pu- pils for such excursions preference is given to children who are anaemic, feeble, convalescent from acute illness or pre-tuberculous. Some districts maintain resorts both at the seaside and in the country, the school doc- tor deciding which place would be of the greatest ad- vantage to a given child. 292 HEALTH WORK IN THE SCHOOLS Mention should be made of the French League of School Hygiene, and also of the Society of Medical Inspectors of Paris and the Seine. Both are active associations, the former publishing the quarterly jour- nal entitled L'Hygiene Scolaire, and the latter the monthly organ La Medecine Scolaire. Switzerland All but a few of the cantons of Switzerland have a well-matured system of medical supervision for the cities, and some of them have extended the work into rural schools as well. The duties of the school doctor usually include the complete sanitary supervision of the school buildings and grounds, and the examina- tion of children for all kinds of defects, debility, and mental deficiency. Both Zurich and Geneva have re- markably efficient school medical service. Lucerne has instituted school medical and dental clinics. The latter registered 3443 attendances in 1908-09. Owing to the high level of intelligence and education among the people of Switzerland the advice of school physicians is almost invariably acted upon, and an elaborate follow-up service is unnecessary. The Swiss Society for School Hygiene, which enrolls over seven hundred active members, has done effective work in promoting medical inspection, and publishes, besides a Year-Book, The Swiss Journal of School Hygiene and Child Protection. WHAT THE WORLD IS DOING 293 Sweden In the medical inspection of schools Sweden has long been a pioneer. As early as 1868 all the public secon- dary schools in the kingdom had medical officers on their staffs. The present code for secondary schools, which dates from 1905, provides for the appointment and remuneration by the Government of at least one medical officer for each school. 1 The method of examination is almost exactly iden- tical with that provided for by the celebrated Wies- baden plan, and so need not be described in detail. 2 The duties of the school physician are, however, of decidedly broader scope than in most other countries, in that they include an administrative as well as an advisory function. The school physician is expected to super- vise the construction of new buildings; to see that the sanitary arrangements are satisfactory; to draw up a plan of procedure for janitors and other employees, and to see that it is carried out; to exercise constant over- sight of the methods of physical education; and finally even to supervise the instruction given in the several branches of the curriculum. We have in this a sugges- tion of the rapidly broadening scope of educational hygiene. For the public elementary schools Sweden has not yet established a general system of medical inspection. 1 It should be noted that Swedish secondary schools correspond to those of Germany, and not to those of the United States. 2 See p. 288. 294 HEALTH WORK IN THE SCHOOLS However, all of the larger cities and some rural com- munities support, on their own initiative, a school medical service similar to that supplied by the Govern- ment to secondary schools. Foremost of the Swedish cities in this respect is Stockholm, which maintains a system of examinations similar to those of Wiesbaden and Paris, and in addition has set the notable example of voting public funds for carrying on research in school hygiene. In 1906, the city granted to Dr. C. Siindell the sum of $495 for the investigation of schoolroom air, in relation to heating and ventilation; $280 to Dr. J. Hanmar, for the study of fatigue, as influenced by various forms of school work; and $55 for an inquiry into the influence of vertical and slant writing upon sitting posture. The budget for 1907 included appro- priations amounting to $1375 for investigations relat- ing to school hygiene. Of this, the sum of $440 was allotted to Dr. Siindell for the study of delicate and anaemic school children, and of the home conditions under which they live; to Dr. Hanmar an equal amount for the continuation of his study of school fatigue; and to Dr. K. Soderling about $500 for the double purpose of investigating the possibilities of natural lighting of schoolrooms (a difficult problem for a part of the school year in Sweden, owing to the high northern lati- tude), and the most suitable sizes of children's school desks. The same amount ($1375) was appropriated for investigations in 1910. If the educational authorities in all parts of the world were simultaneously to emulate this example by WHAT THE WORLD IS DOING 295 undertaking similar investigations, many important and challenging problems of school hygiene would soon be brought to solution. In regard to dental clinics, medical dispensaries, school feeding, and the care of tuberculous children, Swedish schools are on the whole abreast of the most advanced practices in other countries. Medical treat- ment is provided in many polyclinics and in at least six cities by free dental service. Denmark There is no general school medical service in Den- mark, and such inspection as has been carried on has been directed mainly toward the control of infectious diseases. However, Copenhagen, Frederiksberg, and a few of the larger provincial towns have undertaken medical inspection on their own initiative, adopting in most cases the Wiesbaden system. Copenhagen has one part-time physician for 2000 to 4000 children, while Frederiksberg, with its 8000 school children, employs one for full time. The Tuberculosis Act of 1905 has led to an excellent and uniform method of janitor service for all state-managed schools. Norway Since the Education Act of 1896, Norway has re- quired medical inspection of all its public secondary schools. Since 1889 there has been a permissive law for public elementary schools, in towns which are will- ing to meet the expense. Most towns now have such 296 HEALTH WORK IN THE SCHOOLS inspection. As a result of the Tuberculosis Act of 1901, special attention is now given to children who appear anaemic or otherwise debilitated. Scotland In 1902, while the Boer War was in progress and the British nation was effectively roused to questions of physical degeneracy, King Edward VII appointed a committee of nine to inquire into the state of physical training in the schools of Scotland. The committee was composed of some of Scotland's most eminent statesmen and physicians. There resulted in 1908 the Education Act of Scotland, which conferred upon the 971 school boards the powers necessary for a complete system of medical inspection. While this act is nomin- ally not mandatory, it is so in effect. Practically all schools, whether primary, secondary, or technical, including continuation schools, must either provide for medical inspection or give facilities to the school board. Even private schools may provide medical inspection at public expense. The counties, as a rule, provide the same excellent system as do the large cities. As in England, the child hygiene movement in Scot- land has progressed with almost incredible rapidity. According to a recent provision, all candidates for the teaching profession are required to take a course of training in school and personal hygiene embracing not less than seventy hours. For this purpose seven full- time and two part-time physicians are employed as WHAT THE WORLD IS DOING 297 lecturers by the four training schools for teachers. The same physicians also medically examine all stu- dents in training, both at the beginning and the end of their course. The College of Hygiene and Physical Training, founded by the Carnegie Dunfermline Trust, provides highly qualified special teachers of hygiene. Glasgow and Edinburgh support special schools for physically and mentally defective children, but thus far there are few open-air schools in Scotland. One of the most important of all statistical documents yet published, for the study of the sociology of the school child, is the Report, by Dr. W. Leslie Mackenzie and Dr. A. Foster, on The Physical Condition of Children attending the Public Schools of Glasgow. The cause of child hygiene in Scotland owes an incalculable debt of gratitude to the pioneer efforts of Dr. Mackenzie. Ireland In matters of school hygiene Ireland affords the most shocking conditions to be found in any country which lays claim to civilization. The facts as presented by the most responsible writers and observers sound incredible. A majority of the buildings are deplorable struc- tures, extremely small, low, thatched but not ceiled, "old, decayed, rat infested, base, and unsightly hov- els." Many are filthy, squalid, damp, miserably lighted, and absolutely without ventilation. Sometimes as many as 80 children are crowded into a room 13 X23 feet, and retained there from 10 until 2 o'clock without 298 HEALTH WORK IN THE SCHOOLS intermission. The atmosphere becomes pestilential and sickening. The seats are universally crude and ill- fitting. One eighth of the elementary schools of Ireland are without toilet conveniences of any kind. There is often no janitor work beyond what teacher and pupils do voluntarily, nor in many schools is there any provi- sion for heating. One third of the schools of Belfast have no playgrounds whatever. The inevitable results of this neglect appear on every hand. The mortality of school children is higher than for the population generally. Epidemics of mea- sles, scarlet fever, whooping-cough, etc., are frequent. Between the ages of 10 and 15 years the death rate from tuberculosis is appalling, while the relative health- fulness of the children below school age points unequi- vocally to the cause. Canada Ontario passed a permissive act in 1909 and medical service has been inaugurated in Hamilton and Brant- ford. Manitoba passed a similar act in the same year, and Winnipeg at once availed itself of the legislation. The Province of British Columbia adopted, in 1910, a thoroughgoing medical service for all the city and rural schools. The city of Montreal has had school medical service since 1906. Interest in the question was first aroused by the Montreal Women's Club, which in 1902 began a campaign of education looking toward this end. After four years of agitation their efforts were successful. WHAT THE WORLD IS DOING 299 The emphasis is primarily on the prevention of con- tagious disease and the improvement of sanitation, though the work has incidentally had other favorable results. Australia Medical inspection of some kind has been under- taken in most of the Australian provinces. New South Wales has taken up the work in a particularly compre- hensive way, laying stress upon the cooperation of teachers. The results of medical inspection in a country like Australia have special interest, for the reason that they may be expected to afford an index of the influence upon children's health of exceptionally favorable eco- nomic and climatic conditions. Thus far the results are no less disturbing than the disclosures brought about by medical inspection in other countries. Japan The Japanese, who never do educational things by halves, have one of the most thoroughgoing systems to be found in the world. They rightly regard the school child as the nation's most valuable asset, and consider it a matter of national expediency as well as duty to explore the extent and quality of this resource. Ac- cordingly most of the public schools have been annu- ally inspected by salaried school physicians since 1898. Annual records are made of height, weight, chest cir- cumference, nutrition, and all forms of defectiveness. 300 HEALTH WORK IN THE SCHOOLS The resulting statistics are among the most complete and valuable ever collected. Other countries Thus we see that most of the civilized countries of the world have some system or other of school medical supervision. Among others not previously mentioned are Hungary, Austria, Belgium, Holland, Roumania, Bulgaria, Chile, Argentine Republic, South Africa, and even individual cities in such semi-benighted countries as Russia and Egypt. The United States Medical inspection of schools in the United States is of very recent growth. Beginning in Boston in 1894, it was taken up by Chicago in 1895, by New York, in 1897, and by Philadelphia in 1898. At least 90 cities had medical inspection in 1907, 337 in 1910, and prob- ably not far from 500 in 1913. This includes practi- cally all of the larger cities and many of the smaller. In 1910 the cities of the country employed 1194 school doctors and 371 nurses, while 48 employed school dentists. By May, 1911, nineteen States had passed laws pro- viding for the medical inspection of schools. In nine States the laws are mandatory. A few States have since begun the establishment of State Departments of Child Hygiene. Attention may be called to the following salient facts regarding medical inspection of schools in the United WHAT THE WORLD IS DOING 301 States: (1) The control is usually vested in the board of education, instead of the public health author- ities; (2) of the 301 cities supporting a school med- ical service, nearly half confine their work to the detection and control of contagious disease; (3) only one State (New Jersey) has a mandatory provision requiring treatment for defects discovered; (4) tests of vision and hearing are usually made by the teachers; (5) the movement is growing with greater momentum each year; (6) the office of school physician is still wretchedly underpaid. Only sporadic attempts have yet been made in the United States to introduce school feeding or school dentistry. Open-air schools are becoming extremely popular, the number increasing enormously each year. In the way of special schools for defectives we cannot yet match the admirable system of auxiliary schools in Germany, but the movement is being vigorously pushed. The American Association of School Hygiene was organized in 1907, and has published four volumes of Proceedings. Unfortunately we have no journal de- voted to school hygiene. It is hoped that the fourth meeting of the International Congress of School Hygiene, which occurred at Buffalo in 1913, will result in increased momentum to our school health reform. Conclusion It is surely evident, even from this brief account, that the medical inspection of schools is a movement 302 HEALTH WORK IN THE SCHOOLS of great portent. A little time hence we shall doubt- less look back upon the marvelous development of intellectual education of the nineteenth century, and its simultaneous neglect of the body, as one of the strange paradoxes of educational history. Attention, however, should be called to the fact that in most countries the medical service for secondary schools has been made a matter of slight consideration. It is right that those schools which contain the masses of the nation's children should be provided for first, but similar action should follow for all other types of schools. The old assumption that because children attending the higher schools are usually from a better class of homes, they must therefore be practically free from defect, has been entirely disproved. If it be true, as seems probable, that the secondary schools enroll, on an average, pupils of somewhat more than ordinary native endowment, then so much the more important for them are the things which concern health. REFERENCES *1. Ayres, Leonard P.: Medical Inspection Legislation. Bulletin no. 99, Russell Sage Foundation, Dept. Child Hygiene, 1511. *2 Ayres, Leonard P.: "What American Cities are doing for the Health of School Children." The Public Health Movement, 1911, pp. 250-60. Published by the American Academy of Political and Social Science. 3. Burnham, William H.: "Health Inspection in the Schools." Ped. Sem., 1900. 4. Crowley, Dr. R. H.: The Hygiene of School Life. 1909. 5. Dufestel, Dr. L.: Guide Pratique de MSdicin Inspecteur des ftcoles. Paris, 1910. 6. Franke, Kurt: " Schulhygiene in Japan." Zt.f.Schulges., 1912, pp. 729-39. *7. Gulick and Ayres: The Medical Inspection of Schools. 1913. WHAT THE WORLD IS DOING 303 *8. Hogarth, A. H.: The Medical Inspection of Schools, 1909. (Chapter n, "History and Legislation.") *9. Kelynack, T. N.: The Medical Inspection of Schools and Scholars. 1910, pp. 434. (Best summary on medical inspection progress.) "10. Shafer, George H. : " Health Inspection of Schools in the United States." Ped. Sent., 1911, pp. 273-314. 11. Scot, Vere: "The Blight on Irish Schools." School Hygiene, 1912, pp. 230-33. 12. Terman, Lewis M.: "Medical Inspection of Schools in Cali- fornia." Psych. Clinic, March, 1911. *13. Terman, Lewis M.: The Hygiene of the School Child. 1913. 14. Terman, Lewis M.: The Teacher's Health. 1913. 15. See the Proceedings of the International Congresses of School Hygiene, 1904, 1907, 1910, and 1913; also the Annual Reports of the American Congresses of School Hygiene, from 1907; the most important journals of school hygiene, such as Zeitsckrift fur Schulges; Inter. Mag. of Sch. Hyg., and the (English) Journal of School Hygiene. APPENDIX SCHOOL HEALTH ORGANIZATION IN VARIOUS CITIES OF THE UNITED STATES Milwaukee The Milwaukee School Health Department is maintained by the Board of Education, and has (1913) the following organization : — One medical director. Ten assistant medical inspectors. One specialist on diseases of the eye, ear, nose, and throat. One full-time dental inspector. One special assistant for psychological and anthropologi- cal tests. Five school nurses. The medical director, dental inspector, and nurses, devote their entire time to their work; the remainder of the staff give one half of each day. A central office is maintained where the medical director meets parents, conducts special examinations, and carries on the general office work of the department. A dental clinic for indigent children, an out- door school, and a school for crippled children, have re- cently been added. There are four classes for blind children, and four centers for the treatment of speech defects. The city has been divided into ten geographical districts, nine of which are approximately equal in size and contain about the same number of schools; the tenth, located in the central, or slum, portion of the city, covers less area because the schools are closer together and the conditions met among the pupils worse than in the outlying sections of the city. Each district is under the care of one assistant medical inspector. For the work of the nurses, the city has been divided into five districts, the four outlying territories being about equal, and the fifth in the center of the city, being considerably smaller. 306 APPENDIX Each school has been supplied with the following mate- rials: — 1. A case for the filing of the doctor's and nurse's rec- ords. 2. A circular for the principal, explaining in brief the purposes of medical inspection, his duties in its accomplish- ment, and information as to causes and time of exclusions. 3. A circular for each teacher, detailing her duties, and giving information as to the early symptoms of contagious diseases. 4. Code cards for all teachers on which all diseases of importance are indicated, by numbers. 5. Blue cards, for requests from teachers for an immediate examination. 6. Psychological examination blanks, with circular of explanation. 7. Physical examination blanks. 8. An emergency case, containing a stretcher, drugs, and dressings. Complete directions are given to the medical inspectors and nurses in respect to their routine work in the schools. Principals of schools are also instructed in respect to the general plan of health supervision. Indigent children, suf- fering from physical defects, are referred to the various city dispensaries. The general plan of examination is as follows: — A blue card constitutes the request of the teacher for an examination for one of her pupils, whom she suspects of be- ing afflicted with some acute condition requiring immediate care. When the class assembles in the morning, the teacher rapidly inspects her pupils, and if she finds anything abnor- mal in the appearance of a child she makes out this card. On this card she gives the name, address, school, grade, teacher, date, and reason for sending the child. When the doctor's signal is given, or a monitor informs her of the doctor's presence in the school, she gives the child selected for examination its blue card, and sends it to the room in which the doctor makes his examinations. The doctor ex- amines each child presented, makes his diagnosis, and on the stub attached informs the teacher of his findings, whether the child is to be excluded or not, and, if excluded, for how APPENDIX 307 long. The card itself is placed on file, and the case followed up by nurse and doctor until cured, when the card is sent to the central office for tabulation. If the case is such that the doctor considers exclusion desirable, a yellow card is made out, giving the cause for exclusion, the date on which the child is to report for reexamination, and the date of re- examination and readmission. Attached to this card is a letter form which is sent home in a sealed envelope with the child, informing the parents of the exclusion and the cause. Each child in the schools receives also a physical examina- tion. The result of this examination is kept on a blank made out in duplicate, and so arranged as to provide for annual records for a period of nine school years. The information recorded on the blank comprises the name, birthplace, sex, age, school, grade, nationality of father and mother, history of measles, scarlet fever, diphtheria, pertussis, date of phy- sical examination, vaccinations, height, weight, nutrition, presence or absence of hypertrophied tonsils, adenoids, de- fective nasal breathing, defective palate, defective teeth, myopia, hypermetropia, other eye defect, defective hearing, deformities of the spine, trunk or extremities, tubercular lymph nodes, pulmonary, cardiac or nervous disease, chorea, epilepsy or stammering. One copy is sent to the central office and one copy is placed on file at the school, so that the principal and teacher may know the physical condition of each child in the school. When the child is placed under another teacher, either by promotion, demotion, or transfer to another school, the card is presented to this teacher, who is thereby informed concerning any defects which the new pupil may have. The Milwaukee system is as near ideal as any in the coun- try, and is thoroughly practical and efficient in organiza- tion and results obtained. Schools expecting to undertake complete health supervision of their pupils cannot do better than to study the Milwaukee system. Health Organization in the Minneapolis Schools This department is organized to include, so far as possi- ble, all matters pertaining directly to the health of the child. 308 APPENDIX It therefore includes all the physical training activities, gymnastics, folk-dancing, athletics, both high and grade school, those playgrounds that are conducted by the board of education, whatever physical training work is done in the night schools, etc. The school for stammerers, special classes for children who are mentally retarded and deficient, open-air schools, the school gardens, and the truant schools are also all under the general supervision of the school health department. The official organization is as follows : — One medical director (on full time). Eight assistant medical officers (on half time). Eighteen school nurses (on full time). Twelve instructors in physical training (on full time). Eighteen playground instructors during the summer months. One supervising school nurse. The work of the Minneapolis School Health Department is maintained by the board of education, and is one of the most efficient departments now organized. It is interesting to note with what completeness the divisions of medical supervision and physical education are organized and re- lated in this city. Philadelphia Philadelphia, under the management of Dr. Walter Cornell, has recently reorganized its school health work as follows : — The examination of school children is conducted by the city health department, but the expense is borne by the board of education. Under ordinary conditions this plan could not be recommended, but at present it appears to work satisfactorily in Philadelphia. The school nurses are employed and paid by the board of education. The scope of the work at present includes : — 1. Routine examination of every child once each year, as required by the state law. 2. Sanitary inspection of school buildings. 3. The detection and exclusion of children suffering from contagious diseases. APPENDIX 309 4. The examination of absentee children, for the Bureau of Compulsory Education. 5. Special examination of mentally deficient children. 6. Medical supervision of open-air classes for anaemic and tubercular children. 7. Examination of applicants for position of school janitor, and other positions in the department of buildings. 8. Medical supervision of special classes for blind or crippled. 9. The supervision of candies and other foodstuffs sold by vendors around the school premises is being projected, and will soon be put into effect. Oakland Oakland, California, has had since 1909 an excellent or- ganization under the direction of Dr. N. K. Foster. The plan is in some respects unique, and has given splendid results. It consists of the following : — One medical director. One assistant medical officer. Seven school nurses. Each nurse has her own particular schools in which to work. At the beginning of the year a special attempt is made to give attention first to those pupils who are urgently in need of it. This is accomplished through the efforts of the teachers and nurses. In this way the worst cases are detected and followed up early in the year, a point of much importance. After this preliminary work is finished, the nurse examines all of the pupils in her district, and sends notices of defects discovered to parents. Follow-up work is done in the case of each child whose parents receive a notice. An interesting and valuable part of the nurse's work con- sists in simple "health talks" to the individual pupils, at the time of the physical examination, particularly in rela- tion to the defects or disorders from which they suffer. Health talks are also given the entire classes both by the school nurses and school doctors, and special attention is given to instruction in matters pertaining to sex-hygiene. A central office is maintained by the board of education 310 APPENDIX at which the school physicians keep office hours, so that parents may come with their children for special examina- tions and consultations in respect to further action. The entire department is maintained by the board of education, and the plan works admirably in every respect. Health Organization in New York City Schools The medical supervision of school children in New York City is maintained under the division of child hygiene of the city board of health. The division of child hygiene was reorganized in 1912, and at present consists of the following plan : — Organization of the Division DIRECTOR. Assistant Director. Supervising Inspector Superintendent of Nur >£ Milk Stations. ses. Botox Slanl ghof attar* Borough of Brooklyn Bonn The I ghof ronx Borou Que ghof ens Boron Rich ghof nond Bon CI >ugh ief Bore Ch ugh ef Bor Ch >ugh ief Bore Ch ugh ief Bore Ch ugh ief Super Inspe vising :tors Super Inspe vising :tors Super Inspe vising ctors Super. Inspec rising tors Super Inspe vising ctois ' Super Nu vising *ses Super Nui vising ses Super Nui vising ses Super Nui rising ses Super "Nur sisfng ses Medi Inspe :al ctors Medic Inspe al ctors Medi Inspe al ctors Medic Inspe al ctors Medi Inspe al ctors Nurses Nurses Nurses Nurses Nurses Nurses* Assistants Nurses' Assistants Nurses' *- Assistants Nurses' Assistants Nurses* Assistants APPENDIX 311 Borough Organization Borough chief, in each borough. (Directly responsible to the director, and in charge of the indicated borough.) Supervising inspectors. (Each in charge of a squad of from ten to fifteen inspectors and under the direct super- vision of the borough chief.) Supervising nurses. (Each in charge of a squad of from fifteen to twenty nurses, and directly responsible to the supervising inspectors.) Medical inspectors. Nurses. Nurses' assistants. Under the subdivision of school hygiene there are em- ployed, in addition to the supervising school medical officers and supervising school nurses, 74 medical inspectors and 179 school nurses. The control of contagious diseases has been placed in the hands of the school nurses, while the medical officers in the schools devote their time to the work of making physical examinations. School nurses treat many of the eye and skin diseases discovered in the schools, while free dispensary treatment is provided for all other cases which cannot receive attention from family physicians and specialists. Present Procedure Objects: — 1. The repeated and systematic inspection of all school children for the purpose of early recognition of conta- gious disease. 2. Exclusion from school attendance of all children af- fected with an acute contagious disease. 3. Subsequent control of the case with isolation of the patient, and disinfection of the living apartment after termination of the illness. 4. Control and enforced treatment of contagious eye and skin diseases with the purpose of diminishing the num- ber of children excluded from school attendance. 5. Knowledge of unreported cases of contagious disease among school children at home. 312 APPENDIX 6. Complete physical examination of each school child with reference to the existence of any untreated phys- ical abnormality. 7. Education of the parents as to the necessity of ob- taining proper medical care for untreated physical defects. 8. Provision for facilities for the treatment of contagious eye and skin diseases and non-contagious physical defects occurring in school children. The complete system of school medical inspection is carried on in 517 public schools with a registered attendance of 684,207 pupils. In addition, 151 other free schools of the city receive a more or less complete series of inspections for the purpose of detecting contagious diseases. Seventy-four medical inspectors and 179 nurses are detailed to the work of school medical inspection under the immediate super- vision of the staff of supervising inspectors and supervising nurses in each borough. Each inspector is assigned to duty in a group of schools with an average registration of nine thousand pupils. Each nurse is assigned to duty in a group of schools with an average registration of four thousand pupils. Each public school in the city is visited each day by a nurse, except in certain outlying and sparsely populated districts where visits are made at less frequent intervals. Other free schools are visited upon request, or regularly once or twice weekly. The school medical officers follow the routine indicated in the outline which is given below : — The diagnosis and correction of non-contagious untreated phys- ical defects: — 1. The medical inspector visits each school under his jurisdiction for two successive days. A regular schedule is maintained, and the principals of the schools are thus informed of the dates of the inspector's visits. The principals are requested to instruct the children to report, in small squads, to the inspector for physical examination. 2. Examinations are made in the following order: — (a) Children entering school for the first time. APPENDIX 313 (b) Children especially referred by the principals or teachers. (c) Children belonging to the class to be graduated. (d) In the regular course, beginning with children of the lowest grades, and proceeding to the higher grades in regular order. (e) Classes of the same grade are examined in regular order in each school of the group. 3. Each child is thoroughly examined for the following conditions : — Defective vision. Defective hearing. Defective nasal breathing. Hypertrophied tonsils. Tuberculous lymph nodes. Defective teeth. Malnutrition. Pulmonary disease. Cardiac disease. Chorea. Orthopaedic defects. 4. A complete record of each physical examination is made on a special form. If a child is normal, the inspector sends such a report to the borough office of the divi- sion. If abnormalities are found, the record form is given to the school nurse. A duplicate record of each child's condition is also placed on file with the child's school record, thus affording to the educational authorities the fullest information in regard to the child's physical condition, and enabling them to take advantage of this information in adjusting the individual curriculum. The nature and results of the treatment obtained for each defect are thereafter noted upon this school record form by the nurse. The inspectors and nurses are required to cooperate to the fullest extent with the principals and teachers, giving to them all possible data in relation to the children found to be physically defective, and to offer suggestions in the way of school adjustments which may tend to correct the existing defects. 314 APPENDIX The cities cited furnish practical information of what is actually being accomplished in some of the representative places of the United States, and will thus indicate to other cities of a similar size how organization may be successfully begun. 1 1 For an intensive study of the methods and results of medical inspection in twenty-five representative cities of the United States, see Louis W. Rapeer: School Health Administration. 1913, pp. 360. SUGGESTIONS FOR A TEACHER'S PRIVATE LIBRARY IN SCHOOL HYGIENE A. General (A selected list of sixteen of the best books, which retail for a total of $30.25.) 1. Allen, W. H.: Civics and Health. Ginn & Co., Boston, 1909, pp. 411; price $1.50. 2. Ayres, Leonard P.: Open-Air Schools. Doubleday, Page & Co., New York, 1910, pp. 165; price $1.00. 3. Bryant, Louise Stevens: School Feeding. Lippincott Co., Philadelphia, 1913, pp. 345; price $1.50. 4. Cornell, Walter S.: The Health and Medical In- spection of School Children. Davis Co., Philadelphia, 1912, pp. 614; price $3.00. 5. Crowley, Ralph H.: The Hygiene of School Life. Methuen & Co., London, Eng., 1910, pp. 393; price $1.50. 6. Denison, Elsa: Helping School Children. Harper & Bros., New York, 1913, pp. 352; price $1.50. 7. Dresslar, F. B. : School Hygiene. The Macmillan Co., New York, 1913, pp. 369; price $1.25. 8. Gulick, Luther, and Ayres, L. P. : The Medical In- spection of Schools. Russell Sage Foundation, New York, 1913, pp. 224; price $1.50. 9. Hoag, E. B. : The Health Index of Children. Whitaker and Ray-Wiggin Co., San Francisco, 1910, pp. 188; price $.80. 10. Hogarth, A. H.: The Medical Inspection of Schools. Oxford University Press, London, Eng., 1909, pp. 360; price $1.50. 11. Kelynack, T. N: (editor) The Medical Examination of Schools and Scholars. P. S. King & Son, London, Eng., 1910, pp. 434; price $3.00. 316 A TEACHER'S PRIVATE LIBRARY 12. Leland, Arthub: Playground Teaching and Playcraft; price $2.70. 13. Rapeer, Louis W.: School Health Administration. Teachers College, 1913, pp. 360; price $2.25. 14. Terman, Lewis M.: The Hygiene of the School Child. Houghton Mifflin Co., Boston, 1913, pp. 450; price $1.65. 15. Terman, Lewis M.: The Teacher's Health. Houghton Mifflin Co., Boston, 1913, pp. 138; price $.60. 16. Proceedings of the Fourth International Congress of School Hygiene, held at Buffalo, 1913, three volumes; price $5.00. Address Thomas A. Storey, College of the City of New York. B. The Teaching of Hygiene (A selected list of the best books, which retail for a total of $6.83). 1. Gulick, Luther H.: The Gulick Hygiene Series. Ginn & Co., Boston. " Two-Book Course," $1.05; " Five- Book Course," $2.30. 2. Hoag, E. B.: Health Studies. D. C. Heath and Co., Boston, 1909, pp. 223; price $.60. 3. Hutchinson, Woods: The Woods-Hutchinson Health Series, two volumes, Houghton Mifflin Co., Boston; "Book One: The Child's Day," $.40: "Book Two: Handbook of Health," $.65. 4. Ritchie and Caldwell: Primer of Hygiene, and Primer of Sanitation. World Book Company, Yonkers-on-Hud- son, New York. The two for $1.08. 5. Wood and Reesor: Health Instruction in the Elementary Schools. Teachers College, New York, 1912, pp. 140; price $.25. 6. Tolman and Guthrie : Hygiene for the Worker. American Book Co., 1912, pp. 231; price $.50. GLOSSARY anaemia, deficiency of blood, or of red corpuscles. arthritis, inflammation of a joint. astigmatism, a refractive error of vision due to unequal cur- vature of the parts of the eye. atypical, not typical, excep- tional. aurist, a specialist in diseases of the ear. bacteriology, the department of zoology which deals with bacteria. blood-count, referring to the number of corpuscles per unit measure of blood. Bright's disease, a disease of the kidneys. carious, decayed. cervical glands, the lymph glands of the neck. chorea, "St. Vitus's Dance." conjunctivitis, an inflamma- tory disease of the mucous membrane lining the eyelids. dentine, the calcified sub- stance which composes the main part of a tooth. desquamation, peeling-off of the skin. eugenics, the science of im- proving the human race through the application of the laws of heredity, exhalation, the expulsion of air from the lungs. fomite infection, the spread of contagious diseases through the medium of articles or things. haemoglobin, that part of the red corpuscles whose func- tion is to carry oxygen. hydrocephaly, a disease char- acterized by the accumula- tion of a watery fluid on the brain. hyperopia, "far sight." hypertrophied, abnormally en- larged, overgrown. hyphosis, backward curvature of the spine. impetigo, a contagious skin dis- ease due to a fungus. lassitude, weakness or languor, lymphatic, pertaining to the lymph. mastoid, that part of the tem- poral bone situated directly behind the ear. moron, that grade of feeble- mindedness just below the normal. myopia, "near sight." 318 GLOSSARY neurosis, any nervous disor- der. oculist, a physician skilled in treating diseases of the eye. optician, one who makes or deals in optical instruments or glasses. oral hygiene, the hygiene of the mouth. orthodontia, mechanical treat- ment for correcting irregu- larity of the teeth. otitis media, acute infection of the middle ear. passee, faded, worn out. pediculi capitis, head lice, poliomyelitis, a disease of the gray matter of the spinal cord, polypus, a tumorous growth on the mucous membrane, as of the nose. radiograph, an X-ray picture, rickets, a nutritional disease of childhood affecting chiefly the bones. scabies, itch. scoliosis, lateral curvature of the spine, squint, cross-eye, or strabismus, strabismus, cross-eye. suppuration, producing pus. tie, a spasmodic twitching of the muscles. toxaemia, a poisoned condition of the blood. trachoma, a contagious disease of the eye involving granula- tion of the inner surface of the eyelids. varicella, chickenpox. Von Pirquet test, a test for the presence of tuberculosis. INDEX Addams, Jane, 52. Adenoids, 97 ff. Air, as a source infection, 141 ff. Australia, school health work in, 299. Ayres, Leonard P., 7, 198. Binet tests, 105 ff. Blood tests, at open-air schools, 203 ff. Board of health, 25 /. Bradford, school medical clinic, 112; open-air school, 200. Burnham, Dr. W. H., 271. Cabot, Dr. R. C, 59 Canada, school health work in, 298. "Carriers," 142/., 160/. Chapin, Dr., 141, 143, 154, 160. Chickenpox, 171, 192. Christian Science, 11 ff. Cleaning, method of, 214 ff. Clinics. See School clinics. Closure of schools, 142 ff. Contagious diseases, 133 ff.; modes of infection, 137/.; an- nual curve, 145. Cornell, Dr. W., 308. Cups, drinking-cups, 139/. Defectiveness, 91/., 253; amount of, 2, 87 /.; discovery by teachers, 68 /.; treated by school clinics, 111 /. See also Eyes, Ears, Teeth, Nutrition, Nose, Throat, etc. Denmark, school health work in, 295. Dental caries, 130/ Departments of health in the school, Iff., 305/ Diphtheria, 135, 143, 159/., 184, 194. Disinfection, 152. Dock, Dr., 178-79. Dust, 209/ Dustless crayon, 216. Earache, 80. Ears, 71, 115. England, school health work in, 285/ Epidemic meningitis, 181 / Eyes, 72, 80, 84 /., 92 /, 116, 182/ Favus, 189. Feeble-mindedness, 105/ Feeding, in open-air schools, 199. Flexner, 182. Fomite infection, 137 / Food, 88. Food habits, 228. Forsyth Dental Infirmary, 128. Foster, Dr. N. K., 309. France, school health work in, 290/. Fiirst, Dr. Clyde, 286. Germany, school health work in, 287/ Gonorrhoea, 252-53. Haberlin, Dr., 204. Hall, Stanley, 254. Hall, W. S., 228. Hay ward, Dr., 49. Headache, 80. Health supervision, relation of, to private medical practice, 6 / ; opposition to, 11/; de- velopment of, 15 /., 285 /; scope of, 17/; cost of, 23, 45 /.; method of control, 25 /.; state departments, 37 /.; or- ganization of city departments, 41/, 305/; by nurses, 48/; 320 INDEX influence on home, 54 /.; by teachers, 62 ff.; in foreign countries, 285 ff. Hearing, test of, 99 ff. See also Ears. Hoag, Dr. E. B., 90, 145, 315. Hogarth, Dr. A. H., 109, 121. Hookworm disease, 178 ff. Home, influence of health super- vision on, 10 ff.; sanitation of, 241 ff.; responsibility for sex enlightenment, 267. Hygiene departments, of city schools, 305 ff. Hygiene teaching, 9, 103, 231 ff.; in the first six grades, 221 ff. ; in the seventh and eighth grades, 236 ff.; by means of sanitary surveys, 240 ff.; sex education, 252 ff.; teacher's hygiene library, 315-16. Impetigo, 190. Infantile paralysis, 180 ff. Influenza, 194-95. Intelligence tests, 105 ff. Ireland, school health work in, 297. Itch. See "Scabies." Janitors, 219. Japan, school health work in, 299. Jessen, Dr. E., 125. Kerr, Dr. James, 148, 154. Korosi, Dr., 133. Lambert, Dr., 213. "League for Medical Freedom," 11/- London, school clinics in, 112. McCallie test, 96. Mackenzie, Dr. W. Leslie, 297. MacMillan, Margaret, 112. Malnutrition, 176. Measles, 134, 149 ff., 192. Medical inspection. See "Health supervision." Mental conditions, 83, 105/. Milwaukee, school health work in, 305/. Minneapolis, health organiza- tion in, 307. Minnesota, state division of child hygiene, 38 ff. Moll, Dr. Albert, 254. Moral Education, 260. Mumps, 169 ff., 194. Muroscroll, 216. Nervous conditions, 70, 83. New York City, school health department, 310/. Normal schools, and the teach- er's health, 281. Norway, school health work in, 295. Nose and throat, 71, 81, 97/. _ Nurses, 42 /. ; 48 /. ; home visi- tation, 49/.; and absence, 51 /.; number, 56 /.; training, 57/; efficiency, 59/; health surveys, 66/ Oakland, school health depart- ment, 309 / Open-air schools, 198 /. Orthodontia, 130. Osier, Dr., 54, 181. Parental responsibility, 3 /. Parents, notification of, 104 /. Pediculosis capitis, 188/ Philadelphia, school health de- partment, 308/ Physiological age differences, 102 / Porter, Dr. Langley, 177. Posture, 82. Publicity, 33/. Rapeer, Dr. Louis, 17, 59. Records, 29/, 74/ Reinhart, Dr. George, 143. Ringworm, 189. Sanitary surveys, 238. Sanitation, 209 / Scabies, 187. Scarlet fever, 153/., 192. INDEX 321 School buildings, 8. School clinics, demonstration clinics, 90 ff . ; medical clinics, 109/.; cost of, 113; why neces- sary, 114; dental clinics, 125 /■ School nurse. See Nurse. Scotland, school health work in, 296. Skin diseases, 72, 85. Sleep, at open-air schools, 199, 205. Smallpox, 173 ff., 194. Snellen test, 84, 95. Social responsibility for health, Iff., 119 ff. State departments of school hy- giene, 38/. Superannuation of teachers, 272. Sweden, school health work in, 293/. Switzerland, school health work in, 292. Syphilis, 253. Teacher, part in health super- vision, 62 ff.; private library in school hygiene, 315. Teacher's health, 270/. Teeth, 71, 78, 85; dental clinics, 125 ff. Terman, Lewis M., 108, 270, 303, 316. Towels, 138. Trachoma, 97, 185 ff. Tuberculosis, 175; among teach- ers, 273. See also Open-air schools. Vaccination, 174. Vacuum cleaners, 215. Varicella, 171. Virginia, school health work in, 40/. Vision, testing, 95 /. See also Eyes. Vocational guidance for teach- ers, 283. Von Pirquet test, 175. Weight, increase in open-air schools, 200. Whooping-cough, 164, 166/. Wichmann, Dr., 276. Wiesbaden, examination plan, 288. Williams, Dr. Lewis, 111, 114, 119, 120. mSm&JE m CONGRESS 0020313 755 2