Ci)EmiGHT DEPOSm EDUCATIONAL HYGIENE ESSENTIALS OF EDUCATIONAL HYGIENE EDITED BY LOUIS W. RAPEER PRESIDENT, FEDERATION FOR AMERICAN CHILDHOOD DIRECTOR, NATIONAL SCHOOL OF SOCIAL RESEARCH WASHINGTON, D. C. CHARLES SCRIBNER'S SONS NEW YORK CHICAGO BOSTON ^' 0' V"<<^ ■b A Copyright, 1915, 1919, by CHARLES SCRIBNER'S SONS AUG 25 1919 /Sis ^. « rr <> rs O /I >7 PREFACE The remarkable movement for the improvement of school and community health in the last decade has brought the school into such close and intimate relationship with the health work, of the home and the community that ^^ school hygiene" is hardly broad enough as a term to include the various health aspects of the bringing up of children. On the other hand, the term ^^ child hygiene" is too broad. The title ^'Educa- tional Hygiene" has been adopted for the science and art of health preservation and promotion which the school can more or less directly promote through its various health agencies. When the school nurse visits the homes and improves the health of the children below school age as well as that of the pupils of the school, and when school physicians provide for consultation hours for mothers, whether patrons or not, the old-time school hygiene is broadening out into educational hygiene. This movement has but begun, and will inevitably continue to expand. Educational hygiene, furthermore, is desirable as a term, since the subject is now taking its place in professional schools for the training of teachers as correlative with educational psychology, educational sociology, educational philosophy, educational history, educational administration, and the Hke. As educational administration was once termed school admin- istration, so educational hygiene was once termed school hygiene, and the desirability of the change in college courses is probably not less for the latter than for the former. This comparatively new science is broad in scope, cover- ing as it does the five divisions : medical supervision, physical education, school sanitation, the teaching of hygiene, and the hygiene of instruction. Obviously, very few persons can Vi PREEACE make any just claims to being experts in this entire field, and exceedingly few persons have had very much practical and scientific experience in all of them. This volume is an attempt to bring together in organized form the latest information and advice of leading speciahsts in all the large phases of the subject. The hygiene of chil- dren from the standpoint of the school in its relationship to the home and community, from the pre-school period up to the college, is sketched in such detail as is possible in so comprehensive a volume. There has been a constant temp- tation to add chapters on many new phases of the school- health movement, but the editor has tried to limit himself to certain '' minimum essentials," and to give references to the voluminous Hterature which treats at length the many topics discussed here only briefly. Each chapter and parts of many chapters easily furnish topics for much-needed books, some of which have already been provided by contributors to the volume. Effort has been made to lead the reader on from these condensed statements to the monographic literature. The school as a public agency ministering to the dominant needs of the community in the interests of the state is always kept in mind. Each contributor has attempted to show how the public educational agencies may improve their assistance to the solution of the grave problems of national health and vitaHty. Several chapters are comparatively unique in this respect, such, for example, as those on public co-operation for school-health progress. These give a point of view much needed by the' many educators who have neglected educa- tional sociology in their professional studies. A chapter on the health of the teacher was planned, but omitted because the matter, though of great importance, has received little scientific study, and because each teacher should have access to the little book published on this subject by Professor Terman. To the many persons who have so kindly lent their assist- PREFACE Vll ance in contributing to the volume, to his wife, to those who have furnished photographs from many parts of the world, and to the pubhshers for their cheerful co-operation, the editor is sincerely grateful. L. W. R. Washington, D. C. CONTENTS PART ONE Health Sociology CHAPTER PAGE I. Public Health and the Public Schools . . i By Louis W. Rapeer, M.A., Ph.D., President, Federa- tion for American Childhood; Director, National School of Social Research, Washington, D. C. II. The Public-Health Movement 22 By E. H. Lewenski-Corwin, Ph.D., Secretary Health Committee of the New York City Academy of Medi- cine. III. Health and Heredity 45 By Chas. B. Davenport, Ph.D., Carnegie Institution, Cold Spring Harbor, Long Island, N. Y. IV. The Home Hygiene of Children 59 By Ernest B. Hoag, A.M., M.D., Supervisor of Edu- cational Hygiene, Pasadena, California, and Lecturer in Leland Stanford, Jr., University. V. Public Co - operation for School - Health Agencies 82 By Clarence A. Perry, A.B., Director of Division of Recreation, Russell Sage Foundation. VI. The Social Centre and Educational Hygiene . 103 By Edward J. Ward, A.M., Specialist in Community Organization, U. S. Bureau of Education, Washing- ton, D. C. ix CONTENTS PART TWO The Administration op Educational Hygiene CHAPTER PAGE VII. The Initiation of a System of Educational Hygiene in a School System no By the Editor. VIII. The General Administration of Educational Hygiene 127 By the Editor. IX. A Plan of State Co-operation for School- Health Progress 147 By Geo. A. Mirick, A.M., formerly Assistant State Commissioner of Education of New Jersey. X. Rural School-Health Administration . . . 153 By W. I. Larson, S.B., State Inspector of Rural Schools, Madison, Wisconsin. PART THREE The Divisions and Practice of Educational Hygiene I. medical supervision of schools XL The Standardization of the School Medical Service 171 By the Editor. XII. The School Nurse and Her Work .... 204 By LiNA Rogers Struthers, R.N., First Municipal School Nurse of America, recently Supervisor of School Nurses, Toronto, Canada. CONTENTS XI PAGE XIII. School Feeding .217 By Louise Stevens Bryant, Ph.D., Lecturer on Psy- chology at the Pennsylvania School for Social Service, Philadelphia; formerly Assistant in the Psychological Clinic, University of Pennsylvania. XIV. Open-Air and Open- Window Schools .... By S. C. KiNGSLEY, A.M., Director, Welfare Federation, Cleveland, Ohio. 238 II. SCHOOL SANITATION XV. Rural School Sanitation 255 By A. C. MoNAHAN, B.S., Rural School Specialisil, U. S. Bureau of Education. XVI. Hygienic School Environment 280 By L. N. HiNES, A.M., State Superintendent of Public Instruction; Editor of the Educator Journal, Indian- apolis, Indiana. XVII. School Sanitation Standards By the Editor. 298 ni. the hygiene or instruction The General Hygiene of Instruction . . . By Arthur K. Beik, Ph.D., Professor of Psychology and Hygiene, New York State College for Teachers, Albany, New York. 323 XIX. The Hygiene of School Subjects By Arthur K. Beik, Ph.D. 342 XU CONTENTS IV. THE TEACHING OF HYGIENE CHAPTER PAGE XX. The Teaching of Hygiene in Elementary Schools 358 By J. Mace Andress, Ph.D., Head of the Department of Psychology and Child Study, Boston Normal School, Boston, Massachusetts. XXI. Health Teaching in High Schools .... 380 By W. S. Small, Ph.D., Specialist in School Hygiene and Sanitation, U. S. Bureau of Education, Washing- ton, D. C. XXII. Industrial Hygiene and Vocational Education 404 By the Editor. XXIII. Sex Hyglene and Sex Education 413 By Ira S. Wile, M.S., M.D., Editor Medical Review of Reviews; Lecturer in the New York University School of Pedagogy. XXrV. Play and Recreation at the Rural School . 433 By S. H. Curtis, Ph.D., Lecturer on Public Recreation, Olivet, Michigan; formerly Secretary of the Play- ground Association of America. EDUCATIONAL HYGIENE PART I HEALTH SOCIOLOGY CHAPTER I PUBLIC HEALTH AND THE PUBLIC SCHOOLS The Public-Health Problem. — In a recent volume Price Collier has asserted that "the earth will be as cold as the moon before all men reahze that the only neal wealth is health"; 1 and certainly the experiences of the past seem to warrant his conclusion. Health is and will always remain a fundamental value of life, practically inseparable from life itself. Yet on every side, the world over, we are confronted by the fact that health, including normal physical develop- ment, longevity, and splendid bodily resistance, is being only very inadequately achieved by millions of people. When a third of all the children born with such cost into a civilized community like America die before the age of five, when the draft disclosed that more than one-third of the flower of America's manhood was physically unfit for mili- tary service, when the average term of life of our people is some twenty years shorter than it should be, and when ill- ness, deformities, and multifarious physical defects are afflict- ing the race with an immense and overburdening cost, it would seem that every agency which the state has at its dis- posal would be vigorously engaged in preventing and eliminat- ing from the world, or lessening to a fraction of their present destructiveness, these enemies of health and vitality. ^ "Germany and the Germans" (Scribners). 2 EDUCATIONAL HYGIENE Instead of such universal and united resistance to a common foe, what do we find ? In the first place, we find a great private medical profession that lives by the diagnosis and cure of existing ailments, but not primarily by their pre- vention and final ehmination from the world. Outside of China disease has long been the friend, not the enemy, of physicians, for it has been disease that has brought to them their livelihood. To slay the food-bringer has not been the poHcy of the past, and it is one of the greatest glories of the present that an increasing number of physicians are becom- ing willing to make such sacrifice. Unfortunately, the social situation has demanded the wrong thing. It should be made the physician's chief mission and means of liveHhood to ban- ish from the earth the enemies of health and physical per- fection. This Utopian condition is, indeed, coming swiftly upon us in the very rapid increase of pubHc agencies manned by doctors and nurses in great numbers. Such pubKc hygienists as Winslow prophesy, indeed, the complete or almost complete sociaHzation of health service in the next few decades.^ Great insurance societies are finding it to their advantage to keep their policy-holders well by periodical examinations, health instruction, nipping incipient ailments, and by sending visit- ing nurses to those who need their help. Our governmental health service, in the form of local, State, and national health departments or bureaus, has a far greater motive for disease prevention, but it is in general, though with many brilliant exceptions, exceedingly inadequate and inefficient. These bureaus, however, are everywhere so increasing their staffs that preventive medicine is really making fairly rapid progress. Many agencies, more or less efficient, are steadily tending to make the work of the old-time curative-medicine doctor less necessary, and in many places the clash between the factors 1 "Efficiency in the Public-Health Campaign," in the North American Re- view, June, 1913. A free bulletin of the New York State Board of Health, Albany. PUBLIC HEALTH AND THE PUBLIC SCHOOLS 3 for eliminating the causes of disease and for treating disease after it has come into being is not as mild as, to the outsider, it may appear. The inevitable movement will be to push the curative doctor over into the field that for the time being cannot, by the best efforts, both pubHc and private, be con- quered by preventive measures, including hygiene, sanita- tion, physical development, etc. Because of the comparative lack of development of pre- ventive medicine and public-health agencies, we see, in the second place, more clearly than ever before, a great host of only partially utilized agencies for reducing or eliminating our disgraceful and enormous death, illness, and physical-defects losses. Fundamentally, of course, the elimination of un- necessary ill health depends upon the two factors of nature and nurture, of eugenics and hygiene. Doctor Davenport shows briefly in a later chapter the considerab^ and largely unguessed-at influence of heredity upon the amount of disease and physical defects among human beings. Ideally, of course, we should all be the offspring of physically and mentally per- fect parents. This would be our greatest insurance for the possession of Hke characteristics. To help in some measure to bring about such a happy state, to eHminate many of our most terrible losses in the way of feeble-mindedness and gross physical imperfections that are inheritable, and to give sound biological advice to the hygienist working with environment, in order that he may prevent the bringing out of native weak- nesses — these are the objects of many eugenic agencies now springing rapidly into being. Public-Health Agencies. — Certain factors in heredity are, then, of utmost importance to the hygienist, but his chief work falls in the field of nurture, of environmental control.^ It is the duty of the state to insure, within reasonable Hmits, that its children and future citizens be well born; but the duty which is far clearer and simpler at present is that of providing such environmental control of the population, young 1 See Winslow, "Man and the Microbe," Popular Science Monthly, July, 1914- 4 EDUCATIONAL HYGIENE and old, that disease, premature death, and physical defects may be reduced to a minimum. The public agencies for such health-control may be briefly and tentatively classified as follows : 1. Medical or health supervision of the population. 2. Securing in all ways a sanitary environment. 3. Medical or health research. 4. Educational control of the population. Since this is a free country, where very much depends upon the choice of the people, the last-mentioned means, educational control of the population, far outweighs in im- portance all the others. Every agency of health amehoration soon discovers and heralds abroad that the progress of health measures depends absolutely and finally upon the education of the people, old and young. If laws for health improvement are to be enacted, they must have the support of an enlight- ened public both before and after they are passed; if health measures are to be practised they must through some form of educational effort be made habit. In short, the most funda- mental means of health improvement is through education in the habits, knowledge, ideals, and the physical develop- ment which go with socially efficient right living, personal and public. Such education begins at birth and lasts throughout life. It can only be partially monopolized by the public educational, or schooling, system. And yet, since the educa- tional system is extending its beneficent influence over those of pre-school and post-school age, and, moreover, since it influences individuals in their most plastic and formative period, that of childhood, the public school stands out easily as the greatest single instrument for health promotion pos- sessed by the civilized world. Educational Hygiene. — In its widest sense, then, edu- cational hygiene is broader than the school, including, as it does, all agencies for the promotion of health measures through education. The boards of health, the newspapers and magazines, the public lecturers of the American Medical PUBLIC HEALTH AND THE PUBLIC SCHOOLS 5 Association, the leading insurance companies, the anti- tuberculosis and other societies, and many other agencies^ are very largely engaged in the field of educational hygiene. In the narrower sense, as used in this volume, educational hygiene is the name given to all the phases of health promo- tion work which may be and are undertaken by schools, especially pubHc schools, from kindergarten through college, for people of all ages, but especially for those between the ages of four and twenty-four. We have for some time had the science of educational psychology, used especially in the training of teachers. We have also educational sociology, educational administration, educational history, etc., and it is high time that we have an educational hygiene. The exclusive emphasis upon educa- tional psychology in the past has led to a lop-sided knowledge of the educational process and the nature of children. The pathological and physical child is at least as important from the state's point of view as is the ignorant and mental child. This volume attempts to treat of the health and physical well-being of the people, old and young, as it can be affected by public schools. The future extensions of the school in this direction are beyond prophecy. That the school may directly affect the health and normal physical development of persons who do not at the time at- tend the school as pupils hardly needs demonstration, and will be plentifully illustrated in the following pages. When school physicians and nurses have consultation hours for mothers with babes in arms, when the nurses go day after day into the homes to help improve home hygiene, when the schools are used as social centres for the health education and recrea- tion of the community, when there is health vocational guid- ance in and after the school period, when schools use news- papers and various civic organizations for the promotion of *See Dresslar on "Public Health Teaching Agencies" and "Methods and Means of Health Teaching," in the 1912 and 1913 Reports of the U. S. Bureau of Education. 6 EDUCATIONAL HYGIENE the health of the children and community, then we have an influence that is far broader than the old-time ^'school hy- giene/' an influence that may very appropriately go by the name of educational hygiene. The various phases of this rapidly developing science we shall briefly sketch as medical supervision, physical education, school sanitation, the teaching of hygiene, and the hygiene of methods of teaching and management. The National Health Problem. — Before we can say what the schools, through the development of educational hygiene, can do for the health and happiness of our nation, it is neces- sary for us to face the actual health problems of the people and nation. The principal problems of the people and nation set the principal problems for their pubHc educational sys- tems. If the educational systems of the country can be helped to concentrate their energies upon the really big problems of Kfe instead of upon so many little or obsolete ones, their social efficiency can undoubtedly be marvellously increased. The principal phases of the national health problem are shown in the number of preventable deaths, in the prevaiKng and preventable amount of illness, or morbidity, and in the number and preventabihty of physical defects which lower vitality and xeduce working efhciency and happiness. In a somewhat careful investigation, pubHshed elsewhere,^ the writer has attempted to compute from mortality statistics and other sources, by the methods used by Hfe-insurance statisticians, the nature and extent of the national and school health problem. We can here only briefly summarize our relatively inaccurate and tentative findings, in the assurance, however, that great as they may seem the results are probably not exaggerations. Death Losses. — The death losses to our country are enor- mous and largely preventable. The judgment of the best ^ "School Health Administration," published by Teachers College, Columbia University, chapters I and II. (Out of print.) PUBLIC HEALTH AND THE PUBLIC SCHOOLS 7 experts versed in mortality statistics and in the results of various forms of hygienic improvement here and abroad agree pretty well with Professor Fisher's estimates of preventability given in his book on "National Vitality."^ His estimate^ arrived at with the assistance of thirty experts in health matters, is that in general about 42 per cent of the deaths of persons in the United States could be reasonably prevented or postponed, ^'if knowledge now existing among well-in- formed men in the medical profession were actually appKed in a reasonable way and to a reasonable extent." An exami- nation of his tables showing his estimates of preventability for deaths, from the manifold causes, will convince most intelligent persons that they are fairly conservative and that they are based on present data, counting not at all on the as- sured advance in preventive medicine. ^ Some of the leading facts relating to this great problem are as follows: 1. One-fifth of all the children born each year in this country die before they are a year old, approximately a half- million. Where there are fairly efficient and developed health agencies, such as boards of health, carefully conducted infant-mortahty campaigns in this country have cut this death-rate to about one-tenth of these proportions. 2. Half of the persons born in our country die before they are forty years of age, and about half of these before the age of five. 3. The average age of persons dying is gradually rising, but is still below the age of forty — near thirty-eight. 4. Approximately 1,600,000 of our population die each year — about 670,000 (42 per cent) of reasonabty preventable diseases. The economic losses due to these deaths are at least a billion dollars. These losses come in the form of public and private care of the sick and dead and in lost wages, but prin- cipally in the form of cut-off potential earnings. The value of a life at various ages can, in general, be somewhat easily ^ Also published as a government report. 8 EDUCATIONAL HYGIENE DEATHS FROM ALL CAUSES IN INDIANA All Ages 1912 Average for preceding three years P^^yy^r Diphtheria and Croup y^M^/j^^i Suicides \ ^^^^^^^^^^/MM influenza w^M^/^i\ Senility 500 lOJ'O 2000 3000 4000 5000 lUnclassitied Causes Org'c Heart Disease Tuberculosis of the Lungs "Acute Nephritis and Brights' Disease External Causes (Suicides Excepted) Hemorrhage and Softening of the Brain Cancer and Other Malignant Tumors 'Co:ngenital Debility and Malformations Pneumonia Diarrhoea and Enteritis (urnder two years) Other Diseases of the Respiratory System (T..B,. Excepted^ Diseases of the Stoma.cii CCancer Excepted) wy//y>^.yy/y>/^ Typhoid Fever Olher Forms of Tuberculosis 7777J7? Appendicitis S^ Cirrhosis of the Liveir ^^aOther Epidemic Diseases Y'TTTn Intestinal Obstruction f777^ Whooping Cough 7zz^ AciLte Bronchitis mm Cliranic BronchiTis 7777^ Puerpenal Septicemia ^S OtTier Puerperal Accidents of Pregnancy and Laljar y7777\ Tuberculosis Meflinoitis ^zm Nod Canferous Turm:or & other diseases of the female genltsd oj^ans ^ Scarlel Fever * Meflar'ra I3 Simple -Meiilngilis Hernia ^TTTTn Measles aPofiorayelilisCAcute Anterior) 3 Cerebro spinal fever 3 Unknown orill defined diseases Cholera Nostras Smallpox PUBLIC HEALTH AND THE PUBLIC SCHOOLS 9 computed, and the average value for all ages used by econo- mists is $1,700. The table on pages 10 and 11, taken from *^ School Health Administration,'' shows in some detail a condensation of the 1910 mortality statistics made by the author, and shows also the deaths of children of school age and the age groups of most deaths. The registration area is composed of those States and cities sensitive enough to their health needs to enforce reasonable registration of deaths. It reaches about three-fifths of the population.^ Those who wish to study educational hygiene in relation to national and community health problems may well ex- amine the following table. A very desirable addition to such study would be (i) to get a free copy of the latest Mortality Statistics from the United States Census Bureau, and (2) to get the local reports of the boards ^f health of the community and State. Any careful study of such data will immediately raise in the mind of an intelligent and socially minded student and health worker the national and school- health problem. What can we do to prevent these terrible and largely unnecessary losses? Illness and Physical-Defects Losses.— According to the best obtainable data, about 3,000,000 persons in the United States are constantly seriously ill. Their illness causes loss of wages to a computable number, lowered vitality, and fre- quently death. These illnesses, largely and increasingly pre- ventable, cause further enormous economic losses not computed under deaths, which I have estimated, using Professor Fisher's and insurance methods, as about another billion dollars an- nually. The losses in happiness, the evil effects of breaking up homes, and all such losses of a personal, human, and psychological character are, of course, beyond computation. From these serious illnesses and the additional physical de- fects and minor illnesses comes more or less directly a large portion of the most serious blots upon civilization, such as * 1910 U. S. Mortality Statistics. lO EDUCATIONAL HYGIENE TABLE I Causes of Death for the Registration Area, 1910 * All Causes. I. General diseases 1. Typhoid fever 2. Malaria 3. Smallpox 4. Measles 5. Scarlet fever 6. Whooping cough 7. Diphtheria and croup 8. Influenza 9. Cholera nostras 10. Dysentery II. Erysipelas 12. Other epidemic diseases. . 13. Purulent infection, etc... 14. Rabies 15. Tetanus 16. Pellagra 17. Tuberculosis (of lungs) . . . Tuberculosis (other) Rickets Syphilis Gonococcus infection 2 2 . Cancer and other m. tumors 23. Other tumors Acute articular rheumatism Diabetes Leuchemia Anemia, chlorosis Other general diseases i». 19. 20. 21 24. 25- 26. 27. 28. AU ages II. 29. 30. 31- 32. 33- 34- 35- 36. 37- 38. III. 3t)- 40. 41. 42. 43- 44. Nervous sys. — special sense. Encephalitis Meningitis Spinal cord, other dis Apoplexy, cereb. hem Paralysis, without sp. cause Epilepsy Convulsions (nonpuerperal) Chorea, St. Vitus' s dance . . Nervous system, other d. . . Ear diseases Circulatory system Pericarditis Endocarditis, acute Organic d. of the heart Angina pectoris Embolism and thrombosis . Lymphatic system, dis . . . . 805,412 215,692 12,673 1. 167 202 6,598 6,25s 6,146 11,521 7,774 536 3,446 2,442 198 1,877 64 1,373 368 73,214 13,09s 455 3,221 197 41,039 553 3,328 8,040 864 2,614 5,014 77,991 761 7,619 4,101 39,701 7,756 2,287 200 123 2,069 967 100,106 650 4>792 76,178 3,869 1,990 255 CHILDREN OF SCHOOL AGES 5-9 17,943 8,891 684 58 6 588 1,731 228 2,938 122 14 47 8 23 73 13 162 4 489 933 13 24 83 9 327 144 44 39 4 1,368 34 683 264 47 27 79 54 13 70 92 999 32 203 716 7 20 14 10-14 11,736 4,978 854 40 6 152 442 17 700 73 8 15 14 II 62 9 153 5 1,048 586 8 II I 76 4 357 206 35 40 10 889 37 365 146 46 21 118 9 18 58 64 1,319 32 226 1,011 12 19 IS-19 19,772 9,770 1,681 67 17 112 232 10 228 119 7 13 35 3 86 6 88 12 5,166 933 4 36 17 152 6 261 258 39 70 67 976 39 294 130 103 29 172 18 41 63 46 1,447 14 196 1,158 17 33 9 Total 5-14 29,679 13,869 1,537 98 12 740 2,173 245 3,638 195 22 62 22 34 135 22 315 9 1,537 1,519 21 35 I 3 13 684 350 79 79 14 2,257 71 1,048 410 93 48 197 63 31 128 156 2,318 64 429 1,727 19 39 23 Age group of most deaths 25-29 20-24 20-24 0- I 1- 2 5- 9 o- I 5- 9 70-74 o- I O- I O- I o- I O- I 5- 9 O- I 30-34 25-29 20-34 o- I o- I o- I 60-64 65-74 10-14 60-64 40-55 60-64 O- I 70-74 O- I O- I 65-69 70-74 70-74 25-29 5- 9 15-19 50-54 Under i 65-69 65-69 55-59 70-74 65-69 65-69 o- I 1 Condensed from the table giving 189 different causes. The registration area is slowly enlarging, but in this year included only about three-fifths of the population. In many of the registration States the returns are inaccurate, and somewhat incomplete ("at least 90 per cent of the total"). We are far behind most European countries in records of both deaths and births. PUBLIC HEALTH AND THE PUBLIC SCHOOLS II TABLE 1— Continued Causes of Death for the Registration Area, 1910 IV. Respiratory system 45. Nasal fossae disease 46. Larynx, dis. of 47. Bronchitis, acute 48. Bronchitis, chronic 49. Bronchopneumonia 50. Pneumonia 51. Pleurisy 52. Pulmonary cong't'n, p. ap. . 53. Other d. of rasp, system V. Digestive system 54. Mouth and annexa, d 55. Pharynx. 56. Ulcer of stomach 57. Other d. of stomach (not c.) 58. Diarrhea and enteritis 59. Appendicitis and typhlitis.. 60. Hernia 61. Intestinal obstruction 62. Other diseases of the intest. 63. Cirrhosis of liver 64. Other diseases of liver 65. Peritonitis (nonpuerp.) 66. Other d. of digestive system VI. Genito-urinary sys. nonv 67. Nephritis, acute 68. Bright's disease 69. Kidneys, other d. of 70. Other d. of uterus 71. Salpingitis and other f. d.. . VII. The puerperal state VIII. Shin and cellular tissue .. . 72. Gangrene 73. Abscess, acute IX. Bones and locomotive organs 74. Bones, not t. b 75. Joints, not t. b. or rheum. . . X. Malformations 76. Hydrocephalus 77. Congen. m. of heart XI. Early infancy XIL Oldage XIII. External causes 78. Suicide 79. Accidental or undefined XIV. Ill-defined diseases , CHILDREN OF SCHOOL AGES Age AU Total group ages 5-14 of most S-9 10-14 1S-19 deaths 100,835 2,035 956 1,517 299 0- I 135 9 9 5 14 0- I 746 90 13 II 103 0- I 7,229 90 21 21 III 75-79 5,391 62 30 36 92 75-79 25»337 522 148 158 670 0- I 54,187 1,138 664 1,140 1,802 0- I 2,150 66 32 83 98 60-64 24,499 28 17 17 45 0- I 1,174 16 13 28 29 0- I 104,801 1,669 1,270 1,429 2,939 0- I 423 II 4 6 15 0- I 840 123 51 40 174 5- 9 2,203 13 18 47 31 45-49 8,403 116 57 73 173 0- I 63,180 469 132 91 601 0- I 6,128 571 718 754 1,289 15-18 2,192 8 6 2^ 14 65-69 4,486 127 88 117 215 0- I 1,571 25 20 22 45 0- I 7,485 15 16 25 31 50-54 3,092 36 35 34 71 60-64 2,419 132 109 162 241 20-24 329 9 4 7 13 50-54 62,559 509 447 ■780 956 70-74 5,66s 253 165 199 418 40-44 47,665 224 263 440 487 70-74 1,389 22 6 16 28 0- I 774 I 5 29 6 25-29 1,298 I 2 75 3 25-29 8,455 II 620 11 25-29 3,008 26 14 31 40 0- I 1,748 10 7 8 17 75-79 506 12 5 9 17 0- I 1,317 100 95 89 19s 0- I 1,145 93 90 81 183 0- I 119 6 4 5 10 35-39 7,998 76 36 20 112 0- I 685 30 II 4 41 0- I 4,821 2,2, 25 13 55 0- I 39,388 •• •• 0- 1 13,604 •• .. 80-84 57,196 2,193 1,678 3,024 3,871 25-30 8,590 I 31 326 32 35-39 45,416 2,161 1,599 2,525 3,760 20-24 12,462 74 43 68 117 75-79 GROWTH OF THE REGISTRATION AREA FOR DEATHS, 1900-1911 (From U. S. Mortality Statistics, 191 1) Up to 1880 only two States, Massachusetts and New Jersey, had registra- tion laws. 1900 1911 N.DAK. I NEBR. yOVik) KANS, ^\ PER CENT OP UNITED STATES POPULATION AREA -• / N.MEX. f 1 °^*- 1*'"«-/-1"T' rd-rS—' tEXAS \,J ( V \ Note. — In addition to the registration States (shaded in the cartograms) , the registration area includes thirty-eight cities in non-registration States. No accurate data respecting the niimber and causes of death in nearly half our country can yet be made. Laws requiring registration are of first importance in non-registration States. The registration area for births is very much smaller. 12 PUBLIC HEALTH AND THE PUBLIC SCHOOLS 1 3 alcoholism and poverty. Devine estimates that not less than one-fourth of all poverty is directly caused by illness. That from tuberculosis, from the best estimates, seems to be a very large portion of the whole. The lessening of tubercu- losis means the lessening of poverty, and tuberculosis pre- vention is very largely an educational problem. A further statement of the general problem and the various means of solution may be found in the next chapter. In brief, then, we see that the problem of health is one of the most serious that the country faces. The conservation of our natural resources, such as soils, minerals, forests, and water-power, is a mere bagatelle compared with the problem of the conservation of our human resources. Of these we are criminally wasteful. While we are making some headway in the control of typhoid, smallpox, tuberculosis^ the diseases of infancy, and others, there has arisen in recent years an increasing number of degenerative diseases in middle life due largely to ignorance of personal hygiene.^ Such increases tend to keep the death-rate as high as it has been in the past. The School Health Problem. — While the reader is passing through this chamber of horrors and getting some acquaint- ance with a few of the phases of the health problem which it is necessary for us resolutely to face if we are to solve it, he should obtain some ghmpse of the evil effects of ill health upon the schools, their efficiency, their pupils, and their teachers. The death losses of pupils of school age, whether in school or out, are enormous and largely preventable. Undoubtedly many of these deaths are and will continue to be inevitable, but our success in decreasing the death-rate for many of the causes of death in these ages, and many other factors, tends to show that the ratio estabHshed by Fisher of about seventy per cent of preventabiHty for these ages is not too high. iSee Coleman's "The People's Health," p. 228. 14 EDUCATIONAL HYGIENE TABLE III Death-Rates at Various Ages "The following table shows the changes in mortality that have occurred in the eleven years from 1900 to 191 1 in the group of registration States as con- stituted in 1900. This area embraced about one-fourth of the total population of the United States in 191 1 and hence the results are of much significance as showing the general tendency of mortality for the country as a whole." AGE GROUP DEATH-RATE ^ PER I, OOO POPUXATION FOR STATES INCLUDED EST THE REGISTRATION AREA IN IQOO ^ PER CENT DEATH- RATE IN igil REP- RESENTS OE THAT I9II 1900 IN 1900* ■ Both sexes Males Fe- males Both sexes Males Fe- males Both sexes Males Fe- males All ages: Crude rate Corrected rate^ . . Under 5 years Under i year I to 4 years 5 to 9 years 10 to 14 years 15 to 19 years 20 to 24 years 25 to 34 years 35 to 44 years 45 to 54 years 55 to 64 years 65 to 74 years 75 years and over. . . 14.9 14.6 15.8 15.3 14.0 13.9 17.2 17.0 17.9 17.6 16. 5 16.5 87 86 88 87 85 84 36.6 125.5 12.8 3.2 2.2 3-5 5.0 6.3 9.4 14.5 28.4 58.3 143.0 39.8 138.6 13.3 3.4 2.4 3.7 5.3 6.7 10.4 16. 1 30.9 61.6 147.4 33.3 112. 1 12.2 3-1 2.1 3-3 4.7 6.0 • 8.3 12.9 26.0 55.1 139.2 49.9 161. 9 19.8 4-7 3.0 4.8 6.8 8.2 10.3 15.0 27.3 56.5 142.4 54.1 178.4 20.4 4.7 2.9 4.9 7.0 8.3 10.8 15.8 28.8 59.5 145.9 45.7 145.0 19. 1 4.6 3.1 4.8 6.7 8.2 9.8 14.2 25.8 53.7 139.3 73 78 65 68 73 73 74 77 91 97 104 103 100 74 78 65 72 83 76 76 81 96 102 107 104 lOI 73 77 64 67 68 69 70 73 85 91 lOI 103 100 iFrom 191 1 U. S. Mortality Statistics. 2 Exclusive of still-births. 3 Group includes Connecticut, the District of Columbia, Indiana, Maine, Massachu- setts, Michigan, New Hampshire, New Jersey, New York, Rhode Island, and Vermont. 4 The death-rate for 19 11 for both sexes is only 87% of that of 1900 and the death- rate for males greater, loi to 107%, than in 1900. Notice also that infant mortality decreased from 161.9 a thousand to 125.5 a thousand in 1911. 6 Based on the standard million of England and Wales, 1901. Effective health education of pupils and parents, and effect- ive public-health service, ought to make possible an almost complete extermination of a large number of diseases in these hardy age periods from five to twenty.^ 1 " One interesting and notable thing about modern public-health work is its tendency to supplement purely administrative methods by educational ones. " — ^WiNSLOW. PUBLIC HEALTH AND THE PLTBLIC SCHOOLS 15 joU / " HO HISTOGRAM ILLUSTRATING TABLE II, DEATH RATE PER 1,000 POPULATION FOR STATES INCLUDED IN REGISTRATION AREA IN 1900 BOTH SEXES, 1911. Rates for school ages:- 5-9 — 3.2 per 1000 10-14- 2.2 » « 15-19— 3.5 " / f laU / 120 1 / 110 / lOO / 90 1 1 oU /U y 1 OU / 4U / iJU y Zv V ,^ ^ % Bate 5 \ Age Groups :'0-5 5-9 10-14 15-19 20-24 25- -34 35- -44 45- -54 55 -64 65 -74 74 and over Note. — ^The rate for both sexes in igii for these ten States is for the infants less than a year old 125.5, and for the ages two to four inclusive only 12.8. These data do not include still-births. The years ten to fourteen inclusive seem to be the hardiest years of life, although the sickness rate is higher than in cer- tain other age groups. The number of deaths at the lowest part of the curve are as follows: 5-9 — 18,112. 10-14 — 12,337. 15-19 — 21,154. There are, however, in the United States approximately 100,000 children of elementary and high-school age who die each year. Probably at least 60,000 of these deaths were unnecessary losses (^*. 6., preventable), and 50,000, or half, would probably be a low estimate. In looking over the death- rates for various diseases in comparison with the number of cases of illness in many cities it has been found that the num- ber of cases occurring and the proportion of deaths from the various ailments vary quite directly with the efhciency of the pubHc-health agencies. Efficient health agencies decrease the number of cases of illness and the proportion of deaths from them. Many city and State boards of health print on i6 EDUCATIONAL HYGIENE TABLE III Showing the Preventability of Deaths of Children of Elementary School Age, 5-14, for 25 Most Numerous Causes of Death, 19 10 CAUSES OF DEATHS No. deaths in registra- tion area Per cent pre- ventable Total No. deaths in the U. S. No. pre- ventable deaths I 2 3 4 5 6 7 8 9 10 II 12 13 14 IS 16 17 18 19 20 21 22 23 24 25 Accidents Diphtheria and croup. . . Scarlet fever Pneumonia Heart, organic disease. . . Typhoid fever Tuberculosis of lungs Tuberculosis, other Appendicitis Meningitis Measles Rheumatism, articular. . Bronchopneumonia Diarrhea and enteritis. . . Bright's disease, kidneys. Endocarditis, heart Nephritis, acute, kidneys Spinal cord, others Diabetes Tetanus, lockjaw Whooping-cough Peritonitis Intestinal obstruction Epilepsy Influenza, grippe 3,760 3,638 2,173 1, 802 1,727 1,537 1,537 1,519 1,218 1,048 740 684 670 601 487 429 418 410 350 315 245 241 215 197 195 70 50 45 25 85 75 75 50 70 40 10 50 60 40 25 30 10 80 40 55 25 50 6,300 6,200 3,700 3,050 3,000 2,600 2,600 2,560 2,160 1,600 1,250 1,150 1,140 1,020 820 730 700 690 500 530 410 400 390 330 330 26,227 671 44,2702 4,340 1,850 1,370 7SO 2,210 1,950 1,920 1,080 1,120 500 1x6 570 612 328 182 210 '60 424 164 220 97 *82 20,155 Total number of deaths, 5-14, in registration area, 29,679. Total number of deaths, 5-14, in the United States, about 50,000. Total number deaths preventable, about 33,500. Based upon 1910 U. S. Mortality Statistics and Fisher's Preventability Tables. * Fisher's average. 2 Estimated. their various bulletins these significant words: "Public health is purchasable. Within natural Kmitations a community can determine its own death-rate." And the prophecy of Pasteur has in some communities gone far toward reaHzation : namely, that *'it is within the power of man to rid himself of every parasitic disease." The economic losses due to the cost of educating for several years in public schools the children who die in this period are of course a large source of public preventable waste. PUBLIC HEALTH AND THE PUBLIC SCHOOLS 17 TABLE IV Showing the Preventability of Deaths of Children of High-School Age, 15-19, EOR 25 Most Numerous Causes of Death in 1910 2 3 4 5 6 7 8 9 10 II 12 13 14 15 16 17 18 19 20 21 22 23 24 25 CAUSES OF DEATHS Pulmonary tuberculosis . . . Accidents and undefined . . Typhoid fever Heart-disease, organic. . . . Pneumonia Tuberculosis, other parts . . Appendicitis Bright's disease Suicide Meningitis Rheumatism, articular Diabetes Scarlet fever Diphtheria and croup Nephritis, acute Endocarditis (heart) Epilepsy Peritonitis Bronchopneumonia Cancer and other tumors . . Spinal cord, other diseases Influenza, grippe Intestinal obstruction Measles Apoplexy, cerebral hem. . . No. deaths in registra- tion area S,i66 2,525 1,681 1,158 1,140 933 754 440 326 294 261 258 232 228 199 196 172 162 158 152 130 119 117 112 103 17,016 Per cent pre- ventable 75 85 25 45 75 SO 40 70 10 10 50 70 30 25 55 50 50 25 40 35 67' Total No. deaths in the U. S. 8,650 4,230 2,830 1,940 1,920 1,750 1,270 740 550 500 450 450 400 400 340 340 ^00 280 280 260 220 200 200 190 180 28,780 No. pre- ventable deaths 6,487 2,405 485 864 1,177 635 286 350 45 45 200 280 102 85 154 140 100 50 76 63 14,039 U. Total number of deaths, 15-19, in registration area, 19,772. Total number of deaths, 15-19, in the United States, about 34,000. Total number of deaths, 15-19, preventable, about 24,100. Based upon 1910 S. Mortality Statistics and Fisher's Preventability Tables. 1 Fisher's average for all causes of death. The illness and physical-defects losses of both teachers and pupils of the public schools are enormous, coming in the form of personal and public financial loss, of lowered vital efficiency and happiness, and of elimination, non-promotion, and retardation at school. Combined, the physical-defects and illness losses are very great but as yet hardly computable. Ayres, Cornell, and others have given good reason to believe from their investi- gations that a large share of retardation is due to physical iS EDUCATIONAL HYGIENE TABLE V Approximate Expectation of Life in a State that Has Kept Life Statistics for Several Years ^ MASSACHUSETTS (WHITE) 1900 SIX YEARS 1884-189O 1880 AGE Males Fe- males Per- sons Males Fe- males Per- sons Males Fe- males Per- sons O. . . 44.29 47.80 46.05 40.39 42.59 41.49 44.06 45-22 44.64 I. . . 53.13 54-96 54-05 49-29 50.40 49.85 51-18 51.20 51.19 2. . . 54-64 56-28 55-46 52.13 53-15 52.64 53-30 53-06 53.18 3--- 54.69 56.31 55 -SO 52.37 53-45 52.91 53.88 53-60 53.74 r 4--- 54-42 55-97 55 -20 52.20 53.29 52.75 54.05 53-75 53.90 S--- 53 90 55-50 54-70 51-93 53-02 52.48 53-92 53-67 53.80 lO. . . 50.15 51-70 50.93 48.83 49-97 49.40 51.01 50.93 50.97 IS-.- 45-79 47-49 46.64 44-78 45-98 45-38 46.85 46.86 46.86 1-20. . . 41.79 43-54 42.67 41.09 42.42 41.76 43.09 43-49 43.29 25... 38.23 39-71 38-97 37-79 39-04 38.42 39.81 40.44 40.13 30--- 34.66 36.07 35-37 34-50 35-76 35-13 36.38 37.28 36.83 35- •• 31.09 32.42 31.76 31.20 32.48 31.84 32.96 34-13 33-55 40.. . 27.49 28.79 28.14 27.86 29.17 28.52 29.48 30.78 30.13 45- •• 23-89 25.16 24.53 24.51 25-86 25.19 26.01 27-43 26.72 SO... 20.57 21.74 21. 16 21.33 22.56 21.95 22.52 23-93 23.23 55- • ■ 17-25 18.32 17.79 18.15 19-25 18.70 19.02 20.43 19.73 60... 14.48 15-41 14-95 15.35 16.32 15-84 15.98 17.26 16.62 65... 11.70 12.50 12. 10 12.54 13-38 12.96 12.95 14.08 13.52 70. . . 9.69 10.31 10.00 10.38 11.03 10.71 10.63 11.60 II. 12 75..- 7.68 8.12 7.90 8.21 8.68 8.45 8.31 9-13 8.72 80... 6.57 6.83 6.70 6.91 7.17 7.04 7.06 7.62 7.34 85... 5. 46 5-54 5-50 5-60 5-66 5-63 S-82 6.12 5. 97 90... 3.98 4.02 4.00 95... 2.50 2.50 2.50 The school ages are bracketed at the left. In Massachusetts a "person " four years of age in 1884-90 would probably live fifty-three years longer (52.75); m 1880 his chances were extended to fifty-four years, and in 1900 to fifty-five years. Recent health improvements have probably raised it to fifty-six years. 1 From Bulletin 15 of the United States Bureau of the Census, entitled "A Dis- cussion of the Vital Statistics of the Twelfth Census." defects and the absence and illness caused by them.^ I have shown that perhaps 25 per cent or more of all absences from school is caused by illness and that absence is a very large 2 See chapter on "Physical Defects and School Progress" in the last edition of "Medical Inspection of Schools," and the appendix in this volume. PUBLIC HEALTH AND THE PUBLIC SCHOOLS 19 TABLE VI Approximate Expectation of Life in Another State that has Kept Life Statistics for Several Years ^ NEW JERSEY (WHITE) AGE 1900 SIX YEARS 1884-189O 1880 Males Fe- males Per- sons Males Fe- males Per- sons Males Fe- males Per- sons 0. . . 1. . . 2. . . 3--- r 4... j 10. . . 15... I- 20. . . 25.-- 30--- 35--- 40... 45--- 50... 55--- 60. . . 65-.- 70... 75--- 80... 85-.- 90... 95- •• 44.06 52-05 53-63 53-75 53-39 52.86 49-27 45.00 41.04 37-38 33-84 30.29 26.87 23-44 20.18 16.92 14.19 11.46 9-52 7-58 6-47 5-35 3-93 2.50 48.27 54-45 56.07 56.06 55-77 55-28 51-59 47.24 43-12 39-35 35-79 32.22 28.67 25.11 21.64 18.17. 15-23 12.28 10. 16 8.03 6.83 5-62 4.06 2.50 46-17 53.25 54-85 54-91 54-58 54-07 50-43 46.12 42.08 38.37 34.82 31.26 27.77 24.28 20.91 17-55 14.71 11.87 9.84 7.81 6.65 5-49 4.00 2.50 40.11 48^-73 51-66 52.00 52.04 51.79 48.62 44.55 40.72 37-36 34-05 30.73 27.46 24.18 20.97 17.76 14.91 12.05 9-94 7-83 6.71 5.58 43-55 51-08 53-81 54-22 54-25 53-96 50.82 46.79 43-09 39-57 36.18 32.78 29-37 25-95 22.54 19.13 16.09 13-05 10.71 8.37 7-07 5-77 41.83 49-91 52-74 53-11 53.15 52-88 49.72 45-67 41.91 38.47 35-12 31.76 28.42 25.07 21.76 18.45 15-50 12.55 10.33 8.10 6.89 5-68 45-59 52.65 54-39 54-94 54-94 54-71 51-57 47.36 43.29 39.8^ 36.26 32.71 29.20 25.70 22.33 18.96 16. 10 13.25 10.90 8-54 7.40 6.26 48.05 54-23 55.71 56.13 56.03 55.66 52.52 48.40 44.51 41.15 37-76 34-37 30.80 27.24 23.70 20.15 16.89 13-63 II. 12 8.60 7-36 6.13 46.82 53.44 55.05 55.54 55.49 55.19 52.05 47.88 43.90 40.48 37.01 33-54 30.00 26.47 23.02 19.56 16.50 13.44 II. 01 8.57 7.38 6.20 The school ages are bracketed at the left. iFrom Bulletin 15 of the U. S. Bureau of the Census, entitled "A Discussion of the Vital Statistics of the Twelfth Census." factor in causing retardation. Absence has a proved correla- tion with non-promotion, and illness is the chief cause of ab- sence, especially the longer absences. Experiments carried on by Wallin in Cleveland and by Kohnky^ in Cincinnati seem to indicate that mere dental hygiene has probably a decidedly favorable effect on the mental and physical status 2 Kohnky, Journal of Educational Psychology, December, 1913. 20 EDUCATIONAL HYGIENE of school-children. In the Cincinnati investigation a control class was used and the results seem to show a direct causal relationship between mouth hygiene and school progress.^ Doctors and nurses and teachers of the public schools where medical supervision is carried on are unanimous in their opinion, based on observation, that school progress for very- many children is materially hastened by the ehmination of their physical defects and the cure of their ailments.^ My own studies of the rough data gathered in a survey of a number of cities seem to indicate that not less than about 15 per cent of ehmination, 16 per cent of non-promotion, and 1 7 per cent of retardation is caused by the illnesses and phys- ical defects of school-children. We are not yet ready to state, in general nor for any one city, precisely how much an aid to school progress and community health medical supervision and the various phases of educational hygiene are. The belief is warranted that they are great. Before accurate measure- ments can be made we must have very much more accurate statistical records and reports and much improved super- vision by health specialists. Records and reports at the pres- ent time are entirely too vague, variable, and meaningless for any accurate knowledge of school health work. In a later chapter on medical supervision I give a tentative stand- ard plan for the administration of educational hygiene, es- pecially of medical supervision, and offer there for criticism and use a tentative standard terminology and classification of the multitudinous ailments of school-children. There it will be seen that, according to the best data obtainable, not far from one- third of the school-children will, on the average and in any one school year, be found to suffer from no ail- ments of a serious nature, one-third with teeth defects only, one-third with teeth defects and two or more other ailments each.^ *Wallm, Dental Cosmos, April, 1913. 2 See articles in the Psychological Clinic for January, 191 5. ^ See the writer's survey of Rural School Hygiene in the Report on Rural Schools to the Pennsylvania State Educational Association, 1914, State Supt. N. C. Schaeffer, Harrisburg, Pa., Chairman. PUBLIC HEALTH AND THE PUBLIC SCHOOLS 21 These facts, then, set forth rather vaguely and inadequately the school health problem. About half of the school-children may be said to be seriously ailing and defective in any one school year and in grave need of the care of school doctors, nurses, dentists, physical-training teachers, and others. The need is for efficient agencies for discovering the exact health status of the pupil population, the health census, and then for further efficient agencies for preventing such ailments and for getting cured and corrected those found to exist. Un- doubtedly this work, if well carried on, will place the school in close and intimate association with the home, the public- health agencies, the private organizations that may be in- terested in health advancement, and with the real life of the city or community. This is a consummation, of course, de- voutly to be wished. The aim of these school systems is to promote the welfare of the people by developing social efficiency in each child. The relation of educational hygiene to this general aim may be observed on analyzing social efficiency into its elements. These factors are: (i) Vital Efficiency. — Health, freedom from physical de- fects, and physical development. (2) Vocational Efficiency. — AbiHty to make a good living honestly by performing necessary social service. (3) Avocational Efficiency, — The right use of leisure, wholesome enjoyment, and genuine happiness. (4) Civic Efficiency. — Good citizenship, pubHc interest, ability in leadership, and co-operation. (5) Moral Efficiency. — Good- will, spirit of social service, skill in promoting goodness. It may be seen at once that the five divisions of educational hygiene have an intimate bearing on the attainment of these supreme ends of education. Especially do they contribute to the first and third factors of social efficiency. Foundational as it is, health work in the schools cannot be placed second in any list of minimal essentials of schooling for a democracy. What the draft has revealed we must now combat by all means at our command. CHAPTER II THE PUBLIC-HEALTH MOVEMENT Public Health and Public Welfare. — Public health is the most fundamental and basic element of social, economic, and national efficiency. Wealth is but a symptom and func- tion of health. Yet with our innate inclination to consider symptoms rather than to grapple with fundamental causes, we have, in our systems of social philosophy, either entirely left out the element of pubHc health or given to it but pass- ing attention. We have developed an immense science of economics and a philosophy of wealth, but have left the science of pubHc health in a very fragmentary and incomplete state. With the recently awakened active interest in the promotion of public health the need of scientifically established principles is becoming very acute, but with reference to understanding pubHc-health needs we are in a state of almost complete chaos. During the winter session of the various State legislatures, for example, about one thousand bills on pubKc health were considered, ranging in importance from reorganizing whole State departments of health, or passing model vital-statistics laws, to the prohibition of roller towels. Some of the measures are insignificant, others unnecessary, while still others exhibit the propensity merely to follow certain styles or fashions. Doctor Frederick R. Green, the secretary of the Council on Health and PubKc Instruction, of the American Medical As- sociation, commenting on such floods of bills, says that they disclose '^a tendency on the part of the legislatures to follow prevailing fads in lawmaking." ^ "The public-health movement to-day is going almost * The Survey, September 27, 1913, p. 748. 22 THE PUBLIC-HEALTH MOVEMENT 23 too fast/' says Professor Sedgwick/ ''almost faster than the teachers and directors of the movement could wish, because a great many foolish things are being done to-day in the name of public health, and there are pubhc-health fakirs as there are quacks and dealers in quackeries." Since the interest in pubhc health has gained such an impetus, and since so much activity is being displayed by governmental, civic, and private organizations, it becomes imperative to see that the movement is directed along proper channels in order that an unnecessary waste of energy and money may be prevented and that the fragments of public- health science may be woven into a coherent entity for the guide of legislators and public-health administrators. At this stage of the movement it is necessary, therefore, to take stock of the methods used, of the forces at work, and of the achievements accomplished. It is a tremendous task and the present paper is but an elementary attempt to state the problem. Preventive Medicine. — The foundations and possibilities of this great health movement lie largely in preventive medicine. "Although drugs are helpful to the individual in that they may lessen his suffering and hasten his recovery, they are of no avail in preventing disease in a population. Take the best-established cures in medicine, the drugs known as 'specifics' — ^iron in anemia, mercury in syphilis, quinine in malaria, antitoxin in diphtheria and tetanus — and who can say that they have exerted the slightest effect upon the in- cidence of these diseases in human communities? On the other hand, see what preventive medicine has accompKshed in combating puerperal and surgical fevers, smallpox, malaria, yellow fever, rabies (in England it no longer occurs), Mediter- ranean fever, plague, and relapsing fever. . . . Many hun- dreds of thousands of lives throughout the world are now *"The Public Health Movement in America — ^To-day and To-morrow," an address delivered before the Association of Life Insurance Presidents, December, 19 13. 24 EDUCATIONAL HYGIENE saved annually by preventive medicine." ^ And preventive medicine is but in its infancy. Its possibilities are immeas- urable. With every new medical discovery new possibilities arise. The foundation of the public-health movement has already become enormous and it is widening from day to day. The Aims of the Public-Health Movement. — The public- health movement may be broadly defined as a social effort to prevent disease, to lengthen the Kf e and usefulness of every member of society, and to afford opportunities for a normal physical and mental development of society. In its broad aspects pubHc-health work consists in pre- venting preventable diseases by means of early diagnosis and efficient quarantine, in affording opportunities for effective treatment and cure of the sick, in combating filth, un- hygienic Hving, insanitary conditions of work and habita- tion, in health education of individuals and communities, and in providing opportunities for sunlight, fresh air, pure food, and recreation. Each of these main branches divides itself into a great number of constituent elements. I shall not even attempt to enumerate them but shall indicate some of the results already obtained and some of the problems to be attacked.^ Prolongation of Life. — It has been estimated with more or less accuracy that the average length of human Hfe in the sixteenth century was between eighteen and twenty years, and at the end of the eighteenth century was a Httle over thirty years; while to-day it varies in different countries from less than twenty-five to more than fifty years. The general death-rate of the city of BerHn has been reduced from 32.9 per 1,000 in 1875 to 16.4 in 1904, and to 14.7 in 1910. The death-rate of London has decreased from 20.9 for the four- year period of 188 1-5 to 12.7 in 19 10; for the same period 1 Professor Geo. N. F. Nuttall, of Cambridge, England, "Proceedings of the Fifteenth International Congress of Hygiene and Demography," vol. IV, part 2, p. 417. ''See Devine's "Seventeen Health Demands" in The Survey for July 4, 1914. THE PUBLIC-HEALTH MOVEMENT 25 Dublin shows a decrease from 27.5 to 19.9, Amsterdam from 25.1 to 12.4, Stockholm from 24.3 to 14.6, New York from 27.5 to 15. 1 in 1911, Chicago from 21.5 to 14.6, and so along the line. The average death-rate in the whole of the regis- tration area of the United States has decreased from 17.6 in 1900 to 14.2 in 1911. While the average death-rate all over the civilized world has for the last quarter of a century been constantly declining, the chief gains in saving life have been made at the beginning of the course, in the younger age groups. The death-rate in the later age groups, above forty, has been constantly increasing.^ The following is a table showing the death-rates for males and females, by age groups, for the years 1900 and 191 1 re- spectively, for the registration States as they were constituted in the year 1900.^ COMPARISON OF MORTALITY OF MALES AND FEMALES BY AGE GROUPS Death-Rates per 1,000 Population AGE MALES FEMALES igoo 1911 Per cent increase or decrease 1900 1911 Per cent increase or decrease Under 5 S- 9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75 and over. 54-2 4-7 2.9 4.9 7.0 8.3 10.8 15.8 28.9 59.6 146. 1 39.8 3-4 2.4 3-7 5-3 6.7 10.4 . 16. 1 30.9 61.6 147.4 -26.57 — 27.66 -17.24 -24.49 -24.29 -19.28 + 3-70 + 1.90 + 6.92 + 3-36 + 0.89 45 4 3 4 6 8 9 14 25 53 139 8 6 I 8 7 2 8 2 8 8 5 33-3 3-1 2.1 3-3 4-7 6.0 8.3 12.9 26.6 55-1 139.2 -27.29 -32.61 — 32.26 -31-25 -29.8s -26.83 -15.31 -9-iS + 0.78 + 2.42 — 0.22 1 All ages 17.6 15.8 — 10.23 16.5 14.0 -15.15 From this table one can readily see: I. That men's chances for longevity are considerably iSeeTablesII, V, VL 2 Table quoted by Louis I. Dublin, in American Journal of Public Health, December, 1913, p. 1263. 26 EDUCATIONAL HYGIENE poorer than women's, and that the reduction in the mortahty rates has benefited women more than men; and 2. That the mortality rates for males, in 191 1, exhibit a tendency to increase, beginning with the age group of from 45 to 54, and of women with the age group from 55 to 64. These increases in death-rates after 45 are chiefly due to the so-called degenerative diseases (including apoplexy, paralysis, and the diseases of the heart, circulatory system, kidneys, and liver). Mr. Rittenhouse, of the Life Extension Institute, has compiled the following comparative table of these diseases, for the years 1880 and 1909, for Massachusetts:^ DEATH-RATES FOR DEGENERATIVE DISEASES PER I0,000 POPULATION Ages 1880 1909 Per cent of increase All 23.21 7.92 2.91 2.8s 3.10 4.95 10.13 19.70 39.01 102.05 261.10 43.26 10.36 3.95 4.72 5.43 8.09 18.79 37.84 91.30 212.93 558.20 86.38% 30.8 35-7 65.6 75.2 63-4 85.5 92.1 134 -o 108.7 113-0 Under 5 5-9 10-14 15-19 20-29 30-39 40-49- • SO-59 60-69 70 and over. . . It can be seen in the right-hand column that the great increases are for persons over forty, and above that age the increase from 1880 to 1909 is from about 23 to 43 per cent. Another disease deserving consideration in this connection is cancer. Approximately 75,000 deaths annually are at- tributed to this disease in the United States, and the indica- tions are that a steady increase of the death-rate from cancer is taking place in this country at ages over forty-five. Cancer is now of even greater importance than tuberculosis. Whether ^Popular Science Monthly, April, 1913, pp. 376-380. THE PUBLIC-HEALTH MOVEMENT 27 this rise of cancer is a result of a better recognition of the disease or whether it is a real rise cannot as yet be definitely determined. But there is a great possibility for prevention of the disease by education and proper diagnosis in the early stages. Recently a national society has been formed for this purpose. The very large increase in the death-rates from these diseases, particularly noticeable in the age groups above forty, is a sad commentary upon our civiHzation. The wear and tear of modern life, the nervous strain and high tension to which we are all subjected, ill adaptation to changing con- ditions, unsound habits of life, and the pernicious after-effects of the diseases of childhood, youth, and middle age are re- sponsible for this disquieting phenomenon. How living habits affect mortahty is stri^ngly demon- strated by the experience of the United Kingdom Temperance and General Provident Institution, described by Doctor E. L. Fisk.^ According to the records of the above-mentioned in- stitution, ^'two large bodies of hves, almost equal in numbers, and homogeneous except for the use of alcohol, moved along- side of each other for forty years, and the group of abstainers at all times exhibited a markedly superior vitaHty to the other group, the non-abstainers, the total difference in favor of the abstainers during the period covered being 27.4 per cent, although the mortahty among the general, or non- abstaining, class was only 91 per cent of that expected ac- cording to the British 051 Table, representing the experience of sixty-three British officers." We have no similarly direct statistical evidence on the effects upon the death-rate of bad housing conditions, insanitary working conditions, lack of school medical supervision, lack of health education, etc. We know, however, that dark rooms and dusty trades, the use of phosphorus, mercury, lead, and other similar sub- stances in manufacture, and the failure to provide for the health of the young, are potent causes of much morbidity and 1 Popular Science Monthly for April, 1913, p. 382. 28 EDUCATIONAL HYGIENE mortality. It has been estimated that in this country each year about 500,000 industrial accidents occur, at least one- half of which might be prevented; that we have in our midst every year 13,500,000 cases of industrial sickness, involving a loss to society of about $800,000,000, and that of this loss we can save at least one-quarter.^ Here is a burning problem, but the public-health movement cannot as yet boast of great accomplishments in these directions. Studies are be- ing made and remedial legislation devised, but the machinery for its enforcement is inadequate, and, what is almost as im- portant, no adequate educational machinery is at work to in- struct and train the large masses of our people in personal hygiene, sound health habits and ideals of life, and the pre- vention of disease. T3rphoid Fever. — The prevalence of typhoid fever is a good index of social and sanitary conditions. It is a disease whose etiology and method of transmission are well known, and is therefore well controllable. It is a disgrace to our civiHzation that, in the registration area of the United States in 191 1, there should have been from this one disease 12,451 deaths. These deaths from typhoid mean at least 124,510 cases of prolonged sickness (ten times the number of deaths) whose origin was clearly due to the drinking and eating of food which was contaminated by the excreta of typhoid pa- tients. In the majority of our cities drinking-water is obtained from rivers and lakes into which typhoid-infected sewage is or may be discharged. It is gratifying to learn that many of the cities are taking steps to safeguard the quality of the drinking-water by installing filter plants. But still a com- parison of the death-rates from typhoid in European and American cities is a severe indictment of our indifference in matters of health and life protection. The following is a comparative table of the death-rates from t3^hoid fever in certain large cities of the world for the year 19 10: 1 John B. Andrews, "Industrial Diseases and Physicians," Journal of the American Medical Association, April 15, 191 1, vol. 56, p. 113 2. THE PUBLIC-HEALTH MOVEMENT 29 DEATHS FROM TYPHOID FEVER PER 100,000 POPULATION City Death-rate City Death-rate Hamburg 2.5 3.6 4.0 4.1 6.7 4.2 New York Boston II. 6 II. 6 13-7 17.4 23.2 15-5 Chicago Vienna Philadelphia Washington, D. C. Average Paris Not all of the typhoid fever, of course, comes from pol- luted water supplies. A great deal of it comes from polluted milk and its products, from oysters, vegetables, shell-fish, etc. ; and a good deal of it also comes from the polluted fingers of those who are either carriers (well, yet carrying the germs) or who attend patients and do not take care to clean and dis- infect themselves properly. It has been estknated that at TYPHOID FEVER DEATHS IN INDIANA By Ages 160 q 1 2 34 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 90 1 2 ^3 4 < ^5 9 14 19 /24 29 34 39 44 49 54 59 64 69 74 79 90 ! 1 9 1 2 "I ^^^ -Average for Last Ten Years Typhoid fever, like tuberculosis, finds more victims in the years imrnedi- ately following the school period, possibly somewhat earlier. Typhoid is 85 per cent preventable, according to Fisher and others. Most deaths occur from August to December. 30 EDUCATIONAL HYGIENE least lo per cent of typhoid in New York City is of this so- called secondary origin. Here, again, the need of education in hygiene is obviously a potent force in disease prevention. ^ A great deal also remains to be done in the country dis- tricts, where the prevalence of typhoid is very great. Much of our city typhoid is of direct rural origin, as evidenced by the characteristic increase of the wave of prevalence of the dis- ease in the early autumn when people return from their sum- mer vacations in the country. Pure Food. — The fact that many cases of typhoid and other diseases are derived from milk and other perishable foods leads to the consideration of the food problem, which of late has received much popular attention. Unfortunately, however, perhaps too much emphasis is being laid on the use of preservatives in canned foods and not enough stress on the control of perishable foods, which are the most important carriers and disseminators of disease. Very few instances of death or serious illness can be clearly traced to food preserv- atives or to such so-much-discussed substitutes as oleomar- garine, glucose, etc., but hundreds of thousands of deaths are undoubtedly due directly to contaminated milk, water, meat, oysters, and other perishable foods. The pubHc-health movement has not as yet definitely stated the food issue or clearly indicated its proper mode of solution. The food problem has, of course, as great an economic as a health aspect. The economic element of the problem is very important but it should not be confused with the health issue. To add apple jam to raspberry jelly, or potato flour to sausage, may be good business and bad ethics, but it is largely a matter of indifference from the point of view of public health. Whether a certain appetizing and high-priced preparation or expensive cut of meat has Httle nutritive value is also almost entirely an economic problem. That March or April eggs are kept in cold storage till November and then ^See Winslow's article on "Man and the Microbe" in the Popular Science Monthly for July, 1914. THE PUBLIC-HEALTH MOVEMENT 3 1 bring better prices than they would in April is also a matter of practically no concern to the public-health administrator. His concern is to see that the eggs or meat are fresh and sound when put into cold storage, and also that when once taken out of storage and allowed to thaw they are not put there again. Our present stage of industrial development has created a need for cold storage and the production of foods on a factory scale. It would be useless to combat this tendency. It is necessary, however, to control this modern wholesale produc- tion of foods in a rational and scientific manner and see that the conditions under which they are being produced are sani- tary, that the workmen employed are healthy and cleanly, and that the raw products used are free from contamination and disease. The sporadic and irrational outbursts of revolt with little scientific basis have resulted in a hodge-podge of legisla- tion which is a hardship and a nuisance to the honest producer, and is, at best, of Httle benefit to the consumer. At the pres- ent time there is practically no uniformity of standards and no uniformity of requirements. What may be legal in one State may be illegal in another, and vice versa. As Mr. Dunn, the author of a standard digest of food laws, says, "pure food legislation is a mass of inconsistencies. The federal authorities and the State of Wisconsin say that flour bleached with nitro- gen of peroxide is injurious. But Missouri, Oklahoma, Indi- ana, South CaroHna, and Wyoming permit its sale if the bleaching process is indicated in the label. Illinois has made it illegal to bleach grain with sulphur dioxide, yet the sale of this grain, when properly labelled, is permitted by the federal law."i What the public-health movement has not as yet accom- plished in this direction is scientific standardization and the securing of uniformity of legislation. If, after reliable scientific data on a certain problem had been obtained, the represent- atives of the several States would come together and agree » New York Times for January 25, I9i4« 32 EDUCATIONAL HYGIENE on a certain method of procedure and secure approximate or standard legislation for its enforcement, the spectacle of two adjoining States having different laws on the subject, with all its injurious effects, would be made impossible. There are many matters which could even at present be dealt with adequately if a common standard were adopted. Why, for example, should the unscrupulous milk-dealer whose milk has been barred out of one city, because it has been found to be infected with typhoid-fever germs, be allowed to sell it in another city where the regulations are less exacting and thereby cause an epidemic of the disease? Why should the owner of tuberculous cattle be allowed to sell his meat within a State when the federal authorities would condemn it for interstate commerce? These are some of the many problems concerning the food question which the public- health movement must solve in the interest of efficient ad- ministration and the proper protection of society, and which can only be accomplished by proper co-operation of the va- rious public and private health agencies.^ Infant Mortality. — ^As some one has said, the business of being a baby is an extremely hazardous one. As late as the year 191 2, with all our efforts to reduce infant mortality, out of the total of 838,251 deaths in the registration area of the United States, 147,455 deaths, or 17.6 per cent, occurred among children under one year of age, and 204,639 deaths, or 24.4 per cent, among children under five years of age. Almost one-fourth of all the deaths occur before the child reaches the age of five, three-fourths of which occur in the first year of life. Fortunately there has been a marked reduction in the infant death-rate in recent years. The following table gives a com- parison of the death-rates under one year of age in the same States and cities for the years of 1900 and 191 1. In some States and cities the reduction in infant mortality was more than 30 per cent during this twelve-year period. In Rhode Island it has decreased from 197.9 to 138.6 per » See also the chapter on School Feeding. THE PUBLIC-HEALTH MOVEMENT 33 DEATH-RATE PER 1 ,000 POPULATION UNDER ONE YEAR OF AGE Area igii I goo Per cent of decrease STATES OF THE REGISTRA- TION AREA IN 1900 Connecticut Maine 129-5 130.9 1 10. 9 143.3 III. 4 150-3 13I-5 128.8 138.6 102.0 104.8 131.9 170.0 123.3 160.9 123.8 130.6 141-9 159-3 156.8 144. 1 177-8 121. 3 172.0 167.4 159.8 197-9 122. I 152.2 162.3 274-5 146.6 194. I 162.4 189.4 201 .9 19 17 23 19 8 13 21 19 30 16 31 19 38 16 % 17 24 31 30 Massachusetts Michigan New Hampshire New Jersey New York Rhode Island Vermont CITIES WITH 100,000 POPU- LATION OR over: San Francisco Denver Washington, D. C Chicago Boston St. Louis New York City Philadelphia 1,000 children under one year of age. In the city of Wash- ington, D. C, it has been reduced from 274.5 in 1900 to 170.0 in 191 1, and so on. The deaths of infants have both hereditary and environ- mental causes, the latter being much more important; diar- rheal and respiratory diseases which result from bad feeding, bad air, filth, ignorance, carelessness, and poverty being the chief causes of infant mortahty. The main bulk of infant deaths, in the last analysis, are of an environmental origin and can be annihilated only by a change in environment, in- cluding proper education. Milk Stations. — One of the potent factors in reducing infant mortality has been the milk station. Thorough and repeated studies of infant mortahty here and abroad have shown that the chances of a breast-fed child are at least five times better than the chances of an artificially fed baby. Nature did not intend that cows should nurse human babies, and our carelessness and ignorance have added additional 34 EDUCATIONAL HYGIENE dangers to this anomaly. If a large percentage of our babies must, for economic and other reasons, be artificially fed, then steps must be taken to secure for them safe food. Whenever this has been tried and milk depots established, infant mor- tality has been decreased. Education of mothers at the milk depots, at the schools, or both in one, is a factor in the situation whose importance should not be underestimated. In his paper on "Infant Milk Depots,'' read at the Conference on Infant Hygiene held in conjunction with the Philadelphia Baby Saving Show, 191 2, Doctor Rowland G. Freeman estimated on the basis of much experience that milk stations plus education of mothers can produce a 60-per-cent reduction in infant mortality, of which 15 per cent should be credited to instruction, leaving a net gain of 45 per cent due to pure milk.^ These figures are almost as arbitrary as they are optimistic. We have no means to measure the importance of instruction in hygiene, and nowhere in this country have we secured a 60-per-cent reduction in infant mortality. One reason for our failure to secure it lies in the fact that we have not taken steps to de- crease infant mortality from the so-called congenital dis- eases from which deaths occur and which constitute 37 per cent of the total infant mortality in the registration area dur- ing the first month of life. The greatest reduction in mor- tality has taken place in the case of diarrheal diseases, then in respiratory, and very little in congenital diseases, includ- ing in this class of diseases congenital debility, malformations, premature births, injuries at birth, etc. Prenatal Work. — To bring about a further reduction in infant mortality the public-health movement must devise means for reducing the number of deaths from congenital diseases. This can in a large measure be accomplished through centres for prenatal care of the mothers. The report of the Russell Sage Foundation on "Prenatal Work in Certain American Cities," presented at the Fifteenth International * Proceedings of the Conference on Infant Hygiene, 1913, p. 201. THE PUBLIC-HEALTH MOVEMENT 35 DIARRHEAL DISEASES IN INDIANA By Ages 1300 1200 1100 1000 900 800 700 600 500 400 300 200 100 [^ ft i w 1 1 1 1 % 1 1 Ij II II Ml ^ n II 1 li ■^ ■^ ■^ ■(^ ■^ ■^ ■^ f^ ■P ll il ■1 1 1 li ll ll m ■ I Ifci^l I — I 111 fl I — I I — I iWWI !■■■! I — I I^WI I ^11 IBil II M 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 90 9 14 19^24 29 34 39 44 49 54 59 64 69 74 79 90 Average for Last Ten Years These diseases are the chief infant destroyers and are largely preventable. Can we not train for this phase of parenthood in the schools? 36 EDUCATIONAL HYGIENE Congress on Hygiene and Demography in 191 2, shows that the work is still in the initial stages, there being but a few scattered efforts here and there, ^ ReaHzing the lack of care of expectant mothers and the resultant appallingly great death-rate from congenital diseases, Doctor Newmayer ad- vocates municipal supervision of maternity.^ *' There should be legislation which would require all hospitals and dispensaries conducting an outdoor service to report to the health ofhcer the names and addresses of all expectant women presenting themselves at these institutions for confinement. The city authorities should have trained nurses detailed to visit these prospective mothers during the last month or two of pregnancy, observing any signs of ab- normahty, instructing the mother in personal hygiene^, care of the breasts, and preparing the mother for the time of labor. The nurse should continue her visits after the birth of the child, in order to instruct in the care and feeding of the baby. Such precautions would reduce materially the early deaths by avoiding many accidents and would also assure more breast-fed babies. In such work the visiting municipal nurse would be a logical solution of the midwife problem. Foreign mothers, realizing the value of the kind of care and attention given to them, would naturally wean themselves away from the services of careless and uncleanly midwives, and those midwives remaining in practise would be compelled to be- come more skilled and painstaking in their work." This is but a logical extension of the work which is now being carried on by the larger cities of the country in the interests of the conservation of the child and which is bound to expand. Public schools through home-visiting nurses and consultation hours at schools for mothers and expect- ant mothers are already doing much valuable service. The twentieth century has been dedicated to the welfare of the child, and the promise is great. 1 Ellen C. Babbitt, Proceedings of the Congress, vol. 3, pt. i, p. 304. ^S. W. Newmayer, Proceedings of the Congress, vol. 3, pt. i, p. 402. THE PUBLIC-HEALTH MOVEMENT 37 School Medical Supervision. — One of the first activities in the direction of child conservation was medical supervision, or ''inspection," of school-children. When first organized, it met with the objection that it was a measure to pauperize the people, forgetting that pubhc schools were inaugurated as pauper schools and that now they are compulsory. The experience of the last fifteen years goes to show that the com- munities that have introduced medical school inspection have been entirely justified in their expenditures by assuring to their future citizens a good start in life, since the majority of the children's ailments and incipient diseases are being dis- covered at a period when they can easily be remedied. Many of the parents of the children who are found suffering from one or another physical defect take steps to have these de- fects corrected or cured. Many of them, however, are too indifferent, too poor, or too ignorant to take the proper action and are, unfortunately, more ready to evade health advice than to follow it. And here is the point where medical school inspection frequently fails. As at present constituted, it does not commonly go much beyond the pointing out of defects, leaving it to those most interested in the welfare of the chil- dren to have them attended to and treated. A recent study of the efficiency of the system based on the records of four schools in the city of New York showed that when the school authorities co-operate with health officers a very high per- centage of treatments is obtainable, and where there is no such co-operation the percentage of treatments does not in any class of ailments exceed 70 per cent. Then, of the cases treated, at least 25 per cent resulted in "no cure" or ''no improvement." ^ Whooping-Cough. — Great strides have been made in child conservation, yet in this field a great deal remains to be done. We have not as yet turned at all toward prevention of a very serious and fatal disease which kills many thousands of chil- 1 E, H. Lewinski-Corwin, "The Practical Necessity of School Climes," a paper read before the Fourth International Congress of School Hygiene, Buffalo, N. Y., 1913, and later printed in the Popular Science Monthly for May, 1914. 40 35 30 25 20 15 1 MEASLES DEATHS IN INDIANA By Ages 1 I Hi ba _a 40 35 30 25 20 15 10 5 10 15 20 25 80 85 40 4-5 50 6.5 60 65 70 75 80 90 9 14 l§/24 29 34 39 44 4-9 54 5^9 64 69 74 79 90 ■Average for Last Ten Yeaj:s ^ ^. Showing the ages when measles are most fatal and common and the impor- tance of home care in the pre-school years. 700 600 500 400 300 200 100 TUBERCULOSIS DEATHS IN INDIANA By Ages lb - I 700 600 )00 400 300 200 100 1 2 3 4 5 10 15 M 25 80 35 40 45 50 55 60 65 70 75 80 90 1 2 3 4 v5 9 14 19/2.4 2B 34 39 44 49 54 59 64 69 74 79 89 11912 ' ^ ^^^^ Average for Last Ten Years While tuberculosis (all forms) is not relatively very frequent in the school ages according to this chart, yet deaths from tuberculosis stand near the first in causes of death among school-children, and the school must help eliminate the deaths of former pupils. 38 DIPHTHERIA DEATHS IN INDIANA By Ages 180j 160 140 120 100 80 6.0 40 >2Q Mm m ■■1 ^ isa 160 140 120 100 80 60 40 20 1 2 3 4 5 10 15 20 25 30 35 40 45 50 55 60 65 70 1 » 3 4 ^5 9 14 19 ; 24 29 34 39 44 49 54 59 64 69 7S 2|^§- 1912 V ^^^-Avetage far Last Tea Yeats Diphtheria finds its victims in the pre-high-school yiars. Most deaths occur from September to January. SCARLET FEVER DEATHS IN INDIANA By Ages ^-Average for Last Ten Years Scarlet fever is another disease of the pre-high-school period, quite largely. Deaths occur throughout the school year, but the number is a third as great throughout the summer. 39 40 EDUCATIONAL HYGIENE dren per annum and the death-rate of which is as high as that of scarlet fever and, in some parts of the country, much higher. I refer to whooping-cough. The recent reports of Doctor Rucker, of the United States Pubhc Health Service, and of Doctor John Lovett Morse, of Harvard, deserve serious con- sideration. It is true, as Doctor Rucker says, that, "if bubonic plague were to kill as many children in the United States in one year as whooping-cough does, the whole world would quarantine against our country/' And yet the disease is popularly regarded as of a trifling nature, and scarcely any measures are being taken to limit its spread and diminish the death-rate from it. Only twenty-nine of the forty- three States that answered an inquiry made by Doctor Morse re- quire reporting of the disease to the health departments, and in those where notification is required very little attention is paid to it by physicians.^ Disinfection after this disease is required by law in only four States of the Union and "recommended but rarely en- forced" in but one. In some States there is no law forbid- ding the attendance of children with whooping-cough at schools; others forbid but have no regulations as to how long they should be kept out of schools. The same inade- quacy and lack of definiteness relates to regulations pro- hibiting the school attendance of other children in the fam- ily. And then, "there is almost no provision for the hos- pital treatment of whooping-cough in this country." There are only a few hospitals in the country that have provisions made for these cases. In this connection it may be of in- terest to quote the medical officer of the Local Government Board of London, who, in speaking of whooping-cough and measles, says, "the most hopeful line of action in respect to both of these diseases appears to He in the hospital treatment of patients for whom adequate domestic nursing cannot be secured." 2 ^"Whooping-cough," Journal of the American Medical Association, May- Si, 1913, pp. 1677-1680. 2 Forty-first Annual Report of the Local Government Board, 1911-12, p. xxv. THE PUBLIC-HEALTH MOVEMENT 41 There is also no provision for the treatment of these cases in the out-patient departments of the hospitals. In the ma- jority of the clinics the children are not allowed to return for treatment for fear of infecting other children in the waiting- rooms. In some clinics they are allowed to return and are *' treated on the sidewalk," at the beginning or end of the clinics. In a few clinics only are these cases treated at an entirely different hour from the other patients. We have here an important and serious task before us. Contagious Diseases. — The control of contagious dis- eases and the matter of efficient home and school quarantine occupy a central position in public-health administration. Contagious diseases come and go in waves or cycles recurring more or less regularly despite the comparatively definite knowledge we possess of the causes and methods of trans- mission of some of them. To what extent iscjlation or segre- gation of the sick is an element in the control of such diseases we have no direct statistical data to determine. We know that rise and fall in the waves is dependent on the ratio of the number of infected persons to the available infectable population. We can observe this particularly well with ref- erence to some diseases, like smallpox, for instance. When the occurrence of cases of smallpox becomes known in a com- munity there is a universal rush for vaccination and the epi- demic soon dies out. After a lapse of a few years, during which no thought has been given to the disease and during which immunity in many instances has ceased and the avail- able infectable population has increased, the wave begins to rise. This is probably true of every contagious disease. The difference in the incidence of the same disease therefore is an indication of certain conditions with reference to immunity. Segregation and isolation of cases is undoubtedly the most im- portant movement in the situation, the extent of which we are thus far unable statistically to determine. The comparison of the two curves of incidence of measles in Philadelphia and New York shown on a chart pubHshed by the Prudential 42 EDUCATIONAL HYGIENE Life Insurance Company suggests that the tenement-house congestion of a large portion of the population of the city of New York may be the reason for the greater incidence of measles in New York than in Philadelphia. Vital Statistics. — ^As can perhaps be seen from this hasty review, our community health programme has not been worked out in detail; plans for a rational development have not been laid out carefully and with precision; the various elements entering the field have not been scrutinized, balanced, and weighed against each other. There is a great deal of dilettan- teism and inefficiency about our pubHc-health administration. One reason for this state of affairs is lack of the indispensable bases of correct judgment, adequate vital statistics. When only 60 per cent of the population of this country is included in the registration area, when our return^ as they exist are incomplete and unreliable, and then, when collected, no ade- quate analysis of them is made in most of the communities, how can we expect to be able to direct the course of pubKc- health administration with precision? In very many in- stances, in view of the lack of adequate reliable data, we have to depend on theories and suppositions which may or may not be correct, having no foundation in definite ascertain- able facts. Take as an average example the antituberculosis cam- paign. In his masterful pamphlet on ^'The Fight Against Tuberculosis and the Death Rate from Phthisis," ^ Karl Pearson takes exception to certain assertions and points out with great acumen the flimsy and scanty grounds from which we draw our deductions with reference to the various factors in the fight against tuberculosis. The following is an example of perfectly sound reasoning for which no statistical evidence is at present available. The Department of Health of the City of New York has recently published a study made by the Council of Jewish Women on ^'The Subsequent History of Patients Discharged from Tuberculosis Sanatoria."^ San- ^ London, 1911. 2 " ]V[onograph Series," No. 8, October, 1913, p. 18. THE PUBLIC-HEALTH MOVEMENT 43 atoria statistics are extremely poor, and the report, after an analysis of the medical data of three tuberculosis sanatoria, says: "A hasty study of the foregoing three tables might lead to the conclusion that sanatorium treatment of the tu- berculous was largely futile. As a matter of fact, however, this would be a great mistake. The work done by the san- atoria is not only highly beneficial to the patients, but is abso- lutely indispensable in the campaign against tuberculosis." This view is probably entirely right but it does not follow from the statistics analyzed. If public health is ever to be raised to the dignity of a science with sufficient authority to bestow on its adepts the degree of D.P.H. (Doctor of Public Health), it must endeavor to procure indisputable proof for its assertions and beliefs. We are not yet sufficiently aroused to the crying need of what Professor Pearson calls ^'an effi- cient medico-statistical logic." Municipal Expenditures for Health. — In spite of the oft- repeated saying that an ounce of prevention is worth more than a pound of cure, and in spite of the wide-spread recog- nition of the fact that pubHc health is purchasable, our com- munity appropriations for public health do not indicate that we apply these principles on a large scale in practise. Out of a total $449,219,789 spent by 184 cities of the United States in 1910, $9,059,173, or 2 per cent only, went for health conservation proper.* The average per-capita cost of city administration in « the United States (exclud- ing payments for expenses of pubHc-service enterprises) was $16.45 in 1 9 10. Of this amount only 33 cents went for health conservation, about one-fiftieth. The smaller the cities, the smaller is the average per-capita cost for pubHc health. In the cities of Group I, i. e., cities having a population of 300,000 or over, the average for health conservation is 41 cents; in the cities of Group II (from 100,000 to 300,000 population) it falls to 27 cents. Cities of Group III (popu- lation 50,000 to 100,000) spend 21 cents per capita, and those » "Statistics of Cities, 1910," p. 135. 44 EDUCATIONAL HYGIENE of Group IV (population 30,000 to 40,000) can boast of an expenditure for health of but 19 cents. ^ The health conditions in the smaller towns and country districts are particularly unsatisfactory. Conclusion. — The foregoing cursory review presents the main problems of the pubHc-health movement, which is gaining a tremendous impetus in this country. It can be seen that a great deal remains to be done, but the most im- portant problems facing the movement are education, con- centration, and co-operation, all essential to the conservation of effort and to the checking of unnecessary waste of energy and money. After a statement of the hereditary basis of health work in the next chapter, the later chapters will show how to meet many of these problems through the widening influence of the public school, democracy's chief agency for permanent health improvement. ^ Same report, p. 64. CHAPTER III HEALTH AND HEREDITY The Infinite Varieties of Traits in American Children. — Modern views of heredity in man start with the principle of the essential diversity of human beings in any mixed popu- lation such as the United States affords. Though there are countries, using the word in its broadest sense, in the Old World whose population is blue-eyed, others where all the people have curly or kinky hair, others where the nose is aquihne, others where practically all are tall, and so on, in this country all these physical traits are for* the most part much mixed together. It is because the population of this country is so greatly hybridized that the people are so differ- ent. It follows, first of all, that there are few rules that hold for all people. A neglect of this fact is in part responsible for the failure of works on pedagogy, or hygiene, or medicine, to command universal respect. We learn that the child's mind works so and so, in face of the fact that *'the child" is an abstraction; we are taught how to care for the teeth, despite the fact that *'the teeth" are a mythical thing; and we learn of the prognostication of *' typhoid fever" as though it were a definite phenomenon that needed only to be seen to be recognized, instead of the different kinds of behavior of various living human bodies to the parasite that is called bacillus typhosus. As I have said, the child-mind is a pure abstraction. Actu- ally we have the minds of various children which are, in the extreme, so unKke that they have few features in common. Nor does it help much to divide them into the feeble-minded and the normal, or the wayward and the normal, for "the 45 46 EDUCATIONAL HYGIENE normar' is itself a scholastic and pedantic figure of speecli and does not, strictly speaking, correspond with anything found in nature. The teacher who relies solely upon what he has learned from the books about the child's mind will be far less successful than the teacher of common sense who has had a wide range of experience with children's minds} Similarly, the instructions as to the care of ^Hhe teeth" are of comparatively Httle use to certain races, notably West African negroes, whose teeth are highly resistant to caries, and their faithful appHcation will probably do little to delay the ravages of decay in the teeth of those who are non-re- sistant. How often may one hear of a white person who has not lost a tooth in his head and had never been to a dentist and makes little or no use of a tooth-brush. On the other hand, you will frequently find those whose constant use of antiseptic tooth-washes does Httle to stay the rapid loss of the entire set. It has even been contended that {a) were there no tooth-brushes there would be no more caries than at pres- ent, (h) tooth-powder is the real cause of the weakness of our teeth and water only should be used, and (<;) the use of a bristle brush is in the highest degree unnatural and is one of the leading causes of tooth decay! Most other ^'laws of hygiene" are similarly disputed. The fact of this difference of opinion is mute testimony to the fact that individual dif- ferences are not less important, probably much more im- portant, than hygienic conditions. Similarly in respect to typhoid or other diseases, what the reaction of the body to any toxin of a parasite or other un- toward condition working on the body is, depends, within limits, far more upon the constitution of the individual than upon the chemical composition of the toxin, and the partic- ular untoward condition. This, then, is the first lesson of modern biology: Health is, within limits, more a matter of heredity than anything else and 1 See Thorndike's " Individuality." HEALTH AND HEREDITY 47 in so far as hygiene fails to take this fact into account it fails to he of high practical value. Accounting for Individual Differences. — Recognizing then the fundamental importance of individual differences, it is for us to account for them. Now, no person who is an agri- culturist will deny the importance of good conditions of development upon the matured organism. Proper food, protection from extreme environmental conditions, from com- petition, from parasites, and from gross accidents, are impor- tant for any crop of corn or calves; so it is with man. But if under good culture I fail where my neighbor succeeds I must look to my seed or ^^ strain." His potatoes were rot- resistant; his corn was from a ^Mry-f arming" strain; his hogs were cholera-proof, etc. The agriculturist knows that, given certain fundamental conditions of culture, the differ- ence of 3deld depends chiefly upon the hereditary nature of the organism. And we shall find that these hereditary qual- ities so reappear in successive individuals and generations as to warrant us in speaking of this succession of similarly en- dowed individuals as constituting a ^'biotype." Individuals, then, are different largely because they belong to different biotypes. We have next to consider how these differences that distinguish one biotype from another become disseminated throughout the entire population. This is the subject of heredity in its narrow sense. And to understand this sub- ject we must clear our minds of a lot of intellectual rubbish, figures of speech, and mystical ideas. Many persons would say that we inherit traits from our fathers and mothers. Strictly, we do nothing of the sort. It is just as true, in one sense, that a father inherits certain of his quaHties from his son. The fact is that neither inherits from the other any more than the youngest leaf on a growing shoot inherits its shape from the next older one. The leaves are alike, to be sure, but they are ahke because they inherit in succession from the same common stuff, located in the twig at the tip. 48 EDUCATIONAL HYGIENE This common stuff we may call the germ plasm. It is be- cause the successive leaves on a twig are developed out of the same germ plasm that they are alike. It is because father and son are developed out of the same germ plasm that they are alike. The case in man is more complicated, however, in that a loss of materials and an addition of other, foreign materials is made to the germ plasm at the initia- tion of each new individual in the processes called matura- tion of the germ cell and fertilization or union of gametes, so that strictly the son is only a younger half-brother to his father by a different mother. We have got used to think- ing of the eggs in the mother as hers. Strictly they are not hers but are merely a part, left behind, of the fertilized egg out of one part of which she developed. The rest was car- ried in her body, protected, warmed, and fed by that body and put in the way of continuing its history, reaching back to the beginning of life on the globe, provided that *' fertili- zation of the egg'' can be secured. When we think what a history that germ plasm has had, through what billions of accidents of not being continued it passed unscathed to the present day; when we consider how its continuation is absolutely determined by our behavior; when we contemplate the wrong that we should do society and the world if, through our neglect, an excellent germ plasm should not be continued for another generation, then we realize dimly the magnitude of the trusteeship that is ours in the care of this germ plasm that we carry. Then we realize the heinousness of the crime of poisoning it with alcohol, or of rendering it impotent through the access of venereal disease, or of preventing its continuation because, forsooth, we don't want to be bothered with the care of the new soma that might arise from it and so continue this germ plasm to the next following generation. The germ plasm belongs to society, to the state, and to injure it or to prevent it from carry- ing out its manifest destiny, save for eugenical reasons, is to be unfaithful to one's trusteeship, is to commit a crime against HEALTH AND HEREDITY 49 society and the state; and it should be so considered by the state.^ Again, strictly, we do not inherit characteristics from the germ plasm. It is only a figure of speech when I say I in- herited my nose. There was no nose in the germ plasm. The germ plasm carried some things that determined that I should have such bones and cartilages and connective tissues as give the form to my nose. These materials in the germ plasm we call determiners; and it is because of some difference in the determiners for the nose in my germ plasm from the nose determiner of your germ plasm that I have a different form of nose from you. The peculiarity of the nose determiner in my case depends upon certain differentials in the determiner. Noses, then, have their distinguishing characters largely, if not chiefly, by virtue of certain differentials in the germ plasm. We have our hereditary peculiarities because of the. persist- ence, through the stream of germ plasm that passes down the generations, of certain differentials. Environmental Modifications of Determiners. — We in- herit, as we have seen, determiners. The determiner is not the characteristic; it must develop to produce the character- istic. Now, the course of any development is not definitely predetermined, but depends upon surrounding conditions. Here is where environment plays its important role in modi- fying the development of the determiner. All efforts for care of the pregnant woman, of the expectant mother, all child- feeding, milk-station work, all parental training, all school instruction, religious influences, and cultural conditions in general are brought to bear to secure the best possible develop- ment of the determiner of the various elements of the phys- ical, intellectual, and emotional make-up. Good culture can do much to insure the full development of determiners in the 1 "Original nature comes from original nature: inheritance is from germs to the germs. Long before a man is born, the germ-cells that will thirty years later produce his children are set off apart. They do not come from him as a collection from his total make-up, but from the germs that produced him." — Thorndike, in " Education," p. 206. 50 EDUCATIONAL HYGIENE fertiKzed egg; bad conditions may prevent the full develop- ment of determiners; but the best conditions cannot cause to develop in a child any trait the determiner for which is ab- sent, just as rain and sunshine and manures do not cause a plant to arise where no seed has been planted. Here is the clear limit to the power of environment. The Combinations of Determiners, — Finally, each child is derived from the union of two germ plasms — of two bundles of determiners — from two germ cells. In the two bundles that unite there are many determiners that are the same, but there are probably some that are found in one of the germ cells and not in the other. When both germ cells bring to the embryo a determiner for the same trait, the trait may be said to be duplex. When only one germ cell supplies the deter- miner for a trait, the trait in the developed soma is simplex. If neither parent supplies in his germ cells the determiner for a trait, then the trait does not develop in the offspring. When the determiners are duplex in the individual, then, when that individual forms his ripe germ cells, every one of them contains the determiner for the trait. When an in- dividual is simplex in this respect, then, when the germ cells are formed in such an individual, half of them possess and half of them lack the determiner. If the individual has acquired from neither parent the determiner for the trait, then in none of the germ cells of that individual will a determiner be found. This abstract conception may now be illustrated by an example, and I choose that of eye color, (i) When both parents are brown-eyed and belong to brown-eyed stock, so that all of their germ cells carry the determiner for brown iris pigmentation, then all of the children that arise by the union of such germ cells will have the determiner for brown iris pigmentation duplex. (2) If one parent be brown-eyed and of brown-eyed stock, whereas the other is brown-eyed but simplex, then all of the children will have brown eyes but half of them will be duplex and half simplex in this re- spect. (3) If one of the parents be duplex brown-eyed and HEALTH AND HEREDITY 5 1 the other blue-eyed, then all of the children will be brown-eyed but simplex. (4) If both parents be simplex brown-eyed, then one in four of the children will be duplex brown- eyed, two simplex brown-eyed, and one in four will be blue- eyed. (5) If one parent be simplex brown-eyed and the other blue-eyed, then half of the offspring will be simplex brown- eyed and half blue-eyed. (6) If both parents be blue-eyed, then all of the children will have blue eyes. Health and Heredity. — We are now in a position to take up the relation of heredity to health. In treating- of this topic I propose first to speak of the relation of heredity (i) to the physical development of the child, (2) to the mental development, (3) to its moral development, (4) to its resist- ance to physical disease, (5) to its resistance to mental disease, (6) to longevity?- (i) Physical Development and Heredity. — Inat the course of development of the body has a hereditary basis is obvious from a vast number of family histories that have been studied. The methods of inheritance of defects in physical development are of three types so far as known. There are defects due to an extra determiner, those due to the absence of some deter- miner that is typically present, and those that are sex-linked. {a) Physical Defects Due to an Extra Determiner or Deter- miners. — To this category belong certain eye defects. Of these, juvenile cataract is one of the commonest and most important. This consists of a clouding of the lens of the eye and has a pedagogical importance because it interferes greatly with vision and eventually causes practical bUndness. This may begin to appear at birth. Nettleship describes the case of a boy who showed a cataract when the eye was first carefully examined, three months after birth. Usually, how- ever, it begins later, at eight, ten, fifteen, or twenty-five years, or even later. If now the family history be studied, it will be found, practically invariably, that one parent of the affected iSee Davenport's "Heredity in Relation to Eugenics," and Rosenau's " Preventive Medldne and Hygiene." 52 EDUCATIONAL HYGIENE child had also cataract in youth, and this can often be traced back for several generations without a break. Unaffected descendants of affected ancestors do not have affected off- spring. Among other eye diseases that fall in the same category are: glaucoma, or the distension of the ball of the eye by excessive production of internal fluids; retinitis pigmentosa (usually), which is a degeneration of the retina that leads to irremediable blindness; and night-blindness, often associated with the foregoing, which makes it hard to see by artificial light. Imperfections in the development of the male genitalia fall into the category of positive imperfections to develop- ment; in extreme conditions the individual is a ^'hermaph- rodite," and may show psychical conditions as ambiguous as his physical. Finally, nearly all abnormalities of fingers and toes seem to belong to this group, including polydactylism, syn- dactyhsm ('' lobster-claw"), brachydactylism (or two-jointed fingers), double-join tedness of fingers, and crossed or hammer toe. The affected persons tend to reproduce their peculiarity. {b) Physical Defects Due to the Absence of a Determiner. — One of the best examples of this class is defect of pigment, as seen in albinos. This condition is usually complete; the spotted condition is rather rare and is properly not albinism, and seems to be inherited as a positive character. When pig- ment is lacking the hair is, including that of the eyelashes, white; the skin is of a clear, translucent pink; the retina is devoid of pigment, so, as seen through the pupil, the back of the eye looks pink; even the blue of the iris may be absent. Such cases usually arise from consanguineous marriages, be- cause the defect has to be carried in each of the fused germ cells. In addition to albinism there is some reason for believing that excessive growth in stature, congenital deafness, and cleft palate are developmental defects that are due to the absence of each of one or more determiners; but it must be HEALTH AND HEREDITY 53 admitted that heredity in these cases seems to be complex and has been insufficiently analyzed. (c) Physical Defects Due to the Absence of a Sex- Linked Determiner. — ^Here belongs, first of all, hemophiha, or inabihty to coagulate the blood after a wound. The so-called "bleed- ers" are apt to die in consequence of excessive hemorrhages; so that this defect is a very serious one. As in the case of other sex-limited quaHties, it is found typically only in males and only such as have unaffected parents, but the trail of the defect can be traced through the female line to some affected male ancestor. No affected male who marries a normal woman has any affected children, but the daughter of such will have half of her sons affected. Atrophy of the optic nerve and multiple sclerosis are other examples of this trait. (2) Mental Development and Heredity. — Heredity plays a great part in the mental development of the child also; typically by the absence of one or more determiners for com- plete mental development. Thus, there is much evidence that hereditary imbecility is due to the absence of one or more de- terminers; for two parents of the hereditary-imbecile t3^e have t3^ically, if not always, only offspring of this type. In the same way hereditary epilepsy seems to result from the absence of a single determiner that regulates the centres that control movements. Cerebral palsy of infancy is similarly due to a defect. Finally, color-blindness must be mentioned as a type of the sex-linked characters that belong to this category and whose inheritance follows the same law as hemophilia, mentioned in the last paragraph. (3) Moral Development and Heredity. — Heredity has important relations to moral development. Studies of way- ward children have shown that bad temper, especially of the stormy, outbursting kind (tantrums), is clearly dependent on a positive determiner; the trait passes without break from generation to generation. Also extreme eroticism, eroto- mania, is inherited in similar positive fashion. Many other 54 EDUCATIONAL HYGIENE elements of wayward, violent, and criminalistic behavior have a clear hereditary basis, even though the exact method of inheritance cannot yet be given. (4) Resistance to Disease and Heredity. — Inheritance of resistance or susceptibihty to disease has long been recog- nized, but since the grand developments in bacteriology the old theory of diathesis (predisposition) has rather fallen into disrepute; but it is now reviving again. Just as the organs of the body are not in the germ plasm as such but merely de- terminers or differentials of them, so with respect to disease. Susceptibility as opposed to resistance is due to one or more differentials in the germ plasm. In some cases this susceptibihty is due to a positive de- terminer. Thus the tendency to form fluid-filled vesicles in the skin after the sKghtest provocation such as a pressure or a scratch (epidermolysis bullosa) is a trait that shows itself in the first month of Hfe and it is strongly hereditary. It is to be noted that the bullae are not formed without the trauma; they are the reaction of a specially susceptible skin to a sHght trauma. Similarly a tendency to chronic jaundice runs in certain families without skipping a generation. In other cases, and these seem to be commonest of all, the susceptibility is due to an absent determiner. To this class belongs in all probabihty non-resistance to tuberculosis, and to the causes that lead to catarrh; here also, almost cer- tainly, susceptibility to cancer. Thus lack of resistance plays a role of the profoundest importance in some of our worst diseases. (5) Resistance to Mental Disease and Heredity. — In speaking of mental breakdown we are prone to find its cause in some sort of stress, loss of a close relative, disappointment in love, failure in business, etc. But these things happen to many people who do not lose their mental vigor. Those who thus give way have some neural defect, some lack of mental strength. That juvenile dementia is due to an actual lack of some determiner is indicated by its method of inherit- HEALTH AND HEREDITY 55 ance. If both parents be subject to it, all of the children are. There seems to be a little more doubt about the conditions that are classified as manic-depressive. (6) Longevity and Heredity. — That longevity has a he- reditary basis cannot be doubted. It is easy to find frater- nities, even of large size, nearly -all of whose members have lived to be over eighty years of age and in which both parents and at least half of the grandparents had reached the same advanced age. In other families, on the contrary, most if not all are dead by fifty years. We can understand this upon the principle of inherited resistance to specific diseases. A body that is resistant to tuberculosis, to catarrh of the respiratory tract, and to cancer passes unscathed through the most dangerous period of beginning decline of the bodily powers. The foregoing list by no means completes fhe roll of mor- bid, or contrariwise healthy, conditions that have a hereditary basis, hut only those whose method of inheritance is best known. Many, if not most, serious heart troubles that date from early childhood are due to hereditary malformations or bad positions of the heart. Harelip and cleft palate, multiple nipples, hereditary ataxy, Friedrich's disease, amaurotic family idiocy, certain edemas, various disorders of metaboKsm, rheumatism, migraine, dipsomania, and scores of other con- ditions have a clear hereditary factor; and, conversely, the absence of these is largely due to some hereditary source of strength and vigor. An early breakdown can usually be attributed to some weakness in the machine. Eugenics and Health. — The wide-spread absence of phys- ical and mental health in the population is a tremendous handicap to society. Our States spend over $100,000,000 annually in the care of the defectives and the sick, and it may be conjectured that no less a sum is lost privately by illness of one sort and another, due to inherited lack of resistance. Not only is there a huge money loss but a loss of labor of an army of effective persons caring for defectives 56 EDUCATIONAL HYGIENE who might otherwise be engaged in some constructive work. The consideration of all of these facts has led many persons to urge that attempts be made by education and by state interference to diminish the heavy reproduction of these mental and physical weaklings. This is the practical applica- tion of eugenics, which on its theoretical side is largely the study of heredity in man. While it is recognized that the state, by segregation of those unfit to reproduce, or even by sterilization, may di- minish the reproduction of the grossly unfit, many have grave doubts if, by education, anything can be done to influence marriage selection. In this doubt the present writer does not share ; and the reason for his optimism is that scores of per- sons who are thinking of marrying, others who are interested in another, and still others who are so deeply in love that they declare they will die if their love is not satisfied, have written to him to know if the contemplated union will prob- ably result in healthy offspring. And in two cases, at least, on viewing the facts of heredity as displayed by a graphic representation of their own statements, the proposed marriage has been abandoned. These cases were, to be sure, those in which there was home opposition on eugenic grounds and the writer was called upon to act as referee. I mention these facts as justification for my contention that at an early stage in the often prolonged process of falling in love proper in- struction may avert an impending ill-advised match. One great difficulty has been that our knowledge of the inherit- ance of traits is wofully deficient.^ As an instrument of research in human heredity and eugenics there was founded in October, 1910, by Mrs. E. H. Harriman, at Cold Spring Harbor, Long Island, N. Y., the Eugenics Record Office. This office seeks to fill the need of a clearing-house for data on human heredity, and a place where studies on heredity can be made. This office seeks to iSee chapter on "The Hygiene of the High School," in Johnston's "The Modern High School," by the editor. HEALTH AND HEREDITY 57 interest persons in their own family history by distributing, without charge, a schedule called ''Record of Family Traits" to those who agree to fill it out for their own family and return it to the office — a second copy being sent to such as desire to retain it for their own use. In this way thousands of per- sons have had their attention directed to a careful considera- tion of their own traits and the distribution of these traits throughout their family. The application of such family histories is very varied. Many teachers have suggested that every pupil on entering a school should bring with him, filled out, such a schedule so that his teachers might have some knowledge of his hereditary background; might have some notion of the probable poten- tiahties that they are to cultivate. Every teacher learns, usually at the end of the semester, about his student's capac- ities, but it would save much valuable time if* he had some inkhng of this at the very beginning. A knowledge of the heredity of pupils will, of course, be indispensable in any scientific plan of vocational and hygienic guidance. Similarly the family history would be of great advantage to the gym- nasium director in prescribing exercises for any student, and it would be useful in the infirmary in case the student should fall ill. A proper recognition of the facts of hereditary poten- tialities would be of assistance in all aspects of a student's training. To facilitate the inquiry as to the desirabihty of a given marriage from the standpoint of health of the children, the Eugenics Record Office distributes a schedule called "Index to the Germ Plasm," in which may be recorded parallel records of the young man and the young woman. Such a parallel record brings into clear relief the family inheritable traits and enables the expert to say at least something about probable traits of children. The schedule is a somewhat diffi- cult one to fill out, but already scores have been filled out very carefully and served as a basis for a clear statement of probable results of the given combination in so far as the 58 EDUCATIONAL HYGIENE nature of the germ plasm is truly and fully set forth in the schedule. By such means, then, the health of the next generation may be made better than that of this — not merely by curing the sick, not merely by following the ''rules of hygiene," but by breeding a larger proportion of children who shall be in the less need of the rules of hygiene because their bodies are, by nature, highly resistant to health-destroying agencies. CHAPTER IV THE HOME HYGIENE OF CHILDREN Parents' Health Responsibilities. — In the past it has been a too common habit to lay the blame for the production of many of the physical and mental handicaps of children upon the public schools. A closer study of actual conditions, how- ever, reveals the fact that the home plays a far greater part than the school in the production of such handicaps. With- out the close co-operation of home and school little of real value can be developed in the way of improving the health conditions of school-children. In this chapter; an attempt will be made to outHne those points which parents need to understand to co-operate successfully with the school in the physical improvement of children. Parents greatly need to learn correctly to interpret the rather plain signs of common disorders in children. There are many significant habits which indicate such disorders, yet these are frequently either quite ignored or misinterpreted. Then the parent must also remember that symptoms of health are at least as important as those of disease, and that many things which to some seem abnormal are merely normal manifestations in the development of the child. Each individual child requires special study, for there is really no such thing as an average child. ^ All children are in one sense "exceptional." Wise parents should not make the common mistake of attributing many symptoms to one cause, but should often look and expect to find several such causes.^ * See Thorndike's book on " Individuality." 2 Parents will find much help in Professor Ditman's little one-volume cyclo- pedia on "Home Hygiene and the Prevention of Disease" (DufiSeld). 59 6o EDUCATIONAL HYGIENE Heredity. — ^As Doctor Davenport has shown, the matter of heredity is of such paramount importance in any serious study of children that it deserves some discussion before all else, and this is of special interest in respect to a considera- tion of nervous children. Very often the child is blamed both at school and at home for matters which are either the direct or indirect results of heredity and for which the child is little, if at all, responsible. In the home study of the child, parents can do no better than to commence with a careful consideration of those qual- ities which they themselves possess. Such an inquiry often unfolds and explains problems which otherwise might re- main unexplained, and which would therefore be difficult to correct. The child is a small mosaic of all his ancestors, but par- ticularly of his more immediate ones, and it is of the utmost importance to understand as far as may be just what ele- ments enter into his make-up. Why parents should so fre- quently ignore the rather plain manifestations of their own undesirable qualities when they appear in their children in a slightly disguised form is a matter hard to comprehend. "It is difficult to understand,'' says Doctor Leonard G. Guthrie, ",why a subject so important to the welfare of the community as the study of children should have been so long neglected," and one might add that it is still more diffi- cult to understand why a subject so important as the study of parenthood suffers from yet greater neglect. In the schools to-day we hear and see much of the nervous child, but how often is it understood that such nervous, and usually irritable, children have in most instances nervous, irritable fathers or mothers? The correction of nervous dis- orders in children ought often to begin with parents, for even with a bad heredity in this respect much good may be accom- pKshed if the child can be relieved of what is nearly always present under such conditions, namely, an unstable, neurotic home environment. But before parents can successfully study THE HOME HYGIENE OF CHILDREN 6 1 their own nervous tendencies it is often important to recognize the early nervous manifestations of their children. Description of the Nervous Child. — Doctor Francis Warner, in his ^' Study of Children/' has briefly described the nervous type of child perhaps better than any one else, when he says: There is a class of children commonly met with in every commu- nity, termed nervous children. Such are apt to complain of headache, are difficult to put to sleep, they talk at night, and grind their teeth, while in the morning they are tired and not ready for breakfast. They are often bright enough mentally, and affectionate in disposition, but they are likely to be irritable, passionate, and too emotional. They are the children who are delicate without having any definite disease; they are rarely laid up with a definite illness but they are not strong; they cannot walk far without getting tired; some days they are too tired to do anything and must rest; capricious in appetite, yet some- times ravenous, but remaining stationary or increasing slowly in weight. The general balance of the body, as the child stands, is usually asymmetrical, with the head slightly drooped and inclined to one side; while the spine is perhaps bent a little to one side, with unequal shoulders, and the feet unequally planted. The eyes wander much, in place of being directed to objects. In the face the expression may be somewhat diminished, with ful- ness under the eyes indicating fatigue. When the hands are held out in front, asymmetry in balance of the arms is frequent, the left hand usually being held lower. The fingers frequently show twitching movements, if they are held separate from one another so as to be free to move. In mental habit such children are usually quick in learning, talk- ative, playful, and often laughing. In social life they seek one another's company and as they are usu- ally imitative, one may prove a source of mental excitement to another. On looking further at such a child, you will probably find that the face is the best nourished part of the body. The limbs are thin; the teeth are very likely flattened at their tips from the constant habit of tooth grinding. These nervous children are very difficult to feed: the appetite is either very poor or it is capricious. We may further add to this accurate description of Doctor Warner's by stating that nervous children are often restless, 62 EDUCATIONAL HYGIENE inordinately active, busy to no very definite purpose; their emotional natures are often unduly developed, and under very poor control. Laughter and tears are always near the surface. Affection, anger, sorrow, and joy are not very well differentiated. They are inclined to selfishness, fond of at- tracting attention, quick to give offense, but quicker to re- sent it in others. At home children of this type are usually very badly disciplined, and indeed such children often furnish a pretty fair index to the character of one or both parents. Such parents probably use very Httle discretion in matters of discipHne. They cannot bear to see the child suffer and consequently, since it rarely meets with resistance, it wishes to have everything it sees. It wants every whim and caprice satisfied. Such a child soon becomes a perfect young tyrant, and he is not only a source of annoyance to others but he defeats his own happiness also, for he never learns the habit of self-control. Most of the neurasthenic adults who go about in the search for unearned happiness have passed through a childhood similar to that just described, and indeed we may safely state that their nervous disorder is often largely the direct result of faulty early methods of training. Nervous children need definite and rigid, but at the same time kind, home discipline, and in many instances such training might well begin with one or both parents. "Such children,'^ says Doctor I. A. Abt, "should be taught to endure pain with some degree of self-control, to respect the rights of others, to obey just commands, to acquire some de- gree of composure, to five regular fives, to be unselfish, and to love the good, the true, and the just. Particularly high in these quafities is the love of truth. He who is true to himself and others is rarely overtaken with a disorder whose striking characteristics are exaggeration and dissatisfaction.' ' Environment. — It is a difficult matter always to draw a sharp line between the influences of heredity and those of environment, for such influences are constantly overlapping. Even a child with an originally well-balanced nervous system THE HOME HYGIENE OF CHILDREN 63 may well become irritable and generally unstable through the influence of a bad nervous environment. On the other hand, many a child with a faulty heredity or a distinctly nervous predisposition has developed into a normal life through the influence of a favorable environment. Environment has much to do with deciding the character and stability of the child. It acts every hour of the day, tending to form the habits, lines of acting, and modes of thought. Parents control the bodies and minds, hearts and souls of their children, not only through hereditary traits handed down from their ancestors, but also by what they themselves do and think. Example and imitation guide the child in thought and action.* A bad school environment is capable of doing much harm to any child, but the best of school environments can do Httle to offset the constant and pernicious influence of an unwisely conducted home. It is too much to ask of the school that it re-educate a child whose first five or six years of fife have run in wrong channels, or that it correct in a few hours each day the influence of daily faulty habits of the home. Children surrounded day after day by a home environment little or not at all adapted to character formation furnish most of the nervous pupils of our schools. Some Common Functional Nervous Disorders of Chil- dren. — Most of the nervous disorders of children are found in the child of neurotic temperament whose general character- istics have already been described. These disorders are usually one or more of the following group : {a) Habit spasms. (h) Chorea. {c) Stammering and some other speech defects. , {d) Morbid fears. {e) General nervous fatigue. In a discussion such as this, which of necessity must be * Oppenheim. 64 EDUCATIONAL HYGIENE strictly limited, it will only be possible very briefly to outline a few of the leading symptoms in each of the groups men- tioned, with the expectation that the parent, after recogniz- ing the situation, will seek proper medical aid. Habit Spasms. — These are characterized by quick, invol- untary, peculiar movements. They may be easily recognized by the following description by Guthrie: A series of lightning-like blinks or nods or sudden turns of the head aside. The eyebrows may be elevated or corrugated or the upper lids may be raised several times in quick succession, as in a munching rabbit, or the nose may be wrinkled and the nostrils expanded or con- tracted, whilst half a dozen or more little ineffectual sniffs are pro- duced, or a variety of grunts and queer guttural noises are heard. The characteristic of all these simple tics is that they suddenly come and go, and each form will commonly give place to another. It is seldom that more than one trick or antic is present at a time. In a more complicated form of habit spasm or tic the child will often perform the most astounding tricks. Such habit spasms seem often to be a family habit and no doubt usually represent a neurotic family temperament. Scolding, nagging, or punishment on the part of parents only serves to increase this trouble in a nervous child, and prompt advice should be sought from a competent physician. The habits are usually curable under proper conditions. Chorea. — Chorea, or St. Vitus's dance, is often confused Vvdth habit spasms, and this is most unfortunate, as it is of a much more serious nature. It ought to be recognized early, but as a matter of fact it is seldom recognized by parents and teachers until it is well advanced. Any child should be suspected of chorea who has some or all of the following habits: (a) Extreme restlessness. (b) Purposeless motions. (c) Inability to hold pencils, books, knife, fork, etc., securely. {d) Falling down or stumbling easily and frequently. I THE HOME HYGIENE OF CHILDREN 65 The spasmodic symptoms include muscular spasms of various parts of the body, such as contortions of the face, jerky movements of the head, shoulders, arms, and legs. In general, the muscular spasms include larger groups of muscles than in habit spasms. The trouble is often, If not always, closely associated with diseased tonsils and rheumatism, and in many instances the heart is affected. Early and systematic treatment is required, and the child should be removed from school both for his own good and for the good of other pupils, some of whom are very likely to imitate the grimaces and other habits until it becomes a more or less fixed habit on themselves. Children with this disorder require rest in bed, quiet, regular life, nourishing food, and proper medical treatment. Stammering and Stuttering. — Stammering, which is caused by a *' spasmodic arrest of utterance," and stuttering, which consists in *' spasmodic repetition of initial syllables," are both often associated with, if not caused by, a neurotic tem- perament. The basis of these speech defects lies in '' defective nervous control." ^ Doctor Still states that the determining cause may be some depressing illness, or a shock, or some form of physical irritation. Sometimes it appears after diseases such as scarlet fever, diphtheria, or whooping-cough. Fright may initiate the disorder, and so may an accident. In some cases it ap- parently originates through imitation. Most children who suffer from these defects of speech are of superior intelligence, and are usually sensitive and of highly organized disposition. The treatment of speech defects requires special attention unless they are quite mild in nature, and specialists should therefore be consulted. Above all, it should be remembered that nagging, scold- ing, or fault-finding in the cases of children who stammer or stutter will produce great injury to the child. » See Bibliography. 66 EDUCATIONAL HYGIENE As Professor Terman well says, "the stuttering child presents a tragedy to which a majority of teachers and parents are strangely blind, and at home the onset of the disease is a signal for impatience and reproof on the part of parents. The result is often the formation of morbid habits of thought and failure in school work.^^ Morbid Fears. — Nervous children are rather prone to morbid fears of various sorts, and in some instances these fears cau^e an intense suffering, little or not at all understood by parents. Doctor Guthrie well says that the earliest indications of fear should be recognized and should meet with sympathy, encouragement, explanation, and removal of its causes if possible — never with badinage or indifference. Of all emo- tions, he says, it is the one most calculated to produce lasting effects upon a neurotic child. These morbid fears include all sorts of things which the child is quite unable to explain. Often through shame he hides his fears until they become almost an obsession or a fixed idea. Many of the ^' queer ^' habits of children may be explained by these suppressed fears. Sometimes the child is made by them to appear stubborn, or he may develop un- truthfulness, embarrassment, or a variety of other peculiar- ities so often misinterpreted. Such fears include, among many others, fear of the dark to an extreme degree; fear of sounds such as bells, the wind, whistles, etc.; fear of space, of death, of sickness, of crowds; of future punishment, of stories of a grotesque or otherwise fanciful nature; fear of certain real people, or of witches. Some children develop fears of shadows, of the forest, of water, of Hghtning, or even of the most common and ordinary kinds of objects. Not infrequently rehgious fears develop in a sensitive child which fairly paralyze the joy of living. The normal child will not, in fact, be very religious, for religion is 1 Parents and teachers may well read Terman's " The Hygiene of the School Child," and Hoag and Terman's ''Health Work in the Schools." — Ed. THE HOME HYGIENE OF CHILDREN 67 to such children something quite beyond their childish com- prehension, and something in which they are therefore not much interested. An intense religious zeal in a child, as also in some adults, is in itself a symptom of a nervous dis- order, not an evidence of desirable piety. Corporal punishment is always of doubtful value, but in the case of nervous children, and particularly those with mor- bid fears, it must be unhesitatingly condemned. Unnatural remorse for youthful misdemeanors, real or imaginary, is often seen in nervous children, and an '' ex- treme anxiety to be strictly truthful" is again not an evidence of moral rectitude so much as of morbid nervous instability. Worry and apprehension are also sure signs, in children at least, of the neurotic temperament. In childhood many danger signs of future mental unbal- ance may often be discovered by those able* to interpret them, and through this discovery there may be avoided in many instances not only the neuroses of adults but also actual insanity. The prevention of insanity is at last coming to interest the public nearly as much as the prevention of other forms of disease. General Nervous Fatigue. — Fatigue is so common and is produced in such a variety of ways that a full discussion of it at this time is quite impossible. Parents should remem- ber that the normal child does not fatigue easily and that when he does tire he recuperates rapidly after sleep. The chronically fatigued child needs medical advice. Play and other physical activities are normal to the young and anything more noticeable than ordinary weariness in children calls for careful consideration. In real cases of fatigue there is an actual poisoning of the central nervous system through the absorption of fatigue poisons. As Woods Hutchinson says, "whenever the blood is im- poverished below a certain degree or becomes loaded with fatigue poisons or other waste products above a certain point, 68 EDUCATIONAL HYGIENE then the nervous system proceeds to make itself felt. The practical point is that a fatigued child is a sick child and the cause or causes of such sickness must be discovered." Sometimes this is worry, or abnormal fears, or it may be due \o digestive disorders, or wrong food, or too little sleep, or various forms of nervous overpressure. But whatever the causes are, the child has a right to the protection from future troubles of the same sort which only a careful study of his case will afford. Common Errors in Children's Diet.^ — In children of the school age it is very common to notice those who are suffer- ing from some form of malnutrition. Such children usually have the following appearance: they are thin, pale, and nerv- ous; often the lymph glands of the neck are enlarged; some- times the gums and lining of the eyelids are quite colorless; headache is rather common, and either diarrhea or consti- pation is the rule. A careful history of such a case will usually bring out the information that the child is very capricious in appetite, that he has acquired fussy food habits; that he is irritable, and perhaps sleeps poorly or at least is restless at night. Not many of such cases have their basis in any very definite disease, although some are tubercular, as would be clearly demonstrated by the proper tests (Von Pirquet and others). These children are, in the majority of instances, accord- ing to the writer's rather extended experience, neurotic, and their fussiness about food is only one of many other nervous symptoms. Careful questioning brings to light the fact that the child will not eat the ordinary vegetables, with perhaps the excep- tion of potato; that he is inordinately fond of sweets; that he abhors fat, with the possible exception of butter. Sometimes, but less often, the child will eat certain vegetables in excess, * In the preparation of this section the writer acknowledges his obligations to Doctor Adele Jaffa and Doctor Langley Porter. See also the chapter on "School Feeding," by Doctor Bryant. THE HOME HYGIENE OF CHILDREN 69 to the exclusion of meat or other forms of proteids, and often he will utterly refuse to drink milk. In the main, however, the malnourished school-child is addicted to excessive carbo- hydrates (starches and sugars), and consequently suffers from starch indigestion. This form of intestinal indigestion usually leads to headache, gas formation, diarrhea, or less often constipation. He is really a victim of one form of auto-in- toxication, or self-poisoning. With the cause or causes once discovered, the cure is often rather easy. It goes without saying that the fault is in many instances the parents' rather than the child's. Faulty food habits have been condoned if not actually encouraged, until the unfortunate child has become a victim of his vicious habits. Neither scolding, nagging, nor persuasion will avail much, but about the only reasonable course to pursue is for the parent t(^ learn what the proper diet is for a child at different ages and then see to it that he gets the diet suited to his needs. Place the proper foods before the child and then let him eat or go without. Or- dinarily these foods will consist of just what the normal adult members of the family eat, with the exception of tea and coffee.^ When such a child really becomes hungry he will eat good food of the usual varieties. Firm but kind and patient discipHne will always be necessary to secure satis- factory results. Eating between meals Is to be discouraged, at least until the child has established normal food habits. But once he has done so, there can be no valid objection to giving him real food when he is truly hungry. It must not be forgotten, however, that real food does not consist of candies and other sweets, and that in any case it must be given in reasonable moderation. As for water, neither child nor adult can drink too much, provided only that it is not taken to wash down unmasticated food. The proper mastication of food is a habit which should be acquired very early, but it will usually be observed that most children, malnourished as well as 1 More than 50 per cent of school-children drink coffee, and often to excess. 7© EDUCATIONAL HYGIENE others, need definite instruction in this respect. The ques- tion will naturally arise at this point as to what is the proper diet for children of different ages. To answer this question adequately would be quite beyond the limitations of this chapter, but as a very general guide the following suggestions 'are given: For a Child Four Years Old. — The child is to have not more than three meals a day. Not more than one pint of milk should be given to drink, another pint may be given in the form of junket or custard or milk soup during the day. Breakfast. — ^An e^gg, with some thin ■ sHces of bacon; crisp toast and butter; some apple-sauce or stewed fruit or ripe fruit peeled; if the child is constipated, give honey, stewed prunes, or fruit jelly instead of butter on the toast; to replace some of the toast, give such cereals as Force, Shredded Wheat, Triscuit, or Toasted Rice Biscuit. Midday Meal. — Small portion of broth (veal, mutton, or chicken) or milk soup with vegetables pureed into it; small amount of simply cooked meat, no fried meat; at first, meat should be finely chopped and mixed with baked potato or boiled rice or fine Italian paste, upon which may be put some blood gravy or broth; white fish may be given occasionally; a green vegetable which has been put through a fine sieve, preferably cauliflower, green peas, green beans, spinach, or asparagus tips; crisp crackers or toast with butter. Dessert: plain pudding, or stewed fruit, or junket, or blanc-mange, or plain sponge-cake or stale lady-fingers with fruit juice. Supper. — Milk soup with some vegetables pureed into it, or some bread and milk, or junket, or custard; occasionally ice-cream may be given if it is of known quality. Milk jelly or egg jelly or fruit jelly made according to the recipe. Foods for Older Children. — ^After a child reaches the age of five he may ordinarily eat the same food as adults, if it is well selected, with the exception of tea and coffee. Desirable foods include: clean milk, well-cooked cereals, crisp bacon, fish, broiled steak, soups, soft eggs, thin toast, THE HOME HYGIENE OE CHILDREN 7 1 bread and butter, corn bread, crackers, fruit of nearly all kinds, both fresh and cooked, especially baked apples and stewed prunes. Fat in some form is absolutely necessary. This is best taken in the form of butter or oUve oil. Often it is necessary to disguise the fat in some special palatable form. Undesirable foods include : fried meats, veal in any form, salt pork, tea, coffee, hot bread, doughnuts and hot cakes (except in strict moderation), all greasy foods, in general all fried foods. Bananas are rather hard to digest unless baked. Fruits with many seeds, such as raspberries and blackberries, are not desirable for young children. Meals consisting of a deficient variety must be avoided, such as coffee and bread, bread and syrup, potato and bread, or meals which include only starchy foods. There is no objec- tion to water with meals unless it is used to wash down in- sufficiently masticated food, but iced water is best avoided except in very hot weather. School-Children. — In considering the question of how best to feed school-children, it must not be forgotten that the period of school fife extends over a number of years, and that in the schoolhouse we invariably find children of different stages of growth and development and children with very widely different needs. It would be impossible for any di- rections, however lengthy, to cover properly or adequately the requirements of all children, even at the same stage of their lives, with their widely varying tastes and idiosyn- crasies and their special constitutional tendencies. No diet list, however carefully chosen, could be used with good results for all children of any one age, much less for children of all ages. The only hope of a proper solution to this many-sided problem lies in creating in the minds of those people who have the catering in charge, an intelligent understanding of the uses of the various foods, and trusting the rest to their dis- crimination. Many rules of dietetics are only of service when applied by the person who has had experience with 72 EDUCATIONAL HYGIENE the particular child in question, and possesses a thorough understanding of its special needs. Only wide general prin- ciples are universally applicable. Kinds of Foods. — The scientific principles which underlie the proper selection of foods are few and easily understood. Chemical analysis has shown us that all foods, no matter how simple or how complex they may appear, contain only four classes of materials. Each class has many subdivisions containing an infinite variety of chemical compounds. But nothing has been found that cannot be classified under these four heads. Two of these are mineral matter and water, which are not necessary to consider in our present discussion. That leaves us only two main classes of nutrients to under- stand and to deal with — the nitrogenous group and the non- nitrogenous. The question is naturally asked: "Of what use is this classification? In what way does it help?" The answer is at once plain when we consider that these two classes have entirely distinct and separate offices to perform in the body. The protein or nitrogenous group builds tissues — the bones, muscles, nerves, internal organs, etc. It supplies material both for the building of new tissues, as in growth, and for the repair of the old. The non-nitrogenous group furnishes heat to keep the body warm and energy or power with which to perform our work. This material may be stored up in the body for future use in the form of fat, but can never be used to build real or deep tissues. Fat in the body is Hke coal in the basement, ready to be converted into heat and energy. Our need of it after we have accumulated enough fat to round out our frames is in direct proportion to the weather and to the amount of energy we expend in both voluntary and in- ■ voluntary functions. The Httle girl who sits in a warm room " and reads and sews does not need as much as her brother who plays ball in the cold winter air. That brother is the best example of a healthy creature in need of plenty of nourishing food, that we could well find, THE HOME HYGIENE OF CHILDREN 73 especially if he is in his teens. There is every kind of a call for food that could be found under normal conditions. Who else in the family is growing so quickly, who else lengthen- ing out and widening every bond and tissue of the body? The baby of the family may be doing that, but she is not studying or exercising, neither is she under nerve strain. The father may be using his brain in his work and may be under nerve strain, but he is not growing and may not be exercising very much. Rarely indeed do we find a human creature whose demands for food materials are so many and so urgent as those of the boy in his teens. If the problems involved in the proper feeding of a grow- ing boy be solved first, the results may be modified for other children, up and down the line, according to their ages and conditions, and their individual needs. We have come to know a great deal about the food for the first period of rapid growth, that of infancy, since the chemical analysis of mother's milk has furnished us with a perfect model upon which to base our selection of substitutes when the natural food fails us. But the second period, that comes, early in the "teens," is not yet so generally understood. During these years of adolescence, when Nature is making every effort to develop and round out the perfect individual, she needs all the help we can give her. She cannot build if we do not supply her with material, but she can, and often does, build one part at the expense of another. It is a com- mon thing to hear a mother say, with reference to a child, that he "outgrew his strength." Translated, that expression means that the child did not get, or was not able to use, sufficient food material to supply the needs of the entire organism. It is the second and last chance that Nature has to remedy defects in the constitution, and she makes a desperate effort to accomplish it. The results of improper feeding at this time cannot be easily remedied. It is often a case of "now or never," and the work that is not done in this second formative 74 EDUCATIONAL HYGIENE period of Kfe may not be done at all. Weak spots in the building will always remain weak spots, and we should not run any risks at this time. Many of the nervous symptoms usually observed during the period of adolescence are not necessary or normal. The nerves suffer from insufficient and improper nourishment, as well as from other wrong and un- hygienic conditions, during the early ^' teens." The Kind of Food Needed. — ^When the importance of proper nutrition is once fully realized, the first question asked is: *'How can we supply it — what kind of food does the child need ? " The answer is very plain. He needs all kinds, and in sufficient quantities. At first glance it may appear that no real directions have been given for the dietary of a growing child. ''Feed him everything. He eats everything now." But perhaps a second and more careful glance will disclose errors. True, there is no one great radical change advocated, but it is the accumula- tion of all the little things that makes the real difference. Nature works slowly. In order to help her we, too, must work slowly and patiently with carefully thought-out meals, con- scientiously persisted in for years, if we expect to see results. Some apparently slight change made in each meal three times a day for three hundred and sixty-five days in the year would make a great difference in the end. Suppose, for instance, it were decided to add "growing material to the dinner," other than the meat. Suppose the meat soup were replaced occasionally by a bean or pea soup or by one of the various milk soups, and that on other days the potatoes were replaced by rice or macaroni and peas used more frequently than other vegetables, and that on others the pie were replaced by custard or soft home-made candy, would not that alone make considerable difference at the end of the year? And if for breakfast oatmeal were used instead of wheat or wheat foods, breakfast cheese for those who do not eat meat or eggs, milk or cocoa instead of coffee, milk toast in- THE HOME HYGIENE OF CHILDREN 75 stead of dry toast, etc., would not the sum total of the year's breakfasts count? The Lunch. — The meal that usually requires the most radical reconstruction is the lunch. Between the children that rush home and swallow a hasty bite of unsuitable material and hasten back for fear of being late, or else to play with the other children, and those who carry a cold lunch composed of food that would not furnish very much nourishment, even if it were not difficult to digest, there remain probably only a small percentage of children whose lunches are suited to their needs. This is a great drawback in many cases, for it is often the one meal where individual requirements can be most easily attended to. To sHght one meal out of three is to slight a very large portion of the child's opportunities for nourishment. ^ The limch can never be considered alone. It must of necessity depend largely upon what is given for the other meals of the day. It is really not a difficult task to make one meal complementary to the others when the habit of mind is once estabHshed. Having acquired a permanent mental picture of the food groups and knowing the special requirements of the child, it becomes an easy matter to arrange a lunch of nourishing materials not supplied by the other meals. Does he eat heartily of meat at night and perhaps have some for breakfast? The lunch should contain "non-meat protein." Does he prefer the vegetables and dessert at dinner ? Give him meat at noon. Do the other members of the family object to oil or fat? See that the growing boy gets peanut butter or mayonnaise sandwiches, etc., for his lunch. Is his breakfast Hght? His lunch should then be very hearty. Is he tired at dinner-time and sleepy ? His most nourishing meal should be at noon. Does he refuse eggs for breakfast? He may reHsh and digest them well for lunch, and thus it goes. It would be impossible to cover the ground of the various elements involved in the decision. In general, the lunch, as well as the other meals j should be 76 EDUCATIONAL HYGIENE as simple as possible in order to supply the required nourish- ment. The work of handling the quantity and kind of food needed to build up the physical frame and keep the organism in good running order is quite enough strain on the digestive organs, without hampering them with unnecessarily compli- cated or difhcult dishes. As a rule, made dishes, fried food, "warmed-overs," smoked and salted meats, thickened gravies, etc., should not often be given, even to the healthy child, and never to one whose digestion is weak. Food that is difficult of digestion may often be handled perfectly on occasions, when frequent repetitions would cause disastrous results. It must never be forgotten, in this connection, that "what is one man's meat is another man's poison," and careful observation is the only sure guide. Main Points of Feeding. — The main points to keep in mind may be summarized as follows: Be persistent in using foods from each group. Be sure to use plenty of "growing material" without go- ing to an extreme with meat. In using meat substitutes remember: {a) That milk is the most valuable one to use if it agrees, and that skim-milk is just as rich in growing materials as whole milk. (&) That eggs come next in order. {c) That nuts must be ground or very well chewed in order to be properly digested and assimilated. {d) That soup meat has all the growing material left in it, and none of the deleterious elements, and is a cheap and excellent food and can be made into appetizing dishes for breakfast or lunch. (e) That oatmeal, macaroni, rice, and gluten flour have more growing material than potatoes or white flour. (/) That in using nuts, cheese, and beans the question of individual digestion must dictate the choice. In comparing the prices of the different foods, we should consider the amount of nourishment they contain as well as the price per pound. THE HOME HYGIENE OF CHILDREN 77 Eating between meals should only be allowed where it is prompted by hunger and not by a desire for goodies= Only easily digested foods, as crackers and fruit, etc., should be given at such times. The nourishment should be fairly well distributed among the three meals, and not crowded mainly into the dinner. The weekly dietary should contain considerable variety, but the single meal not too great a mixture. Study the effects of combinations before discarding any food from the diet list. Never crowd nourishment nor risk indigestible food on occasions of excitement or fatigue. After indulgence in an unusually heavy or taxing meal see that the next one is unusually simple. When protein is added to the dinner for the sake of the children, the "grown-ups" may eat less of the meat. The necessity for careful mastication is a lesson that children can- not be taught too early. If, in spite of reasonable food habits, a child remains badly nourished, one must seek for deeper causes, in which the aid of a skilful physician will ordinarily be required. Perhaps the child has a local form of tuberculosis or is a sufferer , from malaria (in malarious countries); perhaps he is suffering from fatigue, which again may be caused by a great variety of conditions; or he may have adenoids, or diseased tonsils, or require circumcision. But in most cases careful attention to the bowels, to fresh air, good food, plenty of sleep, to firm discipline and wholesome and interesting play exercises, will solve the problem of the mahiourished school- child. Ventilation. — It would seem that no particular attention need be called to-day to the necessity for good ventilation in the home. The following figures, however, taken from the writer's personal data, will demonstrate that ventilation has as yet not received the attention it deserves in a great many families. 78 EDUCATIONAL HYGIENE Of 68 1 children questioned in fifteen Minnesota cities, 385, or a little over 50 per cent, sleep in unventilated bedrooms. In Chisholm, Minn., of 425 children questioned, 237, or about 50 per cent, confessed to no bedroom ventilation. In another Minnesota city, of 272 children, 176, or about 64 per cent, have no ventilation in the bedroom. These figures correspond closely with those obtained by the writer in other places. Even in Berkeley, California, where the climate is mild, it appears that about 25 per cent of school-children are denied fresh air at night. Poor ventilation affects the health not so much because of chemical changes in the air breathed in a close room, but mainly because in such rooms there is abundant opportunity for infection with various contagious diseases. Yet any one who has enjoyed the privilege of sleeping out of doors, or in an open-air room, knows the exhilaration which is sure to follow, and such people invariably notice the ill effects of a sudden change to indoor sleeping. Poor ventilation, in some way not altogether understood, reduces general vitality, as well as resistance to specific infections, but it may be said that these results are due largely to a high degree of hiunid- ity and lack of movement of air currents. It ought not to be necessary to affirm that fresh air, day or night, injures no one, not even the most delicate; that, on the other hand, it is one of the chief remedies for the cure of tuberculosis, pneumonia, neurasthenia, as well as some less definite general disorders. Headache. — That headache is a common disorder of chil- dren is clearly shown by figures taken from the writer's data. In Owatonna, Minn., 24 per cent of 570 children were found to be sufferers from chronic headache, that is, headache at least as often as two or three times every week, and in many cases every day. In thirteen other Minnesota cities 1,070 children were questioned and of these 23.9 per cent were discovered to have frequent headache. Other figures give similar results, and it is therefore safe THE HOME HYGIENE OP CHILDREN 79 to say that about one-quarter of the children of school age are afiflicted with much headache. The reasons for this rather serious handicap are not en- tirely clear, but in the main it may be said that it is usually due to one or more of the following conditions: (i) Constipation. (2) Eye-strain. (3) Poor ventilation of home or school. (4) Fatigue. (5) Auto-intoxication or intestinal indigestion. The main causes once being understood, it is usually not a difficult matter to correct and control them. Constipation calls for careful inquiry into proper diets, and adequate and abundant use of drinking-water. Eye-strain calls for a visit to the oculist and the use of properly fitted glasses. Do not patronize opticians for vision examinations. Bad air should not be tolerated in any home or school in any climate under any conditions. Fatigue needs careful investigation. The child may be overstrained nervously either at home or at school, and in either case the advice of an intelligent physician will be needed. Auto-intoxication is ordinarily due to starch-indigestion or other diet errors, or to chronic constipation. In respect to constipation, one should understand that the use of cathartics except as temporary expedients is to be strictly condemned. Most cases of constipation may be rather easily corrected by the use of a mixed diet including some coarse foods and plenty of water, combined with vigorous exercise. Massage and other special exercises of the abdominal muscles are often useful. Disorders of the Eyes, Ears, Nose, and Throat. — These disorders are very serious and important, but cannot be given extended discussion. Parents may well consult Terman's "The Hygiene of the School Child" or other good books on these vital topics. 8o EDUCATIONAL HYGIENE Attention may, however, be called to the fact that fre- quent sore throat is an almost infallible sign of diseased tonsils; that rheumatism, tonsilitis, and St. Vitus's dance are closely associated; that adenoids cause mouth breathing, crooked teeth, nasal voice, earache and discharge, and even running ear, and deafness; that pecuHar postures of the head, red eyes, crossed eyes, painful eyes, and granular lids are often caused by defects of vision. Blurring of the print and double vision are sure indications of serious eye trouble.* The parent should also be reminded that defects of vision require the best skill of a reliable oculist and that the "opti- cians" are usually very unreliable in their eye work. The Teeth. — ^At least 65 per cent of children between five and twelve years of age have seriously defective teeth. Often the proportion is much greater. Defects of the teeth are not only offensive to the aesthetic sense, ■ but they produce many bad results to the general health both directly and indirectly. It is only necessary to state here that the first teeth require just as careful attention as the second, and, what is more important but not as well understood, that decay of the teeth, both first and second, is largely preventable by proper hygienic attention. Preventive dentistry is far more important and much less expensive than corrective dentistry. Deformities of teeth and jaws should be corrected early and not allowed to go uncorrected until the bones of the face are completely developed. This is a point which even some dentists and physicians seem not fully to understand. Conclusion. — A very great deal of attention is paid by the national and local governments and by farmers every- where to the proper upbringing of hogs, cattle, horses, sheep, and the like. MilHons of dollars are annually spent to pro- mote the health and proper nurture ®f these domestic brutes, » Teachers will find much help in Cornell's "Health and Medical Inspection of School Children," and in the author's "Health Index of Children," and Hoag and Terman's "Health Work in the Schools." I THE HOME HYGIENE OF CHILDREN 8 1 and a technical science has been developed. Many farmers rear their live stock better than they do their own boys and girls. City parents are about as ignorant. We bespeak for the children the earnest attention and studious care of their parents. The hygiene of children may prove as interesting to learn as bridge whist or the prevention of hog cholera. CHAPTER V PUBLIC CO-OPERATION FOR SCHOOL-HEALTH AGENCIES The Necessity for Public Co-operation. — The reasons for asking public aid in the development of school hygiene arise partly from the conditions under which knowledge is dif- fused and partly from the nature of our democratic institu- tions. The discoveries of new appHcations of scientific prin- ciples are first made by individuals, and they spread to other individuals and groups only through the slow process of publication in periodical, pamphlet, or book. The use of vacuum-producing machinery, for example, for the removal of dirt from floors, is a process which was known to a few some time before it reached school ofiicials generally, and doubtless there are some who even yet are not well informed about it. The latest word in ventilation has reached probably only the immediate circles which surround the scientists who are working upon this problem. Since municipal depart- ments do not ordinarily provide facilities for gaining infor- mation, school officials are obHged to depend upon outside agencies for much of the data regarding the most recent methods if they would keep abreast of the ever-advancing waves of health knowledge. But this is only a minor occasion for seeking outside co-operation. The Inertia of Democratic Institutions. — Since among democratic institutions modification of function, theoretic- ally and practically, generally results from the impact of pubKc sentiment, the adoption of new methods must proceed much more slowly in a democracy than it does in a mon- archical form of government. But if the knowledge of new 82 4 PUBLIC CO-OPERATION 83 hygiene methods spreads slowly, a process even more dila- tory is the assumption of such methods as regular functions by our public institutions. An illustration is found in the case of school medical inspection. In this country its in- ception took place in Boston in 1894, and in 191 1, according to statistics^ compiled by the Russell Sage Foundation, only 443 cities, or 43 per cent of the 1,038 cities reporting, had adopted medical school inspection. And of the 443 only 102 had put in school nurses, and only 69 were employing school dentists. Again, boards of education, like other governmental bodies, are not only slow in initiating novel methods but they are also slow in extending them to all parts of the system. For example, many cities have estabhshed some open-air schools but few if any have as yet made adequate provision for all the anemic or pre-tubercular children now attending their classes. The explanation is to be found in the fact that boards of education cannot move, even when the legal author- ity is clear, without adequate funds, and the appropriation of funds is ultimately dependent upon pubHc approval. Since school officials are Hmited in their power to arouse pubHc sentiment in favor of new machinery, they are obliged to de- pend upon assistance from outside agencies. These can co- operate both in piecing out the partially adopted activity and in developing the pubHc support necessary to place it upon an entirely adequate basis. The Service of Criticism. — It sometimes happens that medical inspection which has been long maintained becomes inefficient. The school authorities may suspect the existence of unsatisfactory conditions and yet not have, or be in the position to obtain, the evidence necessary for their correction. Here again is afforded an opportunity for some friendly ex- ternal organization to carry on an investigation which, be- cause of its foreign auspices, will be considered more impartial than an investigation carried on by the board of education » "Medical Inspection of Schools," Gulick and Ayres, p. 15. 84 EDUCATIONAL HYGIENE itself. Again, in the administration of hygiene activities overlapping sometimes occurs, and thus a condition is brought about which can be remedied only by a third party. Only under rare circumstances can one department co-ordinate its work with that of another without the intervention of all unbiassed umpire. Public Co-operation Increasing. — In the early days when leadership in school matters was more largely left in the hands of prominent citizens, often men of learning and standing as educators, the co-operation of outside agencies was not only not sought but even considered meddlesome. With the in- creasing public concern regarding child welfare, however, and with the development of larger initiative on the part of the school officials themselves, a different order has come about. To-day the school reports from the more enterprising cities are replete with acknowledgments of indebtedness to outside agencies for various kinds of valuable assistance. ^ The Differentiation of the Public. — For the purposes of this chapter the pubHc is considered to include all those per- sons and private bodies which are not under the control of the school authorities. This public, to which school officials may look for co-operation, is divided into individuals and voluntary organizations, and it is from the latter bodies that the most efficient help ordinarily comes. The reason for this latter fact is that voluntary organizations represent and give expression to particular interests. In the act of formation itself a selection is automatically made of those individuals who are either specially interested or proficient in the activity for the performance of which the group was originally called together. The voluntary society is, indeed, a tentative variation in the structure of the social organism whereby certain of its elements combine to perform a new function. If this special activity prove to have a preserva- tive value society nourishes it, provides it with bone and sinew, and finally articulates it with its other fixed institu- tions. » See Cabot's "Volunteer Help to the Schools." PUBLIC CO-OPERATION 85 The Varieties of Private Organizations. — When grouped according to function the various voluntary and quasi-public associations to which school officials may resort for health assistance fall into seven fairly distinct classes, although there is considerable overlapping, many bodies carrying on activ- ities which fall into two or three different categories. (i) The first group is the one upon whose achievements all the others are dependent. It is composed of the organiza- tions which develop new knowledge. Their workers are scientists who are working in the van of advancing civiKza- tion. They include such bodies as the Rockefeller Institute, the Carnegie Foundation, United States Bureau of Health Service, faculties of medical colleges, and other associations which are composed of physicians, sanitary engineers, and research specialists in chemistry, physics, and ^Jie biological sciences. (2) The next group is composed of the bodies whose ex- perts develop through statistical methods the facts regarding the existence of disease, the data of which show the need of improved health methods. Such a body is the Committee of One Hundred on National Vitality of the American Asso- ciation for the Advancement of Science. In this field also the various insurance companies are, through their actuarial de- partments, doing most important work. (3) In the third class fall the organizations which inves- tigate the various methods by which scientific principles of hygiene are put into effect. They examine the results ob- tained under different forms of public administration and make their researches available in pubHshed reports. Among the organizations^ performing this function may be men- tioned the National Association for the Study and Preven- tion of Tuberculosis, the Russell Sage Foundation, the Life Extension Institute, the National Association for the Study and Prevention of Infant Mortality, and the United States Public Health Service. * For a more comprehensive list of these various organizations see " Educa- tional Problems," by G. Stanley Hall, Chapters XI and XII. 86 EDUCATIONAL HYGIENE (4) Associations for propaganda, which stimulate and direct campaigns for the adoption of hygiene activities, con- stitute the next class. Some of these have already been named in the preceding category, since they perform both of these functions. A notable instance is to be found in the national and local bodies which are pushing the fight against tubercu- losis. Other examples are the Playground and Recreation Association of America, the Woman's Christian Temperance Union, the General Federation of Women's Clubs, National Conference of Charities and Correction, and similar organi- zations.^ (5) The local charitable and philanthropic organizations, medical and dental societies, women's clubs, chambers of commerce, and social settlements indicate the character of the next class. These bodies assist by promoting the estab- lishment of hygiene activities in local institutions and by ad- ministrative co-operation in incipient and inadequate sys- tems.. They are often the local groups through which the national bodies mentioned in the preceding category perform their work. (6) Bodies such as the Public Education Association or the Bureau of Municipal Research which do local research work and assist not only in the strengthening of municipal depart- ments but also endeavor to help in the co-ordination of their activities, comprise this group. (7) The last group is composed of mothers' clubs, parent- teacher societies, ward improvement and taxpayers* associa- tions, and other bodies of citizens which maintain a receptive attitude toward health information. These are the groups through which school authorities and other interested bodies can accomplish a diffusion of health facts so as to develop a supporting environment for the school hygiene activities. Information about Hygiene Methods. — The task of keep- ing in touch with the latest school hygiene data is greatly 1 See Report of the Commissioner of Education, 1912, vol. I, "Typical Health Teaching Agencies of the United States," by F. B. Dresslar, pp. 299-358. PUBLIC CO-OPERATION 87 facilitated for school officials nowadays, by the vast numbers of bibliographies and the pamphlets of the propagandistic organizations, and the various government bulletins which the Hbraries are compiling and collecting. The Federal Bureaus of Labor, Education, and Children, and the United States Public Health Service, are constantly sending out pamphlets bearing upon health topics. But the school super- intendent has not only to keep himself informed; for the successful carrying out of his plans it is necessary that the members of the board of education and the principals and teachers constituting his staff should likewise be well informed. For this education in health methods within the school sys- tem much help can be obtained from various volunteer or- ganizations. Lecturers may be obtained from local medical and dental societies, and the staffs of the various propagan- distic organizations working in the health field. Many of these societies have lantern-sHdes or motion-pictures which can be borrowed for public meetings. The platform discussions may also be supplemented by carefully chosen and tactfully dis- tributed pamphlets. Information should be sought, however, not only concern- ing the most improved health methods in other cities, but facts should also be obtained about the sanitary conditions in the superintendent's own system, as without this informa- tion thoroughly efficient administration cannot be maintained. These data the superintendent can to a certain degree obtain for himself; it all depends upon the research facihties at his command. Often he is obliged to call upon some outside agency either for assistance in carrying on an investigation or to take entire charge of one. Since in the latter case, through the mere bringing of a voluntary organization into intimate contact with the school system a certain proportion of the outside public is caused to become vitally concerned about school conditions, this topic affords an appropriate transition to the next subject that requires our consideration. Creating Public Sentiment. — The importance of seeking 8S EDUCATIONAL HYGIENE aid from outside organizations having a large and influential membership in the task of making sanitary surveys is immedi- ately seen when it is realized that the facts as to bad conditions are of little value unless they can be followed up by adminis- trative changes which will remedy and prevent the recurrence of the objectionable conditions. When the members of the woman's club, for example, go about from school to school filling out a sanitation or other questionnaire, they actually enter the environment in which the children of the commu- nity spend a large portion of their days. If this environment is not healthful they are immediately filled with an ardent desire to change it, and thus a vast amount of public senti- ment is automatically created and set to spreading. Miss Elsa Denison's ''Helping School Children" — a most suggestive treatment of the whole subject of public co-opera- tion — describes in Chapters VII and VIII many kinds of assistance which women's organizations are rendering school officials. Mention is made of the investigation of the Boston public schools by a branch of the Association of Collegiate Alumnse, which resulted in the formation of a new school code; also of the survey performed by the Arundel! Club in Baltimore, and by the Public Education Association in Provi- dence. The extensive questionnaire used by the New Jersey Federation of Women's Clubs in its State- wide study of school conditions is also set forth. Getting the Evidence. — In meeting the necessity for concrete, objective evidence, when seeking to bring about extensions or improvements in hygiene activities, school officials have received much assistance from the local medical and dental associations. In Philadelphia Doctor Samuel W. Newmayer developed some data showing the need of the co- operation of school nurses in medical school inspection. His figures^ show that in the four schools where the inspector 1 Reported in the Proceedings of the Fifth Annual Congress of the American School Hygiene Association under the title, "Evidence that the School Nurse Pays." These results are also printed in "Medical Inspection of Schools," Gulick and Ayres, pp. 66-67, revised edition. I PUBLIC CO-OPERATION 89 was assisted by a nurse 89 per cent of the recommendations were acted upon, whereas in an equal number of schools where the medical inspector was unassisted only 24 per cent of the recommendations were followed by action. In Philadelphia also a very effective argument for dustless cleaning in pubHc schools was developed through a tabulation by months of contagious diseases among children. The ev- idence was graphically shown by means of various columns proportioned to the respective monthly figures. The very low columns during the summer months, the open-window period, and the overtowering columns of the winter and early spring months when the windows are closed and the dust-carried germs have undisturbed sway, constitute an illu- minating lesson. There are few cities where it would be difhcult to find some organization or individual who would assist a superintendent by delving into the local t'ital statistics and compiling a similar table. During a mouth hygiene campaign in Cleveland directed by national and local dental associations, over 20,000 pupils were examined and in 97 per cent more or less faulty mouths were found. Facts such as these have a convincing power and a publicity value that is never possessed by any single man's convictions or opinions, however well stated or whatever his reputation. A committee of the Public Education Association of New York City recently employed a specialist to make mental examinations in connection with the work of the ungraded classes in the public schools. On the basis of these examina- tions a reorganization of this department was effected. Many other instances of this form of co-operation could be adduced. Publicity for the Facts. — ^After developing the facts needed to reinforce a request for the introduction or extension of medical inspection, or of any other hygiene activity, a great deal of thought can profitably be given to the best way of causing these facts to reach the pubhc. A very common go EDUCATIONAL HYGIENE method is by means of the superintendent's annual report. A suggestive example is found in the Northampton, Massa- chusetts, school report for 191 2. The superintendent desired a school nurse, and by way of bolstering his argument he mentions some actual cases which came to his attention during a single visit to one school: An intelligent parent who does not agree with the head of the Boston dispensary that two- thirds of the so-called physical defects of children are caused directly or indirectly by decayed teeth allows a child to be poisoned by decaying teeth on the theory that the first teeth being temporary do not need any attention; a hard-working mother who does not know what to do to prevent scabies from spread- ing in her family allows her children to run wild and blames the schools for excluding them; indulgent parents allow a nine-year-old boy to drink six cups of coffee a day, then wonder why he fails to do his work at school and is so nervous that at times he has no self-control; a mother should have her attention called to a vicious habit which a wide-awake teacher has discovered in her eight-year-old boy; a non- English-speaking mother needs help in freeing her children's heads from parasites, as she cannot read the directions sent her from the school. But, since in school reports health matters must necessa- rily be mixed with many other topics, an even better method is available when a volunteer agency makes the investiga- tion, and that is to let it pubHsh its own report. Thus the evidence goes before the pubKc in a conspicuous manner and under supposedly impartial auspices. In the inquiries un- dertaken by the Public Education Association, Bureau of Municipal Research, or the Woman's Club it is customary to pubHsh the results in striking, individual reports. Exhibiting the Facts. — One of the most effective instru- ments for developing public-health sentiment employed in recent years is the child-welfare exhibit, and there are many instances where such exhibits have been arranged by women's clubs, local bureaus of municipal research, and other associa- tions. Detailed information upon exhibit methods can be obtained from the Department of Surveys and Exhibits of the PUBLIC CO-OPERATION 9 1 Russell Sage Foundation, the National Child Welfare Exhibit Committee, and the New York Bureau of Municipal Re- search. Public Meetings. — In campaigns for open-air schools the services of publicity experts can often be secured from the local society for the prevention of tuberculosis. Through long experience with the problem of awakening the public to active measures against the white plague, the people connected with this organization have worked out very successful methods. Campaigns of considerable effectiveness can also be carried on with the aid of the local woman's club, chamber of com- merce, medical associations, and parent-teacher organiza- tions.^ An instance of the boost to school hygiene that is accomplished through the occasional meeting is found in the informal conference and reception held under the auspices of the Social Science Department of the Peoria (Illinois) Women's Club in honor of Miss Crandall, of New York, who spoke on "New Aspects of Visiting Nurse Work," emphasiz- ing the importance of the pubHc-health nurse. To this con- ference the department invited the members of the Visiting Nurses' Association, Registered Nurses' Association, the Mothers' Club, and the Teacher and Kindergarten Clubs. Very often through the social-service departments of the local rehgious denominations, sermons upon the desired topic can be secured in many of the churches. The Newspapers. — One of the chief values of the public meeting as an instrument for developing public opinion is the pubHcity which is thereby gained through the news- papers. To meetings at which prominent persons are brought together, both on the platform and in the audience, columns of space will be devoted, which are more valuable than paid advertisements. Likewise, through the judicious appoint- ment of important persons on committees and the reports of meetings of committees, much helpful publicity can be 1 See "Wider Use of the School Plant," by Perry, Chapter XXI, "Meetings in School Houses." See also Chapter VII. 92 EDUCATIONAL HYGIENE gained through newspaper accounts. The amount of space devoted to meetings can generally be augmented by a careful preparation for the reporters' needs. If copies of the speaker's address and lists of the committee memberships, and other informative documents, are prepared in advance for the news- paper men, their reports are usually not only longer but also much more accurate. As indicative of the value which newspaper editors at- tach to school items, it may be mentioned that in 191 1 the Bureau of Municipal Research^ clipped from twenty news- papers over a thousand news "stories" and editorials on school matters. Many superintendents are now taking ad- vantage of the opportunities afforded by the press in the con- scious development of a public sentiment favorable to their special projects. In accordance with a well-thought-out plan they are systematically selecting happenings in the school system in which the pubHc has a legitimate interest and are turning these items over to the reporters. In some cities, when the annual school report is ready the superintendent hands it out to the newspaper men first and helps them to find its most significant portions. If he has adopted a new school policy of broad import, he seeks a personal interview with the editor and endeavors to get the matter put accurately and in- telligently before the public. If he has completed an investi- gation which has revealed some significant and important facts, he turns his material over to some special writer. If a voluntary organization has rendered an important service, he sees that a definite account of it reaches the news columns. By thus facilitating the acquisition of school news on the part of the press he secures not only wide publicity for school matters but also a favorable attitude toward his work on the part of the most influential organ of public opinion. The Demonstration. — ^A method of developing influential support which seldom fails is that of the demonstration. 1 " Outside Co-operation with the Public Schools of Greater New York," by the Bureau of Municipal Research, p. 12. PUBLIC CO-OPERATION 93 Medical inspection in the schools of New York City was started in 1897, but during the first five years there was no school nurse. In 1902 nearly 18,000 children were excluded from the schools, and the classes were in some cases so de- pleted that it was difficult to carry on school work. To meet the serious situation thus created, the Henry Street Nurses^ Settlement offered the services of a school nurse for one month. At the end of that time the results of her work were so ob- viously beneficial that support was immediately gained from educational authorities, the board of health, and the pubHc for the employment of school nurses.^ Similarly, in Philadelphia the Visiting Nurses' Society loaned a trained nurse to the city to show the value of this adjunct to medical inspection. Like demonstrations have also been carried on in favor of medical inspection through the co-operation of the local associations of physicians and dentists. Securing Codes and Regulations. — The proper result to follow revelations concerning insanitary conditions is the passage of measures or the establishment of activities whereby, it is hoped, the repetition of the evils discovered will be avoided in the future. Thus, through the investigation by the Col- legiate Alumnae, already referred to, Boston received a new school code. But the results of an investigation, a survey, an exhibit, or a campaign of publicity will not automatically translate themselves into new regulations. Unless some one follows them up, the public sentiment they arouse will die away without concrete results. There are plenty of publi- cations which describe the best forms of codes to meet the various exigencies in school hygiene, but they do not often give information as to the best way of manipulating the local social forces through the marshalling and concentration of which the passage of the code will be secured. Every resolution, ordinance, code, or statute has to receive the ap- proval of a certain majority, no two members of which have ^This first municipal school nurse has written a chapter for this volume. — Ed. 94 EDUCATIONAL HYGIENE the same view-point, S)nnpathies, or information, but each of whom can be moved by some influence or other, and not a sordid one at that. The problem is to find the effective in- fluence and to bring it to bear at the right time upon the right person. With one individual it will be more evidence of the actual physical need, and in the case of another evidence of the public demand, or the suasion of an influential friend. The skilful superintendent will make a careful canvass of the opinions of the members from whom he is seeking legis- lation and tabulate the obstacles which stand in the way. He will then deploy the forces at his command with a view to overcoming them, in the same careful way that the general plans a siege of a city. Oftentimes there is to be found in the local civic or philanthropic circles some live secretary who is also something of a poHtical tactician, whose services can be secured for assistance in this work. The school board of MinneapoHs called for a commission of local medical men to advise with the board on all questions of school hygiene. This commission prepared a comprehensive report covering all phases of the subject, and has manifested a willingness to remain as a permanent advisory body. There are few local- ities in which similar co-operation cannot be obtained from public-spirited physicians, dentists, and oculists. Co-operation in Administration. — ^The British Board of Education urges local school authorities to secure the utmost possible degree of co-operation from hospitals and clinics in their physical ministrations to pupils; and the same practise is being followed in many places in the United States. When medical inspection is first inaugurated, it often occurs that sufficient funds are not provided to enable the examination of all pupils with adequate frequency or thoroughness, so that outside assistance is still greatly needed. Frequently a school nurse is not provided, or funds will not allow the pur- chase of the necessary dispensary articles. An open-window schoolroom may be provided but no food or the kind of garments required for fresh-air work during the cold months. PUBLIC CO-OPERATION 95 These shortcomings create an opportunity for outside co- operation which is being very generally utiHzed throughout the country. From Medical Associations. — Prominent in this kind of co-operation are the county or local medical associations and the public-health association. In Kenosha, Wisconsin, eight physicians connected with the local medical association gave their services for three years in the performance of an an- nual medical inspection of school-children. In Rochester, New York, the Public Health Association furnishes food and equipment for the open-air school. Physicians. — Sometimes individual physicians take turns in donating a month's services to the examination of school- children, or nose and throat speciaKsts will co-operate in the running of a cHnic for nose and throat operations. In Houston, Texas, the Association of Optics and Aurists co-operated with the local school board in the work of medical inspection. Many instances of this kind are revealed in the current school re- ports. Dentists. — The Harvard Dental School gives treatment to pupils at reduced rates, while the dental school connected with Tufts College also receives pupils who are sent to it by school nurses. Dental clinics for the benefit of school-children are maintained also in the Louisville (Kentucky) College of Dentistry, the Homeopathic Dispensary at Orange, New Jersey, and the Memorial Hospital at Pawtucket, Rhode Island. Doubtless there are many other institutions of this sort performing a similar service for school-children. Even more common are the instances of co-operation afforded by local dental societies. School reports make fre- quent reference to the inspection, clinical services, and pubHc lectures which are given by members of these organizations. Sometimes the services are free and at other times partly paid. In some instances only the inspection is made, while in others it is followed up with a regular cKnical service. The Cincinnati school report for 1912 has a very suggestive 96 EDUCATIONAL HYGIENE account of the work performed by the Cincinnati Dental Society. Its activities include inspection, maintenance of free clinic, lectures given school-children, parents' clubs and social settlements, and alHed organizations. Recently, in connection with the work of the clinic, experimentation has been carried on with a view to showing the different physical and mental results obtained from a class whose members- mouths were kept in hygienic condition and from a class not receiving systematic attention. Again, individual dentists help school authorities by inspection, free treatment to needy pupils, or even monetary contributions to help carry on the work of the school clinic. Hospitals. — ^The assistance given by hospitals varies more or less in accordance with the facilities of the institu- tion. That afforded by the Boston hospitals is especially notable. The Massachusetts General Hospital gives medical and surgical attention to poor children for a ten-cent fee. The same service is also offered by the out-patient depart- ment of the Massachusetts Homeopathic Hospital, while the Children's Hospital not only furnishes medical treatment for pupils but arranges a course of instruction for school nurses. At the Massachusetts Charitable Eye and Ear In- firmary treatment may be received for a nominal fee, and in addition eye-glasses are supplied and investigations made of the home conditions of afflicted children. The New England Hospital for Women and Children examines children before they are sent out on summer vacations. It also maintains a dispensary service open to pupils. The Boston and the Maverick dispensaries treat children who are sent to them by the school nurses. In the psychopathic department of the Massachusetts State Hospital mental examinations of school- children are carried on. The institutions of many other cities are performing similar services for school-children. Charitable Societies. — From the provident associations, children's aid societies, and other charitable organizations in the same class a vast amount of co-operation is being received PUBLIC CO-OPERATION 97 by the schools in the physical care of children. Eye-glasses and clothing are provided, attention given to special cases reported by the school nurses, and the home conditions in- spected and improved. Some organizations give attention to the work of facilitating country or seashore vacations for needy children. The needs peculiar to crippled children are being at- tended to by organizations established for their particular benefit. Some of these bodies afford transportation, free meals, or medical and surgical aid to those in attendance at the public schools. Others provide educational facihties for those whose condition debars them from the public schools, and in some instances trained nurses are sent to visit the homes of these unfortunates. Likewise the deaf and the blind are the recipients of the special attentions wkich they require from another class of institution. Nursing Associations. — Another source of most valuable co-operation is found in the various nurses' associations. The Instructive Nurses' Association of Boston provides home attention for the particular cases referred to it by school nurses, while the District Nurses' Association of Scran ton, Pennsylvania, supervises the instruction of school nurses; and many other associations are loaning nurses to the school department or helping it to demonstrate the need of this most important adjunct to medical school inspection. The co-operation given to the schools in this field is as miscel- laneous as it is important. Settlements. — Reference has already been made to the nurse who was loaned to the New York schools by the Henry Street Nurses' Settlement. This institution now maintains, under the board of education, a class for mental defectives, and also facilitates country vacations and provides milk for undernourished children. Furnishing school nurses, giving health talks to parents, maintaining open-air schools, special clinics for children with uncommon diseases, schools for sick and shut-in children, agitations for more sanitary buildings, 98 EDUCATIONAL HYGIENE larger playgrounds and more apparatus — these are only samples of the kinds of assistance which settlements through- out the country are rendering school systems. Tuberculosis Societies. — The national and local associa- tions for the prevention of tuberculosis, as might be expected, are giving valuable aid to the school authorities in the estab- lishment of open-air schools. The pioneer work of the Provi- dence (Rhode Island) school committee in this field was stimulated by a suggestion of the local League for the Sup- pression of Tuberculosis, and the physicians who composed the committee of this organization assisted in the selection of pupils for the school. In some instances the local tuber- culosis association erects the building and becomes a chief supporter of the work; in others it provides the coats, suits, and other portions of the equipment or the meals. Some- times the society provides lectures on hygiene in the various schools. In addition to this kind of service the Pawtucket (Rhode Island) Society for the Prevention of Tuberculosis presented forty dollars' worth of tooth-brushes and samples of tooth-paste to the school nursing department. The Wis- consin Anti-Tuberculosis Association offered a complete open- air school equipment to the city of that State making the highest per-capita sale of Christmas seals. This equipment was won by Kenosha, as were also the services of a visiting nurse for one month, furnished by the association. Women's Clubs. — ^A vast amount of service is being given to the promotion of child welfare by the women's clubs. Active from the outset in the playground propaganda, they are now devoting their efforts to the estabhshment of school lunches in high and elementary schools, arranging child-wel- fare exhibits, agitating the estabhshment of open-air schools, supplementing the equipment of school nurses, and urging the importance of the best methods of medical and sanitary school inspection. Parent-Teacher Associations. — Still closer to the school are the parent-teacher organizations with their varied activ- PUBLIC CO-OPERATION 99 ities and services. Some are maintaining school-lunch de- partments, others purchasing playground apparatus, or em- ploying home and school visitors, and installing first-aid outfits. The Fathers' and Mothers' Club of Boston main- tains a farmhouse for anemic children. These organizations, so dependent upon the school for their existence, generally consider opportunities for co-operation in the light of great privileges. Oftentimes the local university is in a position to extend valuable co-operation. The Department of Psychology of the University of Cincinnati gave mental examinations to exceptional children, and the University of Pittsburgh is maintaining a similar service. The local railway companies sometimes assist teachers in their instructions concerning the avoidance of accidents by furnishing blotters teaching the results of carelessness in boarding and departing from street- cars. A Safety League in Kenosha, Wisconsin, arranged lectures in the public schools upon the various methods of promoting safety. Individual Philanthropists. — In the conduct of the Chicago schools for anemic children the board of education supplies the rooms and teachers, while the Elizabeth McCormick Fund provides the extra pay of the physicians and nurses and meets the expense attached to furnishing food and supplying extra clothing and equipment. The Forsyth Dental Infirmary of Boston, just being opened, will attempt to care for the mouth conditions of all the chil- dren of Greater Boston up to sixteen years of age. The in- stitution was founded by two brothers as a family memorial. The benefactors purchased the site, erected the building, which cost $250,000, and have endowed the holding corpora- tion with a maintenance fund of about $1,000,000. The institution has facilities for sixty-four chairs, and auxihary room for forty-four additional ones. It is expected that it will be possible to treat over seven hundred cases daily. The application of philanthropic funds to the field of lOO EDUCATIONAL HYGIENE school hygiene is, according to the signs of the times, likely to show still further extension. Assistance in Bringing about Co-ordination. — This sort of service is illustrated in the work of the PubHc Education As- sociation of the City of New York. It brought together representatives of the departments of Health, Charities, Education, and the Children's Court, as well as a number of private citizens, in a special committee devoted to the pro- motion of child welfare. The purpose of this body was to develop intelligent co-operation between these different de- partments, to define the problems of school hygiene, and to carry on intensive studies of some of the more difficult ones. A member of the association staff was assigned to the work of this committee. Encouraging Voluntary Assistance. — The Boston report for 1 91 3 devotes twenty pages of fine type to a concise state- ment of the one hundred and twelve organizations which are co-operating with the public schools of that city. Many of the current school reports are also stating the needs of the schools, which would afford opportunities for volunteer co- operation. Thus by inviting co-operation and giving accurate credit for the work that is done, the welfare of school-children is being more rapidly advanced than is possible through the unaided activities of present school systems. Educating the Home and the Public in Health Practises. — In order that the school's hygiene activities may fuid sup- port in the pupils' home and neighborhood environment, it is necessary that much miscellaneous health instruction be pro- vided for the community which is outside of the school- building. And in this work the volunteer associations also are unusually helpful. The Public Education Association of Philadelphia prepared and distributed through the school- children ten thousand cards of health instructions to parents. It also prepared and printed an equal number of highly effective pamphlets on the care of the baby for distribution among parents. The regular programmes of the various PUBLIC CO-OPEEATION lOI parent-teacher associations are full of illustrated lectures upon health topics. The women's clubs also arrange public meetings which are addressed by local physicians, dentists, and school inspectors. The Social Welfare Committee of the South Bend Chamber of Commerce arranges addresses upon health subjects before social-centre audiences in the pubHc schools; while the Commercial Club, of Louisville, Kentucky, in one year spent $6,000 on publicity work in behalf of the schools. Such associations as the Woman's Christian Temperance Union and the An ti- Cigarette League are always ready to avail themselves of opportunities to give public lectures upon their causes before schoolhouse audiences. The Boston Milk and Baby Association not only lectures upon its work before pupils but conducts "Httle mothers'" classes in the high schools. In Chicago the Visit- ing Nurses' Association arranged a series of lectures^ upon intestinal diseases in connection with the vacation schools, to which mothers were admitted as well as high and gram- mar school pupils. Many other examples of volunteer aid in the work of spreading the knowledge of health facts among the people in general might be brought forward if space permitted. The instances which have been set forth in this chapter illustrate but do not at all completely enumerate the various ways in which outside organizations are in many places al- ready co-operating, and in others stand ready to co-operate, with the educational authorities in promoting a steady ad- vance in school hygiene. So freely and bountifully, indeed, have the voluntary associations devoted means and personal service to human welfare that, in the light of their deeds, a new meaning now seems to shine forth — especially for all guardians of children — from that old scriptural saying, once rusted over with triteness: "Ask and ye shall receive." The following summarized suggestions by Wm. H. Allen, in his "Woman's Part in Government," are pertinent: *See "Wider Use of the School Plant," by Perry, p. 142. 102 EDUCATIONAL HYGIENE The following first steps are suggested to local schools wishing to increase their power for civic education: 1. Ask for a State law on medical examination of all children, teachers, janitors, buildings, and grounds in all school districts, public^ parochial, private, rural, and urban. 2. Teach personal hygiene by relating it to community hygiene. 3. Keep your communities continuously informed in regard to health needs indexed at school. 4. Realize that every parent interested adds a teacher to your staff. 5. Give your newspapers school stories and thus add 25 per cent to the efficiency of your teaching staff. 6. Make private agencies supplement school work, instead of sup- plementing their work. 7. Make your schools the centre of social-settlement work and up- lift work in your communities. 8. Recognize that it is just as educational to interest the board of education and the voluntary visiting committee as to instruct a child. 9. Provide for civic and health work by your school organizations. 10. Take advantage of budget season to tell 100 per cent of school and health needs and to interest 100 per cent of your community in that story. 11. Welcome complaints and questions as opportunities for civic education. 12. Make more demands upon your State department of education and give it better support. 13. Write your congressmen and senators to give the United States Bureau of Education enough work and enough money. 14. Co-operate with the National Education Association's special committee on uniform and adequate records and reports. CHAPTER VI THE SOCIAL CENTRE AND EDUCATIONAL HYGIENE The Situation. — Sisyphus had to keep on rolling at the stone, even though he could not succeed. He had to keep on, or otherwise it would have rolled back and crushed him. And just so we must keep on spending our force in and through the pubhc-school system as it is to-day in pressing back the forces of disease and death in the programme of educational hygiene. We cannot stop using the means we have, for we, too, are laboring for our lives. % But, away back when first I heard of Sisyphus, I wondered why he did not hold the stone with one hand and shoulder and with the other hand or with his foot place a cobble under it, or somehow reach around and rig a block and tackle at the back of the stone by which his labor might be accom- plished. Had he been able to do that, he would not only have succeeded in his undertaking, but he would, so far, have spoiled and transformed Hades. The social-centre move- ment, the full use of the common-school system as the ma- chinery of adult and older-youth civic, industrial, recreational organization and co-operation, is the rigging of the block and tackle around behind the stone — the means by which the otherwise futile and discouraging enterprise of radically pro- moting public health through the agency of the public-school system shall become an achieving enterprise, whose process will go far toward transforming our inferno. Our experience in trying to make of the common-school system as it is — used one-third of the time, by only the one- third of us who are children, for the mere one- third of the educational process, which consists of children's instruction 103 I04 EDUCATIONAL HYGIENE — an effective and dynamic agency for the promotion of chil- dren's health, seems to necessitate this statement: The common-school system, as at present manned (or rather womaned), as at present housed (or rather barned), as at present stunted, fails, and is Hkely to keep on faihng, to be greatly, radically promotive of even the children's health. On the other hand, the experiments in social-centre de- velopment, even the little timid experiments that have been made thus far, justify this statement: When the characteristic community-building-and-yard equipment of America has ceased to be merely the children's school system, and has come to be really the public-school system, in use as well as in ownership, it will be the adequate machinery of public-health advance and so will make the health service of the children efhcient. Two Factors. — There are two necessary things to be done in order to make the public-school system an effective agency for health promotion. In the first place, the school must be radically improved in the character of its educational staff, in the character of its physical equipment, and in its curric- ulum. In the second place, the problem of sociological ad- justment, political, industrial, and recreational, must be dealt with. To-day the profession of the public-school man or woman is a third-rate profession. The salary standard is third-rate, and, in general, the professional calibre of the men and women employed in public-school service is one-third of what it should be. What is true of the personnel of the public- school service is in general true of the housing, grounding, and equipment of this characteristic American institution. And, judged by a standard of vital practical, economical, and constructive arrangement of physical and mental activ- ity of children in the public schools, the curriculum is not more than a third as good as it should be. What is the answer? " More money for the public schools," says President EHot. Yes, but how are we going to get it? SOCIAL CENTRE AND EDUCATIONAL HYGIENE 105 There are other needs for the improvement of the public schools to the point where they will be efficient agencies in the promotion of health, other needs than money. How are these to be satisfied? The longest way round is often the shortest way home, and the problem of making the public school an efficient agency for health promotion is to be solved most directly by coming at it indirectly. Political Beginning. — The beginning of social-centre devel- opment is poKtical. Whether our objective be citizenship-train- ing improvement, moral-training improvement, industrial- training improvement, or health-promoting improvement in the efficiency of the public schools, the first step is the same. It is the shifting of the voting apparatus into the public schoolhouse. It is the use of the pubHc schoolhouse as the polling-place of its district. • The reason for this is not chiefly its economy, great as that is; it is because the establishment of the voting head- quarters in the school building makes of this building in actual practise a public place of assembly and organization. The ^'pubHc" school as a juvenile instructional institution is not now, in practise, a common place of public assembHng even as the public is represented in the children. There are paro- chial schools. But there is no parochial ballot-box. And when the ballot-box is established in the schoolhouse, the fact is declared and reaHzed that this is a common building, a centre of public organization and expression. See some of the immediate practical results of using the schoolhouse as the polKng-place, results having to do with the improvement of this institution on lines of public-health service. Voting in the schoolhouse implies making the school prin- cipal the voting clerk of the district. He or she is at once brought into official direct contact with the adults of the community. This added function implies some increase in salary and increase in dignity and influence. The building is I06 EDUCATIONAL HYGIENE soiled by Its use for voting, and the splendid Emersonian principle that ''things are good if they are only bad enough" is, as Health Officer George W. Goler, of Rochester, has said, brought into play. The building was dirty as a result of the children's use, but it wasn't dirty enough to necessitate thor- ough cleaning and renovating. Its use as a polling-place points this necessity, and the result is that the building is cleaned. The citizens of the district coming to the school- house see its architectural ugliness and its poverty of equip- ment; and its use as a polling-place, the real headquarters of government in a democracy, tends to its improved archi- tecture. The vitahzing influence of this use of the school building for the primary expression of citizenship upon the civic training of the children is obvious and fundamental in its importance. Deliberative Associations. — ^The next step in social-centre development is the organization of the citizens of each dis- trict whose names are recorded upon the voting register at the polling-place, now established in the schoolhouse, into a deliberative association to use the school building as the dis- trict common-council chamber, the headquarters of presenta- tion and discussion of public questions. This implies the service of the school principal or of an associate as the dis- trict clerk or secretary of the citizenship in its assembling for discussion. The school man, hitherto a man among women and children, becomes a man among men; the agent of the citizenship in the instruction of the children comes to be forti- fied in his influence by his relationship of direct service under the citizenship as the civic secretary. And a more present- minded, capable man or woman is made necessary for this position. The schoolhouse becomes the place of frequent assembling of the adults of the neighborhood. As such its architectural character and its physical equipment depend not only upon the generosity but upon the self-interest of the citizens. The organizing of contemporary public problems into a curriculum of self-education through discussion by the SOCIAL CENTRE AND EDUCATIONAL HYGIENE 107 citizens, sets a vitalizing standard of government-in-action to which the civic training of the children becomes a real ap- prenticeship. Self-Govemiiient Clubs. — Then comes the organization of the boys of the community, the boys between school age and majority, into a self-governing club, modelled upon, or rather patterned after, the adult civic organization. This .imphes the companionship of a club director, which work be- comes a function of the school principal or of a member of his staff. It impHes the interest of another great section of the community, the youth, who may be counted upon always to favor improvement — their interest and ambition for better architecture and equipment. And the connection between the children and the adults, the connection between appren- ticeship and the actual practise of citizenihip, is made and strongly made for the children by setting before them, in the practise of the older boys, training in self-government. What is true of this provision of the schoolhouse as the assembhng-place of the boys who are above school age but have not yet reached twenty-one, as to its need and value, is true of its use as the meeting-place of the neighborhood club of girls between school age and adulthood. Incidentally, this use of the schoolhouse as the club-house for the older boys and for the older girls of the district pro- vides the machinery and the opportunity for their instruc- tion in matters appropriate to their age, matters particularly of public health and personal hygiene. Weekly Meetings. — Next comes the use of the schoolhouse as the weekly gathering-place for general neighborhood as- sembling. With one evening in the week devoted to the gathering of citizens for presentation and discussion of public questions, one evening centred upon the boys' club meeting, one evening given up to the girls' club meeting, and along with these an evening when old and young gather for a programme which begins with the orchestral music provided by the neighborhood orchestra that is bound to get itself Io8 EDUCATIONAL HYGIENE formed to meet this need, and then a half-hour of communal singing and then a lecture or entertainment or motion-picture exhibition, closing with an hour's dancing of young people and older people together, with ideal, homehke chaperonage, the basic organization for social-centre development is com- pleted. Obviously for the arrangement and promotion of such general neighborhood evenings the service of a member of the school staff, whether the school principal or an associate, is necessary, and obviously the inclusion of this function in the ofhce of school man or school woman means the socializ- ing and warming and elevating of that office. Obviously, also, it tends powerfully toward the improvement of the architecture and equipment of the building, for this improve- ment becomes a matter of citizenship self-interest instead of depending merely upon generosity. And plainly this use of the schoolhouse as a centre of neighborhood assembling and attraction will tend to influence, to vitalize, and humanize the curriculum of the children's instruction there. The Social Centre as a Health Agency. — The machinery is now estabhshed for attacking the problem of public health and all other public problems after a constructive and demo- cratic fashion. In the forum of the citizens, the imperative need of pro- viding physical-training opportunities for the community is set forth. The outcome is almost sure to be the equipping of the schoolhouse and the school-grounds with gymnasia indoors and out, and with bathing facilities. If medical, dental, and optical service has not already begun in the school, the matter of its introduction becomes a natural next- thing- to-do, for the use of the schoolhouse as the local health ofhce makes a twofold appeal. On the one hand, those who are interested particularly in the public- health movement see the opportunity that is offered to get at the whole community through having health service and health instruction centred there; and, on the other hand. SOCIAL CENTRE AND EDUCATIONAL HYGIENE IO9 the opportunity of co-operatively providing for the com- niunity's health makes its appeal not only to the parental interest but to the selfishness of the citizens. And not only is the machinery provided for redeeming the medical and pharmaceutical profession of the country by identifying the physician's service with education, and so realizing the true meaning of * doctor" (which is not pill- counter, nor coddler, nor bill-collection worrier, but teacher) ; but the machinery is provided for attacking the roots of in- dividual and social disease in poHtical corruption, economic maladjustment, and leisure-time exploitation — and so ade- quately and effectively deaHng with the problem of pubHc health.i "The Heart of It." — Of the effective pioneers of the public health movement, the one whose memory is most re- vered in Wisconsin is Frank Avery Hutcliins, founder and first secretary of the Wisconsin Anti-Tuberculosis Associa- tion, founder and first secretary of the State Free Library Commission, organizer and, until his death, secretary of the Department of Public Discussion in the University Exten- sion Division. The last words of this clear-eyed construct- ing engineer of Wisconsin's machinery for social and indi- vidual self-enlightenment were spoken in response to the news, brought to his bedside, of the estabHshment of the schoolhouse as the polling place and community centre, and the appointment of the school principal as community sec- retary, in one of the small towns of the State. His words, whispered with the utmost difficulty, but with -a note of profound gladness, were: ''That goes to the heart of it," To him ''it" meant the tremendous problem of making the public whole — which is the problem of public health. 1 See Ward's "The Social Center" (Appleton). PART II THE ADMINISTRATION OF EDUCATIONAL HYGIENE CHAPTER VII THE INITIATION OF A SYSTEM OF EDUCATIONAL HYGIENE IN A SCHOOL SYSTEM Including a School-Health Survey Public Opinion Basis for Public-School Progress. — ^All the principles of pedagogy, social psychology, and poHtics, in the best sense, figure in the initiation of any or all of the phases of educational hygiene in a school system. The prejudices, enthusiasms, and social pecuHarities of the community, or state, must be taken into thoughtful consideration. The superintendent must study the people he is to bring up to a higher standard of personal and pubUc hygiene, at least as carefully as the teacher must study the children she is to educate. PubHc opinion is not a thing to scorn or to disre- gard, and it is Hkewise not a thing impossible to build up, guide, and make effective in the promotion of the public good. We must not thrust educational innovations upon people without first helping them to feel the need of them. It is far better that through skilful indirect guidance they may be led to demand and to work for needed improvements than that they get them by imperial fiat from the superin- tendent's office or mayor's chair. Here is where probably most superintendents fail and where all real leaders of the people succeed. The latter know how to create and to guide the specific form of desirable public opinion, thus promoting no INITIATING EDUCATIONAL HYGIENE III the self-activity of the community, while the latter work at the school as if the school system were in a world of its own and the only function of the community were to furnish the children and the money, especially the latter. David Starr Jordan says somewhere that years ago in southern Indiana he came upon the track of a man's influ- ence on a community that was as clear and as unmistakable as the footprint of a mastodon in the fossil-bearing rock. This man had long since passed on, but he had Hfted the community to higher levels and standards, and had given to it an ineffaceable impress. This man probably knew very well in a practical way plain folk psychology, the methods of rousing public sentiment, of developing this into specific public opinion, and of guiding this onward to public demand and public action, including all the factory of local leader- ship and availability of special groups. Some one should collect from the experience of thousands of teachers and superintendents, as well as from the various men and agen- cies that have been successful or unsuccessful in the moulding of pubHc opinion, the data which when sifted would put into the hands of school people a set of principles, richly illus- trated, setting forth the guiding lines for success in this field. Its relative worth in school-administration courses would be very high. We wish here to outline on an empirical basis a plan for taking the steps toward school-health progress. Steps Toward School-Health Progress (i) Getting Informed. — The superintendent should in- form himself thoroughly on the principles of the work and on what other communities are doing. For this he will need some of the best books and pamphlets and a number of school- health reports, giving particular attention to cities or regions about the same size or smaller than his own. From a pam- phlet published by the Sage Foundation he can learn of the cities and towns with populations near his own in size that 112 EDUCATIONAL HYGIENE are doing superior work in this field. The reports of the national boards of education of England (Whitehall, Lon- don) and Scotland (Edinburgh) are always valuable and suggestive, and many cities and rural regions that are doing able health work can be located by their use, and the local reports, say of Bradford, Cambridge, or Dunfermline, may be obtained. (2) Interesting the Teachers. — ^Next get the teachers with you by principals' and teachers' meetings, if your system is so large. Rural teachers in non-consolidated schools will start directly with the children and people of the community, as described in Carney's 'Country Life and the Country School." Teachers may be led to procure good school- health handbooks to use in reading-circle meetings at the buildings. There may be talks by principals, supervisors, superintendents, doctors, nurses, or other specialists. Further steps in disclosing the local health situation in each teacher's room will readily bring, in most cases, enthusiastic response. (3) Using the Newspapers. — ^About this time newspaper work may well begin, if not earlier. The superintendent should see the editors and talk over the health needs of the schools and the thing he is trying to accomplish. By interviews, articles, quotations from papers, magazines, and books, by pictures of conditions both from other places and the local- ity, by stories of the findings of the doctors and nurses when they begin their work or the findings of the teachers when they make their preliminary surveys, much interesting ma- terial may be used to get the people to thinking along school- health fines and to see to what desirable standards their own community should advance. If superintendents and editors were as skilful as certain advertisers of chewing-gums and safety razors, not to mention other enterprises, the health movement in our country would be vastly accelerated. (4) School-Health Survey by School Officials.— When the teachers realize the importance of more attention to the health problem of the schools and community, it is time to show them how to do something. Doctor Hoag says in a INITIATING EDUCATIONAL HYGIENE II 3 bulletin of the United States Bureau of Education (555) that teachers can without much previous training, but with the help of certain detailed directions, diagnose or discover 90 per cent of the ailments of school-children. The Ohio School Survey shows that there are a few limitations to this gen- eralization, but that teachers can pick out most of the flagrant cases is well demonstrated. I would advise here, then, a school-health survey, or census, made by teachers, principals, and superintendents, with perhaps some voluntary outside assistance. This survey should include: Medical Supervision, School Sanitation, Physical Education, and the Teaching of Hygiene, and perhaps the Hygiene of Methods, or Instruc- tion.^ (a) Medical Supervision. — Use here Doctor Hoag's form for this purpose as given below and published in the bulletin (555) above mentioned, and printed separately ^ as an in- expensive folder for the use of schools. The bulletin men- tioned may be had from the superintendent of documents, Government Printing Ofhce, Washington, D. C. Doctor Hoag's Diagnostic Chart for teachers, given in his '' Health Index of Children" and in ^'Health Work in the Schools," is also valuable for daily use after the survey is over. Snellen test charts may be used for vision tests, and principals or superintendents may even use the Binet-Simon tests for in- telligence for a few selected pupils. When each child has been studied by teachers and principals from the health standpoint in this way, the results as summarized may well be published. Voluntary physicians, dentists, oculists, psy- chologists, and neurologists may be called in to verify any unusual or serious findings. The parents of children found defective should be notified and requested to go to their family physician, specialist, or dispensary, to have the teachers' findings checked up, and the ailments, if any, treated and cured. It is well to be cautious and conservative here, in 1 Doctor Wood's pamphlet on "Health and Education" (University of Chicago Press) will be found very suggestive for each of these five divisions. 2 By Whitaker and Ray-Wiggin Co., San Francisco, Cal. 114 EDUCATIONAL HYGIENE order that real ailments and defects may be reported, so the confidence of the parents may be built up, not shattered. If the voluntary work by specialists, as above suggested, may be brought in to confirm and to modify the teachers' reports, it will be still better. Doctor Hoag's form is here inserted: AN OUTLINE FOR THE HEALTH GRADING OF THE SCHOOL-CHILD 1 BY Dr. Ernest Bryant Hoag child-study specialist, los angeles, cal., formerly special di- rector of school hygiene, minnesota state board of health School Date Pupil's name Grade Teacher's name Town or city HEALTH GRADING OF THE SCHOOL-CHILD (For Teachers or School Nurses) Directions for Use This plan for the health grading of school-children consists of two parts: 1. An outline for a partial health survey to be made with the aid of the pupils themselves, or, in the case of young pupils, with the aid of parents. 2. An outline for a more extensive health survey on the part of teachers. In schools where a medical officer or nurse is employed this out- line will serve as a useful preliminary health survey. With the employment of this survey no school need wait for the appointment of a medical officer or nurse before commencing some effective health work with school-children. It is desirable that the teacher should, in the absence of medical officer or nurse, make this survey as early as possible after the chil- dren enter school, but if necessary the teacher may take her own * A four-leaf folder for each child. INITIATING EDUCATIONAL HYGIENE II 5 time and complete the survey of the children in her room at her own convenience. It is desirable that this survey be made in the case of every child, but in any event the teacher should make it in the case of every pupil whom she suspects of being mentally or physically unsound. The answers obtained to any one question may be of no particular significance, but the answers taken as a whole will be of very great significance. The answers to questions in the same group are often of great importance. For example, it may be discovered that a pupil complains of headache, blurred vision, and inability to see easily what is written on the board. In such a case the pupil is unquestionably suffering .from a more or less serious eye defect. Or, again, it may be noted that the pupil complains of earache, running ear, and perhaps inability to hear easily what the teacher says. Such a group of sig- nificant points would indicate unquestionable ear disease leading to permanent deafness. A peculiar standing posture may indicate any one of a number of things, for example, spinal disease, weak muscles, beginning hip-joint disease, etc. The teacher is strongly recommended to mak? these surveys with- out attracting the attention of the individual pupil too much to the fact that he is under observation. The teacher will soon discover that her powers of observation in matters pertaining to the pupils' health will be greatly increased and her attention will be called to many things of importance which she formerly entirely overlooked. As a matter of fact, one of the most important uses of this health survey consists in the fact that it trains the teacher's powers of observation. When one or more conditions are discovered by the use of this survey, which in the opinion of the teacher require attention from the family physician, specialist, or dentist, a notice should be sent to the parents in the following form: Date Notice to Parents or Guardians: appears to the teacher to be in need of attention. A further examination by your family physician, dentist, or specialist, is advised. Principal. School. The parent will please sign here and return the notice to the principal. Il6 EDUCATIONAL HYGIENE HEALTH SURVEY Part I (Questions to be answered by Pupil or Parent) Name School Date Grade Question i. How old are you? Answer: Question 2. Have you ever had much sickness? Yes No Answer: Questions. Are you well now ? Answer: Question 4. Do you eat breakfast every day? Answer: Question 5. Do you eat dinner every day? Answer: Question 6. Do you drink coffee? Answer: Question 7. Do you drink tea? Answer: Question 8. Do you have your bedroom window open or shut at night ? Answer: Question 9. Have you ever been to a dentist? Answer: Question 10. Do you own a tooth-brush? Answer: Question 11. Do you use a tooth-brush? Answer: „ . . , Question 12. Do you have headache often? Answer: „ . . . Question 13. Can you read easily what is written on the blackboard? Answer: Question 14. Does the print blur in your book? Answer: , Question 15. Do your eyes trouble you in any way? Answer: , . Question 16. Do you often have earache? Answer: Question 17. Do your ears ever run? Answer: INITIATING EDUCATIONAL HYGIENE II7 Question 18. Can you hear easily what the teacher says? Answer : Question 19. Is it hard for you to breathe through your nose? Answer: Question 20. Do you have sore throat often ? Answer: Question 21. Do you tire easily in school? Answer: Question 22. Do you work any out of school hours? Answer: Question 23. What kind of work? Answer: Question 24. How much ? Answer: 2 3 4 5 6 7 8 9 10 I. 2. 3- 4- I. 2. HEALTH SURVEY Part II (Questions to be answered by the Teacher) * 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 heels of the shoes worn evenly ? Is the physiological age of the child apparently equal to his actual age ? B. Mental Conditions Is the child normally advanced in school ? Is he mentally alert ? Does he answer ordinary questions intelligently ? Does he play normally ? C. Nervous Conditions Is the child good-tempered ? Is he free from abnormal emotion ? Yes No * Indicate answers by a check mark. Answer as many questions as possible. ii8 EDUCATIONAL HYGIENE 3. Does he have good powers of muscular co-ordina- tion ? 4. Is the child free from spasmodic movements ?...,.. 5. Is he free from the nail-biting habit ? 6. Does he speak without stammering ? 7. Is he free from pronounced peculiarities such as ir- ritability, timidity, embarrassment, cruelty, mo- roseness, fits, general misbehavior, etc. ? 8. Is he apparently free from bad sexual habits ? 9 . Is he free from so-called ' ' bladder trouble ' ' (requests to "go out") ? 10. Is he usually free from headache? Yes No D. Teeth I 2 3 4 5 6 7 8 9 10 Are the teeth clean-looking ? Are the teeth sound-looking ? Are the six-year molars in good condition ? Has the child been to a dentist within six months ? , Are the teeth regular ? Does the child use a tooth-brush every day ? , Are the gums free from abscesses ? Are the gums healthy-looking ? Are the upper teeth straight (not prominent) ? . . . Have decayed teeth been filled ? E. Nose and Throat Does the child breathe with the mouth closed?. Is he free from chronic nasal discharge ? Is he free from "nasal voice" ? Has he a well-developed face ? Has he a well-developed chin ? Has he straight, even teeth? Is the child mentally alert ? Is he usually free from sore throat ? Is the hearing good ? , . . . F. Ears 1. Does the child usually answer questions without first saying " What " ? 2. Is he fairly attentive? 3. Is he fairly bright-appearing (not stupid) ? INITIATING EDUCATIONAL HYGIENE 119 4. 5- 6. 7. 8. 9- I. 2. 3- 4. 5- 6. 7. 8. I. Does he have a voice with good expression (not ex- pressionless) ? Does he spell fairly well ? Does he read fairly well ? Is he free from complaints of earache? Is he free from ear discharge ? Is he free from any peculiar postures which might indicate deafness ? G. Eyes Are the child's eyes straight ? Is he free from chronic headache ? Does he do his work without fatigue ? Is he free from squinting or frowning ? 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. ? Are the eyes free from redness and discharge ? Are the eyelids healthy-looking ? ? Can the child read writing on the board from his seat ? Have the eyes been tested separately with the Snellen Test Tjrpe ? H. Communicable Diseases of the Skin Is the head free from any signs of disease (lice, ring- worm) ? 2. Is the skin healthy-looking ? I. Eruptive Children's Diseases Is the child free from the following general early indica- tions of contagious diseases ? 1. Flushed face 2. Lassitude 3. Vomiting 4. Eruptions 5. Congested eyes 6. Discharging eyes 7. Nasal discharge 8. Persistent cough 9. Scratching 10. Sleepiness Yes No I20 EDUCATIONAL HYGIENE The following points often indicate the early signs of transmissible diseases in children. They will, of course, not ordinarily be observed at the time of making this Health Survey. 1. Flushed face. 6. Nasal discharge. 2. Lassitude. 7. Persistent cough. 3. Vomiting. 8. Scratching of the skin. 4. Eruptions. 9. Sore throat. 5. Red eyes. 10. General aches and pains. Teachers may use their own judgment about this test. Summary Physical development , Nervous system Nutrition Mental condition Eyes Ears Nose Throat Teeth Skin Eruptive disease Food Ventilation Coffee habit Tea habit Remarks From these individual forms the summaries may be made. The standard classification, terminology, code numbers, and probable frequency of serious ailments given in Chapter VIII may be used for the ailments and defects discovered. (b) School Sanitation. — There are several forms on which the non-expert person may make a reasonably able survey of sanitary conditions. Doctor Ayres gives two brief forms in his survey of the Springfield, III, public schools. Other INITIATING EDUCATIONAL HYGIENE I2I forms will be found in the report of the Ohio School Survey and in Bulletin 524 of the Bureau of Education. The chapter on School Sanitation Standards in this volume, as well as the chapter on Rural School Sanitation, should prove helpful.^ These forms are suggestive and the good points of many may be put together by the principal or superintendent for local use. By this means the superintendent may obtain in com- pact form the sanitary status of his buildings and grounds. If some of the board members can be enlisted to help apply modern standards to the buildings included in the survey, it may be of strategic importance. If discussion arises, the superintendent should have some authoritative text-book on school hygiene, including school sanitation, ready at hand. Dresslar's book, published by Macmillan, will be found help- ful. The survey of the Portland, Ore., school system will be suggestive (health phases made by Professors Terman and Dresslar).2 School Sanitation Forms Used by Doctor A3rres I. PHYSICAL PLANT AND EQUIPMENT, BUILDINGS Building Principal Total number of sittings in classrooms Seating capacity of assembly-room Average attendance: boys girls Average enrolment : boys girls Classrooms: First floor Second floor Third floor Total classrooms Has principal room for office ? . . . . Location of assembly-room Heating system: hot-air furnace, direct steam, indirect steam Thermostatic regulation. ...... Humidification 1 See the form used by the Philadelphia Board of Health, and the author's article on "The Standardization of the Rural School Plant," in School and Society, for February 13, 191 5. 2 The Rural School Hygiene Survey of the Rural Schools of Pennsylvania, made by the author, deals with all five divisions. It may be found in the Report on Rural Schools, State Superintendent N. C. Schaeffer, Harrisburg, Pa., Chairman. 122 EDUCATIONAL HYGIENE Ventilation: window, gravity, plenum fan, exhaust fan Location of fresh-air intake Location of cloakrooms How ventilated Location of toilets Toilets: Number seats for boys Number seats for girls Automatic flush Number of individual urinals for boys Do urinals have automatic flush ? Material of walls and divisions of urinals. . . .of toilet floors Number feet of urinal trough. . . .Material of urinal trough Number of wash-basins Individual soap provided. Individual towels Number of bubbling fountains. . . .How often are windows washed?. System of cleaning employed How often are floors washed?. . . .Are floors oiled? Stairways of fireproof material?. . . .Are stairways enclosed? Material of enclosure .... Hand-rails both sides .... Centre hand-rail , Width of stairways: first floor second floor Width of steps Height of risers .... Width of corridors .... Corridors unobstructed . , Fire-escapes: number and kind , Signal connection with fire department. . . .Inside hose equipment. . , Chemical extinguishers Automatic sprinklers , Automatic fire-alarm , Heating plant separated by fireproof walls, ceilings, and floors ?...., Is buflding of fireproof construction ? Of fire-retarding construction ? Material of outside walls of building. . . .of floor beams , Gymnasium facilities Area of playground Area of site Area of space occupied by building , Date of construction , Sheet S}4 by ii Inches II. PHYSICAL CONDITIONS OF CLASSROOMS Building Teacher Room No Grade Av. attendance . . . .No. sittings: adjustable. . . .Non-adjustable. . . . Total Length .... ft. Width ft. Height ft. Floor area sq.ft. Cubic contents. . . .cub. ft. Square feet of floor area per sitting . . . . sq. ft. Cubic feet of air space per sitting .... cub. ft. Total window area . . . . sq. ft. Distance from top of window to floor. . . ,ft. INITIATING EDUCATIONAL HYGIENE 1 23 Square feet of floor area for each square foot of window area sq. ft. Windows at left, back, right, or front of children Lineal feet of blackboard. . . .ft. Lineal feet per sitting. . . .ft. Inches from base of blackboard to floor. . . .inches. Do seats project under front edge of desk?. . . .How far?. . . .inches. How many pupils cannot easily rest feet on floor ? Distance from rear seat to rear wall .... ft. Color of walls .... Color of ceilings .... Color of window-shades Do shades roll from top or bottom? Has room a thermometer?. . . Card 4 by 6 Inches (c) Physical Education. — We can call attention here to no good forms for investigating physical education. The calis- thenics, plays, and games used, their supervision, kinds of play apparatus, kind of room calisthenics, two-minute exercise drills, games used in the schools, size of school playgrounds, athletics and their supervision, proportion^ of student popu- lation reached effectively by physical-education department, number and training of physical-training and other physical- education teachers and supervisors, the extent to which physical-education instructors discover ailments and defects, school bathing and swimming, athletic leagues, folk-dancing, etc., will be considered. Curtis's books on "Play and Rec- reation'' and "Education Through Play" will be helpful here; likewise the Playground Magazine (No. i Madison Avenue, New York City), and a bulletin issued by the State Department of Public Instruction of Virginia on Play and Athletics, showing desirable home-made apparatus and plays and games. Another bulletin on Recreation, by the State Department of Education of Oregon, and the bulletin of the United States Bureau of Education on Play, are also desir- able. Rapeer's "School Health Administration" has a chap- ter on this problem. (d) The Teaching of Hygiene. — For this we have no good forms, although several surveys have considered the matter, e. g., those of Ohio, Portland, Ore., and Vermont. This would include the kind and quality of text-books used, the amount of attention paid to the formation of good health 124 EDUCATIONAL HYGIENE habits, such as cleanliness of person, tea or coffee drinking, sufficiency of sleep, ventilation of sleeping-rooms at night, etc., as well as attention to the provision of washing faciUties, liquid soap, paper towels, toilet-paper, and sanitary drinking fountains at schools. It would include the time on the daily programme devoted to instruction in hygiene, the efficiency of the methods used, and the amount of correlation with other subjects. The chapters in this volume on the "Teaching of Hygiene" in elementary and high schools, in the author's volume on "Teaching the Elementary School Subjects," and the May, 191 2, number of the Teachers Col- lege Record (Columbia University), on ''Health Instruction in the Elementary School," by Professor Reesor, will prove helpful. {e) The Hygiene of Methods of Teaching and Manage- ment. — ^Here we have problems concerning the daily and weekly programme as to proper alternation of subjects, proper time of day, suitable time between work periods, the hygiene of vision, including reading from bad t5^e, the placing of children with defective vision and hearing at the back rather than the front of the room, etc. They cannot be well surveyed at present. Doctor Beik's two chapters in this volume will prove suggestive. Professor Terman has a volume announced on this interesting topic, namely, "The Hygiene of Instruction." Dresslar has a chapter on the subject in his "School Hygiene." This division may be omitted in the preliminary survey, however, if desired. If teachers, principals, and superintendent do their work well with the first four phases of the survey of educational hy- giene, much will be accomplished. (5) Public Co-operation. — When the school people have submitted themselves, their pupils, and their environment to such scrutiny, in the light of the school-health standards available, they can proceed to do much along all five lines of educational hygiene without calling upon the board for ex- penditures of money. However, their work will necessarily INITIATING EDUCATIONAL HYGIENE 1 25 be somewhat faulty, especially along medical lines. Parents can be visited in the homes by teachers as well as by nurses, of course, but the training of the nurse and the fact that she is a nurse, or is called ''nurse," will give her an advan- tage. The examination by a physician, especially with the parents present, adds much to the effectiveness of the work of medical supervision. Then, too, in cities above 10,000 population there is need of a single school health supervisor who can supervise all phases of educational hygiene. At this stage, then, it is desirable to have direct public co-operation for instituting a trial nurse, doctor, school den- tist, all at once or in pairs. Most school features have been initiated in this manner, namely, first a trial on a limited scale paid for and inaugurated by private groups or individ- uals; demonstrated success, or general conviction that the feature is desirable as a part of pubKc-schoolVork; and, third, the adoption of the measure and its support by pubHc taxation. Here a strong parent-teachers' organization, or several of them, may be formed to promote this work. Dues may be charged and donations collected. Women's clubs and vari- ous private organizations may be appealed to in various ways. Elsa Denison's book on "Helping School Children" and Mrs. Cabot's book on ''Volunteer Help to the Schools," as well as Mr. Perry's chapter in this volume and his book on *'The Wider Use of the School Plant," will be of great as- sistance here. Dresslar's chapters in the 191 2 and 19 13 Reports of the United States Commissioner of Education will also give much help. The superintendent should make a survey of the city to discover all possible individuals, groups, and organizations that will help. Sometimes national bodies can be called in to assist without expense, and at other times the business men's club or commercial club will take the matter up, as the Chicago Club has the matter of vocational education. Such an investigation need not take long. The idea is democratic advance through public awakening and group initiation oj new measures — genuine school leadership. 126 EDUCATIONAL HYGIENE • • (6) Volunteer or Partly Paid Specialists. — ^Along with this will come the appeal to the dentists', physicians', and nurses' organizations for voluntary or partly paid work in the schools. A group of physicians can often be procured each individual of which will offer his services for a certain number of two-hour periods during the year on a schedule made by the superintendent, the latter to notify each physician ahead of time. The same may be done for nurses and dentists. A nurse may be loaned for part time by the visiting nurses' or- ganization while the other part of the time may be paid for by the school associations from the voluntary fund. If possi- ble, a full-time nurse should be employed to begin with. Later a part-time physician may be employed. One nurse for each 1,500 pupils and one physician two hours a day for each 2,500 pupils are good standards. (7) Public Adoption. — Through this volimtary demonstra- tion the ground has been broken for the final step of school- board support. With the public aroused and acquainted with the facts, with constant newspaper articles and pictures, with budget exhibits and play pageants, with records of lowered retardation and ehmination figures, and fewer cases of disease and death, most boards will move forward to oc- cupy the ground broken by private initiative, led by the superintendent. Such leadership is real statesmanship and is of a far higher type than the more obvious kinds often going on under the name of politics/war, diplomacy, and the like. CHAPTER VIII THE GENERAL ADMINISTRATION OF EDUCATIONAL HYGIENE Facing the Health Issue. — The general health problem, which has been sketched in previous chapters from the stand- point of social economy, has in a more or less vague way, during the last decade, been rapidly rising in the national consciousness. Leaders in great numbers in all parts of the country have rather suddenly awakened to the fact that the most important human asset we possess is being wasted and destroyed in the most thoughtless manner, and that the most important kind of conservation of natural resources in which we in America may engage is that of the conservation and development of our national health and vitaHty. The progress of science has developed in many and marvellous ways an unparalleled array of instrumentahties for over- coming death, disease, and physical imperfection. Where we once sat in darkness and shivering fear at the terrible mysteries which robbed us of Hfe, health, and happiness there is now an increasing Hght. The work of Pasteur, of Koch, of Reed, of Galton, and many other scientific students of Hfe and health has borne glorious fruit not only in remark- able additions to human knowledge but in an increasing number of men and women working in the laboratories of life wherever the problem of health and vitahty may be con- cretely and intimately met and studied. By these various means we have come to the amazing spectacle of an enHghtened people in need of these health principles in their daily life and practise and yet from ten to forty years, in general, behind the chariot of Truth drawn 127 128 EDUCATIONAL HYGIENE forward so rapidly by the small number who are her devotees. The new health science is produced and kept in the pos- session of but a very few, while the old mores and customs of the people remain largely untouched. To make this knowl- edge common property and daily, living practise, to create and foster more agencies for learning the truth regarding health and vitality, and to discover how new health standards, ideals, and practises may be so inculcated in the daily hves of the many as appreciably to improve the health and vigor of our nation — these are the problems of educational hygiene. Public-Health Improvement. — In these few early years of the twentieth century, as suggested, the anomaly here presented has been sensed by many leaders in many Knes of work. Newspapers and magazines have taken up the problem, public opinion has been in many places aroused, and the public-health spirit, which has been dormant throughout the long health dark-ages since the early Greeks revered Hygieia, has come by a new birth again into its rightful position among the values of life. The first vague stirring of this new health spirit has been evidenced in a most interesting and excep- tional heterogeneity of efforts directed toward the discovery of the specific nature of our health problems and the best methods of solution. The playground movement, the anti- tuberculosis campaigns, the movement toward registration of births and deaths, the various health philanthropies of an investigative and curative nature, such as those of Rocke- feller, Forsythe, Sage, Carnegie, and many others, the school- medical-inspection movement — these, and hundreds of others, have in infinite variety sprung up spontaneously to fight down the enemies of health. In the schools these various health and development measures have been introduced by many agencies for many purposes. At present they appear to many as a host of uncorrected, poorly manned, and poorly directed agencies, little beyond the stage of miscellaneous fads. There is, for example, the present great and important interest and effort ADMINISTRATION OF EDUCATIONAL HYGIENE 129 along the line of the psychological examination, treatment, and education of mentally deficient or exceptional children; there is the movement for better school sanitation, including better ventilation and Hghting, the aboHtion of common drinking-cups and common towels, etc.; the provision of playgrounds for all children; the creation of school clinics, and medical inspection and examination; and many others. The onlooker who sees these agencies as miscellaneous, weak, uncorrected, and largely inefficient undoubtedly sees them aright, for these adjectives truly describe them. As such, the situation furnishes us a social emergency. For the danger is that the first weak and halting steps in any of these various directions may be taken as permanent standards, as has so often happened; also that the development may be one-sided and faddish, that important agencies wilUlanguish and die out, that the work may be wasteful and expensive, and that the whole health movement, now so promising, may largely fail because it has not risen to the hopes and needs of the times. School-Health Principles. — The efficiency of these various agencies in the schools is the topic of this chapter. Scien- tific management in business, the success due to organization and correlation of scattered parts in great corporations, the supreme importance of supervision and leadership as well as professionally trained workers in the schools, and the scien- tific and democratic needs and tendencies of the times, all furnish suggestions for lowering the cost and increasing the efficiency of school-health work. Some of the important and essential principles seem to be as follows: (i) School health and development work is a specialty and must be placed in the hands of those specially educated for this service. This, however, will not displace, but make more efficient, the teachers, principals, and supervisors. (2) The various phases of school-health work must in each school system be organized into a single department centred on the solution of the school-health problem. (3) The professional training of teachers must henceforth 130 EDUCATIONAL HYGIENE include, as at least correlative with educational psychology, the study and practise of educational hygiene. (4) These teachers and the doctors, nurses, dentists, oculists, and psychologists must have expert leadership and supervision. (5) The adult public must be educated through the schools; and, finally, (6) The parents and general public must be helped as never before to co-operate for school-health progress, not only for the sake of the children and the schools, but for their own educational participation. The Divisions of Educational Hygiene. — ^We cannot here support at length these generahzations. To a large extent they seem self-evident to any one acquainted with the actual conditions in the schools and the actual successes of many able educational and other leaders. They are fairly general principles underlying the success of practically any public agency in a democracy. Of all agencies the pubHc-school systems of the country should for many and sufficient reasons be most democratic and most efficient. We shall attempt in the following pages and chapters to sketch broadly the methods by which the various factors may be correlated in the service of school and national health. Now, what are the more immediate ends to which the schools should direct their efforts in this work? We might give a Kst such as fresh air, good food, sleep, clothing, sun- Hght, recreation, freedom from maHgnant germs, etc. A number of organizations of these health factors might be made. Burk's book on "Health Work in the Schools" has something of the above outhne. Of the many possible we choose the following because of its simplicity, its practicability, and its ease of introduction, namely: (i) Determining the actual physical and mental nature of the children as measured by the normal or typical, with necessary remedial measures. This will practically mean a health census of school-children, with special reference to the ADMINISTRATION OF EDUCATIONAL HYGIENE 131 pathological, actual and incipient, and to the exceptional. This division will determine the actual physical condition of children and attempt to get them placed in normal condi- tion. The best name for a division to work in this field yet suggested seems to be that of Medical Supervision. (2) Providing a hygienic school, home, and community environment. On the basis of what is learned of the physical nature of children there can be gradually developed for them an environment that will promote health and normal physical development. The best name at present for this division is the common one, School Sanitation. (3) Providing for the development of splendid bodily resistance and a healthy, happy body and mind, including medical gymnastics, play, physical training, certain forms of recreation, and others. The best name for this division ap- pears to be Physical Education. (4) When we have learned the actual physical condition of the children and have put them into fairly normal con- dition, after we have provided a hygienic environment for them, and after they are provided with wholesome physical education, then there comes a fourth division devoted to teaching the pupils the principles, the ideals, and many of the habits of health. This division may be termed merely the Teaching of Hygiene. (5) But more is needed than medical supervision, school sanitation, physical education, and the teaching of hygiene. We may put the children into good physical condition, in a hygienic environment; we may furnish them with excellent physical education, and provide skilled teachers of hygiene; and yet the methods of handUng the children, the methods of teaching, examining, training, and curing, may be such as to promote worry, exhaustion, fear, and many other unhy- gienic symptoms. A neurasthenic and *' cranky,'' though scholarly, teacher may injure the health of children by bad methods. This division deals with the hygiene of methods, or as it is commonly termed, perhaps, The Hygiene of Instruction.^ 132 EDUCATIONAL HYGIENE The plate accompanying gives a rough idea of this organ- ization. Now, when we have analyzed out these five functions and created divisions of effort and attention to promote them, we have a fairly complete organization. Some may object to the placing of the work of the clinical psychologist imder medical supervision. However, this is a picture of the actual development now going on in this country and abroad, and seems based on good scientific and practical grounds. When, perhaps, the use of the Binet and other tests of in- telligence, the special classes for mentally subnormal and mentally gifted, and the whole clinical psychology technique is better developed and manned than at present, there will be created in many large school systems this separate division as an actual, outward reality.^ We leave it, however, for the present with the medical supervision in the confidence that the physicians, dentists, nurses, and psychologists can work together very well in the service of the exceptional, or sub- normal, children, physical and mental. It may also be said that the Hygiene of Teaching belongs here as a separate division. This is the hygiene of an occu- pation, teaching, and it is of great importance financially and educationally and much neglected. Terman has em- phasized it in his little book on ^'The Health of the Teacher." But the teacher needs all that the pupils need: medical ex- amination periodically, any necessary treatment, physical education, especially recreation, a healthful environment in which to work, education along the lines of health, and such supervision and administration as will promote her best work and health, not their opposites as so often happens. Through the efforts of the Life Extension Institute many business organizations are using similar methods of guarding the health of their workers. The State is even more bound to exercise such care. Teachers, janitors, and others, then, may be dealt with in the five divisions given. In short, these five divisions seem practically and scientifically justified. ^ As in St. Louis and certain other cities. THE DIVISIONS OF EDUCATIONAL HYGIENE Supervisor of Hygiene MEDICAL SUPERVISION SCHOOL SANITATION PHYSICAL EDUCATION NURSES AND DOCTORS. INSPECTIONS AND ANNUAL EXAMINATION'S DISCOVERING HEALTH NEEDS. CO-OPERATING WITH BOARDS OP HEALTH AND PRIVATE ORGANIZA- TIONS. OPEN AIR SCHOOLS. LIMITING DOCTORS TO EXAMINA- TIONS, SUPERVISION OF NURSES AND WORK IN CLINICS. PSYCHOLO- GISTS, OCULISTS. SURGEONS, DENTISTS. PHYSICIANS. SUPERVISION OP SCHOOL FEEDING. SCIENTIFIC STUDIES OP PREVENTION AND CAUSE OP. DISEASE. CAREFUL RECORDS EMPHASIZINff SERIOUS AILMENTS FOUND AND. CURED. TRAINING SCHOOL NURSES FOR ALL INSPEC- TION AND EXAMINATION. NURSES AS ATTENDANCE OFFICERS. OFl*• in CD r>. CO e35 ^ ^ CM OO ■«*• S7 ^ 1^ '^ "— — •- — "— '" *" CM CM CM CN CM A ■a !S>|JBLU8y 00 a> CO = — r- 3 o Z — — — — — — — — 1 1 1 — — — — — — — — ■C3 ! ; 1 H s>|j^iu9y ■a CO a> CC 11 o K o rr T3 U — ^ ' ' "'-- 1 X o UJ II bJ :s>|j^uj9y u C0 T o i^ CO j: «:> Q o 0) — O U III 3 o c Q. "> S ^ 1 ;s>iJBUi9y < •*> T3 LU (0 X 0) X 3 o - ■a > o CJ. E II o !S>|JBtU9y <1> = « II — 09 *— *£ ■ V .: Ul 1 z c CD E CO o c 13 E 3 O Q 5^, E OJ >l CC 00 CJ 0» c « CO OJ o 00 o E F c o E F «e — CO o .a CO u ■a .a CO u CO CO » 3 05 13 a a> z: 11 GO "o c o CO E c: CO CO cu c to lU ■o cu CD x: a> o CO c« o e lU O 1 to E E o '5. 00 cu E cr E CO c: o o o « o ej J= 3 E E o cz 3 E E O c 3 E E o c 3 E E o UJ •a: ■o: ^ o UJ UJ es 3Z z CO O o UJ UJ CC CO eo :tf o O o o ej eo UJ o ,_ CM en ':^ ITS CO tv. <» f» C5 ,_ CM CO ■— CM CM CM Oi a. < o CO -a: UJ DC u- o L. a CO "> tu CI. 3 (/> O 3 ■a: f- o 1— o Z "c5 >- ■ >■ o t/3 0= 1— >- a CO IXl =1 l- CC >» 2= >• o I- £= COP "tJ c5 to z 6 UI OJ tr z HI CO cc :5 z UJ CD CC Z CO cc Z 2 Ul CO E Z UJ CO q: z Ul to QC Z Ul CO ca Z UJ to cc z IE Ul I h- O a Ul cc o o o UJ > O q: D. 2 C3 Ul Q _l O Ul Q Ul a < Ul cc o Ul 1- < z o o § z 3 o Ul z 8 d Ul to a: Z o "c •S = go a>- OJ . := ia a.cn = £= a_ < c o •CO "o o «J c5o> Ec« E o o __ OJ °g E Q = c -a '> , m °g ii CO "5. Q_ a> = 11 ui z Q o Ul z o O 03 a 11 CO c 0) E o II c<- o Z Qu .4- « EE = o S 2 a: o H « O ea— 1 1- .— >- ^5^2 a 0) 1- S 'S. 3 D- d T3 ■ O 3 „, i_ ° > 3 3 OJ 2= Q- a o E P = DETAILED REPORT OF AILMENTS OVER II Mew" = first found in sciiool year."Old "~ ailments previously reported -before th s week. NUMBER OF AILMENTS MON TUB WED T W FRI SAT TUT/US ceo Ol- Slo 'OUND TREATED pg ay BT - FOUND OUWO FOUND NO,OF- IMP-D PUF'U-S eflAND TOTA^ OF HO, 1 AIIWBJT.S TO OATE | BY DOCTOR AND NURSE o s q S Q ? O ^ UJ -J UJ -1 liJ -1 o z o z o z o ? o S D S q HI J UJ -J Ul J z o z O z o z o 2 Z o s c O o * O o Ul xoi z "*=> = "=3 FOUND CURED NOT CURED 1 ADENOIDS, NA8At.OB8TR. ? ANEMIA to 1- o lij. Lk. UJ C3 —I «* o 00 >- 3Z a. 3 DEAFNESS, HEARING 4 DENTAL, TEETH 5 ENLARGED TONSILS R EYESIGHT, VISION 7 EYES CROSSED, STRABIS. R GLANDS ENLARGED, ADEN. 9 HEART DEFECTS to 10 LUNGS WEAK, NOT TUB. 11 MALNUTRITION, DEBILITY 7 )?. MENTALITY DEF, III 13 NERVOUSNESS, CHOREA 5 J 14 PALATE DEFECTS IS SKELETON, ORTHOPED. 16 SPINE, CURVATURE, ETC. < 17 SPEECH DEFECTS A iij R J C UJ IR ABSCESS. BOILS, ETC. < 19 ACUTE SORE THROAT, ETC. u 1— z S _J -a: s: o o o 20 BRONCHITIS 7. D 5 21 CLEANLINESS NEEDED 22 CATARRH, RHINITIS ?3 COLDS, BAD, eORYZA 24 EAR DISCHARGE, OTITIS 5 25 EARS: MINOR ?fi ECZEMA 13 ?7 EYES; MINOR U ?fi HEADACHE, A SYMPTOM ^ 29 LARYNGITIS u 30 NOSE BLEED, EPISTAXIS «i 31 PHARYNGITIS 3? RHEUMATISM 33 SEX AILMENTS 34 SKIN; MINOR ..J 35 STOMATITIS 3fi WOUNDS, SORES, ETC. 137 URINARY, ENECURESIS D E F o H- C/D •a: or o a. E II o — — 03 — 3 II ® T3 03 03 "03 ^ c 03 Ul E 1 03 3 CO CO •a 03 03 llj < z W CO LU CC Q O < lij Z o X a. II X JB3A »W|J jeax puooas ■IB3A pjim jeax iiiJnoj JB3A M«!a uojpadsui JO uoj^tujiusx^ dq; o} pjeQ sjifi Suuq s^m|V STANDARDIZATION OF SCHOOL MEDICAL SERVICE 187 them with colored clips. At the end of the day the nurse will record all the work of inspection and the findings in the column for that day's work, on the weekly report form. This daily and weekly report will be treated under "exami- nations." (b) Occasional Room-Inspections. — Occasionally other room- inspections (special room-inspection is a good term) must be made by the nurse after the routine one in September. Very rarely will the doctor be needed for such work. The method can be that of the general inspection described, or she can simply pass along the aisles and inspect the children. The latter can have their hands on the desks, and the nurse, passing along from the rear, can easily note the condition of the hair and scalp, as well as other features. The nurses of Newark made an average of nearly 500 occasional classroom inspections each during the school year studied by the writer, besides about 21,000 individual inspections and over a thou- sand home visits each. These room-inspections are especially valuable in poor or foreign districts in bringing up the health and cleanKness standards toward those of civilized America. They are also valuable, as suggested, in the case of an impend- ing epidemic. (c) Individual Inspections. — Individual inspections are to be made principally by the nurse, but also, if necessary, by the physician in the one building he visits for two or more hours each day. Only urgent cases are to be referred either by nurse or teacher to the doctor. The principal classes of individual inspections are as follows: w. Pupils referred at the time of the nurse's visit, by the teachers. X. Pupils entering that school for the first time, any age. y. Pupils who have been out of school for any reason more than three days, especially excluded, or quarantined cases. z. Pupils brought to the attention of the nurse in the homes. Where principals are, or become, qualified, a large num- ber of the readmittance inspections may be left to them. 1 88 EDUCATIONAL HYGIENE The importance of the health training of principals and teachers, and the books they can use in study, will be brought out later. A principal who hasn't such a knowledge of children (child-study) needs to ^' study up." He must, how- ever, beware of cocksureness after little study. The usual place for the individual inspections is at the health-room or the principal's office. A bell is rung indicat- ing the nurse's arrival. A school janitress or a good prin- cipal's clerk may be of great assistance in getting the chil- dren ready. Each child will come with his health-record card in a fold of clean paper, and on this paper may be written the teacher's reason for sending in the pupil. He may be suspected of some ailment, or the teacher has noticed that he is not getting the treatment previously recommended, or for many other reasons, except as punishment. The nurse inspects the child, and, unless he is excluded, sends him back to his room, with a note to the teacher about the case on the same folder-protector of the card. The teacher may clip small memoranda slips on the cards of pupils who have not yet obtained treatment, or put these cards in a special part of her file, or she may use the various colored clip- markers for card indexes, each color of which may be given a standard meaning, as before mentioned. The symptom chart prepared by Doctor E. B. Hoag and printed in his "Health Index of Children," and separately, or some other set of indices to school ailments, such as are used in Cleveland, or printed by the writer in American Education, or those given by Doctor Wood in his "Health and Education," will be of great assistance to the teachers in locating the children needing to be referred to doctor or nurse.^ Most of the present work of medical inspection is really teacher inspection, since most of the cases are first noticed by the teachers and then sent in to the doctors. With all this responsibility, the teachers have not been given a square deal in the way of health instruction in the form of lectures, 1 See also the bulletin of the U. S. Bureau of Education, no, 524, pp, 130-13 1. STANDARDIZATION OF SCHOOL MEDICAL SERVICE 1 89 clinics, teachers' meetings, or books, by which to fit them- selves for their serious responsibility; and their normal or college courses have never, in most probability, even touched upon such matters. "The child," to their professional train- ing institutions, was quite largely a disembodied mentality, and psychology was the only study of his nature. DIAGNOSTIC TABLE, OR SYMPTOM CHART Disorders and Their Indications (to be observed by teachers, nurses, and parents) Teeth Defects Decay of teeth. Offensive breath. Discoloration. Poor articulation. Crooked teeth. .Broken teeth. Prominent teeth. Malnutrition. Disorders of Nose, Throat, and Ear Mouth breathing. Slow mentality. Prominent upper teeth. Deafness. Loud breathing. Poor physical development. Nasal voice. Earache. Catarrh. Discharge. Running nose. Inattention. Frequent colds. Poor spelling. Sore throat. Watching of lips. Offensive breath. Slow progress. Cough. Headache. Blank expression. Eye Disorders and Defects Sore eyes of any kind. Headache. Sties. Peculiar postures when reading. Congested eyes. Holding book too near face. Crossed eye. Poor reading or spelling. Squinting. Dizziness. Infectious Diseases Pallor. Vomiting. Flushed face. Headache. I go EDUCATIONAL HYGIENE Eruptions. Scratching, Sleepiness. Lassitude. Cough. Running nose. Congested eyes. Nervous Disorders Inability to hold objects well. Spasmodic movements. Twitching of eyes, face, or any part of the body. Irritability. Fits. Bad temper. Fainting. Nail-biting. Undue emotion of any sort. Frequent requests to "go out." Timidity. Stammering. Cruelty. Perverted tastes. Moroseness. Solitary habits. Undue embarrassment. Undue activity. Misbehavior. Sex perversions. Nutritional and General Disturbances Pallor. Emaciation. Enlarged glands in neck. PuflSness of face or eyes. Shortness of breath. Lassitude. Perverted tastes (e. g., food). Slow mentality.. Peculiar or faulty postures. Underdevelopment. Excessive fat. Vicious personal habits. Low endurance power. Irritability. Disinclination to play. Fatigue. Defects of the Feet Walking "pigeon-toed." A shuffling, inelastic walk. Toeing markedly out. Advancing foot by exaggerated knee action. Long axes of foot and leg meet at unusually wide angles. Shifting from foot to foot. Standing on outer edge of feet. Locking knees. Leaning against wall or desk. Shoes run over at either side. Front of heel worn down. Outer and back part of heel worn down. Wearing out of soles asymmetric- ally. Congestion of the feet. Swelling, puffiness. Excessive perspiration. Callouses. Twitching of the foot muscles. STANDARDIZATION OF SCHOOL MEDICAL SERVICE 191 Incorrect Posture Unequal height of shoulders. Flat chest. Standing on sides of feet. Curved back. Prominent abdomen. Stooping. If this chart of symptoms devised by Doctor Hoag is printed on a heavy card and furnished each teacher, she will be given much assist- ance in doing her part. See his "Health Index of School Children^' mentioned above. (2) Environmental Inspections. — ^After pupil inspections, according to our outline, come environmental inspections. Home visiting, or home hygiene inspection, by nurses is about their most important work, and the problem of school sanita- tion will soon come up in any thorough system of medical supervision. The home-hygiene inspections^ at the time of the nurse's home visits are becoming exceedingly valuable citizen-making institutions, and no words here can indicate the spirit, the possibilities, or the methods of that humane and scientific work. We arrange for the records of such visits in cipher on each individual record card. Each nurse should obtain Doctor Hoag's or Doctor CornelFs book, and, at least, a book probably now published by the first munic- ipal school nurse of America, Mrs. Lina Rogers Struthers, R.N., recently superintendent of school nurses at Toronto, and formerly of New York City. Doctor Dresslar's book on *' School Hygiene" is also a desirable volume on the whole field. In certain small cities the experiment has been success- fully tried of making the nurse the attendance officer also (thus saving another salary as related), so that she can go to a home and handle a case of truancy effectively, as any other school "case." The possibilities have not yet been half dis- covered in this whole field of home visiting. Even where there are attendance officers, the nurse becomes their most valuable assistant. School sanitation inspection is more naturally the work of the superintendent, director of hygiene, principal, and 192 EDUCATIONAL HYGIENE business manager; but the nurse and the physician should know enough about the subject from such texts as Shaw's or Dresslar's books on ^'School Hygiene/' or the other books mentioned, to do effective work in calling to their attention as often as is necessary evil conditions of lighting, cleaning, heating, ventilating, the condition of toilets, the necessity for play, playgrounds, and play apparatus, sanitary drinking- fountains, the proper kind of dusting, and all such matters. The Board of Health of Philadelphia has a special card form for recording the facts of school sanitation, and Doctor Hoag has a portion of his book and a pamphlet devoted to a "Sanitary Survey of Schools," which is of great assistance to the amateur.^ Quite frequently the nurse or the school physician will observe unhealthful conditions not noticed by teachers or principals and, then, may be even more success- ful than they in remedying these conditions. It depends upon who has the ability to translate private opinion into public opinion and private scientific knowledge into public action. -(C) Examinations. There is no need of calling these physical examinations except where the word examination is (badly) used for inspec- tion. We have suggested that a thorough, routine room- inspection of children for all ailments of a serious character, recorded on the health-record cards, is very much Hke an ex- amination. It is, however, not so individual, so intensive, and so technically diagnostic. Inspections will frequently overlook decayed teeth entirely, and will never include routine vision or hearing tests, nor will they ever require, perhaps, the stripping of each child to the waist, as a matter of routine and without suspicion of some heart or lung ailment. An exami- nation should be a patient, scientific investigation of a child's health status, regardless of whether he is suspected of having ^Whitaker and Ray-Wiggin Co., San Francisco, or Paul Hoeber Co., 69 East 59th Street, New York City. See also the New Jersey form of 1 14 points in the U. S. Bulletin, no. 524, pp. 127-129, and the form used by Doctor Ayres in the Springfield (111.) School Survey, given earlier. For rural schools, Doctor Dresslar's government bulletin on " Rural Schoolhouses and Grounds." STANDARDIZATION OF SCHOOL MEDICAL SERVICE 1 93 an ailment. Such examinations should not be painfully long and impractical, however, in their minutiae. Quick, accurate, and thorough observation and judgment can be developed in this field as in any other. Much will depend upon the phy- sician and the nurse and what they have in their minds as questions and problems regarding each child's health condition. The examinations should be made in the health, or medical, room. This should be about half the size of an elementary schoolroom (25 by 16), and be well Kghted. It should have both hot and cold running water, a toilet adjacent, facilities for a combination tub and shower bath, a couch, several chairs, an anteroom for those awaiting examination, filing cabinets for case cards (for systems needing them), a table or desk or two with drawers, a medicine cabinet, a white- enamelled iron-and-glass stand, white-enamel wash-basins, and the various test-cards, medicines, and the Kke needed by nurse and physician. Types of equipment and suppHes are given in a former chapter. Many schools add to these a platform scale, usually a "Jones," with height standard at- tached. Its necessity as a matter of general routine for all school-children is yet to be demonstrated, however. The Method of the Examinations. — ^As suggested, it will probably be best for the nurse to be present each day during the two hours or more of the examination, so she can confer with the physician over cases and help in handhng the chil- dren, making the vision and hearing tests, taking the records, etc., as can best be arranged. Scientific management in busi- ness does some of its best work with seemingly minor details of daily practise. There is great opportunity for the practise of its principles in medical supervision and especially in the examinations. This condensation of the plan, however, must limit itself to bare essentials, in order not to exceed all space limits. Wie have urged that the vision and hearing examinations, once a year or less often, as is found better, be given by the nurse and not by other persons; and that she do this, as 194 EDUCATIONAL HYGIENE much as possible, at the time the physician of her district makes his two-hour daily visit to some one school. One nurse will work with the physician at all times, while the extra nurses will devote themselves to inspections and home visiting. Here, at the ringing of the bell which indicates the physi- cian's arrival, or before, children suspected of having serious ailments or who for some reason require immediate attention are sent by the teachers or nurse to the health-room. At the same time pupils of the lowest grades, a room at a time, are sent, by threes, to the health or medical (inspection) room. The nurse quickly inspects the serious cases, referring to the doctor for further inspection such as are puzzHng, and then disposes of the first group. If desired, they may be examined at this time. She then prepares, as may be necessary, a child (of the three mentioned) for the doctor's examination, calling his attention to any ailments or history of the child familiar to her and necessary for him to utiHze, and begins, herself, to test the vision and hearing of another child. By the time the doctor is through with his medical examination she will perhaps be through with these two tests, and all can be recorded on the health-record card of the pupil, exclusions can be made, or notices to parents regarding serious physical defects or other ailments signed. Each case (name of child) will be placed in her case-book, or on a case-card on file in the health-room or principal's office. Such cards for de- fective pupils are found necessary in many cities. The one used by Newark is sent to the *' department of medical in- spection" when the case is concluded. Cards not sent in by the end of the school term are used for follow-up work in the summer. Whenever a case is concluded, the teacher should be notified. The word "case" is frequently used to mean both a single child and all his ailments at any one time, and again each one of the ailments found, so that a child might be six or more cases at once. If the term is used (and it probably should not be), it should refer only to STANDARDIZATION OE SCHOOL MEDICAL SERVICE I95 one child with all of his ailments, whether one or many, at any one time. Usually every new ailment he gets will make another case. Then, instead of recording the number of '^ cases," the number of different ailments should be given, and for a large group of children there will always be more ail- ments than pupils — ^probably, on the average, two or more to one. The time of the examination should preferably be from nine to eleven each day, and each day in a different school during a week or longer, depending upon the number of schools it takes to supply about three thousand children, and somewhat upon the locality, of course. Perhaps two thousand for the doctor and the same or fewer for the nurse may be found desirable in a poor, foreign district. For small schools the doctor's visits should be distributed over the year. A school with 200 pupils will mean about ten visits, or one every three or four weeks. Compromises may be made here. "If the nurse and doctor go to the same school, how can we have inspection at other schools each day? '' some one may ask. This is one of the reasons for the extra nurse in the typical city. She will do this work. Otherwise, the prin- cipals and teachers must use their discretion, as they have done for so long, until the nurse can come in the late morn- ing or in the afternoon. Some of these daily inspection visits she can avoid by telephoning to a school and finding whether the teachers have looked and found any urgent cases. On schedule, she will probably get to one or two of these other schools each afternoon anyway. We cannot go into further details with respect to the examinations of various kinds, psychological, scholastic, dental, and others. There is httle need of dentists making dental examinations when nurses and doctors give the neces- sary care to this part of the complete survey of the child. Directions for making vision, hearing, and mental tests may be found in other works. Whenever a referable, non-infectious ailment is found during inspection or examination, the following note to par- 196 EDUCATIONAL HYGIENE ents may be filled out from the cards and enclosed in an en- velope by the nurse to be sent to the parents: Medical Supervision of Schools, Health City, N. J. NOTICE TO PARENTS OR GUARDIANS This notice does NOT exclude the pupil from school. Date , 191. . The parent or guardian of is hereby informed that a physical examination by the school physician seems to show that this child is suffering from You are advised to take this child to your family physician or a specialist, for advice and treatment as soon as possible, in order that the pupil may be better fitted to do successfully and without injury his school work. School Physician. This notice may be placed on a card of a certain color, say yellow, and about 53^ by 3 M inches in size. Some send all such messages by post, but this is in most cases a needless expense. On the back of the card may be printed a permit by the parent for the nurse to take the child to a cHnic or physician for medical or surgical treatment, and an alternative state- ment that the parent has had a physician and the result of the visit, somewhat as follows: PLEASE SEE THAT TmS CARD IS RETURNED TO THE TEACHER This pupil was seen by Doctor on , 19. . , with the following result Signature of parent or guardian, I desire the school nurse to escort my child to. for medical or surgical treatment of the. Signature of parent or guardian, STANDARDIZATION OF SCHOOL MEDICAL SERVICE ,197 If the parent does not respond within three days, and an inspection at that time by the nurse shows no evidence of satisfactory treatment, another notice should be sent. If this notice is not heeded, and it should be printed and worded in such a manner as to command attention and get results, the nurse may visit the home to help the parent see the need of the treatment or to explain and arrange with her the free treatment at some dispensary, the school clinic, or other similar place. If the nurse is unable to get the treatment, and cannot do it herself, the physician, principal, or teacher may attempt the matter. So many parents are so poor and so ignorant, and the provisions for treatment are so inadequate or unsatisfactory, that men and women in the school medical service are soon driven to see the absolute necessity of an adequate school clinic, with an oculist to make eye examinations* and pre- scribe and, at times, furnish free glasses, dentists for dental service, and surgeons for operative work. The surgeons or the nurses attached, or a school physician, can make such treatments as are necessary — those for ringworm of the scalp with X-rays possibly, for favus, for trachoma, ade- noids, tonsils, etc. — and, with the help of the physical-edu- cation division, can give such medical gymnastics as are needed for orthopedic, mouth-breathing, and other cases. The need for an open-air school, and outdoor cooler ('^uncooked") and moister air in the classrooms, will also soon be made mani- fest in even the best of cities. As the examinations extend through the entire year, and the graduating class of February may not be reached by that time, it will be well to give this class an examination early in the term. Other children who may also be examined out of turn are: all the children of a family when a parent has come to the examination, as suggested, children going into athletic contests (very important in some cities), children who are especially referred to the physician by the nurse, or to the nurse by the teacher, and children who have entered 1 98 EDUCATIONAL HYGIENE school, or that school, for the first time after the pupils of their rooms have been examined. Not only parental visiting at the examinations is desir- able, but also school consultations with nurse or physician, when the parent has neglected treatment for the child, for instance. A notice such as the following may be sent, at the end of the three-day period mentioned: DEPARTMENT OF MEDICAL SUPERVISION OF SCHOOLS Date J 19- •• To the parent or guardian of Public School You were notified a few days ago that this child was found on examination by the school physician nurse to be in need of immediate treatment for Please call at the school at o'clock to confer with the school physician nurse. Principal. Cross out either "physician" or "nurse" where they are printed for alternative use. This card may be white in color and 3 ^ by 5 H inches in size. Other devices to obtain treatment will be invented by the thoughtful and interested nurse, physician, or principal. Some cities use attendance officers to force children in whom the doctor or nurse will not admit till treated or cured. Notice is also sometimes sent that parents are keeping children out illegally, even though excluded or referred for treatment. When the time has come, three days after notification, and the pupil is in school, the teacher sends the pupil in for the nurse's or physician's inspection to see if the cure has been obtained. No record of cure or treatment is ever to be made without such inspection. The teacher's opinion is not enough. Doctor Foster, of Oakland, California, has his nurses record cures at the first routine inspection only, and these for ailments found the year previous. Cures take time. STANDARDIZATION OF SCHOOL MEDICAL SERVICE 1:99 A further attempt at accuracy, co-operation, and a check on the work of doctor and nurse, is the principal's monthly report based upon his own and the teachers' records. This may be made very briefly as a part of the monthly report. The following tentative standard classification and termi- nology with probable frequency of ailments should be used for weekly and annual reports. School Ailments and Defects with Probable Number OF Ailments to be Found Among a Thousand Elementary Pupils I. NON-COMMUNICABLE AILMENTS A. Physical Defects. 1. Adenoids, nasal obstruction, etc 50 2. Anemia 10 3. Deafness, defective hearing * 5 4. Dental, teeth defects 660 5. Enlarged tonsils 60 6. Eyesight, vision defects 70 7. Eyes crossed, strabismus, squint 7 8. Glands enlarged, adenitis 10 9. Heart defects 9 10. Lungs very weak, not tubercular 5 11. Malnutrition, debility, indigestion, "general condition" 20 12. Mentality 10 13. Nervousness, chorea, habit spasm, nervous exhaustion 2 14. Palate defects 7 15. Skeleton, orthopedic defects (flat-foot, club-foot, etc.) 2 16. Spine: curvature, posture, round shoulders, etc 8 17. Speech: stuttering, stammering, lisping, etc. 9 B. Common Ailments. 18. Abscess, boils, etc 5 19. Acute sore throat, cough, etc 2 20. Bronchitis i 21. Cleanliness needed 20 22. Catarrh, rhinitis 10 23. Colds, bad. Coryza 30 24. Ear discharge, otitis media 15 25. Ears: earwax (impacted cerumen), foreign bodies, etc., minor 5 200 EDUCATIONAL HYGIENE 26. Eczema 7 27. Eyes: "sore," blepharitis, sties, iritis, etc., minor... 20 28. Headache (a symptom), migraine, neuralgia 15 29. Laryngitis 5 30. Nosebleed, epistaxis 2 31. Pharyngitis, chronic sore throat 3 32. Rheumatism i 33. Sex ailments and habits 10 34. Skin ailments, minor; herpes, seborrhcea, acne (black- heads) , etc 15 35. Stomatitis, mouth ulcers, "canker sores" i 36. Wounds, sores, sprains, poison-ivy, chilblains, "first- aid," etc 150 37. Urinary ailments, incontinence of urine, eneuresis. . . 2 II. COMMUNICABLE AILMENTS A. Parasitic and Minor Infectious Ailments. 38. Conjunctivitis, "pink eye," etc 30 39. Favus, yellow scalp sores i 40. Impetigo "contagioso," infectious sores 20 41. Influenza, grippe, infectious colds of a serious char- acter I 42. Pediculosis, head lice and vermin 50 43. Ringworm, body and scalp 4 44. Scabies, itch 5 45. Tonsilitis, quinsy 10 B. Infectious Diseases. 46. Chicken-pox 6 47. Diphtheria 2 48. Measles 4 49. Mumps 4 50. Scarlet fever 4 51. Trachoma, "granulated eyelids" i 52. Tuberculosis of the lungs, "consumption" i 53. Tuberculosis of the bones and other parts of the body i 54. Whooping-cough, pertussis 2 Total i;409 (D) Treatment, Cure, and Correction. — First-class school climes, as free to the children as text-books but carefully regulated by the school officials, are sure to be made a part of STANDARDIZATION OF SCHOOL MEDICAL SERVICE 20I all school systems, first in the poorer parts of the larger cities, but later everywhere. This is the cheapest and best means the community can take to develop real preventive medicine, for the small amount of clinic treatment in the child's school period, and before, will mean the early detection and eradica- tion of many grave pathological beginnings. A permanent tooth lost, for example, can never be replaced. It is gone for- ever; and no less an ideal than the saving of nearly all teeth up to the age of twenty and beyond can be long tolerated. But such thoroughgoing clinics will be long in coming, as shown in the chapter on that subject, and many substitute measures must be employed. Parents and family physicians must always be given the first chance for most ailments, even when their work is poor. Dental work may be accom- plished by the use of a travelling chair sent from school to school and manned by voluntary or paid dentists. It is com- paratively easy to get individuals or private organizations to give much valuable service in this direction. The splendid work being done abroad can be learned in Doctor Cruick- shank's volume on ^'School Clinics at Home and Abroad." No book has yet been written on the work being done in this country. (E) Prevention. — ^AU the work of medical supervision is preventive from the life standpoint, but the emphasis should be strong on this phase as in no other phase of human effort. The medical supervisor must interest himself in the physical- education department, not only for medical gymnastics and training of mouth-breathers, but for building up gen- eral bodily resistance and vigor. The consultation hours for mothers, now becoming common in schools, will help to get prevention at work very early with the little children yet in- fants. Co-operation with all agencies will centre the best ef- forts of the community on adequate health protection. Superintendent's Annual Report on Medical Inspection. — Much in the way of progress, records, and education of the public depends upon the character of this annual, public re- 202 EDUCATIONAL HYGIENE port. The number of pages of the present reports devoted to this subject varies greatly even by percentages. South Manchester, Connecticut, probably gives a larger share of its report to these newer health matters than any other city. The plan of coming around to health matters every few years for intensive and comparative treatment, while emphasiz- ing certain general features every year, is to be commended. Some of the features of the regular report may well be : (i) The summary of the weekly reports, which have been summarized for the newspapers and for each monthly board meeting during the year, both as to ailments and the general features given on both sides of the weekly report. (2) Comparison with the work of former years. (3) Interpretation of the data presented. (4) Some of the interesting cases handled during the year, to give the intimate personal side, with photographs, if possible. (5) Emphasis on the percentage of ailments cured. (6) The principal needs and problems, and what parents can do to help. (7) Appreciative words for the various voluntary health agencies that have helped during the year, the newspapers, bequests for school clinics, etc. How the various divisions of the hygiene department have co-operated. (8) A general estimate of the health conditions of the school-children. Measuring the Efficiency of Medical Supervision Systems. — The principal efhciency tests are the percentage of the serious ailments existing in the school population that have been found and the percentage of the ailments found that have been cured. The decrease in ailments foimd from year to year due to prevention and curative measures (not to changes in the standards of inspectors) is a third essential factor. The estimate given above of the approximate per- centages of serious ailments to be found in an ordinary school population at the present time, may be used for comparison. STANDARDIZATION OP SCHOOL MEDICAL SERVICE 203 Among a host of other tests of efficiency of this work are the following: (i) Number of physicians and nurses in proportion to the school population, and the number of nurses in relation to the number of physicians. (2) The qualifications and the character of the super- vision of these officials. (3) The percentage of the school population inspected and examined, and the frequency of these. (4) The quaHty of the reporting system, whether it em- phasizes essentials, and whether it promotes accurate records with minimum loss of time from other work. (5) The annual number of hours of work for physicians and nurses, and the regularity and punctuality of attendance upon such work. % (6) The reasonable freedom from epidemics, closing of schools, deaths of school-children, amount of exclusion, quaran- tine, illness, absence and elimination, etc. (7) The quality of the methods of doctors and nurses, to be determined by expert observation. (8) The amount of State-aid money obtained because of efficiency demonstrated to the State Supervisor of Hygiene. Note. — Complete explanation of this plan of health supervision may be found in the editor's volume entitled, " The Administration of School Medical Inspection," published by Teachers College, Columbia University, New York City. CHAPTER XII THE SCHOOL NURSE AND HER WORK^ The Introduction of Nurses. — It was the introduction of the trained nurse to the work of school medical inspection that revolutionized the health supervision of school-children. In England, in 1893, we have the first definite record of the work of the school nurse. This work was done voluntarily by Miss Amy Hughes, a member of the Metropolitan Associa- tion of Nursing, who was asked by one of the managers of a poor school in the Drury Lane district in London to visit the school and attend to the children's small ailments. The result was most beneficial. In 1898 a voluntary association was formed, called the London School Nurses' Society. The following circular was prepared and issued by it: The London School Nurses' Society has been formed with the object of supplying visiting nursing to elementary schools in poor districts. Already three nurses visit some of the poorest schools and attend to the small ills of the scholars — such as sore heels and inflamed eyes. Excellent results follow their ministrations: each is able to visit four schools in one day, and see about one hundred children, who are sent to her one by one by the teachers. It is hoped that the work of the London School Nurses' Society may be done wherever possible by a Queen's nurse, and so avoid the multiplying of agencies. The Jubilee Institute has approved of school nurses in principle. Probably it will be difi&cult to impress on the public the importance of the work to be done, or the necessity for these nurses; but it must be remem- bered that the sore heel soon becomes poisoned if left to London dirt, and the inflamed eyes often lose all power of seeing simply through neglect. There is no surer way of securing the health of the people than to arrest small ills at the beginning; a nurse can see at a glance 1 See also the chapter on "The Professional Trainiog of School-Health Workers." 204 THE SCHOOL NURSE AND HER WORK 205 whether a child should be sent to a doctor; she can impress cleanli- ness; she can follow up bad cases to their homes; she can recognize the early symptoms of fevers, and do much to stop the spread of those infectious diseases which so often devastate our schools. It is found that cases of bad eyes and dirty heads are practically stamped out of a school by six months' regular visiting; consequently each nurse is able to enlarge the scope of her work as time goes on. In 1904 the London county council took over the work, thus placing it under municipal control. But it was in 1902 that school nursing was first put on a municipal basis, and New York City claims the credit for this forward step. New York City History. — Medical inspection of schools had been established for many decades before this, but the results were far from satisfactory. The history of school nurses in New York City is particularly interesting, inasmuch as those who suggested and helped to work%out the scheme of school nursing are still actively engaged. The suggestion came from Miss Lillian D. Wald, who was talking over the health problem of the schools with Doctor Lederle, Health Commissioner of New York City, and Mr. Charles BurHngham, chairman of the Board of Education. The question under discussion was: "What is to be done with all the children who are excluded from school for minor con- tagious diseases by the medical inspectors?" Miss Wald at once said: ''Try a nurse." She herself is a nurse and always sees the great possibilities in new opportunities; so, after some further discussion, it was decided to see what a nurse could do for the children in the schools, and for the return of those who were excluded. The writer was asked to make the ex- periment, and on September i, 1902, began by selecting for test purposes four of the large down-town schools.^ First Duties. — The first duty was to visit the school prin- cipals and explain the work. As no rooms were available, any corner of the schools which could be utilized was selected. ^ Thus the writer of the chapter has the honor of being the first municipal school nurse. — Ed, 2o6 EDUCATIONAL HYGIENE Arrangements were made to have all children examined by the medical inspector sent to the nurse, who treated the minor cases in the school; the remainder were taken to dis- pensaries, except those who were excluded for the major con- tagious diseases, such as scarlet fever, measles, etc. A Ust of the children excluded was obtained from the principal, and these were looked up and returned to school as soon as possible. An hour daily was spent in each of the four schools, and a regular time-table followed. The supplies used were generously donated by the Nurses' Settlement. A course of treatment was outlined and submitted to the Department of Health, which with a few revisions is in use at the present time. This course of treatment is about as follows: Treatment. Pediculosis. — Saturate head and hair with equal parts of kerosene and sweet oil; next day wash with a solution of potassium carbonate (one teaspoonful to one quart of water), followed by soap and water. To remove "nits" saturate hair with hot vinegar. Favus, Ringworm of Scalp. — Mild cases: Scrub with tincture of green soap, cover with flexible collodion. Severe cases: Scrub with tincture of green soap, epilate, paint with tincture of iodine, and cover with flexible collodion. Ringworm of Face and Body. — Wash with tincture of green soap and cover with flexible collodion. Scabies. — Scrub with tincture of green soap, apply sulphur oint- ment. Impetigo. — Remove crusts with tincture of green soap, apply white precipitate ointment (ung. ammon. hydrarg.). Molluscum Contagiosum. — Express contents, apply tincture of iodine on cotton toothpick probe. Conjunctivitis. — Irrigate with solution of boric acid. Supplies. — ^Later the Board of Education provided the following supplies: 1 screen. 2 chairs (i high). I cabinet. I table. THE SCHOOL NURSE AND HER WORK 207 1 scrap-basket. 12 towels. 2 pounds absorbent gauze. I dozen bandages (assorted sizes). I pound boracic-acid powder. I quart tincture of green soap. 4 ounces collodion. 1 pound vaseline. 4 ounces white-precipitate ointment. 2 basins (white granite). I glass jar (i gallon). I ointment jar (glass). 100 bichloride-mercury tablets (to be kept in safe place). These were ordered by the principals with the other regular school supplies and replenished when necessary. Municipal Appointment. — On November 7, 1902, the Board of Health appointed its first school n%irse, Miss Lina L. Rogers, R.N. In December of the same year twelve nurses were appointed, and their work for one month proved of such value to the community that the Board of Estimate appropriated $30,000 for school nurses for the year 1903. This is the beginning of what has developed into one of the most efficient social service organizations of the present day — three hundred and sixty-five school nurses being now employed by the Board of Health of New York City. Growth of Nurses' Work. — In the beginning of the work the nurses' duties were limited to treating the children ex- cluded by the medical inspector and to making home calls to explain what treatment was required for the excluded child. Later on classroom inspections were added to the nurses' duties, giving the medical inspectors more time for the phys- ical examinations. The opportunities for far-reaching social service became evident on the first visits to the homes. Classroom Inspection. — In making the classroom in- spection the nurse took her position by a window so that she might have a good Hght for the inspection of the child. The eyes, ears, nose, throat, skin, and hair were all examined for 208 EDUCATIONAL HYGIENE evidences of disease or defect. Wooden tongue depressors were used for examining the throat, one for each child, and where any symptom of diphtheria was found the child was sent home. Where any defect was present the children were referred to the medical inspector. His duty was to make a diagnosis. A code was devised by which numbers could be used instead of the name of the disease, to conceal from chil- dren the name of the disease, and to lessen the clerical work. Code Used. CODEi 1. Diphtheria. 12. Varicella. 2. Pediculosis. 13. Pertussis. 3. Tonsilitis. 14. Mumps. 4. Pediculosis. 15. Zero. 5. Ac. conjunctivitis. • 16. Scabies. 6. Pediculosis. 17. Ringworm. 7. Trachoma. • 18. Impetigo. 8. Pediculosis. 19. Favus. 9. Zero. 20. MoUuscum contagiosum. 10. Scarlet fever. 21. Acute coryza. 11. Measles. Zero numbers are given to children having no disease, so that all should be given a code number. No feeHngs were hurt by the method. Home Visits. — The nurse took charge of the child after the diagnosis, and by persistent effort and many visits to the home, finally persuaded the parents to have the defect remedied or disease treated. It is this following up and point- ing out the danger of neglect that means so much to the child and to the success of school medical inspection. The whole aspect of the school medical work has changed since nurses have taken such a prominent part in it. It is no longer medical inspection of schools. It is medical or health super- vision of school-children. The child has a future, and some one must in dead earnest point it out to the parents who fail or refuse to see it. » See also code in preceding chapter, prepared by the editor. THE SCHOOL NURSE AND HER WORK 209 School Boards' Duty. — Right here it may be said that some boards of education are not doing their full duty toward the children under their charge, by forcing them to study while they are physically unfit. Where now employed, the school nurse's duties are numerous and varied. Besides making the classroom inspections and referring the cases to the medical inspector she is called upon to do much of the scientific work. In some cities the school nurse takes the swabs for throat cultures, and excludes all suspect cases of diphtheria, scarlet fever, measles, etc., as soon as discovered, notifying the medical inspector of such exclusion as well as the health de- partment. She is also permitted to treat eye diseases in school according to the physician's order. Drills. — She is responsible for the conditions of cleanli- ness of the mouths of the school-children as well as their general cleanliness. Tooth-brush drills are Carried on regu- larly and efficiently in the schools by the nurse. Nose-blowing drills are no longer a fad but a recognized necessary aid to general health habits, and the nurse is the one who sees that this is regularly carried out. It was a nurse who originated these drills in the schools.^ Even now we are learning that this has a very marked effect on the breathing of the children, inculcates cleanly habits, and keeps the air in the classroom purer. Teachers are beginning to see the valuable effect of it on their own health. In the visits to the homes even greater good is being done by the school nurse. Here she imparts instruction on the care of the body, the value of clean surroundings, of wholesome food, of proper clothing, and of right habits of living. She discovers all kinds of unhealthful conditions, concealed cases of contagious disease, rooms without air or light, overcrowded homes where bad moral conditions exist, filthy drains, and leaky plumbing. These and other conditions are being constantly reported by the school nurse to the proper authorities, and adequate relief obtained from the proper sources. ^ The writer herself . — Ed. 2IO EDUCATIONAL HYGIENE Rural School Nursing. — In rural communities health supervision of school-children is quite as important as in the cities. It is not possible for many of the smaller municipal- ities to provide a medical inspector, nor is it always necessary. If a properly qualified nurse is employed she can urge the parents to consult their own family physicians, and in this way have almost all defects removed or diseases cured. It will not be necessary for one school to have a nurse devote her whole time to it. Several districts could unite and have the nurse spend one day a week in each. This would divide expenses and give a good service. Each school should be visited frequently to note progress, to urge the practise of hygienic measures advised, such as the drills, and to give talks on proper food, ventilation, dental care, etc. Relief Organizations. — One of the school nurse's duties will be to find out all the reHef agencies in her district or dis- tricts. If there is no dispensary, she will be the one to find ways and means to estabHsh one. If the authorities cannot aid, some influential women in the neighborhood should be induced to unite and have it started. If relief is required, similar means are taken to secure it. Everything, of course, should be done so far as possible by the municipal authorities. I believe that the school board should furnish freely every- thing that is necessary for the child's health and strength, such as food, clothes, and medical attention, wherever it cannot be furnished by the home. Otherwise it is waste of money to try to educate the child. A weakened brain cannot be active and receptive; therefore strengthen it so that it can. Children who are anemic and undersized should be kept in the open. The school nurse should urge that children be taught in the open all day in country schools as well as the 'city, and what is good for the delicate in this instance is equally good for the strong. Let us have no walls for schools when it is possible to do without. Little Mothers' Classes. — The school nurse also should start Httle mothers' classes in the school as soon as she begins THE SCHOOL NURSE AND HER WORK 211 work. Inestimable good will be done by having these girls taught how to do the essentials of home-making. Gradually they grow into the habit of wanting to know the reasons for this and that, and before long the nurse finds she is a teacher in sex hygiene in the most natural way. Teach the girls to bring their baby sisters and brothers, so that they may learn how to bathe them and note any abnormalities; show them how to make a bed properly; to prepare food for the baby; to make clothes for it; and to look for any unusual conditions in the children of the families who are their friends. School Dental Chairs. — Here is the beginning of a great work in the development of the future race, in looking after the teeth. The *' little mothers" will soon learn to look for the first tooth, and to keep it clean. If this interest is aroused and right habits formed we shall not need to fear for the future of the children's teeth. It is very necessary that all the school-children have regular, systematic dental care. To this end, wherever possi- ble, have a dental chair placed in the school. Experience has proved that the installation of dental chairs in the schools is not a difficult undertaking and is money saved many times over. In Toronto, Canada, the school nurses subscribed $500 and presented it to the Board of Education for the equipment of a dental room in one of its schools. In addition the Board installed three chairs in other schools. This year six more schools have been equipped with dental chairs. A dental surgeon works from nine to twelve daily, and on Saturday from nine to eleven. Many methods may be used to get the money and permission for the first experiments.* The Qualifications of a School Nurse. — The nurse who would be a successful school nurse must have a special train- ing for the work. In addition to the general training in a hospital which has wards set apart for eye, ear, nose, throat, and skin diseases, she should have a course in district nursing. * See chapters on co-operation and initiation of school-health measures. 212 EDUCATIONAL HYGIENE This is most important, as it brings the nurse in contact with home conditions. Here she learns how it is sometimes next to impossible for the parents to get things done, owing to all sorts of unfortunate conditions. A capable, intelligent nurse who knows the agencies in her district can often reheve serious situations at once by a few helpful suggestions as to how relief may be obtained. The school nurse should have a healthy, pleasant appearance. The nurse who fails to keep herself tidy and neat, and whose teeth are not in good condition, does not gain the confidence of the children, and her work is never successful. The school nurse should have a broad social outlook. She must be a power in the community in which she works. She must know how to meet rich and poor ahke, and this is where tact, good sense, and sound judgment are required. She must know how to avoid hurting the feeHngs of the family physician. The most essential requirement is thoroughness. Every detail should be recorded for future use — some may be mental notes. One nurse reported ninety-nine visits to one family before she got results.^ Controlling Authority. — ^The school nurse should be em- ployed by the board of education or board of school trustees as one of the regular school staff. This avoids two authorities controlling the school work. The teachers give heartier co- operation to one of their own associates, and all are working ultimately for the same result — to make the school-child a better citizen both physically and mentally. This has been clearly demonstrated since the school nurses became a part of the medical-inspection system. Rules and Regulations. — In one of the larger cities the following general rules and duties of nurses have been adopted: *Here is where legal compulsion can frequently be used to advantage. — Ed. THE SCHOOL NURSE AND HER WORK 213 GENERAL RULES As teachers, nurses, and medical and dental inspectors are all em- ployed by the board of education, and as all are working for the fullest development of the children, educationally and physically, it should not be necessary to ask for hearty and harmonious co-operation in the work. Always be courteous and sympathetic with parents and children, and thus avoid much needless resentment. Absolutely no suggestions as to treatment shall be given except as hereinafter directed. Medical inspectors and nurses must promptly report all dis- covered cases of contagious disease to the board of health, thus ren- dering efficient assistance in eliminating this menace to the community. The following diseases must be referred to the principals for ex- clusion: smallpox, scarlet fever, diphtheria, measles, German measles, mumps, chicken-pox, acute tonsilitis, whooping-cough, open cases of tuberculosis, and such diseases of skin, scalp, and ^e as, in the judg- ment of the medical inspector, should be excluded. Except in case of sudden illness, request for leave of absence must be forwarded to the department of medical inspection at least one week before such leave is required. In case of inability to report for duty on account of illness, notify the department of medical in- spection by telephone. A written notification must follow within twenty-four hours. When reporting for duty after absence, a certificate of illness from the attending physician must be presented. Daily reports must be forwarded in time to reach the department of medical inspection by the first mail on the following morning. At each school visited, a time-book must be signed, stating the time of arrival and departure. All cases requiring treatment must be referred by card, in sealed envelope, to the family physician. Medical inspectors and nurses must not remove the clothing for examination of children, " without consent *' or in the presence of parent or guardian. Medical inspectors and nurses must not interfere in any way with the school discipline. Duties of Nurses Each nurse is assigned to a group of schools. The hours of duty are from 9 a. m. to 4 p. m., and Saturday, 9 a. m. to 12 noon. Each nurse shall prepare a time schedule for her group of schools 214 EDUCATIONAL HYGIENE which must be forwarded to the superintendent of nurses for approval; a copy must be given to each principal. Each nurse must see cases referred to her by the medical inspector and deal with them as directed. Morning Inspections and Treatments. — In a room designated for the purpose the nurse must receive each morning all children referred to her by the medical inspector, and give instructions or treatment as follows: Pediculosis. — Children affected with pediculosis are to be instructed as to methods of home treatment. Each child must be given a copy of the official circular, entitled "Instructions to Parents on the Care of Children's Hair and Scalp." These children are to be instructed to report to the nurse at her request, and at such times are to be exam- ined for evidence of treatment. In instances of persistent neglect, the child is to be referred to the medical inspector for exclusion. Eye and Skin Diseases. — Methods of treatment to be employed. Favus. — Mild cases: scrub with tincture of green soap and cover with flexible collodion. Severe cases: scrub with tincture of green soap, paint with tincture of iodine, and cover with flexible collodion. Ringworm of Scalp. — Treatment as in favus. Ringworm of Face and Body. — Wash with tincture of green soap and cover with flexible collodion. Scabies. — Wash with tincture of green soap, and apply sulphur ointment. Impetigo. — Remove crusts with tincture of green soap, and apply white-precipitate ointment (ammon. hydrarg.), lo per cent. Conjunctivitis. — Irrigate with warm solution of boric acid. Instructions for Physical Defects.— The nurse must obtain each day from the medical inspector a record of the physical defects of each case examined on that day. When necessary the nurse may request the parents to confer with her at the school regarding the treatment for the child. The dates of these consultations must be noted on the nurse's record copy. The nurse will note on the physical-record card the nature of the treatment received from the family physician. Emergency Cases. — In the absence of the medical inspector the nurse will give first-aid treatment, referring all such cases as require it to the family physician. In the absence of the medical inspector any suspected case of major contagious disease should be referred to the principal for exclusion, and should be reported immediately by telephone to the department of medical inspection, giving child's name and address. A written report must be mailed the same day. The nurse must be ready to give any information to the principal THE SCHOOL NURSE AND HER WORK 215 as to the children under her care. A child must not be sent from school without the consent of the principal. Routine Inspection. — The nurse must make a fortnightly routine inspection of the children in the classrooms. The eyelids, throat, skin, and hair of each pupil are to be examined. The children are to be instructed to pull down the eyelids, open the mouth, and show the hands. Wooden tongue depressors are furnished by the department, and a separate one must be used for each child where such use is necessary. No tongue depressor is to he used more than once under any circumstances. All cases of suspected minor contagious disease found are to be noted on the class record cards, with the data, in appropriate columns. The class record cards must be kept in an accessible place in each school in charge of the nurse. Code numbers or letters must be used to indicate the disease. All suspected cases of contagious eye and skin disease found are to be referred to the medical inspector for diagnosis. Home Visits. — When cases referred by the medical inspector have not been given treatment in a reasonable time, the nurse must visit the parents at home to explain the condition and the necessity for treatment. The nurse must give general directions regarding proper food, ventilations, cleanliness, and general hygiene. Revisits must be made in each instance until evidence of treatment is shown, or parents refuse treatment. No case must be terminated on account of inability to obtain treatment until it has been referred to the medical inspector. If the parents are unable to take the child to a dispensary, the nurse may do so, but must previously obtain in writing a request to that effect, signed by the parent or guardian. No visit shall be made to contagious cases. Home visits and visits to hospital or dispensary must be noted on the nurse's record copy. The form must then be submitted to the medical inspector, who will sign it if the evidence is satisfactory. Evidence that a child is under medical care is sufficient for ter- minating the case. Meetings. — Nurses must report regularly, in person, at such times as may be designated, to the superintendent of nurses. In Conclusion. — The possibilities of the work of the school nurse and the opportunities afforded her of doing real con- structive work, both in the schools and in the homes, cannot be estimated. The bond of friendship which exists between 2l6 EDUCATIONAL HYGIENE the school nurse and the mother in the home makes it pos- sible to secure for the children from infancy onward a far greater degree of care than would, or could, otherwise be given. The school nurse has it in her power not only to remedy the existing conditions which are menaces to right living but has also the opportimity to open up new avenues of social service. Her work is not alone with those who have defects or disease but very largely with those who are well. Her duty will become more and more the supervision of the life habits of the well; therefore much more teaching of the laws of health will be observed and the result to humanity can better be imagined than described. Nurses have a splen- did opportunity for fitting themselves for this new field in nursing by taking a course at Teachers College, Columbia University, where the practical training is also provided. CHAPTER XIII SCHOOL FEEDING School Feeding as an American Problem. — The school lunch has always been an important part of our American school life. The noon hour plays a prominent part in stories of the little old red schoolhouse of former days. It was then that the pent-up energy of social longings found relief, and the most enduring companionships were formed. Al- most all of the young people stayed at the school during the noon hour and ate lunch together because few of them lived near enough to go home. This condition still prevails in rural districts, but where urbanization has taken place schools and homes have been brought nearer together in distance and the school lunch has largely disappeared. But there is one kind of school — the high school — in which the old order has never changed. This is because in towns and smaller cities there is usually but one high school, and even in larger cities each school serves a large district. The consequence is that the children have a long way to go to reach their homes, and so we have developed the single session extending over the noon hour and broken by a short lunch period. As a result, in himdreds of high schools through- out the land, groups of young people numbering from a score to many thousands in each locality are every day confronted by the alternatives of going hungry, eating a lunch brought from home, or buying one near or in the school. How the High School Meets the Problem. — ^The many ways in which the high schools meet or fail to meet the prob- lem may be summarized under the two headings of no pro- vision and supervised provision, either indirect or direct. 217 2l8 EDUCATIONAL HYGIENE The first method is rapidly becoming less common. Under it the school authorities pay little attention to what the young people eat during the lunch period, or where they eat it, so long as they do not annoy the teachers or litter the premises. The results are socially unwholesome and phys- iologically unhealthy. The breaking of bread with one's fellows is an important social matter and the conditions sur- rounding it should be as comfortable and cheerful as circum- stances permit. The health considerations are more important. Where no place is provided in which the boys and girls can eat their lunches conveniently and in leisure, there is every temptation for them to eat nothing at all, or to eat little and bolt that little down with the greatest possible speed. These conditions are frequently but slightly bettered when the school authorities sell to the janitor or some caterer the privilege of maintaining a lunch-room in the school build- ing without official supervision or control. The second form of solution came into being when Bos- ton, in 1894, determined to grapple with the high-school lunch problem and solve it. In that year Mrs. Ellen H. Richards was instrumental in getting the school board to decide that all selling and serving of food in its high schools must be done with its approval and under its supervision. An arrangement was made with the New England Kitchen through which wholesome lunches were prepared and dis- tributed to the city high schools. This plan was successful, and has been developed until at present the fifteen pubhc high schools of Boston are daily suppHed with Imiches pre- pared by the New England Kitchen and sold to the students at cost. The rooms and equipment are furnished by the city and a committee of high-school masters supervises the work. At present the school board is considering taking over the lunch-rooms for direct control. An example of the direct provision of high-school lunches is furnished by Philadelphia, where the work in every school SCHOOL FEEDING 219 is financed and controlled by the board of education. The superintendent of this lunch system has the rank of super- visor in the school government. She is an expert dietitian. Penn^y Lunches bought at School ,u Calories Penny Lunches bought on Street Bean Soup ■ Sausa^e&Roll Rice Pudding H Pretzel Cocoa H Cinnamon Bun Milk H Ice Cake Ro^al Lunch H MarshmallowCake 52 Graham Crackers 1 Calories Popcorn po! 1 Spice Wafers 1 1 Candy 1.%% Dartes 1 1 Licorice Sweet Chocolate 1 I Chocolate Rppermint Stick Candy ■ " Candy Roll RELATIVE FOOD VALUE OF SCHOOL AND STREET LUNCHES The left-hand column represents the food value of a penny portion bought at school when a charge of one-quarter of a cent is made for service. The right-hand column shows the food value of the amount purchased for a cent from the street vendor, who makes all he can on the deal. At school the amount of food given for one cent is always as high as possi- ble. In the street the child can buy something which is not food at all, like licorice. In addition to supervising the preparation of the lunches, she spends several hours daily teaching classes about food uses and values. In this teaching the school lunches are used as examples of economical, carefully planned, and wholesome meals. One of the lessons is that the typical lunch at school, costing ten cents, gives seven hundred calories, while crullers and coffee, a common meal where lunches are 220 EDUCATIONAL HYGIENE unsupervised, yields but two hundred and fifty calories for the same price. Another example of municipal high-school lunches is afforded by Rochester. Since 1903 the two high schools of that city have conducted lunch-rooms directly managed by the board of education. The kitchens and dining-rooms, instead of being adapted basements, were provided for in the original plans of the buildings, and as much attention was given to their construction and location as was devoted to any of the other rooms. The dining-rooms are light and airy, open to the direct rays of the sun, and have a seating capacity of one thousand pupils each. The kitchens are well equipped with such me- chanical contrivances as steam cookers, dish-washers, and potato-peelers. The cooking is done by utiKzing the waste steam from the general heating plant, so that there is no extra expense for fuel. An experienced dietitian, appointed by the board of education, superintends the entire work of pur- chasing, preparing, and selling the food. There are five workers in each school who cook and serve the meals. These lunch-rooms are entirely self-supporting. As les- sons of experience have made the work more efficient, the in- creasing profits have been devoted to providing more food for every five-cent piece paid by students, instead of turning the extra revenue back into the city treasury. The result is that each year has seen an increase in the amount of food purchased for five cents, until at the present time this sum secures for the children generous portions of well-cooked roast beef or roast lamb. Other articles of food are correspondingly cheap. Soups cost five cents, desserts five cents, a large plate of macaroni with cheese and bread five cents, half a pint of certified milk three cents, a buttered roll one cent, and a bread-and-butter sandwich one cent. The money received from the sale of food at these prices covers not only the entire cost of the food itself but that of SCHOOL FEEDING 221 all the salaries of attendants and supervisors, besides the upkeep of equipment. The work done in Rochester and Philadelphia is perhaps more highly developed than is general elsewhere, but never- theless it is only a sample of what many cities are doing. Administration of High-School Lunches. — The New York School Lunch Committee in a recent inquiry found that of 68 cities, ^S furnished students of the high schools with lunches directly; i8 had farmed out concessions to commercial ca- terers; 7 allowed co-operative student organizations to fur- nish lunches under supervision of the board of education; and in 5 cities lunches were sold by private philanthropic organizations, such as women's clubs, etc. In practically all cases the cities supported the lunches to the extent of the overhead charges. There is no doubt that high-school lunches are to-day practically recognized as*a legitimate part of public-school provisions. The general features of administration in sixteen typical cities are shown in the following summary based on data gathered by the Committee on High School Lunches in Bos- ton in 1913. The cities included are: Brooklyn, New York, Buffalo, Rochester, Springfield, Fairhaven, Newtonville, Philadelphia, Pittsburgh, Cincinnati, St. Louis, Kansas City, Grand Rapids, Minneapolis, Omaha, and Seattle. In all these cities the financial risk is finally lodged with the school board. Immediate responsibility for administra- tive detail rests with the domestic-science department in eight cities. In five cities the work is controlled by a special committee of the board. In two cities, where only one high school has the lunch, the work is directed by members of the faculty; and in the remaining city by the High School Students' Association. In a number of cities they had first tried out the experi- ment of having janitors or caterers serve the lunches, but in four cities where the work is relatively new it was begun im- mediately under school-board control. In St. Louis and three 222 EDUCATIONAL HYGIENE other cities the school-luncheon work is under the supervision of the domestic-science department, and cooking classes oc- casionally provide food for the lunch-room. This works out particularly well in the smaller cities where the numbers are not so large — as, for example, in Newtonville, Mass. In at least one case the money is handled by the commercial de- partment of the high school. In Philadelphia the superin- tendent of lunches gives talks at the different high schools on lunches and dietetic principles involved. There has been practically no attempt to connect the work in the high schools with the health department, though this connection is an important feature of the lunches in ele- mentary schools. In Pittsburgh this was proposed and ap- proved by the board, but had not been put in operation ac- cording to the last report. In only one city was the director reported as not specially trained for the work. In thirteen cities the superintendent of lunches ranks as a regular school officer, being either supervisor or a member of the faculty. In nearly all the cities the surplus is designed for im- proving the lunches themselves, as, for example, reducing the price of foods served or buying new equipment. In a few cities, however, the money is returned to the general school fund, and in Springfield it is turned in to a common revenue fund for the city. It is practically a universal custom to charge enough for the lunches to cover food and service. In a majority of cases enough is charged to cover the cost of ice, the upkeep of equipment, and repairs. The cost of superintendence is covered in eight cases, and fuel in five. Light, heat, rent, and water-rates are not included in the cost. The School-Lunch Problem in Elementary Schools. — ^The essential features of the planned and supervised lunch in the best high schools are that the child's need is provided for, the food is sold at cost, and it is wholesome and well served. The lunch-rooms are cheerful, pleasant, and sanitary, and the work SCHOOL FEEDING 223 is under responsible management. Moreover, there is no compulsion, actual or implied, put on any child to buy the school lunch — he is simply given the opportunity. The question that school workers are now asking is: Why cannot the same benefits be secured for the vastly larger number of elementary-school children? In the smaller towns and country districts the younger children face the same noon problem as their older brothers, with the difference that they have a longer afternoon session of work ahead. In mill and factory towns and in the poorer districts of the large cities, even when the children go home at noon, there is frequently no one there to prepare lunch. Both father and mother are absent at their work. Moreover, ignorance about nutritive food and its preparation is so dense and so wide-spread that thousands of children start for school in the morning after a totally insufficient breakfast consisting, for instance, of coffee and bread, and taking with them a few pennies to buy lunches in the shops near the school. In consequence they must wait until night before they get a real meal. The fact that more than fourscore cities are already tak- ing steps to meet this problem shows that it is real, wide- spread, and serious in degree. The first question which con- fronts every one of these cities, as well as the others which have not yet begun to provide for school lunches in elementary schools, is whether or not this work is a legitimate function of the board of education. Objections to School Feeding. — When the project of in- augurating school feeding in elementary schools is proposed to the taxpayer, the citizen, or the school man, the immediate reaction is almost always one of opposition. The expression of this opposition takes many forms, among which the fol- lowing arguments are usually prominent. School feeding, it is claimed, would further complicate the already intricate systems of public education; it would add to the work of already overburdened teachers. The providing of school meals would tend to lessen the responsibility of the home and 224 EDUCATIONAL HYGIENE SO undermine the foundations of family life. If meals are provided at all, they tend to become not only free but uni- versal, which would result in pauperizing the community. As some children would receive meals and others not, the system would tend to promote undesirable distinctions among the children. If children are genuinely underfed at home, the provision at school of one meal per day will not solve the prob- lem of their proper nourishment. The foregoing arguments are the most important of those commonly urged against school feeding and are fairly typical of the rest. On careful analysis, all of these argu- ments fall into two classes. In the first come those objec- tions which form one or another feature of the general argu- ment that the providing of food is not a legitimate function of a department of education. The objections of the second class include arguments that school feeding is socially danger- ous. It seems worth while briefly to consider whether or not the objections against school feeding are so important and valid as permanently to exclude it from among the possible activities of the modern socialized school. To the first objection, that furnishing food is not a legiti- mate function of a department of education, it may be answered that under our systems of compulsory education the power to force every child to attend school carries with it the duty of making it possible for every child to learn. If the child is so hungry that he cannot learn, some means must be pro- vided whereby he shall be fed. Hunger is a stern condition, not a social theory. It cannot be met through the offering of a geography or a grammar. It is clear that where social con- ditions exist which involve the presence in school of large numbers of unfed or underfed children, it is the function of the school to see to it that some means be provided whereby these children can obtain food in order that they may be in condition to obtain knowledge. This does not necessarily involve provision by the school itself. It does involve the facing of the problem and the securing of some solution for it. SCHOOL FEEDING 22 5 The arguments of the second class claim that school feed- ing is socially dangerous, that it tends to undermine the re- sponsibility of the home, and that it results in governmental paternahsm. There is one nearly universal fallacy in the reasoning that lies behind these arguments. This is the assumption that any form of school feeding means the free provision of meals for all children. This assumption is unwarranted by the facts either here or abroad. Such work as that already de- scribed as being carried on in the high schools of Rochester, Boston, Philadelphia, and other great cities has no remote suggestion of the dispensation of alms. What it does provide is the opportunity to purchase wholesome food at cost. This is what school feeding in America has meant up to the present time and, so far as we can foresee, it is in tjie main what it will continue to mean. Moreover, it is in large measure what school feeding means abroad. Elementary-School Feeding and Medical Inspection Anal- ogous. — ^There is a close analogy between the extension of the school's activities to provide an opportunity for purchasing food, and the existing systems of medical inspection which examine children and notify the parents of the steps which need to be taken to put them in such physical condition that they can benefit by the free education provided by the State. Both are extensions of social machinery which provide oppor- tunity for, but do not supply the remedy for, the wrong condi- tion found. The sort of school feeding which we are discuss- ing provides machinery for finding out which children need food, and for giving their parents an opportunity of remedy- ing the situation by purchasing food at cost. In the same way, medical inspection examines the children and discovers exist- ing defects, but does not remedy those defects. It simply gives the parents an opportunity of knowing of existing conditions and it points out the remedy. Public-school cHnics and other forms of public treatment, of course, are rapidly entering the field of free treatment, but for the most part municipal clinics restrict free treatment to those in destitute circumstances. 226 EDUCATIONAL HYGIENE In stating that the estabhshment of school feeding means the provision of opportunity to purchase wholesome food at cost, it would be misleading to overlook the fact that there will always be some children in the poorer sections of our great cities who are genuinely indigent and to whom meals must be furnished free, if they are to be furnished at all. There is nothing new about this situation, nor does it present any insurmountable difhculties. In every State and city where school text-books are purchased, there have been in force for many years different regulations for providing books free of cost to children unable to purchase them. The machinery for solving the same problem with respect to meals has been brought to a high state of perfection in several European coun- tries, though little has been done to meet it here. In America the school-limch movement which has had an astonishing development in the last five years is character- ized by the absence of the relief element. Although a large proportion of our school-children — lo per cent by conservative estimate, 25 per cent by more liberal interpretation — are suf- fering from malnutrition, the relief of this condition is not the primary aim of those advocating school meals. It is the conviction of American school men that, if the school is to assume responsibility, it must be because of educational considerations affecting 100 per cent of the children. This conviction was expressed again and again during the school feeding session at the Fourth International Congress on School Hygiene at Buffalo in August, 1913. Administration of Lunches in Elementary Schools. — Within the last five years the movement for extending the benefit of warm lunches served at cost to the children in the elementary schools has spread from five to ninety cities in twenty-eight States. While in the larger number of instances the work has been inaugurated by private organizations, such as women's clubs, home and school associations, and so forth, it has been always with the moral support of the school au- thorities and personal co-operation of members of the school SCHOOL FEEDING 227 governments, in addition to financial help in the way of over- head charges and fuel. As in the case of the high schools, there is a distinct tendency to regard the work of the private organizations as preliminary demonstration of methods fea- sible for use by the school boards when they assume entire responsibility. According to Edward F. Brown, executive secretary of the New York School Lunch Committee, out of sixty cities thirty-five were serving meals under the jurisdic- tion of the school board. The essential features of the administration of the work in New York, which dates from 1908, are as follows: There is a committee of eighteen men and women, including school- board members, medical inspectors, social workers, and mem- bers of the faculty of Columbia University. The chairman is an experienced dietitian and social worker. The superin- tendent is a graduate dietitian with experience in teaching and dietetic social service in a hospital. The buying, and the engaging and direction of cooks and helpers, are in her hands. There are seventeen schools supplied with lunches at noon from four central kitchens. A year of experience with central kitchens has demonstrated their greater economy and effi- ciency as compared with separate kitchens. The only Kmit to centralization of kitchens is made by the necessity of provid- ing different menus for schools with attendance of different nationalities. Thus, separate provision is made for Italian^ Jewish, and Irish-American children. This is, however, dis- tinctly a problem of very large cities. The cooks are employed for the whole of each school day at a weekly wage of ten dollars. Under the superintendent are a corps of paid supervisors who are present two hours daily at each school to see to the preparation, selling, and dis- tribution of food. The actual serving of the food is done by pupil monitors who wear white aprons, caps, and gloves. These helpers receive their lunches free. Owing to the large numbers, and lack of special dining- room provision, the children eat their lunches standing at 228 EDUCATIONAL HYGIENE long tables erected in the basement. Each child must pur- chase the main dish, a bowl of soup, before being allowed to get the penny extras served at a separate table. The kind of soup varies with the predominant nationality of the chil- dren. Examples of soups served in the American districts are: split pea, tripe, clam chowder, vegetable, Scotch broth, and macaroni. The food value varies from 74 to 148 calories. In the Jewish schools the food is heavier and, to avoid offend- ing the laws of kosher, entirely without meat, as: potato and barley, lentils and rice, lima beans and barley, rice and milk, Obergritz and potatoes, noodles and milk. The average num- ber of calories here is 190. In the Italian schools the special dishes are menestra, rice and tomato, beans and pasta, maca- roni, and rice with cheese and tomato. The average number of calories is 138. After the child has bought the soup he goes to the extra table, where he may purchase one or two other things at a penny apiece. Among the extras are: sandwiches with jam, egg, onion, lettuce, meat, bologna, and cheese; potato, cab- bage, tomato, or lentil salad; bread, chocolate, or rice pudding; cocoa; sweet chocolate squares; crackers, jelly cake; ice- cream; grapes, bananas sliced with milk, prunes, apple sauce, baked apple, apple sugared on stick. A child spending three cents at these tables gets from one-third to one-half of the total amount of food he needs during the day. Feeding in Open-Air Classes. — In classes for tuberculous, anemic, and convalescent children the lunches are as much a part of the treatment as the fresh air itself. The meals are more elaborate than is usual in the regular schools, and they are more frequent. The following menu is typical of the American practise: Breakfast: Cocoa, graham gems, butter, stewed prunes. Lunch: Stew of rice and mutton, or creamed codfish, mashed potato, bread and butter, milk, dates or figs. Supper: Milk, crackers and cream cheese, or preserved fruit. SCHOOL FEEDING 229 These meals supplement the home meals. Counting in the average home meals, the children consume as much as 2,500 calories, which would be far too high for normal children but not for these whose metabolism is overactive or deranged. Lunches in Rural Schools. — One reason that health con- ditions in rural schools have been so long neglected is because of the common idea that country children are naturally vigor- ous and healthy. ''This ought to be so but unfortunately is not," says Doctor Ernest Hoag, in a recent government re- port. He finds that, "in general, food is not as well prepared in the country as it is in the city; the available variety is smaller." Bad methods of ventilation and heating at home and at school, exposure to wet in the long walks to school, and overdressing in the house — all are inroads on the already badly nourished bodies. Investigations sl^ow that malnu- trition and its accompanying diseases are quite as frequent among country as among city children. Steps to remedy this condition are being taken in New Hampshire, Washington, Nebraska, South Dakota, Texas, and Minnesota; in the last two cases, under the direction of the State universities.^ The equipment necessary for the rural-school lunch need not be more elaborate than a top for the stove used for heat- ing, some pots, cups and spoons, and wash-basin and towels. The preparation and service can be done by the children in turn, and is an excellent adjunct to domestic-science lessons. Frequently a single warm dish, like soup or stew, or cocoa, is prepared to supplement the cold lunches brought from home. The two essentials are warmth and the presence of protein, as the lunches brought by the children, as well as their home diet, are apt to be overrich in starches and sugars.^ The Place of Nutrition in the School Hygiene Movement. — ^In 1867 M. Dupre, Commissioner of Education in France, * See report of Doctor Thos. D. Wood to National Education Association in February, 1915. 2 See Andrew's " Education for the Home," part two, section two, bulletin 611 of the U. S. Bureau of Education. 230 EDUCATIONAL HYGIENE recommended to the local directors that they look into the health of their pupils and pay particular attention to their nutritional condition. This is the first time that an official concern for the nutrition of school-children was recorded in any country, although it does not mark the beginning of school feeding. School funds for the support of extra-academic activities, such as lunches and baths, were made general throughout France as a result of M. Dupre's suggestion, and in 1882 the "Caisses des Ecoles" were made compulsory along with general primary education. In 1872 a municipal law in Munich called for a kitchen and dining-room in all new school buildings. This was an official recognition of work which began as a relief measure in 1792. In 1890 the school feeding movement in Germany re- ceived national recognition at a congress of vacation colony workers, where it was decided that the good results of sending children to the country in summer were more than counter- balanced by the evils of bad feeding throughout the year. In 1909 the National Society for People's Welfare, in a three days' conference, reported on work in half the German cities and in many rural districts. In England, between 1866 and 1905, largely through the efforts of teachers, no less than three hundred and sixty sepa- rate societies were organized for the rehef of acute distress re- sulting from hunger. The agitation over "physical deteriora- tion" in England, from 1902 to 1906, resulted in the discovery of malnutrition during the growing period as an important factor in the lowering of the national fitness. The first act of legislation to grow out of this agitation was the Provision of Meals Act, which gave the local educational authorities per- mission to install school restaurants as part of the regular school equipment. Malnutrition and Medical Inspection. — Recently there has been an increasing tendency to make the report on nu- trition of different children the basis of the entire medical- inspection report. This is because it has been demonstrated SCHOOL FEEDING 23 1 again and again that the occurrence of disease and physical defects is largely conditioned by nutritional disturbances. In Paris medical inspectors have charge of the school canteens and are required to report on the nutrition of each child. They are further expected to follow up any child with impaired nutrition and to administer tonics and special care. In England, since 1907, compulsory medical inspection has included inspection of nutrition. Beginning with 1909, the chief medical officer of the National Board of Education has reported yearly on the nutrition of the children through- out the country and on the work of the school feeding centres. In Scotland the medical inspectors are required to see that children suffering from malnutrition are fed properly either by the school or by the parents. As a result of this system- atic work British school doctors are develcfping methods of technique and standards for judging malnutrition, which, on account of its complex and interwoven causes, is very difficult to estimate accurately. • The correlation of disease and malnutrition is every- where acknowledged. It has been worked out with scientific accuracy by Doctor Gastpar, of Stuttgart, who from 1906 to 191 2 examined 65,000 children, making a thorough physical and medical examination, and then, dividing the children into five different nutritional groups, determined the propor- tion of disease and defects in each group.^ Briefly, his results were as follows: If the children in the best-nourished group, who numbered 13,229, were compared with those of the worst- nourished group, who numbered 15,807, it was found that among 100 well-nourished children there were j6 defects, whereas among 100 badly nourished children there were 18^ defects. The defects noted in this summary were: scoliosis, diseased glands, tuberculosis, heart-trouble, eye defects, ear ^ For a preliminary report of this work see Zeitschrift fiir Schulgesund heitspflege, vol. 21, 1908, pp. 689-702. A detailed account of the entire in- vestigation is in preparation by the author of the present paper. 232 EDUCATIONAL HYGIENE defects, albuminuria, and anemia. As the badly nourished all had anemia, it would be perhaps fairer to call anemia part of the nutritional condition rather than a separate defect. In this case there would be 8^ defects to every 100 badly nour- ished, anemic children instead of 18^ defects. The Classification of Nutrition. — Doctor Gastpar's method of classifying nutrition, which is known as the group method, is one of the most satisfactory yet devised for working use. It is briefly as follows: (i) There is first an individual examination of each child, in which measurements of height and weight are taken, and the state of nutrition determined by these and other factors, such as the state of the superficial circulation, the muscula- ture, skin tonicity, the condition of the mucous membrane, the expression of the eyes and the entire face, the roughness or smoothness of the hair, etc. At the same time other physical defects are noted that may bear upon nutrition, as the condition of the teeth, presence of adenoids, and particu- larly the presence or absence of anemia. (2) After these records have been made for each individual child, the children are then divided according to their ages. Then the children of each group are divided into those having anemia and those without it. These two groups are further subdivided until, in order of nutritional excellence, children in each age-group stand thus: {a) good; {h) fair; {c) fair with anemia; {d) poor; {e) poor with anemia. Experience in the application of this plan of classifica- tion has developed three general rules that are valid for ap- plication in any country. Briefly these rules are as follows: {a) Every child is examined separately in a room specially provided, where the light and temperature may be regulated. {h) One physician should make all the examinations for any given group of children. (c) The examining physician should be familiar with the racial peculiarities of growth, complexion, and coloring. This system involves time and care, but it insures a fair degree of accuracy in a subject not easy to define rigidly. SCHOOL FEEDING 233 Some such scheme is absolutely necessary if experience is to be shared. This has been found specially valuable in record- keeping, and in finding the correlation between the state of nutrition and other physical conditions. Extent of Malnutrition among School-Children. — Until the practise of measuring nutrition by some such standard as that outlined above becomes more general, the present dis- crepancies in reports as to the exact extent of malnutrition among school-children will continue. In American cities no record of the nutrition of the entire school population has been made. In 1907 in New York the Committee on Physical Welfare of School- Children reported 13 per cent of 990 chil- dren, selected as typical of the whole city, to be suffering from malnutrition. A similar investigation of 10,090 children in Chicago in 1908 revealed 12 per cent badly nourished in all grades, the proportion decreasing from 15 per cent in the kindergarten to 6 per cent in the fifth grade and above. Wherever an attempt has been made to include all classes of children in the examinations, the percentages found suffering from acute malnutrition run from 10 to 15. Where only schools in the poorer districts are included, the percentages are far higher, and vary between 20 and 40. However, it must be remembered that children from the poorer districts far outnumber those in other schools, so that in point of figures the actual proportion of children suffering from malnutrition is probably nearer the second estimate. Doctor Thomas F. Wood, of Columbia, gives 25 per cent as the estimate for the school population of the whole country. "The longer a medical officer remains at school inspec- tion," remarks Doctor Hope, of Liverpool, in a report for 191 2, "the more severe becomes his standard of nutrition, and the less readily does he pass a child as being well nour- ished." The truth of this is shown in the British reports, which from year to year show in the aggregate an increasing pro- portion of children grouped in the division of subnormally nourished. In 191 1 the average per cent reported was 11 234 EDUCATIONAL HYGIENE for twenty- three communities; in 191 2 the average for twenty- seven cities was 13. The percentages from the different places varied from 3 to 30. In Stuttgart all the children were examined during six successive years, and classified according to the Gast^ar method described. Out of 65,000, 24 per cent fell in the group of ^'poorly nourished, with anemia,'' and only 20 per cent merited the grouping ''good." Malnutrition and Retardation. — ^In an address before the superintendents' section of the National Education Associa- tion in 1913, Superintendent Francis, of Los Angeles, gave as his opinion that a systematic provision of lunches in the schools would greatly reduce the cost of retardation. Princi- pals of Philadelphia schools have reported a substantial reduc- tion in afternoon truancy following the introduction of lunches. In 1894 lunches were introduced into Milan schools, where the average daily attendance was only 72 per cent of the en- rolment. This percentage increased after the introduction of the lunches to 94 per cent in 1905. A survey of the fac- tors making for non-promotion in Manchester, Connecticut, showed that of all the children who failed of promotion 25 per cent were suffering from malnutrition as opposed to 9 per cent among those promoted. Among mentally defective children, the proportion that are badly nourished is reported in Germany, England, and this country as being from 60 to 65 per cent. Lunches are being introduced into the special classes as a partial remedy for this condition. Planning of Dietaries. — The problems of school dietaries are: first, how to assure the children a lunch that shall satisfy the appetite, yield a fair proportion of the day's total ration, and make up for deficiencies of protein and fat found in the children's home diets; and, second, how to do all this while keeping the cost of food, preparation, and service within the ability of the children to pay. It must be remembered that the children's unit of payment is a cent. SCHOOL FEEDING 235 This problem has been most satisfactorily solved in Bradford, England, where the meals are so well planned and conducted as to serve as a model not only for England but for us as well. There are seventeen dinner menus served in rotation, thus pro\dding the very necessary variety. A sam- ple dinner— meat pie, bread, green peas, gravy, and stewed fruit — ^yields a total fuel value of 894 calories, with 33 grams of tissue-building protein, 21 grams of fat, and 168 grams of starch and sugar. The cost of this meal to the city, including superintendence, preparation, and service, is three cents, and this is what the children pay. Experience in planning dietaries in different countries indicates that if the ration is in accordance with the needs of the average ten-year-old child weighing sixty pounds, this may be varied up and down quite easily for the older and younger children. The following is a practical basis for a plan of the whole day's needs: Protein 60 grams yielding 240 calories. Fats 40 grams yielding 360 calories. Carbohydrates 250 grams yielding 1,000 calories. Total 350 grams yielding 1,600 calories. The nutritive ratio of this dietary is i to 4.8. A study of the food values of the lunches in use in well- organized systems of school feeding in England, Switzerland, and Germany indicates that they furnish over one-half of the day's total ration — a little over one-half of the protein and not quite half of the fat. Money Value and Food Value. — If there is no school lunch provided, a large and growing proportion of the children buy their own lunches from venders at the door, and at near-by shops. The average value of one-cent lunches in Philadel- phia is 114 calories; children buying of the venders are able at best to get only 52 calories. Moreover, the street food is unclean and in many cases adulterated. Most school princi- pals and teachers have met with the serious and pernicious 236 EDUCATIONAL HYGIENE influence of the cheap, adulterated candy and pastry sold at the inevitable parasitic "little candy store" near most schools. Present Extent of the School Feeding Movement. — • Lunches in the elementary schools form part of the regular educational provisions in practically aU the great countries of Europe. The movement has been made the subject of national legislation in France, Switzerland, Holland, Great Britain, Denmark, and Bavaria. It is national in scope, with direct support by the municipalities in Germany, Italy, Sweden, Norway, Finland, Austria, and Belgium. It has been started in Spain and Russia. In America lunches are commonly provided in the more progressive high schools. There are eighty-nine cities, in twenty-eight States, where lunches have been introduced in the elementary schools, and six States in which the move- ment for warm lunches in rural schools is under way. The Progressive party included school feeding in its 19 13 platform for New York State, and Colonel Roosevelt has gone on record as favoring its incorporation in the State plat- forms generally. The Socialist party has long had school feeding as one of its immediate demands. The Massachusetts Legislature, early in 1913, passed an act providing that school systems might use funds for the support of lunches, subject to a referendum vote of the citizens. As the question is bound to come up for consideration in many State legislatures, the following act has been formulated on the basis of the best available experience to serve as a model for school systems contemplating such legislation: AN ACT TO PROTECT AND CONSERVE THE HEALTH OF SCHOOL-CHILDREN AND PROMOTE THEIR EF- FICIENCY BY PROVIDING MEALS AT COST IN THE PUBLIC SCHOOLS Section i. Any board of education in a school district may pro- vide for serving lunches and selling them to pupils attending the public schools at such prices as it may fix, not exceeding the cost of purchase and preparation and service of the food. SCHOOL FEEDING 237 Sec. 2. Said board of education may employ a director of school lunches and other necessary assistants, and fix their rates of remunera- tion and draw up rules regulating the conduct of the lunches and the duties of the said employees. Sec. 3. Said board of education may appoint for the proper supervision of the school lunches a school-lunch committee which shall include in its membership the superintendent of schools, the chief medical inspector, and the director of school lunches or such other persons as the board may designate. Sec. 4. The expenses incurred under the provisions of this act shall be paid in the same manner as are the ordinary expenses for the support of public schools in the several school districts. Sec. 5. This act shall take effect immediately. Note. — See the writer's volume on the above subject. — Ed, CHAPTER XIV OPEN-AIR AND OPEN-WINDOW SCHOOLS The Problem. — The open-air school movement has gained a definite place . among the educational and ameKorating forces of the United States. Its development has been rapid, for it is based upon the experiences and knowledge acquired by an increasing number of social workers and social agencies over a considerable number of years. Settlement workers, agents for charitable organizations, tuberculosis agents, visit- ing nurses, juvenile court workers, infant welfare nurses, probation officers, church visitors, teachers and members of school boards, and a growing number of interested citizens have made the acquaintance of thousands of children living under our rapidly changing modern conditions. In increasing numbers these representatives have gone into the homes where poverty, sickness, delinquency, defect- iveness, and all manner of unfortunate circumstances have called them on their errands of neighborhness. They have come close to the homes of the poor and have acquired a first-hand knowledge of the handicaps under which less for- tunate people Hve. The bearing which untoward circum- stances have upon the Hves of children has impressed itself upon these workers as of paramount importance to the com- munity and the nation. The earher efforts were for measures of reHef. They endeavored to secure braces for crooked legs and crooked backs, to get hospital care for children who were iU, to acquire an imderstanding which would help them to get boys and girls out of trouble, or to secure them employment; or they went from the compulsory education department to force children into school; or from the courts to secure infor- 238 OPEN-AIR AND OPEN- WINDOW SCHOOLS 239 nation about dependency and delinquency. These workers ound large numbers of children anemic, undersized, and ill )repared physically and mentally for the duties of life. They earned that thousands of them had dropped out of school at m early age and that the school experience had effected little )r no beneficial result. A procession of something like 100,000 children a year lies before the courts of the country, and the stories that lave been confided to the ear of the friendly judge by troubled :hildren and heart-broken parents have been challenging the .ttention of the nation. In following the trail of these little )eople into their homes, probation officers have become pos- essed of information and understanding which throws a ;reat deal of fight on the reasons why children drop out of chool, as well as why they fail in their studies and cannot :eep up with the procession, why they get into trouble and Lo not fit into the industrial life of the community. From )urely palfiative and remedial work a widening number of aterested people have been challenging the situation and de- aanding a constructive programme. What the problem is for ine disease the following figures suggest. Influence of Medical Inspection. — Medical inspection in he pubfic schools has had a great bearing on the problem, n 191 1 over five hundred cities in the United States had a ystem of medical examination of school-children. Between tne-half and two-thirds of the children examined were found o have one or more physical defects sufficiently pronounced o need attention, many of them so serious as to handicap the :hild in his school work, and still others so marked as to make lis attendance at school dangerous to himself and to others. Discovering defects was the first step, but only the first. )0 far, less than one-half of the defects discovered have )een corrected. This work is becoming more efficient as chool nursing is provided, but there is still need for increasing he facilities for hospital, dispensary, and dental care, for ye defects, and for operations for adenoids and tonsils. 240 EDUCATIONAL HYGIENE In a recent book, "The Prevention of Destitution/' Sid- ney Webb writes as follows of medical inspection and its re- sults in England: When we get the child to school, knowledge of its condition becomes forced upon the community. The first results of systematic medical inspection are bringing home to our minds what every teacher knows, namely, that a large proportion of the children are not in a fit state to have the public money spent on teaching them, because they are suffering to such an extent from neglect as to be unable to obtain full advantage of the instruction. What emerges from the cautious sum- maries of the chief medical officer of the Board of Education for England and Wales (Scotland and Ireland being at least as bad) is that out of all the 6,000,000 children in the elementary schools about 10 per cent suffer from serious defects in vision; from 3 to 5 per cent suffer from defective hearing; i to 3 per cent from suppurating ears; 8 per cent have adenoids or enlarged tonsils of sufficient degree to obstruct the nose or throat and to require surgical treatment; 20 to 40 per cent suffer from extensive and injurious decay of the teeth; 40 per cent have unclean heads; about i per cent suffer from ringworm; I per cent are affected with tuberculosis of readily recognizable form; and >^ to 2 per cent are afflicted with heart-disease. Infant Welfare Organizations. — One of the newer and most fundamental movements has gone straight to the heart of the problem of physical welfare of children, and that is the work of the infant welfare organizations. These people have found that we have about 250,000 baby funerals in this country annually of children in their first year. This means about 150 out of every 1,000 babies. This is better than the figure in Russia, where it is 263, but it is a sad comparison with New Zealand, where it is less than 75. These were our figures as given by the American Association for the Preven- tion and Study of Infant Mortality in 191 1. It has been stated that the mortality among infants is one of the best indexes of the community's concern for human life. The story of such mortality as this is not fully told in the frequent use of the white hearse, for many children sur- vive only to emerge from the dangers of babyland with im- OPEN-AIR AND OPEN-WINDOW SCHOOLS 241 paired physique and weakened resistance. All children must be babies first, and the candidates for the schools must pass through the ignorance and dangers of babyland; and these figures show that being a baby is about the most hazardous pursuit in the world. TABLE 1 Death-Rate from Tuberculosis AGE PERIOD death-rate from tuberculosis (all forms) per 100,000 population of the states in- cluded in the registration area in igoo.' (94,205 deaths) PER CENT WHICH RATE IN I9II REPRESENTS OF I9II 1901 THAT IN 1 90 1 Both sexes Males Fe- males Both sexes Males Fe- males Both sexes Males Fe- males All ages: Crude rate Corrected rate'. . . Under 5 years r 5 to 9 years < 10 to 14 years .... ( 15 to 19 years 20 to 24 years 25 to 34 years. ..... 35 to 44 years 45 to 54 years 55 to 64 years 65 to 74 years 75 years and over. . . 25 years and over: Crude rate Corrected rate^, . . 158.9 150-1 179.4 167.0 138.0 134-4 188.8 181. 3 199-9 189.3 I77%6 173-8 84 83 90 88 78 77 126.7 3I-I 35-6 115-3 188.0 217.8 228.4 191. 193-6 194-3 158.6 209.3 206.5 133-3 31-4 27.6 99-9 190.9 230.4 278.5 253-5 253-0 229.9 177. 1 249.1 248.8 120.0 30.9 43-7 130.4 185.2 204.6 175-5 124.6 133-4 160.6 143 -I 168. 1 168.6 138.2 31-0 39.4 144.2 251-9 282.6 254-7 208.8 220.2 253.5 241.0 251.0 249.1 147-7 31.6 26.5 118. 1 247-3 287.0 285.9 256.5 267.3 284.3 256.3 277.7 277.6 128.6 30.4 52.4 169. 1 256.2 278.2 221 .6 159-0 173-9 224.3 227.5 223.7 223.6 92 100 90 80 75 77 90 91 88 77 66 83 83 90 99 104 85 77 80 97 99 95 81 69 90 90 93 102 83 77 72 74 79 78 77 72 63 75 75 iFrom 191 1 U. S. Mortality Statistics. 2 Includes Connecticut, the District of Columbia, Indiana, Maine, Massachusetts, Michigan, New Hampshire, New Jersey, New York, Rhode Island, and Vermont. Regis- tration area included 63.1 per cent of the population. 3 Corrected on basis of standard million of England and Wales, 1901. Note. — ^The colvmin for "both sexes" third from the right side means, for example, that the crude rate from tuberculosis for all ages was only 84 per cent of what it was ia 1 901, and that the rate for children from S to 9 years was unchanged. Our schools, then, are constantly recruited by an army of little people of weakened resistance, ill nourished, im- properly cared for, and poor material to be wrought upon by the school regime. The school process has gone on without 242 EDUCATIONAL HYGIENE that consciousness of individual needs, that discriminating concern for each child, to which it would seem that the most handicapped, at least, are entitled. The general tuberculosis crusade with its carefully worked out programmes has been one of the most pronounced factors in setting the commimity at work. The open-air school is one of the pieces of social ma- chinery that have come into existence because of these ex- periences and the convictions which have grown out of them. Open-Air Schools at Home and Abroad. — ^The open-air school, in the modern acceptance of the term, was started in Charlottenburg in 1904 as a rest-recovery school. It was a fresh-air camp for debilitated children, located in a beauti- ful pine forest just outside Charlottenburg, a suburb of Berlin. The German people were first in the field in sanatorium treatment for tuberculosis. They soon discovered that if de- bilitated children were sent to the sanatorium, while they gained in health they lost in educational progress. On the other hand, if they were kept in the public schools they de- teriorated in health. The now famous Waldschule provided the missing link and became a real educational experiment, but with the teaching always secondary to health. New methods of in- struction were devised, and a rich and varied programme was worked out for the children. Their school day included, be- sides the ordinary recitations, gardening, walks in the forest, nature-study work, five feedings a day, sim-bath, gymnastics in the open air, and a rest period from one to two hours in length. In his report for 191 2 the chief medical officer of the Board of Education in London makes the following statement: Open-air education was practised by the Greeks and Romans, was commended by the educationalists of the seventeenth and eighteenth centuries — Locke, Rousseau, and Pestalozzi — and has been attempted in various forms since 1876, when Bion, of Zurich, initiated the chil- dren's country-holiday movement. The growing of the towns, the in- OPEN-AIR AND OPEN-WINDOW SCHOOLS 243 crease of social effort and experiment, and the movement for the pre- vention and treatment of tuberculosis have, no doubt, been factors in the recent progress of the open-air school movement. In 1907 the London County Council established a school of this kind at Bostall Wood, and there are now about a dozen schools in different parts of the country. France, Switzerland, Italy, and Hungary have open-air schools with similar curricula and management. In general, the tendency in Europe is to construct open-air schools in the country on a plan which permits giving the children day and night care until their recovery is assured. The first open-air school in the United States was estab- lished in 1908 at Providence, Rhode Island. There are at the time of writing more than 500 open-air schools and open- window classes in the United States. Passijig through the makeshift period, when ferry-boats, piazzas, and tents were used for schoolrooms, the open-air school movement has pro- gressed to the stage where school architects are incorporating specially designed rooms for such work in the plans of their most recent buildings. Principles and Methods of Open-Air Schools. — ^The method and aim of the open-air school is to furnish the child with a programme suited to his needs. It is not merely school in the open air; it comprises a way of life and a system both of education and medical treatment. The children are ad- mitted to such schools through a careful medical examina- tion, the aim of which is to secure accurate knowledge of the child's physical condition. This information furnishes the guide for such medical treatment and correction of physical defects as are necessary to estabhsh the efficiency of the pupil. A daily inspection by the physician in charge gives opportu- nity to check any temporary indisposition and to study the effect of the modified regime upon the individual child. In most open-air schools temperature and pulse are re- corded at least once daily and the children are weighed at stated intervals. A daily cold shower-bath or a weekly warm 244 EDUCATIONAL HYGIENE cleansing bath is ordinarily given at the school. Meals are served from once to three times during the day. The physi- cian plans the diet list and often orders special diets for badly undernourished children. A rest period usually follows the noon meal. All the children recline on canvas cots or steamer-chairs for a period varying from forty-five minutes to two hours. Ordinarily, two- thirds sleep regularly; at any rate, they rest. Where a child does not waken at the end of the period and has seemed to be in special need of rest, the teacher may permit him to remain asleep until the close of the school day. The nursing supervision extends from the school into the home. The majority of open-air schools in this country are in the congested portions of cities, where the daily lives and habits of children are not so well or so carefully regulated as they would be in smaller communities. The children go to bed late and usually sleep with other persons in poorly ven- tilated rooms. The 19 1 2 report of the London Board of Education points out ''that it would be diihcult to exaggerate the physical and mental injury its children suffer from a lack of sufficient sleep and genuine rest. Large numbers of children who re- quire for physical health at least ten hours' rest at night are, in fact, obtaining much less than that amount; and this one condition is responsible for not a little of their physical un- fitness and mental dulness. Further, there are various mal- adies from which they suffer and which are being revealed by medical inspection, which call for the therapeutic remedy of rest." The teacher in a Boston open-air school says that the open- air school must, in an unusual sense, be mother and school both. "It is found," she says, ''that many of our pupils are up until all hours of the night and out again early in the morn- ing. They are improperly clothed, improperly fed, never bathed, and live in rooms that are never ventilated and are occupied by three, four, and five others. Often they come to OPEN-AIR AND OPEN-WINDOW SCHOOLS 245 school unfed, not always because there is no food, but because there is no regular living and food has not happened to come their way. If it does, it is more than probably not the right kind. It may have been soggy, half-baked bread with a little pepper on it to 'keep them warm.' '* The nurse who cares for the children at the school goes with them to their homes and tries to enlist the co-operation of the parents in giving the child better food, better ven- tilation, and better sleeping-quarters. In the Chicago open- air schools it was found necessary to make a ruling that any child who persisted in remaining up after eight o'clock at night, without good reason, should be excluded from the school. The influence of the nurse has often accomplished the removal of a whole family from insanitary quarters where privacy and decency were well-nigh impossible to homes which corresponded more nearly with hygienic standards. The nurse accompanies the children to the dispensaries, in- vestigates at once in case of absence from the open-air school, and, in general, watches over the physical well-being not only of the pupil himself but of his family. Structure and Equipment. — The distinctly open-air school is one where the air is practically the equivalent of outdoor air. Windows and wind-breaks are so placed as to control the entrance of storm and wind. The first open-air schools in the United States utilized existing buildings by modifying the window structure, or erected cheap temporary shacks to serve as their experiment stations. Thus Providence established the first school in an abandoned schoolhouse, Boston on the roof of a park re- fectory, Pittsburg on a hospital balcony. New York on dis- used ferry-boats, while Chicago built asbestos shacks on the roofs of convenient buildings in the tenement districts. Climate and local conditions determine absolutely the type of building best suited for open-air work in any particular community. The rapid increase in the number of open-air schools has led several cities to make permanent provision in 246 EDUCATIONAL HYGIENE their regular school system for open-air work. Boston, New York, and Oakland, California, are among the cities which have definitely decided to incorporate fresh-air rooms in all new buildings to be erected. This new development in schoolhouse architecture is more marked as yet in those Western States whose climates permit of open windows and no heat during a good part of the school year. In California practically all the new buildings are being erected in such a way that they can be thrown entirely open on at least one side. In the Eastern cities, where ground is at a premium and transportation is poor, more roofs have been pressed into service. Cleveland has a magnificent new build- ing, the roof of which was specially planned to accommodate four open-air schools. The children are taken to the roof by an electric elevator, and play-space, recitation-rooms, rest- rooms, kitchen, and dining-room are all provided on the roof. Detroit will erect two such buildings within a year. Many cities are modifying the style of windows in their school- houses, substituting for the old-style windows hinged windows, to swing either in or up and to occupy a larger portion of the wall space. Another recent suggestion is that of substituting open verandas for the long, dark hallways of the ordinary school- house. The architect claims that such a building would be much less expensive to construct and far safer in case of fire. It would permit of long windows opening on the verandas, which could be thrown open in case of favorable weather. Portable buildings are used in the yards of schoolhouses in many places. In Europe the Doecker portables are used very largely for open-air work and were awarded a gold medal at the Third International Congress on School Hygiene. The open-window room is a room in the ordinary school building in which an attempt is made to approximate outside conditions by regulating the amount of heat supplied and by keeping the windows constantly open. Here, also, wind- OPEN-AIR AND OPEN- WINDOW SCHOOLS 247 shields of various devices are used to keep the air from blow- ing directly on the children. The temperature in cold weather averages about fifty-five degrees in such rooms. The contrast between the freshness and purity of the air in the open rooms and that in other rooms of the same building with artificial ventilation in use is extremely marked. The difference in temperature is made up by extra feeding and by extra clothes. There is always the need of careful medical supervision, and it would be a hardship to the children to subject them to the lower temperature without adequate provision for clothing. In the schools of Chicago children are furnished with lumbermen's boots or other foot-protection, and with sweaters or Eskimo suits for schoolroom use. There is always need that either the physician or teacher, especially the latter, shall see to it that the children put on wraps when the tem- perature is low, as they will often themselvesMeclare they are warm enough and fail to put on the additional garments. The individual equipment for a child in an open-air school includes boots, Eskimo suit or other warm, loose gar- ments with gloves or mittens, sleeping-bag, blankets, cot, tooth-brush, paper napkins, and thermometer. The school equipment must include, in addition to desks, blackboards, and the ordinary furnishings of the schoolroom, provision for serving meals and some kind of locker in which the suits and other articles of individual equipment may be kept. Results of Treatment. — So uniform has been the record of the mental and physical improvement of the children under the open-air regime that detailed statements of gains seem hardly necessary. We expect increases in weight, height, chest-expansion, and muscular power, improved nutrition, better color, and more erect carriage; and we know that with these physical gains will come greater alertness and more power of concentration, consequently better scholarship and more regular attendance. It is of special interest, however, to compare these records with those of children in the public schools. Such a comparison 248 EDUCATIONAL HYGIENE was made during the school year 191 2-13 by Doctor Harold Brown Keyes between the children in the outdoor classes of the Horace Mann School, Columbia University, and cor- responding grades indoors in the same school. These are all supposedly normal children from good homes. The hemoglobin tests given at a six months' interval showed that, although both indoor and outdoor children lost in hemoglobin, the outdoor children lost only about one-ninth as much as the indoor. A comparison between the past at- tendance-records of fourteen fourth-grade children in the open- air school and indoors gave a better record of 4.3 per cent in favor of the outdoor schools. The children were two years older, however, than when the first record was made. A record of contagious diseases kept during the year showed that 12.5 per cent of the outdoor children had con- tagious disease to 17.9 per cent of indoor children. No con- tagious disease "went through" an outdoor room, as happened in one of the indoor rooms. There was far less absence for illness. In the mental tests, to quote only two examples, the third- grade open-air school children tested in formal English showed a 20 per cent improvement from December to May, while the indoor gained 13 per cent; the outdoor fourth grade gained 7 per cent and the indoor fourth grade lost 3 per cent. In arith- metic, the third-grade open-air improved 20 per cent and the indoor 6 per cent, while the fourth grade made 41 per cent in the open air and 35 per cent indoors. The supervising physician of the Bradford, England, open- air school reports that the results for 191 2 showed remarkable gains in weight and health and increase of the percentage of hemoglobin in the blood. The average attendance for the year was 138.3 and the average duration of attendance rather more than five months. The average gain in weight was about four and one-half pounds. There was an increase of 21.5 hemoglobin, and the chest-measurements showed an average increase of 1.12 inches. OPEN-AIR AND OPEN- WINDOW SCHOOLS 249 The school medical officer at Halifax, England, draws certain general conclusions from his additional experience in the treatment of debilitated children. He states: (i) Cases of malnutrition with its attendant anemia, debility, etc., give uniformly good results under open-air school treatment, unless counteracted by home influences at night and week-ends. (2) Simple tubercular glands are quickly influenced. In the three cases reported "fair" or "worse," there were lung signs suffi- cient to account for the poor progress. (3) Heart cases if compensated, and enfeebled circulation, respond well. (4) Early manifest phthisis responds better than the latent or suspected type characterized above as pretubercular. This confirms our previous experience that a child saturated with tuberculous poison, without manifest signs, is a more difficult problem than the child with an open lesion. Should the children themselves be asked now the open-air school has affected them, they would almost without exception give unconscious testimony to the change which has been wrought in their mental attitude as well as in their physical condition. A little Italian boy in Boston, writing to his teacher in an English exercise, says: '^I come to school to learn. When I went through the rooms I am going to college, and after I went to college I am going to work in an office, and I thank you, Miss Dally, for making me smart, and I thank you for the malted milk, and I thank you for bringing me into the yard." An Open-Air Letter. — ^Another child in a Chicago open-air school wrote the following autobiography for The Open Air Smile, a little paper which is published monthly by the chil- dren attending the Elizabeth McCormick open-air schools: I was born in Russia, May 25, 1899. I can speak the Russian language and my nationality is Jewish. I was born in a little gray house in a little country town near the city of Kiev. When I was two years old my downfall began. First I fell sick 250^ EDUCATIONAL HYGIENE and had the scarlet fever, and as soon as I was cured of that I caught diphtheria, and after I was cured of that I caught pneumonia. I stayed in bed for a year and I never got out of bed for that long time. I believe that all of these sicknesses left me tubercular. When I was six years old I came to America and to the city of Chicago. Everybody had told us in Russia that gold was lying every- where in the streets. I started to go to school at the Garfield school. Later we moved to a different street, so I took a transfer to the Lang- land school, and later on we moved again, and then I came to the Goodrich school, which I attended a couple of years. When I was finally in the seventh grade I was sent out to the Winfield Tuberculosis camp. I stayed there six months because I was charged v/ith having tuberculosis. Those six months passed away so quickly that it seemed to me like six weeks. I think it was the happiest time of my life stay- ing out there. Everybody was very kind and nice to me out there. They were very sorry when I went home, but when I finally came back from Winfield I was a changed fellow. Hardly anybody recognized me, because I was not the sick little fellow that I was when I went to Win- field, but a big, strong and healthy boy with cheeks like roses. Later on I was put in the Foster Open Window Room, where I am now in the eighth grade. Other items which show the restilts of the open-air school upon the child's attitude follow: When I was on the street car and was going to open the window the conductor said that I should keep the window closed. I told him that I was not used to closed windows. There was a lady sitting right next to me and she said that I was right. I did not open the window, but I went out where the motorman stands. I told him that and he laughed about the conductor. I asked him to open the window and he opened it. When I got home I told my mother and she said I was right. We almost lost two of our classmates this month. Harry Row's and Olga Zemit's fathers moved out of the district. All their brothers and sisters got transfers and are going to another school, but Olga and Harry take the car and come to our school every day. They said their mothers did not want them to leave our room because they were so much better than they used to be, and they were afraid they would not keep so well if they left us. OPEN-AIR AND OPEN- WINDOW SCHOOLS 251 When I told my mother that we did not have any school for a whole week, she said, "I bet you will be two pounds less." When I got back to school and was weighed I was two pounds and a quarter less, so my mother was right. Effect on Teachers. — ^The reflex action of the outdoor life on the teacher can best be stated by those who have experi- enced it. ^' Those who have tried the outdoor work have been capable of more prolonged labor with far less fatigue," says the teacher of the first Boston open-air school. ''The work is heavier in an open-air class but I feel much more able to accompHsh it. After the day's work I now return home fresh and do not suffer from the usual headache and dryness of throat that follow teaching in the ordinary room," comes from New York; while an Elizabeth McCormick open- air-school teacher testifies that backache, ^xtreme fatigue, and nervousness have been overcome by the fresh air and sunshine on the roof. A district supervisor of the Chicago public schools reports to the board of education in regard to the open-air school teachers who are under her direct supervision as follows: When a teacher has twenty-five pupils who represent anywhere from two to seven different grades; when her recitations are inter- rupted by the call of a physician or nurse; when entire classes are put to rest for the day at the menacing demand of a "rise in temperature," she is obliged to meet the situation with cleverness and calm. How is she enabled to do this ? Not alone because she is breathing the purest air this smoky city can bestow, but because her small number of pupils, her comprehensive knowledge of their physical, mental, and home conditions, her interest in their all-around development, have brought her into a close human relationship with them not often attainable under the conditions of the ordinary schoolroom. She is their intimate friend as well as their teacher. The teachers pass on the enthusiasm for fresh air to their fellow workers, and gradually the impression permeates the teaching force that it is better to have the windows open and the room temperature lower. Engineers and janitors fall into 252 EDUCATIONAL HYGIENE line, and presently the parents discover that school ventila- tion is a very live issue. In December, 19 13, the superintendent of schools in Middletown, Conn., issued what is supposed to be the first sweeping order to turn practically every school in the town into an open-window school. The parents were notified that beginning on a certain date the temperature in all school- rooms would be lowered and the windows kept open; that care would be taken to keep draughts from blowing directly upon the children and any child who brought a written ex- cuse from the family physician would be placed in a heated room. Parents unable to provide extra clothing for their children were to be helped by the board of education. The influence which the open-air schools are exerting upon schoolhouse architecture has been indicated under the section on "Construction and Equipment." With our increased knowledge of tuberculosis and the best means of avoiding it, and our realization of the large number of physically subnormal children in addition to those definitely tuberculous who would be benefited by the open- air school regime, the open-air school question is assuming large proportions. The Pennsylvania school code already excludes from the public schools any person having tuberculosis of the lungs, whether it be teacher, pupil, janitor, or other employee. The result in Pennsylvania has been to stimulate the establish- ment of a large number of open-air schools which have been uniformly successful in caring for the excluded children. In England the tuberculosis regulations of 191 2 make the notification of all forms of tuberculosis compulsory. This means that English cities can now for the first time tell definitely how many tuberculous children they have for whom some kind of provision must be made in the public schools. The estimate of the examining medical officer of London is that at least 10 per cent, including the anemics and the malnourished, are suitable subjects for open-air schools. OPEN-AIR AND OPEN-WINDOW SCHOOLS 253 Essentials of a Community Programme. — Most commu- nities are becoming conscious of the needs of their school- children, and are endeavoring to create forces to meet these conditions. In The School Review for December, 19 13, Fred- erick L. Hoffman estimates that in 1913 12,229 deaths among children and young persons of school age occurred in the United States from tuberculosis. First. In the schools of every large city will be found certain children who have open, active tuberculosis, and who need sanatorium care where they can be given continuous treatment until the process is arrested. A part of each com- munity's child-welfare programme should include a sana- torium built, equipped, and operated to serve the peculiar needs of children. Second. There will be other children wjio should have the kind of care that is afforded in the hospital school, where the health of the child is the paramount issue, and the aca- demic work is absolutely secondary and tempered carefully to the child's physical abilities. Boston has such a school. It is run under the auspices of hospital authorities and in connection with a hospital sanatorium. "Such a place is for children manifestly tuberculous who ought not to go to the regular public schools, or even open-air rooms, and yet who are not sick enough to require bed treatment in the hospital sanatorium." Some of the children go only for the day, others stay the whole week, returning Saturdays. There are many children of this type in the schools of a large city. Third. There- should be open-air schools where children may go during the regular school hours daily. These schools should have outdoor conditions of air, and the children should be selected and supervised in accordance with the medical and nursing regime described before. Feeding, rest, and careful co-operation with the home should be features of this pro- gramme. This school will deal with the anemic child, with contact cases, and with children who are predisposed to tu- berculosis. 254 EDUCATIONAL HYGIENE Fourth. The open-window room. Some of the most advanced cities are planning to have such a room in every school. To these rooms the children who need special con- sideration and care may be admitted. The temperature in such rooms is more easily modified, but the air can be kept fresh and invigorating by keeping the windows open, care being taken not to have the wind blow directly on the chil- dren, and to see that additional wraps are provided and that the children wear these wraps when they need them. It seems to be necessary in our educational processes to learn our most vital lessons from defective, delinquent, and physically subnormal children. Not many years ago the only place to secure manual training was in the reform- atories or correctional institutions. Madame Montessori and other educators have taken some of their most vital lessons from backward children. The best attendance in the Chicago schools during a recent term was in a room fitted up with manual-training and other similar devices and to which a lot of truant boys were assigned. Any commimity that will provide along these lines for its special groups of children will in the process have learned that such facilities are also good for normal children. The ultimate aim and goal of the open-air school movement is nothing short of right conditions of sanitation, hygiene, and school opportunity for the 20,000,000 boys and girls in the schools of the United States. Children should not neces- sarily be sick or backward or wayward to enjoy privileges and processes which in a peculiar way appeal to child nature and satisfy its intrinsic demands. Note. — See the writer's volume on "Open Air Crusaders." — ^Ed. II. SCHOOL SANITATION CHAPTER XV RURAL SCHOOL SANITATION The Need for Rural School Sanitation. — In this chapter^ only those features of school sanitation in which the rural problem differs from the general problem will be discussed. The difference lies principally in the arrangements and equip- ment adopted to make the school sanitary, as different means must be employed in the country from those employed in the city. Especially is this true in the one-teacher schools. Also, rural school sanitation is concerned with mote than urban school sanitation on account of its wider field of influence. The following principal reasons why the rural school building and grounds should be made sanitary may well be reviewed: First: So that they may be as attractive as possible to the pupils. Second: So that the health of the school-children and teachers may not be endangered. Third: So that the health of the community may not be endangered through diseases disseminated from the school by the children, or by other agencies such as the wind, rain, and animals, particularly insects. Fourth: So that the children may learn directly what sanitation means, and may acquire sanitary habits in the school for use at home, both while pupils in school and in their lives after the school-days are over. Fifth: As a demonstration of sanitation and of sanitary equipment to the citizens of the school district. All of these factors should be borne in mind in planning the rural school. Consideration is seldom given to the first, *See also cliapter X on "Rural School-Health Administration." 255 256 EDUCATIONAL HYGIENE since it is generally supposed that children take little notice of the sanitary arrangements of the school plant. This is true only to a certain extent. The insanitary outhouse is very repulsive to the children, especially to those who come from homes where clean, comfortable ones are provided. They are much more repulsive at an early age than later when the child has grown accustomed to the objectionable conditions. President John R. Kirke, of the Kirksville, Missouri, Normal School, tells of a boy who wanted to attend a ''model one- teacher rural school" maintained on the normal campus as a demonstration and training school for students preparing for rural teaching. Children are brought in to the school each day in one large transportation wagon. This boy, nine years old, lived three miles from the model school and not on the wagon route. He was willing to tramp in to the school each day if allowed to attend, giving as his reason for not liking the district school near his home, "They haven't got any modern toilets out there." The second reason is the one usually given for having a san- itary plant, but it is of no more importance than some of the others. Much sickness on the part of school-children comes directly from the school — ^poor lighting, bad ventilation, over or under heating, being some of the causes. Many dis- eases are contracted from other children either directly or indirectly. Insanitary outhouses are often the cause of the pollution of the water supply of neighboring farms or the source of disease spread about by flies and other insects. Only recently typhoid fever, which caused the death of two young women in the same family in Kentucky, was found to have resulted from the use of spring water contaminated from a school privy located a short distance away. The fourth and fifth reasons seem to me to be very impor- tant. If the child, unaccustomed to sanitary practises at home, acquires sanitary habits at the school and becomes familiar with sanitary equipment, he will probably do what he can to provide himself with similar improvements at his RURAL SCHOOL SANITATION 257 parents' home and later at his own home. In this way the school assists in the great campaign for improved sanitation now being conducted throughout the country. It assists not only the families represented in the school but also the entire community, for its sanitary equipment is to the com- munity an actual demonstration. In many parts of the country little headway has yet been made in securing the adoption of faciHties for making the farm and farm home sanitary. Several diseases that have almost entirely disap- peared from cities with proper sewage-disposal systems are still rampant in rural districts. Hookworm, with which probably one million persons in the United States are now suffering, is confined wholly to rural territory, and typhoid, while not wholly a rural disease, is more prevalent in the country than in the city. When occurring in the city it is found usually to have come from contaminated food suppKes, or milk or water brought in from the country. It is there- fore desirable that country life be made more sanitary, not only for the benefit of those living in the country but also for city people as well. It cannot be accomplished wholly by preaching the dangers of disease, but must be accom- panied by actual demonstrations of sanitary equipment. This it is the privilege and duty of the school to do. A sani- tarily equipped farmhouse is a demonstration only to the few who have access to the house; the sanitarily equipped school is a demonstration to all, because all may visit the school. It has been the experience of schools where such improve- ments have been installed that many persons have come to inspect the equipment. A few years ago the Farragut School, at Concord, Tennessee, installed a water system, water being obtained from a neighboring spring. Sanitary closets, show- er-baths, and drinking-fountains were placed in the school. Few farmers of the surrounding country had ever seen such provisions before their installation in the school, but there are very few now who have not seen the school equipment i 258 EDUCATIONAL HYGIENE and many, since seeing it, have installed similar equipment in their own homes. When the principal of a small consolidated school in a backward community in northern Louisiana had his schoolboys make screens for the schoolhouse windows, and for the windows of his house, which was located on the school grounds, he thereby introduced screens into the com- munity. None had been used before. The neighbors of the school saw the benefits immediately, and the windows and doors of probably every house in the territory served by the school are now screened.^ In selecting equipment for the rural school it is necessary to bear in mind that it is to serve a wider sphere of useful- ness than that of making the school sanitary. Its adaptabil- ity to the home should receive strong consideration. When equipment suitable to the home as well as to the school can be obtained, it should in general be selected in preference to equipment suitable for school use only. Equipment should be obtained, whenever possible, within the reach, so far as the cost is concerned, of the average family of the community. The Sanitary Rural School Plant. — In locating, building, and equipping the rural school the following points relative to sanitation should be observed: (i) The yard should be sufficiently dry to be used as a playground at all times except on unusually wet days. (2) The building must be well enough built to be comfort- able on cold, windy, or wet days. (3) The building must be properly heated, ventilated, and lighted, and the interior decorated in the colors most restful to the eyes. (4) Proper arrangements must be made for cleaning the building. (5) A supply of pure drinking water must be available, also suitable arrangements for washing hands and faces. * See bulletin on " Consolidation of Rural Schools and Transportation of Pupils at Public Expense," by the writer. (Bureau of Education, Washington, D. C.) RUIIAL SCHOOL SANITATION 259 (6) The grounds must be free from filth of any sort, es- pecially from decaying food material or animal refuse. (7) Clean, sanitary toilets must be provided. The School Lot. — The school, if possible, should be lo- cated on a site naturally drained, so that artificial drainage is unnecessary. If such a lot cannot be secured, the site should be thoroughly underdrained with tile pipe. Open ditches should not be made on the school grounds, as they are not only unsightly but are always an attraction to small boys, and wet feet and clothes are bound to follow. Even with the yard well drained, gravel, board, stone, or cement walks should be built from the road to the doors of the building and from the building to the outhouses, so that the children may keep their feet dry under all conditions. Moreover, the space under the building should be thoroughly drained, as well as the yard itself. Lighting. — ^Little need be said in this chapter regarding the building itself, since what has been said in the chapter in this book on school buildings applies to rural schools as well as to city schools. There are, however, special features con- cerning the lighting, heating, and ventilation of the rural school, particularly the one-room school, that require mention here. The great majority of rural one-teacher schools are lighted from windows on both the right and left sides of the room; many have windows on three sides; and one-room school buildings with windows on four sides are not uncom- mon. The best arrangement is generally conceded to be with windows placed on the left and rear. Where the windows are placed on opposite sides, a cross-light results which is assumed to be tiresome to the eyes. In buildings with this arrange- ment, shades should be provided, so that the light from the lower half of right-hand windows may be cut out. Under no circumstances should desks be placed facing windows. Light coming to the children from, directly in front of them is injuri- ous to the eyes, and while it may not always cause permanent 26o EDUCATIONAL HYGIENE injury it does cause eye-strain and headache, and renders the children unfit for the best work possible. Whenever con- venient, the building should be placed with the windows facing the east or west so that sunlight may enter. The windows should be placed high, extending nearly to the ceiling, and the total window space should be equal to or exceed one-fifth of the floor space. If the walls are tinted a light gray, a soft, diffused light is distributed evenly about the room, restful to the eyes and helpful in permitting the pupils to work with the greatest ease. Glossily finished walls or blackboards must be avoided, since they cause a direct reflection instead of a dif- fusion of light. Windows on the right and rear should be high and of single sash, easily opened for ventilation and air move- ment. Heating and Ventilation. — ^The usual method of heating the small country school is by the means of a single stove placed in the centre of the room with a stovepipe ascending directly upward into a brick chimney the base of which is sup- ported on the cross-beams in the ceiling. This is uneconom- ical, since much of the heat is lost through the chimney. It is unsatisfactory in many ways, but particularly because of the imeven temperature resulting in the room, especially on cold and windy days. A slight improvement is made when the chimney is placed at one end of the building, the stove near the other end, and the stovepipe suspended from the ceiHng the length of the room. A much greater improvement is easily and cheaply made by surrounding the stove with a sheet-iron jacket standing a few inches from the floor and projecting a foot or so above the stove. All direct radiation is then cut off; the air inside the jacket is heated, rises, spreads about near the ceiling, and gradually settles downward. Cold air from near the floor is drawn in under the jacket. As a result a circulation is created which results in comparatively even temperature throughout the room. If the jacket fits about the stove properly, the stove may be placed in one cor- ner of the room with entirely satisfactory results, provided RURAL SCHOOL SANITATIOIST 261 the building is ordinarily weather-tight. Stoves built with jackets may be purchased at very reasonable prices and are usually more satisfactory than the ordinary stoves with make- shift jackets. Such an arrangement as just described does not especially improve the ventilation. However, jacketed stoves with BASEMENT PLAN, MODEL RURAL SCHOOL, KIRKSVILLE, MO. Courtesy United States Bureau of Education ventilating attachments are manufactured by several firms and are quite satisfactory. In these the jacket fits closely to the floor, with an opening either through the wall or through the floor so that fresh air from outside the building may be drawn in to replace the heated air rising from inside the jacket. Thus a constant supply of fresh air is being brought into the room. Provision must be made, however, for the removal of the foul air coming from the lungs and bodies of the children. This foul air, as is generally understood, 262 EDUCATIONAL HYGIENE settles to the floor of the room. It is most easily removed, if the chimney is of brick and extends to the floor of the building, by removing a few bricks in the bottom of the chim- ney near the floor. An upward draft is created in the chimney by the heat from the stovepipe. This draws the foul air from the floor. A circulation is created, the heat of FIRST FLOOR PLAN, MODEL RURAL SCHOOL. KIRKSVILLE, MO. Courtesy United States Bureau of Education the stove drawing in fresh air from outside the building, causing it to ascend and spread throughout the room. It is then taken into the lungs of the children, exhaled, and finally settles to the floor, from whence it is drawn off through the chimney by the waste heat in the stovepipe. If the brick chimney does not extend to the floor, an escape for the foul air is made by use of a large stovepipe extending from within a few inches above the floor upward to the chimney, surround- ing the regular stovepipe before it enters the chimney. Tests made with these jacketed stoves and ventilating attachments RUIIAL SCHOOL SANITATION 263 prove them to be both satisfactory and economical. The stove may be placed in one of the corners of the room as much out of the way as possible and it will heat the room to a sufh- ciently even temperature and supply every part of it with fresh air. Mere shields of iron to protect the nearest pupils WEST SIDE I TABLE 48* :iX20- SKY !^' LIGHT SANITARV ORIMKIN&*— ' FOUNTAIN CASOLINE "^WASH BOWL. MTR-fiENCH UTRBENCM O : « i Z L _4a X20- SKY LIGHT ,1 r- 4.8-! X20 SltYjjLICHT^ J 1 1 ATTIC PLAN EAST SUE ATTIC PLAN, MODEL RURAL SCHOOL, KIRKSVILLE, MO. Courtesy United States Bureau of Education from the heat are not "jackets" and do not provide for thor- ough movement of the air. The writer has seen several one-teacher schools heated with ordinary hot-air furnaces placed in cellars. This neces- sitates the digging of cellars and is, of course, somewhat more expensive, although often the cellars may be used for wood- work shops, for agriculture, or other purposes. The plan has the advantage that all heating apparatus is removed from the schoolroom and so much space saved. The room is no more satisfactorily heated, however, than with the jacketed stove, 264 EDUCATIONAL HYGIENE and no better ventilation is secured. Probably the extra expense, except where two or more rooms are to be heated, will not ordinarily justify the installation of the hot-air fur- nace except where new buildings are erected. Ventilation without the jacketed stove or hot-air furnace is difficult to accomplish. With the ordinary stove it is prob- ably best obtained by arranging the windows so that they may be lowered from the top, or by using a window-board. This is a board, eight to twelve inches wide, fitted into the lower part of the window-frame on the inside of the sash. It slopes inward so that the top is four or five inches from the sash. When the window is raised at the bottom, fresh air enters between the window and the board and is projected upward into the room in such a way that no draft is created on the children. Instead of a board, window-glass in a special sash is frequently used. This has the advantage of cutting out no light. Rooms should be flushed with fresh air at recesses and frequently at other times. Direct drafts on the children as seated should be avoided. Cleaning the Schoolroom. — The method of cleaning the ordinary country school building is given little attention. In probably more than half of the one-teacher country schools the janitor work is done by the teacher or by one of the older boys. The buildings are swept usually once or twice a week and with the corn broom — sometimes the floor being sprinkled with water before the sweeping. After the dust has settled it is customary to dust off the furniture with a feather duster, driving the dust into the air to settle again on the desks and chairs. It is almost needless to say this is un- satisfactory and insanitary. It will be many years before the great majority of country schools are supplied with many of the modern sanitary ap- pliances for cleaning now being used in city schools. The sweeping will be done for some time to come with the ordi- nary broom. Methods of sweeping, however, may be im- proved. Sprinkling the floor is effectual in preventing the RURAL SCHOOL SANITATION 265 raising of dust but it binds the dirt to the floor and only part of it is removed. A simple improvement consists in the use of moist sawdust sprinkled on the floor and swept along with the dirt. This holds the dust and leaves the floor clean. Many patented materials are on the market for use on the floor to pre- vent a dust when sweeping. Most of them may be used several times. They are cheap, economical, and satisfactory in every way. The oil brush is also cheap and satisfactory. This is a sweeping-brush carrying a reservoir from which kerosene oil is released slowly enough to keep the bristles of the brush moistened. Sweeping with it is clean and dustless. Even with the use of patented dust-holders or of the oil brush, the floor must occasionally be washed with hot suds. Much of the dirt may be kept out of the building by providing some kind of iron scraper at the stoop, and encouraging the boys and girls to scrape carefully the extra muA and dirt from their shoes before entering. The scraper and a corn-husk or bristle mat at the door would help keep the floor clean, and their use might establish habits in some of the boys and girls which would be practised at their homes, and for which many overworked, tired, and weary mothers would thank the teacher. The ordinary feather duster should never be used. Large cloths moistened in water or oil should be used instead, and with them the desks, chairs, and all furniture should be care- fully wiped each day. The Water Supply. — ^The dangers from impure water, dirty water, the common drinking-cup, and the unclean drinking-cup are discussed elsewhere in the book, so that nothing further needs to be said here. In regard to the sup- ply, it may be said that every country school should have a handy source of pure water either on the school grounds or near the school grounds, and under the authority of the school officials, so that the purity of the water may be protected. If the source of the water supply is a well, it should be so located that pollution from outhouses or barnyards may not 266 EDUCATIONAL HYGIENE take place. It must be remembered that pollution may result from surface water; therefore the well should be so constructed that surface water cannot enter. To prevent all foreign matter from getting in, a tight cover should be placed over the well. Pollution may also take place from soil — water percolating through the soil from a source of con- tamination several hundred feet away. This will take place when the rock strata slope from the source of contamination toward the well, and it must be borne in mind that the sur- face of the land and the underljdng rock strata are often not parallel and many times are foimd sloping in opposite direc- tions. Water collected from the roof of the buildings and stored in cisterns is used at many schools. Where this water is used, some arrangements should be provided so that the first water coming from the roof at the beginning of each storm will not enter the cistern. After an interval of several days without rain, the roof is always covered with more or less dust; it is also usually soiled from the droppings of birds. Whatever the source may be, a supply of pure, cool drink- ing water should be kept where it can be easily reached by the children at all times. The common drinking-cup should not be used. If the water is kept in a pail, a cover should be provided, also a dipper with a long handle for transferring the water from the pail to the drinking-cup. Much more satisfactory, however, is a water-tank with a faucet near the bottom so that the water may be drawn out without the use of the dipper. Such tanks are inexpensive. The double tanks, with an air space between the two walls, keep the heat out of the water for a much longer period than the others, but are of course more expensive. Several tanks are on the mar- ket with an attachment for drinking similar to the bubbhng fountain. By use of the pneumatic pressure-tank running water may be had for the country school at a very much lower cost than is usually supposed. A metal tank, the size of the ordi- RURAL SCHOOL SANITATION 267 nary kitchen hot-water tank or larger, is buried in the ground below the frost line to act as a reservoir and pressure- tank combined. It is connected with a force-pump at the well and with the drinking-fountain in the schoolroom. Both pipes to the tank must be connected at the lowest part of the tank. Water is pumped into the tank from the well by the force- pump. The tank is already full of air, which, as more and more water is forced in, becomes com- pressed, forming a pressure on the surface of the water and in- creasing until it is no longer possible to force in more water. This pressure will force the water through the supply pipes up to the drinking-fountain. This form of water-tank is much more satisfactory than an elevated tank inside or on top of the building. There is always suffi- cient "boy power" around the country school to get the tank filled with pressure great enough to supply the building with running water. Under ordinary conditions ^ve minutes' pumping a day will furnish plenty of water for drinking purposes, and ten minutes' if a water-flush closet is used. Such tanks become occasionally "water-logged," that is, the air becomes dissolved in the water and carried away until not enough is left to furnish the required pressure. Therefore it is necessary to have some means of pumping in air, either with the water or by a hand air-pump. The pneumatic pressure- tank, pump, piping, and drinking- foimtain can be purchased for from $100 to $250. With it not only may the sanitary drinking-fountain be provided but SANITARY DRINKING-FOUNTAIN, RUNNING WATER IN WASH- BOWLS AND FLUSH-TOILETS BY MEANS OF AN ORDINARY FORCE- PUMP From Dresslar's " Rural Schoolhouses and Grounds." Courtesy Bureau of Edu- cation 268 EDUCATIONAL HYGIENE also a convenient sink for washing hands, and sanitary indoor closets instead of the ordinary outhouses. Toilets. — The most difficult problem, and the one con- cerning which comparatively little has been done, is that of supplying sanitary closets. At thousands of country schools in the United States to-day, no closets of any kind are pro- vided and children must resort to the shelter of neighboring woods. In thousands of others closets are provided but they are so filthy that the children prefer the woods. The great majority of one-teacher country schools will probably continue to use the outhouse privy for several years to come, and when properly constructed and cared for it may be satisfactory. The sanitary privy should be so constructed that its use will not be disagreeable to the user, and so that the ex- creta will be protected from any agencies which might dis- seminate disease-germs from them, such as the rain, hogs, insects, etc. The closet itself should be made tight, with a close-fitting door, a small window for light, preferably over the door, and an opening near the top for ventilation. In States where snow and severe cold are uncommon, one opening covered with a wire insect-netting is sufficient. In the closet should be placed a permanent box in which a supply of earth or lime should be kept, to be used every time the closet is used. The inside walls should be painted, and sprinkled with sand while the paint is yet fresh, so that a rough surface will be formed on which pupils and others cannot write with pencils. The receptacle should be made tight, with hinged covers, so that as little odor as possible may enter the closet. Probably the best form of the receptacle for all States where severe freezing does not take place consists of a tight box the floor of which is a continuation of the floor of the closet, and with a hinged door on the rear of the closet open- ing outward and upward. In this box is placed, under each cover, a galvanized iron or heavy tin bucket or tub to hold the excreta. These buckets should be taken out once or twice RURAL SCHOOL SANITATION 269 a week and the contents buried in a place where they can- not contaminate the water supply of the school or neighboring farms. The receptacle should have a small opening for the escape of odors, but this should be covered with a netting to prevent the entrance of flies or other insects. In colder countries where freezing would make this arrange- ment impracticable, a water-tight cesspool should be built for a receptacle, except where the soil is of such a character as to furnish a natural under- drainage, and where to do so admits no danger of pollution of water used for household purposes or for farm stock. In such a case an excavation or pit may be made under the closet, deep enough so that the excreta cannot be washed out. Whether the cesspool or excavation is used, both must be covered tightly so that rain, water, and animals, particularly insects, are prevented from entering. After each time the privy is used, earth, ashes, or lime should be thrown into the receptacle to cover the excreta. The earth used should be of rather a loamy nature, if possible, and porous. Sandy soil is of little value. A heap of earth should be collected in summer and dried in the sim for winter use. Lime is much better than earth. Where the cesspool or buckets are used, a few inches of water may be kept in the receptacle; this aids the excreta in fermenting and hque- fying. When this is done, a half -pint of kerosene oil should KENTUCKY SANITARY PRIVY. VERTICAL SECTION OF TANK AND HOUSE From Dresslar's " Rural Schoolhouses and Grounds " 270 EDUCATIONAL HYGIENE be kept on the surface of the water to repel insects. A five-per-cent solution of crude carbolic acid or a solution of creosol may be, used. In warm climates the closets should be placed some dis- tance from the schools. Separate buildings should be pro- vided for boys and girls and the entrances should be screened to insure privacy. In some cases the closets must be placed in the same building. When this is necessary, a double par- tition should separate the boys from the girls and a board fence at least six feet high and extending from the building at least twenty feet should separate the entrances. In northern States closets are often placed in an addition to the school building which contains also the coal or wood supply. When the fuel-room is between the schoolroom and the closets this plan is satisfactory, provided proper care is used in the closets. The closets may be entered either from the outside or directly from the schoolroom. The boys' closet, wherever located, should be provided with a urinal as well as seats. This in its simplest form is a trough constructed across one end of the outhouse with sufficient slope to carry the water away rapidly either to the soil or into the cesspool. The trough should be made of metal, cement, or wood lined with copper or galvanized iron. In certain sections a chemical closet is being used which is reported as giving satisfaction. This consists of an all- metal box with a door on the front, and a seat with a cover fitting air-tight on top. If the closet is used in a room inside the school building, a three-inch pipe connects the top of the box with a chimney. The suction in the chimney creates a draft through the box which removes from it all gases and odors. A metal receptacle is placed inside of the box to hold the excreta. In this is placed two to six inches of water in which are dissolved certain chemicals that destroy all germs of diseases in the excreta. The most satisfactory of all closets is the sanitary flush closet. This is easily possible in many country schools, even RURAL SCHOOL SANITATION 271 in one-room schools. A supply of water with the necessary pressure may be obtained from an overhead tank filled by a common force-pump, or from the pneumatic tank previously described. Sewage Disposal. — The great difficulty with the use of the water-flush closet is the disposal of the sewage. The most satisfactory, inexpensive way is by use of the septic tank and a subsurface system of distribution of the water. In its simplest form this is an underground tank to which the liquids from the closets are brought and in which they are retained for from twelve to twenty-four hours and then rapidly dis- charged into open jointed tiles from which they leak out into the soil to disappear. The discharge from the tank is regu- lated by a siphon. This intermittent flow from the tank into the soil allows the air to enter the soil while the tank is filling and oxidize the organic matter contained*in the sewage, converting it into harmless mineral forms suitable for plant- food. A better form of tank is the double tank, with the first chamber to retain the solid matter and scum until they dis- solve, and the second chamber to accumulate the liquids and discharge them intermittently by means of a siphon. The solids dissolve rapidly and but little settHngs remain in the first tank. The pipe connecting the first tank with the second tank is arranged so that the first tank is always filled to a certain depth with liquids and so that the liquids taken out are taken from midway between the surface and bottom. Then neither the scum nor settlings are disturbed. Satisfactory tanks may be constructed of cement by any farmer or carpenter at a cost varying from $25 to $50. Several patented septic tanks are on the market and may be purchased at a reasonable cost. Conclusion. — Improved rural school sanitation is impera- tive, not only for the sake of the children who are compelled by law to attend the schools for several of the most plastic years of their lives, but because of the direct and indirect 272 EDUCATIONAL HYGIENE effects on rural hygiene in general. Progress in sanitation and preventive medicine has quite largely passed by the rural portions of our country, and the public school is the chief instrument for catching up with the times. Through Federal dissemination of information, through State aid in money and expert guidance, and through teachers and county superintendents better educated in rural hygiene, we may ex- pect speedy readjustments. The following statement of minimum sanitary essentials for rural schools is authoritative and very irnportant: MINIMUM SANITARY REQUIREMENTS FOR RURAL SCHOOLS 1 It is the desire and purpose of this committee to help establish a standard of fundamental health essentials in the rural school and its material equipment, so that attainment of this minimum standard may be demanded by educational authorities and by public opinion of every rural school throughout the country. Possession of the minimum sanitary requirements should be absolutely necessary to the pride and self-respect of the community, and to the sanction and approval of county, State, and other super- vising and interested ofificial or social agencies. Neglect of anything essential for health in construction, equip- ment, and care of the rural school plant is at least an educational sin of omission and may reasonably be considered a social and civic crime or misdemeanor. The country school should be as sanitary and wholesome in all essential particulars as the best home in the community. Further, it should be pleasing and attractive in appearance, in furnishings, and in surroundings, so that the community as a whole may be proud of it; so that the pupils and teacher may take pleasure in attending school and in caring for and improving it. ^ Proposed by the Joint Committees on Health Problems in Education of the National Council of the National Education Association and of the Ameri- can Medical Association. Pamphlet published by the American Medical As- sociation, Chicago. See also Dresslar's bulletin (U. S. Bureau of Education) on "Rural Schoolhouses and Grounds" and Rapeer's " Standardization of the Rural School Plant" in School and Society for Feb. 15, 191 5, and his survey of "Rural School Hygiene" in the Pennsylvania "Rural School Report" to the State Educational Association, 1914. RURAL SCHOOL SANITATION 273 I. Location and Surroundings The school should be located in as healthful a place as exists in the community. Noise and all other objectionable factors should be eliminated from the immediate environment of the rural school. Accessibility. — Not more than two miles from the most distant home, if the children walk. Not more than six miles from most dis- tant home, if school wagons are provided. Drainage. — School ground must be well drained and as dry as possible. If natural drainage is not adequate, artificial subsoil drain- age should be provided. Soil. — As every rural school ground should have trees, shrubs, and a real garden or experimental farm, the soil of the school grounds should be fertile and tillable. Rock and clay soil should always be avoided. If the soil is muddy when wet, a good layer of sand and fine gravel should be used to make the children's playground as useful as possible in all kinds of weather. Size of School Grounds. — For the schoolhouse a^jid playground at least three acres are required.^ Playground is not a luxury but a necessity. A school without a playground is an educational deformity and presents a gross injustice to childhood. Arrangement of Grounds. — The school grounds should have trees, plants, and shrubs grouped with artistic effect but without interfering with the children's playground, 11. Schoolhouse The schoolhouse should be made as nearly fire-proof as possible. Doors should always open outward and the main door should have a covered entrance; a separate fuel-room should be provided, also separate cloak-rooms for boys and for girls. A basement or cellar, if provided, should be well ventilated and absolutely dry. The one-teacher country school should contain, in addition to the classroom: (a) A small entrance-hall, not less than 6 by 8 feet. {h) A small retiring-room, not less than 8 by 10 feet, to be used as an emergency-room in case of illness or accident, for a teacher's ^ If the rural school plant includes the additional features (a teacher' s home, a garden, and an experimental farm), which are already in some progressive States accepted and established as educational essentials, then the school grounds should contain eight to ten acres. 274 EDUCATIONAL HYGIENE conference-room, for school library, and for health inspection, a fea- ture now being added to the work of the rural school. (c) A small room, not less than 8 by lo feet, for a workshop, for instruction in cooking, and for the preparation of refreshments when the school is used, as it should be, for social purposes. Classroom should not be less than 30 feet long, 20 feet wide, and 12 feet high. This will provide space enough for a maximum of thirty pupils. III. Ventilation and Heating The schoolroom should always receive fresh air coming directly from out of doors in one of the following arrangements: {a) Through wide-open windows in mild weather. (b) Through window-board ventilators under all other con- ditions, except when, with furnace or jacketed stove, special and ade- quate inlets and exits for air are provided. Heating. — Unless furnace or some other basement system of heat- ing is installed, at least a properly jacketed stove is required. (No un- jacketed stove should be tolerated in any school.) The jacketed stove should have a direct fresh-air inlet about 12 inches square, opening through the wall of the schoolhouse into the jacket against the middle or hottest part of the stove. The exit for foul air should be through an opening at least r6 inches square on the wall near the floor, on the same side of the room as the stove is located. A fireplace with flue adjoining the stove chimney makes a good exit for bad air.^ Temperature. — Every school should have a thermometer, and the temperature in cold weather should be kept between 66 and 68 de- grees Fahrenheit. IV. Lighting The schoolroom should receive an abundance of light, sufficient for darkest days, with all parts of the room adequately illuminated. The area of glass in windows should be from one-fifth to one- fourth of the floor area. The best arrangement, according to present ideas, is to have the light come only from the left side of the pupils and from the long wall of the classroom. Windows may be allowed on rear as well as on the ^ The following arrangement for ventilating-flue is required in one Western State: A circular sheet -steel smoke-flue, passing up in centre of ventilating shaft (foul -air exit), 20 inches square in the clear. RURAL SCHOOL SANITATION 275 left side. High windows not less than seven feet from the floor may- be permitted on the right side as an aid to cross- ventilation, but noi for lighting. There should be no trees or shrubbery near the schoolhouse which will interfere with the lighting of the classroom. The school building should so face with reference to the windows that the schoolroom will receive the direct sunlight at some time dur- ing the day. Shades should be provided at tops and bottoms of windows, with the dark shades at top, so that light may be properly controlled on bright days. Schoolroom Colors. — The best colors for the schoolroom in relation to lighting are: Ceiling — white and light cream. Walls — light gray, green. Blackboards — black. V. Cleanliness The schoolhouse and surroundings should be kept as clean as a good housekeeper keeps her home. {a) No dry sweeping or dusting should be allowed. {h) Floors and furniture should be cleaned with damp sweepers and oily cloths.^ (c) Scrubbing and airing are better than any form of fumigation. VI. Drinking Water Drinking water should be available for every pupil at any time of day which does not interfere with the school programme. Every rural school should have a sanitary drinking-fountain located just inside or outside the schoolhouse entrance. Drinking water should come from a safe source. Its purity should be certified by an examination by the State board of health or by some other equally reliable authority. A common drinking-cup is always dangerous and should never be tolerated. Individual drinking-cups are theoretically, and in some conditions, all right, but practical experience has proven that in schools individual cups, to be used more than once, are unsatisfactory and unhygienic. Therefore they are not to be advocated nor approved for any school. ^ Sweeping compounds in moisture-proof containers may be obtained in the market. 276 EDUCATIONAL HYGIENE Sufficient pressure for running water for drinking-fountain or other uses in the rural school may always be provided from any source without excessive expense by a storage-tank or by pressure-tank with force-pump. VII. Water for Washing Children in all schools should have facilities for washing hands available at least: (a) Always after the use of the toilet. (b) Always before eating. (c) Frequently after playing outdoors, writing on blackboard or doing other forms of hand-work connected with the school. Individual clean towels should always be used. Paper towels are the cheapest and most practicable. The common towel is as dangerous to health as the common drinking-cup. VIII. Furniture School seats and desks should be hygienic in type and adjusted to the size and needs of growing children. Seats and desks should be individual — separate — adjustable — clean. Books and other materials of instruction should not only be sani- tary but attractive enough to stimulate a wholesome response from the pupils. IX. Toilets and Privies Toilets and privies should be sanitary in location, construction, and in maintenance. (a) If water-carriage system for sewage is available, separate toilets for boys and girls should be located in the schoolhouse, with separate entrances on different sides or corners of the school building. (b) If there is no water-carriage system, separate privies should be located at least fifty feet in the different directions from the school- house, with the entrances well screened. (c) The privy should be rainproof, well ventilated, and one of the following types: (i) Dry earth closet. (2) Septic-tank container. (3) With a water-tight vault or box. All containers of excreta should be water-tight, thoroughly screened against insects, and easily emptied and cleaned at frequent intervals. RURAL SCHOOL SANITATION 277 No cesspool should be used unless it is water-tight and easily- emptied and cleaned. All excreta should be either burned, buried, treated by subsoil drainage, reduced by septic-tank treatment, or properly distributed on tilled land as fertilizer. X. All Schoolhouses and Privies Should be Thoroughly and Effectively Screened against Flies and Mosquitoes XI. Schoolhouses and Outhouses Should be Absolutely Free FROM All Defacing and Obscene Marks XII. Buildings Should be Kept in Good Repair and with Whole Windows STANDARDS Provision and equipment of adequate school plant depends on in- telligence, interest, pride, and financial ability of community. Maintenance of a clean and sanitary school plant depends on efficient housekeeping, and on interest and willing co-operation of pupils. No community should be satisfied by the minimum requirements indicated in the foregoing, but every country school should be so at- tractive and well equipped as to minister with some abundance of satisfaction to the physical, mental, aesthetic, social, and moral well- being of those who provide it, who own it, who use it, and who enjoy it. Present Conditions Among the reasons which explain the present deplorable con- ditions of rural schoolhouses, the following are prominent: (a) Low architectural and sanitary standards in rural regions generally throughout the country. (b) Ignorance regarding the physical, mental, social, and moral effects of unattractive and unsanitary school buildings on the children and on the community as a whole. (c) False economy expressed by local school boards in failure to vote enough money to build and maintain suitable school buildings. (d) Lack of supervision or assistance by the State, which is usually necessary to maintain desirable standards. 278 EDUCATIONAL HYGIENE Improvement How shall the rural schools throughout this country be improved up to a reasonably satisfactory standard? I. By a popular campaign of education regarding the conditions desirable and possible in the country school. Such a campaign would profitably include many or most of the following: (a) The United States Bureau of Education and State depart- ments of education should furnish plans and instructions for construc- tion and equipment of rural school buildings. The United States Bureau of Education in Washington is already supplying, on request, valuable help of this kind, and a few State departments of education are demonstrating what may be done by supervision and support which aids without controlling. (&) State departments of education should supply supervision of rural schools and should have power: (i) To condemn insanitary and wholly unsuitable buildings. (2) To give State aid to rural schools when the local authorities fulfil certain desirable and reasonable conditions. (c) Ideas and standards of school sanitation should be inculcated in minds of local school patrons and school authorities who control school funds and who administer the affairs of the schools. Public lectures on health topics should be provided in the schoolhouse and elsewhere. {d) Effective school health courses should be introduced in normal schools and teachers' institutes. Better education of rural school-teachers, county superintendents, and rural school supervisors in the principles and practise of school hygiene and sanitation should be assured. {e) Interest in and enthusiasm for the improvement and care of all features of the school and its surroundings which affect health and happiness should be inspired in the minds of rural school pupils. Organizations such as "Pupils' Board of Health," " Civic Leagues," or "Health Militias" may profitably be formed among pupils. (/■) Organizations like "The Granges," Women's Clubs, County Medical Societies, and other groups so situated that they may further the cause of health and efl&ciency, should co-operate with the rural school. (g) Attractive but rehable health information should be furnished abundantly by the public press. II. Emulation and competition should be recognized and re- warded in ways that will promote wholesomely and progressively the welfare of the community as a whole. RURAL SCHOOL SANITATION 279 TEN SANITARY COMMANDMENTS FOR RURAL SCHOOLS In every school which may be considered passably sanitary the following conditions shall obtain: 1. Heating by at least a properly jacketed stove. (No unjacketed stove to be allowed.) Ventilation by direct outdoor-air inlets and by adequate and di- rect foul-air outlets. 2. Lighting from left side of room (or from left and rear) through window space at least one-fifth of floor space in area. 3. Cleanliness of school as good as in the home of a careful house- keeper. 4. Furniture sanitary in kind, and easily and frequently cleaned. Seats and desks adjustable and hygienic in type. 5. Drinking water from a pure source provided by a sanitary drinking-fountain. 6. Facilities for washing hands, and individual Rowels. 7. Toilets and privies sanitary in type and in care (with no cess- pools unless water-tight) and no neglected privy boxes or vaults. 8. Flies and mosquitoes excluded by thorough screening of school- house and toilets. 9. Obscene and defacing marks absolutely absent from school- house and privies. 10. Playground of adequate size for every rural school. CHAPTER XVI HYGIENIC SCHOOL ENVIRONMENT The Problem. — ^The public-school system must be satisfied with nothing less than the ideal, not only in methods of teach- ing and the results these methods accomplish but also in the surroundings the school gives the pupils while they are in its care. The public school should be a leader not only in the matters of mere learning but also in giving lessons, by ex- ample, on how to live with the end in view of securing the proper sanitary surroundings in the homes and business world. The public of every school community has a right to demand, that only the best principles and the highest ideals should emanate from the school, with respect to cultivating the mind, methods of living, and habits of life. Childhood is the im- pressionable time. What is woven into the mind and heart and nervous system in youth is likely to persist to the end. If a child grows up in unclean surroundings, his life will proba- bly show throughout something of the influences of his youth. Insufficient clothing, bad food, poor light, foul air — all these cast their blight over children. Some one has said that the race advances on the feet of little children. If the children of our present day can have better conditions under which to de- velop than did the children of the generation just past, then the race has made a distinct advance. If better habits can be developed in children that now attend our schools, then the race has so far gained over what it received from the schools of the past. 280 HYGIENIC SCHOOL ENVIRONMENT 281 The responsibility of those who administer our schools is a tremendous one; the call to higher and better things is an insistent one. What any new day may bring forth can be, of course, only problematical, but all things point to that better time when every child in our schools will not only be well taught but will have about him every life-giving and healthful condition: when he will have God-given fresh air to breathe and not the baked air that devitalizes; when he will have pure water to drink and not the germ-laden fluid from well and stream and pool that often carries disease and death; when the great and beautiful light of God's out-of- doors will have unhindered access to every schoolroom in place of the half-lights and shades that dim the eye and worry the nervous sys.tem; when every child shall have playground space enough to exercise all his body powers; when every teacher and school administrator shall know accurately what school conditions ought to be, and shall leave no stone un- turned until those conditions are obtained; when the world shall demand that every school be a perfect place for children and that there they may attain to the fullest development of their mental and physical powers. This problem of better sanitary conditions in our schools is one that must be soon solved. We are at the dawn of a better day as to the care of our children, and there can be no work that is more important. Some Sanitary Conditions. — This problem of getting the best sanitary conditions in and about the schoolroom is not merely a school problem; it is quite clearly a community problem as well. The school will not for any considerable length of time be very much better or very much worse than the people want it to be, either as to the physical condition of the building or the quality of the teaching that is done in the building. These statements are especially applicable to the United States, where every enterprise rests directly or in- directly on public opinion, public sentiment, and the will of the people. Any nation-wide survey of American schools will lead to the conclusion that there are thousands and thou- 282 EDUCATIONAL HYGIENE sands of school communities that need to wake up and then to catch up with the best thought of the time on how to take care of the children that must attend the schools. The re- sponsibility for bad conditions is seen to be especially heavy when it is reahzed that in most of the States there are com- pulsory-education laws and that children must be submit- ted to the conditions of the schoolroom, be those conditions good or bad. In a multitude of communities children are forced into schools where poor light, air that is continually foul, and contaminated water endanger the health and sow the seeds of disease and death. It is a hard thing to be com- pelled to say, but there are many communities where the school surroundings are so bad that the children would be far better off out of school than in. Practically every school survey reveals this fact. There is a tremendous need of the gospel of school hygiene. Every person that preaches it is indeed a missionary. This gospel needs to go into many dark places, for there are hundreds of schools in which those in authority violate every known law of the proper housing and physical care of children. There are schools that are on low, small, and poorly drained sites. Especially is this true in many country districts where the schools were placed on land that was not good for any- thing else in particular. There are numerous schools whose architecture is that of a barn, whose ventilation is unscien- tific, inefficient, and continually harmful, and whose lighting systems had no further planning than the leaving of a few square holes in the walls and filling them with windows. It is hard to refrain from making seemingly hysterical and overcolored statements when one discusses actual conditions in a multitude of American schoolrooms. There are rooms into which the light is admitted from all four directions, others into which the fight comes from three directions, and an uncounted number that receive light from two opposite sides. The unjacketed stove of our fathers is still doing duty in HYGIENIC SCHOOL ENVIRONMENT 283 schoolrooms everywhere, and many an urchin is being baked on one side and chilled on the other while he seeks to follow the devious ways of knowledge. Even in many instances where more elaborate systems of heating have been installed, the most deplorable results are obtained. Foul air-ducts do not do their work properly, rooms are overheated, and the air is baked till it becomes dryer than the atmosphere in the ONE ROOM TOWNSHIP CENTRALIZED & CONSOLIDATED ■ RATIO LESS THAN 1:8 [BAD] g BETWEEN RATIOS 1:8 AND 1:5 [POOR] □ RATIO 1:5 AND OVER [PERMISSIBLE] RATIO OF WINDOW SPACE TO FLOOR SPACE IN OfflO RURAL SCHOOLS From Ohio School Survey most arid regions of the earth. Colds, coughs, and kindred troubles come, children are carried off by death, and the ignorant school community sighs and wonders at the ways of a mysterious Providence that sees fit to strike down the fairest flowers in this garden of earth. If such communities would abandon attributing to Providence the results of their own ignorance and laziness, and arouse themselves from their lethargy and indifference, their children would have a better chance to live out the lives that Providence has offered them. Pure Drinking Water. — Along with the matters of ven- tilating, lighting, and heating comes the question of obtain- ing a proper supply of drinking water. The best way to pro- vide water is by means of drinking-f ountains, but sometimes 284 EDUCATIONAL HYGIENE the water so provided is of poor quality because of the loca- tion of the school or the community in which the school is located. The best that can be done is the thing to do, of course, but there is little or no excuse for the criminal negli- gence and ignorance that prevail in some schools. In all too many cases, in rural communities, water is carried from neighboring farms and is allowed to stand all day exposed to the foul air and the dust of the schoolroom. No more is brought till the supply in the bucket is exhausted, or till it gets so bad or so warm that it is necessary to go for more. In some cases the water-supply is obtained from springs or shallow wells that catch the drainage and possible contamina-^ tion from the surrounding ground. Where such conditions prevail the cause is usually found in the fact that those re- sponsible are either too ignorant or too niggardly to provide the proper kind of a well on the school premises. There is nothing in the world so sacred as the taxpayer's dollar, not even the lives of little children, in the view of many men who administer the financial ends of school organizations. Every human being must have plenty of pure, fresh water every day if he is to keep in health. The State has undertaken to gather children together in groups and to educate them. The State commits a crime when it does not safeguard the health and lives of these little ones on whom the future depends. The foolish, the careless, the ignorant, and the indifferent ought never to be intrusted with the care of the children in. our schools. Many additional details might be given to show that many conditions in our schools the country over are far from satis- factory from a hygienic standpoint. It is safe to say that very few school-buildings even approximate ideal conditions. The surface has barely been touched in what has been written above. There are many schoolrooms that are looked after by teachers and janitors who have never even heard of some of the modern appliances for the proper care of school build- ings. For the sake of reminding the reader in regard to the HYGIENIC SCHOOL ENVIRONMENT 285 conditions, methods, and appliances that ought to be in use in every ideally equipped and managed school, a list of subheads given by the editor of this volume under the general topic of '' School Sanitation" is submitted herewith: sites, archi- tecture, ventilation, lighting, heating, drinking-water, drink- ing-fountains, cleaning and vacuum cleaners, school baths, hygienic toilet facilities, seats and desks, decoration, fire-proof construction, rest and emergency rooms, play-rooms and roof playgrounds, open-window rooms, supervision of janitors, hygienic cloak-rooms, drying and warming seats, investiga- tions of recirculation, humidity, air-cleaning, disinfection, etc. This is rather a formidable list, is it not? One can readily surmise that to understand and to apply the things suggested takes something more than the mere qualification of being elected to a school ofhce or of being able t« pass a teacher's examination in the three R's with accessories. The proper hygienic administration of a modern school is a big problem. The general schoolroom conditions that prevail in this country are far from satisfactory — every survey shows that. The State cannot fairly and honestly force children to attend school and then not properly care for their health. There is splendid public-health work ahead for the schoolmaster and the school- mistress of the present time. Sanitary Surveys. — The enthusiastic inquirer into what ought to be done under the circumstances can be given plenty of things to do. The first thing that ought to be on the pro- gramme of school betterment from a sanitary standpoint, in every State, is the matter of a proper sanitary survey. If every schoolhouse in the nation could be visited by one or more experts and its physical surroundings made note of, if all the data in regard to every schoolhouse could be set down on standard forms in use by all other experts so that there could be no confusion in regard to the results of indi- vidual surveys, then a big start would be made toward getting better conditions. If, for instance, it could be known for any given school year just how many schoolhouses in this coun- 286 EDUCATIONAL HYGIENE try are improperly heated, lighted, and ventilated, how many have poor water-supplies, how many owe their poor condition to backward and ignorant school communities, etc., every thinking person would derive a tremendous inspiration and help in this fight for better things. There is no stimulant like scientifically determined standards and exact knowledge. A thorough national survey of our schools would let all the world know just what are the conditions in every individual school. With the knowledge of poor conditions in any given school district would come ridicule, then shame, then deter- mination to have better things. Community pride would be appealed to, and straightway the children in that community would have a better chance to enjoy life and health and, withal, to get a better education because of better, healthier bodies with which to get that education. It will probably be many years before there will be a general, simultaneous, national school survey, but it ought nevertheless to be made. There is no reason why the more progressive States, like Ohio, cannot take up this work.^ The results would be invaluable not only in a direct way to the schools themselves but to the State at large in the way of educating the people. There is an almost immeasurable opportunity here for some State to take the lead in this direction. Occasionally a school survey is undertaken by sending out blanks for teachers or others to fill out. This method is good so far as it goes, but it has many faults. With the pres- ent attitude of the public toward such movements, how- ever, it is about the only method that is attainable at this time. Those who administer pubHc funds have not yet come to the place where they will permit a body of experts sufficient remuneration for travelling about over the country and finding out things that only experts can find out. Even if every questionnaire blank sent out in any given survey were answered in full, much of the information obtained thereby would be inaccurate and unreliable. How many teachers * See recent survey reports for Ohio, Pennsylvania, and Illinois. HYGIENIC SCHOOL ENVIRONMENT 287 or school officers, even with stated standards, are proper judges of ventilation, lighting, heating, the quality of drink- ing water, the proper colors to put on the walls and ceilings of schoolrooms, hygienic cloak-rooms, humidity, disinfection, and kindred topics that have to do with the proper care of children? Even where, for instance, the ratio of window space to floor space is the correct one and the teacher knows that ratio or standard to be correct, there may actually be an insufficient amount of light coming into the schoolroom. Neighboring trees or buildings or other obstructions may shut out light. These interfering and complicating features may easily be lost sight of by the inexpert. A report may show that a building is thoroughly equipped with a plenum system of heating and ventilating and yet some part of that system may be working in a manner that is far from satis^ctory. Drink- ing water may be obtained from a source that ordinarily would be safe enough, and kept in sanitary drinking- fountain tanks, and yet that water may be daily endangering the lives of those who drink it. The questionnaire method, while it is the best that can be used under most circumstances, has, then, its apparent dangers of misinformation and unreliabil- ity. The best method is to send the expert in person to in- spect and report. A mass of information gathered in this way will then form a reliable basis on which to base con- clusions. The average school executive, however, will ask what he can or ought to do under the existing circumstances, and not what he might do with plenty of money and an abundance of expert assistance. The first thing for any school execu- tive to do, no matter whether he be superintendent, princi- pal, teacher, or other person in authority, is to begin with what he has in hand in the way of equipment. He can first inform himself as to needed standards and requirements, and then by investigation and experiment find out whether the pupils under his care are working and living under satis- factory conditions. He can measure the window space in 288 EDUCATIONAL HYGIENE each room and find out whether, according to the best stand- ards, sufficient light is being admitted. He can measure the cubic contents of each room and ascertain whether each pupil has enough air space. He can measure the air currents that enter and leave each room in a plenum system and find out whether each pupil is receiving enough air per minute. He can test the drinking water or send it to a State chemist or other chemists for investigation. He can cultivate his judgment by the use of his common sense and scientific standards as to whether the colors on the schoolroom walls are what they ought to be. By experiment and standard instruments he can determine whether the humidity of his schoolrooms is what it should be. He can inspect closely the work of janitors and see whether they get reasonably satisfactory results. He can, after a little reading and other investigation, deter- mine whether a thorough, workable, and constantly used system of disinfection should be installed. In short, after some study of his sanitary situation, he can give a tolerably accurate account of it and what it needs. This kind of a sanitary survey is likely to bring the best results because of its having been done by the person who, more than any one else, is responsible for it and for its being remedied. Ex- pert sanitary surveys made at large have the advantage of being well done, but the survey made by the person that must remedy conditions found to be bad is ordinarily of the most use, because it is more likely to result in efficient and forcible action. The school official who is anxious to make a sanitary survey and to get health results therefrom need not lack for information as to what to do. The health officers of his com- munity and the constantly growing body of literature on the subject of public-school health will thoroughly inform him, if he is anxious to be informed. One of the greatest services that any school official can perform for his community is to make or have made a complete sanitary survey of the school property under his care.^ ^ For cities, the sanitary inspection forms used by the Philadelphia schools will prove suggestive. HYGIENIC SCHOOL ENVIRONMENT 289 The Health Officer and the School.— The local health officer, following the rounds of his ordinary duties in looking after the public health, can do no greater service than that of constantly agitating the matter of better sanitary conditions in the schools. Agitation ought to be the first thing on his pro- gramme, and then he ought to see to it that all the teachers and school officers who come under his jurisdiction are thor- oughly informed as to reasonable sanitary standards and know just what to do under all ordinary circumstances. School of- ficials may want to have sanitary matters just right and yet may not know just how to obtain their ends. Energetic and well-informed health officers can step in at this juncture and be of inestimable service to the schools. Such officers can furnish definite and clear rules for the construction and sanitary main- tenance of schoolhouses. They can inteij)ret and apply school-health legislation. Through the legal powers given them they can usually close up schoolrooms that are en- dangering the health of children and that will never be im- proved except through some such vigorous compulsion. Especially can State boards of health, when given enough support by law, serve their States in a great and vigorous way. This is markedly true in cases where the executive officers of such boards are men of unusual vigor, enthusiasm, and devotion to the cause in which they are enlisted. The particular thing that any health officer or board can do, with the assurance of rendering an immediate service, is the dis- semination of information as to sanitary matters, in language that is clear, definite, and untechnical. Further than this, if such information, when scientific, can be enacted into law or if the decisions of health boards can have the weight of law, the communities affected will have a still greater service rendered them. Perhaps one of the most striking instances of a State board of health that is serving the schools of its State in this definite way is furnished by the health board of a middle- Western State (Indiana). Legal enactments and judicial decisions have given to the actions of this board the weight 290 EDUCATIONAL HYGIENE of law. This board has a great advantage in this direction. It demands right conditions. School people throughout the State must obey its behests. The problem before the board, then, is extremely simple — ^put into clear and direct language a set of rules, based on the best modern standards, to govern the construction and care of all school-buildings. Since these rules have the weight of law, they must be obeyed. Such a set of rules has in this State recently been formulated. These rules cover everything from the minimum number of square feet per pupil on the playground to the reheating of air under certain conditions. Any intelligent person can understand these rules. They operate for all. The first and the per- manent effect has been the Hfting of sanitary operations in all schools to a much higher level. Fortunate is the school system of any State that can have such imiform and thorough administration as to health matters. Where they are under the supervision of the State boards, and where these State boards have definite and clear-headed policies as to what ought to be done, the local boards of health can, of course, attack their problems with more vigor. And where there are in the State department of education efficient departments of hygiene, the same results or better can be obtained. Sites. — ^AU school sites should be easy of approach, some- what elevated, and thoroughly drained. Water should never stand on a school yard. A schoolhouse should not be near any condition or situation that might impair the work or the health of the children. No school should be near any industry that pollutes the atmosphere, or near any stagnant water or other objectionable situation. Every school should have a playground of not less than one acre. Especially is this true in the country, where land is comparatively cheap. In addition to the playground, there should be room for school gardening, and for other activities that have to do with health and the implanting of correct ideals as to what beauti- ful school grounds ought to be. Where there is a consoli- dated school, ten to twenty acres for a school farm should be HYGIENIC SCHOOL ENVIRONMENT 291 added. The playground part of the school site should con- tain an area of not less than thirty square feet for each pupil. The grounds should really be much larger than this standard. In the opinion of the writer, healthful out-of-doors play is far Viamond !> a^~fir-n a O fi n^'"iK^xy'£ w « n rji \.-i r<^ a f-or^^^ 7r^€^ t> a V ij tv Ti-acfjery Oarttcn G £ Ht> o ■ tf o o o e c tin Effiartnwfthi/ ie lt> f> ft c^