UNIVERSITY OF CALIFORNIA AT LOS ANGELES EDUCATIONAL HYGIENE 10 n rx O ^ o nnHMH i^^ EDUCATIONAL HYGIENE FROM THE PRE-SCHOOL PERIOD TO THE UNIVERSITY EDITED BY LOUIS W. RAPEER, Ph.D. PROFESSOR OF EDUCATION, PENNSYLVANIA STATE COLLEGE ILLUSTRATED CHARLES SCRIBNER'S SONS NEW YORK CHICAGO BOSTON -;^S 6 G ( COPYKIGHT, 1915, BV CHARLES SCRIBNER'S SONS ^.1 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 like. 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 V VI PREFACE 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 specialists 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 through the college, is sketched in such detail as is possible in so comprehensive a volume. There has been a constant temptation 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 literature 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 vitality. 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. Another chapter on the hygiene of normal schools could well take a place in Part IV. Both topics are briefly PREFACE Vii treated, however, in the chapters presented. Attention is called to the appendices and to the bibliography at the end of the volume. To the many persons who have so kindly lent their assist- ance in contributing to the volume, to his wife, to those who have furnished photographs from many parts of the world, and to the publishers for their cheerful co-operation, the editor is sincerely grateful. L. W. R. State College, Pa. CONTENTS PART ONE Health Sociology CHAPTER i-^ PAGE I. Public Health and the Public Schools . . i By Louis W. Rapeer, M.A., Ph.D., Professor of <^ Education, Pennsylvania State College. II. The Public-Health Movement 22 By E. H. Lewenski-Corwin, Ph.D., Sec. Health Committee of the New York City Academy of Medicine. III. Health and Heredity 45 By Chas. B. Davenport, Ph.D., Carnegie Institution. rV. The Home Hygiene of Children .... 59 By Ernest B. Hoag, A.M., M.D., Supervisor of Educational Hygiene, Long Beach, 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., Professor of Social Centre Extension, University of Wisconsin. CONTENTS PART TWO The Administration of 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. City School-Health Administration . . . 153 By Geo. R. Leslie, Formerly Director of Health and Clinical Psychology, Los Angeles Public Schools. XI. Rural School-Health Administration . . 178 By \V. L Larsox, S.B., State Inspector of Rural Schools, Madison, Wisconsin. PART THREE The Divisions and Practice of Educational Hygiene I. MEDICAL supervision OF SCHOOLS XII. The Standardization of the School Medical Service 197 By the Editor. XIII. The School Nurse and Her Work .... 230 By LiNA Rogers Struthers, R.N., First Municipal School Nurse of America, recently Supervisor of School Nurses, Toronto, Canada. CONTENTS XI XIV. Public School Clinics 243 By Jesse D. Burks, Ph.D., Director of Municipal Bureau of Efficiency, and Frances Williston Burks, A.B., Los Angeles, California. XV. Open-Air and Open- Window Schools . . . 256 By S. C. KiNGSLEY, A.M., Director of the Elizabeth ^ McCormick Memorial Fund, formerly Superin- tendent of United Charities, Chicago, Illinois. XVE. School Feeding 273 By Louise Stevens Bryant, Ph.D., Lecturer on Psychology at the Pennsylvania School for Social Service, Philadelphia; Probation Officer of the Criminal Division of the Municipal Court of Phila- delphia; formerly Assistant in the Psychological Clinic, University of Pennsylvania. XVII. Medical Supervision and the Exceptional Child 294 By Clinton P. McCord, A.B., M.D., Director of Health, including the Medico-Psychological Labora- tory, Albany, New York, Public Schools ; Lecturer on Child Hygiene in Albany Medical College. II. SCHOOL sanitation XVIII. Hygienic School Environment 312 By Superintendent L. N. Hines, A.M., Crawfords- viUe, Indiana, President of the Division of Child Hygiene of the National Education Association; Associate Editor of the Educator Journal. XIX. School Sanitation Standards 330 By the Editor. XX. Rural School Sanitation 355 By A. C. Monahan, B.S., Rural School Speciahst, U. S. Bureau of Education. in. PHYSICAL education XXI. Play and Playgrounds in Cities .... 380 By Geo. E. Johnson, Ph.D., of the New York School of Philanthropy, formerly Supervisor of Play- grounds, Pittsburgh, Pennsylvania. Xll CONTENTS CHAPTER XXIL Physical Education in Elementary Schools 410 By C. Ward Crampton, M.A., M.D., Director of Physical Training, Athletics, and Hygiene in the Public Schools of New York City, Secretary of the Public Schools Athletic League. XXIII. Physical Education and Athletics in the High Schools 439 By Edgar Faitver, A.B., M.D., Professor of Physical Education, Wesleyan University. XXIV. Play and Recreation at the Rural School 456 By S. H. Curtis, Ph.D., Lecturer on Public Recrea- tion, Albion, Michigan; formerly Secretary of the Playground Association of America. w^ XXV. IV. U^ the teaching of hygiene _ The Teaching of Hygiene in Elementary \ Schools 472 \ By J. Mace Andress, A.M., Director of the Depart- ment of Psychology and Hygiene, State Normal School, Worcester, Massachusetts. XXVI. Health Teaching in High Schools .... By W. S. Small, Ph.D., Principal of the Eastern High School, Washington, D. C. 494 XXVII. Professional Training of School-Health Workers 518 By Ella Phillips Crandall, Executive Secretary of the National Organization for Public Health Nursing, New York City, and the Editor. XXVIII. Industrial Hygiene and Vocational Educa- tion 538 By the Editor. XXIX. Sex Hygiene and Sex Education .... By Ira S. Wile, M.S., M.D., Editor Medical Review of Reviews ; Lecturer in the New York University School of Pedagogy; member of the Board of Edu- cation, New York City. 547 CONTENTS XIU V. THE HYGIENE OF INSTRUCTION CHAPTER PAGE XXX. The General Hygiene of Instruction . . 567 By Arthur K. Beik, Ph.D., Assistant Professor of Psychology and Pedagogy, Olivet College. XXXI. The Hygiene of School Subjects .... 586 By Arthur K. Beik, Ph.D., Assistant Professor of Psychology and Pedagogy, Olivet College. PART FOUR The Hygiene of the College XXXII. The Hygiene of Women's Colleges . , . 602 By Kristine Mann, A.M., M.D., Health Director of the Department Store Educational Association, New York City, formerly Instructor in Hygiene and Physical Education, Wellesley College. XXXIII. The Hygiene of Men's Colleges .... 617 By Geo. R. Meylan, A.B., M.D., Professor of Phys- ical Education, Columbia University. Bibliography 629 Appendix I: Health and School Progress . 635 Appendix II: Communicable Diseases Among Children Facing 642 Appendix III: Physical-Record Card, Girls' High School, Providing for Four Annual Examinations 642 Appendix IV: Letter to Parents on Care of Teeth 643 Index 647 ILLUSTRATIONS Doors that insure protection in case of fire Frontispiece PAGE Deaths from all causes in Indiana 8 Growth of the registration area for deaths, 1900-1911 ... 12 Death-rate per 1,000 population for States included in registra- tion area in 1900 15 Practical health instruction in the care of the sick, Woodward High School, Cincinnati, O Facing 24 Typhoid fever deaths in Indiana 29 Dressing the baby. Little Mothers' League, Toronto, Canada Facing 32 Diarrheal diseases in Indiana 35 Measles deaths in Indiana 38 Tuberculosis deaths in Indiana 38 Diphtheria deaths in Indiana 39 Scarlet fever deaths in Indiana 39 A co-operative playground, Lexington, Mo. . . . Facing 84 The first water in the swimming-pool of the co-operative play- ground at Lexington, Mo Facing 86 A home and school meeting at the University of Chicago Ele- mentary School Facing 88 Child-welfare exhibits Facing 90 School dental clinic at Cincinnati, O. (i) . . . . Facing 96 School dental clinic at Cincinnati, O. (2) . . . . Facing 96 Auditorium in William Penn High School for Girls, Philadelphia Facing 106 XV XVI ILLUSTRATIONS PAGE School nurse giving parents' notifications to school-children, Toronto, Canada Facing 162 School nurses taking school-children to clinics, Toronto, Canada Facing 162 Snellen test sheet Between pages 168 and i6g A sanitary school hack for transporting pupils to consolidated schools Facing 180 Interior of school hack Facing 180 Model rural school, Kirksville, Mo Facing 184 Interior of a rural school, illustrating method of ventilation, use of single seats, and sanitary drinking-fountain . . Facing 184 A thorough physical examination in Cincinnati public schools Facing 216 Relative frequency of school ailments in 25 cities Between pages 228 and 229 School nurse making home visits, Toronto, Canada . Facing 234 Nose-blowing drill in the classroom, Toronto, Canada Facing 236 The school nurse in the home, Boston Public-School Hygiene Department Facing 238 "Little mothers" taught to wash "baby brothers" in summer playgrounds, Hartford, Conn Facing 240 Dental clinic; operating-room, Strasburg, Germany Facing 248 Orthopedic Clinic, Dunfermline, Scotland . . . Facing 248 Orthopedic Clinic, Dunfermline, Scotland . . . Facing 252 Open-air classroom, exterior, Hackensack, N. J. . . Facing 258 Open-air classroom, interior, Hackensack, N. J. . . Facing 258 Open-air school, first grade, Sacramento, Cal. . . . Facing 262 Weight recorded each Monday and Friday, Dyer Open-Air School, Cincinnati, O Facing 266 Open-air school dance on the roof, Dyer School, Cincinnati, O. Facing 268 ILLUSTRATIONS XVll PAGE Tubercular children attending the " Httle red schoolhouse " Facing 270 High-school girls at luncheon Facing 274 Relative food value of school and street lunches 275 Scientific feeding of children, William Penn High School for Girls, Philadelphia, Pa Facing 278 An exhibit used at the Fourth International Hygiene Congress Facing 282 Ratio of window space to floor space in Ohio rural schools . . 315 Country school farm 323 Fire protection legislation for schoolhouses 335 Laws relating to schoolhouse construction in each State in 191 2 335 One of the newer types of high-school buildings . . Facing 340 The Austral window, showing method of ventilating without drafts Facing 346 Moulthrop school desk-chair Facing 350 The "panic bolt" Facing 350 Basement plan, model rural school, Kirksville, Mo 361 First floor plan, model rural school, Kirksville, Mo 362 A model consolidated school building Facing 362 Part of the basement of a renovated rural school . . Facing 362 Attic plan, model rural school, Kirksville, Mo s^3 Looking into library and cloak-rooms of the Cross Roads School Facing 364 Corner of kitchen, rural school in Louisiana . . . Facing 364 Sanitary drinking-fountains for rural schools . . . Facing 366 Sanitary drinking-fountain 367 Sanitary chemical closet Facing 368 Jacketed stove and ventilating system of modern type for rural schools Facing 368 XVIU ILLUSTRATIONS PAGE Kentucky sanitary privy 369 Outdoor exercise at the University of Chicago Elementary School Facing 382 Calisthenic drill by three thousand pupils from the city schools of Manila Facing 386 Outdoor physical training at Motley School, Minneapolis Facing 390 School play activities at Milwaukee, Wis Facing 398 Tennis and volley-ball at Pasadena, Cal Facing 398 A public-school swimming-pool Facing 400 A volley-ball game over a tennis-net. Oak Park Grammer School, Sacramento, Cal Facing 402 Girls at playground ball and volley-ball; boys at tennis Facing 402 A vacant-lot playground well used in Boston, Mass. . Facing 404 A play corner at Cincinnati, showing a variety of apparatus Facing 406 Typical sand-box play, Hartford, Conn Facing 408 Folk-dance, Kinderpolka, Lincoln Elementary School, Sacra- mento, Cal Facing 416 Prospective teachers learning folk-dancing and gymnastic drills at the State Normal School, Indiana, Pa. . . . Facing 420 National dances, playground festival, public schools, Hackensack, N. J Facing 424 Boys of the University of Chicago Elementary School in their gymnasium suits Facing 430 Gymnastics in the William Penn High School for Girls, Phila- delphia Facing 440 A girls' gymnasium class at the University of Chicago Elementary School Facing 444 A boys' gymnasium class in an elementary school at Milwaukee, Wis Facing 446 National dances, playground festival, public schools, Hackensack, N. J Facing 448 The girls' basket-ball team from Iloilo, P. I. Champions of the \'isayan Islands, 1914 Facing 448 ILLUSTRATIONS XIX PAGE Schoolroom game, Cleveland, O Facing 452 Schoolroom games Facing 458 Boys on giant stride and girls at volley-ball at Pasadena, Cal. Facing 462 Physical training in the open air, Pasadena, Cal. . . Facing 462 Tomatoes — summer-school garden, Montclair, N. J. . Facing 470 School gardens Facing 470 "Tooth-brush drill," Boston public school. Department of Hy- giene Facing 482 Inculcating the tooth-brush habit and ideal at Cincinnati, O. Facing 482 A special class in Albany, N. Y Facing 540 A group of ungraded school-children, Albany, N. Y. . Facing 540 A class in industrial training, Boys' Special School, Cincinnati, O. Facing 544 One of the many types of outdoor recreation and athletics at Wellesley College Facing 606 Examination of vision by the retinoscope. College of the City of New York Facing 618 Swimming-pool at the College of the City of New York Facing 620 The Yale bowl, where 70,000 view the great games and partici- pate sufficiently to make a positive contribution to physical and mental health Facing 622 The great public-school stadium, playground, and recreation centre at Tacoma, Wash Facing 622 Stadium for the athletic field of the College of the City of New York Facing 624 Secondary school and gymnasium of the College of the City of New York Facing 624 Health instruction by the gymnasium teacher for secondary and college students at the College of the City of New York Facing 626 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 realize that the only real 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, and half are dead before the age of twenty-three, when the average term of life is but thirty-eight years instead of fifty or sixty, and when illness, deformities, and multifarious physical defects are afflicting the race with an immense and overburdening cost, it would seem that every agency which the state has at its disposal would be vigorously engaged in preventing and eliminating from the world, or lessening ta 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 elimination 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 Hvelihood. To slay the food-bringer has not been the policy 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 livelihood 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 public agencies manned by doctors and nurses in great numbers. Such public hygienists as Winslow prophesy, indeed, the complete or almost complete socialization 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 stafTs that preventive medicine is really making fairly rapid progress. Many agencies, more or less efl&cient, 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 •"Efficiency in the Public-Health Campaign," in the North American Re- view, June, 19 13. 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 public 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 n urtu re, of eugenics and h ygien e. Doctor Davenport shows briefly in a later chapter the considerable 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 like characteristics. To help in some measure to bring about such a happy state, to eliminate 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 limits, 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 ' 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 amelioration 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 efiticient 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- l 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 public 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-^specially in the training of teachers. We have also ed^ucational sociology, educational administration, educational history, etc., and it is high time that we have an educational hygiene. The exclusive e mphasis 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 afTected 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 191 2 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 public educational sys- tems. If the educational systems of the country can be helped to concentrate their energies upon the really big problems of life 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 prevailing and preventable amount of illness, or morbidity, and in the number and preventability of physical defects which lower vitality and reduce working efficiency and happiness. In a somewhat careful investigation, published elsewhere,^ the writer has attempted to compute from mortality statistics and other sources, by the methods used by life-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. I, Death Losses. — The death losses to our country are enor- mous and largely preventable. The judgment of the best ' "Srhool 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^rms 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 oJ persons in the United States could be reasonably prevented or postponed, "ii knowledge now existing among well-in- formed men in the medical profession were actually applied 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 intelKgent 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-mortality 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 twenty-three 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 reasonably 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. EDUCATIONAL HYGIENE DEATHS FROM ALL CAUSES IN INDIANA All Ages '°'2 V//////^/A Average for preceding three years 500 1000 2000 3000 4000 5000 — ■ Diphtheria and Croup — — > Suicides S5S| Other Forms of Tuberculosis ' /A ' v/^v.T i Influenza I Unclassified Causes 'Oro'c Heart Disease 1 Tuberculosis of the Lungs "Acute Nephritis and Brights' Disease 'External Causes (Suicides Excepted) 'Hemorrhage and Softening of the Brain 'Cancer and Other Malignant Tumors rCongenital Debility and IVlalformations Pneumonia I Diarrhoea and Enteritis (under two years) ' Other Diseases of the Respiratory System (T.B. Excepted) ' Diseases of the Stomach (Cancer Excepted) 3 Typhoid Fever CZ3 Senility [2223 Appendicitis ww.M Cirrhosis of the Liver sa Other Epidemic Diseases TTTTT^ Intestinal Obstruction ps3za Whooping Cough 77T^ Acute Bronchitis ^ra Chronic Bronchitis 7T-77:\ Puerperal Septicemia 1 Other Puerperal Accidents of Pregnancy and Labor 2ZZ3 Tuberculosis Meningitis )pzi Non Cancerous Tumor & other diseases of the female genital organs rrr\ Scarlet Fever Malaria ^Simple Meningitis Hernia ■77m Measles 3 Poliomyelitis (Acute Anterior) 3 Cerebro spinal fever a Unknown or ill 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 of 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 ph3Asical 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. Gnieral diseases 1. Typhoid fever 2. Malaria 3. Smallpox 4. Measles 5. Scarlet fever 6. Whooping cough 7. Diphtheria and croup 8. Influenza g. Cholera nostras 10. Dysentery I I . Erysipelas 12. Other epidemic diseases. . . . 13. Purulent infection, etc 14. Rabies 15. Tetanus 16. Pellagra 17. Tuberculosis (of lungs) 18. Tuberculosis (other) 19. Rickets Syphilis Gonococcus infection Cancer and other m. tumors Other tumors 24. Acute articular rheumatism 25. Diabetes 26. Leuchemia 27. Anemia, chlorosis 20. 23- 28. Other general diseases. Nervous sys. — special sense Encephalitis Meningitis Spinal cord, other dis .\poplexy, 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. . . All ages 805,412 215,692 12,673 1,167 202 6,598 6,255 6,146 11,521 7,774 536 3.446 2,442 198 1,877 64 1,373 368 73,214 13,095 455 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 17,943 8,891 684 58 6 S88 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 IS 14 II 62 9 IS3 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 9 19,772 9,770 1,681 67 17 112 232 10 228 119 7 13 35 3 86 6 88 12 S,i66 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 5-1 4 29,679 13,869 1,537 740 2,173 245 3,638 19s 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 > Condensed from the table giving 189 different causes. The registration area is slowly enlarging, hut 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 go per cent of the total"). We are far behind most European countries in records of both deaths and births. PUBLIC HEALTH AND THE PL^LIC SCHOOLS II TABLE I — Continued Causes of Death for the Registration* Area, 1910 AU ages 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 resp. 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. 03. Cirrhosis of liver 64. Other diseases of liver 65. Peritonitis (nonpuerp.)- • ■ ■ 66. Other d. of digestive system VI. Genitourinary sys. nonv 67. Nephritis, acute 08. Bright's disease 69. Kidneys, other d. of 70. Other d. of uterus 71. Salpingitis and other f. d.. . VII. The puerperal slate. VIII. Skin 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. XII. Oldage XIII. External causes 78. Suicide 70. Accidental or undefined. 100,83s 135 746 7,229 S.391 25.337 54.187 2,150 24,499 1. 174 104,801 423 840 2,203 8,403 63.180 6,128 2,192 4,486 I.57I 7,485 3,092 2,419 329 6a,5S9 5.665 47.665 1,389 774 1,298 8,455 3,008 1.748 506 1,317 1,145 119 7,998 685 4,821 39.388 13,604 57,196 8.590 45.416 CHILDREN OF SCHOOI, AGES S-9 2,035 9 90 90 62 522 1,138 66 28 16 1,669 II 123 13 116 469 571 8 127 25 15 36 132 9 S09 253 224 22 26 100 93 6 XIV. IV -defined diseases 12,462 2,193 I 2,161 74 956 9 13 21 30 148 664 32 17 13 1,270 4 51 18 57 132 718 6 88 20 16 35 109 4 447 16s 263 6 5 36 25 1,678 31 1,599 43 1,517 5 36 158 1,140 83 17 28 1.439 6 40 47 73 91 754 21 117 22 25 34 162 7 780 199 440 16 29 75 630 31 8 9 3,024 326 2,525 68 Total S-14 399 14 103 III 92 670 1,802 98 45 29 3.939 15 174 31 173 601 1,289 14 215 45 31 71 241 13 9S6 418 487 28 6 3 40 17 17 19s 183 10 113 41 55 3.871 32 3.760 117 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 I Mont. .. j N.DAK. \ -,. / ^^O; j S.DAK. ! / ^— -T— .' ^YO. I ^— — / r^"7 I A ' / ] A IOWA "^ \^^^\ P^' \ L__ KANS. M0.\ M" >,,yVA^ "<. i "■-— -vL i^^ssu\.^.\ GA. ^y/ PER CENT OF UNITED STATES \ TEXAS "iL A i 7 ' ' ^^ ^A POPULATION AREA ^ • r^— ""'^'^'^'^^V^/'X \ 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 resi)ecting the number and causes of death in nearly half our country can yet be made. Laws requiring registration are of first imiiortance In non-registration States. The registration area for births is very much srnaller. I? PUBLIC HEALTH AND THE PUBLIC SCHOOLS 1 3 alcoholism and poverty. Devine estimates that not less 1 than one-fourth of all poverty is directly caused by illness, j 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 glimpse 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 established by Fisher of about seventy per cent of preventabihty for these ages is not too high. * See Coleman's "The People's Health," p. 228. 14 EDUCATIONAL HYGIENE TABLE II » 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 19 11 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 1 ,000 POPULATION FOR STATES INCLUDED IN THE REGISTRATION AREA IN igOO* PER CENT DEATH- RATE IN 191 1 REP- 1911 1900 IN igcjo* 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 iS-3 14.0 13-9 17.2 17.0 17.9 17.6 16.5 16. 5 87 86 88 87 8S 84 36.6 125-5 12.8 3-2 2.2 35 50 6.3 9.4 14-5 28.4 58.3 143 -o 39-8 138.6 133 3-4 2.4 3-7 5-3 6.7 10.4 16. 1 309 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 30 4.8 6.8 8.2 10.3 150 27-3 56.5 142.4 54-1 178.4 20.4 4-7 2.9 4.9 7.0 8.3 10.8 IS. 8 28.8 59-5 145-9 45-7 1450 19. 1 4.6 31 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 6S 72 83 76 76 81 96 102 107 104 lOI 73 77 64 67 68 69 70 73 85 91 lOI 103 100 'From igii U. S. Mortality Statistics. = 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. *The death-rate for 1911 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. ' Based on the standard million of England and Wales, 1901. Effective health education of pupils and parents, and efTect- 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.' • "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 PLTELIC SCHOOLS 15 1 / " HISTOGRAM ILLUSTRATING TABLE II. DEATH RATE PER 1,000 POPULATION FOR STATES INCLUDED IN REGISTRATION AREA IN 1900 BOTH SEXES. 1911. Rates tor school aaes;- 5-9 — 3.2 per 1000 10-14- 2.2 •• •• 15-19-3.5 " - / f / 120 no i r / 100 / 90 i ' / / } / / / / I ^ y Rate 5 ^sj n ^ Age Groups 0-5 5-9 10-14 15-19 20-24 25- -34 35- -44 45- -54 55- -64 65- -74 74 and iver Note. — The rate for both sexes in 1911 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 {i. e., 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 efficiency of the public-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, iqio CAUSES OF DEATHS 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 No. deaths in registra- tion area 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 26,227 Per cent pre- ventable 70 SO 45 25 85 75 75 50 70 40 10 50 60 40 25 30 80 40 55 25 50 67> Total No. deaths in the U. S. 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 44,270' No. pre- ventable deaths 4,340 1,850 1,370 7SO 2,210 1,950 1,920 1,080 1,120 500 116 S70 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. » Estimated. their various bulletins these significant words: "Public health is purchasable. Within natural limitations a community can determine its own death-rate." And the prophecy of Pasteur has in some communities gone far toward realization : 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, for 25 Most Nuaierous Causes of Death in 1910 CAUSES OF DEATHS No. deaths in registra- tion area Per cent pre- ventable Total No. deaths in the U. S. No. pre- ventable 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 BronchopneiHnonia Cancer and other tumors. . Spinal cord, other diseases Influenza, grippe Intestinal obstruction Measles Apoplexy, cerebral hem. . . S.166 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 75 25 45 75 50 40 70 SO 70 30 25 55 50 50 25 40 35 17,016 67> 8,650 4,230 2,830 1,940 1,920 1,750 1,270 740 550 500 450 450 400 400 340 340 300 280 280 260 220 200 200 190 28,780 6,487 2,405 48s 864 1,177 635 2 86 350 45 45 200 280 102 85 154 140 100 50 76 63 14,039 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 U. 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 efiiciency 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 beHeve from their investi- gations that a large share of retardation is due to physical i8 EDUCATIONAL HYGIENE TABLE V Approximate Expectation of Life in a State that Has Kept Life Statistics for Several Years ' MASSACHUSETTS (WHITE) SIX YEARS 1900 I 884-1890 1880 Males Fe- males Per- sons Males Fe- males Per- sons Males Fe- males Per- sons 0. . . 44-29 47-80 46.0s 40.39 42.59 41.49 44.06 45.22 44.64 I . . . 53-13 54.96 54.05 49.29 50.40 49 -8s 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 55.50 52.37 53-45 52.91 53.88 53.60 S3. 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 10. . . SO-15 51-70 50.93 48.83 49-97 49.40 51.01 50.93 50.97 IS-.- 45-79 47-49 40.64 44-78 45-98 45-38 46.8s 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 2 1. 16 21.33 22.56 21.95 22.52 23.93 23.23 55- • ■ 17-25 1S.32 17-79 18. IS 19 25 18.70 19. oi 20.43 19.73 60 . . . 14-48 15.41 1495 15. 35 16.32 15.84 15.98 17.26 16.62 65... T 1 . 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.QI 7-17 7.04 7.06 7.62 7.34 85... 5.46 5.54 5 -50 5.60 5.66 5.63 5.82 6.12 5.97 yo. . . 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); in 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 " 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. . . I . . . 2. . . 3--- r 4... 5..- 1 10. . . i5--- '-20. . . 25... 30-. - 35--- 40... 45--- 50-.- 55 •■ • - 60... 6s... 70... 75- •• 80... 85... 90. . . 95.- 44.06 52.0s 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 S.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. II 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. OS 9.94 7.83 6.71 S-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 S-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 39-80 36.26 32.71 29.20 25.70 22.33 18.96 16.10 13-25 10.90 8-54 7.40 6.26 48.0s 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 3701 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 efTect on the mental and physical status ^ 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 elimination, 16 per cent of non-promotion, and 17 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 behef 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 speciaHsts. 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} ' Wallin, Dental Cosmos, April, 1913. 'See articles in the Psychological Clink for January, 1915. 'See the writer's survey of Rural School Hygiene in the Report on Rural Schools to the Pennsylvania State Educational Association, 19 4, 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 mjiy be said to be seriously aihng 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 efl&cient 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 pubUc- 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 following chapters give the latest word of a number of leading specialists on the various ways and means by which school systems may markedly influence the life of the times by increasing the health and happiness of our people. CHAPTER II THE PUBLIC-HEALTH MOVEMENT Public Health and Public Welfare.— ^Public health is the I most fundamental and basic element of social, economic, I 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 public 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 public 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 public-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 public 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 Public 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. THE PUBLIC-HEALTH MOVEMENT 27, too fast," says Professor Sedgwick/ "almost faster than the teachers and directors of the movement could wish, because a great many foohsh things are being done to-day in the name of public health, and there are public-health fakirs as there are quacks and dealers in quackeries." Since the interest in public 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, 1913. 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 life and usefulness of every member of society, and to afford opportunities for a normal physical and mental development of society. In its broad aspects public-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 living, insanitary conditions of work and habita- tion, in health education of individuals and communities, and in providing opportunities for sunhght, 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. 2 Prolongation of Life. — It has been estimated with more or less accuracy that the average length of human life in the sixteenth century was between eighteen and twenty years, and at the end of the eighteenth century was a little 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 Berlin 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 ' 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 19C0 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 1900.2 COMPARISON OF MORTALITY OF MALES AND FEMALES BY AGE GROUPS Death-Rates per 1,000 Population AGE MALES FEMALES 1900 igii Per cent increase or decrease 1900 1911 Per cent increase or decrease Under 5 5-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75 and over. 54 4 2 4 7 8 10 15 28 59 146 2 7 9 9 3 8 8 9 6 I 39 3 2 3 5 6 10 16 30 61 147 8 4 4 7 3 7 4 1 9 6 4 -26.57 — 27.66 -17.24 -24-49 -24.29 -19.28 + 370 + 1.90 + 6.92 + 336 + 0.89 45 4 3 4 6 8 9 14 25 53 139 8 6 1 8 7 2 8 2 8 8 5 33-3 3-1 2.1 3-3 4-7 6.0 8.3 12.9 26.0 55 -r 139.2 -27.29 -32.61 -32.26 -31-25 -29.8s -26.83 -1S-31 -9-15 + 0.78 + 2.42 — 0.22 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, VI. * 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 mortality rates has benefited women more than men; and 2. That the mortahty 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 All Under 5 5-9 10-14 IS-IQ 20-29 30-39 40-49 SO-S9 6o-6g 70 and over 1880 23.21 7.92 2.91 2.85 3 10 4-95 10.13 19.70 3901 102.05 261 . lO 43.26 37 91 21 2 558 Per cent of increase 86.38% 30.8 35-7 65.6 75-2 63 -4 85.5 92.1 1340 113. o 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 possibihty 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 civilization. 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 Hfe, and the pernicious after-effects of the diseases of childhood, youth, and middle age are re- sponsible for this disquieting phenomenon. How Hving habits affect mortaUty is strikingly 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 \'itaHty 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 O™ 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 ' 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. Typhoid 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 civilization 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 typhoid fever in certain large cities of the world for the year 1910: 'John B. Andrews, "Industrial Diseases and Physicians," Journal of the American Medical Association, April 15, 1911, vol. 56, p. 1132. THE PUBLIC-HEALTH MOVEMENT 29 DEATHS FROM TYPHOID FEVER PER 100,000 POPULATION City Death-rate City Death-rate Hamburg Berlin 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 iS-5 Chicago Philadelphia Washington, D. C. Average Paris Average 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 estimated that at TYPHOID FEVER DEATHS IN INDIANA By Ages IBOr 140 120 100- 80- 60- 40- 20- m _ 1 1 i 1 i 1 ^ S; ^ ^ ^ 1 ^ ifi Ui-iu^^ MafMk\ E .: III IllItQ un 160 140 120 100 80 60 40 20 15 20 25 30 35 40 45 50 55 60 65 70 75 80 90 19/24 29 34 39 44 49 54 59 64 69 74 79 90 [ ^^ . ^ -Average for Last Ten Years Typhoid fever, like tuberculosis, finds more victims in the years immedi- ately following the school period, possibly somewhat earlier. Tj^jhoid 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 public-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 pubhc health. Whether a certain appetizing and high-priced preparation or expensive cut of meat has little 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 cleanl}^, 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 little 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 Carolina, 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 pubUc-health movement has not as yet accom- phshed 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, 19 14. 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 pubhc- 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 pubHc 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 Hfe. 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 I,000 POPULATION UNDER ONE YEAR OF AGE Area STATES OF THE REGISTRA HON AREA IN IQOO... Connecticut Maine 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 129. 5 130.9 no. 9 143 -3 III .4 150.3 131-5 128.8 138.6 102.0 104.8 131-9 170.0 123-3 160.9 123.8 130.6 141.9 159-3 156.8 144. 1 177.8 121. 3 172.0 167.4 159.8 197.9 122. 1 152.2 162.3 274-5 146.6 194. 1 162.4 189.4 201 .9 Per cent of decrease 19 17 23 19 8 13 21 19 30 16 31 19 38 16 17 24 31 30 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 mortahty 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 1100 1000 900 800 700 600 500 400 300 200 100 j ! 1 ■J 1 t i n !l i 1 1 1 1 1 1 -^ li ■^ ■^ ■ ITI ■ F^ ■E^ wm ■^ ■^ IF1 ■n iFI if r 1 in 1 1 ■i 1 2 3 4 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 1912 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 officer 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- normality, 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 mid wives, 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. '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 public 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- • E. H. Lewinski-Corwin, "The Practical Necessity of School Clinics," 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. MEASLES DEATHS IN INDIANA By Ages 40 ^ 1 25 1 1 1 ^0 ^ i ■^ y 1 10 5 1 \ it F 1 1 1 1 1 1 IP ■ _ in F i: iQ IQ _E Is P ^_ 40 35 30 25 20 10 -1912 5 10 15 20 25 30 35 40 45 50 5.5 60 65 70 75 80 90 9 14 JJ/ 24 29 34 39 44 49 54 59 64 69 74 79 90 [ ]-Avefage for Last Ten Yeacs 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 lOOl TUBERCULOSIS DEATHS IN INDIANA By Ages loLlDl 700 600 500 400 300 200 100 2 3 4 5 10 15 20 2-5 80 35 40 45 50 55 60 65 70 75 80 90 3 4 v5 9 14 19/24 2.9 34 39 44 49 54 59 64 69 74 79 1912 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 180/ 160 140 120 100 80 eo 40 20 i ^ 1 p , R - ^ 1 r li .^ l^ln La. Irn )■ 180 160 140 120 100 80 60 40 20 4 5 10 15 20 25 30 35 40 45 50 55 60 65 70 5 9 1 4 19 / 2^ 29 94 39 44 49 54 59 64 69 79 I j -Averape lor Last Ten Yeais Diphtheria finds its victims in the pre-high-school years. Most deaths occur from September to January. SCARLET FEVER DEATHS IN INDI.\NA By Ages 1 1 2 2 3 3 4 4 ^5 5 10 9 14 15 20 19y 24 25 29 30 35 45 55 34 44 54 90 >r" 1 ^^-1912 M -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 siunmer. 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 lie in the hospital treatment of patients for whom adequate domestic nursing cannot be secured. "2 '"Whooping-cough," Journal of the American Medical Association, May 31, 1913, pp. 1677-1680. * Forty-first Annual Report of the Local Government Board, 1911-12, p. x.xv. THE PUBLIC-HEALTH MOVEMENT 4I 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 climes 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 pubhc-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 isolation 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 published 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- tism and inefficiency about our public-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 returns as they exist are incomplete and unreliable, and then, when collected, no ade- quate analysis of them is made in most of the communities, bow can we expect to be able to direct the course of public- 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. '"Monograph Series," No, 8, October, 1913, p. 18, THE PUBLIC-HEALTH MO\EMENT 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 behefs. 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 public health is purchasable, our com- munity appropriations for pubHc 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 public-service enterprises) was $16.45 ill 1910. 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 public 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 1" 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. 1 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 aflfords. 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 aquiline, 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 unlike 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 normal" is itself a scholastic and pedantic figure of speech 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 "the teeth" are of comparatively Httle use to certain races, notably West African negroes, whose teeth are highly resistant to caries, and their faithful application 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 Uttle or no use of a tooth-brush. On the other hand, you will frequently find those whose constant use of antiseptic tooth-washes does little 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 (c) 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 * See Thorndike's " Individuality." HEALTH AND HEREDITY 47 in so far as hygiene fails to take this fact into account it fails to be 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." EQs potatoes were rot- resistant; his corn was from a "dry-farming" strain; his hogs were cholera-proof, etc. The agriculturist knows that, given certain fimdamental conditions of culture, the differ- ence of yield 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 ariother become disseminated throughout the entire populg,tion. 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 qualities 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 alike 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-hroiher 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 reahze 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, tleterminers. 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 '"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 fertilized egg; bad conditions may prevent the full develop- ment of determiners; but the best conditions cannot cause to develop in a cliild 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.— That 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 blindness. 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 'See Davenport's "Heredity in Relation to Eugenics," and Rosenau's "Preventive Medicine 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 genitaha 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 polydactyHsm, syn- dactyHsm ("lobster-claw"), brachydactyUsm (or two- jointed fingers), double- join tedness of fingers, and crossed or hammer toe. The affected persons tend to reproduce their pecuUarity. (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, hemophilia, or inability 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 qualities, 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 type have typically, 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 susceptibiUty 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 susceptibility is due to a positive de- terminer. Thus the tendency to form fluid-filled vesicles in the skin after the shghtest provocation such as a pressure or a scratch (epidermolysis bullosa) is a trait that shows itself in the first month of life 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 probability 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 Httle 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 Hved 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 famiHes, 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 the 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. Harehp and cleft palate, multiple nipples, hereditary ataxy, Friedrich's disease, amaurotic family idiocy, certain edemas, various disorders of metaboHsm, 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 50 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 Ofhce. 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 'See 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 appHcation 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- tialities 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 inkling 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 desirability 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 outline 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 symptorns 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." ^ Parents will find much help in Professor Ditman's little one-volume cyclo- pedia on "Home Hygiene and the Prevention of Disease" (DufSeld). 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- pHshed 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 arc 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 little 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 live regular lives, to be unselfish, and to love the good, the true, and the just. Particularly high in these qualities 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, njany a child with a faulty heredity or a distinctly nervous predisposition has developed into a normal life through the influence of a favorable en\dronment. Environment has much to do wath deciding the character and stabiUty 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 en\aronment 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 life 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) InabiHty to hold pencils, books, knife, fork, etc., securely. (d) Falling down or stumbling easily and frequently. 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 fLxed habit on themselves. Children with this disorder require rest in bed, quiet, regular Hfe, 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. 06 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 cause an intense suffering, Httle or not at all understood by parents. Doctor Guthrie well says that the earHest 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 pecuHar- 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 ' 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 rehgious 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 instabiUty. 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 to 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 of School Children," 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 to 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 discipline 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 > More than 50 per cent of school-children drink coffee, and often to excess. 70 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 egg, 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 quahty. 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 coflfee. Desirable foods include: clean milk, well-cooked cereals, crisp bacon, fish, broiled steak, soups, soft eggs, thin toast, THE HOME HYGIENE OF 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- sufffciently 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 life 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 appHed 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 little 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 life 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 lunch can never be considered alone. It must of necessity depend largely upon what is given for the other meals of the day. It is really not a difficult task to make one meal 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 light? His lunch should then be very hearty. Is he tired at dinner-time and sleepy ? His most nourishing meal should be at noon. Does he refuse eggs for breakfast? He may relish and digest them 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, 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 diflEicult 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. (b) 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 tiihercidosis 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 malnourished 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 resista,nce to specific infections, but it may be said that these results are due largely to a high degree of humid- 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 frcm 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 OF CHILDREN 79 to say that about one-quarter of the children of school age are afflicted 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 \asion 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 cither 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, tonsiUtis, 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 peculiar 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 ocuHst 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. Millions of dollars are annually spent to pro- mote the health and proper nurture of 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." THE HOME HYGEEXE OF CHILDREN 8 1 and a technical science has been developed. ISIany 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 applications 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 officials 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 obliged 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 public 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 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 tliis 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 established 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 public approval. Since school officials are Hmited in their power to arouse public 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 public 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 J "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 an 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 ofiicials 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 carrjdng 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 civiliza- 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 the 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 pubKc 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 itall, 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 » 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 libraries are compiHng and collecting. The Federal Bureaus of Labor, Education, and Children, and the United States PubUc Health Service, are constantly sending out pamphlets bearing upon health topics. But the school super- intendent has not only to keep himself informed; for tht 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-slides 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 pubUc 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 88 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 pubhc schools by a branch of the Association of Collegiate Alumnae, which resulted in the formation of a new school code; also of the survey performed by the Arundell Club in Baltimore, and by the Pubhc 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 > 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. 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 difficult to find some organization or individual who would assist a superintendent by delving into the local vital 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 pubUc. 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 publish its own report. Thus the evidence goes before the public 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 publish 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 v^'W 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 public-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 religious 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 publicity 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 ' 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 public 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 coluums. 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 demonsti a tion. > "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 public 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 ^Tbis first municipal school nurse has written a chapter for this volume, — Ep, 94 EDUCATIONAL HYGIENE the same view-point, sympathies, 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 political tactician, whose services can be secured for assistance in this work. The school board of Minneapolis 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 utilized 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 specialists will co-operate in the running of a clinic 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 cHnics 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 public 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 clinical service. The Cincinnati school report for 191 2 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 alUed organizations. Recently, in connection with the work of the cUnic, 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 '4 ^PJ School dental clinic at Cincinnati, O. (i) School dental clinic at Cincinnati, O. (2) Here we see the dental phase of the complete physical examination of the pupils at the Woodward High School, Cincinnati, O. 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 facihtating country or seashore vacations for needy children. The needs peculiar to crippled children are being at- tended to by organizations estabhshed 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 which 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 Scranton, 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 establishment of school lunches in high and elementary schools, arranging child-wel- fare exhibits, agitating the establishment 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 auxiliary 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 Public 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 1 913 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 find 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-OPERATION 10 1 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 pubKc 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 Anti-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 "little 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 hght 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 neivs papers 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 public-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 likely to keep on failing, 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 efficient. 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 Eliot. 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 poUtical. 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 pubUc 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 estabUshment 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 assembling even as the pubUc 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 realized 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 polling-place, results having to do with the improvement of this institution on fines of public-health service. Voting in the schoolhouse impfies 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 impfies some increase in salary and' increase in dignity and influence. The building is Io6 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 vitalizing 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-Govemment 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 implies the companionship of a club director, which work be- comes a function of the school principal or of a member of his staff. It implies 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 citizenship, 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 assembling-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 pubhc liealth 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 bv the neighborhood orchestra that is bound to get itself I08 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, homelike 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 office 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 established 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 office 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- munity'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 political corruption, economic maladjustment, and leisure-time exploitation — and so ade- quately and efifectively dealing with the problem of public 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 Hutchins, 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 difhculty, 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. »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 peculiarities 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 pubHc 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 likewise not a thing impossible to build up, guide, and make effective in the promotion of the pubHc 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 pubHc opinion, thus promoting INITIATING EDUCATIONAL HYGIENE III the self-acti\dty 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 pubHc sentiment, of developing this into specific public opinion, and of guiding this onward to public demand and pubHc action, including all the factors of local leader- ship and availabih'ty 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 pubUc 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 lines 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" II3 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 Super\'ision, 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 Offtce, 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 'Doctor Wood's pamphlet on "Health and Education" (University of Chicago Press) will be found very suggestive for each of these five divisions. * 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 ea h child. INITIATING EDUCATIONAL HYGIENE I15 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, biit tlie 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 easUy 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 make 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: Question 3. 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: , I. 2. 3- 4- I. 8. 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 9- lO. Does he have good powers of muscular co-ordina- tion ? Is the child free from spasmodic movements? Is he free from the nail-biting habit ? Does he speak without stammering ? Is he free from pronounced peculiarities such as ir- ritability, timidity, embarrassment, cruelty, mo- roseness, fits, general misbehavior, etc. ? Is he apparently free from bad sexual habits? Is he free from so-called " bladder trouble" (requests to "go out")? Is he usuallj'^ free from headache? Yes No D. Teeth 1. Are the teeth clean-looking? 2. Are the teeth sound-looking? 3. Are the six-year molars in good condition? 4. Has the child been to a dentist within six months?. 5. Are the teeth regular? 6. Does the child use a tooth-brush every day? 7. Are the gums free from abscesses? 8. Are the gums healthy-looking ? 9. Are the upper teeth straight (not prominent) ? . . . . 10. Have decayed teeth been filled ? E. Nose and Throat 1. Does the child breathe with the mouth closed ? . 2. Is he free from chronic nasal discharge? 3. Is he free from "nasal voice"? 4. Has he a well-developed face ? 5. Has he a well-developed chin ? 6. Has he straight, even teeth ? 7. Is the child mentally alert? 8. Is he usually free from sore throat ? 9. Is the hearing good ? F. Ears Does the child usually answer questions without first saying "What"? Is he fairly attentive? Is he fairly bright-appearing (not stupid) ? INITIATING EDUCATIONAL HYGIENE 119 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 Type ? H. Communicable Diseases of the Skin Is the head free from any signs of disease (lice, ring- worm) ? 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. 3. Vomiting. 8. 4. Eruptions. 9. 5. Red eyes. 10. Persistent cough. Scratching of the skin. Sore throat. 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 121 lorms 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).^ School Sanitation Forms Used by Doctor Ayres 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 ' 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. ' 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 building 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; Hkewise 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 cleanUness 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 facilities, 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 oj 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 type, 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 calHng 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 public-school work; and, third, the adoption of the measure and its support by public 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 1913 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 of new mecLsures — 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 voluntary 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 elimination 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 Hke. 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 vitality. The progress of science has developed in many and marvellous ways an unparalleled array of instrumentalities 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 life, health, and happiness there is now an increasing light. The work of Pasteur, of Koch, of Reed, of Galton, and many other scientific students of Ufe 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 Hfe wherever the problem of health and vitality may be con- cretely and intimately met and studied. By these various means we have come to the amazing spectacle of an enlightened 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, Kving 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 lives 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 lines 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 \'ariety 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 1 29 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 lighting, the aboKtion 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 will languish 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 I30 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 pubhc 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 pubUc-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 Ust such as fresh air, good food, sleep, clothing, sun- light, recreation, freedom from maUgnant 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 simpHcity, its practicabihty, 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 handhng 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 under 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 INSPECTIONS AND ANNUAL EXAMINATIONS DISCOVBRINO HEALTH NEEDS. CO-OPERATINO WITH BOARDS OP HEALTH AND PRIVATE OROANIZA- TIONS. OPEN AIR SCHOOLS. LIMITING DOCTORS TO EXAMINA- TIONS, B0PERVIS1ON OP NURSES AND WORK IN CLINICS. PSYCHOLO- GISTS. OCULISTS. SURGEONS, DENTISTS. PHYSICIANS. SUPERVISION or SCHOOL FEEDING. SCIENTIFIC STUDIES OP PREVENTION AND CAUSE OF DISEASE. CAREFUL RECORDS EMPHASIZmO SERIOUS AILMENTS FOUND AND CURED. TRAINING SCHOOL NURSES FOB ALL INSPEC- TION AND EXAMINATION. NURSES AS ATTENDANCE OFFICERS. SCHOOL SANITATION SCHOOL SITES AND ARCHI- TECTURE. VENTILATION. DRINKING WATER AND FOUNTAINS. HTOIENIC TOILET FACILITIES. DECORATION. THE STAND- ARD SCHOOL BOOM. PIRE-PROOP CONSTRUC- TION. HEALTH. REST. AND EMER- GENCY ROOMS. PLAYROOMS AND ROOF PLAYOROUNDa DRYING AND WARMING SEATS. TNVESTIGA- TIONS OF RE- CIRCULATION, HUMIDITY, AIR-CLEAN- ING, DISIN- FECTION, BTC. PHYSICAL EDUCATION PHYSICAL TRAINING AND GYM- NASTICS. POSTURE AND CORRECTIONAL EXBRCISBB. ASSISTING IN MEDICAL SUPERVISION. RECREATION. SCHOOL EXCURSIONS AND TRAMPS. BOY SCOUTS AND CAMP FIRB GIRLS. GYMNASIUMS AND ATHLETIC FIELDS. POOLS. SHOW- ERS AND BEACHES. PHYSICAL EDUCATORS WITH MEDICAL KNOWLEDGE. PAY FOR SUPERVISING PLAY AFTER SCHOOL AND SATURDAYS. CULTIVATING THE GREEK IDEAL OF PHYSICAL AND MENTAL PERFECTION. TEACHINC HYGIENE HEALTH EDU- CATION OF TEACHERS. ADVISING CHOICE OF BEST HYGIENE TE.XTS AND TOPICS. FORMING PERSO.N'AL HYGIENE HABITS. PUBLIC HYGIENE STUDY AND CO-OPERATION. HEALTH EDU- CATION OP PARENTS. FEEDING. CLOTHING AND SLEEP OF CHILDREN. HOME HYOIENK IN DOMESTIC SCIENCE. VOCATIONAL HYGIENE IN INDUSTRIAL SUBJECTS. TALKS BY DOCTORS, NURSES AVD SPECIALISTS. FIRST AID. SEX HYGIENE STUDYING COM.MU.VlTT HEALTH PROBLEMS A.VD METHODS OP IMPROVE- MENT. DAILY ORAL QUESTION- NAIRE ON HOME HYGIENE: USE OF TOOTH-BRUSH, COFFEE DRINKING, VE.N'TILATION, ETC. HEALTH KNOWLEDOB. HEALTH IDEALS, HYGIENIC TEACHINC ■THI} HYGIENE OP INSTRUC- TION." FATIGUE, OVER-WORK AND UNDER- WORK. THE HYGIENE OF SCHOOL SUBJECTS. INTER-RECI- TATION RE- CREATION. TRANSFORM- ING NEURAS- THENIC AND •CRANKY- TEACHERS. MOTOR ASPECTS OP TEACHING. THE HYGIENE OF JOY IN SCHOOLS. PREVENTINO PHYSICAL DEFECTS AND PATHOLOGICAL CONDITIONS. TNPLUENCB OF VACA- TIONS AND HOLIDAYS. HYGIENIC EFFECTS OP DIFFERENT METHODS. THE TEACHER AS MEDICAL GUARDIAN. 134 EDUCATIONAL HYGIENE We have now an organization of the field of educational h}'gicne. How are we going to get these various phases of the service to work together with the greatest efficiency and the least expense? How are we to provide the expert super- vision and service which we have named as essential? With- out going into the detail desirable, and attempting to avoid the pitfalls of devising a general cure-all for all kinds of school systems, we offer for consideration the following plan of ad- ministrative organization: The Administration of Educational Hygiene: A Tenta- tive Standard Plan. — School superintendents are not special- ists in the field of educational hygiene. Their education has generally been very much lacking in training along the lines of the physical, rather than the mental, nature of children, and most of the various health measures have come into the schools because of pressure by organizations and individuals from without school systems. The average superintendent probably spends very much less than one per cent of his time in stud>4ng and superintending school-health work. As there have been added in most progressive school systems super- visors of the various special phases of school work, so there must be supervisors of educational hygiene. In the past, and to a large extent at present, we have supervisors and teachers of physical training, and supervisors and instructors for play- grounds; doctors and nurses are rapidly being added ;^ dentists, oculists, dermatologists, psychologists, and surgeons are being provided. The regular teachers need education and inspira- tion along the lines of health work. There should be, then, a specialist in the schools to co-operate with and to lead the many civic and other bodies that have or may take a part in school-health work. All these needs and heterogeneous agents furnish the problem for organization and scientific management. 'The Bureau of Education reported in 1914 that of 1,300 cities with a popu- lation of 2,500 to 30,000 inclusive 516 cities report medical-inspection systems, and that 86 of the 516 have one or more school nurses. ADMINiSTRATION OF EDUCATIONAL HYGIENE 135 The only one who can adequately organize, supervise, and make efficient these miscellaneous instrumentalities and agents must be the educational hygienist. The educational hygienist should be one who knows well and can successfully supervise all the manifold phases of school-health work. The average physician is Httle versed in pediatrics, and not at all in school work and the phases of educational hygiene outside of mere medical inspection. The average physical-training teacher or supervisor knows something of her subject, but little more. The educational hygienist must know the schools and their problems; he must either be a physician skilled in the field of children's diseases and child hygiene, or an educator who has had such study and experience in the fields of school sanitation, sociology, the phases of medical training which may function in school medical supervision, in physical education, and, perhaps, in the two remaining divisions of educational hygiene, as will enable him to super- vise all school-health work. The ordinary medical course is a very poor training for such work. We need a four-year course that is designed especially to develop educational hygienists. Such a course may be provided in connection with some progressive college for the training of teachers, such as Teachers College, Columbia University, which is now purely a graduate institution, in some good medical school, or in connection with the courses that are now pro- vided at the University of Wisconsin, at Cambridge, Eng- land, and elsewhere, to educate doctors of pubUc health — D.P.H. A teachers college near and connected wdth a medical school would make a very desirable combination. Not having such training courses as yet, we should take physicians who have had experience in physical education, physician-physical-educators, or take educators who have had the elements of a medical education and who are versed in physical education, including normal diagnosis, medical gymnastics, play and playgrounds, and so on. The average physician has almost as far to go in perfecting himself for 136 EDUCATIONAL HYGIENE this work as has the educator. In an effort to provide such educational hygienists for several cities and State depart- ments of education the writer has found in this country over twenty available physicians who have had sufficient experi- ence in physical education and school work to make success possible in this new field. Several cities, such as Boston, Albany, Minneapolis, New York, and others, have such men as supervisors of hygiene for the schools, and a number of State departments of education are looking forward to pro- viding such officers. The State Board of Health of Minne- sota employed for some time such a hygienist. Doctor Hoag, who has a chapter in this volume and whose report of this work is printed by the United States Bureau of Education. As soon as universities estabUsh chairs and departments of educational hygiene, similar to those established at Clark, Stanford, and Teachers College, Columbia University, and as soon as more cities and rural regions demand such school- health officers, we shall have forthcoming a sufficient supply of eager and qualified young men. Such an official could be made co-ordinate in rank with other supervising officers under the general superintendent of schools, and could in many places so reduce school expenses as to save his own salary. The salary of such men must be between two and four thousand dollars, almost the salary of superintendents. Such an official, however, can frequently do the work of several part-time physicians, or medical ex- aminers or inspectors; he can frequently take the place of one or more physical- training teachers or supervisors; he can di- rect athletics and summer playground work, evening recrea- tion centres, and pubhc-school athletic leagues; he can fre- quently direct the school nurses in such a manner as to eUminate one or more special truant officers; and he can make the work of the whole health and development corps more efficient, eliminating waste, testing results, cutting down exclusions and illness-absence, and consequently retardation, elimination, and non-promotion. The health of the children ADMIN ISTIL\TION OF EDUCATION AX HYGIENE 137 of the schools and nation will not be adequately preserved and developed until such a definite organization and such health leaders are incorporated in school systems. Efficient leadership furnishes that scientific management, inspiration, and breath of Ufe necessary in all successful social organiza- tion, and the school cannot afford longer to miss its advantages in the fundamental field of health. The United States Bureau of Education and the English and Scottish National Boards of Education at present have such supervisors of educational hygiene, the last two being physicians and the first not. France, Germany, and Sweden, especially the last, have gone a long way in this direction. The State Commissioners of Education in Massachusetts and New Jersey have both recently made efforts toward getting such officers added to their departments for State supervision. The demands of economy, of leadership, and of efficiency will soon force most other States and most cities, as well as many rural regions, to supply such officers. Boards of Education, not Boards of Health. — This work must be placed everywhere, except perhaps in certain rural regions for a time, in the hands of the boards of education, not of the boards of health. I have treated this problem at some length in "School Health Administration," examining all sides of the question. Efficiency cannot come through ad- ministering any part of the school's work for children by some outside agency. Statistics and experience prove this; and the tendency is everywhere toward placing the work in the hands of the boards of education. Doctor E. H. Lewinski-Corwin has shown that a great factor in the success of medical super- N-ision is the degree of co-operation which the medical and health officials obtain from the teaching corps.^ Such co- operation can never be generally attained with this work in the hands of boards of health. Many other facts in the ' "The Practical Necessity of School Clinics," an investigation of the treat- ment of school-children in New York City, in the Popular Science Monthly for May, 1914. 138 EDUCATIONAL HYGIENE situation favor the school's administration of this work, while few favor board-of-health control. Scientific Organization with Little Increased Expense. — As stated above, the expenditure for such a supervisor of hygi- ene, in cities that already are doing their duty to the children in the Hne of health, with school doctors, nurses, and physical- training teachers, frequently may require little or no addi- tion to the present school budget, the work being merely that of reorganization of the various health provisions which have, in various ways and for several years, been coming into the school systems. In all but the largest cities the director can take the place of one or more part-time physi- cians, and can also do the work of one or more supervisors, or teachers, of physical training in the elementary schools. Money can also be saved as suggested by having him direct the summer playground work which now costs a number of cities considerable sums, the school clinic or clinics when started, high and elementary school athletics, evening recre- ation, and a number of other savings which may go to make up his salary. The nurses, when so directed, may take the places of attendance officers in many cities, and so save an- other considerable item. The present expenditures in these fields and the reorgan- ized expenditures have been given for twenty-five cities in "School Health Administration." Most cities have not yet caught up with the school-health needs; but most cities of average size can secure such departments of hygiene for little over 2/03 per cent of current school expenditures. In many, the added expense will, as suggested, be inconsiderable. For further concreteness, the old and the new reorgan- ized expenditures, for a fairly typical city already possessing the elements of such a department, are here given. This city has a population of about 50,000; there are fifteen schools, a public-school average enrolment of 6,000 pupils; and an- nual current expenditures amounting to about $250,000. ADMINISTRATION OF EDUCATIONAL HYGIENE 1 39 OLD, UNCORRELATED SYSTEM 2 high-school teachers of physical training $2,200 2 elementary-school teachers of physical training 1,800 6 physicians, two one-hour school visits weekly, at $300 1,800 3 school nurses, 44 hours a week, at $750, ten months 2,250 Total $8,050 REORGANIZED, DIRECTED SYSTEM 1 supervisor of hygiene, full time, 11 months $3,000 2 high-school teachers of physical education 2,200 I assistant physician, two hours a day, ten hours a week. . . . 400 3 school nurses, 44 hours a week, 2 at $825, i at $750 2,400 Total $8,000 Here we have the new organized and directed system at less than the original cost. There remain $50 toward more efficient records and blank forms. We have deducted nothing for saved expenditures for attendance officers, play- ground direction, etc., nothing but five unnecessary part-time physicians and the two elementary teachers of physical train- ing. Where the latter officials are paid less in the old system and the supervisor $2,500 instead of $3,000, there is another balancing of expenditures. The point is that the added ex- pense need not be great. The third nurse may not be added the first year, which would give a further reduction of $750. Perhaps scientific management may make her permanently unnecessary in many cities. The tendency is, however, in the other direction. The supervisor can, with the daily help of one of the two or three nurses, for two hours a day, examine the same number of children as the assistant physician, 3,000; and he can call the teachers together by grades and teach them how to carry on the physical-training work at the schools; and can take part of each day in supervising their work. The assistant physician is paid $100 more a month, and I40 EDUCATIONAL HYGIENE gives two full hours in one school daily. With the assistance of one of the nurses he can examine during the school year the other half of the school population (3,000 pupils), and can help make such inspections as are necessary. The third nurse, if employed, is left free for individual and classroom inspections and for follow-up work. Neither the teachers nor the physicians are bothered with vision and hearing tests, the nurses making them; and practically all clerical work connected with medical supervision will also be done by the latter. The physicians will be free for technical medical work, and the teachers will be less interrupted. Two of the nurses are paid for an extra month in the summer, one for July and one for August, to follow up cases not cured at the end of the school year and for necessary inspection of children at summer schools and playgrounds. Some of the most valuable work now being done by nurses is accomplished in these summer months; and the number of skin, parasitic, and infectious ailments is very much less at the opening of the next school year. The two high-school teachers of physical training, one a man and the other a woman, are left at perhaps the same salaries ($1,300 and $900). The supervisor of hygiene gives his entire time to the work, not for ten but for eleven months. If he obtains a thoroughly good assistant school-physician, the salary of the latter may be raised from $400 to $500 or more, but not sufficient to make possible the employment of another nurse at the same sum perhaps. It may be well to employ a woman physician as part-time medical examiner so she may better examine the high-school girls. The trials and tribulations of the superintendent in try- ing to get regular and responsible work from part-time physicians and in attempting to direct medical work without medical knowledge are now at an end. He has a small, com- pact, and almost entirely full-time force. These are essentials. The entire part-time element may yet be eliminated, but it ADMINISTRATION OF EDUCATIONAL HYGIENE I41 will mean salaries from $1,500 to $2,000, at least, for full- time assistant physicians. Later developments of the system can be made, however, after intelligent study and experience. If another physician is desired he may be obtained, and if, as the city grows, an assistant in physical education for the elementary schools is found necessary, the addition can be made. But these ad- ditions are intelHgent choices by an expert in educational hygiene, after reasonable investigation. We attempt to give here only minimum essentials and suggestions for beginning or reorganizing the work. At the recent International Congress on School Hygiene at Buffalo the writer was given practically the following facts by a member of a board of education of a typical New Eng- land city (about 9,000 pupils) with a request for a plan of efficient reorganization: PRESENT "INEFFICIENT" SYSTEM 12 part-time physicians at $500 $6,000 nurses 000 2 truant oflficers 2,500 1 elementary physical-training teacher 1,000 I summer director of playgrounds 150 Total $9,650 This system, recognized by the board of education as inefficient and not getting results, is a finely devised machine for securing Httle more than a collection of pathological sta- tistics of school population. The time the physicians spend in the schools is unknown; and they have no supervision nor nurses to follow up cases and get treatments and cures. There are no pubHc dispensaries for free treatment of children, and a large share of the population is too poor to pay $20 for an adenoid operation, for example, or to provide regular daily or weekly treatment for favus, ringworm, discharging ears, and other ailments. There is enough money being spent, however, 142 EDUCATIONAL HYGIENE to get efficient results in this field. Leaving the high-school directors of physical education in their places at the same salaries, we have for a beginning the following: PLAN OF REORGANIZATION 1 supervisor of hygiene, a physician-physical-educator $2,500 6 school nurses, 4 at $700, 2 at $770 4,44° 2 part-time physicians, two hours daily, at $500 1,000 I school cUnic, with dental, surgical, and medical divisions. . 1,000 I school dentist, with staff of voluntary dentists 500 New blank forms for records and reports 210 Total $9,650 Here we have a vastly more efficient system at the same expenditure of money; we have skilled leadership and super- vision; we have a plan which unifies all school-health agencies; and we have the emphasis where it belongs, on prevention and cures. Necessary changes can be made after adequate investigation by the hygiene supervisor and superintendent of schools. After the first year the thousand dollars of the budget spent for equipping the school chnic will be available as a salary appropriation for one or two part-time physicians. For the largest cities, such a health reorganization can easily be made, and it is practically possible for many cities having a population almost as small as eight or ten thousand. Several towns may even go together and employ such an expert, as superintendents are now employed in several States. And even rural districts may unite in the same way for the expert services of an educational hygienist and several nurses.^ The great need is for health experts and for health leadership. The people will respond and act along the best health lines when the health knowledge, now the possession of the few, is made the possession of the many. We have suggested here a possible channel for such general health enlightenment. ' See the writer's survey of rural school hygiene in Pennsylvania as given in the 1Q14 "Rural School Report" to the Pennsylvania State Educational Asso- ciation. ADMINISTRATION OF EDUCATIONAL HYGIENE 1 43 The far-reaching influence of such school-health leadership on national health and vitaHty can as yet hardly be imagined. Other Plans for the School Medical Service. — Disregard- ing as ineffective the physician-alone plan for school-medical work, we have two principal alternatives for serious considera- tion: the physician-and-nurse plan, already suggested, and the nurse-alone plan. For both there is the need of a super- vising director of hygiene, unless the superintendent of a small city is exceptionally well qualified medically and has time to devote to the work. We need supervisors of hygiene as much or more than we need supervisors of music, drawing, and such subjects. For both plans we may have either phys- ical examinations with inspection or only inspection alone. We shall take the stand that routine examinations, annually, are important as well as inspections. In the nurse-alone plan the routine inspections, with the use of individual cumulative health-record cards, can, at first, take the place of complete medical examinations, by simply adding the vision and hear- ing tests. The nurse-alone plan is, in general, far superior to the physician-alone plan, for a number of reasons, chief of which is that the former gets treatment and cure for a large per- centage of the cases, while the latter procures treatment and cure for but 5 or 6 to 20 per cent of the cases. Furthermore, the nurses can find most of the cases of all kinds, and can inspect satisfactorily, as proved in New York, for infectious diseases, especially when under supervision (September, 1911, Report of Bureau of Municipal Research). Cities as small as Canton, Mass., with less than 5,000 population, and as large as Oakland, Cal., with nearly 200,000, get good work with only nurses, under supervision. (Reports and letters of Doctor Arthur T. Cabot and of Doctor N. K. Foster, respectively.) Newark, with thirty-eight doctors and eight nurses, has reversed these figures by exchanging two doctors for each added nurse. Only five or six doctors were kept as dis- trict supervisors of the nurses. With the general supervisor 144 EDUCATIONAL HYGIENE as before, tliis has already greatly increased the efficiency for the money expended. Further, physicians can work but part time, while nurses devote their entire time to the work. The physicians are irregular and difficult to control in large numbers, while nurses, with practically no serious competing interests, are easily directed. And, finally, they are less than half, and frequently only one-fifth, as costly, hour for hour, and for the year, as physicians. The tables given in the writer's volume previously mentioned show even greater dispropor- tions of cost in a number of cities, when the annual number of daily visits, and number of hours each, are taken into con- sideration. Good, regular physicians, furthermore, can spare Uttle more than two hours a day regularly and punctually from their practise; and physicians for longer periods must be paid too much and cannot well stand the strain and monotony of long-continued examination or inspection. Diminishing returns, with the larger salaries for full-time physicians, bring in the school nurse often much more efficient hour for hour than such physicians as can be obtained. That the nurses need training, before and while in service, and that they must have competent supervision, is immediately apparent. The plan here outhned, however, places the emphasis upon the nurse and the physician, the physician-nurse plan. Get- ting full-time work from all school-health officials, a great desideratum, remains a nice problem for careful study and local adjustment. The first thing is to get the hygiene super- visor, next the nurses, and, finally, part or full time physicians. A very small city unable to obtain, with others even, a super- visor should start if possible with a nurse rather than with part-time physicians. If only a physician is employed the principal and teachers must do the follow-up work. In either case the record and report forms given in a later chapter may be used. Where to Obtain School Nurses. — As with all other forms of public service, the success of medical and health work depends very largely upon the character of the persons ADMINISTRATION OF EDUCATIONAL HYGIENE 1 45 chosen to carry it on. The greatest weakness of our school systems at the present time is due to the fact that our teachers are quite generally young women novices with a teaching tenure of three to five years only, and very largely ignorant of, and inexperienced in, the real Ufe of the community and nation about them. Educational readjustment must wait upon the improvement of the character of the teaching force. With even the best of supervision and the most scientific plans of management the health service, likewise, can remain palsied, feeble, and inefficient. After deciding to obtain officials for the school-health work, therefore, the practical problem becomes one of ob- taining high-class health agents. For nurses, we must as yet depend very largely upon the various training schools for visiting nurses, and the visiting nurses' associations. The Department of Nursing and Health, under the direction of Miss M, A. Nutting, R.N., at Teachers College, Columbia University, in New York City, is at present the only insti- tution in the country which gives special instruction and training for school nurses, and the number who can be sup- plied is at present very small. This is the first source I should recommend. Miss E. P. Crandall, R.N., Executive Secretary of the National Organization for PubHc Health Nursing, 52 East Thirty-fourth Street, New York City, and Miss E. L. Foley, R.N., Superintendent of the Visiting Nurse Association, 104 South Michigan Avenue, Chicago, may also be depended upon to advise school systems of graduate nurses who are specially quahfied for and looking toward public-school work. Miss Fannie F. Clement, 713 Union Trust Building, Wash- ington, D. C, can give valuable information regarding the Red Cross Rural Nursing Service and persons available as school nurses. The Boston District Nurses Association in afiiHation with the Boston School for Social Workers, as well as the Cleveland Visiting Nurses Association in affiliation with Western Reserve University, and, finally, Phipps In- 146 EDUCATIONAL HYGIENE stitute of Philadelphia are also in touch with most nurses in the country. The editor will be pleased to send the names of any persons known to be qualified either as hygiene supervisors or as school nurses to responsible persons, without charge to either party. Like Albany, N. Y., a city may find in its midst a man qualified both as a physician and a physical educator for such work, and good nurses amenable to training in the school service. The Future. — It is not to be expected, of course, that this plan is a cure-all. It is based on the actual conditions and needs of schools and does not represent anything impossible in the way of money. In this country and abroad cities and states are actually adopting it with sHght variations, and we believe it is scientific and along the right lines for the best future growth. The recommendation of a skilled supervisor of hygiene in each school system or group of schools is the best guarantee of study, growth, adaptation, and improvement. The plan as extended to medical supervision I give in a later chapter. The State's responsibility and opportunity for school health administration and extension will next be taken up. CHAPTER rX A PLAN OF STATE CO-OPERATION FOR SCHOOL- HEALTH PROGRESS Importance of Co-operation in School-Health Adminis- tration. — The co-operative commonwealth has been the dream of many a philosophical imagination. No one dream has ever come true in detail. But that co-operation is a funda- mental necessity in community life is becoming more and more evident with the increasing variety and complexity of human relations. This co-operation is desirable and neces- sary not only to conduct successfully business, social, and political affairs, but it is yet more necessary to ward off and to correct the ills of the community, both the present ills and those that threaten. Differing points of view on matters of vital importance, due in the main to differing habits of thought and of action and to unequal distribution of knowledge, are largely respon- sible for those conditions in community life that are dangerous. An extremely unequal distribution of wealth is harmful and often dangerous; but the condition of ignorance regarding the fundamental facts that may be known in matters per- taining to health and industry creates situations that menace community prosperity. For from such ignorance result un- hygienic and wasteful habits of life and serious, antagonistic prejudices. Education and Health.— Education, i. e., the process of in- forming and training in right practises, appears to be the sole force by which those community conditions that menace health and prosperity may be bettered. In the evolution of 147 I4S EDUCATIONAL HYGIENE the general educational programme every important commu- nity activity is involved, and it requires for its carrying out the employment of national and State as well as local agencies and resources. Particularly is this true of education in hygiene. Responsibility of State Departments of Education for Public Health.— It is not the purpose of this chapter to dis- cuss national and State legislation and administration of health agencies, but to call attention to the fact that a State department of education must accept in any general educa- tional programme a larger responsibility than it has assumed in the past, viz., the responsibility for systematically promot- ing educational propaganda among the adult, non-school- attending part of the population. With this responsibility it must also assume the task of securing general approval and support in the State for those educational measures that it is desirable to introduce into the schools. Lectures and widely circulated printed bulletins have been the principal means employed by the State in the past for disseminating information. More recently specific training has been offered by the State in a desultory sort of way to adult citizens, in agriculture and other industries. But the numerous voluntary organizations now found in every State may become powerful allies in any proper educational move- ment. The State's Share of Responsibility. — Some part the State must take in the affairs of each community, but in a democracy it would appear: First. — -That the State should take over completely only those responsibilities that by their nature cannot be shared successfully with local authorities. Second. — That it should become a partner in those re- sponsibiUties only which by their nature are partly extra- local. Third. — That it should not regulate any local activities except those upon which the prosperity of the State depends, and these only when local regulation has proved ineffective. STATE CO-OPERATION 1 49 Fourth. — That so far as possible the State should express itself by the avenues of advice, inspiration, and information rather than by dictation and compulsion. The individuahty of a locality must be preserved, its in- telUgence must be promoted, its initiative must be strength- ened, its conscience must be kept ahve, its citizenship must be trained, because the "locality" is the training-ground for whatever citizenship is in the State. If the State is to succeed by democratic rather than by autocratic means, its measures and proposals must have the approval of "pubUc sentiment." To secure this approval and to transform it from a passive to an active force, it would appear that the State must be in close co-operative relation with those factors in the State that are intelHgent and pow- erful enough to create a favorable "public sentiment" and aggressively to support a given poHcy in each locaHty. Getting Health Agencies to Work Together for a Conimon Purpose. — These considerations were forced upon our atten- tion when the commissioner of education decided to formu- late a comprehensive plan of instruction and training in hygiene for the schools of New Jersey. It was evident that any such plan to be effective in the schools must comprehend the adrdt population, also, since knowledge, conviction, and prac- tise in matters pertaining to hygiene were lacking in many localities. Moreover, inasmuch as the plan of school in- struction was based on the idea that instruction was to find an immediate application not only in the school Ufe but also in the home and community life, there was danger that passive popular indifference might become active antagonism unless the community became partners in carrying out the plan. A tabulation of the agencies in the State whose co-opera- tion the department of pubKc instruction might secure showed the following: 150 EDUCATIONAL HYGIENE AGENCIES AVAILABLE IN THE STATE FOR PURPOSES OF EDUCATION IN HYGIENE I. State Agencies for Education 1. State Board of Education. 2. Department of Public Instruction. Commissioner of Education. Assistant Commissioners. State Inspector of School Buildings. County Superintendents. 3. State Normal Schools. 4. State Summer Schools. 5. Extension Normal-School Courses. II. Local School Agencies 1. Boards of Education. 2. City Superintendents. 3. School Supervisors and Principals, 4. Directors of Physical Education. 5. Teachers. 6. School Medical Inspectors and Nurses. III. Agencies in the State Interested in the Provision OF Health 1. State Board of Health. Lecturer on Hygiene. Lecturer on Tuberculosis. 2. State Medical Society. 3. State Sanitary Association. 4. State Dental Association. 5. State Board of Architects. 6. Commissioners of Charities and Correction. 7. State Grange. 8. Local Boards of Health. 9. New Jersey Congress of Mothers. 10. Woman's Christian Temperance Union. 11. New Jersey State Federation of Women's Clubs. 12. New Jersey Sons of Temperance. 13. United Friends' Order of American Mechanics. 14. Patriotic Order Sons of America. 15. Local Playground Associations. STATE CO-OPERATION 151 16. Local Civic Organizations. 17. State Agricultural Experiment Station. 18. Princeton University — Department of Hygiene. 19. Rutgers College — Department of Education. More than half of these agencies have assisted in working out the details of the plan of educational hygiene for the schools. These agencies are influential in the State as a whole and their members are scattered throughout the State. It has, therefore, already been practically proved that the State has a most valuable asset in its civic organizations, an asset that should not be ignored in any programme of education involving interests which they and the State edu- cational authorities have in common. Health Education of Adults. — But the general plan of education in hygiene will be only partially carried out when the programme of work for the schools has been completed and distributed, and is operative in the schools with the general approval of the local communities. As before sug- gested, the time has come for the State department of edu- cation to assume responsibihties for the systematic education of those not connected with the schools, who cannot be reached directly through them. The theory that the habits of thought and conduct of adults cannot be affected by edu- cation is not soimd. Opportunities are being offered to adults in many States to learn more about their own trade, or to learn a new one. These vocational school courses are super- vised and wholly or in part financed by the State. There would seem to be no escape from the conclusion that, inasmuch as health is more fundamental than industry. the State must assume responsibility for the maintenance of the public health on as high a plane as it can be maintained. It is not enough to have officers going about enforcing pure- food laws and laws for the protection of water sources. The rapidly accumulating body of knowledge regarding matters of health in all its phases must be brought to the people in such a way that they will become inteUigent partners with 1^2 EDUCATIONAL HYGIENE the State in maintaining their own health and improving it on their own initiative. This hygienic intelHgence, hygienic conscience, and hy- gienic practise can be promoted only by the process of edu- cation; a process of education that is operative not only in the schools, but continuously and systematically among the adults who do not attend school. The responsibiUty for the formulation and carrying out of this twofold or two-sided plan of education in hygiene can rest nowhere but in a State department of public education. State Supervisor of Educational Hygiene. — To carry out any such plan there should be a State supervisor of educational hygiene. This supervisor should have had training and ex- perience as a physician and as a teacher. He should be com- petent in the fields of medical supervision, school sanitation, physical education, the teaching of hygiene, and the hygiene of methods of instruction. He should also be a student of sociology, and should be able to stimulate, guide, and help make efficient all phases of school hygiene and the general education in hygiene. In brief, the health of the State is so fundamentally important that the maintenance of it must be assumed by the State. Education in matters of health is the only means of making hygienic practises prevail in the life of each citizen. This education must affect the life of the adult as well as of the young citizen in school. Any general programme of education in hygiene will require in its formulation and for its effective working the co-operation of other State departments interested in matters of health and of all available civic forces focussed in organizations throughout the State. The bigness and the importance of the problem require that its solution be placed in the hands of a supervisor of educational hygiene. One of the prime functions of such a supervisor is to secure this active, guided co-operation to the end that hygienic intelHgence, convic- tion, and practises may be promoted in every community in the State. CHAPTER X CITY SCHOOL-HEALTH ADMINISTRATION School-Health Departments. — The educational progress of the future is conditioned to a large degree by the right solution of the problems of educational hygiene. Educational hygiene is therefore vital in education. Its scope is broad. Its organization is varied and requires skill and ability of high order. It has been developed and exists at present in cities under the different captions: School-Health Depart- ment, Department of Hygiene, Department of Health and Development, Medical and Dental Inspection of Schools, Department of Child Study and Educational Research, De- partment of Psychology, etc. These departments are at present under the control of boards of health, of boards of education, or of both boards acting jointly. It is the purpose of this chapter to discuss the scope and purpose of the entire field of work as at present administered, in part or as a whole, under the above captions and to suggest future development and organization. The development of this science and practise in its best expression at present is as follows: (i) Adequate medical inspection of schools by medical experts for the detection of and prevention of infectious dis- eases. (2) The co-operation of medical experts with city, county, and State officials in the problems of pubUc health. (3) Sanitary inspection of school buildings and grounds. This is the older form of medical inspection of schools. It is well established in the leading cities of the United States. There are, however, even at present, instances of extremely 153 154 EDUCATIONAL HYGIENE poor administration of this absolutely essential field of work from the standpoint of pubhc health. This statement is especially true of the sanitary inspection of school buildings and grounds. To this must be added: (4) That part of the field of work essential for the more intelligent handling of pupils and students throughout their period of educational training. (5) Thorough examination for physical defects. (6) The maintenance of hygienic activity, and hygiene of instruction. (7) Adequate teaching of hygiene. (8) Correction and cure of ailments found. These various phases are comprehended by the fivefold discussion of the subject in this volume. Purposes of the Work. — ^(i) The estabHshment of bien- nial, annual, and, when advisable or necessary, more frequent skilled physical and developmental examinations of pupils by a staff of experts. (2) The establishment of psychological examination of pupils and students by a staff of psychological experts, to make reliable tests of the mental traits and capacities of pupils at such times as may be necessary for more accurate knowledge of mental development, for more inteUigent classification, gradation, and educational training of pupils. (3) By effective action based upon the data of skilled physical and psychological examinations to secure: (a) The correction of physical defects and other defective develop- ment and thus remove the growth barriers of children and youths, {b) To maintain a scientific and systematic investi- gation of mental retardation and of mental and moral devia- tion of pupils in the pubhc schools, (c) Through the agency of skilled examination to provide school authorities with in- formation essential for the better adjustment of educational training to the requirements of physical and mental health, growth, and development of pupils, (d) To bring about the estabHshment of medical and dental clinics, and to provide CITY SCHOOL-HEALTH ADMINISTRATION 1 55 medical and dental aid for pupils whose parents are financially unable to provide such aid. (4) The establishment of skilled physical and health examination and skilled psychological examination of candi- dates for teachers'' positions prior to their election to determine fitness for work and thereafter to maintain health and efl&- ciency supervision of teachers as related to the work of the schools. (5) {a) To provide courses of technical instruction in hy- giene and related subjects for pupils and students, in the means of conservation of physical and mental health, growth, and development, and in the means of correction and prevention of defects, disease, and degeneracy. (6) As far as may be advisable, to give technical and practical instruction to the teaching force of the schools in the initial physical, psycho- logical, and developmental examinations of pupils normal, subnormal, and supernormal, and to organize such initial examinations and surveys of pupils by the teaching force of the schools under the direction of experts. (6) To establish and maintain well-equipped medical, anthropometric, and psychological laboratories in the public schools which will ' afford opportunity and equipment ^ {a) for sufficiently skilful medical, anthropometric, and psy- chological examination of exceptional pupils and of all pupils requiring examination; {h) for the technical training of teachers in the laboratory and experimental phases of edu- cational hygiene. (7) To provide an emergency service to supply skilled medical aid to the injured in the schools. (8) To exercise expert sanitary supervision in the plan- ning, construction, and maintenance of school buildings and grounds.^ > Similar perhaps to the excellent College of Hygiene at Dunfermline, Scot- land. ' See the Springfield Survey of the Sage Foundation for evidence of the need of this provision. 156 EDUCATIONAL HYGIENE ~ - (9) To so arrange this field of work that each department of educational hygiene shall constitute a bureau of practical investigation and research, and as such to co-operate with State bureaus of educational hygiene for the organization and supervision of State- wide work and investigation in this special field of education. Skilled Physical and Developmental Examinations by A Staff of Experts — A General Plan Biennial Developmental Examinations — Approximate Oc- currence, ^cj. Upon entering school 6 Prior to transition period 8 Subsequent to transition period 10 Prepubertal period 12 Pubertal period 14 Postpubertal period 16 Approximate attainment of physical growth 18 Biermial, Annual, and More Frequent Examinations. — Groups of pupils will stand out for which thoroughgoing biennial examinations are probably sufficient. Other groups will stand out which require annual or more frequent exam- ination. Examination for all pupils should occur sufficiently often to maintain efficient health, growth, and activity; super- vision — biennial, annual, monthly, or daily — in accordance with the needs of pupils. An annual examination with fre- quent inspections will probably be found most practical and efficient where the staff is large enough. GENERAL ILLUSTRATION OF AN ESSENTIAL PHYSICAL AND developmental EXAMINATION 1 (by a staff of experts and trained assistants) General health and growth, past and present. Family history (ex- ceptional pupils), height, weight, and vitality. ' Following the report form given in another chapter. CITY SCHOOL-HEALTH ADMINISTRATION 1 57 Eyesight. — Visual acuity, approximate determination of hyperopia, hyperopic astigmatism, myopia, myopic astigmatism, esophoria, exophoria, hyperphoria, infectious eye defects, other diseased con- ditions, and exceptional features. Color-blindness (exceptional pupils). Hearing. — Auditory acuity. Defective hearing due to middle-ear defects or to nerve deafness. Diseased conditions, exceptional features. Pitch discrimination. Teeth. — General conditions and cleanliness of temporary and perma- nent teeth, amount of decay, exceptional features. Examination of teeth to be conducted by skilled dentists whenever possible, except that teachers, nurses, and medical examiners may report such cases to school dental clinics for further examination, and treatment if necessary. Mouth and Palate. — Malformation and indications of degeneracy. Speech. — Defects of articulation, lisping, stammering, etc. Nose and Throat. — Presence or absence of nasal obstruction, diseased or enlarged tonsils, presence of adenoids, polypi, catarrh, etc., and any exceptional features. Glandular Conditions. — Enlarged submaxillary or cervical glands. Lmig Action and Respiratory Development. — Normal, rough, or bron- chial breathing. Rales — mucous, sibilant, sonorous, pleuritic. Chest development and expansion (tuberculosis, tendencies to same). Respiratory development. Exceptional features. Heart Action. — Normal, irregular. Murmurs, functional or organic. (Transition period 8 to 10.) Any abnormal condition requiring modification of school conditions or exercises. Thorough exami- nation conditioning physical training. Deformity. — Deformities of head, trunk, limbs, spinal curvature, bone disease, deformed chest, shortened limbs, etc. Nervous System. — ^Normal. Nervous instability, incipient, marked. Neurasthenic or hysterical tendencies. Chorea, tics, epilepsy, signs of overstrain, fatigue, etc. Sex Examinations. — Thorough sex examinations when advisable. Parents should be present. Anthropometric Measurements and Strength Tests. — Essential for de- velopmental and corrective physical training and for accurate knowledge of growth. (These can be made of value where there is a skilled supervisor of hygiene to use them. Usually they take much time but are not utilized.) General. — -Any weakness, defect, or disease specially unfitting pupils and students for ordinary school life and activities, and requiring modification of school activities. 158 EDUCATIONAL HYGIENE Physiological Age — Developmental Periods. — The determination of the physiological age of exceptional pupils, subnormal and super- normal, and the adjustment of educational activities to growth and development needs, especially at transition periods of de- velopment — 8 to 10 years — and puberty. Application of the Data of Skilled Physical and De- velopmental Examinations When Correlated with THE Data of Psychological Examinations The Assignment of School Activities. — (i) General As- signment. — When taken in connection with the order of school work outlined in the courses of study and in connection with the sociological factors of the pupils' environment, the in- formation given by these examinations should form a reliable basis for the general assignment of school activities, physical and mental, in adjustment to the health and growth needs and working condition of pupils, thus including the field of the hygiene of instruction — of proper hygienic ways of han- dling and educating pupils. (2) Special Assignment. — The assignment of pupils to un- graded rooms, to special classes, and special schools that have been estabhshed in our larger cities, and the adjustment of educational training in those schools, are markedly in need of a better plan of procedure. The information given by skilled physical and psychological examinations, along with socio- logical studies of home and community environment of such pupils, is essential to more intelligent assignment and adjust- ment of educational training of pupils in these schools and to the more intelligent issuance of work permits by school authorities. Physical Education and Its Adjustment to Health and Growth Needs. — (i) Physical Training and Playground Ac- tivities. — Physical education aims at the preservation of health and the development of normal physical growth, bodily re- sistance and vigor, and, through these values, an increased capacity for mental and physical work. Developmental and CITY SCHOOL-HEALTH ADMINISTRATION 1 59 corrective physical exercises and sports which supply activity for the developing instincts are the means to this end in physical training and playground activities. However, to in- telligently adjust such training to the demands of health and to the different levels of development requires skill of high order. To this end the physical director or instructor must be skilled in physical diagnosis, in certain phases of medicine, and in applied hygiene, personal and developmental. He may or may not have had a physician's training, but in either case in certain emergency instances and special cases he may need the advice and help of a skilled practising physician. In the past this work has not always been well done. Too often it has been the case that the physical instructor has not had sufficient skill in diagnosis nor sufficient knowledge of elementary medicine, or physicians have attempted the work who were not experts in physical education. Developmental mass training has been the rule in physical education as in mental education. Developmental and corrective individual training has been at a minimum. The greater emphasis that is now being placed upon phys- ical activities, upon personal and developmental hygiene, and upon a higher order of skill, where such is wanting, will plainly contribute to increased health efficiency. (2) Manual Training and Industrial Work. — Manual training and industrial work, and physical training and play- ground activities, together constitute the entire physical-edu- cation department of the schools. Education has been slow to learn the lesson taught by the structure and functions of the motor area of the brain. Health and developmental needs demand a much larger amount of manual and industrial training (motor training) than is usually possible at present in the schools, and the adjustment of such training to the individual and to the typical needs of pupils. In these re- gards educational hygiene has in the immediate future a work to do of a very high order. l6o EDUCATIONAL HYGIENE Physical Defects. — Mental and Dental Aid. — The records of physical examinations in the United States and in Europe have shown that from one-half to two-thirds of all pupils in the schools have physical defects and ailments, mostly re- mediable, that interfere to a greater or less extent with health, growth, and efficiency. It is a safe estimate that at least one-half of these defects are sufficiently serious to need special care, and that it is wisdom to attend to all. Vital efficiency is too valuable to waste, even to a small extent. Moreover, parents and pupils are largely unaware of the presence of these defective conditions or unaware of their far-reaching effects. The result in the schools is a large amount of retarded or arrested physical growth and poor vitality; a large amount of mental retardation and inefficiency, of degeneracy, of more or less crime; and also a large unnecessary expenditure of public funds. Economy and efficiency in educational work require effective action on the part of boards of education, in co-operation with the parents, to remedy this life-efficiency waste. Incipient Diseases — School Environment. — Thirty to forty per cent of all who die between twenty and thirty years of age die of tuberculosis; the curve of juvenile insanity rises rapidly between thirteen and fifteen years; preventable in- cipient nervous diseases abound in the schools; there is a marked increase in the death-rate of girls at about the age of eighteen, due both to incipient and slow-acting diseases; more than one-half of all the children born in the world die before the age of twenty- three; and there can be no doubt that too much of this enormous loss of human life is due to unwholesome conditions in the schools and to lack of skilled school care. Follow-up Service, Getting Results. — To inaugurate a plan of action which will secure the co-operation of parents and school authorities so that pupils will secure the needed medical, surgical, or dental aid is a work requiring skill, tact, and educational ability of high order. CITY SCHOOL-HEALTH ADMINISTRATION l6l Parents must be notified of the results of expert examina- tions. In many instances the consent of parents to the ex- amination itself must first be secured. Those conducting the work must possess sufficient tact and abihty to command the highest respect of parents and school authorities in this field of work, and to secure the co-operation of physicians and dentists from the standpoint of education. An educational plan of action must be persistently carried forward until results for which the work was inaugurated follow. Mandatory State laws are found in certain States, but until the work is well estabhshed mandatory means will meet with much opposition. Mandatory laws are not ad- visable until educational pubhcity work has brought about the right attitude, and has secured the co-operation of a large majority of parents and teachers. We must recognize that large numbers of people yet interpret the efforts of school authorities in securing the correction of physical defects and in providing other essential medical or dental aid as a move in the interest of the practise of medicine and dentistry in- stead of the practise of education. Permissive laws coupled with skilful educational work, patience, and persistence will usually succeed. School Nurses. — The service of the trained school nurse in education is one of the main factors in making health in- spection effective. The work of the school nurse is essentially as follows: (i) To assist experts in skilled examination of pupils and teachers and to notify parents of the results of examina- tions. (2) To assist teachers in making preHminary health and growth surveys and initial examinations or inspections of pupils. (3) To visit parents and discuss with them the health and growth needs of their children, to secure remedial action where necessary, and to give parents information of the na- ture and extent of the examinations and the purpose of the work, thus avoiding opposition and securing co-operation. 1 62 EDUCATIONAL HYGIENE (4) To furnish efficient aid in emergencies; to supply efficient skilled service at school and other clinics; to attend to minor ailmentg' in the schools; to teach practical hygiene to pupils, teachers, and parents. (5) To share largely in the inspection of pupils, and fre- quently to make the vision and hearing examinations. Co-operative Educational Work. — The Staff of Experts. — The teaching force of the schools and school nurses, working from the standpoint of education in their special field, form an educational corps to bring about effective co-operation of home, school, and health authorities in meeting the de- mands of the health, growth, and development of children and youth. The Establishment of Medical and Dental Clinics by Municipal Aid, by Medical and Dental Societies, and by Boards of Education. — Essential in this field of work is the establishment of medical and dental cUnics to provide medical and dental aid for pupils whose parents are financially unable to pay the customary fees for such aid. Cities and counties throughout the United States abound in large numbers of homes in which parents are financially unable to pay the customary fees, but many can pay partial fees. The embar- rassment resulting by the making known of financial need by parents, and many other difficulties, make the establishment of clinics of this kind a marked necessity. Clinics of this order have been established and are being established by municipal aid, by medical and dental societies, and, in certain instances, by boards of education. The re- sults are most valuable, since without them many thousands of children would never receive the needed health and growth aid; and, further, the results are most valuable in promoting this work, since they give a tangible meaning to the service where the need is most evident. Both parents and teachers appreciate the tangible results. The further development of the whole field of work thereafter is easier and more com- plete. It ought to be a function of boards of education either School nurse gi\'ing parents' notifications to school-children, Toronto, Canada Note the equipment of this nurse's room School nurses taking school-children to clinics, Toronto, Canada CITY SCHOOL-HEALTH ADMINISTRATION 1 63 to utilize municipal agencies for the establishment of clinics of this order, or to establish and maintain such clinics as a part of the work of the schools, preferably the latter. Educational and Clinical Psychology. — The scope and extent of psychological examinations and related work is essentially as follows: (i) Investigation of the hereditary and family history, of the health history, of the growth and development history of pupils, and investigation of the record of school activities, physical and mental. (2) The investi- gation of the data of skilled physical and developmental examination and such further psycho-physical examination as may be essential to the work. The data of physical ex- aminations ought to be supplied by the medical and physical- training examinations. If not, such examination must be made by examiners in psychological work. Such data are es- sential for a knowledge of health and strength, of normal or arrested physical growth, and of functional and developmental conditions. The usual medical examinations or physical-train- ing examinations are not sufficiently complete for the work of clinical psychology. (3) The Determination of the Mental Age of Pupils and Degree of Development of Specific Mental Functions — Tests. — The Binet-Simon measuring scale for intelligence: tests of general intelligence, attention, perception, comprehension, memory, association, imagination, invention, and construc- tion. Learning processes — reasoning power, judgment, motor co-ordination, reaction time, other psychological tests. The Binet-Simon scale approximately answers the purpose of determining mental age. It has recently been revised and improved. Psychologist educators and physician educators are working continually to ampKfy and perfect this scale. In its more complete development it will become a still more valuable instrument in determining mental age — the "mental station" at which a pupil as a whole has arrived. Psychological Tests for Specific Mental Functions, Abil- ities, or Traits. — During recent years reliable tests of specific 164 EDUCATIONAL HYGIENE mental abilities, together with the extended use of the Binet- Simon scale, have been put into practise (i) in schools for the feeble-minded; (2) in the practise of medicine; (3) in psychological clinics in the pubhc schools for the segregation of imbeciles and morons and borderland cases, with the pur- pose of assigning special training in special schools; (4) to some extent in the public schools to determine the specific development of specific mental traits and abilities of all pupils so that educational training might be better adjusted to health, growth, and efficiency needs; (5) research work in normal schools and universities. (4) Tlie Determination of Norms of Development of Specific Mental Abilities. — The evolution of the work has been rapid. The results on practical work in the schools of recent research make it reasonably certain that in the near future reliable norms of mental development and efficiency will be established which will make possible: {a) the determination of the nor- mal condition or acceleration or arrest of specific mental traits ; {h) the specific character of such arrests or accelerations of growth; (c) the improvement which different traits undergo from month to month and from year to year under the train- ing which pupils receive in the schools; {d) the improvement resulting from medical and dental aid. By the aid of such norms of development and efficiency educators can much more intelligently classify or grade, as- sign and adjust, educational activities. While it is most valuable to know how many years a pupil's mental growth is accelerated or retarded, it is much more important to know specifically the development of specific mental traits and abihties. To know that a twelve-year-old pupil is two or three years accelerated or arrested in mental development as a whole, does not mean nearly so much to educators as to know whether his attention, association, memories, percep- tion, comprehension, different learning processes, etc., are arrested or accelerated in their specific development and to what extent. It means just as much to know these facts CITY SCHOOL-HEALTH ADMINISTRATION 165 specifically as to know the excellence or defect of eyesight, hearing, heart action, or other physical function. Reliable Mental Tests of All Pupils. — -As far as practicable, reliable tests of the specific mental traits of all pupils ought to be made at such periods as the intelhgent direction of their growth, development, and school activities demands. Careful records ought to be kept and correlated with the records of health and of physical growth, and with the records of school work. This is a field for practical work, investigation, and research. By such procedure school authorities could adjust edu- cational activities more intelligently to health, growth, and activity needs. The school grades would become more nearly levels of capacity; individual training would become a more intelhgent fine of action; a large amount of mental retarda- tion would not occur; the potential abihties of pupils of ex- ceptional worth would be better conserved; truancy pupils and cases of incipient crime would be more intelligently handled; mental-deficiency cases would be rightly segregated and trained; the determination of fitness for vocational work and the discovery of talent would be realized to a greater extent; and increased efiiciency would characterize educa- tional work. This work for all pupils is yet in its beginning, but suffi- cient advance has been made to justify the statement that the near future will witness a marked extension of the work already done in psychological chnics and in special schools. The results of progressive work and research in the schools and research in universities and normal schools will be a suffi- cient guide to future progress. Mental Retardation and Arrested Growth— The Conser- vation of Excellence. — -This phase of education is of the high- est importance. There is a vast army of pupils in our pubHc schools whose growth is more or less arrested. Statistics from all sections of the country show this condition. It is a safe estimate that out of the 20,000,000 pupils in the public 1 66 EDUCATIONAL HYGIENE schools of the nation 3,000,000 are repeating a grade a second, third, or even fourth or fifth time, at a cost of approximately $100,000,000 annually, an expense largely wasted and pre- ventable, to say nothing of the loss of life efiticiency. The more extreme stages of arrested growth, namely, the idiot, the imbecile, and moron, afford features of marked educational interest to the public schools. The mental age of the idiot is never greater than that of a child of two years, no matter what his chronological age. The mental age of the imbecile does not exceed the eight-year level. The mental age of the moron ranges from eight to thirteen years, not ex- ceeding the thirteen-year level. Passing these extreme levels of arrested growth in our schools and homes, all grades of mental age and all stages of more or less marked arrested growth stand out. Further, we know that the predisposition to insanity and degeneracy is marked in the more extreme stages of arrested growth, markedly greater in the feeble- minded than in the ordinary population. We know further that arrests of development of the more marked type grade insensibly into the higher levels of arrested growth found in large numbers in our public schools and in our homes, and that the same predisposition to degeneracy to a greater or less extent is an accompaniment of all stages of arrested growth. However, important as it may be to take intelligent care of the idiots, the imbeciles, the morons, and the insane, it never- theless is these higher retardation levels that should especially concern us, because of their close kinship with feeble-minded- ness on the one hand and with adult deterioration on the other. There is a marked need of systematic and scientific study and investigation of the moral and criminal traits of delin- quent and abnormal pupils in our schools; of the variation of criminal tendencies and moral defect with physical defect- iveness, with types of disease, with transitory states as ex- hibited in certain forms of epilepsy, in delusional and maniac depressive forms of insanity which show themselves in klep- CITY SCHOOL-HEALTH ADMINISTRATION 1 67 tomaniac and suicidal tendencies, and other forms of degen- eracy. There is a marked need to safeguard all pupils, and es- pecially defective pupils, by skilled training and by hygienic environment against overpressure and not sufficiently in- telligent handhng, particularly at the transition periods — eight to ten years and thirteen to fifteen years. The marked increase in juvenile crime and juvenile insanity during the pubertal years is a known condition which ought to mean much in safeguarding all pupils at the period of growth against possi- ble weakness and inefficiency. It is especially important to exercise skilled oversight of pupils prior to the transition periods of growth, before immoral and criminal tendencies be- come fixed; before weakness and inefficiency are allowed to develop; before excellence and super-qualities, physical and mental, are allowed to remain undeveloped. There is marked need of skilled determination or discovery of the supernormal pupils of the public schools and the ad- justment of educational activities to their growth and de- velopment needs. The highest excellence and genius of the race for the future is found, in potential and evolutionary form, in supernormal children who embody in quantitatively superior degrees those capacities that are exhibited in less degree by the masses of the young. There is a marked need of investigation by a skilled staff of the mental capacities, and of the physiologic, anthropologic, sociologic, and hered- itary problems underlying their evolution, and of skilled han- dling of these pupils. No type of pupil has been so neglected as the pupil of highest excellence and possibiHties. Excep- tional talent, superior capacity, and intelligence, that remain undeveloped or are directed in lower lines of action, are a loss not only to the individual but to the State and the nation. Physical and Psychological Tests and Fitness for Voca- tional Work. — Physical and psychological tests to ascertain fitness for vocational work are an application of and an ad- dition to the testing above outlined appUed to the needs of 1 68 EDUCATIONAL HYGIENE adult life. Such tests are especially valuable in high schools in correlation with other essential work connected with voca- tional guidance. Tests for vocational fitness vary from tests of vision, hearing, color discrimination, pitch discrimination, and re- action time to tests of general intelligence, of memory, per- ception, association, accuracy and rapidity of movement, and other psychological tests. At present, as a part of a skilled physical examination, accurate tests of vision, color dis- crimination, and hearing are required of all recruits for the army, navy, and marine corps. Recently the Binet-Simon tests have been used in testing recruits for the marine corps with interesting results. The testing of the intelhgence of army recruits and of immigrants is another interesting field for investigation. The management of steam and electric railways and of electric street-car lines in different instances requires ac- curate physical and psychological examination of different employees — in the case of motormen, psychological examina- tion to determine ability to avoid accidents. In different instances telephone companies have inaugurated skilled phys- ical and psychological examination as a guide in the selection of employees. Pilots and officers of ships, chauffeurs, type- writers, stenographers, employees of automobile companies for certain kinds of work, have undergone skilled physical or psychological examinations or both. This work is yet in its infancy but has progressed sufficiently far to demonstrate its value. It is a field of investigation of high order for future vocational efficiency. Its future development in the schools depends largely upon the efficiency of departments of educa- tional hygiene of which it is a part. Physical Health and Psychological Examinations of Teachers. — The health of teachers is one of the most impor- tant factors of the pupil's environment. Whatever action is essential ought to be taken by school authorities to insure physical and mental health as a fundamental characteristic al s' .t- st of ise ila , on i" to p on- a I ons t ling f « and • wise i It of I le to I ance. rtant J ctive se of each- :hers' Pupils Field cation e part :al ex- make pupils SNELLEN TEST SHEET, 70ftor21m. D L N soft, or 15 m. P T E R 40 tt. or 12 m. F Z B D E c 30 ft or 9 m. o r L C T G 20 (L or 6 m. APEORFDZ 15 ft. or 4.5 m. ITPRTVZBDFHKO If a cHId cannot read the thirty-foot line with cither eye, he should be referred to an oculist • I CITY SCHOOL-HEALTH ADMINISTRATION 1 69 of the teaching force of the public schools. For this purpose the skilled physical and health examinations furnish essential data and should be required of all candidates for teachers' positions prior to their employment and thereafter, in what- ever particulars may be essential to protect the schools against inefficient teaching due to lack of vitaUty and poor health of teachers, on the one hand; and, on the other hand, to exercise such hygienic supervision of school environment and curricula as may be essential to safeguard the teachers' occupation against unhygienic requirements and conditions of work; to act as an educational force in establishing such hygienic con- ditions and requirements of teachers as shall make possible the highest efficiency in the teachers' profession.^ The psychological examination of candidates for positions as teachers is logically a part of a system for determining fitness for vocational work. This field is as yet untried. It is a field for practical work, investigation, and research. Psychological testing of the specific mental traits and capacities of teachers will yield information not otherwise to be obtained, of value in education from the standpoint of vocational guidance. Such examination will be valuable to teachers in bringing about the earher recognition of excellence. The health and efficiency of the teaching body is an important aspect of educational hygiene and as such requires the effective carrying out of some reasonable and practicable course of procedure in regard both to the actual health of the teach- ers and to the conditions and requirements of the teachers' work. Initial Physical and Psychological Examination of Pupils by Teachers, and Seminar Work with Teachers in the Field of Educational Hygiene. — Increased efficiency in education requires a certain degree of skill and proficiency on the part of teachers to conduct initial physical and psychological ex- amination of pupils under the direction of experts; to make preHminary health and development surveys of the pupils 1 See Terman's " The Teacher's Health." 170 EDUCATIONAL HYGIENE over which they have charge. Efficiency requires that teach- ers of special classes and special schools should develop to a considerable extent the insight of the skilled diagnostician. Many teachers can make important contributions both in general growth problems and in diagnosis, especially in the solution of specific problems. It is therefore essential to efficiency that experts in educational hygiene enlist the co- operation of the teaching force of the schools not only in the immediate technical work of physical and mental examina- tions but in the solution of specific problems of educational hygiene of vital interest in the schools. Such work on the part of experts consists in part in giving more or less laboratory and technical instruction, including typical examination of pupils for teachers, in the initial ex- amination of eyesight, hearing, indication of nose and throat defects, condition of teeth, indications of defective heart and lung action, of malnutrition, sex aberrations, defective phys- ical growth and development, indications of excellence and signs of degeneracy; mental examinations of pupils; giving the Binet-Simon tests; specific tests of attention, perception, comprehension, memory, association, invention, and con- struction, learning capacity, etc., in so far as teachers are quahfied. Associated with this immediate work of physical and mental examination is the special investigation of mental retardation and of arrested physical growth — a study of mental deficiency in its varied phases, the study of excellence and genius as well as retardation and degeneracy. Supplementary work of this order may well take the form of seminar work in educational hygiene — the results and problems growing out of school examinations forming the laboratory basis of such discussions. The teacher is the ever-present health, growth, and development officer in the schools; every school- room is a psychological laboratory; and such co-operative work is of high scientific and professional order and essential to a high degree of efficiency. CITY SCHOOL-HEALTH ADMINISTRATION 171 Co-operative Educational Work by Physical Educators, Instructors in Biology, Medical, Dental, and Psychological Experts. — One of the needs, and one of the opportunities, of the schools is the practical and more or less technical teach- ing of certain phases of biology, physiology, anthropology, psychology, certain phases of medicine and dentistry, and certain phases of pubhc health work. This work may be well done in large classes and by means of public lectures. It is the opportunity of the instructors in biology and physical education in high schools and of the medical, dental, and psychological experts of city systems to organize and carry out in co-operation valuable courses of instruction of this order, supplementary to the instruction in hygiene in the schools. These lectures necessarily will be somewhat popular in form but full of information, and should contain the results of the latest investigation and research in many lines of work of vital interest to all. In the schools the results of physical examination and the developmental and corrective physical training constitute a laboratory of personal physical hygiene. The results of psychoclinical examination and the resulting special edu- cational training constitute a laboratory of mental hygiene. The results of investigation and research in the educational hygiene work of the schools as a whole constitute a laboratory basis which may well serve as a basis for more extended edu- cational work which will give larger perspective to the work of the schools and will also be of pubHc service. The Planning and Maintenance of School Buildings and Grounds. — The planning and maintenance of proper hy- gienic and physical conditions of school buildings and grounds is a work of which the main purpose and facts are well known, and one which in the past has been markedly disregarded. Reliable authorities agree in saying that there has been no place where all consideration of health has been so disre- garded as in the construction of school buildings, churches, public halls, and the buildings of the average college or uni- 172 EDUCATIONAL HYGIENE versity. A recent writer states: "The total value of all public school buildings of America is $700,000,000, but in point of fact one-half of them are so abominable that they should be torn down forthwith, and a quarter more of them should be reconstructed." Recent school buildings are much better, and yet any number of faulty constructions are still going on. What is needed is a yet more vigorous educational campaign in what hygiene, sanitation, and efficient living require. What is needed still more is: (i) The indorsement of certain standards and require- ments in the planning and maintenance of school buildings and grounds by State and national educational and medical organizations. (2) The enactment of legislation which will define these standards and insure the erection and modification of school buildings in accordance therewith. A Bureau of Investigation and Research. — Each Depart- ment of Educational Hygiene should act, so far as practicable and consistent with the required established work of the schools, as a bureau of investigation and research. The functions of departments of educational hygiene are twofold: (i) Carrying out certain established work of the schools. (2) Research in the field of educational hygiene. Research in the Field of Educational Hygiene. — As technical experts, members of educational-hygiene staffs have a most important function in the field of research. The con- servation of vision is a marked illustration. About 10 per cent of school-children have defective eyesight. How much of such defect is due to unhygienic environment and activity ? Ordinary vision requires fifteen to twenty movements per minute under conditions which permit frequent changes in accommodation. School work demands of the immature eye one hundred and fifty to two hundred separate move- ments per minute with the accompanying accurate accom- modation and convergence. Is the school work adjusted to such changes when the child enters school and thereafter? CITY SCHOOL-HEALTH ADMINISTRATION 1 73 No sufi&cient standards based on adequate research have yet been estabUshed as to the length of lines and size of type for the various ages of school-children — shapes of letters, spacing of letters and words, the lighting of schoolrooms, and similar problems. Sufficiently thorough examination of eyesight and mus- cular balance is rarely made in the regular physical examina- tions. Every one knows that the reflex effects of eye-strain are markedly detrimental. Is there not a much better con- servation of vision possible than exists to-day? The state- ment is current that of the 20,000,000 school- children in the United States 40 to 50 per cent contract tuberculosis at least once during their school course and that probably 2,000,000 school-children now in our schools will die of this disease; further, that of these 20,000,000 school-children probably half a million will sooner or later become inejB&cient nervous adults and failures because of the different neuroses. Are these statements true? In the annual report of the Boston schools for 1913 it is stated that out of 110,000 school-children of that city only 150 tuberculous children were found — a different result from the usual 5 per cent quoted as the number suffering from tuber- culosis. In how many cities of the United States are the usual medical examinations sufi&ciently thorough to diagnose incipient tuberculosis ? Is it true that by segregating the 2.000,000 school-chil- dren above referred to and placing them in open-air schools we should save a large proportion of their lives ? ^ Is the school a factor in the undoubted increase of markedly nervous men and women and in the increase of insanity? Does the school develop nervous stabihty? With skilled adjustment of physical and mental activities might not a very large pro- portion of the half-million nervous school-children above re- ' Investigations by Superintendent D. C. Bliss, of Montclair, N. J., throw doubt on the alleged efficacy of fresh-air rooms. Psychological Clinic for May, 19 1 5. 174 EDUCATIONAL HYGIENE ferred to develop excellent nervous stability and many of them marked talent ? The imbeciles, morons, and borderland pupils in the public schools are undergoing skilled psycho- cHnical examinations and are being segregated and placed in special schools and given special training. Are school author- ities conserving the pupils of exceptional ability by the same process? Are school authorities conserving the abilities of all pupils with sufficient skill? To this end, research work for the establishment of standard norms of mental efficiency is a marked need of the hour in education. Growth is the central problem in education. Retarded or arrested growth is responsible for much of the failure, misery, and inefficiency of the world. So far as skill is available, how many schools make sufficiently accurate physical and mental measurements to ascertain whether pupils are growing normally? Problems in physical education: in the discovery and proving of mental tests; in the establishing of norms of mental efficiency; medical and dental matters of vital interest; the classification, grading, and training of pupils in accordance with growth conditions; the heating, Hghting, ventilation, and proper construction of school buildings; the psychological examination of pupils and teachers for vocational fitness. These and many other problems call for research work by experts and the close co-operation of such experts with the teaching force. Experts in Educational Hygiene. — Five classes of experts stand out as best qualified for work in this special field of education. (i) The psychologist educator: an expert in educational and clinical psychology and in experimental pedagogy, skilled in physical and mental diagnosis of normal and ab- normal growth and development, and having a knowledge of elementary medicine. (2) The physical educator: skilled in physical diagnosis, who has a knowledge of elementary medicine, or who has had a physician's training. CITY SCHOOL-HEALTH ADMINISTRATION 1 75 (3) The skilled physician who has sufi&cient acquaintance with educational work. (4) The skilled dentist who has sufi&cient acquaintance with educational work. (5) The skilled school nurse. Suggested Organization for Cities — under the control and direction of boards of education with power to delegate their authority with reference to the cure of contagious diseases in the public schools to local health authorities. (A) A Department of Educational Hygiene. Experts: Whenever practicable it is advisable to include the following experts on the staff of examiners, qualifications as stated above, all under the supervision of an expert school hygienist: {a) Psychologist educators; (&) physical educators; (c) skilled physicians; {d) skilled dentists; {e) skilled nurses. {B) Division of the Educational Hygiene Field into Two Departments: (i) A department of health and physical development (medical and dental super\'ision of schools). Skilled phys- ical examinations essential for physical education and for all educational work, including corrective clinical agencies. Department Work : (a) Adequate inspection of the schools for the detection and prevention of infectious diseases in the public schools and the reporting of same to boards of health; {h) skilled physical examination of pupils essen- tial for a knowledge of the pupil's health, detection of physical defects, fitness for physical training and for par- ticipation iii playground activities, with recommendations for educational training; (c) the physical and health exami- nation of teachers; {d) sanitary inspection of school build- ings and grounds; (e) research; (/) prevention and cure. Whenever practicable it is advisable that the staff of ex- aminers include the following experts — qualifications as given above: (a) skilled physicians; {h) physical educators; (c) skilled dentists; {d) school nurses. 176 EDUCATIONAL HYGIENE (2) A Department of Educational and Clinical Psychology {Child Study and Educational Research). Department Work: By psychological examination and by investigation of the health and growth history, of the hered- itary history, of the data of physical examinations, and of such additional data as may be essential to correctly diagnose normal, accelerated, retarded, or arrested growth and to recommend educational activities. To carry forward the following: (a) As far as practicable the determination of the degree of development of the specific mental abilities and the mental ages of all pupils with recommendations for classi- fication and training; (b) the more thorough selection and discovery of pupils of exceptional worth (supernormal) with recommendations for classification and training; (c) the segre- gation of mental defectives with recommendations for classi- fication and training; (d) special fitness of pupils and teachers for vocational work; (e) research work in educational and clinical psychology. Experts of the Department: Psychologist Educators — quali- fications as given above. The co-operation of psychological experts of the department of psychology with the physicians of the medical department meets the need for skilled medical service when such aid is essential in the department of psy- chology. The department of psychology is a field for a cer- tain amount of practical and careful constructive work, and for a large amount of research work in the discovery and proving of mental tests; in the estabHshment of norms of mental efficiency and related work, and for close co-operation with the teaching force of the schools in the application of the results of the work to educational needs. (C) A Department of Educational Hygiene representing a greater or less part of the entire field of work — whatever part is necessary to supplement local work already undertaken under different forms of organization which it may be impossible or unwise to reorganize — with the employment of such experts and other employees as may be necessary to carry forward the same. CITY SCHOOL-HEALTH ADMINISTRATION 1 77 The above outlines of administration may suggest future administration where work has not been organized, or may suggest adjustment of the entire field of work to different forms of local organization which conduct the work in part only. The Outlook. — In the different evolutionary stages of educational hygiene in the United States at the beginning of 191 2, seven States had enacted mandatory laws, ten States permissive laws, two States and the District of Columbia had such laws that medical inspection carried on by city boards of health has the force of laws. The remaining States at the above date had no laws with reference to this field of work.^ The field of work, therefore, in the United States is in the early stages of a splendid evolution. For this reason those who shape and forge the work ought to exercise skill and wisdom equal to the opportunity. The right solutions of the problems of educational hygiene condition to a marked de- gree the efficiency of all educational work. That efficiency may characterize its administration, the field of work should receive adequate administrative recognition at the hands of school authorities. Practical plans of procedure should be inaugurated and carried out so that both city schools and rural schools may avail themselves of the work in its most efficient forms. Future State laws enacted ought to incorporate those legal provisions which experience has proved most valuable, and those features of the work which practical work in the schools and research clearly indicate. State bureaus of educational hygiene ought to be established and State experts appointed for the initiation and State- wide supervision of the work. State aid and county administration of school work will probably be necessary to the fullest development. » "Medical Inspection of Schools," 1913, Gulick and Ayres. CHAPTER XI RURAL SCHOOL-HEALTH ADMINISTRATION The Rural Health Problem.' — Health is the greatest asset in Ufe. Upon it human welfare depends. Not only is health a condition essential to happiness, but it is also of the highest economic importance. Hygiene and sanitation are important phases of sociology, economics, and civics, because whatever affects the welfare of the people affects the welfare of the whole State. Almost one-half of the people of our nation live in rural communities, and the welfare of these people should be considered a vastly important function of the government, because they are engaged largely in the produc- tion of the materials which, either raw or manufactured, are the essentials of national life and progress. The more efficient these people are in every respect, the greater the production. Ill health and physical defects on the part of those who pro- duce these materials are not only a loss to the State but a menace to the health of those who use them. The sanitation and health of rural communities are therefore subjects of direct vital importance not only to the rural dwellers them- selves but to all. Health and sanitation being vital factors to the welfare of the people, it is a paramount duty of the State to make a study of these problems to the end that rehable information may be obtained and made available to the people. It is furthermore a paramount duty of the State to exercise super- vision over health conditions in order that the causes for dis- ease, physical defects, and ill health may be removed as far as it is possible. Especially should the State make its schools > See also the chapter on " Rural School Sanitation." 178 RURAL SCHOOL-HEALTH ADMINISTRATION 1 79 a common medium for the dissemination of this information ; and in order to render this instruction as effective as possible the school itself should be a model hygienically. The State already considers the training of its citizens academically a paramount duty and compels attendance at school. With such compulsion there ought also to be a provision whereby the State can guarantee a safe and sanitary environment for the young people while they attend. The schools are the homes of the children for a large portion of their early years, and to live in sanitary surroundings during those years means the inculcation of a definite sanitary sense which ulti- mately determines the hygienic standard of the home. Improvement of Health Largely a Matter of Education. — To conserve, to develop, and to enrich human hfe physically, intellectually, and spiritually, in order that man may reach the highest development of which he is capable, should be the great purpose of education. Hygiene and sanitation are de- partments of education of \dtal importance to the welfare and happiness of all. A consideration of what has been done to improve health conditions in rural schools will serve as a basis for considering what can be done in the future. Among the educational agencies which have been instrumental in the betterment of rural schools may be mentioned: (i) School-Board Conventions. — In several States large meetings of school officers have been held for a number of years. In some States these meetings are provided for by law and the officers are paid a per-diem and mileage for at- tending, while in other States the meetings are voluntary associations or are held in connection with teachers' in- stitutes. A member of the State department of education and the county superintendent are generally in attendance, and thus are afforded excellent opportunities for the depart- ment to learn the conditions and needs of the schools and the people. In Wisconsin the statutes give the teachers the right to attend these conventions without loss of pay or time. Phases of school sanitation always come up for discussion l8o EDUCATIONAL HYGIENE and much has been done, not only to create better school sentiment, but also to spread information regarding methods of managing schools and caring for the health of the chil- dren and the community. (2) Teachers^ Meetings. — Institutes of various kinds are held in most States and at such gatherings matters pertaining to hygiene and sanitation are frequently taken up. All States provide by law that physiology and hygiene, with special reference to the effects of stimulants and narcotics, shall be taught in the public schools, and this naturally leads to other health topics. Some of the States have, by recent enact- ment, provided for teaching prevention of accidents. In Michigan the following law was enacted in 1909: Section i. There shall be taught in every year in every public school in Michigan the principal modes by which each of the danger- ous communicable diseases is spread and the best methods for the restriction and prevention of each such disease. Such instruction shall be given by the aid of text-books on physiology, supplemented by oral and blackboard instruction. From and after July ist, nine- teen hundred ten, no text-book on physiology shall be adopted for use in the public schools of this State, unless it shall give at least one- eighth of its space to the causes and prevention of dangerous com- municable diseases. Text-books used in giving the foregoing instruc- tion shall, before being adopted for use in the public schools, have that portion given to the instruction in communicable diseases approved by the State Board of Health to the State Board of Education. (3) Farmers^ Institutes, Community Gatherings, and Rural Organizations of Various Kinds. — All these agencies are edu- cational and incidentally do much to disseminate knowledge concerning hygiene. Bovine tuberculosis with the possibil- ity of its transmission to human beings has been discussed quite generally and with much vigor at farmers' institutes. Home sanitation is a subject for earnest discussion in local farmers' clubs. The Grange and other rural organizations have been and are always active in spreading information that will better rural conditions. The social-centre move- Cuiirlesy of the Fort Wayne Waion Works A sanitary school hack for transporting pupils to consolidated schools A small heater may be attached to the bottom of the wagon-bed Interior of school hack shown above. Where a heater is used a register is placed in the floor Driver sits with the children RURAL SCHOOL-HEALTH ADMINISTRATION l8l merit that has for its object the general use of the schoolhouse for community gatherings is gaining strength and the depart- ments of education in various States are helping by means of bulletins and circulars containing helpful suggestions. (4) The School. — The rural school itself, humble though it may be, is becoming a great agency for influencing the com- munity in the many phases of rural life. It is true that the teaching of hygiene, like the teaching of other branches, has not been productive of the best possible results, but the re- sults obtained demonstrate that the rural school can be made a potent factor in improving conditions. In some local- ities good health habits have been inculcated in children by giving school credit for personal care at home, as outlined in a pamphlet published by ex-State Superintendent E. L. Alderman, of Oregon. The same home-credit plan where tried has been found to exert a strong influence in establishing a proper attitude toward matters of health on the part of the child and sometimes on the part of the older members of the family. One county superintendent during the past year, through his teachers, school officers, and the school-children, made a campaign on the house-fly; another on the care of the teeth; and, through the efforts of another superintendent, all of the school outbuildings of a county were placed in proper condition and kept so throughout the year. Occasionally we find superintendents and teachers taking up specific problems of sanitation with excellent results; and these superintendents and teachers tell other superintendents and teachers what has been accomplished and they are often stimulated to try the same things. Can any one doubt the far-reaching results of such sanitary instruction? The teaching of physiology and hygiene in the country schools is continually improving: first, because more adequate provisions are made every year for training the teachers; second, better and saner text-books are available; and, third, the courses of study call for simple and practical instruction. (5) Literature on Hygiene. — In addition to the regular 1 82 EDUCATIONAL HYGIENE text-books there are many excellent supplementary books, bulletins, and magazine articles dealing with health and sanitary suggestions in a popular way. The libraries con- tain many excellent books for home reading. In some of the States traveUing libraries are sent through the rural com- munities and these often contain popular works on hygiene. Many of the State boards of health publish and disseminate excellent bulletins deaUng with various phases of health. Public Health, pubHshed by the Michigan State Board, is especially excellent. Tracts, leaflets, and circulars deahng with contagious diseases, the hygiene of children, and other matters pertaining to the welfare of the pubUc are published and distributed according to the needs of each particular State, so far as the funds will permit. Unfortunately, in many of the States health departments are not given the financial support that they should have.^ It is also true that the general press of the country is more than ever interesting itself in discussing hygiene and public sanitation. Not only is more newspaper space given to the subject than formerly, but the articles are far better in quahty. Though much of the material written on educa- tional and hygienic subjects is not high-class and wholly re- liable, the better magazines and periodicals are securing the services of the most eminent medical practitioners and authorities giving information of the highest value. (6) Training-Schools for Teachers. — Much more attention is given now than formerly to the preparation of teachers for rural school work. Though much of this work is yet in a somewhat crude state, yet some success has been achieved in giving to these young teachers some knowledge of the subject- matter, some method, and some definite preparation. A number of the normal schools have introduced special courses for rural school-teachers, and training courses are being ad- ministered in connection with high schools. In Wisconsin, ' The New York State Board of Health is publishing a health almanac similar to those of Kansas and Virginia. RURAL SCHOOL-HEALTH ADMINISTRATION 1 83 county training-schools with two-year courses for rural school- teachers have been established. In these special schools much attention is given to instruction in hygiene, physical educa- tion, and school sanitation. (7) The State Boards of Health. — Reference has already been made to the Hterature sent out by these boards. Be- sides circulating Hterature, they also do much in educating people directly. Members of boards of health sometimes ad- dress teachers' institutes, school officers' meetings, and other gatherings. Through their regular work of inspection they and the local boards do much to impress upon the people the importance of sanitary surroundings. In many of the States the rules of the State board of health have the force and effect of law and many reforms have been brought about, such as the abohtion of the common drinking-cup. (8) The State Department of Public Instruction and the County Superintendents. — As far as time and means permit, these educational forces endeavor to secure better sanitary conditions in the school surroundings and profitable school instruction in hygiene. Their responsibility is direct and great. Improvements that Have Been Made in the Sanitation of Rural Schools. — It is impossible in a short article to go into all the details of improvement in the various States and to give statistical information as to what has or has not been done. It is rather our purpose here to tell of some of the things that have been done administratively by the various agencies mentioned in order that we may be guided in further efforts. (i) School Buildings. — In some of the States provision has been made by law for the condemnation of insanitary school buildings. In Wisconsin this power is given to the inspectors in the department of public instruction, who are delegated by the State superintendent to inspect school buildings when appHcations come to him for such inspections. In the capacity of State rural-school inspector it has been my 184 EDUCATIONAL HYGIENE pleasant duty since the law was enacted in 1909 to put out of existence more than eighty health-destroying school buildings. The other inspectors in the department have also had their share in the good work, so that we now have inspected and removed, or improved, over three hundred buildings. The inspectors are empowered to order a new building, or the old one repaired. In North Dakota the county board of health, of which the county superintendent of schools is a member ex oflficio, has the power to condemn school buildings, and insanitary school buildings are often ordered discontinued. Several of the States have made provision by law for the approval of schoolhouse plans by some authority. In certain cases plans are provided by the State and sent to any district desiring to use them. In this way great changes have been made in rural-school architecture and in rural-school conveniences during the last decade. Some State depart- ments of education issue bulletins containing suggestions for remodeUing old schools. In numerous instances county superintendents have done excellent work in bringing about improved conditions and there are locaHties where many new, sanitary, up-to-date rural school buildings are found; and, as a rule, when one such building has been erected several others are built in neighboring districts shortly after. Good things are contagious as well as disease. (2) Sanitation of School Buildings. — The progress that has been made in school sanitation is usually due to one of two factors: (a) the educational work that has been done among the people themselves because of suggestions gathered at school-board conventions, teachers' meetings, community gatherings, etc.; (b) the State laws that have been passed regulating sanitary conditions, and the proper administration of such laws. Regarding the first agency, Superintendent J. A. Churchill, of Oregon, writes: The county superintendents in a large number of counties have taken up the matter of better sanitary conditions by calling parents' JNIodel rural school, Kirksville, ^le .?^3S**3K!!S» Interior of a rural school, illustrating method of ventilation, use of single seats, and sanitary drinking-fountain RURAL SCHOOL-HEALTH ADMINISTRATION 1 85 meetings, especially in the rural districts, and making an appeal to the people. As a result of these meetings we have counties in which every rural school building has the windows arranged so that the light comes from the left, where a special system of ventilation is pro- vided or the windows arranged with window-boards, and where the outbuildings are in absolutely sanitary condition. This work has been accomplished through an appeal to the people rather than by compulsion. The State board of health has helped us a great deal in this work by sending lecturers. In some States, notably Pennsylvania and Indiana, the law provides specifically for the proper sanitary condition of all school buildings. In Indiana regulations have been drawn up in the law for school sites, school buildings, lighting and seating, blackboards and cloak-rooms, water supply and drinking arrangements, heating and ventilation, water- closets and outhouses. A penalty is attached to this law, which reads as follows:^ Any agent, person, firm or corporation, selling, trading or giving to any township trustee, school trustee or board of school commis- sioners, any materials, supplies, sanitary apparatus or systems, which when constructed or remodelled or installed, in or for any school house, hereafter constructed or remodelled, which do not in all respects comply with the provisions of this act, shall be guilty of a misde- meanor, and upon conviction thereof, shall be fined in any sum not more than five hundred ($500.00) dollars, to which may be added im- prisonment in the county jail for any determinate period not more than six (6) months and shall be punished by a further fine of not less than five ($5.00) dollars for each day he shall fail to comply with any order of any court having jurisdiction for the correction of any such defects in such school houses hereafter constructed or remodelled; and any money claim for the construction or remodelling, or for any materials, supplies, sanitary apparatus or systems furnished or con- structed in or for any school house hereafter constructed or remodelled, which does not in every way and in all respects comply with the re- quirements of this act, shall be null and void. (3) Cleanliness. — In many sections where school senti- ment has been low, cleanliness especially has been at a dis- ' See the bulletin of the U. S. Bureau of Education on " Sanitary School- houses." 1 86 EDUCATIONAL HYGIENE count. In some States laws have been enacted providing for the cleaning of the schoolhouses. Where such laws have been passed, where school officers' meetings are being held, and where the county superintendent has the energy and abiUty to do things, we find some excellent conditions. There are localities where most of the school buildings are thoroughly cleaned once a month. At least one State requires, by a vigorous statute, the use of something to keep down the dust in the daily sweeping of all pubHc buildings, including schools. Lest we become too optimistic in this matter, how- ever, let us remember that there are still thousands of rural schoolhouses that do not get more than an annual soap-and- water cleaning; but such are rapidly disappearing. Maine has on its statute-books a law dealing with the cleanliness of the children themselves. Several other States have similar laws deaUng with contagious diseases. The Maine law reads as follows: When a teacher becomes aware or suspects that any of the pupils attending his school are in a condition which renders them a source of offense or danger to the other pupils in school on account of filthi- ness, or because they are the bearers of vermin or parasites, or have an infection or contagious disease of the skin, mouth or eyes, he shall notify the superintendent of schools, and when a superintendent of schools knows or learns that any of the pupils attending any school within his jurisdiction, are affected with any of the conditions, infec- tions, or diseases herein mentioned, he shall notify the parents to cleanse the clothing and the bodies of the children and to furnish them with the required home or medical treatment, for the relief of their trouble, and the superintendent of schools may, when he deems it necessary, exclude such children from the schools temporarily or until they may be cured, cleansed and disinfected. Parents thus notified of the condition of their children shall forth- with have them and their clothing cleansed and shall promptly do what is necessary, or furnish them such medical treatment as may be required to rid the children of vermin, parasites, or contagion; and any parent who fails to do what is required so that the children may re- turn to school with as little loss of time as is possible, shall be guilty of a misdemeanor and shall be liable to a fine not to exceed five dol- lars for the first offense, and not to exceed ten dollars for a second or subsequent offense. RURAL SCHOOL-HEALTH ADMINISTRATION 1 87 (4) Seating.— In this matter, as in everything else con- nected with the country school, progress depends upon en- lightenment. Where the most educational work has been done we find the best conditions. There are country schools in which no one could sell any kind of desk except the best. In some localities the people have no knowledge of what is the best and frequently do not care. It is a pecuHar fact that some of the worst conditions are often found in communi- ties where the material progress is the greatest, and some of the worst schoolhouses I have seen have often been those in wealthy communities. (5) Medical Inspection.- — Some progress has been made in the matter of medical inspection in rural schools. In New Jersey provision is made for the medical inspection of pupils in all schools. The law was enacted in 1903 and is quite com- plete in its details. Massachusetts enacted a law in 1906 which makes the following provisions: The school committee of every city and town in the commonwealth shall appoint one or more school physicians, shall assign one to each public school within its city or town, and shall provide them with the proper facilities for the performance of their duties as prescribed in this act. Every school physician shall make a prompt examination and diagnosis of all children referred to him, . . . and such further examination of teachers, janitors, and school buildings as in his opinion the protection of the health of the pupils may require. . . . The school committee . . . shall cause every child in the public schools to be separately and carefully tested and examined at least once every school year to ascertain whether he is suffering from de- fective sight or hearing or from any other disability or defect tending to prevent his receiving the full benefit of his school work or requiring a modification of the school work in order to prevent injury to the child or to secure the best educational results. The tests of sight and hearing shall be made by teachers. The State board of health prescribes the directions for these tests and furnishes cards, blanks, record books, etc. A booklet has been issued containing suggestions to teachers and school physicians. 1 88 EDUCATIONAL HYGIENE From the report of the Massachusetts State Board of Education we find that this law is well enforced in some places, but in regard to enforcement elsewhere the following state- ments are made: In a considerable number of towns no general medical examina- tion of all the children has ever been made. Undoubtedly this general examination is far more important to the school and to the community than the special and casual ones. It reveals defects which have be- come chronic and which will permanently and vitally affect the wel- fare of the children. The responsibility for this examination rests directly upon the school committee and not upon the school physician, unless it is specifically included in his contract. The report shows that where the law is fulfilled excel- lent hygienic conditions prevail, while in some communities " medical inspection is practically a nominal affair" and " there is no medical inspection worthy of the name." In Connecticut the law provides that the school board "way appoint one or more school physicians and assign one to any public school . . . and shall provide such school physicians, when so appointed, with proper facilities for the performance of their duties." The law is quite explicit as to what shall be done in case physicians are appointed. The State board of health in its biennial report for 1911-12 makes the following recommendations: We have had a law on the statute books for some time permitting school boards to employ medical inspectors. This ought now to be amended so as to make medical inspection of schools obligatory. Some may think it a foolish expenditure of money for which the citi- zen should not be taxed, but such objections will not bear scrutiny. The authority which has the right to compel attendance at school has the added duty of seeing that no harm comes to those going there, and humanity requires that medical assistance be given children who may suffer through the ignorance or neglect of their parents. With the lengthening of the school term and the increase in the years of schooling demancied, there has come an advance in the work required. When the standards were low the work was not beyond the capacity of the weaker children, but with fuller courses and higher standards this has changed, and inquiries must be made regarding the RURAL SCHOOL-HEALTH ADMINISTRATION 1 89 children who do not keep up with their classes, in order to diminish the present economic waste from misdirected educational efforts. These objects can only be obtained by a system of routine inspec- tion of the children by medical men interested not only in public health but also in education. In New York the legislature enacted a law in 1913 re- quiring medical inspection in all public schools. The act also provides for the appointment of a State medical in- spector of schools, by the State commissioner of education. The department of education has therefore a real depart- ment of school hygiene. The Pennsylvania law also provides for medical inspec- tion of all schools, but it has a provision to the effect that school districts of the fourth class (which would include rural districts) may decide by vote not to have inspection, and the medical inspection does not come under the jurisdiction of the State department.^ In Minnesota, Virginia, and Michigan specialists are employed to visit as many schools as possible. The work that has been done in Minnesota is given in the bulletin, "Organized Health Work in Schools," published by the United States Bureau of Education. The school law of Utah provides that the teachers of the State shall conduct certain physical examinations of the school-children. These examinations are made under rules prescribed by the State board of health. Provision is also made that the boards of education may employ regularly licensed physicians to make these tests. The State legislature of Ohio enacted a medical-inspection law in 19 13 which makes it optional for school boards to employ one or more medical inspectors. Two or more dis- tricts may unite in the employment of one inspector. The provision is made that the inspector must be a regularly licensed physician. ' See the Rural School Hygiene Survey by the Editor in the Report on Rural Schools, Superintendent N. C. Schaeffer, Harrisburg, Pa. IQO EDUCATIONAL HYGIENE (6) School Outhiiildings. — The toilet facilities in many country schools are inadequate and this results in insanitary conditions. School officers' meetings, the training given to teachers for rural schools, and the enactment of statutes pro- viding specific standards for outbuildings, have much improved conditions in many localities, but in order to bring about proper and permanent results it is necessary to secure the co- operation of school officers, teachers, parents, and children. The improvement of conditions in these respects is of itself a phase of the general educational problem.^ In the discussion of the above topics attention has been called to some of the things that have been done to improve health conditions in the rural schools. It has not been the aim to give a full account of the conditions as they actually exist. Such an account would have no particular value in connection with this work, but from what has been done we can formulate some plans as to what can and ought to be done, and in planning the work it is well to keep in mind that progress involves: (i) A campaign to interest the people in work of hygiene and sanitation, thus securing their hearty co-operation; and, (2) The co-operation of all agencies and forces having part in the work, in order that the most efficient system of health supervision may be established as described in a previous chapter. Following are some suggestions made to improve health conditions in rural schools and through them general health conditions in rural communities. The State departments of education need to he strengthened in many cases. It should be kept in mind that the State superintendent is the educational director for the State. The campaign for better health should be made a part of the regular State educational propaganda, all forces and agencies working under the direction of, or in co-operation with, the * See Dresslar's bulletin on " Rural Schoolhouses and Grounds," U. S. Bureau of Education- RURAL SCHOOL-HEALTH ADMINISTRATION 191 department of education. Enforcement of law depends upon popular opinion and popular will, and these, in turn, depend upon the education of the people. It is encouraging to note that the State departments in many States have been materially strengthened of late. In Iowa two field workers were added by the last legislature, and in Wisconsin the State superintendent's "official family" now numbers fifteen members. In Alabama the State super- intendent has been enabled to secure the services of two rural-school supervisors through an appropriation made by the General Education Board. In many of the other Southern States one or more rural school supervisors are secured through appropriations made by this Board. In many of the States there is now possible a strong organization of the educational work. With a strong staff the State superintendent can direct effectively a health programme in the schools. He should have the aid of all the educational agencies of the State; and the services of the State university, the normal schools, and all other educational institutions and forces should be at his disposal, so that he may feel free at any time to utiHze any specialist that may be adapted for this work. With the strengthening of the State department of education must come also a higher conception in the minds of the people of the importance of the office of county^ district, or local super- intendent of schools. This official naturally holds the key to the educational situation in his administrative area. The county superintendent's position is, however, often inade- quately provided for, either with funds or with office assist- ance. With the limited means at their command and the great amount of work to be done, it is, however, surprising that so many county superintendents find time to be the real educational leaders that they are. The State hoards of health need strengthening in many instances, in order that on their own initiative and in co- operation with the State department of education they may 192 EDUCATIONAL HYGIENE issue publications of an educational, advisory, and adminis- trative character, and also help conduct meetings of various kinds. The two departments working hand in hand can accomplish far greater results than both working alone. The local hoards of health need to be improved in effi- ciency. In some States there are county boards of health or a county health officer, while in other States the local boards have charge of townships, villages, and cities. Fre- quently the local officer is a physician, but often he is not. In the latter case he usually knows little about his duties and does not have the confidence of the people. In some States it would seem that conditions could be improved by raising the qualifications of the local health official. I have frequently been asked in school-board conventions questions regarding procedure in certain cases. When I have answered that this is a matter for the local health officer, I have received the reply: "He knows no more about the matter than we do." In the appointment of health officers it should be kept in mind also that such officials need to have tact in handling people as well as knowledge in handling cases of disease, es- pecially when school questions are involved. There should be co-operation between the local educa- tional officers and the local health officers. The local school boards should be advised by the local health officers in all matters pertaining to health, and all orders of the health officers. State and local, should be enforced by the school officials. The plan of North Dakota to have the county superintendent an ex-officio member of the county board of health seems good. The plan, suggested by the editor of this volume, of having supervisors of hygiene who are physicians and physical educators for rural administrative areas, would make for remarkable rural hygiene development. A most commendable practice is to have also a local school nurse who gives all her time to the schools within her jurisdiction. Such an officer would be a large factor in es- tablishing the proper relations between the schools and the RURAL SCHOOL-HEALTH ADMINISTRATION 1 93 homes. She would work under the direction of the local board of education and in co-operation with the health officer and county superintendent. In Wisconsin a law was enacted in 1913 permitting the county board of supervisors to pro- vide for the employment of a visiting nurse. In Pennsyl- vania any board of school directors may employ one or more school nurses. The rural school nurse will probably come before the rural educational hygienist, except as the latter is employed by the State and very progressive counties. A reasonably adequate system for health or medical supervision in the rural schools would include the following: (i) A State board of health with power to make rules that shall have the force of law, this board to work in co- operation with the State department of public instruction in its educational propaganda; and (2) A State supervisor of educational hygiene, with as- sistants to act as State inspectors as at present. (3) A local board of education (preferably county) to guide the work in co-operation with the local boards of health, and school-health officers and visiting nurses to work under the direction of the local board, and all to execute the general orders issued by the State boards of health and instruction. A steady, sane campaign in behalf of better health is, of course, indispensable, and every opportunity and agency should be utilized to spread information and to create the proper civic sentiment. The Rural Hygiene Working Forces.— Having roughly sketched a plan for rural school-health supervision, we may next consider its working forces. The Teacher.— Some inspection and care must always be exercised by the teacher. She should know the symptoms of common contagious diseases and be given authority to send home children having these symptoms, and the cases should then be referred to the health officers. The teacher should also have some knowledge of phys- ical defects of children, in order that she may be able to de- 194 EDUCATIONAL HYGIENE tect faults of vision, hearing, speaking, etc., and to deter- mine their probable causes, as well as to suggest remedies. Here, however, is where the great value of the school nurse comes in. Having special training, she can intelligently sug- gest to the teachers and parents what ought to be done in each individual case. By working with the teacher and county superintendent she can add immeasurably to the health and efficiency of the school and the community. Cases which are too difficult for the teacher to handle can always be taken in hand by the nurse. The teacher should also be, to a great extent, her own sanitary inspector. A knowledge of the laws enacted by the legislature or rules passed by the State board of health fixing certain hygienic standards for country schools should be a part of her attainments, and it should be the duty of the teacher and the school board, under the direction of the county superintendent, to see that these regulations are com- plied with. Any intelligent teacher can in a short time read one or more of the new and informing books on school and community health. The County Superintendent. — An inspection of sanitary conditions can be made by the county superintendent in con- nection with his visits to the schools. He should have the power to enforce the laws and rules of the State by being given the power to pass upon a district'' s right to participate in the apportionment of State school funds. Cases of physical defects coming to his attention should be reported to the school nurse, the medical inspector, or the parents. The county superintendent, being the educational leader of the county, should also plan and arrange for the discussion of hygienic topics at teachers' meetings, school-board conven- tions, parents' meetings, and other gatherings. He should also be a vital factor in training teachers and should frequently visit schools and classes where his future teachers are being educated and trained. The more closely the students can be made to know actual conditions, the better they can be RURAL SCHOOL-HEALTH ADMINISTRATION 1 95 trained to improve these conditions when they become teach- ers. The School Nurse. — If a school nurse is employed, she should become the most important factor in the health super- vision of the county or the community. She should make regular inspections of the pupils under her jurisdiction and keep records of their conditions. She should, without delay, visit and inspect localities where epidemics are reported. She should help the teachers and county superintendent in the various meetings. She should follow up cases of ill health or physical defects, and thus become an invaluable help to the parents. Many valuable suggestions will be made to the teachers incidentally and it is easy to see that in a short time the standard of efhciency for the teachers would be raised. The nurse should also be a vital factor in the preparation of teachers for their work and should therefore be an adviser of the faculties having in charge the training of teachers. The Local Health Officers and Medical Inspector.— li a visiting nurse is not secured, most of the work she would do will have to be assumed by the local health officer. In case a nurse has been secured, the work of the health officer will be largely to act in case of contagious diseases, and to have charge of the legal phases of the problem, such as quarantine, closing school, disinfection, etc. Cases would also be referred to him which might be beyond the power of the school nurse to care for. He should be the chief factor involved in send- ing defective children to proper institutions and the proper person to take the matter up with the judge who has power to commit individuals to such institutions. The State hygiene inspectors would be called upon in ex- traordinary cases only as far as the general administration of the law is concerned. They would, however, spend con- siderable time in the field studying conditions, in order that the best methods might be adopted, school and rural-life hy- giene promoted, and epidemics prevented. Having a knowl- edge of the actual health conditions, they would be able to 196 EDUCATIONAL HYGIENE carry on an educational health campaign with the members of the State department of health, who also spend a large part of their time in the field. Only under the wise and dis- creet leadership of these two departments acting together will the local officers and boards of the State be able to reach their greatest possible efficiency. PART III THE DIVISIONS AND PRACTICE OF EDU- CATIONAL HYGIENE I. MEDICAL SUPERVISION OF SCHOOLS CHAPTER XII THE STANDARDIZATION OF THE SCHOOL MEDICAL SERVICE The Health Census of School-Children. — After a plan of administration is effected, the first problem confronting school- health officials is that of learning the exact health status of all the children in the school system. Until a health census of the pupils has been taken and an accurate diagnosis of pre- vailing ailments made, school-health agents do not know the problem they are to solve. Accurate knowledge of the phys- ical and mental natures of the children must be the basis of all curative, preventive, educational, and developmental work. For this and other reasons we set medical supervision first among the five divisions of school-health practice. It would probably be more attractive to start with play and playgrounds and the glorification of health and splendid phys- ical development, but the need of carefully examining our difficulties and sizing up the nature of our problem probably outweighs this feature. Too much of our educational work is now done in the dark, with little sense of just what the prob- lem is which confronts us. We need not trace the history of medical supervision. It started on an active, vigorous course only in the opening years of the twentieth century, although scattered and feeble efforts may be noted before. It was, in this country, an invention of 197 198 EDUCATIONAL HYGIENE Doctor Durgin, of the Boston Board of Health, devised for the purpose of lessening the frightful losses due to the various infectious diseases of childhood. Doctors visited the schools at intervals and either went into the classrooms to inspect the children for signs of infectious ailments or had teachers send to the ofhce or doctor's room in the building such chil- dren as the teachers suspected of showing symptoms of in- fectious ailments. This was medical inspection, and it has had a wide vogue and has done much good. In many cities teachers have been depended on almost entirely to detect symptoms of ailments and to isolate the children on the doctor's arrival. This system is really teacher inspection rather than medical inspection. To-day an entirely new spirit has entered into school medical work — the spirit of preventive medicine. Instead of limiting itself to discovering and isolating contagious dis- eases, an effort is made also to discover and to correct physical defects and incipient ailments before irremediable damage is done, and to place the whole emphasis upon pre- vention rather than cure. Instead of a sHght and passing inspection for the mere signs of infectious ailments, thor- ough periodic physical examinations of all pupils, and vigorous follow-up, educational, developmental, preventive, and cura- tive work, are carried on. No phase of preventive medicine offers more promise of great development and usefulness than school medical supervision. In the plan here presented the term inspection is contrasted with examination, and both terms are necessary; consequently a broader term than medical inspection is desirable. In Ger- many and in a number of cities in this country the term medical supervision has been used for this broader medical work. Some persons have recommended the term health supervision; but this is poor in that it applies to the work of the whole hygiene department with its five divisions. Since medicine is broadening to take in prevention, although the latter is not yet legally a part of the work of medicine STANDARDIZATION OF SCHOOL MEDICAL SERVICE 1 99 as defined by statute-books according to Doctor Goldwater, there will soon be little or no objection to the term medical, except from the ubiquitous health fakirs. No term so well covers this field, it seems, as medical supervision. School Examinations and Adult Examinations. — The care- ful routine and periodic examination of individuals, with oc- casional less complete inspections and careful advice and pre- ventive work, is not confined to schools alone. Insurance companies have long had examinations, and lately they have quite vigorously entered the field of preventive medicine. If the saving of lives thus effected is profitable to business cor- porations, how much more profitable to the state is the saving of its prospective citizens ! Through the efforts of The Life Ex- tension Institute principally, many business organizations out- side of the field of insurance are now taking upon themselves the duty of employing expert physicians to make careful phys- ical examinations, periodically, of all employees. Thousands of employees are now getting such assistance. The examina- tions are more thorough than those for insurance, including blood pressure, blood analysis, urine and other tests, and a most careful inquiry into habits of life, heredity, and slight symptoms of pathological beginnings. The disclosures from such examinations are remarkable and in many cases alarming. Doctor S. S. Goldwater, Com- missioner of Health of New York City, reports as follows: "Eight hundred garment- trade workers were examined; 62 per cent of those examined were found to be in need of medical treatment. In a similar investigation in Germany fifteen dis- eases or conditions of physical impairment were found among every ten workers examined. In a recent examination of the employees of a New York City bank 100 per cent of the employees were found to be abnormal and on the sure road to diseases of heart, lungs, kidneys, or blood-vessels."^ Doctor Goldwater and others maintain the same position 1 See also the symposium by Dublin, Winslow, Fisk, and Davenport in the Popular Science Monthly for April, 1915. 200 EDUCATIONAL HYGIENE as that expressed by the writer on the first pages of this volume, namely, that preventive medicine and public health agencies cannot do their proper work and utmost good until quahfied physicians, educated in preventive medicine, are employed for the whole population, by the people, for the people; and that such health agents are not merely for the treatment of acute and advanced cases of disease, but as medical advisers and protectors of health, for keeping them well rather than getting them well. More private physicians must become State officials if we are ever to insure the automatic discovery of the beginnings of disease and physical defects, and especially of those various degenerative diseases now increasing in this country. Such State health examination and education must be- gin at the beginning of life and continue through all ages. The work of the schools reaching, through school nurses (such as are already employed for adults by health departments and business firms), the children of pre-school age and even infants, are not doing something entirely unique. They are working along the line of a common development which is bound to take place — the socialization of preventive medicine. In Sweden the public medical examination reaches beyond school life for most children, there being an actively enforced law requiring that each minor under eighteen years of age be medically examined annually, at the expense of the govern- ment, to determine how far the work in which the youth is engaged may have injured his health. If the examination shows that the occupation has been injurious to the youth's health, he is forbidden to continue, and is given simple voca- tional guidance of a health character. Halsey says that in 191 1 there were 39,971 working children examined, and of these 501 were assigned to more hygienic work, while 81 were absolutely forbidden to continue work and shown how to build up their health. This is a fine beginning. National or State insurance, such as exists abroad in England, Germany, Austria, and elsewhere, is bringing on universal medical STANDARDIZATION OF SCHOOL MEDICAL SERVICE 20I supervision; and the control of occupational, degenerative, and infectious diseases will help it along. Even now the State of Pennsylvania requires at least monthly expert medical examinations at the employers' expense of all persons working in the lead industries, and requires elaborate preventive measures in connection therewith. School medical supervision must, then, unite with the general movement of preventive medicine as its most prom- ising child. This whole movement in general has, accord- ing to Goldwater, three essential phases: " (i) Education, which is essential to an understanding of the dangers which the individual encounters. '' (2) Regulation, to prevent environmental conditions which are inimical to health. " (3) Periodic medical examination, a necessary test of the value and the effectiveness of education and of sanitary regu- lation." These measures well describe the work of a school depart- ment of hygiene. As we have divided the field, medical super- vision of schools limits itself more to the study of the physical and mental condition of the children and the cure of patholog- ical and subnormal conditions. To some extent also the medical examiners, nurses, and workers in clinics are also sanitary inspectors of schools, homes, and community, and educators of children, parents, and pubhc. Usually school sanitation, inspection, and improvement and the education of the children will be done by other than the medical workers. The various phases of medical-supervision work are given below.^ The Divisions of Medical Supervision. — The various phases or divisions of the work of medical supervision^ in this plan and, for the most part, but largely unrecognized, in the best systems now in vogue, are about as follows: • From "School Health Administration," by the writer. 'The term will probably remain medical inspection, even if it is a mis- nomer in good systems. 202 EDUCATIONAL HYGIENE (A) Preliminary clinic, for instruction and standardiza- tion. (B) Inspections. (i) Pupil inspections. (a) September room inspection of all pupils, by doctors and nurses. (b) Occasional room inspections of classes of children, by nurses. (c) Individual inspection, by teachers, nurses, and doctors. (2) Environmental inspections. {a) Home hygiene inspection, during home visits of nurses. {h) Sanitary inspections of the school premises, by any delegated and competent officer. (C) Examinations, complete physical, annually for all pupils. (i) Scholastic: vision and hearing examinations, and per- haps others, by the nurses. (2) Medical: only those technical phases which the nurses cannot do well, if any, by doctors. (3) Psychological: in special cases where mental defect- iveness is suspected, by psychologists. (4) Anthropological: measurements of height, weight, chest-expansion, and the like, only if required. Of doubtful value as usually made and followed. (5) Work certificate: will probably not be needed in well- conducted systems, since the pupil's health condition is always well known ; but vocational guidance may play an important part here. {D) Treatment, cure, and correction. (i) By home and family physicians, dentists, or oculists. (2) By school nurses. (3) By dispensaries or other free clinics. (4) By public-school chnic, with various divisions. {E) Prevention. By looking for causes, co-operating with other divisions of educational hygiene, and other pubHc and private health STANDARDIZATION OF SCHOOL MEDICAL SERVICE 203 agencies, and by placing the emphasis upon preventive rather than merely curative agencies. How to carry on efficiently and economically these dif- ferent phases of the work will be the problem of this chapter.^ {A) The Preliminary Standardization Clinic. In the typical city for which the reorganized expendi- tures were given, ^ with a proportion of little over 3 per cent of current school expenditures for the entire depart- ment, including medical inspection, we have two physicians and three nurses for 6,000 pupils from kindergarten through high school, 3,000 for each physician (one, the director), and 2,000 for each nurse. For a city of 12,000 children we should have, of course, twice as many nurses and three assistant physicians. But no matter how large or how small the de- partment may be, even one physician and one nurse, there should be, when they begin to work together, and, if several, at the beginning of each year or oftener, a meetifig at which children are examined or inspected, or both, and standards for referring cases to parents, for exclusions, for readmissions, for best methods of doing the work, and the like, are discussed. Teachers and principals may be present at such meetings, and all may take a hand in coming to some common agree- ment, without which there will, in isolation, develop the greatest irregularity among different workers and frequent in- justice to children and parents through conflicting standards and methods. This is also the opportunity for the supervisor to outline the work of the year, and to get suggestions from all con- cerned as to its improvement. It is a time for inspiration and education. All need them. Such clinics can be held at one or more of the several schools, if desired, or at teachers' meetings, for the purpose of giving the teachers necessary elements of child-study of a medical character, which prob- *See Hoag and Terman's " Health Work in the Schools," pages 16 to 25. 2 Chapter VIII. 204 EDUCATIONAL HYGIENE ably never appeared in any course in their professional prepa- ration. No city known by the writer now employs this means for making efficient medical supervision, and he hopes for its speedy experimental testing. Besides these will come, of course, monthly or semimonthly department meetings, which are now quite common in good systems. (B) Inspections. — (i) Pupil Inspections. (a) September Classroom Inspections. — Since this plan of administration gives the physician as many pupils as he can examine in the entire year, beginning in September about the third week, and taking pupils in the same order each year, we must provide what many cities have been driven to by hard experience, namely, a preliminary, complete, routine, classroom inspection of all pupils. With 3,000 pupils, each pair of nurses and physicians will have about seventy-five rooms, counting 40 pupils to a room. By requir- ing the part-time physicians to spend three hours a day in this first general inspection, and with the nurses all at the same work, counting a classroom, after practice, for each half-hour, and records made, where two work together, we can see that the inspection of all children can be made in about two weeks. Some doctors lay claim to 250 pupils room-inspected an hour, but these are only very partial inspections, for signs of parasitic or infectious disorders. This first general routine inspection would make a fair substitute for an examination, especially if there were any careful attention given to vision and hearing. It is a general inspection of the child for any serious defects, ailments, or conditions which should receive early treatment and care. No vision or hearing tests, as such, are made, but all obvious cases, like strabismus (cross- eye), 01 inflamed eyes from eye-strain, may be recorded and referred with instructions. The principal ailments found will probably be minor skin ailments of a filth or infectious character, although most STANDARDIZATION OF SCHOOL MEDICAL SERVICE 205 ailments will be represented. If there have been nurse in- spections during the summer, fewer cases will be found, but there are always sufficient numbers to warrant rigorous measures for nipping their spread in the bud. The Method of Classroom Inspections. — The central instrument in all medical supervision ("inspection") is the individual, cumulative health-record card of each pupil. On it is recorded the health history of the child during his school years, and in some cases for the years pre\dous to his entering school. The development of the science of educational hy- giene and the practical control of health matters must very much depend upon such individual health histories. Scien- tific control of Hving conditions of children, or of any other phenomena, rests upon the basis of accurate and carefully selected facts. We present herewith the faces of two such health-record cards devised by the writer. For complete descriptions and standard keys the reader is referred to the tentative standard plan above mentioned. The physician should usually make this first inspection while the nurse records and observes the work of the physician. Only the more severe cases, the infectious ailments, parasitic ailments, and the like, should be recorded and referred or excluded at this time. Vision and hearing need not be tested, and heart and lung examinations need not be made except in special cases. Care should be taken to record and attempt to get treated and cured only real and severe cases. Doctors have a tend- ency to defeat their efforts by referring very minor and in- significant ailments. Better concentrate on important cases and succeed in getting them cured. This inspection of all children may be made in the rooms or in the halls outside the rooms. Nurses can do the work quite well when trained, and teachers may help with the record work by the use of the code given on the weekly report by numbers. Exclusions should be made for diphtheria, sore throat, tonsilitis, scarlet fever, whooping-cough, chicken-pox, measles, mumps, tra- 2o6 EDUCATIONAL HYGIENE choma, and other acute infectious diseases, and such parasitic and minor infectious ailments as prove necessary. Every effort should be made to keep children in school, and it should never be necessary to close schools. Pediculosis, impetigo, and such ailments may be treated at home or school, and the children kept in school. In several cities school janitresses handle pediculosis cases. The nurse may make out the exclusion slip, which should be simple, dignified, and adequately instructive. If the back can be used for health advice, the chance should not be missed. The seal of the city printed on each, as is done in the State forms of Massachusetts and certain cities, will ap- peal in the right way to many parents. The following ex- clusion form has several advantages in the way of economy: EXCLUSION RECORD No Date , 191 . . School Room Pupil Address Cause of Exclusion: Readmitted, School days lost. , 191. . MEDICAL SUPERVISION OF SCHOOLS ,191- Grade .... Health City, New Jersey. Date School Room. . Pupil's name Home address The above-named pupil is hereby or- dered to discontinue attendance at school temporarily for the following reasons: School Nurse, M.D. (Hand to pupil excluded.) foverl This entire form need not be more than six inches long and two and a half inches wide. On the back of the long part, not the stub, should be printed these and any other directions, general advice, or short article from city or State laws: STANDARDIZATION OF SCHOOL MEDICAL SERVICE 207 The ailment mentioned on the other side of this notice is infectious (contagious), and liable to be transmitted, or "given," to other chil- dren. The child should receive prompt treatment by a physician or the school nurse, and should return to school 191. ., for inspection by the school physician or nurse. If found free from infection he may then resume attendance at school. Every reasonable effort should be made to give each child the full benefit of every possible day of school attendance. A Duplicate Book for Doctor and Nurse. — This form, separable from its stub, should be printed as is a check-book, and, whenever desirable, as in the case of acute infectious dis- eases, will, with small sheets of copying carbon, give four forms, the original for the parent, the stub for the hygiene department, the carbon copy for the board of health as their notification, and the carbon stub for the nurse's or doctor's record. The notice can be sent home in several different ways, depending upon circumstances. One of these exclusion books should be kept in each school, and for its pupils only. To avoid conflict of jurisdiction, the city health officer and the director of hygiene', or superintendent, should meet and agree upon a plan of co-operation for readmitting pupils after exclusion or illness absence. Reporting the Room-Inspection. — When the class has been room-inspected, the nurse will take all the cards of ailing pupils to the principal's ofiice or the health-room, where they can be reported after the morning's work wdth the physician. In her case-book for each school she will write down the name, address, room, and ailment of each defective and ail- ing child and the date. When she sends notices home with the children who are ailing but not excluded and gets no satisfactory results in treatment within three days or a week, the time for a second notice, or for home visiting, has come, which may even end with the doctor's visit or that of an officer of the law. After the list of cases has been placed in her book the cards can be returned to the room, where the teacher will give them a separate place in her file, or mark - |M[|m|->»-|'n|«o »** ■o !S>|JBUiaa ,y"*v in M s fr) I 1 — K - C) ^ t-H - s !S)tJBU13y E hJ _ io < cc ;z; II K-l — — •s. p:; o DC ■o o "^^ o o II UJ !S>|JBlU3y w ^ X - ,. o " J c i Pi O • u o — w O J D o UJ P a: t L M ^ I : 1- • -1 J < i > c 1 :s>|jeuj3y p^ UJ » w < In r 3 U u c — Pi -o > o r ) II W Pi :S>|JBLU9y M H •s J 3 < II ® M ^J ■s < t3 •s Ol Q > I— 1 Q < 1 1 o CO 8 o o > C9 o o o 3 o ! E 00 F F o 1 c E o o CO c o E E o it c o E E o ^ o ■* c 1 II "o o 1 C i a C 1 ^ CB —1 u = ^ Z " u. 00 CQ CO o :j !S>|JEUJ8y 1 •£ ki « s c o ^ .E CO CO ii ;s>|jeLU9y j 3 ■ s ■s" c3 1. < o i. II JS>|JEU19y o - i O a: t II — •£ •• ■- c J ^. » 6 io £ ca d g zc J= J2 _o "S «> 3 J e o !^- ^ •< •< -< -< ^ = I F z s s > O) o > ° ? M M 1— s. S o o F O F s 3 1 1 ^ a: -o lS o "o o X o «« a J UJ UJ o 3: £ CO 5 C3> iS UJ cc c 00 CO 3 O o i E o o E o h o CJ t o O ^^ .n ro f^ o ,— CM m -r m CO r^ <» 03 o — CN m ■^ < Z 4 Z — *— -- ^— •— — ^- ^- ^- ^- uoipec SU| JO U0!1BU]UJEX3 9q; 0\ pJEQ SJH^ Suuq SitBM|V 1 5 GO ai S LU s 'ho >. o o "> o. CO o o 8 o Z a >• o J >- o cc i a > o ce > o 0) IS OS £ c 3 Z E 3 Z Q z s 3 z s" 3 Z D E 3 Z Z e' a z 3 I o o o i 3 t- E O < z o < z 3 z 5 o E 3 Z ll ^ > a. a o — zo c e' UJ cc I o c o op o Si Q.*0 E o o E g Q- Zl2 2 z O g o o ll J "il 'o Z Q. EE 3 O zs: 1 i QJ ^ O 1— 'i d z Q O 3 -. w O > z a. C3 ^ ^ -a II 1 DETAILED REPORT OF AILMENTS VER "Iiew" = first found in school year."OId"= ailments previously reported-beforetiiis week. NUMBER OF AILMENTS MET DURING THE WEEK BY DOCTOR AND NURSE MON TUE WED THU '" SAT TOT.U z< Tnnastics 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 Httle 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. — v^ Much in the way of progress, records, and education of the public depends upon the character of this annual, public re- 2 28 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 efficiency 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 found 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. Total numbei in one schoo;NTS both doctors t frequency. Pediculosis, |"*^^ Dental defect^^^"" Enlarged toi Adenoids anijTOTAL Wounds, sord Eyesight, via Impetigo cot cfandf enlar^05« OF TOTAL Conjunctivitii Skin ailment Ringworm . Anemia . . . .i Eye ailments Malnutrition, Tonsilitis, q£R 9Q^ OF TOTAL Deafness, hi Scabies, itch Mumps .... Scarlet fevei Ear discharg Measles .... Chicken pox Diphtheria , Heart defec< Pharyngitis Eyes crossed Catarrh, rhii Skeleton,' or Palate defe< Whooping cj Headache, rn Mentality de Colds, bad. Lungs weakj Nervousness Tuberculosis Bronchitis . Cleanliness Speech def^ Abscesses, bi Sore throat. Trachoma, g Laryngitis Spine, curva Ears, minoi Favus, yello Urinary, eiv Nose-bleed Stomatitis, Influenza, g Sex ailmenl Tuberculosil Rheumatism IN 25 CITIES E 229 are the I to the .tion to super- ted and • it em- records ysicians sndance )sing of quaran- irses, to :ause of y^giene. m may be d1 Medical New York RELATIVE FREQUENCY OF SCHOOL AILMENTS IN 25 CITIES FIRST FIVE, 60:5 OF TOTAL viin, >n ",.:::: lis orlhopedi !?^:; "■.;i;;';; .'.'f;:;: .,,::., U '■"-" H.:'°'w'i l,^ ".:.::: i^B '^ p'oVii;; s,";.mi "liJJJi- .i;;i-;: Tjif'S ■°? o'fbo nS".:: FIRST TEN, NEABI.V 80^ OF TOT«L FIRST EIGHTEEN, OVER 90* OF TOTAL 3 STANDARDIZATION OF SCHOOL MEDICAL SERVICE 229 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 quahlications and the character of the super- vision of these ofhcials. (3) The percentage of the school population inspected and examined, and the frequency of these. (4) The quality 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 punctuaHty 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 ehmination, etc. (7) The quahty 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 XIII THE SCHOOL NURSE AND HER WORK i 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 MetropoHtan 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 difficult 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 " See also the chapter on "The Professional Training of Schcx)l-Health Workers." 230 THE SCHOOL NURSE AND HER WORK 23 1 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 estabHshed 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. 232 EDUCATIONAL HYGIENE Arrangements were made to have all children examined b}- 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 list 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 suppUes 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 {ting, 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 233 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 nurse, 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 234 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 ly. ravus. 20. MoUuscum contagiosum. 21. Acute coryza. 1. Diphtheria, 12. Varicella. 2. Pediculosis. 13. Pertussis. 3. Tonsihtis. 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. 10. Scarlet fever. 11. Measles. Zero numbers are given to children having no disease', so that all should be given a code number. No feelings 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 235 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 \dsits 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 liN-ing. She discovers all kinds of imhealthful 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 rehef obtained from the proper sources. ' The writer herself. — Ed. 236 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 relief 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 little mothers' classes in the gchool as soon as she begins THE SCHOOL NURSE AND HER WORK 237 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. 238 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 relieve serious situations at once by a few helpful suggestions as to how reHef 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 alike, and this is| where tact, good sense, and sound judgment are required. She must know how to avoid hurting the feelings of the family] physician. The most essential requirement is thoroughness. Everj 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 in the home, Boston Public-School Hygiene Department THE SCHOOL NURSE AND HER WORK 239 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 eye 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 q 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 240 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 24 1 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 be 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 F15//5.— 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 242 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 opportunity 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 XIV PUBLIC SCHOOL CLINICS Health Supervision Beginnings. — Health supervision, like public education, was first established as a means of relief for the poor. Subsequently, Hke public education, it became free, democratic, and even respectable. It now remains for health supervision to enter the third stage of its development and to become not only free but compulsory. In its first stages, health supervision has emphasized in- spection, description, and recommendation as the appropriate means for locating physical defects and securing the co-opera- tion of parents and physicians in their treatment. In its final, compulsory stage it must inevitably place the emphasis upon constructive measures and provide the facihties for making its authority effective. The relief and prevention of physical defects, through adequate treatment on the one hand and effective control of causes on the other, will be the primary function of health supervision; medical inspection be- ing only an introductory and incidental step toward a com- prehensive programme of physical education, medical and den- tal treatment as needed, and training in hygienic and sanitary habits, that will be carried out with each pupil through every day of school hfe. The Problem of Treatment. — The greatest difficulty in executing so broad a health programme lies in securing the necessary medical and dental treatment; and this problem is undoubtedly the most pressing one relating to the health of school-children to-day. In time we may develop such sanitary schools and such wholesome courses of study, and educate both parents and pupils so successfully in the prin- 243 244 EDUCATIONAL HYGIENE ciples and practise of hygiene, that the defects and ailments of school-children will cease to exist. Until that time, however, the children who are handicapped and suffering must be helped; and it is gradually becoming evident that the surest, most effective, and most economical way of doing this is through the school clinic. The school clinic has only recently come into existence, the term being applied to any dispensary that is conducted for school-children. Five or six years ago the term was generally understood to mean a dental dispensary for school- children. This is still the case almost everywhere except in Great Britain. The term polyclinic is often used to indicate a dispensary where various kinds of cases are treated, but the simpler term is gaining in favor, and in time a school clinic will be understood to be a place where school-children can receive any form of treatment that does not require them to remain in bed. Los Angeles has a well-developed cHnic of this sort. It occupies an entire building, which is equipped to accommodate various kinds of cases that can be handled in a single day. Here the children's eyes, ears, noses, throats, and teeth are treated, and circumcision is performed. A second building, adjoining the clinic, houses a carefully con- ducted hospital where children may remain as long as neces- sary as guests of the Parent-Teachers Association. School clinics in this country are still comparatively rare and sporadic, though the amount of publicity given to the few that have been established might lead the unthinking to believe that our 20,000,000 school-children must by this time be fairly well provided for. We have, indeed, made progress since 1907, when the New York Children's Aid Soci- ety opened the first dental clinic in this country; but the pro- portion of dental clinics that we now have to those we still need may safely be estimated as 100 to 15,000. Before this discrepancy can be much reduced the American people must be roused to the point of demanding medical and dental treat- ment for all the children who need it, and of understanding 1 PUBLIC-SCHOOL CLINICS 245 clearly that the school clinic is the one best agency for meet- ing this need. The Facts of the Case. — The pubUc demand for free med- ical and dental service will assert itself just as fast as the facts regarding the present health and the best methods of treating school-children become generally known. The facts already well established are briefly as follows: 1 . Six to eight school-children out of ten need during any given year the service of a dentist or doctor. 2. More than 70 per cent of these children never get it. 3. Certain progressive school systems by persistent and costly follow-up work and by pressing into their service all available outside agencies — public dispensaries, hospitals, dis- trict physicians, and private doctors — have secured treatment for somewhat more than half tJie children who need it. 4. A certain amount of treatment thus secured is invari- ably worthless or even harmful. 5 . Public treatment under expert management is the only means at present of getting reliable service for 100 per cent of the school-children who need it. 6. A clinic conducted by a well-paid expert is the most economical arrangement for giving dental or medical treat- ment, the cost per treatment being only a small fraction of the charge that would be made for a similar service by a re- liable private practitioner. 7. Giving school-children the dental and medical treat- ment they need increases school attendance and school ef- ficiency, reduces grade-repeaters, and saves schooling expense. 8. School clinics, in or near schools, have three notable advantages over any other kind of dispensary open to chil- dren; namely: {a) Promptness and convenience of suitable treatment. {h) Cultivation of helpful relations between the home and school. (c) Opportunities for health education. These three advantages will be discussed in turn. 246 EDUCATIONAL HYGIENE Promptness and Convenience of Suitable Treatment. — The value of the promptness and convenience in medical service as rendered by the school clinic can hardly be over- estimated. Under the haphazard method of sending out children to get treatment if they can, wherever and whenever they can, not only do many children fail to receive any treat- ment or get it too late, but many who are treated meet such unsuitable handling that their condition is as bad as or worse than it would have been with complete neglect. Even when school-children are received at a good general cUnic, if this happens to be at a distance from home or school, the dififi- culty of travelling back and forth and of losing further time by waiting turns at the clinic, makes it practically impossible for all the children to receive the regular and frequent treat- ments that many of them need. On the other hand, the school cHnic which is in or near the school and conducted under expert control has the best standards and appliances for treatment available for all the children at the time they need them. This makes possible the cure of many chronic ailments which otherwise would receive no medical attention at all and which in many cases would result in permanent injury to the children. The care- ful daily treatment of running ears, inflamed eyes, ulcerated teeth, and certain skin diseases can be easily and properly ad- ministered in the school clinic and hardly through any other means. Such ailments, moreover, are prevented from gain- ing the headway they often do by their prompt detection and cure in the school clinic. The promptness and convenience of school treatment brings as marked an advantage to the school as to the pupil in its direct result of increasing school attendance. For in- stance, when children may be treated at school for minor contagious ailments they need not, as formerly, be excluded from school until they can show evidence of having received satisfactory treatment. The introduction in New York of prescribed treatment of this sort by school nurses reduced PUBLIC- SCHOOL CLINICS 247 the number of exclusions for contagious disease from 57,000 in 1903 to slightly over 3,000 in 191 1, and this in spite of the great increase in the number of school-children in that time. Cultivation of Helpful Relations Between the Home and School. — Any agency that unites school authorities and parents in their common task of developing vigorous citizens is exceedingly valuable. The school cHnic offers unique op- portunity for such a relation; allowing nurses and doctors to gain the friendly intimacy uith school famihes that in some way they must gain before they can hope to exert effective influence among them. Parents who see their children's health improving under the careful, friendly efforts of school officials gain a new confidence in the pubUc schools. At the same time they gain a new sense of the value of health and the importance of cherishing it in their children; the result being that they co-operate cordially with the work of the clinic. While directly promoting home welfare, the close per- sonal relations possible in the school clinic are of great aid to the doctors and nurses in their professional work. Chil- dren are not merely "cases," as they are likely to be in large public dispensaries without social-service departments. In a school clinic the children themselves and their famihes become the objects of interest and care. It is possible to follow up the life-history of each child and, through the school, to keep him constantly under observation. This continued acquaint- ance with the children and their families ine\'itably leads to the detection and correction of causes of ill health that could never be discovered under the impersonal management of an ordinary pubUc dispensary. Opportunities for Health Education and Research. — While the primary purpose of the school cUnic is to give treatment, its educational possibilities are no less important. Its very existence in the community is an educational force. Neither children nor parents can visit a well-conducted cUnic without being permanently impressed with its sanitary and hygienic standards. Merely to see one dressing performed by 248 EDUCATIONAL HYGIENE surgically clean methods and to observe the scrupulous care that is taken to keep the entire clinic and all its appliances dustless and spotless are object-lessons worth many weeks of theoretical instruction. The educational influence of a school clinic need not, of course, be limited to its patients and their famihes. With an expert stafif of doctors and nurses at command, it can and should be used for giving frequent demonstrations and ex- hibits as a means of interesting the entire community in the fundamental concerns of health. The school clinic is not only well equipped to give instruc- tion but to carry on research. It is the ideal training-ground of the school hygienist. Such study of the life-history of in- dividual school-children as is possible in a school clinic, in addition to facihtating greatly the treatment of individual cases, may readily furnish a thoroughly scientific basis for the improvement of health conditions for all school-children and ultimately for the entire community. The scientific com- piling, interpretation, and use of records is a twentieth- century invention not yet widely incorporated among school systems; and thus far school clinics, both at home and abroad, have shown little tendency to outstrip the schools in the ap- plication of statistical methods. The number and kinds of cases treated and the gross cost incurred is practically all the information to be gained from the records of many very active and well-equipped clinics. The present general neglect of the statistical method in conducting school clinics is reflected in Doctor Cruickshank's otherwise excellent book on "School Clinics at Home and Abroad." It is impossible in this latest and most extensive study of school clinics to find any report which measures definitely the actual effect of school clinics upon the health of children. The nearest approach to such a report is the general statement (p. 154) that "the clinic at Freiburg i. B. has been at work for some years with the result that less and less treatment is required every year." Dental clinic, opcraling-room, Strasburg, Germany The first school dental clinic OnlioiK'dic clinic, Dunfermline, Scotland Treatment of spinal cur\-ature PUBLIC-SCHOOL CLINICS 249 Neglect of statistical method is perhaps natural during the initial years of school clinics when much energy must necessarily go to the mere starting of the machinery, but this must not continue if the school clinic is to become more than an unregulated machine. Whether all the children needing treatment are receiving it; how many who have been treated remain well; whether physical defects are diminishing; whether the general health of the school-children and the condition of their teeth is better and by how much, since the school clinic began work; whether improved school work follows improved health and to what extent; what are the causes of ailments treated and what has been done to remove them — these are some of the facts that the records of any school clinic should disclose and which some of the more progressive clinics are already recording. An example of such scientific record-keeping is the work re- ported by t^mma Kohnky. of Cincinnati, in the Journal of Educational Psychology, December, 19 13. In the Cincin- nati experiment it was found that a fifth-grade class of forty children who received all necessary dental care for seven months showed in four out of five psychological tests a gain over an- other fifth-grade class of the same number and the same gen- eral social and physical condition but which received no more dental care than is usual with school-children — that is, prac- tically none. Instructive records of this sort will gradually become the rule as the organization and methods of school clinics become thoroughly developed and standardized. School Clinics as Research Laboratories. — In the larger cities the possibilities of school clinics as research laboratories are enormous. They may easily be made the means of es- tablishing scientifically the effect upon health of school and home conditions, such as protracted desk work, length of school hours, fresh-air classes, home study, length of noon intermission, frequency and length of recesses, number of hours of sleep, character of diet and ventilation, and a score 2SO EDUCATIONAL HYGIENE of Other conditions the effects of which are still conjectural. Having once established such facts, school-health authorities will be in a position to enforce their acceptance as guiding principles in the entire programme of the school. Combining, as it may, a scientific method and a close, constant touch with the people, the well-conducted school clinic will probably become the most important of all the agencies that make for the nation's health. It will gradually outgrow the restricted title "school cHnic" and be known by some such name as "public health centre"; for the emphasis in time will be shifted from the curing of physical ills to the conserving and developing of health, and the school-child who is at present its sole beneficiary will share its benefits with the entire family. It is already obvious that a little tinkering of the bodies of children between the ages of six and fourteen will not make an entire community healthy. What is gained, for instance, by ridding a child of vermin and sending him directly back to an infected family; or what be- lated treatment can help a child of six whose eyes have been made useless by four years of neglect before he was old enough to claim the advantage of the school clinic? The foundation of bodily vigor rests in family life. The care that is given from babyhood on, together with the Hving conditions of the home and the sanitary organization and management of the community, are the real determinants of health. It is these factors which health officials must control if their work is to be more than merely patching up mistakes. The pubHc health centre into which the school chnic will develop will have its child nurses, its diet experts, neighbor- hood inspectors, and house sanitarians to show fathers and mothers how to keep their children healthy and their homes and surroundings sanitary. This comprehensive kind of health education which will ultimately be connected with our pubHc schools is now def- initely foreshadowed in various forms of philanthropic and pul^lic enterprise. Milk stations, diet .kitchens, creches, PUBLIC-SCHOOL CLINICS 251 municipal nurses, school doctors, school nurses, and an oc- casional school clinic are doing, here and there for a few, some of the work that public health centres wdll eventually do for all who need it. School Climes at Home and Abroad. — The school clinic which seems destined to absorb most of these health en- terprises has already made a substantial start. It exists, indeed, in rudimentary form wherever a school nurse is em- powered to administer prescribed treatment for minor ail- ments or first aid in emergency cases, as is the case in New York and in a number of other American cities. Thus far, however, the development of the school clinic has been most active in England, the education board in 1907 having granted the power to local school boards of appropriating under their sanction a proportion of the education tax for the medical and dental treatment of school-children. This act promptly resulted in the establishment of many school clinics. By 191 2 there were not less than 118 centres where organizations for treatment of some kind or fully equipped school clinics were in operation. Of these, 78 had received the sanction of the national board and 51 were en- tirely provided for by the school tax, the others being partly subsidized or wholly philanthropic. Defective teeth, as well as minor ailments, such as septic sores, discharging ears, and inflamed eyes, were cared for in practically all of these clinics. In 49 centres defective vision was treated; in 48 skin diseases; and in 16 tonsils and adenoids. In 5 centres remedial ex- ercises were given for spinal deformities and the effects of adenoids; in 3 tuberculous cases were treated, and in i help was given to stammerers. Compared with the treatment provided for school-chil- dren in any other country, this is a notable showing, but even these apparently numerous clinics are serving only 9 per cent of the school-children of Great Britain. In America the percentage of children served by school clinics is far smaller even than in England, in spite of the fact 25^ EDUCATIONAL HYGIENE that many leading cities have lately established dental clinics. Here and there, as in New York and Philadelphia, we find an eye cHnic or one that treats nose and throat obstructions, but there is no evidence that there are as yet a dozen clinics in the country that give treatment for anything but defective teeth. This situation will not last, however. The fair be- ginning already made insures a rapid advance. Such an in- stitution as the Forsythe Dental Infirmary, incorporated in Boston in 1910 with an endowment of over $1,000,000, will give great impetus to the entire country in the direction of the pubUc treatment as well as the health education of school- children. The staff of the Forsythe Infirmary is composed of a number of consulting dentists who give their services, and a permanent paid staff of proved ability. The assistants are drawn from authorized dental schools. The building itself is planned for the most thorough kind of service; provision being made for one hundred and eight chairs, and, in addition to this, a waiting room, sterilizing room, research laboratories, museum, lecture room, extracting and anesthesia rooms, re- covery and consulting rooms. While few communities at present will probably be able to duplicate the Forsythe Dental Infirmary, many can profit enormously by the standards and methods worked out in this highly favored institution. The equipment of school clinics is already fairly well standardized and it is possible with httle difficulty and out- lay to fit up a moderate-sized clinic with thoroughly sanitary and serviceable arrangements. Detailed directions and specifications for equipping school clinics, from the simplest to the most elaborate, are to be found in "School Clinics at Home and Abroad," by Lewis D. Cruickshank, M.D., and in ''Medical Inspection of Schools," by A. H. Hogarth, Oxford University Press.^ ' The annual reports of the Chief Medical Officer of the National Board of Education, Whitehall, London, and the reports of such cities as Bradford, Cambridge, and Manchester will be of great suggestive value.— Ed. PUBLIC-SCHOOL CLINICS 253 How to start Clinics. — For the most part the one-chair or one-doctor clinic will have to answer the needs of the nation's children, and how to get even that small, simple clinic started will be the pressing problem in most communi- ties for the next few years. The big cities may be trusted to work out their own problems. It is the country communities, where most American children still live, which are in most urgent need of help. Miss Denison, in her book on "Help- ing School Children," gives an excellent programme for developing sentiment in favor of giving medical treatment to school-children. In the chapter on *'The Dentist's Message" she calls attention to the three centres of influence that must be conquered in either town or country in order to bring re- sults. These are the superintendent of schools, the leading dental or medical society, and the most energetic lay organiza- tion. To quote from Miss Denison: Through the first you have control of principals, teachers, pupils, and their parents; through the second, of individual dentists, small groups and larger, important county or State organizations; through the third, of mothers' clubs, women's clubs, charity organizations, public education associations, and groups of business men and min- isters. And the press is always eager for good stories. From the experience of many communities there are certain good moves advisable anywhere: Dental hygiene exhibit. Talks at school and parents' meetings. Newspaper stories about dental work in other cities. Volunteer committee of dentists to make preliminary survey of one or more schools. Publicity of results. Programme outlined for dental clinics and inspection. Support of lay organizations for board of education's requests for appropriation. Combination of dental and lay organizations to secure a compulsory law. When a community has reached the point of demanding a school clinic, the next considerations must of course be gov- 254 EDUCATIONAL HYGIENE erned by local conditions. How the support is to be provided , whether treatment shall be for public-school children only oi for private and parochial school children as well; whether it shall be free for all or any children, or for a .nominal or sHding fee — these are all questions that must be worked out locally as long as they are not determined by legislation.^ No matter how local conditions and difficulties may vary, however, it must be remembered that the fundamental needs of American children do not vary. Seven or eight children out of ten in Walla Walla need dental attention just as badly as they do in Boston. Obstructed breathing interferes with the strength and happiness of as great a proportion of children in Dakota as in New York. Everywhere in this country the children need help in securing sound bodies. The school clinic is the logical provision for this need and it is only a question of well-directed effort on the part of intelligent leaders when this institution will be as general and as highly valued as the public school. SUGGESTED EQUIPMENT FOR A DENTAL CLINIC 2 The rooms selected for dental work should have ample light. North light is preferred, as it is more uniform and shadows are less intense. The equipment of a dental clinic is rather expensive, but consider- ing its permanent nature, and the numbers that are likely to benefit, it is relatively less expensive than the equipment of other departments. It is scarcely necessary to give a detailed list of all the dressings, etc., that may be required. The following list of fittings and instruments is taken from the report of the School Dentists' Society: A dental chair. Cabinet. Bracket table. Spittoon (including saliva ejector). Five pairs of dental forceps and an elevator. Two dental probes, double-ended. Oiie dental machine with No. 7 handpiece and No. 2 right-angle attachment. • See also Cabot, " Volunteer Work for the Schools." 2 Prom Cruickshank's "School Dental Clinics at Home and Abroad." PUBLIC-SCHOOL CLINICS 255 One gross of burs, assorted. One dozen excavators, N. P. assorted. Two chisels. Three scalers. Four plastic instruments. One spatula. One glass slab. One glass pestle and mortar. One college tweezers. One amalgam spoon. One mercury holder. One chip syringe. One water syringe. Three mouth mirrors. One spirit lamp. One sterilizing tank (gas or spirit). One crystal glass sterilizing vase. Gas apparatus, consisting of stand with upright, bag, tubing, mounts, aseptic 3-way stop-cock, celluloid face-piece, and two 100- gallon cylinders filled with nitrous-oxide gas. Three mouth props. One tongue forceps. One mouth opener. One sponge holder. CHAPTER XV OPEN-AIR AND OPEN-WINDOW SCHOOLS The Problem. — The open-air school movement has gained a definite place among the educational and ameliorating 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 neighborliness. 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 live. The bearing which untoward circum- stances have upon the lives of children has impressed itself upon these workers as of paramount importance to the com- munity and the nation. The earlier efforts were for measures of relief. They endeavored to secure braces for crooked legs and crooked backs, to get hospital care for children who were ill, to acquire an understanding 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- 256 OPEN-AIR AND OPEN- WINDOW SCHOOLS 257 mation about dependency and delinquency. These workers found large numbers of children anemic, undersized, and ill prepared physically and mentally for the duties of life. They learned that thousands of them had dropped out of school at an early age and that the school experience had effected little or no beneficial result. A procession of something like 100,000 children a year files before the courts of the country, and the stories that have been confided to the ear of the friendly judge by troubled children and heart-broken parents have been challenging the attention of the nation. In following the trail of these little people into their homes, probation officers have become pos- sessed of information and understanding which throws a great deal of light on the reasons why children drop out of school, as well as why they fail in their studies and cannot keep up with the procession, why they get into trouble and do not fit into the industrial life of the community. From purely palliative and remedial work a widening number of interested people have been challenging the situation and de- manding a constructive programme. What the problem is for one disease the following figures suggest. Influence of Medical Inspection. — Medical inspection in the public schools has had a great bearing on the problem. In 191 1 over five hundred cities in the United States had a system of medical examination of school-children. Between one-half and two-thirds of the children examined were found to have one or more physical defects sufficiently pronounced to need attention, many of them so serious as to handicap the child in his school work, and still others so marked as to make his attendance at school dangerous to himself and to others. Discovering defects was the first step, but only the first. So far, less than one-half of the defects discovered have been corrected. This work is becoming more efficient as school nursing is provided, but there is still need for increasing the faciUties for hospital, dispensary, and dental care, for eye defects, and for operations for adenoids and tonsils. 2 58 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 e.xtensive 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 1911. 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 mortahty 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 classrocm, exterior, Hackensack, X. J. Open-air ckissroom, interior, Hackensack, X. J. Note equipment. Cots in the foreground OPEN-AIR AND OPEN-WINDOW SCHOOLS 259 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 IQOO." (94,20s deaths) PER CENT WHICH RATE IN I91I REPRESENTS OF I9II 1901 THAT IN 1901 Both sexes Males Fe- males Both sexes Males Fe- males Both sexes Males Fe- males All ages: Crude rate Corrected rate' . . . Under 5 years f 5 to g years < 10 to 14 years. . . . ( IS 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. 3 199.9 189.3 177.6 173.8 84 83 90 88 78 77 126.7 35-6 iiS-3 188.0 217.8 228.4 191. 193.6 IQ4-3 158-6 209.3 206.5 133-3 31-4 27.6 99.9 190.9 230.4 278.5 253-S 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 i6o.6 143 -I 168. 1 168.6 138.2 310 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 go 90 93 102 83 77 72 74 79 78 77 72 63 75 75 iFrom igii 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. ' Corrected on basis of standard million of England and Wales, igoi. Note. — ^The column 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 in 1901, and that the rate for children from 5 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 26o 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 community 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, sun-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 26 1 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 Pro\ddence, Rhode Island. There are at the time of writing more than 500 open-air schools and open- window classes in the United States. Passing 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 establish 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 262 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 difficult 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 263 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 estabhshed 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 264 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 265 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 themselves declare 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 266 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. Weight recorded each Monday and Friday. Friday gain and Monday loss noted. Dyer Open Air School, Cincinnati, O. OPEN-AIR AND OPEN- WINDOW SCHOOLS 267 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 how 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 Enghsh 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 268 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 with 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. Latei on I was put in the Foster Open Window Room, where I am now in the eighth grade. Other items which show the results 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 269 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 accomplish 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, extreme 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 270 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 27 1 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, 1913, 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 the}^ 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 who 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 t}pe 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. 272 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 community that will provide along these Hnes 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. CHAPTER XVI 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 hundreds of high schools through- out the land, groups of young people numbering from a score to many thousands in each locaHty 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. 273 274 EDUCATIONAL HYGIENE The first method is rapidly becoming less common. L'nder 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 Httle 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 189^, 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. .\n 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 public high schools of Boston are daily supphed with lunches 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. .-Vt [) resent 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 275 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. Penny Lunches bought at School u4 Cafories Penny Lunches bought on Street Bean Soup Sausa^e&Roll Rice Pudding Pretzel Cocoa Cinnamon Bun Milk Ice Cake Ro^al Lunch Marshmal low Cake Graham Crackers g| Popcorn Roll Spice Wafers H Cand7 Ess Da-tes IB Licorice Sweet Chocolate H Chocolate l^ppermint Stick Candy H 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. Xn 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 276 EDUCATIONAL HYGIENE unsupenised, 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 utilizing 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 277 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, 38 furnished students of the high schools with lunches directly; 18 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 pubHc-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: Brookl}^, New York, Buffalo, Rochester, Springfield, Fairhaven, Newton\'ille, 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 27S 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 arc cheerful, pleasant, and sanitary, and the work 4 SCHOOL FEEDING 279 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: Wh}- 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 28o 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 251 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 paternalism. 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 proxdsion 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 purchasjejdiQlesome 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 the 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 acti\dties 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 clinics 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. 282 EDUCATIONAL HYGIENE In stating that the establishment 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 difficulties. 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-lunch 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 — 10 per cent by conservative estimate, 25 per cent by more liberal interpretation — are suf- fering from malnutrition, the rehef 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 u SCHOOL FEEDING 283 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 limit 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 284 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 285 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 show 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. ^ See Andrew's " Education for the Home," part two, section two, bulletin 61 1 of the U. S. Bureau of Education. 286 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 dcs 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 relief 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- insjjection report. This is because it has been demonstrated SCHOOL FEEDING 287 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 ofificer 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 developing 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 iS^ 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 Zeitsckrift ftir 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. 2S8 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 8s dejects to every loo badly nour- i>hiHl. anemic children instead of iSj dejects. The Classification of Nutrition. — Doctor Gastpar's method of classif)ing 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 subtlivided until, in order of nutritional excellence, children in each age-group stand thus: (a) good; {h) fair; (c) fair with anemia; (d) poor; (c) 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 grouj) 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 flegrce of accuracy in a subject not easy to define rigidly. SCHOOL FEEDING 289 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 1912, "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 11 290 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 sj:;: successive years, and classified according to the Gastpar 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 tbf children's home diets; and, second, how to do all this while keeping the cost of food, preparation, and service within the ability ()f the children to pay. It must be remembered that the ( hildrt-n's unit of payment is a cent. SCHOOL FEEDING 29 1 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 onlv for England but for us as well. There are seventeen dinner menus served in rotation, thus providing 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 an^^^ 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 292 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 all 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 293 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. S- This act shall take effect immediately. Note. — See the writer's volume on the above subject. — Ed. CHAPTER XVII MEDICAL SUPERVISION AND THE EXCEPTIONAL CHILD Purposes of Health Supervision. — The chief purposes of a system of educational hygiene in the public schools may brictly be set down as: First: The diagnosis and exclusion of cases of contagious and parasitic diseases, so that other children may be protected and those afllicted may receive prompt treatment. Second: The recognition of physical defects in children and the correction of these defects through the co-operation of the school principal, school nurse, parent, and family or dispensary physician. Third: The correction of bad conditions in the physical environment of the child in school, and the establishment of modern methods of prevention, including health supervision of teachers and janitors. Fourth: The practical teaching of hygiene. Fifth: The recognition, classification, and segregation of cases of mental deficiency. Sixth: The correlation of medicine and pedagogy so that the greatest good both physical and mental may accrue to the child. With the first four points we are not concerned in this chapter. They belong to the consideration of health super- vision in its general aspects, a subject which has been most ably and comprehensively dealt with by the editor of this work, and by other authorities on school hygiene. In considering the fifth of these purposes let us remember that the term "mental deficiency" here has the general signifi- 294 THE EXCEPTIONAL CHILD 295 cance given it by Doctor Cornell, and covers mental back- wardness of all degrees, from that of the child who is simply dull from poor health or physical defects, or retarded from ir- regular attendance, late entrance, ignorance of Enghsh, ^r bad environment, down to the mental state of the child who is feeble-minded in the technical sense. Under the sixth heading we must interpret the correla- tion of medicine and pedagogy as meaning that school efficiency is to be increased and pedagogy lifted to the level of a real science by bringing to bear upon educational procedures all that medicine has to offer in its broad sense of biology, eu- genics, sociology, psychiatry, and psychology. With the above scope indicated it must appear that the supervisor of hygiene in any given school system will find a definite phase of his work interlocking with a variety of social and child-helping agencies. If his cultural training has been broad, he must early appreciate the fact that his work is by no means confined to investigations of nose and throat conditions in a few thousand children or to surveys of the physical conditions under which these children spend so large a measure of their waking hours, however important these efforts for improved health conditions may be. A very im- portant phase of his work has to do with the problems that fall under the head to which Doctor Rapeer has directed spe- cial attention, namely, the hygiene of methods of teaching and management. The supervisor of hygiene in this field becomes the medico-educationist. It is here that pedagogy and medi- cine in its broad sense join hands for the welfare of the child. The Exceptional Child. Terminology. Classification. — The term "exceptional" was at first used to designate th~ unusually able or brilliant child. Now we speak of this type of child as "gifted," and the term "exceptional" has lost definition and has become a general heading under which are grouped a variety of classes and subclasses, composed of children bearing almost any defect or suffering from almost any disease or environmental handicap that unfits them for 296 EDUCATIONAL HYGIENE routine school work under conditions provided for the aver- age, normal pupil. In a 1912 Bulletin of the United States Bureau of Educa- tion on "Provision for Exceptional Children in Public Schools," prepared by Superintendent J. H. Van Sickle, of Springfield, .Mass.. Doctor Lightner Witmer, of the University of Penn- sylvania, and Doctor Leonard P. Ayres, of the Russell Sage Foundation, we find a tentative or temporary grouping of ex- ceptional children, a grouping which these investigators stated at the time of the study they would not feel under obligation to defend at a later date, but which they felt might help in clarif}ing the thought of those professionally interested in exceptional children. The increased knowledge of the social and eugenic aspects of feeble-mindedness since the publica- tion of this bulletin indicates the modifications that these in- vestigators foresaw and alluded to. The classification, how- ever, focusses attention upon the scope of the problem and directs the attention of educational executives to the various types that must be considered. I. Institutional cases. (To be dismissed from the over- sight and care of the public-school authorities.) 1. Morally insane children. 2. Violently insane children. 3. Demented children. 4. All feeble-minded children below the grade of middle-grade imbecile (Barr's classification). 5. High-grade moral imbeciles. 6. Severe cases of epilepsy. ^ 7. Cases of contagious and infectious diseases (some to be dis- missed temporarily, some for prolonged periods). 8. Children helplessly crippled or suffering from revolting phys- ical deformity. II. Children for special classes or special instruction in the public schools. 1. Foreign. 2. Late entering. 3. Backward but capable of rapid restoration to normal grade. THE EXCEPTIONAL CHILD 297 4. Dull and feebly gifted. 5. Children requiring vocational training. 6. Children of precocious physical development, especially of precocious sex development. 7. Exceptionally gifted or able children. 8. Children suffering from various physical defects of minor char- acter but interfering with their progress and unfitting them tempora- rily or permanently for the grades. 9. Speech cases. 10. Social cases; those whose retardation is chiefly due to home conditions calling for the services of a social visitor as well as a special teacher. III. Children of uncertain classification. Institutional or special cases. 1. Blind and semiblind. 2. Deaf and semideaf. 3. Delinquents, including persistent truants. 4. High-grade imbeciles (Barr's classification). 5. All feeble-minded children of higher grade than high-grade im- beciles. 6. Crippled children. 7. Children suffering from epilepsy in mild degree or from nervous or other diseases rendering them difiicult or improper members of or- dinary classes. Doctor Hill's Classification. — As a more restricted group- ing the following, by Doctor Hill, of the Department of Edu- cational Research of the city of New Orleans, is of interest:' Class A. Feeble-minded or insane children who should be under institutional or home care rather than in the public schools. Class B. Backward children (not in Class A) or those who ur- gently need special educational methods in special classes within the public schools. Class C. Exceptionally able or gifted children. Class D. Incorrigible, habitually vicious children (i) who seem to be of defective mentality; (2) who seem to be of normal mentahty. Class E. Children of apparently good intelligence, but suffering obviously from some serious physical defect, temporarily or perma- nently unfitting them for the work of the grades: (i) defective vision; 1 See also Sandiford's classification given in his " Mental and Physical Nature of School-Children" (Longmans). 2(^8 EDUCATIONAL HYGIENE (;) deaf and semideaf; (3) suffering from speech defects; (4) crippled children; (5) epileptics. Meeting the Problem. — Inasmuch as the practical result that we desire to see follow child classification is provision for the treatment and training of the various classes, let us inquire as to which class is most urgently claiming our at- tention. Some half-dozen cities have established special classes for exceptionally "gifted" children; a few cities have provision for the milder epileptics and for cripples; special provision has been made in a relatively small number of systems for proper training of children suffering from defects of speech; but by far the greatest effort has been toward providing facilities for the special training of truants, incorrigibles, backward and feeble-minded children in the ungraded and special classes of many cities. More vigorous pioneer work has been done along this line during the past few years than that directed toward any other type of exceptional child. It is true that not all epileptic, insane, or other psychic cases need be considered in reference to their intelligence, yet ep- ilepsy, insanity, and feeble-mindedness constitute the inter- locking factors of one great problem, and the first question that confronts the supervisor of hygiene in reference to the majority of exceptional children, be they truant, incorrigible, "slow to learn," "stubborn," "foolish," vicious, or otherwise peculiar, is: what is the child's intelligence? Emphasizing the question of intelligence, and classifying school-children according to mentality, we find them falling into the following groups: I. Supernormal or gifted. II. Normal. III. Subnormal or mentally deficient Backward. Backward-delinquent. Borderline. [ Moron. Feeble-minded i Imbecile. [ Idiot, THE EXCEPTIONAL CHILD 299 The Curve of Normal Distribution. — In any typical school system about 2 per cent of the children will, according to our best standards of measurement, be found to be feeble-minded. Idiotic children are seldom found in school, although after the opening of special classes the most frequent petitioners are parents who beg to enter idiotic or low-grade imbecile children that have hitherto been kept at home. These cases are naturally the ones that lead parents to grasp at some agent of help, since the condition here strikes even the parent as unusual, whereas the higher grades of imbecility and mo- ronity may be fully appreciated only by a trained or expe- rienced observer. Ranking above these feeble-minded children comes a group roughly designated as "backward," and which for practical school purposes includes the borderline cases (until such are definitely diagnosed as feeble-minded); the so-called back- ward-delinquents, excepting those who are feeble-minded; and the mentally sound but slow children, including those to whom the methods and curriculum are poorly adapted. This back- ward squad constitutes from 10 per cent to 50 per cent of the school population, perhaps being about 30 per cent in the average city. Above this group ranks the great mass of average, normal school-children, constituting about 40 per cent to 80 per cent of the membership of the system. At the top of the scale rank the 4 per cent of children that compose the group of unusually able or ''gifted" pupils. The Practical Problem. — Expert examination of school- children shows that about 2 per cent are of such mental con- stitution that they can never profit by the work of the regular grades. These children, scattered through the regular classes, are either neglected or punished instead of being studied. They bring to us a part of the problem of truancy, in- corrigibiHty, and inability to learn or "get along," and are a tremendous drain upon the energies of the regular grade teacher. This type of child cannot be managed like other ■j^QQ EDUCATIONAL HYGIENE children, and he therefore requires special care and treatment under conditions suited to his abilities. A somewhat larger number of pupils, classed as backward, would profit greatly by having special class opportunities. Not only are the regular classes thus relieved from the bad example and drag e.xerted by these backward and feeble-minded children, but by the school's acceptance of its duty many of these children will be saved from a life of crime, trouble, and failure, and will be made happy and useful to the extent of their powers. The State of New Jersey requires by law that special classes be established in every district where there are at least ten backward children. The educational authorities of many cities are alive to the great need of the proper segrega- tion and training of these cases, not only for their own welfare but for that of the normal pupils and of society at large. The training of such children is a specialty in education, based upon a special psychology plus expert classification and studv from a medico-psychological standpoint. To be able successfully to conduct a class of such children, with the least waste of time and energy, the teacher must have special apti- tude and training. There is an opportunity in such work for a teacher to broaden her knowledge of child nature and to live close to one of the most vital movements in modern education. Approximately i6 per cent of children in Amer- ican cities are "repeaters" (pupils who spend more than one year in any one grade); and they cost $27,000,000 a year more to be passed along through the first eight grades of school as a result. Special classes will bring about much saving in dollars and cents in the case of many of these backward children. But there will be another saving, with the feeble-minded and bcjrderlinc cases, in the protection to the community from the probleni of juvenile delinquency and even grave crime. Consideration of Causative Factors. — To say a child is mentally backward may be in general equivalent to saying that he has decayed teeth, if we accept certain studies that have been made by noted school hygienists; that he has en- THE EXCEPTIONAL CHILD 3OI larged cryptic tonsils with absorption of toxins and slow poisoning of the system; that his naso-pharynx is stuffed with adenoid tissue entailing poor oxygenation of the blood, nasopharyngeal catarrh, and defective hearing; that his eyes photograph and transmit to his brain with great strain only one-half or one-tenth of what he should be cognizant of through this sense; that his hearing apparatus collects and transmits to his brain only a part of what yours or mine col- lects and transmits; that his digestive and assimilative forces find it impossible to provide fit blood to nourish brain cells and cause them to function normally on the quantity or quahty of food furnished; that he is constantly absorbing poisons from tuberculous or S3^hilitic bones or glands or from a malformed, sluggish, and clogged intestinal tract; that scarlet fever, measles, rickets, or meningitis has left a blight from infancy; that prolonged delivery or improper instru- mental delivery at birth may have worked injury to brain centres. These are the children who are backward because of physical defect, disease, or accident. When the recognition and removal of such defects is followed by improvement in the child's mentality and when the child that previously was stupid, troublesome, or even criminalistic becomes studious, obedient, and progressive in school work, we may feel that the defect in question was perhaps the cause of his backward- ness. Remarkable cases of this kind have been recorded. The moral is that such conditions must be eliminated or cor- rected in order that our subsequent study of any particular child's backwardness may culminate in a scientific diag- nosis. Outside of deafness (which is probably the most serious physical handicap in school work that the child is likely to possess) and the more serious cases of defective vision and poor nutrition, we are coming to believe that physical defects per se have less influence on school progress than has been claimed by writers in the popular magazines and even by trained examiners of school-children. The fact that many ^502 EDUCATIONAL HYGIENE so-called "environmental cases" — backward children that are said to owe their state to bad home conditions, neglect, and lack of opportunity — come to an examiner with a variety of physical defects, may have given color to such a belief. Doubtless the majority of these cases in the near future will come to be seen as products primarily of bad heredity and absence of prenatal hygiene. Upon the subject of backward- ness resulting from disease or physical defect we find rather a wide range of figures. Figures here mean little. It is enough to know that the curve of normal distribution locates from lo per cent to 50 per cent of school-children in the backward squad. Of this number some fall under the class we have dis- cussed — those backward by reason of defect or disease and those who are victims of bad home conditions. Others be- long to the class that has had a new and difficult language to struggle with, and still others have been so irregular in at- tendance that little progress has been possible. In these groups there is much overlapping and combining of causes, and the exciting and the contributory causes are often hard to differentiate. A considerable proportion of the retarded children that clog the machinery of most city school systems without doubt owe their backwardness to school curricula and teaching methods that are not in accord with the abihties of these children that will usually be found to be motor-minded. Proper child classification should be the first step toward the correction of these conditions. Feeble-Minded Children. — We must not forget that school work is not always a correct measure of a child's abihties. It is true, however, that children that are dull in the outside world as a rule have been dull in school work. The child must be studied under varying conditions. This brings us to a consideration of the children of this major group whose l)ackwardness is of such degree or such character that one familiar with this type of child may make the diagnosis of fecble-mindedness. To the untrained, all these children. THE EXCEPTIONAL CHILD 303 except the most openly peculiar, are referred to as "back- ward" or "subnormal." As a standard the term backward is scientifically applied only to children who, with certain physical, educational, racial, or environmental handicaps re- moved, attain to fairly normal standards of intelligence, prog- ress, and behavior, and may eventually become self-support- ing, respectable citizens. The remainder of these so-called backward cases constitutes the group of children properly called feeble-minded. Their condition is incurable. They are not able to do regular school work to any purpose and they will never become useful or safe, self -directing citizens. The best treatment for most of them in the pubHc schools at present is that given in the special classes for mentally de- ficient children, where specially fitted teachers train them, chiefly along manual and domestic lines. They should be classed apart from backward and from vicious children. Educators and teachers in the past have thought of truancy and incorrigibility as things to be dealt with as definite peda- gogical entities, whereas they are usually but a couple of symptoms. The child's incorrigibility is based on reasons beyond his control under the usual conditions. The first step toward dealing ^vith these children is to classify them and then train them in accordance with their abilities. The greatest good that results from this step is that ac- cruing to the 40 per cent to 80 per cent of average, normal children, because of improved conditions and methods de- veloped through a recognition of the needs of unusual chil- dren. The teacher, for instance, of the backward child will almost surely point the way to a newer and better pedagogy for teachers of normal children. The classification of these children is work for experts, since some high-grade feeble- minded children appear to their teachers and others far brighter than many children that are merely backward from physical defect or bad environmeat. The practical point here lies in the fact that while the ^04 EDUCATIONAL HYGIENE latter condition is curable and the children harmless, the feeble-mind is incurable, and these children, who will soon have the bodies of men and women but will ever remain chil- dren in intelligence, are a social responsibihty that an en- lightened civilization cannot shirk. Over 60 per cent of these cases of feeble-mind are hereditary, and it is the control of this tainted stream of life that must concern in considerable measure the trained social workers of the next thirty years. The science of medical sociology is being born, and the social worker who directs his or her energies along the lines of great- est service will find a definite share of the work awaiting de- velopment. We should not stop with this enumeration of the causes of mental retardation in children. We must see the futility of a knowledge of these conditions without the response of time and money and service in an attempt at correction and prevention. We only epitomize this thought when we conclude that in deaUng with the problem of the backward and feeble-minded child, whether he be in school, on the street, or before the juvenile court, the first step toward dealing with him humanely and practically is scientific child classification. With his status determined and estab- lished, educational, social, judicial, philanthropic, and public health agencies may well unite in giving him the care, protec- tion, and treatment that are proper for his needs and are commensurate with his abilities. Thus will the individual be best served and society best conserved. Diagnosis.^— Many school systems take no note of mentally deficient children through the health-supervision corps, but classify their backward children on a basis of retardation or pedagogical record. This, of course, is not scientific. These cases demand a careful consideration under four main heads: fi) Medical; (2) Sociological; (3) Pedagogical; (4) Psycho- logical. It seems most desirable to have all diagnostic agencies within the educational system. The supervisor of hygiene outside the larger centres should be equipped to handle these THE EXCEPTIONAL CHILD. 305 cases or have at his disposal the proper experts. In every city of 100,000 or more population there should be, as a fea- ture of the department of education, a medico-psychological laboratory under the direction of the supervisor of hygiene, where an intensive study may be made of all children that are not profiting by the regular work of the grades. A study of any child in question, to culminate in a scientific diagnosis, must place before the examiner a careful family history. When possible, the parents should be seen either by the ex- aminer or by a trained representative. It is in this work that a school nurse definitely assigned to the special classes can be of most valuable service. She may be made responsible for frequent home visitation in the case of these children; the compilation of family histories; the work with parents pre- liminary to the commitment to institutions as rapidly as possible of all cases that have been definitely diagnosed as feeble-minded; the "follow-up" system in connection with backward and delinquent children that leave school to go to work — -in fact, the many activities along sociological lines peculiar to the work with the atypical child, if he is to be dealt with in a manner best for himself and most economical for society, may be hers. A recent law in Xew York State makes it possible to commit a feeble-minded child through any court of record to an institution without parental consent, but the cases that probably will be reached by this law are not the urgent ones, and proper disposition of cases of high-grade feeble-mindedness implies an increase in knowledge of the significance and dangers of moronity which judges in general will probably not possess for several years. Returning to a consideration of evidence upon which a diagnosis may be based, the examiner must take cognizance of anatomical and physiological variations and pathological findings — the so- called stigmata. Along this hne he will note the size and shape of the head, the ears, any congenital defects indicative of an incomplete make-up, the expression of the face, mus- cular co-ordination, emotional control, presence of any of the 3o6 EDUCATIONAL HYGIENE various paralyses, state of nutrition, condition of the various sense channels, neuromuscular tone, and the character of the speech. The thorough medical examination should perhaps be the first step, and this may advantageously include anthropo- metrical data as follows: height (standing and sitting), weight, and spirometer and dynamometer findings, from which the psycho-physical curve may be determined. The evidences of defective neuromuscular tone and poor muscular co- ordination as well as the signs of organic brain disease must be sought through skilful observation, device, and direct ex- amination. From parents or family physician may be learned the early medical history of the child — prenatal hygiene, accidents, the acute infections from which he has sutTered, antl the time when he learned to walk and to talk. From parents and teachers will be learned how he has behaved in play, and the extent and character of the work he has been able successfully to grapple with. From these sources will also come much valuable testimony concerning his personal habits and his temperamental make-up, and, what is very significant, the record of his work in school under the con- ditions and requirements imposed upon hundreds of other children. The social nurse will also secure data concerning his home environment and the influences, physical and moral, to which he is subjected outside of school. The evidence resulting to an examiner from the preceding investigations under the headings, medical, educational, and sociological, will not always, nor even frequently, be positive so far as a diagnosis in a case of feeble-mindedness is con- cerned. It is usually only corroborative. There remains the most important line of procedure — psychological examination. Professor Binet has neatly em- [)hasized this by stating that medical investigation reveals possible signs of defect; pedagogical investigation reveals probable signs of defect; psychological investigation reveals certain signs of defect. THE EXCEPTIONAL CHILD 307 Psychological Examination. — This line of investigaaon may take the form of: (i) Definite tests of certain mental processes, as imita- tion; attention; perception of form, color, size, number, and weight; memory; conception; reason or judgment. These tests are of greatest use in determining the mental condition of a young child or a child of low mental development. Most of the series of graded tests for measuring intelligence involve tests of the principal mental processes above named. The Form Board. — It has been stated by Doctor Goddard that the form board gives more valuable information in a shorter time than any other piece of apparatus. The time and manner in which the test is done, and the improvement upon successive trials, together serve as an index of a child's trainability. As a diagnostic aid the form-board record should always be available. Doctor Cornell states that, as a fair rule, a child of school age unable to place the blocks in thirty seconds is a feeble- minded child. This virtually agrees with the Vineland Laboratory report on this piece of apparatus that we have inherited from Seguin. Many valuable and suggestive tests have been given us by Healy, Fernald, Whipple, and Huey. (2) The direct measuring of intelligence by a series of graded tests. De Sanctis^ s Tests. — These tests, six in number, formulated by Professor Sante de Sanctis, of the University of Rome, Italy, are simple, easily applied, and, when positive, furnish suggestive evidence of feeble mind. The grading is not close, but with these tests Professor de Sanctis beheves it is possible to decide that a child is, to use our terminology, a moron, imbecile, or idiot. Binet-Simon Scale. — This graded series of tests devised by Doctor Alfred Binet and Th. Simon, of the University of Paris, and first translated into EngKsh by Doctor H. H. Goddard, Director of Research in the Training School at Vine- land, N. J., has given the examiner of exceptional children 3o8 EDUCATIONAL HYGIENE the most valuable set of diagnostic procedures at his command. With this scale an expert that is familiar with exceptional children and is trained in psychology may determine with great accuracy the intelligence of a child in terms of mental age. Mental age in relation to chronological age furnishes information of the greatest value as a basis for classification of exceptional children, and is of vital significance in the matter of pedagogical prognosis and treatment. For details and technic of all the tests mentioned in this chapter, and for more complete statements of the chief diagnostic procedures in a consideration of exceptional children, the reader is referred to the authorities set down in the appended bibliography. The examination of these children by the supervisor of hy- giene or his assistants, and a classification of them in reference to their trainability or their need of permanent custodial care, will bring to the teachers of special classes a scientific basis for their work. These teachers, if they have open minds, are ready to accept the truth about these children, even though it may upset all their ideas of child nature and child training. Health supervision of schools is a specialty and con- stitutes far more than examination of children for contagious disease and physical defect. The work of the supervisor of educational hygiene during the next decade will to a large degree fuse with the spirit of the medico-educationalist, and ideally he should be a medico-psychological expert with a s}Tnpathetic understanding of the duties and ideals of educa- tional executives. If we could train a man^ especially for these duties in our public schools (and we shall be doing this every- where ten years hence), we would train him first as a school executive, then as a psychologist, and then as a physician. He should have a good outlook upon sociological conditions if he is io secure the co-operation of the various organizations that mean so much in a comprehensive consideration of the feeble-minded or delinquent child. With the above definition ' Let us remember that " man " is here used in the generic sense, for this field invites particularly the service of able women. THE EXCEPTIONAL CHILD 309 of the scope of this special phase of the work of the hygiene corps, it appears that a city should either employ as its di- rector of hygiene a man so trained, or engage as his assistants the needed specialists — a plan that has been adopted with satisfaction in quite a number of our large cities. Only with such a staff and equipment can constructive work be done. Disposition of Exceptional Children. — The following out- line of adequate provision for the treatment and training of exceptional children may seem to suggest a system impossible of attainment in the near future, yet nearly all cities with systems organized under superintendents have made pro- vision for some type of exceptional child; a large number of cities have made a good start in the work with backward and feeble-minded children; a considerable number of systems have special provision for speech cases; for some years a number of cities have maintained classes for truants and disciplinary cases, and a few cities have included in their educational policy the hulk of the following suggested plan. Other cities will press the matter to a successful issue. The larger centres will handle the problem of the mentally deficient child as systematically and effectively as they have dealt with the child suffering from infectious disease or physical defect. With the adequate training of physicians entering the field of educational hygiene, and the general awakening of the pub- lic to the needs of the exceptional child and the rights of the normal child, the wisdom of the following provisions will be so apparent that they will be recognized as indispensable features of a school system in any community that is per- forming its duties with enlightened economic and civic sense. (i) Medico- psychological Laboratory.— This should serve as a "clearing-house" for exceptional children, and the super- visor of educational hygiene and his staff should be equipped for an intensive study of these cases. (2) Special Classes.— The system should be of sufficient scope to offer training to the gifted, the backward, the cases of speech defect, and to the borderline cases until a definite 3IO EDUCATIONAL HYGIENE diagnosis of feeble-mindedncss has been made. Adolescent boys and girls should be grouped in separate classes. Some of the cases of speech defect represent common types that are cured by a couple of weeks of simple training, but a num- ber of them are cases that should be separated from normal children and should have the advantage of a special teacher for a considerable period of time. The evil results of per- mitting these pupils to continue in classes with normal chil- dren He in the bad example to their classmates as well as the pronounced nervous strain upon the affected pupils and teachers. In some of these cases the speech defect is only one of a number of manifestations that mark them as degen- erate children. Certain suitable teachers should be desig- nated to perfect themselves in the methods of training chil- dren that have the more easily cured speech defects, so that the majority of cases of this type may be promptly corrected and these children saved the nervous strain and retardation that frequently accompany the condition when allowed to persist for any considerable time. All transfers to and from special classes for any type of exceptional child should be made only above the signature of the supervisor of hygiene. (3) Parental and Residential Schools. — These schools should care for deUnquents who are not feeble-minded or insane. If properly conducted they can supply the elements of home Ufe and the disciphne so pitiably lacking in the ex- perience of most of these children. The so-called "environ- mental case" can here be given a fair chance to become an honest and useful citizen. (4) Municipal Farm Colonies. — These should be main- tained within reasonable distance of the city, so that parents may visit them and be led to see the benefits of the life there olTcred. In these colonies should be placed the feeble-minded, including all that are capable of any training or usefulness along industrial lines. When child-bearing age is reached separate colonies will solve the problem for those that are self-supporting, or nearly so, under direction. Cases that be- THE EXCEPTIONAL CHILD 311 come purely custodial at any time should pass into the care of the State. Epileptics who are not feeble-minded also might find their brightest haven on separate farm colonies of the municipal type. The insane, the morally degenerate (who, however, are seldom defective in the moral sense alone), low grades of the feeble-minded, and the feeble-minded epileptics should be placed as rapidly as possible in State institutions for perma- nent custodial care. (5) Lastly, provision should be made in all city training schools for proper instruction of prospective teachers on the health of school-children and the hygiene of school Hfe, and especially should these training-school students be made familiar with the exceptional child. There should also be pro- vided special training for teachers who wish to become teach- ers of special classes. A system of health supervision in the schools may in a few years banish much disease, remove many physical defects, and work great reforms in the hygiene of the physical child. Doctor Ralph Crowley, a national school-hygiene supervisor of England, well says that the school medical ofi&cer should be "not merely a functionary charged with specific duties" but a "pervading influence," making himself master of the various problems of child development, all of which have their roots deep down in physiological law. The problems considered in this chapter must be appreciated as having a broad biologic significance, and years of patient work he before the educational hygienist and the constructive edu- cator, working hand in hand and alive to the presence and needs of the exceptional child. II. SCHOOL SANITATION CHAPTER XVIII HYGIENIC SCHOOL ENVIRONMENT An Introductory Survey 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 accomphsh but also in the surroundings the school gives the pupils while they are in its care. The pubHc 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 j:)roper 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 schocjls of the })ast. 312 HYGIENIC SCHOOL ENVIRONMENT 313 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 system ; 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 l/nited States, where every enterprise rests directly or in- directly on public opinion, public sentim.ent, and the will of the people. Any nation-wide survey of American schools will lead to the conclusion that there are thousands and thou- ,14 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 realized 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 of! 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 filHng them with windows. It is hard to refrain from making seemingly hysterical and overcolorcd 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 light 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 315 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;5AND OVER [PERMISSiBLE] RATIO OF WINDOW SPACE TO FLOOR SPACE IN OHIO 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-fountains, but sometimes ^l6 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 giv^n 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 317 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 office or of being able to 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- 3i8 EDUCATIONAL HYGIENE try arc 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 public funds have not yet come to the place where they will permit a body of experts sufikient 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 ' Sec rcccnl survc3- rqjorts for Ohio, Pennsylvania, and Illinois- HYGIENIC SCHOOL ENVIRONMENT 319 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 compKcating 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 satisfactory. 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 ^jO EDUCATIONAL HYGIENE each room and lind 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 oflicial can perform for his community is to make or have made a complete sanitary survey of the school l)r()j)erty under his care.^ ' For ciiics, the sanitary inspection forms used by the Philadelphia schools will prove suggestive. HYGIENIC SCHOOL ENVIRONIVIENT 32I 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 interpret 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 322 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 lifting of sanitary operations in all schools to a much higher level. Fortunate is the school system of any State that can have such uniform 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 poHcies 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. — All 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 323 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 "PuBL/e HlQMWAy Cbu/tnz Y 5C/fO0L fARM icole (From Dresslar's "Rural Schoolhouses and Grounds." Courtesy U. S. Bureau of Education.) to be preferred to any and all systems of calisthenics in school or other rooms. The child that has the room to run and play as he desires has a big help in the matter of having good health. If his playground is well drained and gravelled, free from depressions in which water can stand, and equipped 324 EDUCATIONAL HYGIENE with enough apparatus to afford proper exercise for him, he is fortunate indeed; for his school will probably be more attractive to him and his tendency to be out of, or late in ar- riving at, school will be reduced to a minimum. One of the greatest assets in maintaining the health of any set of school- children is to have a school site that is big, healthful, and serviceable enough to make it possible for children to get the most out of life. " Excessive housing " has been called one of the dangers of modern civilization. It is the duty of the school to combat this tendency by having school grounds big enough to serve to the fullest the needs of all the children.^ Standards of Construction. — The construction of school buildings is an extensive topic. It includes all the details of planning and arrangement, the specification of materials, and construction according to the latest and most approved ideas as to sanitation. However, some general rules can be laid down that should apply to the construction of almost every schoolhouse. Local conditions may possibly produce variations from these standard rules, but in the main they probably should prevail. The first of these suggestions is that no school building should be more than two stories in height, above the basement. The objection will at once be made that in cities, where the price of real estate is largely beyond the reach of school funds and where the number of children to be taken care of is large, it is absolutely necessary to build schoolhouses more than two stories in height. The necessity may in certain atypical cases seem to exist, but there are some people who claim that the health and lives of chil- dren are more precious than real estate, and that every school should have room enough in which to take care of every child in the way it ought to be taken care of. Children more than two stories from the ground, with the best of modern fireproofing of buildings, are running serious dangers from fire, and they probably undergo undue strain in constantly chmb- ing two or more flights of stairs. The second general rule in » See Chapter XXIV. HYGIENIC SCHOOL ENVIRONMENT 325 construction is that all school-buildings shall be constructed so as to be absolutely fire-proof or as nearly so as is possible. All exits should be as wide as possible, and all interior wood finish should be as small in amount as possible. Further- more, all wood finish and all plastering should be so constructed as to minimize or prevent the collection of dust. Every window-sash ought to contain as few panes of glass as possible, and where it seems difficult to light rooms properly prism glass should be used. Especial attention should be paid to the matter of fighting, for mistakes in this direction are often not easily detected and may produce much harm. Heating and ventilating systems should take fresh air from outside the building, diflfuse it throughout each schoolroom, and carry out the foul air at a rate of not less than eighteen hundred cubic feet per hour for each two hundred and twenty- five cubic feet of schoolroom space, in all conditions of the outside atmosphere. Even where stoves are used, apparatus should be installed to take air from outside the school - house and to conduct to the outside the foul air. The health authorities in any community should prevent the use of a school-building that does not approximate in fresh-air ef- ficiency the standard set out above. Automatic tempera- ture regulation should be provided in all buildings with cen- tral heating systems. No matter how faithful the teacher or the janitor may be in looking after the heating and ventila- tion, he cannot be as efficient as the best modern regulating apparatus. The very fact that a teacher is in and inured to the schoolroom often disquafifies him for quickly and ac- curately judging whether the room is too warm or too cold, and whether fresh air is needed. The usual temperature formerly recommended for the schoolroom was seventy de- grees, and the ordinary regulation apparatus is set for that figure, but children may have as good or better health at a lower temperature, especially if there is a proper degree of humidity in the schoolroom. The usual heating apparatus should provide easily a temperature ranging from sixty-six to 326 EDUCATIONAL HYGIENE sixty-eight degrees. In summary, the proper amounts of heat, light, and fresh air are the first things to be taken into con- sideration in the erection of any building. Another feature that must be looked after carefully is the proper installation of toilet and wash-room facihties. Cleaning the building should also be made as easy as possible. Vacuum sweepers and every other modern appliance ought to be put in the trained hands of the janitors. Wherever possible, inclines should be substituted for stairways, since inclines permit each person ascending them to take such steps as suit him; there is consequently less physical strain; and the inclines are in many ways more serviceable than the stairs. All dry dusting and sweeping must in every school be strictly prohibited. In fact, the one thought of every architect, builder, and administrator of every school-build- ing ought to be that the children are to be looked after first, last, and always. Their health and their general welfare are to be considered at all times, and everything that is done should point principally toward that end. No building is ever erected merely for the purpose of giving any teacher, janitor, or other person a position on the public pay-roll. And, al- though these persons should also be given the best possible hygienic conditions, ''Service to Cliildren " should be the motto whenever and wherever a public school is built and maintained. The Janitor. — There is one very important factor in the care of every schoolhouse and that is the character of the work of the janitor. It is useless to talk of school hygiene and to construct sanitary buildings unless these buildings are to be cared for in the correct way. The importance of the janitor's work is often underestimated, and that person him- self is all too often not given a fair chance either to know what to do or to have the tools with which to do his work as it should be done. Some one has suggested that since it is thought necessary in these days of classes in domestic economy to train homekeepers who have charge of the health of in- dividual families, it might also be well to train the men and HYGIENIC SCHOOL ENVIRONMENT 327 women who take care of school-buildings, many of which contain hundreds of people where the home usually contains but a few individuals. The fact of the matter is that most campaigns for better sanitary school conditions begin at the wrong place. The first thing to do, in many instances, is to see that the man, woman, or boy who daily cleans the schoolroom and cares for the rest of the schoolhouse under- stands his problem, knows why it is harmful to do dry sweep- ing, appreciates the necessity for having plenty of fresh air coming into the room all the time, and reaHzes in a general way how important his work is. Further, teachers, prin- cipals, and superintendent ought to understand the work of the janitor. In many cases, if there were a fuller understand- ing there would be more sympathy and, consequently, better work. Further, school officials should see to it that the janitor has all the necessary appliances and arrangements with which to do his work. If school health is the first consideration, then the means of securing and maintaining that health should always be at hand. Cutting down on the amount of the janitor's supplies is a poor way to economize if any ef- fectual sanitary work is to be done. He should have all the appliances that are necessary for him to do his work well. All are agreed that it is best to have all persons who care for the child's mental development take courses of instruc- tion and pass certain examinations. Why would it not be well to require courses of instruction and examinations for the persons who are to have a very important part in caring for the children's physical welfare? Will it be possible to secure the best results in school sanitation before some such instruction and tests are required of all janitors? In all too many cases the janitor owes his position to the fact that he belongs to some political faction or that he has some in- fluence other than fitness for the work he is appointed to do. No other consideration than ability and faithfulness should enter into the process of employing and retaining a janitor. Further, a good work can be done by any school execu- 328 EDUCATIONAL HYGIENE tive if he will get his janitors together occasionally and dis- cuss with them the various matters that have to do with the proper care of school buildings. For instance, the subject of the proper lighting of schoolrooms could be explained at a meeting of the janitorial force. Discussions, illustrations, and experiments could be utilized in an effort to get all to under- stand the great importance and standard requirements of the subject. Other meetings could be called for the consider- ation of other problems. A feeHng of sympathy between the janitors and the school authorities could thus be created that would not otherwise exist. The whole situation would be materially improved in any school system where such a well-planned scheme of bettering sanitary conditions through the janitor is undertaken. The janitor's work is of the greatest importance. He cannot know too much about his work and there cannot be too great an understanding of and sympathy with the magnitude of his tasks and the difificulties that they present. A General View. — In a broad survey of school conditions in this country there is to be found much that is hopeful in general as well as in the particular phases that have to do with school sanitation. Progress in any one school line must eventually mean progress in all other lines. Generally speak- ing, the most modern methods of teaching are found in the most modern buildings. The community that wants good teaching generally wants good school-buildings and will get them if possible. In sanitary as well as other matters the dream of to-day will be the actuality of to-morrow, and we shall constantly move on to better things. Conclusions. — This introductory survey of sanitary con- ditions in the schools throughout the country leads to certain general conclusions of a practical nature, namely: Practically everywhere in our country there is the spirit of progress in matters of school sanitation. There is to-day a very much greater expenditure for sani- tary measures and appliances than ever before. HYGIENIC SCHOOL ENVIRONMENT 329 City schools spend proportionately more along sanitary lines than do country schools. As a rule, city school-buildings excel in matters of heat- ing, lighting, and ventilation, as well as in several other im- portant features. There are many exceptions to this rule, but it nevertheless prevails. Every school should have plenty of light; plenty of good, pure, unbaked, Hfe-giving air; good water; bathing facihties; roomy playgrounds; in many instances school-prepared noon lunches; and all other things that go to the making and main- taining of health. Whenever our people get ready to spend as much money on public education and health as on their hogs and cattle, and on some of the unnecessary and harmful things in which they indulge, there will readily come to pass all the things of which we dream. The schoolhouse should be the model for the community in all sanitary matters. It should be the centre of a radiating gospel of good health. Finally, the one great opportunity to lay the foundations of a superior public health is to be found in the public schools. CHAPTER XIX SCHOOL SANITATION STANDARDS A Sanitary School Environment. — The problem of furnish- ing children of a community with a thoroughly hygienic and sanitary environment can be seen, in the light of past chapters, to be one of great difificulty as well as one of supreme impor- tance. Sanitary home and neighborhood conditions are only a part of the problem. When we come to the school main- tained by the State with compulsory attendance for all chil- dren up to a certain age, we have the problem in an acute form. The State is not only responsible for the health of its involun- tary charges, but it is extremely interested in their hygienic welfare. It is, moreover, bound to set as high an ideal of sanitation as possible as an example to the public, which has a right to take it as a standard. The most sanitary home in the country is not too high a standard for the State public school.* Moreover, the problem offers many new difficulties non- existent in the ordinary home. The average family is from four to six in number, while the average detached house or apartment has about the same number of rooms, an average of about one to a person. At the school, the average is about thirty to forty persons to a room, instead of but one to a room. Moreover, these persons are from many different homes and sources of possible contagion. In the home, free movement about the house is possible; at the school, each pupil leads, for the most part, a sedentary life in a seat usually screwed to a fixed spot in the room. These and many other considerations have led to innumerable grievous sanitary errors on the part of school directors, carpenters, and janitors. Their "apper- ceptive basis" has been that of home conditions, and this 'See Professor Irvinj^ King's recent bulletin on "Hygienic Conditions in Iowa Schools," published May 29, 191 5, by the University of Iowa, Iowa City, Iowa. 330 SCHOOL SANITATION STANDARDS 33 1 has been mechanically transferred to the construction and sanitation of schools. Much if not most of the recent interest and development in the field of educational hygiene has been along school- sanitation lines and a number of the recent flood of books indicate this emphasis, one of the best of them devoting about fifteen chapters to school sanitation, seven to medical inspec- tion, two to the hygiene of instruction, one to physical educa- tion, and none to the teaching of hygiene. A large part of this interest and development has been brought about by the fortunate competition of school engineers, architects, and supply houses for the large money rewards in this field. The competition of inventive genius and the nation-wide adver- tising of sanitary drinking-fountains has, for example, been a big factor in this one step of sanitary improvement. Other illustrations are innumerable. It is manifestly impossible to treat in a few pages or chapters of an average book the details of this rapidly develop- ing science and practise. We must limit our discussion to the barest fundamentals. These fundamentals must and should be of the nature of standards or norms by which to test and to guide effort in this field. But on looking for such standards one must at once be struck with the fact that we are practically without real scientific standards of school sanitation. We have numerous tentative standards, a lot of consensus of opinion and practise, a great deal of dogmatism and imitation, but few scientifically established standards. The recent investigations of ventilation, for example, have destroyed the old opinion-standards of the baleful effects of carbon dioxide and lack of oxygen in classrooms, and there is a tendency to deride the costly and intricate mechanical ven- tilation systems of the present and to rush to open and fresh- air rooms and schools. Any observant person in education knows of multitudes of expensive school sanitation fads and fashions that have come and gone, seeming to benefit princi- pally only the fashioners and sellers of the "latest thing" to unsuspecting school men and boards of education. 332 EDUCATIONAL HYGIENE Undoubtedly great good, as well as much harm, has been done by the wide-spread adoption of new opinion-standards. The remarkable progress of city school sanitation is due largely to this one factor. The unrivalled advance in hospital and office-building architecture and sanitation has had, too, its more scientific influence. But think of the cost and the injury of such methods! Millions for change but not one cent for scientific investigation, has been our motto. Word goes out from some bureau, book, or self-styled expert that, for instance, the lighting of schools should be from the left side only, and schools everywhere gradually adopt this norm. But the schools of the future, especially small rural schools, may some day be changing back to lighting on both sides of the classroom, because scientific study may show that the shadows of pupils' pencils and hands on their papers are not seriously detrimental if at all, or that other features, such as more illumination, or cross ventilation in hot weather, are of greater hygienic importance. We do not know! It is quite possible, at any rate, for a scientific investigation of school ventilation problems, such as the Thorndike-Winslow^ experimentation now going on, to overthrow many cherished- as-absolute standards of the past, and to do a million times more real lasting good than man}^ whole State surveys which say: "This is bad according to our (opinion) standard and your laws must be immediately made to enforce the change." Being practically without very stable and scientific standards, then, we must content ourselves with cautious statement, in the briefest terms, of some of the empirically derived and established standards now available. They can be found scattered in many publications and in evidence in many schools in many places. We shall emphasize the larger, city school because the rural school problem has two chapters devoted to it. In certain cases sanitary standards will of course have to be sacrificed for large educational or ' See " Some Results of the First Year's Work of the N. Y. State Commis- sion on Ventilation," American Journal of Public Health, Feb., 1915. SCHOOL SANITATION STANDARDS 333 social ends. The centre of a neighborhood, for example, may not have as good soil as other locations and yet it may be best to choose it, all things considered. Tentative School Sanitation Standards I. The Site. — (i) Speaking generally, as we must through- out, the site should be on rather elevated, porous, uncon- taminated soil, preferably gravel and sand. Muddy, wet feet and clothing, and foul air rising through the basement from a contaminated soil, must be avoided. (2) Size. — Ten to twenty acres of good land should be made available for consohdated rural schools, two to three acres for school and neighborhood playgrounds. Thirty square feet of play space for each pupil as a minimum has been made a standard by the National Playground Association of America. Dresslar is authority for the statement that "according to the rules of the London School Board 100 square feet of play space is required for each pupil. "^ Allow- ance must be made for the future extensions of the building and for any parking space absolutely required. A full city block is a convenient minimum standard. Where blocks are as small as 200 feet square, two for each school will frequently be standard. (3) Surroundings .^ — The school site must be in a quiet place, free from dust, bad odors, and gases, overshadowing buildings, and away from sources of ill health or injury to pupils. This standard rules out thousands of American schools, now located on street-car, automobile, heavy-traffic, and even steam-railway streets or lines, or near dusty roads or factories, gas-houses, livery barns, planing-mills, saloons and other such houses, etc. Foresight and the law must be used to protect schools from such dangers to life, nerves, health, and sanitation. II. The Building. — (i) The building should be arranged longitudinally, so classrooms may have unilateral east or west * Portland, Oregon, School Survey, p. 220. 334 EDUCATIONAL HYGIENE lighting, the children in the rooms on the west side of the building (if of several rooms) facing north and those in rooms on the east facing south. (2) If possible, the building should be placed at the west side of the school site, with the separate heating plant to the west of the building. This puts almost the entire playground in front of the school building, where it can be supervised to some extent from the principal's ofhce (when he cannot get out), which should probably be in the middle of the front on the second floor. If this part of the building is made to pro- ject somewhat, windows may be put into the office to give north and south views of the playground also. The Bernard Moose School, of Chicago, designed by Dwight L. Perkins, is built in this manner. (3) The rear of the building to the west, with its separate heating plant and smoke-stack, should be made as attractive as the front if possible, so the building will not have to "turn its back" on any neighborhood. (4) Practically every school should have a well-lighted concrete basement. In smaller schools the heating plant will be located here. Great care should be taken to prevent the upward movement of moisture in the walls to the school walls above. Slate, pitch, and other substances are used to cut off this upward movement. (5) Arched roofs and steeples are rapidly giving way to flat roofs, and very low towers if any, on the larger school l)uildings of four or more rooms. Roof playgrounds should be provided where needed. (6) Every school building should be as nearly fire-proof as possible, and the larger the building the more emphasis there should be on this factor. We have lost too many build- ings and children by fire. An average of ten school buildings burn each week of the year, two each school day. (7) The following helpful suggestions for making schools fire and panic proof are taken from "Fire Protection in Public Schools," distributed by the Division of Education, Russell Sage Foundation. See also the maps which follow. States having no laws FIRE PROTECTION LEGISLATION FOR SCHOOLHOUSES No Regulation LAWS RELATING TO SCHOOLHOUSE CONSTRUc 1 ION IN EACH STATE IN 1912 (From " A Comparative Study of Public School Systems in Forty-Eight States " by the Russell Sage Foundation.) ^^6 EDUCATIONAL HYGIENE STAIR AND EXIT RULE OF NEW YORK CITY» (i) All school buildings of two or more stories in height shall have at least two stairways. The number and width of stairways shall be apportioned as follows: Four feet for the first 50 pupils and six inches additional width for each additional 50 pupils. Note. — The number of stairways shall be sufficient to permit of building being vacated in orderly manner within three minutes from sounding of signal. Most fires spread rapidly. Any longer delay may result in exits being cut off. (2) In estimating number of occupants for each story, an allowance shall be made of fifteen square feet of floor space per person per class- room. (3) Stairs shall not be less than four feet nor more than five feet in width between strings. The four-foot width for elementary schools is preferable. Width is fixed at four feet to prevent a third line of pupils without handrail support. (4) There shall be a handrail on each side. (5) No closets shall be placed under stairs. Where they exist they shall be kept empty and locked. (6) All stairs shall be enclosed in wire-glass and steel or other fire- proof partitions from top to bottom, access being by means of self- closing fire-proof doors. These doors are held open by fusible links. (7) There shall be an allowance made of fifteen lineal feet width of doorways for the first 500, and six inches additional width for each 100 additional, persons. These widths should be increased by 50 per cent if there be an auditorium on the first floor, or basement which has not direct exits. IF YOU ARE TO HAVE A NEW SCHOOL BUILDING (i) Employ an architect who knows what it means to erect a fire- proof building and then (2) See that his plans call for: (a) Fire-proof construction. (6) Building of not more than three, and if possible not more than two, stories. (c) If a large school, each floor constructed with fire-proof parti- tions, so that one section may be completely shut off from the rest. (d) Heating plant separated from rest of building by fire-proof walls, ceilings, and doors. (e) Assembly-room on ground floor. (/) Attic cut by at least one partition, to prevent draughts. * From a Sage Foundation pamphlet on fire prevention. SCHOOL SANITATION STANDARDS 337 (g) Stairs located at opposite ends of building, and leading di- rectly to exits. (h) Stairs built according to the "stair rule." (See above.) (/) Halls wide, well lighted, and absolutely free from obstructions, (j) Outer doors furnished with "panic bolts" which can be opened from inside by slight pressure. (k) Automatic sprinklers in storeroom and fuel-room. And then — (3) See that the building is constructed according to the specifi- cations. IF YOU HAVE AN OLD SCHOOL BUILDING (i) Transform stairs into fire-proof exits by following the rule given above. See that stairs lead directly to outer doors, even if their location has to be changed. (2) Make basement ceiling fire-proof. , (3) Abolish double doors. Substitute single doors, swinging out- ward, side by side, and equipped with "panic bolts." Absolutely prohibit fastening of any outside door during school hours. (4) See that ashes, waste paper, and other rubbish are placed separately in metal, self-closing receivers, and removed from building at close of each day. (5) See that building is equipped with: (a) Automatic fire-alarm. (b) Complete system of fire signals. (c) Signal connection with fire headquarters. (6) Require halls to be kept absolutely free from lockers, tables, chairs, and all other obstructions. (7) Insist on a fire-drill every two weeks. (8) The building must be as free from dust-catchers as possible. All interior v^oodwork should be without unneces- sary flutes and grooves. Fluted or beaded ceilings or wain- scoting, and much-decorated washboards and blackboard frames, are inadmissible. Picture mouldings are recom- mended, but they should be devised to catch little dust. Dresslar would eliminate them, but they seem desirable for non-sanitary reasons. The hospital ideal is not too good for the schools. Beauty need not be sacrificed but may be en- hanced by thoroughly sanitary construction. (9) Corridors may be a standard width of 14 feet in schools 338 EDUCATIONAL HYGIENE of several rooms. In the far West a new standard of having one-story buildings with classrooms on one side of the cor- ridor only is being advocated, and seems desirable for that climate in cities that will provide the necessary land space. All corridors should be well lighted, should have cement or light-colored composition floors, should be unencumbered with lockers or wardrobes, and should be provided with satisfactory drinking-fountains, preferably in "batteries" of four or more over a narrow trough close to the wall. The latter need not be as elaborate and costly as are frequently purchased. (10) All other flooring should be sound-proofed and made of close-grained hardwood or of rift-sawed pine. As soon as laid, the floor should be given, well rubbed in, two coats of boiling linseed-oil, in which one pound of parafifin to each gallon of oil has been dissolved. This coating closes up and protects the wood and provides a vitreous-like surface easily cleaned and hard to splinter. ^ (See later standards for clean- ing.) III. The Standard Classroom. Elementary Schools. — Standards for elementary classrooms have been gradually developed on the basis of present knowledge and theory until many of the features have been finally adopted by school officials in many parts of the country, especially by State boards of education and progressive school architects. Within certain limits there will remain considerable variation, es- pecially as our scientific knowledge of children and of sanita- tion increases. The classroom is the centre of the school. Here teacher and pupils engage for most of the time in that activity for which schools are primarily created. The san- itation of the classroom should therefore be as perfect as possible. We cannot give here the arguments leading up to each feature, nor a discussion of reasonable variations. A statement of a desirable norm only is attempted. 1 See the Springfield, 111., Survey for attention to better specifications and better supervision of construction. SCHOOL SANITATION STANDARDS 339 (i) Architects must provide one or more standard class- rooms for each school building. The standard classroom is the unit of construction. Instead of devising a building of a certain size and then putting in classrooms, they must reverse the usual process and provide the required number of standard classrooms and erect the building about them. With so many millions of dollars going each year into new school buildings, coupled with the fact that so many old schools are burning down, it seems that tliis country should soon ex- perimentally develop ideal buildings. Scientific study and expert school architects only are lacking to make the most of our opportunities, but they are surely, though slowly, coming. (2) Size. — The best size for an elementary classroom for about forty pupils seems to be, all matters considered: length 32 feet, height 13 feet, width 24 feet. This size has in consideration suflEicient lighting space, the carrying power of voices, distance for seeing and hearing, ease of class man- agement and instruction, ventilation, building economy, etc. The height may be reduced six inches and the length a foot or more, if desired. In high schools the height should be the same, but the floor area and shape must be variable.^ (3) Lighting. — In standard classrooms the lighting, meas- ured in area of window-glass, should be at least one-fifth to one-fourth of the area of the floor space. The floor area (24 X 32) is 768 square feet. One-fourth of this is 192 square feet and one-fifth is 153 square feet. This lighting should be from the left side only of the pupils seated, with few ex- ceptions later to be mentioned. Windows should reach to within five or six inches of the ceiling — the higher the better, since about one-third of the light comes in at the upper fourth of the windows. The windows, on the thirteen-foot wall, should not reach below a line three and one -half feet above the floor; should extend as far toward the rear of the room as 1 See Dresslar's "School Architecture," published by the U. S. Bureau of Education, for valuable data on high schools. 34<^ EDUCATIONAL HYGIENE possible (within eighteen inches) ; should not extend far enough forward to throw much light into pupils' eyes; and should have the narrowest possible piers or mullions between the windows, say one foot as a maximum and these bevelled. Round or gothic topped windows should not be permitted. In upper grades, the height from the floor may be four feet. This leaves an eight and one-half or nine-foot window in length. The width of the glass panes may well be about forty-two inches and height forty-five inches. Small panes are generally less desirable. Starting the windows with the glass of the rear window about fifteen or eighteen inches from the rear wall and leaving not over twelve inches between windows, glass to glass, for mullions and (steel) lintels, with nine-foot windows, we find that we can put in five such windows and get a glass surface of about one hundred and sixty square feet, leaving nine feet of blank wall at the front of the room. Not less than six or seven feet should be left a solid wall at the front. By reducing the width of windows three inches (to thirty-nine inches) six windows may be put in, giving a lighting area of about one hundred and seventy-five square feet. The latter is probably preferable in most cases. The use of a twelve and one-half foot ceiling is economical but makes nine-foot win- dows impossible except in primary rooms where the bottoms are only three and a half feet from the floor. ^ An increase in the width of the windows to four feet has been tried successfully in some schools. Such width helps to reduce the number of mullions between windows by one, and gives a lighting space of about one hundred and eighty square feet with five windows. This is almost ideal, but re- quires that the windows be well put in so they may be easily handled. This gives also a well-lighted blackboard, but 'Dresslar recommends this, however, in his "School Hygiene," p. 6i. The Sharp-Millar photometer is a good instrument for measuring actual illu- mination. Standard : three foot-candles at worst-lighted desk on a cloudy da}'. Dr. Fitz gives a new method of determining lighting values in the Proceedings of the Fourth International Congress on School Hygiene. SCHOOL SANITATION STANDARDS 34I teachers should not make a habit of standing near the front, window side of the room, in order to keep children from facing the light when looking at her. A door into the cloak-room at the front of the room on the lighted side makes it impossible to place a blackboard in this corner, which is an advantage from this point of view. It is injurious to the eyes to face windows, both for teachers and pupils; consequently there should be no windows on the front wall, and on the rear wall only when it is thought de- sirable for ventilation. If the rear wall is an outside wall, small windows placed high (eight feet from the floor), with their tops on a level with the other windows and with stained or other glass not admitting much light, may be used. This gives a window the size of the upper sash of the other win- dows. These half-windows may, however, be narrower, and should be hinged at the bottom and have a spring catch at the top. Light from the rear is good for the pupils but not for the teacher. It is possible to have such windows also on the right side of the pupils seated, thus giving light and ventilation into the corridor. These may well swing on a pivot and be controlled by iron levers. These extra openings are principally for ventilation, however, rather than for lighting. I have seen such "transoms" working admirably. Windows in rear or right-side walls need not be put in merely for the sake of outside decoration. Architects have de- vised many ways of beautifying blank walls where there are no windows. Artificial Lighting. — All classrooms should have arti- ficial hghting for use on very dark days and especially for evening use. If possible, electricity should always be used, and all buildings should be well wired when constructed. Gas-pipes should also be installed where gas is available. Acetylene lighting has been found satisfactory in rural schools where the other forms are unavailable. Much attention should be given to the proper placing of the various ceiling 342 EDUCATIONAL HYGIENE lights and to bringing sufficient light from the proper angle to all seats in the room. Where there are six rows of well-placed single seats, the front row of ceiling lights, say three in number, may be placed a little in front and to the left of the first desk near the window, the third desk from the window, and the fifth. The second row may be over the first, third, and fifth desks in the third cross row of seats, while the third row may be placed similarly just back of the fifth row.^ Window-Shades. — Most window-shades in schools are ob- jectionable, either because they are not translucent and so cut off too much light when down, or they are hard to manage, or they cannot be adjusted to diminish only the light which is too bright for the pupils' eyes. The Draper and other window-shades can be easily adjusted to cut out light where desired, and the plan of having the curtain roll at the bottom instead of the top, or of having two rolls at the middle, is to be commended. Ecru or light-tan color has been highly recommended. Dark green should be avoided. Light green or light gray may be used to harmonize with wall colors. The ideal is to get plenty of light without cutting off too much and without allowing the direct rays of the sun to fall on the pupils' work. 2 Wall Colors. — All walls should be smooth but not glossy, and painted with washable fiat paint in light tans, light greens, hght buffs, or light grays. A cement dado should take the place of the ordinary wooden wainscoting, and may be painted a darker color than the walls above. The ceiling may be nearly white in color. Great differences in light can be made by giving care to wall colors. In corridors, more white can be used without injury to pupils' eyes, and white tiling for the first four or five feet above the floor is desirable. *See Dresslar's "School Hygiene," p. 78. ''Doctor Ayres found in the Springfield, III., Survey that the illumination was kept below the standard of three foot-candles even on bright days, because teachers did not properly adjust the shades, and that windows covered with dirt and coal-soot cut off in some cases 50 per cent of the light. SCHOOL SANITATION STANDARDS 343 Blackboards absorb much light but can easily be covered by curtains, matching the wall color, which can be pulled down when blackboards are not in use. Such curtains function also in keeping work that the teacher puts on at intermission from the children's gaze until they are ready to work on it. Sliding blackboards have been invented. (4) Heating. — The standards for heating one or two room buildings are discussed in other chapters. The proper tem- perature for classrooms in this country is from 65 to 68 degrees. Rooms should be allowed to go above 70 degrees only on cold mornings while the building is being heated up. The air should be about half-saturated with moisture, say 55 per cent. No dogmatic and general standards can be made here for all sections of a great country like America, and for schools of all sizes from one to a hundred rooms. Hot-air furnaces for small schools of two to six rooms are in some cases desirable, especially in the places where there are mild winters. Hot-water heating has many advantages, but is slow, and not desirable for the more northern schools, perhaps. Steam-heating is growing in favor in all of the larger schools. It works well with a fan (plenum or exhaust or both) system of ventilation, l^hen we have the air entering the rooms slightly heated and the air heated indirectly by radiators also, we have what is called the very common and desirable "di- rect-indirect" method of heating schools. (5) Ventilation. — ^The problem of furnishing 40 or more children, seated for hours at a time in a single room contain- ing less than 10,000 cubic feet of space, with a sufficient amount of fresh warm air without draughts is one of the most serious problems of school sanitation. Two movements tend to disturb our standards in this field at the present time: The open-air-school movement has brought a great emphasis on obtaining outdoor conditions without great discomfort, and a wide-spread discontent with current methods of ven- tilation. Secondly, the numerous scientific studies and ex- periments of recent years have fairly well proved that it is 344 EDUCATIONAL HYGIENE not the lack of oxygen, or the excess of carbon dioxide or of organic particles that makes schoolroom air unfit to breathe, but that it is improper temperature, lack of variation in temperature and movement of the air, and lack of humidity that cause the bad effects. These two beliefs have led to two principal applications: furnish less heat and make classrooms into fresh or open air rooms, and, second, make classrooms into closed-air rooms, and by the use of return ducts and careful air- washing and humidifying return all air to the class- rooms, thus making it recirculate over and over again. Not counting the initial costs of any changes in windows or the purchase of bags for the children to sit in in cold weather the open-air room is evidently more economical than the fan system, saving very much in the way of coal. Likewise, overlooking the cost of return ducts, air-washers, and closing up of cracks, the recirculation of the air for given lengths of time is very much more economical than the pres- ent systems, which heat up a lot of air and then force it out almost immediately in the effort to get proper ventilation. Experiments made at Springfield, Massachusetts, and else- where indicate a saving of about 40 per cent in fuel. The air is cleaned, made moist, and is used for a half-day or so at a time without change. It is claimed that the air is unobjec- tionable by this method and that it is even better than the outside air, being free from dust. By bringing such air into the rooms near the pupils' faces, as in the Minnesota experi- ment,^ and by varying the velocity occasionally, coupled with arrangements by which rooms are occasionally flushed with fresh outdoor air, it seems that we have here the beginnings of an economical method quite different from the one so long employed where we have tried to heat up and push through schoolrooms and on outdoors 2,000 cubic feet per minute per classroom. We must await further experiments and tests • See address by Professor Bass in the Proceedings of the Fourth Interna- tional School Hygiene Congress, also addresses by McCurdy, CJulick, and others. See also articles by Kimball and W'inslow in Science for April 30, 1915. SCHOOL SANITATION STANDARDS 345 along this line. Perhaps the open-air method can in the future be employed in mild and warm weather and the re- circulation device utilized in cold weather.^ Open- Air Rooms. — Another chapter deals with open-air rooms and schools. The proper construction of windows for such rooms is still in the experimental stage, although such bodies as the Boston Schoolhouse Commission and others have given the matter much study and have succeeded fairly well. The Oakland School-Building Inquiry recom- mended that "in each new building there shall be at least one open-air schoolroom that cannot be entirely closed, preferably opening to the east. In all new buildings there shall be pro- vision made whereby every classroom may be easily trans- formed into an open-air room, such transforming measures not to be under the control of teachers and pupils." One plan that has seemed to work has been that of making the entire window in one sash and hinging this at the top so it can be pulled inward and upward by a strong cord and fastened. Many other plans are being used. Common Methods of Ventilation.- — Three common methods of ventilation are in vogue: window ventilation, gravity ven- tilation, and mechanical ventilation. Most schools of our country use the first method but with notoriously poor re- sults. Little attention is paid to ventilation in most homes, since there are so few persons to a room, since all are free to move about, and since enough air frequently slips in at cracks and through walls to supply fairly well the needs of ventila- tion, although there is probably also a great lack of proper ventilation in many homes, especially in sleeping-rooms. Most schools have in the past been provided \vith as little means of proper ventilation as most homes, but the conditions are entirely different, especially in the great number of per- ' See chapter on the " Physiology of Ventilation" in Terman's "The Hygi- ene of the School Child," Hill's pamphlet on "The Relation of the Atmosphere to Our Health," published by the Smithsonian Institution, Washington, D. C, and Kimball's articles in the School Board Journal for 1914-15. 346 EDUCATIONAL HYGIENE sons from different families that are here collected together to remain relatively fixed in stationary seats. Teachers are typically young women without a professional education and with little training or knowledge of ventilation needs and devices. They must study and be trained along these lines. Window Methods. — Windows should be opened and the rooms flushed out with outdoor air at all recesses and inter- missions. Further, teachers and pupils need not be afraid of fresh air in classrooms. By keeping on more clothing than in a seventy-degree atmosphere teachers and pupils can easily and quickly accustom themselves to almost outdoor con- ditions even in cold weather. They usually profit by it, be- coming enthusiastic champions of fresh air. Draughts should be avoided when they strike directly on pupils. Window- boards six inches in width and the width of the window in length may be placed beneath the window in such a way as completely to close up the space at the bottom of the window but leave a space between the sashes in the middle of the win- dow where the air will come in when it is colder outside than inside, without a draught on any pupil. Such boards are awk- ward to remove unless they are cut into and hinged in the middle. Any boy can make one for each window in a short time or, better still, a group of boys can make them co-opera- tively. If too much light is cut out by this method, upward and inward slanting glass deflectors may be used. Dresslar de- scribes three kinds in his article on "Ventilation" in Monroe's "Cyclopedia of Education," volume five. Teachers should study the matter even where they have gravity systems of ventilation. Iflri the middle of a period the room gets foul, the children may be given calisthenics or marching, or may be sent to run around the house once or twice, while the room is being flushed. The teacher must cultivate a sensitive nose for bad air and remember at all times that the tendency is to get gradually accustomed to poorer air as a period goes forward. Gravity Systems. — Differences in weight of warm and cold air make possible in cold weather, when windows cannot well The Austral window, showing method of venlilatinK without drafts SCHOOL SANITATION STANDARDS 347 be opened without draughts and heat-expense, systems known as gravity systems. They are generally not ejSicient enough for schools except in the coldest weather, but must be used in all small schools where forced, mechanical draughts are out of the question because of the expense. The jacketed stove has been described in the chapter on "Rural School Sanita- tion" by Mr. Monahan. Heat within the jacket and heat in the chimney about the aspirating or outlet duct for foul air causes the air to rise and spread in the room and to be forced out by the colder air coming from without through a flue passing under the floor to a vent within the jacket of the stove. Care must be taken to insure that the fresh air brought in is not that from under the building and that the opening to the outside is covered with a screen. The hot-air furnace is another gravity system. The fur- nace is usually placed beneath the floor in the basement and has a flue bringing in outside air and other flues or pipes taking the air up to the room or rooms. The fresh air coming from the furnace should enter the room on an inside wall if possible and about eight feet from the floor. All persons putting in such devices should get expert advice from either the State department of education located in the capital city or from the United States Bureau of Education at Washing- ton. This applies to most sanitary features, especially to the plans and construction of the school itself, and is about the most valuable recommendation of this entire chapter. Get expert advice and save for years to come not only the money of the community but its comfort and health. Mechanical Systems of Ventilation. — This plan does not depend upon gravity alone but puts a fan into the system to force the air into the rooms, the plenum system; and fre- quently adds to this in large buildings another fan near the top of the building to blow the air out, the vacuum or exhaust system. Where the upper fan is omitted, a feature of the gravity system is sometimes added in the form of small steam coils in the foul-air flues to heat the outgoing air and make it 348 EDUCATIONAL HYGIENE rise faster. Generally the plenum fan or blower in the base- ment is sufficient. Accepted standards for such ventilation require at least thirty cubic feet of air for each person in the room per minute. The air should enter the room at a height of eight feet above the floor through a vent about two feet square. If a grating is placed over this inlet it should be of such small cross-bars as not seriously to retard the air. It should also have de- flectors attached to throw the air upward and toward all parts of the room. The speed of the entering air should not be more than 400 feet a minute as measured by the anemometer (a small fan wheel connected with a clock-like recording arrangement to measure velocity). The ducts to each room of forty pupils should be at least four feet square in cross-section, so as to keep the velocity within them down below 600 feet a minute. The entrance duct may be at the front of the room and the outlet duct (four square feet in area) at the floor in the same wall, with another outlet six to eight feet above the floor in the cloak-room behind the front wall of the classroom. The air can be made to reach the cloak-room by placing openings in the bottom of the doors leading from the classroom to the cloak-room. Such an arrangement helps to dry and aerify the clothing. Long hooks far enough apart should be used to keep the. clothing from contact, and open for drying and aeration. This cloak-room should be about six feet in width and should have no door leading into the corridor. A large window should light it well, and drip- troughs for umbrellas and pigeonholes for overshoes should be provided. The fan or blower in the basement should be noiseless and should be large enough to provide an ounce of pressure without running more than three hundred revolutions per minute.^ The fresh air should be taken from a point where there is little dust or smoke, which in cities is usually high in the air above the roof. If the air is still dusty or smoky it should be washed ' Professor Caswell Ellis in the School Board Journal for September, 1913. SCHOOL SANITATION STANDARDS 349 before entering the rooms. Numerous devices for air-wash- ing have been devised, about the best at present providing for passing the air through a stream or "rain" of water dropping from small holes in a pipe across the passage. Pro- fessor Whipple, of Harvard, has made a number of very valu- able experiments in this field. Such an arrangement if properly- put in may provide sufficient humidity to the warmed air also. The standard for humidity is about 55 per cent saturation.^ Steam pans, as in the Horace Mann School, Columbia Uni- versity, work very well as humidifiers if large and well regu- lated by automatic devices controlling both temperature and amount of moisture, but do not clean the air appreciably. A great fault with most such systems is that janitors persist- ently overheat ("cook") the air. It is doubtful if the air should ever be hotter than 65 degrees Fahrenheit in the fan- room of the basement, and very little warmer when it enters the rooms. The radiators principally should be depended on for heat. The air should be kept as cool as possible consistent with comfort. Provision should be made whereby the air may be shunted at times into the ducts without passing through the heat coils across the entrance to the fan-room, thus mak- ing it possible to get fresh .outdoor air at physical training or other periods. In the writer's own experiments a hinged screen was thrown in front of the coils and a door at the side opened into the fan-room to let the fresh air directly into the fan. The air velocity of all rooms should be measured once or twice a year or whenever a room seems to be getting too much or too little air. The supervisor of hygiene may do this or teach principals how to do it. The velocity of the incoming air should be taken as the average of several measurements at 1 The sling psychrometer, or hygrometer, especially the one made by Max Kohl, is a good instrument for measuring the percentages of moistures. Tables must be used, however, to calculate the amount. The best simple instrument which dispenses with calculation and can be read directly is the hair hygrom- eter, as easily read by a teacher or pupil as a clock. (Made by the Central Scientific Co., Chicago.) 350 EDUCATIONAL HYGIENE several points on the four-square-foot surface of the mouth of the duct. This average velocity for the whole area should be multiplied by the area in square feet to get the quantity entering for a given length of time, say thirty seconds. This product divided by the number of pupils and teachers in the room will give the average amount coming in for each person. (6) Blackboards. — Blackboards should be of slate, al- though glass and composition boards are being slowly per- fected. In the standard classroom, blackboards will be placed on the rear, right, and front walls. They must be written on by both teacher and pupils and should conse- quently be wide enough to meet the needs of both. The front board may well be 5^ feet wide, the others 4 feet, or perhaps 3^ feet, to avoid as much light-absorption as possible. In primary rooms the bottoms of the boards should be not higher than about 26 inches from the floor, and in upper grades and high school about 30 to 38 inches above the floor. The increase in height may be graded between these ex- tremes. Hard, dustless chalk should be used, and wire hinged screens should cover chalk troughs. Curtains on rollers of a light color may be used, as suggested, to cover boards when not in use, in order to prevent light-absorption. Soft, dustless erasers should be used and these should be cleaned once a week or of tener by the janitor or other persons. Where there is a vacuum-cleaning system, erasers furnish no problem. Dresslar in his "School Hygiene" gives several good sugges- tions along this line. (7) Water. — Some have set the standard of hot and cold running water in a fixed bowl in every classroom or cloak- room, and certainly this will come in all of the most sanitary schools. Pupils need plenty of water to drink and they need to keep clean. Drawing and other forms of work require water and some forms make pupils dirty enough to require washing. Where the basin is located in the cloak-room the floor may be made of the same composition as that of the corridors — ^cement, tile, asphalt, or composition. The cold- water faucet should be equipped with a sanitary drinking- Moulthrop school desk-chair, adjustable and movable, new style The "panic bolt" illustrated in frontispiece SCHOOL SANITATION STANDARDS 351 fountain. Rural schools may now have drinking-fountains, as shown in another chapter. Common cups and individual cups should go. Common towels should also disappear like the old feather duster. Paper towels are now cheap and efficient enough to be provided all children. Real sanitary habits can- not come without them. Soap may be supplied in liquid form from automatic containers. Health habits cannot be developed with no opportunity to practise health acts. Anti- Typhoid Mary habits come with exercise. (8) School Desks. — School desks are in a transitional stage also. They should provide for different types of work than formerly, e. g., manual training; they must be individual; they must be adjustable, seat and desk; they should be thor- oughly sanitary (neither dust-catchers nor hard to clean under) ; the tops should be adjustable for writing, reading, and manual work; and many are now demanding that they be movable on the floor. The Moulthrop school chair, a combined seat and desk, is about the best type that at the present meets the last and several other of the standards. The top can be tilted to hold a book while a pupil is reading or singing, and it can be moved forward and backward and up and down. The seat part is not yet made adjustable but is made in dif- ferent sizes. These chairs can be moved by pupils to any part of the room, as the teacher or janitor wishes. For a seat screwed to the floor, as few legs to interfere with sweeping and cleaning as possible should be provided — one for each pupil, instead of four to six, as is customary, if possible. The single-pedestal combined desk and seat meets this requirement well, the base being a large oval (front and back), closed iron standard. Such desks must be well put down to avoid wiggling by the pupil on the seat in front. Dresslar gives twenty-one excellent standards for school desks in Monroe's "Cyclopedia of Education," which should be observed in every schoolhouse. IV. Cleaning and Sanitation. — Cleanliness is the first principle of sanitation. Since most diseases are caused by germs and since these are best eradicated by cleanliness, we 352 EDUCATIONAL HYGIENE have a fundamental law of school sanitation: Keep every- thing as clean as possible. First, we must have clean chil- dren with clean clothing and clean and filled teeth. This requires tactful work on the part of school-teachers and nurses, and co-operation on the part of parents. There must inevitably be provided in many places school baths and free school dentistry. Habits of personal cleanliness at the school must be inculcated persistently, such as cleaning the feet thoroughly on mats and scrapers provided, before entering the school, using a handkerchief (some teachers and nurses have used handkerchief as well as tooth-brush drills), bathing at least once a week, washing thoroughly before coming to school and at school when necessary, etc. Hot and cold water in stationary bowls for washing, paper towels, and liquid soap are requisites, especially in toilet-rooms. Second, the school must be in a clean location with clean air, walks, and yards. Third, the janitor must be trained to do his work in the best way. Feather dusters and dry sweeping should be abolished. Vacuum cleaning should be provided wherever possible. Floors should be oiled with a light oil several times during the year, thoroughly rubbed in and then carefully wiped off. Where there are no vacuum cleaners, oiled-hair filter brushes should be used instead of brooms. Every janitor and teacher should know how to make damp or oiled sawdust for sweeping, and teachers should demand that such a sweeping compound be used to keep down dust. Dusting should be done with a damp or oiled cloth, never with a dry cloth or feather duster. All floors should be swept daily and windows should be washed often enough to keep them clean, at least three times a year. Blackboards should be washed once a week. Toilet seats should be scrubbed daily. Floors should be scrubbed frequently if they are not oiled. Strange to say, floors may be scrubbed with oil and the floors kept fairly white and clean after years of oiling. As a principal I once had the teachers vote on the oiling or scrub- bing of floors. They voted for scrubbing without the use of SCHOOL SANITATION STANDARDS 353 oil, but in a month or two voted in again the use of oil. The janitor knew how to put it on and how to remove the part not absorbed by the wood, so skirts were little injured. The oil kept down the dust and kept the floor from wearing. Third, the promiscuous use of pencils should be abso- lutely prohibited. One or two outbreaks of diphtheria and other diseases have been definitely traced to this pernicious custom this year. It is hoped that medical supervision will permanently kill this practise. If possible, pencils should never be collected together, not even in numbered recep- tacles, and pupils should be taught to avoid putting into their mouths the pencils of others or anything else another person has had in his mouth or possession, with few exceptions. School-books are not put into the mouth very much but should probably be steriHzed occasionally by heated moist air. Rules along this line can be worked out by the super- visors of hygiene.^ V. Sanitation of Special Rooms and Features. — The above principles apply fairly well to all rooms. Toilets furnish a perpetual problem in this respect. Some of the newer build- ings of Chicago and other cities have developed the tower construction for toilets, one toilet on each floor for both sexes, for pupils and for teachers. The towers provide separate ventilation and privacy, and seem a desirable invention. Many of our best city schools are taking the standard of a toilet-room for both sexes in connection with each class-room, so teachers may have better control, and so the usual mixture of all children from all rooms will not need to congregate to- gether. The best practical plan for most schools at present is to have dry, well-lighted, and ventilated basements for the large toilet-rooms and to have smaller ones of one stool each on each floor for both sexes. Separate exhaust fans for toilets are necessary in large buildings. The number of toilet seats needed is standardized at ^ See " Man and the Microbe," by Winslow, in the Popular Science Monthly for July, 19 14. 354 EDUCATIONAL HYGIENE about one for each fifteen girls and one for about each twenty- five boys. One urinal stall for each thirty boys will be found sufficient, if the younger pupils are dismissed earlier than the older and the janitor supervises the toilet-room. The standards given by Dresslar in Monroe's "Cyclopedia of Education" are here again recommended. In conclusion, let us steadfastly keep a scientific attitude of mind in establishing and using school sanitation standards. Carefully controlled research and experimentation is the only true method of advance. CHAPTER XX 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 more 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 chapter XI on "Rural School-Health Administration." 355 356 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 357 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 famihes 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 Httle 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 supplies, 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; 358 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. 1 See bulletin on " Consolidation of Rural Schools and Transportation of Pupils at Public E.xpense," by the writer. (Bureau of Education, Washington, D. C.) RURAL SCHOOL SANITATION 359 (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 360 EDUCATIONAL HYGIENE injury it does cause eye-strain and headache, and renders the cliildren 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 ceih'ng, 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 uneven 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 SANITATION 361 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 I COLO AIR DUCT ■ WATER TANK AOO.CAL DRYING ROOM %J QCASMUCR DYNAMi (~ )WATtR COOLER 4YMNASIUM l2)tX23 » --VI «iR PRCSSURt/ MACHINC . 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, 362 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 A model consolidated school building The old single-room rural schools are rapidly being abandoned, children being transported in school hacks to consolidated schools Part of the basement of a renovated rural school Note end of pressure-tank, sink, drinking-fountain, and wash-bowl From Dresslar's " Rural Schoolhouses and Grounds " RURAL SCHOOL SANITATION 363 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 suffi- ciently even temperature and supply every part of it with fresh air. Mere shields of iron to protect the nearest pupils i — m CASOLINC SANITABV ^ Q ^WASH BOWL _4S XZOr SKV LIGHT ATTIC PLAN "ST side 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. 364 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. SprinkHng the floor is effectual in preventing the Looking into library and cloak-rooms of the Cross Roads School From Dresslar's "Rural Schoolhouses and Grounds," U. S. Bureau of Education Corner of kitchen, rural school in Louisiana RURAL SCHOOL SANITATION 365 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 mud 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 366 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 underlying rock strata are often not parallel and many times are found 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- Sanitary drinkin^-fountains for rural schools \ RURAL SCHOOL SANITATION 3^7 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 five 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- fountain can be purchased for from $ioo 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 368 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 I RURAL SCHOOL SANITATION 369 jW^ 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 sun 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 lique- 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 " 370 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 pro\dded 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. Tliis 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 37 1 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 difhculty 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 sohd 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 settlings 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 fives, but because of the direct and indirect 372 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 important: MINIMUM SANITARY REQUIREMENTS FOR RURAL SCHOOLS > 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 official 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 373 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 and 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. II. 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. {b) 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 1 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. 374 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 16 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 375 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 not 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. (o) No dry sweeping or dusting should be allowed. {b) 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. 376 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. (/;) 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 difTerent directions from the school- house, with the entrances well screened. ((•) 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 377 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 efificient 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. 378 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. (h) 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) EfTective 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 efiiciency, should co-operate with the rural school. (g) Attractive but reliable 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 379 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 towels. 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. III. PHYSICAL EDUCATION CHAPTER XXI PLAY AND PLAYGROUNDS IN CITIES The Problem. — Every one is familiar with the fact that the modern city has greatly restricted the natural play op- portunities of the children. The recognition of the need to restore opportunities to city children by providing municipal playgrounds has been one phase of a more general recognition of the nature and significance of play itself and its relation to child welfare generally. It is the purpose of this chapter to suggest how play is an essential in child development and education, and how it may be utilized. Common Misconceptions Concerning Play. — At the out- set of this discussion of play and playgrounds let us attempt to clear away some common misconceptions concerning play. (i) Contrary to the common idea of play, play is serious. Children often make their games the object of their prayers. And not children only, for young men have done the same, in manner hardly different from that of Washington kneeling at Valley Forge. Players, both children and adults, come at their play frequently in all seriousness. But play is regarded seriously also by those who are not the players, as every observer of the followers of a favorite team can testify. Plato and Froebel, as we all know, regarded play as serious. Guths Muths, the father of play in Germany, said, "Pro patria est, cum ludere videmur," and the regeneration of Germany is recognized as having been influenced greatly by the revival of play under Guths Muths and Jahn. Pro- 380 PLAY AND PLAYGROUNDS LN CITIES 381 fessor Dewey says: "Because amusement is contrasted with serious things, we have forgotten that the function of recrea- tion, of the spending of the hours of leisure, is one of the most serious questions, intellectually and morally, of life.''^ Play contributes to human progress. Biologically consid- ered, play has doubtless been the largest element in human advancement. Acting like an instinct, it has conserved the essential powers of the race and impelled activities to more complicated and efficient forms. On the other hand, play has doubtless contributed to decadence when prostituted into evil channels. Professor O'Shea has cited the effect of un- desirable forms of play on the decay of nations, and warns us that, when the absorbing interests of youth follow undesirable forms or become excessive, decadence begins. There is no greater national concern than what and how the people play. In this connection it is of interest to note the path of prog- ress of play as it has expressed the tribal or national con- sciousness. Many games and dances, as is well known, originated in some religious ceremony. Some of the festival customs of to-day, for example, have come down through the Roman ferice. the Saturnalia, and the barbaric festivals of the Middle Ages. Gradually there was lost the ceremonial significance. Festivals and games became barbaric as in the horrible ludi of the Colosseum, the barbarism persisting even now in some sections of the world in bull-fights, prize-fighting, or demoralised football. But, on the whole, the heroic games of to-day are, as Beulah Kennard has said, civilized. Even boxing, according to Maeterlinck, has become the "acme of convention." No one in decent circles could remain an acceptable boxer who did not adhere most rigidly to the recognized social standards of the game. Our national game of baseball, the most striking national play interest of the world of to-day, has in the great leagues become in standards fully civilized and holds unprecedented confidence of the public for honesty and good sportsmanship. 1 "Play," Monroe's "Cyclopedia of Education." 382 EDUCATIONAL HYGIENE (2) Contrary to the common idea also, play is concerned with result and not with activity only. In such play as nutting, hunting, fishing, and construction the player is often greatly concerned with the product or result of the activity. Likewise the increased skill of the player, or the honor of victory, or the prestige of success, is scarcely less a real ob- jective result or less an ulterior purpose than is the success of the man or woman in public life. (3) Play is not always pursued just for the fun of it; that is, play is not always and continuously pleasurable. Play is often painful. Boxing, wrestling, rowing, racing, football, and nearly all hardy games are often accompanied by pain. It is significant that our word "agony" comes from the Greek word a^ycovia^ the word used to designate the public games and contests of the Greeks. No one who has seen the models of the faces of athletes by Doctor R. Tait McKenzie can fail to get a suggestion of the agony which a runner often en- dures in a race. Play courts the difficult and the heroic, and not necessarily the soft and the easy. (4) Contrary to the idea of many, play can he taught. While there are many forms of play that are pursued as instinctively as birds build nests, yet the more complicated forms of plays or games have to be taught. According to Culin and E. B. Taylor, probably no games are played to-day the rudiments of which, at least, have not been taught from generation to generation ever since the building of the Eg>'p- tian pyramids or earlier. It is by the teaching of play only that play traditions have endured, or games developed into their present form. It is evident that without teaching the boys of to-day would be no more likely to play the American game of baseball than were the children in the streets of Beni Hassan four thousand years ago. The "teaching of play," in the modern sense, is at most only changing the teacher from a child to an adult, from a novice to an expert. From the above it will be seen that characteristics com- monly supposed to belong to work only, belong also to play. m^ PLAY AND PLAYGROUNDS IN CITLES 383 Many excellent educators fear that the emphasis upon play may weaken the capacity of the child for work, and make it less possible to harness activity and direct it toward the ac- complishment of definite ends. This is a groundless fear, be- cause in many cases play lends itself to definite ends much better than work. It is almost hopeless to try to discover any exact differentiation of play and work, because the dis- tinction lies so often in the subjective attitude of the indi- vidual alone, and the very same activity becomes play or work by some subtle shift of the point of view. However, it may be said that the more work takes on the character- istics of play the better. Brinton has well said : ''The measure of the value of play is the amount of work there is in it; and the measure of the value of work is the amount of play there is in it."^ Why Children Play. — Without entering at length into a discussion of the nature of play, it may be briefly stated that all plays and games are imitations or repetitions of types of activity that have been followed in the development of the race. Further, it may be stated that the play of animals varies according to the structure or physical characteristics of the animals. The play of puppies and the play of kittens, for example, differs as the structure of their bodies and nervous systems differ. Dogs in their play run, chase, and tear, or cling with their teeth more than cats. Cats in their play stalk, scratch, and strike with their paws more than dogs. These differences coincide with the differences both as to the structure and the experiences of the animals. Now, some biologists tell us that the structure of the cat's paw and that of the dog have come about in each case through the differ- entiation of activities pursued by the cats and the dogs of previous generations. Function, they say, determined struc- ' For further discussion of play and work the reader is referred to Carr's "The Survival Values of Play," University of Colorado Studies; Dewey's "Play," in Monroe's "Cyclopedia of Education"; the author's "Play versus Work in Education," Proceedings of the National Congress of School Hygiene, J913; and Curtis's "Play and Recreation" and "Education Through Play." 384 EDUCATIONAL HYGIENE ture. To illustrate: the ameba has four functions, namely, nutrition, locomotion, sensation, reproduction. Yet it has no special organs. It eats, digests, and assimilates food, but it has no organs of locomotion; it responds to stimuli but it has no nervous system; it reproduces its kind but it has no organs of reproduction. As we go up the scale of life we find these same four functions and no more. But there is a tendency in nature always to do things better and better, and special organs gradually developed. These biologists, therefore, formulated a law, namely, that function determined structure, that doing fashioned the organ that does the doing. For example, so they believe, the structure of the human hand and the structure of that part of the nervous system controlling it differ from the structure of the hand and of the corresponding part of the nervous system of the ape because of what the hand of man has done. The increased function of the human hand over that of the ape has deter- mined its distinctive structure. Thus the various and marvellously complex organs of the human body, according to this view, developed through dif- ferentiation of function. The law holds good also, they thought, when function diminished. Structure then deteri- orated, as illustrated in the vestigial organs of the human body such as the notorious and nefarious appendix and the muscles that once moved the ears or nose. There are other biologists, however, who believe that structure preceded rather than followed function. Accord- ing to these (and they seem now to be having their inning) structure was determined in the germ plasm and not at all directly through exercise or experience. Their proposition is the converse of the other, namely, structure determined function. Now, both these propositions are of great interest to the student of play, for each suggests one and the same cor- ollary, namely, structure demands function. It does not matter materially to us whether nature first created a struc- PLAY AND PLAYGROUNDS IN CITIES 385 ture and then found a use for it or first found a use and then created a structure to meet it; whether the ancestors of the wart-hog, for example, developed callosities on'their knees by kneeling as they rooted for a living or took that advantageous position because they were born with callosities on their knees. In either case we come face to face with the fact that when in the course of generations structure has been de- veloped, or mutations and variations in structure have by selection come about, in each succeeding generation this inherited structure demands its appropriate function. During the long process of evolution the great complexity and inter- relations of the members and organs of the human body and nervous system have been developed through function or through variation and selection as the case may be, and as each organ evolves through the various stages of immaturity toward maturity there is at every phase of its development, under the physiological condition of good nutrition and ap- propriate stimuli, an impulse, a hunger, a passion, for the same general kind of activity or function that determined, or accompanied, the corresponding structure in the species. There are infinite manifestations of this craving for func- tion. When a blind child stands before the window and flickers his open fingers before his face, letting now the light, now the shade fall upon his sightless eyes, he is trying to satisfy the craving of the optic nerve which has been cheated of its appropriate function. When the idiotic child sits through long hours, with arms folded upon a bench before him, and beats his head upon his arms with insatiable zeal until great calli are formed upon his wrists and forehead, he does it in response to this craving for function. When the infant smiles into its mother's face, or grasps with its chubby hand and kicks, or coos, or strives to lift itself for freer vision of light or shadow or color or object, or listens for a sound, or creeps, or climbs, or handles, or tastes, the same law is manifest. When the child responds to the awakening power of speech, or of memory, or of strength of limbs, or of 386 EDUCATIONAL HYGIENE appreciation of companionship or of social relations, or of reasoning, or of expression in different forms, or of leader- ship, or of organization, again we see structure demanding function. When a lad of the streets snatches and runs in the hope of being chased ; when he stones cars or windows or pries open a door in the freight-car; when he pilfers trinkets and stores them in a rendezvous, or, inspired by a nickelodeon, breaks and enters a store for mischief; when he joins a gang; when he steals lumber and builds a hut and plays cards and gambles there with the gang, the law of structure and func- tion still holds. When the "spirit of youth" seeks the "city streets," or a youth the company of a maiden, or a young man the warmth and brilliance of the saloon, or the colored lights of the city where he would not be seen, here also, in its last analysis, is a response to this same deep-seated craving for function. When a mature man or woman strives for some desired achievement in society, politics, literature, art, or religion, or seeks for personal power or wealth or fame, the same law holds. Play is, as James said of instinct, the cor- relative of structure, it is that for which man is structurally predisposed. To our forefathers it was "original sin." To us it has as good a right to be "original virtue," The educational significance of this is apparent. If the play interests have their genesis in structure and if, in the case of the young, the development of structure or organ depends upon its receiving appropriate exercise, especially during the period of growth, as is now generally believed, the educational value of play in conserving and developing hereditary powers is apparent. One need not say with Groos that the young play in order to prepare for future serious oc- cupations, or with Hall that the young play in response to inherited memory of past experiences of the race. One may rather say that play is the normal functioning of structure in accord with its own peculiar nature and needs. Play is of the present rather than of the past or of the future. Its existence may be explained by the past, its nature may be a PLAY AND PLAYGROUNDS IN CITIES 387 prophecy of the future; but play is essentially a manifestation of the present life and present nature and present needs of the organism. Yet play does educate, does prepare for the future, for the mature man has no powers or interests or oc- cupations that are not based upon past powers or interests or occupations of the race and that do not in the fulness of time appear in prototype in the plays and games of child- hood or youth. So far as education is concerned with the development of right interests and powers, play is the line of least resistance, least fatigue, greatest plasticity, and greatest interest and intensity.^ So far as these interests and powers can serve social ends, play, not work, remains logically and naturally the most efficient means of education.^ Play and Health. — The relation of play to health, there- fore, is obvious. From ameba to man the essential conditions to life and health have been few and plain. Through all the ages of that slow ascent, but with varying emphasis, there have been food, air, sunshine, exercise. Upon the supply of these in proper kind and amount depends the health of ameba, worm, fish, bird, dog, or man. Omitting the first of these for obvious reasons, let us con- sider the importance of each of the others in child hygiene and the ofhce of the playground in supplying them. Air. — The playground is the only place where a school- child gets air in the proper amount and kind, the only place where he obtains full and complete aeration of the blood. A despicable fraction of schoolrooms have standard ventilat- ing apparatus, and the rooms that have do not always ade- quately benefit thereby. I have personally tested a score of schoolrooms almost under the shadow of the capitol of a State that has the best of existing laws, and found the supply of air to equal the standard in only two of the rooms, and in some it fell to less than one-fourth of that amount. But even could ventilation be perfect in a schoolroom, ' See Carr's " Survival Values of Play," University of Colorado Studies. -See also "Games," Monroe's "Cyclopedia of Education." 388 EDUCATIONAL HYGIENE there would not be the same aeration of the blood in a seated studying child as in a child on the playground. There must be the exhilaration of joyous exercise, the strengthened pulse, the quickened, deepened breathing, the full chest of sustained effort, that drives the air to the very apexes of the lungs, to meet the needs of the growing child. The school- room may be made less and less objectionable, but so long as it remains a schoolroom it cannot escape the imperative need of the playground as a factor in school hygiene. As is well known, it is not only the lack of oxygen but also the presence of organic poison in exhaled air that makes ventilation so important. It is a fact noted by biologists that all animal life excretes a poison destructive to itself. This is as true of the single-celled animal as of higher life. Bacteria may thrive luxuriantly for a time in culture media, but if they are not transferred to fresh culture media they pass into a period of lessened activity and finally die poisoned by their own excretions. A child's body is an accumulation of a vast number of cells, each of which by its very functional activity likewise excretes products so poisonous to itself and the system generally that accumulation beyond a certain limit results in death. Now, nature has gradually placed more and more emphasis upon this cleansing process. If you trace the evolution of the vital organs from the single cell to man, you will find a general increase in the number of the excretory organs. The newer organs have developed as supplementary to the older, and all together they form a co-operative system, a weakness in any part of which places an added burden on the rest. Nature here gives us no uncertain hint as to the needs of the child. Playground activities not only purify the blood through the increased activity of the lungs in the pure air out-of-doors, as the activities of the school cannot do, but also stimulate the healthful activity of all the excretory organs, preserving a well-balanced system. The most recent ventilation hypoth- esis, that not the composition but the condition of the air PLAY AND PLAYGROUNDS IN CITIES 389 is the important feature, strongly reinforces the need for outdoor playgrounds, for here change, temperature, humidity, and freedom from dust are generally superior. Sunshine. — "Where the sun does not go, the doctor does," is an Italian proverb quoted by Koetelmann. Try as we may, we cannot get the sun sufficiently into all our schoolrooms, and if we could we would shut it out again as soon as we let the children in to study, because, we say, it hurts their eyes. Where, then, shall the children bathe in the sunshine as they should but on the playground? We do well to debar contagious diseases from the schools, but let myriads of bacilli fly over our children's clothing and the most malig- nant will in a short time, in the joy and the sunshine of the playground, perish. Few disease-germs have been discovered that can survive even for one hour the streaming sun on the face of a laughing child. You remember the experiment with the tadpoles. They were placed away from the sunlight for thirty days and during all that time ceased to grow. Returned to the sunlight, they resumed their growth and advanced further in one day than in all the previous thirty. Placed once more away from the sunlight and again returned to normal conditions, they grew to stunted froghood. Just such an experiment society tried with babies in the dark rooms of New York's tenements, and every baby, almost without exception, born and kept in those rooms died. But when Jacob Riis and others tore down the windowless walls and the light of heaven streamed in, the babies began to live. In our cities and larger towns everywhere we are still repeating, in a measure, the same experiment, and place our children, like the unfortunate tadpoles, in darkened homes, in narrow, shaded, and smoke-enveloped alleys, and in school- rooms into which the sun seldom if ever enters — nay, often in schoolrooms lit even in the middle of the day by natural or artificial gas! Bring to these little ones medical inspection, examine their eyes, remove their adenoids, protect them from 39© EDUCATIONAL HYGIENE measles and all the rest, but shall we not also provide a play- ground where for a part of the day they may bathe in the sun as God alinighty has said they must if they are to live! Exercise. -^Exercise is life, and the absence of it is the sure sign of death. By exercise came evolution. Exercise shaped the body, determined the vital organs, built the brain. By exercise the child takes possession of his inheritance from the race. To him it is the past, the present, and the promise of the future. But that exercise no man can dictate, no teacher devise, no scholar fully define. It comes forth unbidden from the child, declares his nature, discovers him to himself, defines his relation to his mates, shows him the world. It is his play; it is himself. Can the school alone do this, be this? In the long process in which exercise shaped the body and built the brain, there was determined for all time the path by which the child must come into his own. In that shortened process we call childhood every faculty, every power, every organ that fails to receive its due exercise shrivels, and health by so much suffers, and by so much the man becomes less a man. It would require a book to speak in full of the exercises of the playground that meet the needs of health — physical, mental, moral, aesthetic, social health; for all these are elements in the health of the body, as we all have come to understand. But in many respects, in the very nature of the case, these exercises are impossible in the school-building; they are pos- sible only on the playground. Just as we have awakened to the fact that the school pro- vides but a small fraction of a child's education, and that the environment, which included everything that comes into the child's experience, is teaching him every waking moment of the day, so we have come to understand that the activities of the school provide but a small fraction of the exercise necessary for the health of a child in this larger meaning. In the long process of race development, every organ and in- stinct with which a normal child is born has been tried and PLAY AND PLAYGROUNDS IN CITIES 39 1 found good, has been refined and passed on, and some yet higher function, some yet nobler conduct shall spring from their roots. Not in the school but on the playground can these deep instincts of workmanship, imitation, rivalry, co- operation, find their true and genetic expression, and as the swift seasons roll build more stately mansions in the soul. These instincts calling from the deeps of the child's nature are not voices calling him astray or to delay his upward prog- ress.^ They are the voices saying to him and to the race: "Build thee more stately mansions, O my soul, As the swift seasons roll, Leave thy low-vaulted past. Let each new temple, nobler than the last. Shut thee from Heaven with a dome more vast, Till thou at length art free, Leaving thine outgrown shell by life's unresting sea." Play and Character.— We have not always understood the real nature of boyish misdemeanors. The playground is helping us to understand. Some one has suggested that a boy is a whole menagerie. This is, indeed, a rather narrow limitation of a boy's relation to the animal kingdom. In one way or another, he seems to run the whole gamut of the animal kingdom. He crawls like a worm; he creeps like a turtle ; he dives and swims like a frog ; he walks like a quad- ruped; he climbs like a monkey; he runs like a deer; he squeals like a pig; he screeches like a parrot; he hoots like an owl; he whistles like a mocking-bird ; he sings like a lark. He digs, builds, roams, hunts, pillages, hoards, tames wild animals, and makes boon companions of dogs; dams streams; makes toy weapons; descends beneath the waters, under snow and into the bowels of the earth. He ascends to housetops, into trees, and there abides; he tries the heavens with flying toys, arrows, balloons, kites, and aeroplanes. He conjures with 'See Thorndike's volume on "The Original Nature of Man," Vol. I of his "Educational Psychology." 392 EDUCATIONAL HYGIENE the stars, creates mysteries, makes rhymes, composes songs and music, dances, and fills the air with unearthly din. He teases, mimics, and acts many parts; he competes, does stunts, undergoes ordeals, fights, forms gangs, organizes clubs, and institutes rituals. There is no creature in the heavens above nor in the earth beneath nor in the waters under the earth which he does not at times become.^ We have suggested under "Why Children Play" an ex- planation of this panzoism of a boy. There, also, we found a suggestion of the relation of play to certain forms of misde- meanors. A man ran away from his usual duties one day to attend a session of the juvenile court. He wondered if he should not find some children detained there for committing acts which if they had been done under somewhat different relations would have been not only right but even desirable. He was not disappointed. Very soon nine boys were called to answer to the charge of improper snowballing. They were accustomed, so the complainant said, to gather once or twice a week and annoy him by snowballing his house. The Throwing Instinct. — This complaint of improper throwing in some form or other is one very frequently made against boys in juvenile courts. Sometimes it is for breaking windows in vacant houses, sometimes for throwing stones at passenger trains, sometimes for annoying somebody with snowballs, sometimes for throwing a baseball in the streets. Judging from the cases in the juvenile courts, one might easily infer that the passion for throwing is one of the "original sins" of boyhood. We will not stop here to inquire how this besetting sin got into the blood and nature of boys and how it is passed on to |( each succeeding generation. It is obvious enough that the art of throwing must once have meant much to the race, and it is certain that all normal boys are "structurally pre- disposed" to throwing. It is also obvious how great a fas- cination this art, the very acme of which is exemplified in the i^i 'See "Education by Plays and Games," by the writer. PLAY AND PLAYGROUNDS IN CITIES 393 modern baseball pitcher, has for the people generally who flock by tens of thousands to witness a "battle of pitchers." We can scarcely fail to acknowledge this, at least, that the boy comes honestly enough by it. One feels very confident that if those nine boys had been gathered into a gymnasium or playground and allowed to play indoor baseball and basket- ball, as they were not, the juvenile court would not have heard of them. The Chasing Instinct. — Looking out of a street-car win- dow one day, I chanced to see a boy snatch something which looked Hke a banana from a stand in front of a store and run with all speed down the street. There was something about the boy, in the way he ran, in the way he carried himself, in his general appearance, that somehow gave an impression not of guilt but of a game, and one wondered whether the fellow was eager for a banana or for excitement. A boy was arrested and brought to our juvenile court for stealing apples. He was warned and allowed to go. Not long after he was in court again for stealing apples. He was placed under a probation officer and sent home. Not long after he was again arrested and brought to court on the old charge of stealing apples. In despair the probation officer took the boy aside and said: "Now, Tim, tell me honestly, why do you steal those apples? Do you get so hungry for apples you just can't help steahng them ?" The boy hung his head a moment and a new thought seemed to come to him. He raised his head, looked up at the probation officer, and said: "Why, I don't care much about eating 'em, but I do Hke to have old chase me." Is this passion for chasing and being chased, which at a cer- tain age crops out in every healthy boy, also an evidence of total depravity, an original sin, like the passion for throwing? A study of juvenile court records would suggest that it is. At any rate, boys at a certain age are "structurally predis- posed" to running, and the devil entices many a boy to evil by means of it. And it is so easy for him to do this in the 394 EDUCATIONAL HYGIENE city! The city streets interfere with every fair game of chase. They suggest and aid only the unfair games. A game of tag or prisoner's base would be quickly spoiled in the streets, but to snatch and run and disappear in the crowd and get away for good is easy. Collecting Instinct. — ^There is another besetting passion of boys, the passion to collect and hoard. Probably not one man in ten who may chance to read this article failed in boyhood to make a collection of something — buttons, minerals, birds' eggs, bugs, leaves, tobacco-tags, coins, or stamps. In the city there is small opportunity for the legitimate practise of collecting. About all that boys can collect is what they buy. Three boys were arrested and brought to the juvenile court for looting trinkets from a ten-cent store. They had a ren- dezvous where they hoarded all their curious collection. Another boy whom the writer knew was taken into a play- ground. Hs had the reputation of being the toughest boy in the public school. Under the direction of the playground teacher he made a collection of bugs and butterflies. He gathered caterpillars, fed them, made cages for them, watched them spin cocoons, made a net, caught specimens, mounted them, and his collection at the end of the summer was a pride to him and to his teacher. And all this time he did no mis- chief. Who will say that the future thief and the future scientist do not sometimes take their first departure from each other in the way they practise the collecting instinct? Instinct of Construction. — Some boys were brought to our juvenile court on the charge of mahcious mischief. They had built a hut in a vacant lot. They were bad boys, no doubt, and made a bad use of the hut, perhaps, but do not boys come honestly enough by this passion to build and own a shelter? What would the world be to-day but for this in- stinct of construction? Had there been a proper outlet and direction of this interest of the boys, the majesty of the law would not have been offended and the divine right of these boys would not have been violated. PLAY AND PLAYGROUNDS IN CITLES 395 Imitation and Suggestion. — Several boys in our city went into a nickelodeon and saw the moving pictures of "Fun in a Grocery Store." Not many nights later these boys broke and entered a grocery store. They took very Httle away with them, but the store was a sight to look upon — bags ripped open, groceries scattered about, and the grocer's cat left smothered in flour. We have long expressed faith in the saying that example is better than precept, but in practical life we often abandon our boys to evil suggestion and utterly desert them in one of the strongest passions of the human race, that of the drama. The Social Instinct. — One day in winter fourteen boys in a certain city were arrested and taken to the police station in a patrol wagon. They had been hanging around the rail- road station. They had been warned, but when they asked, "Where shall we go?" there was no answer. They had com- mitted no mischief, but because they had socialized in the warmest place except a saloon that was open to them they became transgressors of the law. But what would the world be like to-day if it had not been for this instinct for getting together? Upon this instinct which crops out so strongly in boys in their early teens, in a crude and often dangerous way, really depends the capacity of a people for any great public or national achievement. The nations of the earth that stand in the forefront of human progress are the nations which have shown the greatest capacity for "getting together," for co-operative action. As one studies boys he becomes more and more convinced that the departure from right to wrong is often far too subtle for a boy to realize the distinction fully. And yet the most deep-seated forces of his nature are impelling him constantly onward to one or the other. If he does the right thing in the wrong way, ten to one society is far more to blame than he is. At least, this is the conviction of the advocates of play- grounds, and consistently with their belief they attempt to supply the elements in a boy's environment that will naturally 396 EDUCATIONAL HYGIENE and safely turn his energy into the right instead of the wrong channel. Of course, boys will throw things. A place is pro- vided where they can play ball. Of course, they want to chase and be chased. The playground provides ample opportunity for running games. Of course, boys collect and hoard. Our playgrounds direct this interest also, and vacant lots and parks yield treasures that before were not known by city boys to exist at all. Of course, boys will build or else destroy. The playground furnishes a chance for most interesting con- structive play and use of tools. Of course, boys will imitate and make believe and dramatize. Our playgrounds provide an outlet for imitation and make-believe, not only through the dramatic plays and games, but through dramatic clubs as well. Of course, boys will organize, form gangs and clubs. The playground offers an opportunity for the most interest- ing of all clubs for boys, the baseball and basket-ball and football teams. That the playground does save boys from delinquency is the uniform testimony of probation officers. Unfortunately, few statistical studies have yet been made, but one made in Chicago on a thoroughly scientific basis seemed to show that in those sections of the city where play- grounds were provided there was a decrease in delinquency of from eighteen to forty-eight per cent as compared with sec- tions of the city where there were no playgrounds. Public schools notorious for truancy and disorder have been prac- tically made over by a wise and systematic use of the school playground. The Girl Problem. — The playground throws equal light upon the girl prolilem, as a study of delinquent girls will show. Society generally has been too apt to place women in two classes, the thoroughly good and the thoroughly bad. Society has generally regarded boys as peculiarly subject to temptation and danger, but it has seemed to regard girls as good by nature or bad because they wished to be bad. A great deal more has been said and a great deal more has been done in the matter of preventive work for boys than foi PLAY AND PLAYGROUNDS IN CITLES 397 girls. Until within a few years the work for girls has been more largely one of rescue and redemption than one of pre- vention. Boys' clubs have been more numerous than girls' clubs, and most playgrounds have been planned and conducted to meet the needs of boys rather more than to meet the needs of girls. But is it true that girls need playgrounds less than boys? Is it true that the slum home is less bad for a girl than for a boy, that the city streets are safer for girls than they are for boys? It is true that not so many girls as boys are brought before the juvenile court. The "besetting sins" of girls are not so many as those of boys; at least, when the social offenses of girls are classified they do not represent so many different classes as do those of boys. A rough classification of the cases of the juvenile court for one year showed that boys committed nearly three times as many different kinds of offenses as girls. Boys are more variable, more daring, and more original in their offenses than girls, but the misde- meanors of girls are hardly less serious than those of boys. Moreover, girls coming under probation seem to be less amenable to improvement than boys. The records of the juvenile court for one year showed that, while three out of four boys satisfied their probation requirements, only about one girl in three came up to the standard. In certain ways the slum home is even worse for the girl than it is for the boy, and the streets of the city harm her more than they harm him. For the same reason the play- ground becomes, in a certain sense, more helpful to girls than to boys, more necessary in supplying those elements in her life that her home environment fails to give her. Bringing the Playground to the GirL — ^The playground fight for the welfare of girls, as the playground fight for the welfare of boys, begins by enlarging and improving the envi- ronment. The playground brings to girls a new environment almost comparable to a new natural world for them to live in. Many alleys of a large city are as barren of growing 398 EDUCATIONAL HYGIENE things, of grass, of trees, of birds, of fresh water and clean soil, as is the moon itself. All the things that little children should come in contact with these alleys seem to lack, and many, many things they should not see and touch and hear seem to be there. A biologist once selected tadpoles of the same parentage, age, size, and vigor and placed them in a series of vessels varying regularly in size. He placed the same number of tadpoles in each vessel and reared them under exactly the same conditions, so far as possible, except as to the size of the vessels. At the end of a certain period he found that the tadpoles had developed proportionately to their environment, to the size of the vessel they were kept in. The least de- veloped tadpoles were in the smallest vessel, the next better developed in the next size, and so on, the best being in the largest vessel. Many city alleys are vessels into which have been crowded many little human tadpoles. The playground, however, enlarges the vessel, increases and improves the en- vironment, until almost a new world comes into the child's life. There is water to wade in, there is clean sand to dig in, there is fresh soil to plant seeds in, there are grass, and shrubs, and trees, and flowers, and little gardens, and pets to feed and play with. One recalls Luther Burbank's delightful child's cosmos. He says in "The Training of the Human Plant": "Every child should have mud pies, grasshoppers, water- bugs, tadpoles, frogs, mud-turtles, elderberries, wild straw- berries, acorns, chestnuts, trees to climb, brooks to wade in, water-lilies, woodchucks, bats, bees, butterflies, various ani- mals to pet, hay-fields, pine-cones, rocks to roll, sand, snakes, huckleberries, and hornets. And any child who has been deprived of these has been deprived of the best part of his education." Early in the nineteenth century there appeared in Nurem- berg a boy of sixteen years of age about whom there was a great mystery. All his life he had been confined in a dark room, never leaving it. He was as ignorant and untrained as an imbecile, but under instruction showed that he was pos- School play activities at Milwaukee, Wis. Note arc lights for night use of playground. Indoor baseball, basket-ball, and volley-ball Tennis and volley-ball at Pasadena, Cal. i PLAY AND PLAYGROUNDS LN CITIES 399 sessed of normal original powers of mind. His sad condition awakened great sympathy and several books were written con- cerning him. So far as is known, this case is the only experi- ment that man has ever tried in narrowing to the limit the environment of a child. But one recognizes that society in a certain sense is constantly repeating the experiment of the un- fortunate Kaspar Hauser in innumerable children of the slums. Few people can easily realize how restricted is the world of many of these children, how narrow is their environment, how perverted their ideas of life. Beulah Kennard, of the Pitts- burg board of education, tells the following: "A little girl of the playgrounds said to her teacher : ' Have you ever rode in a patrol wagon ? My father has three times and mother once, and when I am big I am going to.' " A little boy in the tene- ment district of New York was asked what signs of coming spring he had noted, and he said: "The swinging-doors of the saloons are on." The Mother Instinct and the Doll. — Perhaps Luther Burbank, when he enumerated what every child should have, was thinking of boys only, for he failed to mention the doll. In the playground the little slum girl finds, perhaps, her first opportunity to re-experience in genuine doll play the racial joy of motherhood. Real doll play is very different psycholog- ically and educationally from the prolonged serious care of babies which falls so grievously upon many young shoulders too weak to bear it and which lessens the possibihty of future joyous motherhood in the world. The playground corrals out of the wild and untrained life of the streets the homing, nurturing, mothering instincts of little .girls, feeds them and guides them, laying the idealistic and emotional foundation for enlightened and exalted motherhood to an extent impos- sible in the slum home. Playing-in-the- Water Instinct. — "The measure of civili- zation is the bath," says some one. At all events, the bath is associated with both moral and physical cleanness. The fight for the honor of girls in the playground includes attention to 400 EDUCATIONAL HYGIENE cleanliness. For little folks the tub, for older girls the shower or the swimming-pool is provided, as well as the wash-bowl. These give the playground an advantage in this respect over many public schools which have no bathing facilities. All is easy and delightful in the playground provided with baths and a swimming-pool, as one can easily imagine who has wit- nessed the mad delight of children in the water. "You can catch more flies with sugar than with vinegar" is a homely saying, and the swimming-pool is a lasting monument to the efficiency of play education. The deep-seated aversion to soap and water is swallowed up in the deeper instinctive love of playing in the water. Children would go through fire, soap and water, or anything else to get to the swimrhing-pool, and before they know it they have grown to enjoy the feeling of cleanliness and to regard soap and water for what they will do for them. The Playground and the Races. — The playground work is closely related to the problem of mixed races. Five, six, even ten or more different nationalities are found represented at the same time in a single playground. Race prejudice ap- pears in girls as well as boys. One pathetic feature is the well- known tendency of the children of foreign-born parents to despise the nation and customs of their parents. One recalls the story told by Jacob Riis. Mr. Riis found a little fellow crying bitterly. The kindly man endeavored to comfort the boy, who had just received a beating from his father. Finally, when the future American citizen could command the words and a steady voice, he exclaimed: *'/ don't care nothin' for the lickin\ but I hate to be licked by a Manned foreigner." It is not uncommon for girls in the playground or social centre to de- spise the lace-making or other skilled hand -work of their kinspeople until they see the admiration of the teacher for the hitherto despised accomplishments of their mothers, and then a new interest and a new sympathy are awakened which mean much in the home. The activity of the playground is often related to the needs PLAY AND PLAYGROUNDS LN CITIES 4OI of the home. Sewing and even cooking are activities in some play centres. These occupations, which to many women mean only drudgery and the sweat-shop, become, under the strange alchemy of childhood, occupations of interest and delight. These occupations become as popular as the games if offered to the girls at an age when the constructive inter- ests are awakening. When seized at the right time and fixed in habit, this interest abides for good and the girl advances safely over a critical period and is further along on the way toward the woman who "looketh well to the ways of her household and eateth not the bread of idleness." Athletic games have long been regarded as moral prophy- lactics for boys, but it is only comparatively recently that active games have been regarded as serving a similar purpose in the case of girls. If boys especially need some morally and physically healthful and absorbing interest outside of them- selves, it is equally true that girls have been less Hkely than boys to find such interests. Many running games and ball games, if properly conducted, serve as good a purpose in the case of girls as ever they do in the case of boys. Girls in the street are even less Hkely than boys to learn the games they should know and the w^ay they should play them. If the street is a bad play school for boys, it is, for obvious reasons, surely worse for girls. The traditional folk-games which have held a large place in the street play of girls are very apt to acquire objectionable features in the streets. The play- ground elevates and enlarges the play repertoire of girls pro- portionately even more than it does that of the boys. IVIany beautiful folk-games and folk-dances, moreover, would be en- tirely unknown to the children of the streets were it not for the supervised play of the playground. Many of the games and dances of foreign parents become known and preserved in their children through the playground which otherwise would not be learned, or if learned would be despised by the children in the process of Americanization. The love of finery which tempts a girl to pilfer cheap 402 EDUCATIONAL HVGIENE jewelry from the department stores, or to steal money to buy better clothes to wear, is not so very distantly related to the love of beauty. The cultivation of the love of the beautiful doubtless stimulates the moral sense also, but if that were not the case the playground arts and crafts open a legitimate way to the enjoyment of beauty in form, in color, or texture, that is salutary if not morally elevating. The girl who can fashion a beautiful belt-buckle in bronze from a design of her own, or can embroider a belt, or make a bit of lace, or design and embroider her collars and cuffs, is thereby inoculated against pilfering similar articles for the adornment of her person. The moving- picture show is sometimes prominent in the history of wayward girls. This great educational possibility, often turned over to low commercial exploitation and cor- rupted with evil associations, is fast becoming a social rendez- vous for boys and girls. Unfortunately, also, as a rule, the more needy the people the lower is the standard of the pic- tures. Through its appeal to the dramatic interest of children and by its children's-theatre work, the playground or play centre offers a counter-attraction to the undesirable cheap theatre or nickelodeon and is steadily uplifting the dramatic standards of boys and girls. Moving pictures have already begun to take their place among the features of playground work in many cities and much hope is entertained for their high value in the near future. Play and Moral Education. — Thus in many ways the play- ground serves as a safeguard to character. But the relation of play to character is not confined to prophylactics. Play has a definite, positive effect in moral training. Play doubtless of- fers the best opportunity for the development of fundamental traits of character. This is evident when we consider the relation of play to conservation. Just as it is the office of the instincts to conserve racial habits, so it is the office of play to habituate to certain moral reactions. "If," says James, "a boy grows up alone at the age of games and sports, A volley-ball game over a tennis-net, Oak Park Grammar School, Sacramento, Cal. Girls at playground ball and volley-ball; boys at tennis Basket-ball goals also in evidence, Pasadena, Cal. PLAY AND PLAYGROUNDS IN CITLES 403 and learns to play neither baseball, nor row, nor sail, nor ride, nor skate, nor fish, nor shoot, probably he will be sedentary to the end of his days; and, though the best of opportunities be afforded him for learning these things later, it is a hundred to one but he will pass them by and shrink back from the effort of taking those necessary first steps the prospects of which at an earlier stage would have filled him with eager delight." So, on the moral side, if a boy grows up alone and does not learn to play games which call for great activity, competition, courage, fortitude, perseverance, fairness, gener- osity, loyalty, co-operation, sacrifice, he loses the most favor- able opportunity for the development of these traits in him. Providing Playgrounds. — While the statement of Doctor Woods Hutchinson, "Better a playground without a school than a school without a playground," has naturally not re- ceived instant and universal approval, yet the essential idea in the statement commends itself to every thoughtful student of city conditions. Playgrounds are needed proportionately as schools are needed, and a city that has located its schools with foresight and wisdom needs at least as many playgrounds as schools. Naturally there has been a tendency to purchase new playgrounds apart from school-buildings. First, because land is usually less available and more expensive adjoining school-buildings than in some other section of the city, and, second, because the people interested in providing playgrounds have not realized the very great advantage of having play- grounds adjacent to schools. Obviously, however, the school is the natural civic and social centre of a neighborhood, and there would be a great economy in construction, equipment, and administration, as well as increased use, if the school plant were at once the centre of the social and the play and recre- ational activities of the neighborhood and served as a school, a small park, a playground, and a neighborhood home all in one. At present there is no consensus of opinion as to how large such a school playground should be. States that have 404 EDUCATIONAL HYGIENE passed laws requiring that when new school-buildings are erected an adequate playground shall be provided do not state how large an adequate playground would be. Obviously the size of school playgrounds in cities generally has been determined by the cost of land and not by the needs of the children. Perhaps city playgrounds must always be too small. Yet with the increased facilities of transportation and in view of the experiments already successfully tried in the consolidation of schools, the free transportation of school- children, and the providing of lunches, it seems wholly war- rantable to state that there is no sufficient reason why any city should not in some manner provide an adequate play- ground for every school. What constitutes an adequate playground, however, is yet to be determined. School playgrounds in American cities vary all the way from practically nothing at all to several acres. Standards have been suggested, such as thirty square feet of space per child, one hundred square feet per child, a block per school, and others. It is obvious that the efficiency of a playground is not determined by its size so much as by its administration and use. At present it seems impossible to determine any universal standard for size of school play- grounds. Playgrounds must be large enough and admin- istered in such manner as will provide ample opportunity for the plays and games which are essential in the education of children. To discuss these plays and games adequately is not possible here.^ Standards.— But not to leave the subject of the size of school playgrounds wholly without definite suggestions, it may be said, after a careful consideration of the general problem and of the space needed for educationally essential plays and games, that a minimum standard for school yards should be: for every elementary school of less than loo children a play space of ten thousand square feet exclusive of school-buildings. ^ See Bancroft's "Games for Playground, Home, and School," and John- son's "Education by Plays and Games." PLAY .A>rD PLAYGROL'XDS IX CITIES 405 For elementary schools of 100 or more children there should be added 4,000 square feet per each additional 100 children or fraction thereof. Thus, for a school of 200 children we should have as a minimum a school yard of 18,000 square feet, or a plot, say, 180 by 100 feet exclusive of the buildings; for a school of 1,000 children a play space of 50,000 square feet, or a plot, say, 200 by 250 feet. This is a minimum standard and is not adequate for such games as regulation baseball and football, but with skilful administration and rotation of groups it would serve well the need of elementar\- schools. But where the school with its playground is to serve as a social and recreation centre for the neighborhood, it cannot adequately meet the needs of the neighborhood with less than four acres, while from sLx to twelve acres are desirable accord- ing to the density of the population. Four acres is the very minimum, and is necessary in order to meet the problems of "composition," track and field sports, football and baseball, the divisions of the playground, etc. Equipment and Apparatus. — We have not advanced very far in the science of playground equipment and apparatus. Most conclusions have been arrived at empirically. Yet there are a few underlying principles which we may even now apply in attempting to determine what should be provided as mechanical aids to the play of children. What we know of child development and child ps>'chology indicates that the educational import of the first six years of life is to a large extent the development of the senses and ac- quiring of sense facts, getting control of the fundamental movements of the body and limbs, habituating to physical activities, the beginning of sociability, development of speech, imitation, imagination, and self-assertion. Obviously, the race in its development was in unhindered contact with the forces and elements of nature. Under crowded city conditions this natural relation to and contact with earth, water, plants, trees, animal life, and a thousand and one natural objects are greatly restricted. It is the office of the playground to re- 406 EDUCATIONAL HYGIENE store in such degree as is practicable the relation of the child ti) the objects and forces of nature. Our equipment and apparatus, therefore, should provide play involving the sense impressions otherwise lost in city life — such as the contact of hands and feet and body with clean earth, sand, clay, as in the sand-pile and in modelling with mud or clay; the contact with water as in a wading-pool (or in shallow troughs in the case of the youngest); constructive play with crude raw material, as in the sand-box with sand and clay, blocks, stones, sticks, etc. ; the delightful emotional shocks, the playful sense of danger, difficulty, achievement, as in jumping downward, flying through the air, falling, sliding, climbing, clinging, bal- ancing, experienced in play with such apparatus as the swing, the slide, the see-saw, jumping-hole, and raised-rail or walking-beam. The imitative and imaginative play at this age also requires a great variety of simple toys, dolls, carts, reins, toy household utensils, and the like, which the play- ground may legitimately provide. The social needs of this period are admirably met in the playing together in sand or water, on the slide or see-saw, in climbing, jumping, and walking in difficult places or ways together, the relations in- volved developing sociability and the regard for rights, yet respecting individuality and self-assertion desirable at this age. In the case of children over six and under ten, similar needs are recognized and similar but somewhat more difficult activities should be aided by the equipment and the ap- paratus. In addition, also, there should be supplied apparatus for simple games of competition and skill — balls, bean-bags, ring-toss, tenpins, etc. The apparatus for children from ten to twelve should meet the needs of the developing co-ordination of the sensory and motor apparatus. More ambitious "stunts" should be suggested by the teeter-ladders, the giant stride, the general outdoor gymnastic apparatus and swimming-pool, also balls, bats, quoits, goals, jumping and vaulting standards, jump- I PLAY AND PLAYGROUNDS IN CITIES 407 lanes, running- track, etc. Up to this point the suggestions offered, with a few obvious exceptions, apply nearly equally well to both boys and girls. From thirteen or fourteen on, in the case of boys more stress should be laid upon the co-operative competitive games: baseball, basket-ball, football, track and field events, for which familiar apparatus is necessary. This very brief discussion of the principles underlying the selection of apparatus suggests the division of playgrounds to meet the needs of at least three groups: children under ten, girls over ten, boys over ten. A further division, of ap- paratus at least, for children seven to nine would be ad- vantageous. The age limits mentioned, of course, are not intended to be applied with exactness. Individual differences in temperament and development should determine division rather than the exact age. There is great advantage in fencing a playground and in fencing off divisions when such is practicable, as a matter of safety, psychological value, and ease of administration. It is not the purpose of this chapter to go into the con- struction of apparatus. Much of the apparatus mentioned above can be made easily by a good mechanic. Nearly all of it can be bought now ready-made. Playground Administration. — We have had developed in this country within the last ten or twelve years four types of public playgrounds: the reorganized school playground, the small detached playground, the larger detached playground or recreation park or small park, the reorganized large park. The adequate consideration of these types of playgrounds would involve a discussion of organizing and administrative agencies for the conduct of play and recreation centres. The various types of playgrounds mentioned have developed be- cause of the various agencies which created or reorganized them. Park boards have established outdoor gymnasia and children's playgrounds in the large parks and, separate from the large parks, the recreation park or recreation centre. 408 EDUCATIONAL HYGIENE Playground associations and playground commissions have established detached small playgrounds and recreation parks. School boards have reorganized school playgrounds and es- tablished recreation or social centres in pubhc-school buildings. The "Year Book of the Playground and Recreation Association of America for 191 2-13" shows that playground commissions were concerned, alone or in combination with other organiza- tions, in maintaining play centres in 46 communities, park boards in 55 communities, boards of education in 56 commu- nities, playground associations in 68 communities, and miscel- laneous agencies in 116 communities. Obviously, each agency has been influenced by its own view-point in determining the characteristics and the location of its play centres. Whether city playgrounds are to be de- veloped and administered as a part of the public education system or as a part of the park system, or under some new agency independently of both educational and park systems, so far as the immediate future is concerned, will doubtless be determined mainly by local conditions. The ultimate trend, however, will doubtless be determined by the answers to the following questions: (i) Are playground, recreation, and social-centre problems mainly physical, moral, and social-education problems or pub- lic-convenience problems ? (2) Can play, recreation, and social centres be acquired or developed more economically under the school system, the park system, or some new agency? (3) Under which agency can the centres be most efficiently and economically administered? Quite evidently, so far as children of school age are con- cerned, the problems are predominantly educational and nat- urally and logically belong under the educational system. It is perfectly evident also that so far as the general neigh- borhood is concerned the problems are those of physical, moral, and social education far more than of public conve- nience and administration. w PLAY AND PLAYGROUNDS IN CITIES 409 Local conditions enter more prominently into the con- sideration of the second question, but here, so far as children of school age are concerned and so far as evening activities of the public generally are concerned, the centres can be acquired or developed more economically under the educa- tional body with its present vast sums invested in buildings and grounds than under any other pubHc body. So far as the problems are educational and so far as the activities of school age or evening activities of the general public are concerned, the educational body has the decided advantage over all other bodies in the matter of efficient and also economical administration. So far as the outdoor, day- time activities requiring large areas or water-fronts, such as golfing, motoring, horseback-riding, dri\dng, picnics, boating, sailing, canoeing, ocean and river bathing, etc., are concerned, the park board seems to hold as natural and logical a position as the educational body in the case of the others. But it would seem that so far as organized, supervised, or directed plays, games, and sports are concerned, whether in small centres or by privilege of park boards in large parks, one body should be responsible for all and this body naturally and logically would be the educational one. CHAPTER XXII PHYSICAL EDUCATION IN ELEMENTARY SCHOOLS Definition. — Physical education is the training of body and mind by motor work. This broad definition includes certain forms of physical training, such as drawing, manual training, writing, and the like, which are usually considered separate subjects. In addition, however, physical training properly includes certain health activities, such as hygiene, bathing, physical examinations, and medical inspection. In elementary schools physical training should include folk-dancing, games, story gymnastics, athletics, gymnastics, instruction in hygiene, and medical inspection. The last two will be omitted from this chapter and considered else- where. Purposes. — Physical training has two major aims, health and motor education. The author has divided all physical- training procedure according to the purpose and function of the exercises into the following classes, all of which appear in proper sequence in a typical lesson as shown in table on next page. This formation of the day's order is new and is based upon the principle — selection and segregation of exercises ac- cording to their function. It recognizes the fact that for the various purposes of physical training different exercises and different methods are indicated. Their separate pursuit eliminates all necessity for compromise in choice of matter and method. Moreover, it permits the attention of teacher and pupil to be centred on one thing at a time, and the result- ing singleness of purpose allows the teacher and pupil to un- derstand the aim of the procedure. This stimulates interest 410 PHYSICAL EDUCATION IN ELEMENTARY SCHOOLS 41I Typical Content Typical Method Results Introductory. Military. Response commands for alertness and precision. Floor formation; mental and so- matic preparation for the lesson. Corrective. 1. Static. 2. Short range. 3. Slow movements. Elevation cues; sus- tained contraction. Good posture. Educational. Gymnastics empha- sizing accuracy. Response commands. Neuromuscular and psychomotor edu- cation: inhibition, precision, alert- ness. Hygienic. Exercises of trunk, leg, and back, rapid and heavy. Rhythmic ; serial commands. Organic stimulation; development of ab- dominal muscles. Recreative. Natural exercises, i. e., athletics, games, dances. Rhythmic; music or no commands. Knowledge of exer- cises. Happiness. All educational and hygienic results. Assembly. Military. Response commands. Control and quiet. and arouses co-operation, often wanting, particularly in formal gymnastics.^ I. Introductory exercises are for the purpose of {a) form- ing the class for work; {h) mildly stimulating the body in preparation for harder work ; and (c) placing the class mentally en rapport with the teacher. The content is composed of the simplest and best-known exercises, mainly marching and fac- ing to response commands. II. Corrective exercises are designed to improve bad pos- ture and insure good posture. Good posture is {a) a good adjustment of body parts to each other so that they may function to best advantage and {h) a good adjustment oj the body to its environment, task, or work. All bad adjustment of body parts to each other is a ptosis {i. e., a depression of body parts) due to acute or chronic fatigue. It is usually associated with blood ptosis. It can ' See chapter on " Acquiring Motor Control " in Parker's " Methods of Teach- ing in High Schools." 412 EDUCATIONAL HYGIENE be corrected only by good hygiene (including hygienic exer- cises, in which the strengthening of the abdominal muscles has a most important part) and elevation exercises specifically designed to train the pupil in good posture and to strengthen muscles which support correct posture. Corrective work has four phases, namely: (i) Corrective cues. (2) Corrective exercises. (3) Devices. (4) Hygiene and hygienic exercises. (i) Corrective cues are elevation commands such as "head up," "chest up," "stand tall," "stretch the body upward," which are primary, and others which are secondary, such as "waist flat," "weight forward," etc. Other homely appeals, such as "stand like a soldier" and "have some style about you," have a direct effect. All cues leading to forward or backward correction are bad, because {a) they do not pro- duce elevation, (&) there is no objective limit to their range and the proper point cannot be stated definitely, and (c) they lead to faulty posture. Hence, "neck back against collar," "shoulders back," "chest out" must be discarded, and "weight forward" is to be omitted when possible. Cues should be used in every lesson to obtain good posture. (2) Corrective exercises, (a) Static exercises consist of posi- tions which lift the chest and head and hold the position raised to the utmost (from three to six seconds) while eleva- tion cues are used. These are the most important and ef- fective corrective exercises and are peculiar to this system. (b) Vigorous exercises of upper dorsal and posterior neck muscles limited to the last one-fourth or one-fifth of their range of movement. These shorten and strengthen the muscles which support good posture. These are of minor importance, (c) Slow movements of the arms with which is associated the idea of elevation of parts. III. Devices. Good posture is a matter of habit and pride as well as of physical tone, hence the following devices assist PHYSICAL EDUCATION IN ELEMENTARY SCHOOLS 413 in obtaining it: (a) Marking pupils in posture, (b) Dividing the class into two or more groups according to posture habits. (c) Noting posture by teacher or monitors at times other than during the gymnastic lesson, (d) Permitting pupils to vote on good or bad posture of all other pupils in turn, (e) As- signment of home exercises. (/) Special work with the poor- posture group, the "Slouch Class." The following rules should be applied to corrective exer- cises : (i) The exercises must be simple and easy to do. The whole attention of teacher and pupil must be centred upon the result (i. e., good posture). There must be no distraction from this result on the part of the teacher in preparing the exercise, in making it serve its single and proper purpose, nor on the part of the pupil in understanding or doing it. (2) It must not be contra-corrective. "Neck firm," "arms back and down" are open to serious objection and are not to be used unless other exercises will not serve. (3) The exercise must be effective in actually correcting the fault, and in addition overcorrecting it. (4) There is no " gymnastic ^^ progression in corrective ex- ercises. The fewer different exercises used the better. (5) Throughout the gymnastic period: (a) No contra-corrective exercise should be chosen for any purpose unless no other exercise will serve. (b) All else being equal, the exercises which have a posi- tive corrective value should be preferred for any purpose. (c) Good posture should be insisted upon at all times, though this must be secondary to the main purpose of the matter in hand. (d) Accuracy is to be obtained especially in introductory and educational work. For these purposes should be chosen exercises, the correct performance of which will result in good posture. (e) All exercises should have, if possible, a strong elevation position. This should be emphasized. 414 EDUCATIONAL HYGIENE (/) All "return to position" after an exercise should be a return to good standing posture. Educational Exercises. — Physical training has the follow- ing educational functions: First, the learning of useful movements. (i) For use in ordinary daily life, i. e., how to walk, cHmb stairs, sit down, stand up. (2) For use in emergency. Jumping (on and off cars), running, and climbing. It is useful to train pupils to respond to an unexpected command, i. e., Jump — (front, back, right, or left). (3) For use in an avocation. Tennis, baseball, golf, ath- letics, running, etc., to develop a taste and ability to indulge in healthful recreation. (4) For artistic use. Dancing and heavy apparatus work of the exhibition type. (5) For subsequent use in gymnastics. Second, the development of fundamental neuromuscular abilities. — Accuracy as to time and place, alertness, speed, grace, economy, and co-ordination of movement. Third, reflex mental results.— (i) Inhibition. This is the ability to withhold from action until the proper time. It is developed by sustaining the pause in the response command and varying it so that the pupils are held in a state of alert- ness ready to move upon the executive command. (2) Ac- curacy, speed, and alertness in movement result in the de- velopment of the same mental qualities. Concentration, directness, clearness of thought, and the formation of complete motor images with respect to physical activity and control are among the most important educa- tional results of physical training. All these are dependent upon training in accuracy. Fourth, esthetic mental training. — Every body position and bodily movement induces a corresponding mental state, and is just as important to mental development as food is to the tissues. Inasmuch as extensor positions are probably corrc- PHYSICAL EDUCATION IN ELEMENTARY SCHOOLS 415 lated with mental states of the "courage type" and flexor positions with mental states of the "fear type," the former should be emphasized. Body movements and positions im- press their qualities upon the mind. It is equally important to develop motor facihty for the purpose of expressing men- tal states. Training in "impression" and "expression" are therefore potent modes of mental development and have a large place in physical training. Hygienic Exercises. — Purpose. — The organic effects of ex- ercise are: (i) the stimulation of the vaso-motor system and the heart and lungs, (2) organic massage, and (3) a general ex- ercise of the muscles leading to their normal tone and develop- ment. For this purpose large movements of large muscles are used. Exercises should be simple and well known, so that no time is lost in learning them. They should be given to rhythmic serial count, and not to response commands, for the latter involve static contraction and loss of time. The teacher should aim for amphtude rather than accuracy, and should emphasize extensor positions. The greatest attention should be given to exercises of the trunk. Next in order of importance are flexion and extension of the thighs, using the body weight as a load. Under this section should be placed training in athletics and the practise of folk-dances of the simple running type consisting of many repetitions of large simple movements. Recreative Exercises. — Recreative exercises have two phases — teaching and practise. They must be carefully taught and thoroughly learned, for not until they become the possession of the child and the expression of his unthink- ing pleasure in activity do they become most useful as recreation. Teaching is subjective and practise objective, and the latter attitude should be obtained as soon as possible. For this reason comparatively few forms of recreative exer- cises are to be taught. It is better to know a few games well and enjoy them than to know many and continually think of the rules. 41 6 EDUCATIONAL HYGIENE Games. — A carefully graded series of games has been es- tablished, beginning in the lower grades with the traditional singing games and proceeding through the individual running and chase series to the highly organized competitive team games. They provide (i) hygienic exercise, (2) neuromuscular education, (3) social and ethical training, (4) recreation. In the selection of games for physical-training purposes each function should be considered with reference to (i) adminis- trative necessities, (2) other forms of physical training used, (3) the stage of mental and physical development of the chil- dren, (4) the social necessities of the group. Folk-Dances. — These are dances which have been handed down from generation to generation, preserving their form and rhythm with but little modification. They present various forms, i. e. (i) simple singing games with or without a dra- matic content, (2) dramatic dances, describing a vocation, etc., (3) festival dances, (4) contra-dances, (5) dances of solo, couple, and quadrille formations. Folk-dances should be dis- tinguished from (i) social dances which sometimes develop from them, (2) fancy steps and gymnastic dances which are devised for hygienic or educational purposes, and (3) esthetic dances which seek to develop expression or impression of an artistic nature, and (4) theatrical dances which are mainly for display. Folk-dances should be chosen with reference to their (i) authenticity, (2) dosage of exercise, (3) simplicity and ease of administration, (4) appropriateness to psychological and physiological development, (5) social and ethical elements. Mimetic Exercises. — In the lowest grades exercises in- volving imitation of simple motor activities should be intro- duced, as blowing up paper bags, scooping sand, imitating the wind blowing through the trees, and the like. These may be organized into gymnastic stories in which the teacher relates an interesting story and the children dramatize its various features. Typical of these is the "Fireman's Story," "A Walk in the Woods," "Snowball Play." t4 PHYSICAL EDUCATION IN ELEMENTARY SCHOOLS 417 Athletics. — Athletics are natural forms of exercise which are practised in spontaneous competition. The fundamental movements in athletics are running, jumping, climbing, swimming, and throwing, all of which have been of the great- est importance to the human race in its struggle for survival. For this reason there is an instinctive desire to excel in these exercises, coupled with a desire to prove superiority. Inas- much as these are old racial movements, they have impressed themselves upon human structure, and we find the bodies of children fitted for their practise and dependent upon it for their orderly development. In prescribing these and other natural forms of exercise, it is necessary for us to follow the principle: determine what children would naturally do under normal conditions and replace the practise of these movements in their lives which otherwise would be abnormal. The fundamental movements of athletics are taught in the lower grades as gymnastic exercises and play. Following the phys- ical and social development of the child, a series of athletic events and their derivatives in the forms of athletic games has been devised and applied to elementary schools. Thus the instruction in gymnastics serves to prepare the way for a more free indulgence in athletics and athletic games. Organized Athletics. — Athletics are useful on account of their motivation for good hygiene, neuromuscular education, and the social intermingling of children engaged in natural exercise. There are two types, the intensive and the exten- sive. The former is the natural outgrowth of the compet- itive instinct. It results in the selection of the best runner and jumper to represent his school in large athletic meets. The hygienic and educational benefit is thus frequently re- stricted to the children who need it least. The social results, however, are important, for a large number of boys become acquainted with athletics and are stimulated to train. The focussing of interest of the student body upon the maintenance of school prestige and honor is a constructive and solidifying, socializing force. Intensive athletics are a necessity prelimi- 41 8 EDUCATIONAL HYGIENE nary to the introduction of extensive athletics, in which all boys may take part. Of this type there are two forms, com- petition against standards and group competitions. The athletic badge test of the New York City schools provides a series of standards which nearly every boy can attain by consistent practise. If he passes his test he is given a smaH bronze or silver badge bearing the figure of the Winged. Victory. Fifty thousand of these badges have been dis- tributed by the Board of Education of New York City. The tests are as follows: ATHLETIC BADGE TEST IN THE ELEMENTARY SCHOOLS The Athletic Badge Test may be held at any time during the year. The names of successful boys should be sent to the office of the Public Schools Athletic League, not later than May ist. During the month of May the official test will be held. Standards Class A. — Bronze Badge 60 Yards Dash 83-5 seconds Pull-up (chinning on bar) 4 times Standing Broad Jump 5 feet 9 inches Class B. — Bronze Silver Badge 60 Yards Dash, indoors 8 seconds (or) 100 Yards Dash, outdoors 14 seconds Pull-up (chinning) 6 times Standing Broad Jump 6 feet 6 inches Note. — All age, weight, or height classifications are disregarded ^:ii the Athletic Badge Test and boys are given a Class A or Class ^^ badge according to their qualifications. Conditions Only those boys shall be admitted to the Athletic Badge Test who received a mark of at least "B" for the month previous in effort, proficiency, and deportment, and who arz making satisfactory effort to secure good posture. PHYSICAL EDUCATION IN ELEMENTARY SCHOOLS 419 In order to win a badge a boy must qualify in all three events in his class. Winners of last year's badges are not debarred from competition. Rules The following general rules shall govern the final competition : There shall be but one trial chinning, one in the dashes, and three in the jumps. Sixty Yards Dash and One Hundred Yards Dash. — The general rules of competition, as set forth in the P. S. A. L. Handbook, shall govern this test, except there shall be no finals. Chinning. — The boy shall extend himself to his full length before and after each pull-up, and shall be obliged to raise his body without a kick, snap, jerk, or swing to such a height as to bring his chin higher than the bar. Jumping. — The rules of the P. S. A. L., as set forth in the Hand- book, Rules XXV and XXVII, shall govern this test, except that, as there is no real contest, i. e., there is no striving for first, second, or third place, the finals shall be dispensed with. The Winthrop Trophy will be awarded for one year to the school that qualifies for the Athletic Badge and highest percentage of its enrolled grammar boys (fifth, sixth, seventh, and eighth year pupils). A Silk Banner will be presented to the school in each borough having the highest percentage of enrolled pupils qualifying. Boys below the fifth year may compete for the Athletic Badge but are not to be counted in determining the school's percentage. The school reporting the highest percentage in Athletic Badge competition will be ofiicially tested, and if the percentage attained at the official test is still higher than any other reported percentage, the school will be awarded the trophy. If, however, in the official test the school falls below other reported percentages these other schools will be tested in the orde' of their standing until a school is found whose official percentage Is higher than any other reported percentage. Each school is expected to conduct its own tests. If assistance is required, application should be made to the secretary of the P. S. A. L. Badges can be secured only through the Supply Department of the Board of Education. Requisition for the same is to be made in the usual manner. Public Schools Athletic League, 157 East 67th Street, New York City. Typical of the group competitions is class athletics, in which there are three seasons: for running, jumping, and 420 EDUCATIONAL HYGIENE chinning. The whole class trains and endeavors to improve in performance, so that the average record of the class will compare favorably with all other classes of a similar grade, and possibly obtain the coveted prize. In New York City over sixty thousand boys regularly enter these tests, (Bulletin for boys' grammar classes) CLASS ATHLETICS Athletics for All the Boys In this form of athletics a record is made by the whole class in- stead of by an individual. At least 80 per cent of the boys enrolled in the class must take part in order to have the record stand. The number taking part must not be less than twelve. Trophies to be held one year will be awarded in each borough by the Public Schools Athletic League to the fifth, sixth, seventh, and eighth year classes for the best Class Records made in each of the following events: Standing broad jump Tested in the fall Pull-up, or "chinning" Tested in the winter Running Tested in the spring (Distances for running: fifth year, 40 yards; sixth year, 50 yards; seventh year, 60 yards; eighth year, 80 yards.) Classes may be tested as follows: Standing Broad Jump The best record made in three trial jumps is taken for each boy. The class record is determined by adding the individual records and dividing the total by the number of boys competing. Jumping must be done from a line. Schools not provided with a jumping-mat should take steps to obtain one. Pull-up The boy shall extend himself to his full length before and after each pull-up, and shall be obliged to raise his body, without a kick, snap, jerk, or swing, to such a height as to bring his chin higher than the bar. PHYSICAL EDUCATION IN ELEMENTARY SCHOOLS 42 1 Running In order to lessen the possibility of error in timing the competitors, the following method has been adopted: The boys are hned up behind the starting-mark in the order in which they are to run; the timer, who also acts as starter, stands at the finish line and gives the signal for each boy to start. As the first runner crosses the finish hne the second runner is given the signal to start. As the last boy crosses the finish line the watch is stopped. The record is found by dividing the time elapsed by the number of boys competing. If an ordinary watch is used, the first boy should be started when the second hand is over the "60" mark. Blanks will be furnished for reporting the tests, which are to be sent in as follows: Standing broad jump On or before December i Pull-up On or before March 15 Running On or before May 15 Each school is expected to conduct its own tests. All boys are considered eligible for Class Athletics, subject to the approval of the Principal. When the records are all in, the three classes in each borough having the best records for their grade wiU be tested officially. If a record is then made better than any other record sent in, the trophy will be awarded to the class making it. If, however, the records made at the official test are lower than other reported records, the classes will be tested in order until a record is made at an official test that is higher than any other reported or official record. The trophies are perpetual. They are in the form of a shield, with bronze plates for engraving the names of schools that win them from time to time. These trophies are offered for competition once each year. This form of athletics is especially desirable, as it gives every boy an opportunity to take part, and the size of the school does not in any way affect the chances of winning a trophy. The boys should practise by themselves in the yard, on the street, at home, or elsewhere, prior to the tests. Frequent preliminary tests are recommended. Dr. C. Ward Craiipton, Secretary, Public Schools Athletic League, 157 East 67th Street, New York City. 422 EDUCATIONAL HYGIENE The full development of athletics involves the careful management of its intensive and extensive forms, the holding of city, district, and school championships, and the extension of training facilities to the utmost administrative limit. In New York City 163 school playgrounds have been opened for after-school athletic practise and forty thousand boys practise regularly every day. Athletics for Girls. — Girls are recognized as different physically, mentally, and socially from boys during their elementary school course. They are also to be prepared during the period of youth for an entirely different adoles- cent and adult life. Boys have a racially-old instinct for vigorous competition which girls, in a measure, lack. Girls are more normally interested in rhythmic exercise, particularly dancing. There is an equal need of general exercise and of out-of-door play. The most appropriate form of group exer- cise for girls is folk-dancing, on account of its instinctive ap- peal, its happy content of music and rhythm, its development of a social consciousness, and its economy of administration. In addition it must be realized that girls desire to indulge in athletic play and should do so. For this purpose games have been adopted and devised which give much interesting and valuable exercise. In the elementary schools, athletics for girls have been developed during the after-school time. Clubs are formed and practise weekly in folk-dancing, relay races (shuttle, potato, all-up, hurdle, pass-ball), basket-ball throw for distance, and various team games including endball, captain-ball, basket- ball, and punchball, the last a modification of the baseball. In addition the clubs are taken upon walking excursions. A system of rewards has been devised whereby the girl who attends a certain number of sessions of the club will receive an athletic badge. Competitions between clubs take place at the end of the season and the girls of the club obtaining the victory are given badges of another form. The emphasis of this procedure is based upon the successful performance PHYSICAL EDUCATION IN ELEMENTARY SCHOOLS 423 of a certain amount of exercise and less upon competition against others or against standards which are characteristic of athletics for boys. In conducting athletics for girls it is necessary to guard against a prostitution of the activity into a mere training for an exhibition. It is important that ex- hibitions of folk-dancing and athletics for girls should not be permitted for unselected audiences; and exhibitions to which the public may pay to attend should be avoided. Indi- vidual competition and individual exhibition should be wholly eliminated. It is advisable also that special costumes of an expensive nature should not be required; and all forms of interschool competition should be discouraged. The follow- ing rules have been adopted by the girls' branch of the Public Schools Athletic League: ATHLETIC RULES FOR ELEMENTARY SCHOOLS Rule I. Athletic Membership The Girls' Branch recognizes as athletic members all public-school girls members of elementary schools who belong to girls' athletic clubs registered in the League. Rule II. Eligibility (Girls) (a) Athletic membership is open only to girls from the third to the eighth school year, inclusive. (b) Eligibility for membership in clubs is left to the discretion of the principal, with the one proviso that a physician's statement be secured in cases of doubtful physical fitness. But (c) Any girl to be eligible to compete in the contests conducted under the auspices of the Girls' Branch or to win any of its athletic pins must meet all of the following requirements: (i) The girl must have been in the school at least one month. (2) She must be a member of a club that has fulfilled the require- ments for amount of work done. (3) She must have taken part in active practise of at least twenty sessions of her club. 424 EDUCATIONAL HYGIENE (4) She must have a standing in school work of B in effort, deport- ment, proficiency, and posture at the time of the meet or at the time of the completion of her season of all-round athletics. Rule III. Eligibility (Clubs) In order that the members may be eligible to take part in contests or win athletic pins, a club must (a) Register with the Executive Secretary of the Girls' Branch, Public Schools Athletic League, 157 East 67th Street (on blanks fur- nished by the League), not later than November i, and begin practise not later than November i. (b) Hold at least twenty-four practise meetings during the school year. (c) Keep a record of the season's practise on blanks furnished by the League. (This applies only to "all-round athletic" practise.) {d) Practise only such folk-dances, games, and other athletics as are sanctioned by the Girls' Branch. Rule IV. Winning of Athletic Pins I. All-round athletics (blue-and-silver AU-Round Athletic Pins won by individuals on season's record, irrespective of competition). II. School interclub contests (bronze Winged Victory pins, won by members of club-winning contest). Note. — It is possible to win both pins in one year if the require- ments for each are fulfilled. I. All-Round Athletics (for blue-and-silver All-Round Athletic Pin) General Requirements (a) Eligibility. — To win an all-round athletic pin a girl must be eligible according to Rule II, Article c. (b) Required Attendance.— Stho. must have actively participated in at least twenty athletic meetings of a club which is eligible, according to Rule III, Article a, and which has fulfilled the following requirements: Specific Requirements (c) Club Meetings. — The club must hold at least twenty-four active athletic meetings during the school year. {d) Outdoor Practise. — At least eight of these twenty-four meetings must be out-of-doors (a greater proportion of time out-of-doors is strongly recommended wherever it is possible). J PHYSICAL EDUCATION IN ELEMENTARY SCHOOLS 425 (e) Required Record for Ail-Round Athletics. — The sancUoncd ele- mentary school athletic activities are classified in four groups as follows: Group I. Walking 1 Swimming } any or alL Ice skating J Group 2. Folk-dances approved by the League. Group 3. Captain-ball End-ball Basket-ball Punch-ball Group 4. Pass-ball relay All-up relay Shuttle relay Potato relay Hurdle relay Basket-ball throw any or all. four or more. It is required that a club select at least three of these groups and during the season devote an equal amount of time to the practise of each of the chosen groups. This rule is hard and fast, with one excep- tion, which is that, at the discretion of the principal, sessions of activities belonging to Group 2, 3, or 4 may be substituted for some of the sessions under Group i, provided that there be a minimum of five actual walks or swims for which nothing else is substituted. In other words, if a club had selected all four groups for all-round athletic practise, six sessions of each group would then be necessary. In this case it would be allowable for one session of games, dancing, or relays to be substituted for one of the walking or swimming sessions. If a club had selected but three groups, then eight sessions of each group would be necessary. In this case it would be allowable for three sessions of games, dancing, or relays to be substituted for three of the walking or swimming sessions. (/) Certified Official Record Sheet. — An official record of a club's all-round athletic practise must be kept on an official blank furnished by the League and must show that it has completed the required record. This is signed by the principal and teacher in charge, and is sent in at the completion of the season's practise to the Executive Secretary of the Girls' Branch, together with a (g) Certified List of Eligible Candidates. — This list is on the reverse side of the record sheet and should contain the names of all members of the club who have attended at least twenty sessions of the club and who have met all requirements as to eligibility. (Rule II, Ar- ticle c.) 426 EDUCATIONAL HYGIENE (h) Pins. — To secure the all-round athletic pins, it is absolutely necessary for the principal to take the following steps immediately after the completion of the season's record: (i) Send the official record of all-round athletics, together with the certified list of eligible candidates, to the Executive Secretary of the Girls' Branch. (2) At the same time send in to the Director of Physical Training, 157 East 67th Street, a requisition for "All-round Athletic Pins" on the regular school-supply blank (first having it signed by the district superintendent), together with its duplicate, calling for a number sufficient for the eligible candidates, including the teacher or teachers who have had active charge of the club's practise. II. School Interclub Contests (for Bronze Winged Victory Pins) (a) Place. — All contests shall be held in the school building or grounds, except in case there be no suitable place or when held in connection with a school Field Day. In order to secure a place for the purpose other than the school premises, it is necessary to secure the approval of both the district superintendent and the Girls' Branch. (b) Date. — Notice of the proposed date for a contest shall be sent to the Executive Secretary of the Girls' Branch, Public Schools Ath- letic League, 157 East 67th Street, at least three weeks in advance. No contest shall be held earlier than 3.45 P. M. unless by special permission. (c) All competitions shall be between clubs, classes, or teams of one school. No interschool competition is allowed in girls' athletics. {d) All competitions shall be between groups, and there shall be no competition between individuals. {e) Eligibility. — All clubs and members of clubs must be eligible. (Rule II, Article c; Rule III, Articles a, b, d.) if) Programme. — The competition numbers in the programme shall consist of at least four of the athletic events sanctioned for elementary schools, and folk-dancing. Every club entered in the con- test shall take part in each athletic event, and each club shall dance two folk-dances, one of these to be an individual one, i. e., a different one from those danced by the other clubs, the other a common dance, i. e., one that is danced by all the clubs as a basis of comparison by the judges. PHYSICAL EDUCATION IN ELEMENTARY SCHOOLS 427 (g) Chief Judge. — A chief judge (officially assigned through the League) shall be in charge of the contest. It shall be the duty of the chief judge to decide all questions relating to the actual conduct of the contest whose final settlement is not otherwise covered by these rules. This judge shall assign the assistant judges and inspectors to duty and shall be responsible for the conduct of the contest. The decision of the chief judge is final and without appeal. (h) Other Officials. — A school shall supply in advance two assistant judges and three inspectors to act under the chief judge. These officials may be from the teaching force, but not of the school conducting the meet. (i) Score. — The official score shall be kept by the chief judge. This score-card, containing the official score, the name of the winning club (exactly as it should be engraved on the trophy or appear on the records), the principal's signature of approval as to eligibility, and the official report and signature of the chief judge, shall be returned by the chief judge immediately after the contest to the Executive Secre- tary of the Girls' Branch. (/) Marking Grounds. — The floor should be plainly and accurately marked for all events before the hour of the meet. These marks should include all bases and goal lines for the team games, starting-lines for the relay races, circles for the All-up Relay when that is used, or lines and circle for the basket-ball distance throw should that be on the pro- gramme. (k) Costume. — No special or fancy costumes for dances are al- lowable. (Gymnasium suits and shoes are strongly urged, but are not obligatory. Gymnasium shoes with ordinary dress are recommended in case gymnasium suits are not obtainable.) (I) Good Sportsmanship. — All games should be conducted strictly in accordance with the rules for them specified in this handbook. Players should be instructed prior to a meet on the points of good sports- manship, which should include especially how to lose with good spirit; never to question the decision of an official; to cheer for a defeated op- ponent; and to play a game for the game's sake rather than to win at all costs. {m) Pins and Trophy. — When the winning team is announced at the close of the contest by the chief judge, bronze Winged Victory pins shall be awarded, one to each member of the winning team and one to each teacher who has had active charge of the competing clubs during the season's practise. If the school has a trophy for girls' athletics it shall be awarded to the winning team to be held by them until the contest the following year.. 428 EDUCATIONAL HYGIENE Time for Physical Training. — The following time is given in New York City schools: First year minutes Second year minutes Third year minutes Fourth year minutes Fifth year minutes Sixth year minutes Seventh year minutes Eighth year minutes Physical train- ing, recesses, physiology, and hygiene ^00-450 180-210 180-210 150-180 90-120 90-120 80-120 80-120 In the three lower grades recesses are called for, and these are carefully organized according to the following plan: (i) Recesses should be taken out-of-doors unless lack of space or bad weather absolutely prohibits. (2) Every opportunity for exercise should be improved. Children should run or skip to their places instead of marching. Standing in line should be reduced to a minimum. Children may be dismissed by squads to attend the toilet; those awaiting their turn should mean- while engage in play. (3) Each child should be encouraged to take a drink of water. (4) Play should be vigorous. The games chosen should insure each child's taking active part. There should be at least one min- ute's running in each recess. (5) If the indoor playground is used, the temperature should range from 60 to 65 degrees. Windows and doors should be opened to pro- vide sufficient fresh air unless the outdoor temperature is very low. Too little ventilation and too high temperatures are most serious evils and should be carefully guarded against. (6) If the play raises any dust it should be stopped at once and the children should return to their classrooms. The principal should be informed and the recess taken at another time, after the playground has been cleaned. (7) In the use of the singing game: (a) It should not occupy more than one-half of the playing time. (b) Not more than one singing game should be used in a recess. (c) Too frequent repetition in the same game should be avoided- (d) Only one singing game should be in progress at one time. (e) The song element of the game may be taught in the classroom. (/) The song should be carefully pitched within the proper range of voice, and for this purpose the pitch-pipe should be used. Special PHYSICAL EDUCATION IN ELEMENTARY SCHOOLS 429 atlention should be given to singing softly and to proper enunciation. The special teachers of music will assist the teachers as to the proper manner of singing. The singing should make appropriate use of the head voice, and chest tones should be avoided. If there is a tendency to become out of breath, the children may sing alternately by groups or classes. (8) The programme for the recess should be varied to avoid monotony. It may well contain a game, a song play, and a simple folk-dance. It is more important that a few games or dances should be thoroughly learned and enjoyed than to become acquainted with many forms of play. The following tests should be applied to all play procedure: (a) Are all the children actively engaged more than half the time? (b) Are they happy? (c) May the play be stopped and quiet attention obtained instan- taneously upon signal from the teacher in charge? In the lower grades the time is broken up into short periods of ten to twenty minutes, for folk-dancing, gymnastic stories, gymnastic games, recesses, and formal gymnastics. In addition to the above time, every child in all grades has a two-minute drill at 10, 11, and 2 o'clock, with the windows of the classroom wide open. THE TWO-MINUTE DRILL Grades from 3-A to 8-B inclusive Monitors open windows without command. Class. — Stand. (Face windows without command.) (i) Breathing — four times. In — out. (Six seconds for inhalation, four for exhalation — -do not hold breath.) Right or left — face. (2) Relaxing and stretching — four times. Relax (with arms and back relaxed, bend the trunk forward). Stretch (straighten the body and arms upward; stretch to fullest extent). Down (turn hands and bring arms down to sides quickly, without noise). (3) Knee bending and stretching — eight times. (Thumbs locked behind without command.) Down — up (must be done quickly to get hygienic result). Right or left — face. (4) Breathing — four times (same as above). In — out. Class. — Sit. 430 EDUCATIONAL HYGIENE This type of exercise is very much more beneficial where teachers get it done, not as a dead, perfunctory task, but as a joyous, exhilarating opportunity. Organization. — In a large city a department should be organized as follows: Director of hygiene. Assistant directors of physical training. Assistant directors of educational hygiene. Division of medical inspection. Inspectors of athletics for boys. Inspectors of athletics for girls. Special teachers of physical training (district supervisors, elementary schools). Special teachers of physical training (high and training schools) . Local supervisors of physical training (elementary schools). The directors and assistants should be highly qualified with reference to their particular work. Each special teacher should be assigned to the supervision of four hundred class teachers, to visit them as often as possible, to advise, direct, and inspire their work. They should pass an examination on the theory and practise of physical training, and should pre- sent evidence of high-school and normal-school (physical training) graduation. They should be employed for one year as substitutes, and then if found satisfactory receive an annual license for three years, after which time the license may be made permanent. A special teacher should visit the class teacher, observe her work, make corrections, and teach the required new exercises. She should make a memorandum of the results of her observations and leave a written series of suggestions to the class teacher, retaining a carbon as an official permanent record. The following form is used in the New York City schools: i PHYSICAL EDUCATION IN ELEMENTARY SCHOOLS 431 DEPARTMENT OF EDU- CATION, CITY OF NEW YORK SPECIAL TEACHER'S MEMORANDUM P. S. No. Boro. SYLLABUS GYMNASTICS T) S 3 C 1 i si s E bo 1 a •V M "o 3 < b a E E 3 CO CI. Tr. 3 1 a < a a B ,x: 1 3 < •3 0. > Grade Date 19 Date 19 Date 19 ' 1 1 1 1 Date 19.. SUGGESTIONS TO CLASS TEACHER Date 19.. SUGGESTIONS TO CLASS TEACHER Date 19.. SUGGESTIONS TO CLASS FEACHER At the end of the term the special teacher makes out the record shown on pages 432 and 433 for each school. It is necessary to support the work of the special teacher by a system of local supervision. This requires that the prin- cipal, assistant principal, or other assistant in the school itself shall be charged with the duty of visiting and supervis- ing the work in all classes in the interval of the special teacher's visit. The special teacher always confers with the local super- visor upon entering the school. She receives a report of the work and a request to visit certain teachers in special need of assistance. The local supervisor, in so far as possible, should accompany the special teacher on her visit. At the end of the day the special teacher again confers with the local supervisor, suggesting methods of procedure. Inasmuch as < I- < oe > X 0. Bi s H Pi ? o UJ a: 5 y- z < t- O 2 Q 2 H S U H i T r- 2 1 ^ z a 2 U b: « o 7 (O t j! 2 Q 2 W S n u I — 1 1 2! 2 Q 2 » I g s t 2 g e n >- o 1- a o 1- > a O u < z o 1- < o D O o z a I > < o o S h o z 2 o 1- > d o o 1- d 6 o a g a I 1- < I t- < < o h Z I 1- < O o I (r 1- z > < a o O z 1- 1- z g h IS c (- z o i 1- < 3 o I 1- < 5 u d a O i a >- a a T O h UJ Z P d z 0.' z d o H M H M •i u < a 3 a >. '0 1 e 3 1 B i d < a 3 0. 1 1 n s u %■ U) 6 a s i Q o ! Q o 2 >< Q Z 6 Z d ■o la C t > a 1 a 1 1 s S a 1 Q a s S o H U I n < X Z ' u I c Z >• ce K z u > 1 1 1 1 i d n 6 Pi S 3 « a B ci a o s a •0 W % I n > Z 1 >> > n 1 § a 1 X o 1 e p. a a ■S « 0. a 1 a a s a 8 a a o 1 J4 a o 1 H s s 5 < z S >• » a z z u t c K ■ 3 C K K u > z Q 1 n Q a o 03 Q 1 » 1 1 1 i 1 1 s; d X 1 no .2 o a i 1 a s 1 a <: '£ »% X \ 1 ■0 ■o nearly 50,000. Even more striking is the acceleration of increase in the last four years of the series: 72,000 in 1909, and 131,501 in 191 2. The increase in 191 2 is 50 per cent greater than the average of the three years next preceding, and more than three times as great as the average of the preceding twenty years. The proportion of high-school pupils to the total school population has increased threefold in that time. About 23 per cent of the children of the present generation receive some high-school education. There is also a slow but steady in- crease in the number of pupils who persist through the four years of high school. In" 1906-7 there were 89,882 pupils, or 12^ per cent, in the fourth year; in 1911-12 there were 166,- 266 pupils, or i2,y2 per cent. In 1890 the high-school students were slightly less than one-half of one per cent of the total population of the country; in 191 2 a Httle more than 1.3 per cent.^ The significance of these figures lies not in the facts of increase but in the potential community leadership of this rapidly increasing part of the body politic that receives the ' " High School Education," ed. by Charles Hughes Johnston, Introd. (Scribners). = Rep. United States Com. Ed., 1Q12, vol. 2, chap. 8. 'Assuming that the annual increment in population in 1911 and 1912 is about the same as for the two decades preceding. HEALTH TEACHING IN HIGH SCHOOLS 499 impetus of high-school education. The impact upon society of this stream of high-school- trained citizens becomes inevi- tably more massive. Whether it shall be effective in propor- tion to its mass depends upon the character of the high-school training. Whether it shall raise the health standards of the community in proportion to its possibihties for such service depends upon the emphasis that is placed in the high school itself upon the practise and the study of health. It is possible for the high school to ignore both the practise and the teach- ing of hygiene; it is possible for bad practise to nulHfy good instruction; it is also possible for practise and instruction to co-operate in safeguarding and promoting the vitahty of pupils, and in enlightening their understanding with respect to the significance of public and personal hygiene. Not the least of the problems of the "new" high school is this of building up a public-health conscience. The Physical Conscience. — It has been pointed out many times that the worship of Hygeia, so characteristic of the Greek civilization, and so repugnant to the early Christian culture, has revived within the last half-century. The modern at- titude toward health is something more than admiration for physical strength, grace, and beauty. It involves also the idea of duty, the duty of realizing in oneself the physical virtues of strength, efficiency, and endurance. These are es- sential to the achievement of the "aesthetic, intellectual, and spiritual development to which our own age aspires."^ It is the idea of duty in this conception that justifies us in speaking of " the physical conscience." It is the development of the physical conscience that is the special task of health instruc- tion in the high school. Obviously the physical conscience cannot be a resultant of the study of quadratic equations, Latin declensions, and Burke's orations; it must be the re- sultant of hygienic environment, habituation to the practises of hygienic living, and an understanding of the principles of hygiene. ' Ibid., p. 346. 500 EDUCATIONAL HYGIENE The Physical Status of High-School Pupils. — How much the development of the physical conscience is needed is ap- parent when one investigates the physical status of high- school pupils; and even more, perhaps, when one examines their health ideas and ideals. The records of physical ex- amination show a large amount of defect and ailment among high-school pupils; examination of their health ideas and ideals shows an appalling amount of ignorance of both per- sonal and public hygiene and an equally appalling amount of complacency with respect to ill health. Many exhibit an almost fatalistic acceptance of physical inferiority. They recognize neither the disgrace of being weak nor the duty of being strong. Casual observation of high-school pupils shows a surpris- ingly large amount of physical imperfection. Careful phys- ical examination fully confirms casual observation. Recent records of physical examinations in Newark, N. J.,' and Wash- ington, D. C.,^ are probably typical. In Newark during the years of 1911-12 and 191 2-13 prac- tically all of the high-school pupils of both sexes were given systematic and thorough physical examination. The Wash- ington record is of 284 girls in the Eastern High School of that city. In Newark the physical examination showed the fol- lowing results for the two years: Average number of pupils examined 2,186 Average number of pupils normal 802 Average number of pupils with defects 1,384, or 63 per cent The average total number of defects for the two years was 2,204, distributed as follows: adenoids, nasal obstructions, * Rapeer, in "The Modern High School," ed. by Charles Hughes Johnston, chap. XXVII. "^ Small, W. S., "Some Results of Systematic Physical Examination of High School Pupils." Proceedings Fourth International Congress on School Hygiene, 1913. (Reprinted in The School Journal, January, 1914.) HEALTH TEACHING IN HIGH SCHOOLS 50 1 etc., loi; defective hearing, 103; dental defects, 740; enlarged tonsils, 298; visual defects, 555; enlarged glands, 17; heart defects, 102; weak lungs (not tuberculous), 22; malnutrition and debility, 78; mentally defective, i; nervous affections, 5; defective palate, 8; orthopedic, skeleton, chest, 42; spinal de- fects, 19; speech defects, 5; all skin ailments, no. According to these figures two- thirds of the high-school pupils in Newark are physically defective. This does not take account of about thirty classes of ailments not reported in the returns. This is a larger percentage of defect than is found among elementary-school pupils, according to Doctor Rapeer.^ It is probable that there is exaggeration in the Newark figures of the number of cases of defective hearing, defective vision, enlarged tonsils, heart defects, and orthopedic defects. The ratio of these per 1,000 pupils is so much greater for these high-school pupils than for elementary-school pupils, as estimated by Doctor Rapeer, upon the basis of extensive and carefully analyzed data, that the presumption is against the accuracy of the figures. In the case of vision the exaggeration is obvious, as the "standard for defective vision is fixed at 20/30 instead of 20/40, which permits the recording of many minor cases of defective vision that are not referred for glasses." It is likely that the same is true also of the other types of defect. On the other hand, it is not improbable that the examination of these high-school pupils is more thorough than that or- dinarily given to elementary-school pupils. The physical-examination record of 284 girls in the Eastern High School of Washington in 191 2-13 shows general corre- spondence with the Newark record. These students had been in school from one to four years. The numbers are much smaller than the Newark numbers; only girls are concerned; and the examination was a physical rather than a medical examination. On the other hand, the examinations were semiannually repeated. The girls were continuously under » Ibid., p. 686. 502 EDUCATIONAL HYGIENE observation, and medical examinations were made in doubt- ful cases. The examination records were supi)lemented by notes of observations. They are a fuller chart of the health of the individuals concerned than are the Newark records. Of the 284 girls, 168 girls, or 59 per cent, had defects of some kind — 59 per cent as compared with 63 per cent in New- ark. These 168 girls had a total of 378 defects, an average of more than two each. The recorded defects were distributed as follows: eyes, 93; ears, 24; spine, 30; heart, 29; lungs, 2; nose and throat, 19; enlarged glands, 26; developmental, 48; carriage, 71; ankles, 36. These two sets of figures show a large amount of defect and ailment among high-school pupils. The type and fre- quency of ailment found in the high school and the elementary school are similar, and point to an urgent need of enlighten- ment of high-school pupils with respect to health. The significance, however, of figures in regard to the de- fects of high-school pupils lies not chiefly in the prevalence and distribution of defects; it Hes rather in improvement and improvability. The correction of defects and the improve- ment of health during the high-school course are evidence at once of effective health teaching and of the development of the physical conscience. The persistence of remediable de- fects may be no reflection upon the teaching, but it is in- fallible e\'idence that the physical conscience has not been aroused. The Newark records show nothing in this connection. In the Washington school the record of corrections is as follows: Of the 378 defects recorded for 168 girls cited above, 116 defects, or 30 per cent, had been corrected at the end of 1913; and of the 168 girls with defects, 88, or 52 per cent, had had some defects corrected. One-half of the defects of the fourth- year class had been corrected; one-eighth of those of the first year. Thirty-five girls who had been continuously in the school for four years show the following record of correction of defects: HEALTH TEACHING IN HIGH SCHOOLS 503 Year Number of girls with defects Total Number of defects Number of defects corrected I 35 32 29 28 35 25 72 61 56 45 79* 40 13 7 II 8 39 39 II Ill IV Total Number at end of fourth year * Seven new defects were discovered after the first year. The progressive correction of defects is noticeable. In this fourth-year group, 50 per cent of the defects were cor- rected and 30 per cent of the defectives were improved. On the other hand, the number of remediable defects not remedied is eloquent testimony to failure. In case of the 35 girls above mentioned, there were 40 uncorrected defects; only 6, or 15 per cent, were irremediable. In all other cases, the pupils didn't care enough about health to pursue faith- fully the regimen that would have corrected the defect. Oc- casionally the mental, mind-stuff theory of disease stands in the way. In some cases, it is the vulgar fatalism that ac- cepts defect as a matter of course. More frequently, it is mere thoughtless indifference — don't want to take the trouble. In still other cases, vanity rebels against the necessary pre- scriptions as to clothes, shoes, glasses, etc. Unhygienic hab- its of life in some instances are so deeply rooted that a com- plete revolution in respect to diet, dress, sleep, exercise, and work would be required. There is no physical conscience, no appreciation of either the beauty or duty of health. Status of Health Teaching in the High School. — Both in character and extent the present status of health teaching in the high school is unsatisfactory. In 1910 Doctor Gulick^ re- ported that of 2,392 representative high schools throughout the ' Gulick, L. H., "Report on Status of Physical Education in Normal Schools and High Schools," Proceedings Fourth Congress American School Hygiene Association, 1910, p. 174. 504 EDUCATIONAL HYGIENE country, only 16 per cent gave regular instruction in hygiene and only 6 per cent had i)hysical examination of pupils. In II per cent, instruction in hygiene was compulsory. Studies by Crosby 1 and Hunter ^ show that physiology and hygiene in many schools are taught only in the first year of the course, prior to the study of any basic science. The method and matter are merely a rehash of elementary- school instruction. In general, the subject does not command either the interest or respect of the pupils. The case with physical training is no better. Doctor Gulick's report shows that only 8 per cent of the high schools gave regular instruction in gymnastics. In most cases the instruction is formal and involves little collateral teaching of hygiene. There are, however, encouraging signs. In a few States health instruction is compulsory in high schools as well as in elementary schools, and the number is increasing. The rapid growth of medical inspection of schools and the development of medical inspection into health supervision, with a complete programme of health promotion and control in all the public schools, is giving a new impetus to health teaching in the high schools. The organization of health instruction in high schools is making progress. There is still need for propaganda, but the important problem is the content and method of health instruction. Lack of College Credit. — It is alleged that failure of col- leges to give entrance credit for physiology and hygiene is one reason for the neglect and inefiQciency of the teaching in the high schools. This is probably true, as the high school has been and still is strongly influenced by college-entrance requirements. In general, subjects have been legitimized in the high-school course by college favor. Other subjects have come in as poor relations and have been nurtured accordingly. ' Crosby, Clifford, "Physiology, How and How Much?" School Science and Malhcmatics, vol. 7, 1907, p. 738. - Hunter, G. VV., "Biological Science in Secondary Schools," School Science and Mathematics, vol. 5, 19 10, p. 3. HEALTH TEACHING IN HIGH SCHOOLS 505 Three factors, however, are likely to effect a change with respect to hygiene. The first of these is the essential impor- tance of the subject itself. From the practical standpoint its importance is recognized by those colleges which now demand a physical examination as one of the evidences of fitness for college entrance. As soon as it is recognized that systematic instruction in physiology and hygiene has practical relations with health habits and ideals, there will be a more hospitable attitude on the part of the colleges. The second factor is germane to the first — -the colleges are rapidly coming to recog- nize the necessity and the potency of health instruction in college. The necessity is frequently attributed to the failure of the lower schools to provide such instruction, which is, of course, a confession that the high school ought to provide it, *'In 1884 hygiene was taught in 61 per cent of the 46 leading colleges. In 1909 it was taught in 84 per cent of the 116 leading colleges." At the present time "80 per cent of the colleges offering regular courses in hygiene give positive credit for these courses toward the bachelor's degree." The tend- ency is for all college subjects, that are within the capacity of the early adolescent mind, to gravitate, sooner or later, into the secondary school. Obviously hygiene is of this class. The third factor is the growing tendency of colleges to accept for entrance credit any high-school subject that is valuable and well taught. Successful teaching of hygiene in strong high schools will be cogent argument for college-entrance recog- nition. On the other hand, recognition by the colleges would be a powerful stimulus to sound teaching of hygiene in the weaker and more timorous high schools. For the sake not only of the high school but also of its own higher efficiency, the college should encourage this teaching by granting en- tra^xe credit. The Locus of Health Teaching in the High-School Course. — The aim of health teaching in the high school as stated by Doctor Berry is "to give the pupil a scientific knowledge, as far as possible, of the principles of physiology, hygiene, san- 506 EDUCATIONAL HYGIENE itation, and physical education, with a view to their practical application. But if this aim is to be realized the pupil must have acquired some knowledge of biology, and should also have studied chemistry and physics before beginning the proposed course in physiology and hygiene." ^ This means, of course, that this subject must be placed as late as the third year of the course; and, as most high- school courses are or- ganized, it must be placed in the fourth year. This is partly right and partly wrong. That the knowledge acquired by pupils in such a course should be "scientific as far as possible," is self-evident. That instruction in hygiene and physiology must be delayed until late in the course on the ground that the study of biology, chemistry, and physics is a prerequisite, is probably both impractical and unnecessary. The plan presupposes that these three sciences are pre- scribed for all pupils. This may be desirable, but there is slight probability of the general adoption of such a prescrip- tion. Even were it adopted, there would still be the objection that only a minority of high-school pupils would be reached. In 1906-7 the distribution of high-school pupils for the nation was as follows: fourth year, 12.25 P^^ cent; third year, 18.17 per cent; second year, 27.23 per cent; first year, 42.35 per cent. There is a constantly increasing persistence of high-school pupils, as is shown by the corresponding figures for the year 1913-14: fourth year, 14.27; third year, 18.84; second year, 26.75; first year, 40.14.2 Allowing for factors other than mortality, it is certain that even now less than one-half the pupils who enter high school ever reach the fourth year. If instruction in physiology and hygiene is as important as we have contended, then it is imperative that all high-school pupils should have the benefits of such instruction. This is recognized by those States which require this teaching in the first high-school year. There must be health instruction in the first year, but this does not exclude further instruction ^Ibid., p. 357. ^U. S. Bureau of Education, Statistics of Public and Private High Schools. HEALTH TEACHING IN HIGH SCHOOLS 507 in subsequent years. There should be continuous teaching of health, collaterally and incidentally, in all the years of the course; and there should be in the last year a systematic course in physiology, anatomy, and hygiene utilizing the knowledge of the basic sciences that may have been acquired by the pupils, the experience of the students in matters of public and personal hygiene, the data of physical training, the other health agencies and instrumentalities of the school, and the public-health agencies, both governmental and voluntary. There is a great deal of health instruction that is collateral to other subjects and incidental to school life. Wherever facts and principles of hygiene are germane, they should be taught. There need be no fear of wasteful repetition. Repetition under varying conditions and with varying associations means organized, vital knowledge. The relation of air and health will serve as an illustration of direct and collateral teaching. This topic may be taught in the first-year course in hygiene, in chemistry, in biology, in physics, in civics, and in the fourth- year course in hygiene. There need be no repetition that will cause students to "go stale" on the subject. In the first-year hygiene, emphasis will be placed upon the general physiolog- ical facts in regard to air and health. This can be scientific without laboratory or apparatus. It is only necessary that cause and effect be emphasized constantly. For example, give as a problem for analysis the results in health and mental improvement of the open-air school. The report of the re- sults of a year's work in any carefully conducted open-air school will provide the data. Then let the students analyze the conditions and state the factors contributing to results. The work will thus be rescued from the doldrums of grade- school repetition and given interest and vitality. It will be scientific but will not involve technical knowledge of biology, chemistry, or physics. When the student comes to the study of chemistry, he will learn the chemical composition of the air and will have experiments in air- testing. In physics he will learn the significance of air currents, of temperature, humid- 5oS EDUCATIONAL HYGIENE ity, and perhaps the mechanism of artificial ventilation. In biology there should be study of the relation of air to the cells of the body and study of the bacteria of the air. In civics the relation of pure air to industrial efficiency, and laws and ordinances relating to ventilation of schools, factories, etc., should be considered. In the systematic work of the fourth year there should be co-ordination and integration of the knowledge of all the pupils. In few, if any, high schools would all the fourth- year pupils have studied all the subjects specified above. This would not be entirely a disadvantage, as it would give opportunity for co-operative work by mem- bers of the class. For example, those who had studied chemistry might demonstrate the chemical tests of air. The result would be mutual contribution and fuller and more vital knowledge.^ Such a plan of procedure would integrate health teaching. The direct and collateral teaching would not be unrelated and unsystematic, but rather would be co-operative factors in producing the desired result — knowledge that is at once scien- tific and practical. Content of Instruction. — Assuming that formal health in- struction is to have place in both the first and the fourth years, what should be the content of the courses P^ Berry suggests as the essentials "physiology, bacteriology (which is essential to the understanding of the nature of infectious disease), personal and social hygiene, sanitation, and phys- ical education. . . . Now is the time to emphasize social hygiene and sanitation. Let the youth realize that in living hygienically he is doing but half his duty; the other half is to co-operate with others in the struggle to transform an en- ' Davis recommends that hygiene be taught in the first year as a phase of general science. (Report of the N. Y. School Inquiry, Vol. II.) ^ If limited to one year, the content need not on that account differ ma- terially from that suggested infra. If given in the first year, there would be no difference, though in schools where biology is prescribed in the first year the hygiene might be included in the biology. If given in the fourth year, the dif- ference would be in extent rather than in kind. HEALTH TEACHING IN HIGH SCHOOLS 509 vironment unfavorable to the health of the community. . . . There are few pages in modern history more fascinating, and few illustrate more strikingly the power of knowledge, than those which tell of man's desperate struggle with disease. "^ Moseley would prescribe a course for all students in anat- omy, physiology, and hygiene. The character of the course given in the first semester in the Sandusky High School is sketched as follows: "The mere learning and reciting of lessons from a book may not be useless, but it should be supplemented by experiments, some of which the pupils can do at home and report on at school. A fresh heart and lungs should be obtained from a butcher and the lungs inflated. Each pupil should see the circulation in the web of a frog's foot or some other animal membrane. Models of the eye and several other organs should be examined. The application of the lessons to actual living should be discussed freely and the difficulties of properly applying the knowledge acquired should be overcome if possible. The pupil while in the secondary school will not become much of an anatomist or physiologist, but should acquire sufficient knowledge of these subjects to help materially in understanding hygiene." ^ He also emphasizes the conquest of disease. "In a town in Africa I interviewed schoolboys, apparently about twelve years old, who could tell me about Louis Pasteur. In this country are we to turn out high-school graduates who can name the wives of Henry VIII but who have never heard of Pasteur, or Koch, or Chittenden? Are the adventures of JEnesLS at the court of Dido more important or more interest- ing than the discoveries of Reed, Carroll, or Lazear?" An- other urges that the high-school course in hygiene be "dif- ferentiated to meet the needs of pupils entering specific types of vocations." ' ^ Ibid., p. 358. 2 Moseley, "Some Ways of Teaching Practical Hygiene," School Science and Mathematics, vol. 12, no. i, January, 1912. ' Towne, Lillian H., ibid., p. 75. 5IO EDUCATIONAL HYGIENE These citations illustrate the tendency to emphasize social and community hygiene in the high-school course. If the pupils entering the high school have been taught the elements of personal h3'giene in the elementary schools, then the first-year course in the high school should emphasize the social and community phases of the subject.^ The following topics certainly should be included: air and health, including a study of the ventilation of the school; the public water supply, its reason for being and its condition; milk-supply; insect carriers of disease; prevention and control of infectious diseases, including immunity; vital statistics; ^ food, cooking, and pure-food laws; industrial hygiene; the work of the health departments. State and national as well as local; and a review of personal hygiene with special reference to matters of im- mediate significance, such as exercise, military drill, ^ recrea- tion, sleep, vision, elements of mental hygiene, stimulants and drugs, and clothing. Such a content could be given satis- factorily in a half-year course of five periods a week; it could be given better if integrated with the physical-education work, as suggested in the following section, and carried through the first year. The Drama of Preventive Medicine. — Two of the writers quoted above. Berry and Moseley, emphasize what might be called the drama of preventive medicine. This is well. Here is opportunity to appeal to the ancient fighting instinct and turn it to account in the conservation, rather than the de- struction, of human life. There is the patient heroism of research students like Pasteur, Koch, and Chittenden, com- parable to the labors of military strategists; there is the mar- tyrdom of those like Carroll, Lazear, and Ricketts who have ' If the work in the grades has been perfunctory, superficial, or desultory, then the upper-grade book of any of the series mentioned above would serve admirably as the basis of the first-year high-school course. Another useful first-year book is Tolman and Guthrie's "Hygiene for the Worker." ^ Bibb-Hartmann's "The Human Body and Its Enemies" has an admirable chapter on this subject, entitled, "Keeping Account of Our Treasure." ^ In schools that have military drill. HEALTH TEACHING IN HIGH SCHOOLS 511 sacrificed life on the firing-line of health science, correspond- ing to the martial heroes who have held life cheap on many a bloody field; and there are the knights errant of medical science like Goodhue of Molokai, who serve the outcasts of the earth and at the same time add to the knowledge which conquers disease.^ A large part of the instruction in social and community hygiene might radiate from this centre. The teaching easily becomes vital, scientific, and dramatic. Let the starting-point be biography; let the heroism of the sacrifices and the nobility of the martyrs shine forth; but let the scientific achievement in each case be clearly revealed. Concretely, suppose a class of thirty pupils. Let the teacher select for study five or six of these heroic figures, each representing an important sci- entific achievement. Assign each to a group of five or six students, give references, and have reports covering in each case: (i) a brief biography, (2) the special episode, (3) the scientific achievement. The class exercise will consist of presentation and discussion of reports, the teacher correcting, clarifying, and vitalizing the process. Science will acquire for these students a new dignity, and life a new sanctity. Systematic Work in Final Year. — As suggested above, the systematic course in the fourth year should unify and deepen the knowledge of health matters that may have been acquired by the students both in their school studies and in their personal experience. This should occupy one semes- ter. Two plans are feasible : a rather narrowly defined course in physiology based upon laboratory experiment; or a topical ' The drama includes privates who are rarely heard of, as well as the laurel- crowned leaders. After the death of Doctor Lazear in Cuba two private soldiers, John R. Kissinger and John J. Moran, volunteered as subjects .of ex- periment. Major Reed explained to them the danger of the experiment, the inevitable suffering and possible death resulting from the bite of the infected mosquitoes; but as they remained firm he then offered them money compen- sation. Both declined, saying that they volunteered "in the interest of human- ity and the cause of science." "In my opinion," wrote Major Reed afterward, "this exhibition of courage has never been surpassed in the army of the United States." (Coleman, "The People's Health," p. 144.) 512 EDUCATIONAL HYGIENE course, synthetic in character, utilizing the pupils' knowl- edge of the basic sciences, personal experiences, data of phys- ical training, and the various health agencies. If the former method is followed, a well-equipped laboratory is necessary. An adequate text-book and laboratory manual are almost equally necessary.^ If the second method is followed, the plan in use in the Sandusky High School is a suggestive model. 2 The study of hygiene is carried on in connection with rhetoricals. "In the first half of the senior year the essays all pertain to matters of health and are followed by comments by the teacher and sometimes discussion by the pupils." Sub- jects: "Various diseases, their effects, their causes, and how they may be avoided; the pupil choosing a subject, if pos- sible, which he knows about from experience." Other sub- jects are: "The most important factors in the maintenance of health, the most neglected factors in the maintenance of health, erroneous notions about health and disease, length of human life, occupation, exercise, gymnastics, rest, sleep, worry, overwork, clothing, bathing, care of the eyes, care of the teeth, medical education, a doctor's experiences, trained nurses, medical frauds, patent medicines, what a city should do for the public health, and quite a list of subjects pertain- ing to food and drink." The Teacher. — It is essential that the health teaching should be "conducted by a teacher who is interested in it and will endeavor to make it of practical value. "^ This is logically the teacher of physical education. The cultivation of health habits and ideals is the chief function of the physical trainer. Drills, setting-up exercises, apparatus work, dancing, games, athletics, are all worth while but only as they are instrumental in building up positive health in the pupils and quickening in them a sense of the dignity and the worth of physical fitness. ' Such as Eddy's "Text-book in General Anatomy and Physiology and Experimental Physiology and Anatomy" (American Book Co.) and Hough and Sedgwick's "The Human Mechanism" (Ginn & Co.). 2 Moseley, ibid., p. 3. » Moseley, ibid., p. 2. HEALTH TEACHING IN HIGH SCHOOLS 513 The gymnasium and the playground are laboratories for the study and the application of the principles of hygiene. "The teacher of physical training and gymnastics is the most effective because the most intimate teacher of personal hy- giene. The physical examination and the conduct of phys- ical exercises give occasion and opportunity for instruction in every important aspect of hygiene both personal and general. The harvest from this field is rich for the high-minded and adequately prepared teacher.'*^ After all, effective teaching is not that which develops a subject but that which touches the individual. Adequate physical examination, without which physical training is shooting at random, brings the teacher into the closest and most confidential relations with pupils. It enables the teacher not only to prescribe regimen for the individual but also to generalize the physical conditions and needs of the mass of pupils. It opens the way for effective co-operation with parents, without which instruction is largely void of practical results. It is rational and economical, therefore, to concentrate in the hands of the physical- training teacher both the practical training in physical morals and the scientific and formal teaching of physiology and hygiene. This is in line with the tendency, in the general super- vision of health in school systems, to concentrate all health activities in one department. The Boston Department of School Hygiene, which is the prototype of many others, has general control of all matters affecting the physical welfare of pupils and teachers, except inspection for contagious dis- ease, which is under the Board of Health. The director has charge of physical examinations, nurses, instruction in phys- iology and hygiene, gymnastics, athletics, and playground in- struction. Newmayer^ gives as the functions of "medical » Small, W. S., "Biologic Science and Health," Proceedings First Congress of the American Association for the Study and Prevention of Infant Mor- tality, p. 34. 2 "Medical and Sanitary Inspection of Schools, Philadelphia," Lea & Febiger, 1913. See also Rapeer, "School Health Administration," Teachers' College Press, 19 13. 514 EDUCATIONAL HYGIENE inspection": detection of contagious diseases, detection of physical defects, finding capacity of individual pupil, insuring hygienic surroundings, and teaching hygiene and healthful living. The movement toward the centralization and co- ordination of all the health factors in the educational practise and environment is very marked. The concentration of all the physical-welfare interests of college students in the department of physical education is already an accomphshed fact in most colleges. The activities usually so grouped "include the teaching of hygiene, gym- nastics, and athletics, care of students' health, and, in some cases, the supervision of the sanitary conditions of school- buildings, dormitories, kitchens, water-supply, and grounds. The further development of this growing tendency is limited only by the supply of competent men." ^ In the College of the City of New York such co-ordination has been very com- pletely worked out under the direction of the professor of hygiene and physical education. ^ It might seem that this plan would emphasize personal hygiene at the expense of social hygiene, but that is far from necessary. Wherever students have community interests and practises there will arise problems of community hygiene. "The sanitation of the exercising hall, the locker- room, and the swimming-pool are emphasized as matters of community importance and each student is taught the obligation to him- self and to the community in which he lives in his relation to his fellow students. In this connection it may be noted that the swimming-pool serves as a sort of index to the standard of hygiene maintained by the student community using the j)ool. If the bacteriological analysis shows evidences of human contamination, the fact is brought to the attention of the ' Meylan, " Report of the Committee on Status of Instruction in Hygiene in American lukicational Institutions," Proceedings Fourth Congress of American School Hj-gienc Association, iqio, p. 173. - Storey, " Protection of Student Health in the College of the City of New York," Bulletin No. 46, U. S. Bureau of Education, 1913, "School Hygiene," P- 75- HEALTH TEACHING IN HIGH SCHOOLS 515 classes using the pool and responsibility is placed upon them."i At present the swimming-pool is exceptional in the high- school equipment. Within the next decade it will be common in large new high schools. Where it exists, no better means of community hygiene instruction could be desired. The co- operation of the biological department is required for bac- teriological analysis. Where there are shower-baths, students are frequently careless about the use of dressing-booths and towels. A scarcely less impressive lesson might be based upon bacteriological analysis of towels. The active co-opera- tion of the student body in promoting cleanliness and general community hygiene may be organized. This, indeed, may be done independent of any formal teaching of hygiene by physical trainer or any other teacher,^ but would be a natu- ral development of organized hygiene work in the physical- training department. Physical training should be compulsory through all four years. The logical plan would be to have the teachers of physical training give the first-year course in physiology and hygiene, as specified above, carefully co-ordinated with the practical work in physical education. The most vital prob- lems of personal and community hygiene should be selected for treatment. Time should be allowed for incidental instruction in hygiene throughout the course. To insure realization in conduct of knowledge acquired in the first year, there must be the constant reinforcement of repetition. Application and implication must be renewed, emphasized, amplified. It would not be necessary or even desirable to have a fixed time for such instruction, but the teacher should be alert for occasions for such instruction. Violations of hygienic recti- tude by members of the class, illness or quarantine of a mem- ' Storey, ihid., p. 76. 2 Hunter, U. S. Bureau of Education, Bulletin No. 48, 1913, "School Hy- giene," p. 48. An account of an interesting and successful movement of this nature in the DeWitt Clinton High School. 5l6 EDUCATIONAL HYGIENE ber, revelations of "unfitness" in athletic meets, results of physical examinations, improvements made in sanitary con- ditions of the school, lunch habits of students, care of lockers, ventilation of classrooms — these are illustrations of occasions for halting physical exercises and having a heart-to-heart talk with (with, not merely to) a class group. Further, there should be the means in the gymnasium for demonstrating physic- logical and anatomical facts as occasion may arise. A mani- kin, models of important organs, charts, and lantern slides should be essential parts of the equipment of the physical- training room. References should be easily available so that important topics may be studied further and reported upon. Conclusion. — Two objections may be made to this plan of procedure — one, that as yet comparatively few high schools have a teacher of physical training; the other, that com- paratively few teachers of physical training possess the scien- tific training in biology, physiology, and hygiene requisite for the successful conduct of the health teaching as outlined. These objections lie not against the plan itself but only against its present feasibility. It is true that few schools have a teacher of physical training — 8 per cent according to Gulick's investigation, cited above — but it is equally true that few schools include health teaching in their courses of study. Recognition of the unitary character of these two factors in health education will give both impetus and direction to the movement for definite and systematic teaching of the sub- ject. The other objection is no more substantial. It is prob- ably true that many, if not a majority, of the present high school teachers of physical training are disciples of some "school" of gymnastics. Comparatively few have been broadly trained in the sciences that are fundamental to the understanding of hygiene. They are teachers of gymnastics, not of hygiene. This condition, however, is improving. Uni- versities, colleges, normal schools, and the special schools of physical training are gradually establishing physical educa- tion on the right basis. An insistent demand for teachers HEALTH TEACHING IN HIGH SCHOOLS 517 of physical education, adequately trained according to the standards indicated in this chapter, will tend to hasten the supply. In the meantime, the instant need must be met in the practical way suggested at the beginning of this section, by placing the health instruction in the hands of a teacher, regardless of his major subject, who is interested in the matter and will grow up with the work. CHAPTER XXVII PROFESSIONAL TRAINING OF SCHOOL-HEALTH WORKERS Teachers, Nurses, Physicians, Physical-Educationists, AND Hygiene Supervisors The Demand of Public Opinion. — The recent arousal of the American people to a fair sense of the importance of the values of health, vigor, bodily resistance, conservation of vitality, and normal physical development is without parallel since the days of ancient Greece. The playground move- ment, the tuberculosis movement, the medical-inspection movement, the anti-fly, the anti-common-cup and common- towel movements, the open-air-school movement — these and a great many more health developments have moved over this country in the last few years hke fire in dry prairie grass. ^ Were we able to plot for all these movements a composite curve of growth, we should undoubtedly be able to demon- strate what Gulick and Ayres in 1910 showed for medical inspection, that at the rate of increase now going on most cities and villages, at least, will in a few years be supplied with most modern school-health provisions. The school-health movement could hardly be said to have begun before 1904 or 1906, and is therefore little over eight or ten years old, about the age of a child when he enters his first serious " tran- sitional" stage of development. This has been the public demand, and it has caused the movement to grow with such rapidity that its transitional stage now imminent bids fair to be as serious as that of children when they lose their temporary teeth, become weak and flabby, and suffer a high morbidity. According to ' See the heallh and mortality symposium in the Popular Science Monthly for April, 1915. S18 TRAINING OF SCHOOL-HEALTH WORKERS 519 a rule of our democracy, of which Lowell long ago spoke, we Americans have a hip-hip-hurrah manner of quickly taking up new movements; hiring some persons, chosen almost at random from our midst, to start the picked-up machinery; and then, thinking we have done our entire democratic and patriotic duty, have either rushed off after some other new idea or have complacently gone home, never after giving a thought to the new agency we have called into being until it breaks down from sheer inefficiency and lack of public sup- port, thus reminding us of our former dreams of automatic governmental achievement. We have, then, according to this method, many new phases of health work and multitudes of new health responsibilities thrust upon the schools. The administrative machinery is poor or absent altogether; the nurses are "visiting" or other nurses picked up almost at random, or even substitute teachers of the schools; the doctors are commonly part-time physi- cians of the kind so ably and so mercilessly described by Flexner in his searching investigation of American medical schools; the teachers are supposed to inspect their children medically and send down the ailing ones to doctor or nurse, when they have for the task neither medical nor hygienic training or interest; the physical-educationists face their en- larged duties with still less training if possible, even though they have been supposed to be the special guardians of the physical welfare of the children. Moreover, all these people are miserably paid for their work; there seems to be httle evidence of much increase of attention to their education to meet their larger responsibilities; and if this new health in- strument and agency, like so many before, does not actually break down from a lack of the necessary democratic "follow- up" method, the school-health movement is, in this predica- ment, doomed to only very limited and half-hearted success. The problem of the strengthening of the movement by the fundamental method of strengthening its agents is the problem of this chapter. 520 EDUCATIONAL HYGIENE Limitations in Meeting the Demand. — In meeting the demand of pubHc opinion and public sentiment, however, there are decidedly discouraging limitations. It is all very well to describe in a general way what the talented and well- trained professional teacher should or may do in meeting the health and developmental needs of her children, her school environment, and her community. But when we remember that few teachers, comparatively, are talented, well trained, or professional; that few have an education at a normal school where there is a yet unrealized possibility of getting some knowledge of educational hygiene; that half of the teachers of this country, according to Coffman and other investigators, have not even a high-school education; that for all teachers in elementary and high schools the average period of service in teaching is only four years; and that the large majority of these uneducated teachers are young girl novices without ex- perience and without any very professional interests or abil- ities, then we see some of the peculiar and serious limitations set upon the school-health movement. There is little need of idealizing over what the schools will in a few years do for the health of this country, when we are confronted by a situation like this with respect to the fundamental school- health agent, the teacher. What is said of teachers will also apply in general to the other more or less specialized health workers. The best plans we have yet had made for the development of school-health work in this country agree pretty well in the demand for one nurse and one part-time physician for each two to three thousand pupils in the public schools. Taking twenty-five hundred instead of these numbers as the standard and dividing this into twenty million, the number of school- children, we see that the tendency is strongly in the direction of the appointment of some eight thousand doctors and eight thousand nurses for public-school work, not counting medical supervisors, nor physicians and dentists in clinics. Of teachers we have a half million, one-fourth of whom are TRAINING OF SCHOOL-HEALTH WORKERS 52 1 dropping out of teaching each year, while normal and other professional- training schools furnish only about twenty thou- sand — -less than a sixth of the annual number needed. When it comes to psychologists for pubHc-school psychological clinics we are little better off. How to Meet the Problem. — Evidently we shall be com- pelled under existing conditions to depend on many more mechanical and routine factors than the health training of teachers before or after they enter the profession. Among some of these factors that now present themselves as being most practical are the following: (i) The appointment of investigating committees to study and to recommend definite standards for as many phases of school hygiene as possible. (2) The establishment of departments of educational hy- giene in State and local departments of education with men at their heads who are first-class speciaHsts in this field, and who are given a good deal of power and financial resources to enable them to put into the hands of the teachers, nurses, doctors, school boards, and others the school-health stand- ards developed by the specialists, and which they can more or less mechanically follow. Such reasonable standards as jacketed stoves for rural schools, lighting space which is equal in area to one-fifth or more of the floor space, and the 20/40 dividing line for defective vision with Snellen's test-charts used as directed — all such standards can be enforced by expert State and local authorities with considerable improvement in school-health conditions. Often the reason communities and school workers do not get health results is because they do not know reasonable health standards. They do not know, for example, how much light a school should have or how ap- proximately to measure it. When they are told the standard, they may be enticed or made to act in accordance therewith. (3) State and local surveys, such as the recent Ohio, Pennsylvania, Illinois, and Vermont surveys, which will show up the health needs, as measured by certain standards given wide publicity. 522 EDUCATIONAL HYGIENE (4) The establishment of departments oj school co-operation in State and local departments of education, where skilled public-opinion and public-sentiment developers may help all lay and professional organizations of the State to put their shoulders to the wheels of school-health progress, thus fur- nishing the schools both with public-opinion pressure and public-opinion support for progressive health measures. Such a department has recently been established in the reorganized State Department of Education of Ohio. (5) The school-health training of teachers, nurses, doctors, and others while in service. (6) The education of prospective school-health workers in the science and practise of educational hygiene, in high schools, normal schools, medical schools, and elsewhere. The Health Education of Teachers. — For the sixth or seventh of the teaching force of the country that receive some professional preparation at normal and other professional schools a vast improvement in health education is necessary and easily possible. If the work in personal and public hy- giene, physical education, medical supervision, etc., were well done in the elementary and secondary schools, the re- sponsibilities of professional institutions would not be so great. But this foundation work is very deficient, as all studies and surveys show. Several studies show how the pro- fessional institutions are meeting the problem. While most training institutions have required courses in educational psychology, educational history, educational methods, and even educational administration and educational sociology, yet very few if any have satisfactory courses in educational hygiene. Several studies show how pedagogical training schools are meeting the problem. We may refer to but one or two. Terman, in his volume on "The Teacher's Health," briefly summarizes Heche's investigation by questionnaire of "The Teaching and Practise of Hygiene in the Public Normal Schools of the United States," returns from eighty-four of the better class of schools being used and showing: TRAINING OF SCHOOL-HEALTH WORKERS 523 (i) That one-half of the eighty-four schools offer either no hygiene at all, or else none aside from that given incidentally in connection with physiology. Nine schools give neither hygiene nor physiology, and those giving the latter devote so little time to it (usually one- third or one-half of a year) that very little can be accomplished in hygiene. (2) That courses in personal hygiene, school hygiene, sanitation, prophylaxis, clinical psychology, etc., are only slowly finding a place in the normal-school course of study, and that mental hygiene is re- ceiving scarcely any attention. (3) That comparatively little is being done with the problem of sex hygiene in the way of direct instruction, and that the normal schools are not making the best of their opportunity to train teachers who can use nature study and biology as an approach to the subject. (4) That in the practise of hygiene nearly two-thirds of the schools confess themselves guilty of harboring conditions that should not be allowed to exist, chiefly inadequate ventilation, improper lighting, unsatisfactory boarding and rooming places, and overpressure. (5) That 25 per cent of the schools do not have a gymnasium in the charge of a physical director and that athletics and recreation do not receive the attention they should. (6) That but few of our normal schools are giving special training to teachers in the observation of physical defectiveness or in the ap- plication of mental and physical tests. (7) That only one of the eighty-four schools attempts to train special teachers of hygiene for the public schools. (8) That, on the whole, sufficient science is offered (though not necessarily required) to serve as a reasonably good foundation for the various forms of hygiene instruction, and that a good proportion of the teachers of physiology and hygiene in these schools have uni- versity or college degrees and are probably capable of doing better work than their present allotment of time permits. In the light of the modern advances in preventive medicine, to- gether with the wide-spread interest in the social aspects of hygiene and the recognition of the importance of athletics, play, and the phys- ical side generally in the scheme of education, the present compara- tive neglect of educational hygiene in the normal schools becomes an intolerable anachronism. These conclusions are verified from many different angles, such, for example, as the inability of teachers to care for their own health. And if these chosen few who go into the schools with professional training are so deficient on the whole 524 EDUCATIONAL HYGIENE physical side of development, then, hygienically speaking, we have in the schools little more than the blind leading the blind. Every teacher should learn before she is ready to enter the normal school or the schoolroom the principal facts of personal and public hygiene. If she lives in the country and is to teach in the country, then her study of public hygiene should be principally that of rural hygiene closely related to the serious health, medical, recreational, and sanitary problems of rural life. If in the city, she should "know her city" from the health standpoint. This teaching must be done in ele- xnentary and high schools. Then, with some study of biology, chemistry, domestic science, and elementary sociology, rural or urban, she should go forward into the field of educational hygiene, not to master the whole science but such facts as are most essential for our teachers in their schools and class- rooms to know. This will mean that she will learn not only the mental nature of children but she will learn to understand and recog- nize mental and physical abnormalities with reference to certain norms or standards. She will learn to look upon chil- dren not as mere disembodied mentalities but as physical beings as well. To a large extent, with a little study and practise, each intelligent young teacher can learn in her pro- fessional training course how to inspect medically and test her pupils. Doctor Hoag says a good teacher can easily learn to pick out 80 per cent of the ailments and defects of children and will miss very few serious cases. If she has the jight kind of ability, too, and learns how to meet parents and utilize other curative agencies, she can get most ailments and defects cared for. Of course, she should be relieved by a good nurse, but even where there are nurses the responsibility of teachers is great and growing in this direction. The normal school should have clinics for elementary diagnosis, where a number of children are brought in before the classes and the symptoms of the important ailments and deficiencies pointed TRAINING OF SCHOOL-HEALTH WORKERS 525 out by a competent person. It will not be long before actual and prospective teachers will have for their daily use con- venient and practical handbooks of school health which in the simplest and most convenient form will place before them, not a great cumbrous science filled with engineering, medical, and administrative problems which will never confront a teacher, but the main facts regarding the health of herself and children, of the sanitation of her own and the pupils' environ- ment, the teaching of modern hygiene, physical education, and the hygiene of instruction, over which she and the pupils and parents have some immediate control and responsibility. Along with this study should be furnished simple symptom charts^ showing teachers how to read each child's "health index"; simple statements of reasonable standards for the health and physical development of children; simple forms for surveying the sanitary condition of the schoolhouse, the school-yards and their equipment, with clear statement of reasonable standards to work for ; simple statements of how to promote the physical development of children, with reason- able standards of physical proficiency to be striven for at various ages for different groups; simple statements of the subject-matter, methods, and texts that will bring about most readily the best health knowledge, health ideals, and health habits for pupils and community; and, finally, simple statements of how to teach in such a way as to make the very life of the school and the methods and atmosphere of its work contribute to health, well-being, and happiness instead of nervousness, overpressure, antagonism, routinism, and dis- piriting inefl&ciency. For those teachers who have not had the advantage of pro- fessional training — the large majority — we must resort to a variety of methods besides those mentioned, such as furnish- ing them health handbooks and forms, and insuring them good hygienic training in their elementary and high-school courses. They must have a large amount of skilled health supervision »See page 215. 526 EDUCATIONAL HYGIENE according to some such administrative plan as that suggested in earlier chapters; their communities must be set buzzing about their ears demanding superior school-health provisions, as suggested in chapters on pubUc co-operation; teachers' institutes, teachers' meetings and associations, reading cir- cles, lectures, traveUing moving pictures, models of sanitary schoolhouses and equipment to be sent to districts requesting them, bulletins from the State and Federal bureaus of educa- tion, the assistance of doctors and nurses, parents' associations, health days in the schools, budget exhibits, the co-operation of school-children for school-health work along the lines of self-government, student investigations of school and com- munity sanitary conditions — these and a great many more methods can be utilized to improve the health conditions of schools in spite of the limitations of poor, inexperienced, transient teachers. The Training of Nurses.^ — Next to the teacher the most important health agent in the average community will be the well-trained or the adaptable school nurse. Unfortunately, the education of nurses is about as poorly provided for as is that of teachers, and is claiming a great deal of attention on the part of those interested in school-health advance. The school nurse is the most important special health agent the school is to acquire in this movement, and upon her skill and breadth of training depends very greatly the extent of the school's service to the public. She must hereafter be regarded as an integral part of our educational system. That system has through long years of development been brought to a high state of organization. Pupils have been graded, subjects have been elaborately de- lined for every grade, teachers have been provided for every subject, a body of officers of varying rank and degree have been installed. iThe editor has received the skilled assistance of Ella Phillips Crandall, R.N., Executive Secretary of the National Organization for Public Health Nursing, in the preparation of this section, most of it being her work. TRAINING OF SCHOOL-HEALTH WORKERS 527 In like manner an appropriate system of training has been elaborated for each member of the teaching and official body wherewith to give him suitable command of the subjects he teaches and the duties he performs. We have gone still farther. Laws have been procured requiring that persons desiring to teach shall equip themselves in certain well-de- fined ways, and shall pass certain prescribed examinations, and shall receive certificates testifying to their adequate prepara- tion to do the work required. In like manner and in the same degree is it necessary that we should require for a branch of school work so vitally im- portant as the health of the children, workers who have been carefully and adequately prepared for the work which they have to do and whose training has been directed toward a definite and special end. But how have we carried out these principles in this new and important addition to our public-school forces? What are the present requirements, so far as any exist, for the prep- aration of school nurses? Whether medical inspection is conducted under depart- ments of education or departments of health, the usual quali- fication for appointment of the school nurse is that the candi- date for the nursing service shall have had the training of a nurse. In most instances this is the highest if not the only requirement. In a few places additional qualifications are that the candidate shall be a registered nurse and shall have passed civil-service examinations. However, even the funda- mental requirement that the candidate shall be a graduate nurse, having received the full ordinary training of a nurse, is not always required. There have been numerous instances in which personal friendships or political interests have con- trolled their appointments, to the obliteration of all suitable standards of training and general education. What Graduate or Trained Nurse Means. — The present general requirement, then, is graduation from a training school for nurses, and it is necessary, therefore, to understand 528 EDUCATIONAL HYGIENE clearly what, in the present state of nursing education, this means. To set forth fully the present status of training schools for nurses would require more time than is allotted to this paper. We can only point out very briefly a few perti- nent facts and some of their causes. Practically all training schools are under the control of the hospital management to which they are attached. All are created primarily for the purpose of serving the hospital rather than of educating nurses. The hospitals themselves vary in size from ten to one thousand beds, and their range of service is as varied as their capacity. Some are intended and equipped for the treatment of one kind of disease only, others for general service. Because of these facts, the clinical op- portunities afforded by these institutions and the attitude of their boards toward the importance of the nurse's education determine both the character and extent of her training rather than any suitable, recognized, and accepted standard. Therefore the term "graduate" or "trained" nurse is at pres- ent capable of many interpretations and is no guarantee what- ever of even a sound general training in nursing. Nothing more clearly demonstrates this fact than the existence of the numerous short-term and correspondence schools. For instance, the Chautauqua Correspondence School alone graduated during the past ten years approxi- mately twelve thousand students as compared with approxi- mately eight thousand from all the registered schools of New York State. Among other efforts to improve these conditions, attempts have been made in thirty-five States to establish standards of training for nurses by statute and by the use of the term "registered nurse" applied to those whose training has covered certain prescribed ground and who have passed certain re- quired tests and examinations. In States where such laws obtain, the basic qualification for a school nurse should be not a "graduate nurse" only but a "registered nurse." This not only upholds and strengthens efforts to maintain educa- TRAINING OF SCHOOL-HEALTH WORKERS 529 tional standards, but also affords the only guarantee at present existing that the candidate has received even a minimum of suitable training and experience. Qualifications of a School Nurse. — But even this com- paratively recent and by no means general requirement does not express the measure of preparation necessary for the school nurse or for any other worker in the various fields of public-health nursing. The nurse should stand educationally on a level with the teaching staff. Her qualifications should go back of and beyond that of registration. It should be in- sisted upon that her preliminary education shall be at least a high-school graduation or its equivalent. At present the stat- utory requirement in some States is one year of high school, and nurses are holding even that standard with difficulty, owing to pressure from institutions determined to lower educational requirements for admission. At present, therefore, it is obviously necessary to select carefully even among registered nurses to secure those who have had suitable general education, and yet there should not be placed upon the staff of the public schools in the capacity of school nurses women of much lower educational attainments than would be appointed to any other office in the schools, either as teachers or supervisors. As a fair proportion of women graduating from our nurses' training schools have had full high-school work or normal training, while several have college degrees, or a partial college course, it will be possible ultimately to secure women of such education when once the requirement is made. Such a re- quirement will be of great help to nurses' training schools, lending support and strength to their efforts to maintain suit- able educational admission standards= But we must go farther. The public-school nurse needs a very considerable amount of special training not at present provided in any school of nursing. It is to be hoped that the day may not be far distant when our training schools may be free to so enlarge and extend their curricula as to provide 530 EDUCATIONAL HYGIExNE several courses of education for their students, each leading to its own diploma, and that this may be done without hazard to the present standards of work in our institutions, w^hich in a great many instances are even now pathetically meagre. Until then the special training needed must be sought and found in postgraduate study. Training with Children. — The work of the school nurse, though dealing with all classes and ages of people, is primarily among children. Some hospitals afford no opportunity what- ever for training in this branch of work, and no general hos- pital, as a rule, gives enough to prepare a nurse properly for school work. The school nurse needs a very special and practical train- ing in the observation, study, and care of children. She should be quite familiar with the ordinary diseases of children. She should be especially so with all the commoner infectious dis- eases of childhood and with their early symptoms. Nothing short of several months in a children's ward or hospital can pro- vide a nurse with that first-hand knowledge and experience which her work among children calls for. In addition to this, there should be some further study in a dispensary or clinic in the following special subjects: dis- eases of the eye, ear, nose, throat, and infectious and skin diseases. The quick recognition of any departure from the normal in all of these should be expected of the school nurse. She must, in other words, diagnose that something needs to he diagnosed. This means only that the nurse exercises the function which every mother exercises whenever she sends for the doctor, except that the nurse acts upon the intelligent judgment which comes from more expert knowledge. Her work is by no means limited to the school. It ex- tends to the home — a highly important part; indeed, by some considered the most important — where, for such reasons as the exclusion of the child from school because of some infec- tious condition or for other causes equally urgent, the mother needs advice and instruction. Many questions arise in the TRAINING OF SCHOOL-HEALTH WORKERS 53 1 course of the nurse's home visiting which do not bear di- rectly upon the child's physical condition or care, yet do in- directly affect it and therefore must be not only recognized and understood by the nurse but handled intelligently. Education in Health Sociology. — It is here that school nurses have failed often and seriously for lack of adequate preparation for their work, and in consequence have been subjected to severe criticism from their social-worker col- leagues. It cannot be urged too strongly that, because of the nurse's unique opportunity (due directly to her intimate re- lation in the homes which she enters) to render a many-sided service, she should be so trained as to qualify her to meet and handle effectively the varied demands that are made upon her. These may be any of the problems which arise in the indus- trial family. They range from improper home conditions and parental neglect, owing to ignorance or bad habits, to bad housing or other conditions due to private or municipal neglect, or they may be those of extreme poverty. To deal with these intelligently requires a special training in the treatment of social and municipal problems. This training should include something of housing laws, of domestic and municipal sanitation, and of such local regulations relating to them as will enable the nurse to lay hold promptly and with assurance upon all public agencies. In like manner the nurse must be equipped to meet the almost constant demands for relief, for it takes a special train- ing to know how to give this so that it will not prove to be a positive injury. The right persons or agencies must be sought for the treatment of such problems as cannot be handled ap- propriately by the nurse. She will be the one to discover the problem; she will not always be the right one to deal best with it, but in either instance the nurse is called upon to render a social diagnosis for which the treatment may involve serious and lasting consequences to the family. Home Hygiene. — To teach the mother how to feed her children becomes one of the nurse's most frequent duties. 532 EDUCATIONAL HYGIENE To do this requires a special training in nutrition and in dietaries for children of different ages, whereas in her training school the nurse has learned only foods and cookery for the sick. And to this should be added a very careful study of food economics, so that the mother may be taught how to buy economically as well as cook properly the desirable food for her family. To become an expert in her field, the nurse must go still farther — she will find it necessary to specialize on the subject of child life, the physiology, hygiene, and diseases of chil- dren, and child psychology; she will study the history and present status of the movement in behalf of conservation of infant and child life, and these will call for at least elementary courses in sociology, economics, and vital statistics. She will also acquaint herself with the present problems and tendencies of education in order to make herself an intelligent and sym- pathetic co-operator with teachers and officers of the school system. Moreover, there are occasional demands upon the nurse to teach elementary hygiene in the younger grades. To do this requires the same special preparation as is demanded for regular teachers, but, granting the nurse is thus equipped, she should be exceptionally capable of presenting the subject of hygiene in a telling and vivid way. There is still another tendency in some places, i. e., to place the sanitary supervision of the school-buildings in the hands of the school nurse, and there can be little doubt that a vastly higher standard of common cleanliness would prevail in our schools if nurses were given some authority in this de- partment of school hygiene. It is freely acknowledged by some sanitary experts that nurses make the best inspectors of homes. In the light of recent investigations made by the Russell Sage Foundation' and others revealing conditions of uncleanliness in some of our schools which are a constant menace to the health of the children, it cannot be too much 'See Report No. loi, "Department of Child Hygiene." TRAINING OP SCHOOL-HEALTH WORKERS 533 to say that the conscience and intelligence of a trained woman could well direct the activities of the ordinary school janitor. Summary of Professional Training Needed. — The nurse who would adequately prepare herself for expert service as a school nurse should add to her general hospital training the following : (i) Special theory and practical experience in the care and study of infants and children, including general diseases of childhood, contagious and skin diseases, and those of eye, ear, nose, and throat. (2) Special dietaries and food economics and nutrition. (3) Physiology, hygiene, and psychology of childhood. (4) History of the movements in behalf of child welfare. (5) Domestic and municipal sanitation, including house construction. (6) Principles and methods of relief. (7) Principles and methods of teaching. (8) All of these will have their foundation in at least the elements of sociology, economics, and vital statistics. Departments providing such training are now established in several of our universities, and certain elementary courses of instruction are provided for those whose work brings them every day into the midst of social problems and compels them to take at least the first steps toward a proper handling of those problems. Nurses themselves are painfully conscious of their in- sufficient preparation for this important work, which is fast assuming the proportions of a national service, and are in steadily increasing numbers seeking to supplement their hard-earned experience with more fundamental knowledge. Therefore, while the claims made in the beginning of this paper, i. e., that in spite of her meagre preparation the school nurse's work has been to a large degree efifective and that she has already become an indispensable factor to the cause of school hygiene, still we confidently assure our friends and co- workers, the teachers and doctors, that each year will witness 534 EDUCATIONAL HYGIENE a substantial lengthening of the role of adequately prepared women to direct the work of school nursing. Training of Supervisors of Hygiene and Assistant Physi- cians. — The average physician is poorly trained for school- health work. Few medical schools give much attention to pediatrics, and the course is not usually required. The gen- eral physician is usually far from being a child hygienist or children's physician. Much of his course in the ordinar}^ medical school contributes little or nothing to his efficiency in school work. Several entire courses and many phases of certain subjects could be omitted from his training. Disre- garding the low state of efficiency of many medical schools, according to Flexner's expose, the whole spirit and purpose of these schools is different from that which should be held by the school physician. Their purpose is to train men to cure existent disease; his purpose is to prevent, diagnose, and help to get cured, largely through agents other than himself, the ailments and defects of school-children. The knowledge of the school physician must be of children, mentally and phys- ically; and it must be gained from the standpoint of a state official in public service. Cities and rural regions should demand evidences of special training on the part of physicians in the field of educational hygiene, especially of school medical supervision, and the supervisors should give them further training while in service. Where whole-time assistant physicians are employed, as is now becoming the case in our largest cities, we have the be- ginning of a new branch of the medical profession, or per- haps rather of the educational profession, that will require special courses different from those usually given for the M.D. degree. The best medical schools now require three years of college work and four years of medical work, or seven years beyond high-school graduation. As the rapidly widening field of school-health work offers better salaries and numerous opportunities, arising from the demands made by communities, many young men will wish to make special j)roparation for such work. TRAINING OF SCHOOL-HEALTH WORKERS 535 This specialized course cannot well be arranged either at a teachers' college or at a medical school alone, although a good start could be made by adding a professor of educational hy- giene to some of the best medical schools, and providing for dif- ferentiated medical courses, emphasizing pediatrics, practical sociology, and educational hygiene, including medical super- vision and the other four divisions (five, if we take child psychology, including mental tests, etc., out of medical super- vision and make of it a separate division). Such a course, supplemented by a period of service in a children's hospital and dispensary, would be satisfactory for assistant physicians. The study of obstetrics, pharmacology, and the diagnosis and treatment of adult diseases might be either omitted or short- ened, thus giving time for the educational work. Such courses may ultimately be completed at an earlier age than at present by the adoption of several of the short-cut, waste-eliminating methods now being tested experimentally at the University of Chicago and elsewhere for the course of education from the elementary school up. The specialized training in educational hygiene cannot well be expected from part-time school physicians. They will require training in service by the supervisors of hygiene and in short summer courses at professional schools; but by careful selection through examinations and other means such physicians may be selected as have had preliminary training and experience somewhat along the lines of child hygiene. The demand for such qualifications, backed up by adequate salaries, will prompt many young physicians in training to obtain courses and experience along these Hnes. The supervisor of hygiene should be a child hygienist, a doctor of public health along school lines, a practical sociolo- gist, an educator, especially in the field of physical education, a sanitarian, and a psychologist. Obviously, such all-round training cannot now be procured in a reasonable length of time. The task becomes one of selecting that knowledge and experience which is of most worth, and the development of courses which will provide in a few years the essential ele- 536 EDUCATIONAL HYGIENE ments necessary for success in supervising the several phases of health work, especially medical supervision (including psychological examinations), school sanitation, and physical education. With adequate vocational guidance, such a train- ing for many young men could begin in the high schools. Boys interested in science, skilled in play and athletics, and with a capacity for leadership may easily be guided, with benefit to all, into medicine, and that form of public prevent- ive medicine which we here call educational hygiene. The college course preliminary to the professional training may also be arranged with this object in view. The work in phys- ical education may all be done in the college course, perhaps, so that the young man need spend little time in the study of physical education, normal diagnosis, etc., after graduation from college. Of course, he must know more of this field than the teachers of physical education he supervises, at least in a general way. Obviously, too, a supervisor so trained will command a salary of two to four thousand dollars when he is ready to take up his work. Several cities are now paying this amount, and the tendency is strong in the direction of the appointment of such men. New York City has recently appointed several educational hygienists at good salaries by competitive examinations. Physical-Educationists. — Numerous excellent courses at various institutions provide to-day fairly satisfactory training for those who wish to take up the work of physical education in schools. Some persons specialize in play and playground management, others in physical training and gymnastics, others in folk-dancing, others in athletics, and still others in aquatics, etc. The supervisor of hygiene will, of course, take an all-round course, and should have practical experi- ence in this work, perhaps, before taking a position as general supervisor. The regular teachers and supervisors of physical education should also have wide acquaintance with the various forms. The training at present is weak along the lines of general TRAINING OF SCHOOL-HEALTH WORKERS 537 education, of sociology, and of medicine, although a marked tendency exists at the best institutions in the direction of broadening such work. In many places the teacher of phys- ical training or the playground instructor may make very grave errors in attempting to train children who need pre- liminary medical examination and direction. Some work in normal and pathological diagnosis should be provided in such courses. Doctor Hoag and others assert that teachers can be trained to detect 80 per cent of the important and serious defects and ailments of school-children, and the physical- educationist should be even better able to do this. Frequently he meets all the children of a school several times a week in a way that easily makes possible preliminary medical inspection. Meeting such a responsibility will broaden him and his pro- fession, and this should be foreseen in his professional courses. Medical gymnastics, and the examination of vision and hear- ing, should also be taught. The best courses now include a reasonable amount of teaching of health and hygiene, and the physical-educationist should be well versed in this field. School hygiene may well be made a part of the course for all those who would teach this subject. CHAPTER XXVIII INDUSTRIAL HYGIENE AND VOCATIONAL EDUCATION The Anomaly. — To those who have studied the pressing problems of working people, a serious anomaly appears in American industrial education. The movement for industrial education has been a most desirable effort to help the great masses of our people solve successfully through pubHc educa- tion one of the most serious problems of life — that of making a living. A rough analysis of this problem has associated vocational preparation with forges and lathes, special schools, and costly apparatus. Educators have clamored long and loudly for appropriations with which to begin this work. They have said: We can do nothing until we get the money with which to purchase this equipment. And they have done nothing without it. Now a more thorough survey of the prime needs of the world's workers will reveal two very essential and funda- mental factors of vocational education which most indus- trial courses and schools very largely overlook, and which are moreover comparatively inexpensive. These are, first, the development of general industrial intelligence, including acquaintanceship with the complex industrial world of the present; and, secondly, thoroughgoing education in gen- eral, industrial, and occupational hygiene. While they are waiting for appropriations, school systems could be giving, without very great outlays of money, fundamental instruction with regard to our complex industrial life, and this invalu- able health education largely by the use of the schoolmaster's favorite instrument — the book, a simple, inexpensive tool. 538 HYGIENE AND VOCATIONAL EDUCATION 539 Health Education for Workers as Vocational Education.^ — Let us glance at just one of these propositions — that in reference to health education for workers as primary voca- tional education. What is the health problem for our work- ing people ? From extensive studies of mortality statistics and the data of private and public insurance agencies here and abroad, as well as from many special studies, we learn with respect to the illness problem that there are in this coun- try not less than 13,000,000 cases of sickness each year among those engaged in industrial pursuits. The effects of such illnesses are well known. Illness reduces bodily efficiency, causes losses of work and of wages, and frequently ends in death. Webb, Devine, and other social students and workers are agreed that to the sickness of workers is directly due over 25 per cent of all poverty and destitution. Health Conditions of Workers. — Rubinow, in his " Social Insurance," reports that in Austria, where the government insures workers against illness and where accurate records are kept of the illness problem of workers, with nearly three mil- lion workers insured in 1907, there occurred 1,623,000 cases of sickness, causing a loss of 28,000,000 days. Fifty-three per cent of the entire working army suffered such loss, and the average time lost was 17 days each. How much of low vital working efficiency there resulted could not well be measured. In Germany, with over 13,000,000 insured against sick- ness, there were (in 1908) 5,200,000 cases of illness, or 40 per hundred persons, and the number of days lost was 104,- 000,000, or 20 days for each case of sickness, and an aver- age of eight days for each of the thirteen million insured. Of course, these are only partial costs, since the public taxa- tion for public hospitals and other such health agencies is not here included, and still other costs are omitted. , Since we have as yet in this country no such systems of social insurance, we do not yet have accurate statistics of the health problem of our own workers. But these illness losses ' This chapter appeared in the Educational Review for December, 1914. 540 EDUCATIONAL HYGIENE may from several sources be computed as an average of over two weeks of work and not far from 5 to 15 per cent of the workers' annual wages, including medical, burial, and other such expenses, both private and public. When we study the annual wages of our workers, a large proportion of them now being industrial wage-earners of the factory type, and find that the median annual wage is not far from $650 to $700, and that this sum is hardly up to, and certainly not above, the minimum amount necessary for a family with which to maintain a minimum standard of living — when we see our industrial population working so close to this mini- mum — then we realize what the direct and indirect loss of even one-twentieth of the annual wages for sickness really means, especially when we learn further that about 50 per cent of it is reasonably preventable. Our working people cannot afford it. Yet such data scarcely show up the complete death and lowered vital efficiency problems of workers. Over one- fifth of the children brought into the world each year, at such cost, die in the first year; one-fourth are dead before the age of five; and half of all born into the homes of our workers die before the age of twenty-three. Over 1,600,000 of our total population die each year, 100,000 of them of school age. This is an annual loss of about 2 per cent of our total population, which, in an enlightened civilisation, is about double what it should be. We cannot avoid the conclusion that the most fundamental form of general and vocational training is that which would enable the working population to meet more effectively these death, illness, and lowered vital efficiency losses. More- over, the young men and women, the boys and girls of our schools, very much need this type of vocational education be- cause they themselves are seriously defective and ailing. Doctor Chisholm's studies of the girls preparing for work in Manchester, England, the great amount of data collected in our medical supervision of schools, and the statistics of ex- A special class in Albany, N. Y. Three-fourths of the programme is devoted to hand-work and special activities. The freedom and happiness of the children is the striking feature A group of ungraded school-children, Albany, N. Y. Nine different lines of hand-work are represented HYGIENE AND VOCATIONAL EDUCATION 54 1 aminations for army recruits and for those entering industry abroad, all show the extreme importance of complete and thoroughgoing systems of educational hygiene for our work- ing i^eople. Health and the Working Girl. — Mrs. Woolman says of the girls entering the Manhattan Trade School for Girls: "The young wage-earner who goes into trade untrained at fourteen years of age is greatly handicapped by her physical condition. Either through ignorance or neglect, early symp- toms of disease are disregarded, and it is not until she finds herself out of employment as a result of physical weakness that she realizes that good health is the capital of the working girl." And again: "The young wage-earner ... is much handicapped by her physical condition; heredity, poor habits of life, and insanitary homes show their effects on her. The girls, however, are young enough to remedy many of their defects. In a few months they will be in positions demanding eight or more hours a day in which they must strain every nerve and bend all their energies to meet the standard brought about by trade competition." We do not need to demonstrate by the statistical studies that have been made that the general, the industrial, and the occupational hygiene phases of vocational education for health efficiency are wofully neglected in the schools of this country. Our teachers do not know the elements of general, personal, and public hygiene, not to mention industrial and occupational hygiene. We have few good text-books in hygiene in use, and little or no time is given to the subject as a school study. An extensive study of actual courses in vocational education shows that, with but practically one exception, the only progressive work of this type is being done abroad. Our vocational courses, like our general elementary and high-school courses, almost entirely overlook this form of vocational preparation. The anomaly, then, in summary, is about as follows: hygienic education an indispensable phase of vocational 542 EDUCATIONAL HYGIENE education; and yet an almost total lack or great inefficiency of health education, both general and vocational; miUions of workers suffering high illness, death, and lowered vitality losses; and yet the spectacle of educators clamoring for- the costly tools for a narrow type of vocational training while at the same time neglecting the preparation so near, so fundamental, and so comparatively inexpensive. What is Being Done. — The best evidences I have been able to find of adequate attention to this important matter have been in Munich, Germany, some schools of England, the schools of Sweden, and the Manhattan Trade School for Girls (not true for the one for boys as yet) in New York City. Doctor Kerchensteiner in Munich has not only medical ex- aminations and follow-up work and attention to sanitation and physical education, but he has a regular course intended to give intelligence with respect to the complex industrial and civic world of to-day and the elements of general, indus- trial, and occupational hygiene. His course is called Civics and Hygiene. Sweden has all these features but adds to them a most progressive feature in the form of health vocational guid- ance and follow-up work, including annual medical examina- tions by government medical examiners until the youth reaches the age of eighteen. A young man may be changed from occupation to occupation; he may be given shorter hours and guidance as to his health regimen; and may even be kept out of work altogether until he is physically fit. In England, medical supervision and follow-up work with some health vocational guidance is rapidly making its way. In these countries the insurance of workers against sickness by the state makes the problem of health preparation perhaps not such an acute one as here, yet these countries are leading the way in school-health work. An American Example. — The Manhattan Trade School for Girls gives each girl careful physical examinations, an- nually or more often, and supplements this with thorough HYGIENE AND VOCATIONAL EDUCATION 543 follow-up work; the home and school environments are made as sanitary as possible; medical, corrective, and recreational gymnastics, including plays and games, are much used, meeting individual and class needs; there is a great deal of practical teaching of general personal and public hygiene, and of the most usable phases of industrial hygiene, developing later into specific occupational hygiene for those going into definite trades. Last, but quite important, is careful guidance and follow-up work along sanitary and personal-health Hues after the girls have gone into industry. Further than these few examples, we can point to little that is worth while. Employers Awakening to Health as Capital. — The recent success of the Life Extension Institute in getting employers of hundreds and thousands of working people to furnish each one free of charge with an annual, very thoroughgoing medical examination, and the remarkable revelations of the low health status of most of these industrial workers, show what the world of industry is beginning to think of thorough health education from the earliest years on. It moreover in- dicates that we are here on the right track. What Must be Done. — Now we have seen the anomaly and what is being done in a few places here and abroad to eliminate it. Let us next see what in this country must be done along this line. Briefly we must have: (i) Thoroughgoing medical supervision of all school- children, and those before and after the school years so far as possible, especially annual or more frequent examinations and follow-up work of a corrective and preventive character. (2) An improved sanitary environment at home, in school, and at work. (3) Adequate individual and collective physical education, including medical and corrective gymnastics, plays, games, recreation, etc. (4) Improved teaching of hygiene, general personal and public, general industrial, and occupational hygiene, each person getting as much of each as is reasonably possible. 544 EDUCATIONAL HYGIENE (5) Careful health vocational guidance up to the age of eighteen or twenty if possible. School-Health Work. — Elementary and high schools must pay more attention to these phases of health education, using teachers who have improved health training, and text-books superior to those in vogue, along the lines perhaps of the Gulick, the O'Shea, and the Ritchie series. In the year or so before pupils go out into industry, they must have added to their instruction some general industrial hygiene such as is desirable for all workers of their kind. And, third, if pos- sible, they must have some knowledge of the special hygienic precautions necessary in the special occupation the pupils are sure to take up, occupational hygiene. Those going into teach- ing, for example, must, in their professional training, know the hygiene of their occupation, namely, teaching; those going into the lead industries must know how to meet the lead- poisoning problem; and so on. Hygiene Texts for Vocational and Social Preparation. — Fortunately, some good texts are being published which will aid in the teaching side of the problem, including gen- eral personal and public hygiene, and general industrial hygiene. I take time to mention one entitled "Hygiene for the Worker," by Tolman, a text-book on personal, pubhc, and industrial hygiene which hooks on to the keen interest of children to go out into industry, and which sets them at work in direct industrial preparation in the ways of health knowledge, health ideals, and health habits of value to them as workers. The chapter headings of this volume may indicate the wealth of modern hygienic knowledge recently developed which can now be put at the disposal of those who wish to help our working people to get fundamental preparation for their work. These chapter headings are as follows: "Applying for the Position," "Preparing for the Day's Work," "Good Habits for the Worker," "Suitable Clothing, Food, and Drink," "Alcohol and Tobacco," "The Noon Hour," "Hygiene of the HYGIENE AND VOCATIONAL EDUCATION 545 Workroom," "Fatigue," "After Hours," "Holidays and Outings," "Choice of an Occupation," "Occupational Dan- gers," "Accidents," "Poisons and Fumes," "Fire," "First Aid to the Injured," "What the Worker Has a Right to Ex- pect," "Seasonal Hygiene and Tuberculosis." This is the best attempt made so far to meet the need of a text in indus- trial hygiene for prospective workers. Another new and high-class text for upper grades and high school but more general in its appeal and in its subject- matter, yet of very great importance, is Coleman's "The People's Health." This volume will be a good introduction to special industrial hygiene for those who go on into or through high schools and trade schools of secondary grade. The chapter headings will here again give an idea of the wealth of subject-matter available for vital preventive medi- cine in the way of education in general and industrial hygiene, namely: "The Need of Public Hygiene," "Fresh Air and the Prevention of Disease," "The Prevention of Disease by Pure Water," "Clean Milk and the Prevention of Disease," "Pure Food and Pure Food Laws," "Food Values and Economy in Food," "The Prevention of Infection," "Human Carriers," "Insect Carriers," "Hygiene of Work and Play," "Mental Hygiene," "A Sanitary Home," "School Sanita- tion," "The Pubhc Health Department," "Health and City Life," "Rural Sanitation," "Industrial Hygiene," and "A Sound Body Conquers Disease." This volume is even more profusely illustrated with remarkably telHng illustrations than the former. Dr. Florence Richards has published also a practical "Hygiene for Girls," which is of the new order. The Public School and the Public Health.— Here, then, we have a tentative programme for helping vocational edu- cation to enlarge its service, slightly beyond the giving of mere trade skill, to help the workers of the country meet in a healthy, vigorous manner these serious problems of life and attain genuine social efficiency so long held to be the aim of 54(> EDUCATIONAL HYGIENE education. It may seem a somewhat progressive programme, but it is not in any sense ultra. As Seager says in his " Social Insurance": "In the United States we are still so far from considering illness as anything beyond a private misfortun- against which each individual and each family should prote:^, itself as best it may, that Germany's heroic method of attack ing it as a national evil through governmental machinery seems to us to belong to another planet." But this feeling will soon pass; and the governmental machinery we should chiefly use in this democratic country is the machinery of our public schools, especially our industrial courses and schools.' ' The State of Wisconsin has recently entered the field of public industrial insurance. This will soon show the condition of the working population with respect to health and will indicate a needed reform in vocational education. CHAPTER XXIX SEX HYGIENE AND SEX EDUCATION Sex Education. — Sex hygiene is a term that has come into popular usage to indicate a phase of education which has escaped the attention of educators, owing to the ignorance of its importance as well as to the inhibiting force of tradition and taboo. In its general significance, it embraces all the themes which centre about the sex characteristics of the species. It has a special meaning to various teachers according to their basic interests. Some educators are carried away by the idea that merely teaching the facts of reproduction constitutes sex hygiene. Various other teachers and writers regard the facts concerning the social evil, the venereal diseases, or eugenics, as the main elements of information to be imparted in sex hygiene. These conceptions are obviously limited. While each constitutes one phase of the sex problem, it by no means encompasses the field of sex hygiene. From the standpoint of education, the term sex hygiene is a misnomer. Sex physiology, sex pedagogy, or sex ethics would equally describe the educational content of a course of study designed to yield to youthful minds the body of facts essential for their wholesome development. The preferable and comprehensive term for the field in the mind of educators is sex education. This includes the natural training of children along rjonnal lines in their duties and responsibilities for the development and maintenance of their manhood and woman- hood, and involves preparing them for their highest duties as the potential parents of future generations. A slight knowl- edge of anatomy is essential. Physiology naturally must be interpreted in terms of hygiene. All instruction would fail 547 548 EDUCATIONAL HYGIENE in effective results were it not based upon an intelligent un- derstanding of sex psychology and sex ethics. The methods of imparting instruction would be blind and chaotic without a lull appreciation of the methods and values bound up in sex pedagogy. Sex knowledge, sex understanding, and sex interpretation are equally indispensable. Correlation of Sex Education with General Education.^ Owing to the fact that the importance of sex education has suddenly dawned upon the educational world, it has been im- mersed in an unusually strong light, and singled out as an isolated subject free from correlation with the rest of the school curriculum. This unfortunate point of view, arising from the concentrated attention now bestowed on the subject, loses sight of the fact that sex education is not essentially a separate educational problem, but is intricately interwoven in the fabric of general education. Assuming that education implies the imparting of the facts, processes, and ideals es- sential for the development of effective citizenship, it cannot be denied that training for parenthood is involved in the gen- eral function of education. As courses of study are at pres- ent developed, there is a prevailing habit to omit all conscious references to the facts pertaining to sex, in so far as they may arise in the study and teaching of various subjects now in- cluded in the curriculum. It is patent that, to properly interpret mythology, a thoughtful mind could receive a wide education in facts pertaining to sex that would make no im- press upon the youthful minds save as related to mythology. The interpretation of the literature of all nations involves a close attention to sex evolution, sex facts, and sex content that affords abundant opportunity for the gradual and normal inculcation of sex idealism. History, music, n^jffti^-^tudy, sociology, botany, and biology are practically " c^J^fi^ers of broad lessons in sex education which have largely been neg- lected, owing to the fear of polluting the child mind with sex facts tending to moral degeneration. Religious instruc- tion itself, based upon the use of the Bible, cannot be ade- SEX HYGIENE AND SEX EDUCATION 549 quately developed without opening up to the child mind vistas of thought to be appreciated only in the light of an in- telligent understanding of the vocabulary contained in the Bible itself. The Bible has not been utilized as its content warrants for the giving of sex education. Its use has been neglected almost entirely by the religious teachers in whose hands for centuries has been the problem of moral education of the youth. The Problem of the School. — Considerable agitation has arisen over the suggestion that sex education be imparted to the young. The fundamental opposition has arisen from a failure to recognize that sex education is constantly being acquired by children. Furthermore, there has been a possible lack of understanding that the real problem does not consist in determining whether sex education should be given to chil- dren, but under what conditions and by which teachers. Ignorance and innocence in childhood, in so far as sex themes are concerned, are not one and the same thing. There may be chastity with a full knowledge and understanding of the facts of life, or there may be gross immorality without any true knowledge of the underlying physiology or hygiene of sex life. The great problem for educators to determine is whether they are to assume the responsibiUty for the normal and health- ful instruction of the young with regard to the facts pertain- ing to sex, or whether they are to continue to permit childhood to gain its information from corrupt and foul sources, from erotic literature, or from the evil traditions of the gang. Ob viouslyJIJ^ teacher cannot shirk his responsibility, while educati^l^a^^^-ned essential for the betterment of the human race. «yt1iroug]i the error of centuries sex education has been negle(^Pl^'aes^e its important educational value, then it is incumbent* upon the teachers to realize the existent necessity for imparting sex instruction and to ascertain the methods best calculated to prove effective. Sex education merits careful consideration because it is 550 EDUCATIONAL HYGIENE an essential feature of the implied educational value of edu- cation itself. The taboo which has existed since creation is gradually being raised. The traditions involving different standards of morality for the two sexes have been the cause of great social waste and devastation, and are opposed to race progress. The church, the home, and the school have uniformly and consciously avoided giving the essential in- formation for proper sex conduct, despite the fact that such neglect has brought untold suffering to humanity. In the inculcation of virtues, stress is placed upon honesty, justice, chastity, courage, kindliness, and honor, but in so far as these values are to be secured through a conscious appeal to sex psychology and sex control, education has been wofully silent and indifferent. The basis of family life, as a unity for the development of society, is founded upon the development, direction, and con- trol of the sex instinct. As the basis of love, physical or spiritual, the sex instinct demands guidance and development in the interests of racial progress. Unfortunately, the ordi- nary approach to the subject of sex education has been from the pathological side. A recognition of the horrors of the social evil, and an appreciation of the relation of the venereal diseases to blindness, idiocy, and racial deterioration, have served as the starting-point for demanding conscious sex in- struction as a palliative measure. From this point of ap- proach, it is easy to understand why teachers have feared to discuss the subject. The traditional barriers of modesty and fear have created a position so difficult that few teachers have had the courage to attempt to devj^^^nethod for dispersing ignorance and giving enlightenii^^^^fc|ft the un- derlying facts necessarily to be imparted ^^^^^^^ lessen these social ravages. ^^^^^^f A few educators, with an understanding^^HBmore seri- ous problems involved, have sought to discoverThe basic facts^ pertaining to sex which should be imparted to children, and have sought to devise methods for offering this instruction. SEX HYGIENE AND SEX EDUCATION 551 They have come to realize that a constructive plan of sex ed- ucation, pedagogically analyzed, involves a full recognition of the part that sex plays in social development and personal progress. As a result of analysis, sex education no longer can be re- garded as a special subject isolated from the rest of life. Sex hygiene is bound up in all the subjects of the curriculum. Be- cause of the attempts to isolate it from the other subjects in the curriculum, it has assumed a monstrous form, astonishing and stupefying those seeking only the dangers in the impart- ing of sex instruction. If sex education were to be classified as a specific carnal subject, it would present most tremen- dous difficulties. Constituting a part of general education, however, it so sinks its identity in the various subjects now taught as to deprive it of the dangers and salacious tendencies so greatly feared. Sex instruction should be approached in a normal manner, evaluating sex facts in terms of the child mind. The great obstacle to giving such instruction has arisen from the fact that adults rich in experience, saturated with tradition, and conscious of sex physiology have failed to appreciate the spiritual, ethical, and scientific values of the subject as they may be developed in the plastic and undefiled minds of children. Pedagogical hesitancy has been founded upon a failure to interpret the facts, the processes, and the ideals involved in sex education in terms of children's under- standing. Sex Education According to Stages of Child Development. — It is patent that sex education is neither a special subject nor one Jj^fci essentially to any period of child development. Virtual^HH^lucation is a constant process extending from infamy to rnaiurity and even until senility. The methods devi^d for i Jfruction in Uterature, mathematics, history, and nature^JffiHpRaturally vary at different periods of the psycho- logical development of children. Similarly, the methods em- ployed in imparting sex instruction must vary according to the age, sex, family environment, nationality, sex precocity, 552 EDUCATIONAL HYGIENE and mental development of children. For the purpose of convenience in considering educational methods to be em- ployed, it has been suggested by a committee of the American Federation of Sex Hygiene that the matters and methods of sex education should vary according to more or less definite age periods, as, for example: one to six years, six to twelve years, twelve to sixteen years, and sixteen years and there- after. From the standpoint of the psychological develop- ment of children, regardless of distinct chronological limita- tions, I have suggested that the matter and methods of sex education be divided according to three stages of child de- velopment, which I have termed the age of mythology, the age of chivalry, and the age of civic awakening. The age of mythology constitutes that period of child life that is particularly keen in imagination. Mentally, the fairy-tale, the ro- mance, the animal story, and nature wonders supply the best intel- lectual pabulum. Gradually the child outgrows the age of mythology and enters the age of chivalry. There is no sharp line of demarcation of the two periods, nor can any age be given when the transition occurs. The age of chivalry really begins as a prepubertal period. For purposes of convenience one may regard it as embracing the years from eight to fifteen. Each child, however, is a law unto himself, and the spe- cific period of his life that represents the age of chivalry can only be determined by noting the physical and psychological development of the particular child. The child's body is beginning to take on new growth, the sexual functions are beginning to expand, the emotional side is unfolding at a very rapid pace. The actual expression of the sexual development may be marked by the intensification of affection for the family. The period of civic awakening in turn marks a further develop- ment of character. The child in beginning adolesceaMffla^preciates that he is part of a community. The world of ideS^^HMJanded. No longer is the sharp focus on himself. His thou(g;Ht'sjH^^fcs cen- tripetal. There is a realization of the world outside '^^Km home and a recognition of the fact that competition is goin^ on in it. The awakening is, however, all designed to view llie future. The understanding of the relation of the individual to the community or the state is slowly coming to play a part in the individual's life. How wonderful becomes the sense of power on realizing that each individual SEX HYGIENE AND SEX EDUCATION 553 is laden wilh responsibility for the health, morals, and progress of many others ! Not preservation of self for self, but self-preservation to protect others, becomes a new incentive. The selfish idea in the prevention of disease, physical or moral, takes on an altruistic aspect. Self-happiness at last begins to recognize that it includes and depends upon the happiness of others. Bearing in mind this artificial classification, it is obvious that sex education is a complex problem meriting thorough investigation with a view to determining the scope of informa- tion to be imparted and the methods for its presentation. Despite the fact that sex education appears to be an im- perative need, I do not believe that for many years to come it will be regarded as a definite subject. Attempts have been made to legislate it into the school curriculum, but thus far it has been forced into only a few high schools, and sufficient time has not elapsed to judge of its effect. In view of the history of compulsory teaching as related to alcohol and to- bacco, it seems inadvisable to suggest that sex education should be made the basis of mandatory instruction. It is unwise to give to the subject an abnormal position in the category of school studies. Dangerous results would surely ensue if fanatics, impressed with the importance of this sub- ject, should endeavor to compel its instruction in the ele- mentary schools previous to a complete understanding of its function there. Carefully devised methods must be thor- oughly tested out under normal conditions. While sex in- struction must be regarded as an essential phase of educational development, it must not be viewed as a dominating force in education nor as a basic subject of cultural value or of mental development. Its highest significance lies within the realm of ethifs and the development of self-control. WhS' Should Teach It? — Recognizing the practical impor- tance of sex education, one immediately faces the question as to who should teach it. It requires no special evidence to prove that the responsibility for sex education has been shifted in turn upon the church, the home, and the schools. 554 EDUCATIONAL HYGIENE In SO far as the fundamental facts in sex education are to be acquired previous to school age, it is manifest that the re- sponsibility for laying this foundation rests upon the home. Parents, however, have not been keenly alive to the necessity of this prehminary instruction, nor do they feel themselves particularly fitted for undertaking the task. Parental timidity is largely responsible for the sin of omission. Attempts to arouse parents through the medium of the school would un- doubtedly awaken their consciences so that they would re- spond to the appeal to give the necessary facts along the lines suggested by capable teachers. Parents are particularly capable of giving natural instruction, once they appreciate their opportunities for such instruction in view of their famil- iarity with the vocabulary of their children, their companions, and their general experiences. In the school itself the difficulties of giving sex education arc multipHed by virtue of the size of classes, the mixture of nationalities, the variations in age, and the diversity of sex experience. Coupled with these difficulties are the lack of training among teachers and their consequent reluctance to impart sex instruction. The Training of Teachers. — A great problem arises as to which teacher should give instruction, particularly view- ing sex education as a specific subject. There should be no specific teaching of sex education below the seventh grade in the elementary schools. The great problem, therefore, is to train all grade teachers as to the methods of imparting the general sex content of all the subjects in the curriculum in a norm.al and constructive manner without making it ap- pear that any unusual topic is being discussed. To achieve this end, some training-schools for teachers are engaged in developing courses for teachers that will give to them the broad vision necessary for understanding the place of sex education in the public schools and will acquaint them with the facts which should be developed from the general subject- matter and the methods of presenting them to the pupils. SEX HYGIENE AND SEX EDUCATION 555 In the higher classes where departmental systems exist, or in the high schools where children are at puberty or in adoles- cence, there is a more general effort to devise definite lectures upon specific sex themes of informational value and moral force. Various teachers claim that the best instructors are the directors of physical training, or the biologists, or the teachers of nature-study, or the school physicians or school nurses. When specific instruction is indicated, the greatest stress should be placed not so much upon the subject that is taught as on the characteristics of the instructor. Tact, sym- pathy, understanding, and example are of equal importance to the possession of the facts to be imparted. In possession of the knowledge to be disseminated, a teacher of Latin, history, or mathematics might be preferred as the definite instructor of the specific problems related to adolescence rather than a blunt, unsympathetic, or callous teacher in biology, physical training, or medicine. The basis of selection of a teacher in sex education should include the personal elements entering into teaching ability as well as the recog- nition of the general educational power of the teacher. Ob- viously, the teacher to whom is to be intrusted the careful process of sex education must be possessed of a knowledge of the matter to be presented, the methods of presenting it, and a broad comprehension of the relation of the subject to human effort and efiiciency. He must possess judgment to determine whether information should be given to individuals or to groups and be able to weigh the effects of his instruction. Sex education must be achieved without the development of sex self-consciousness and without the stimulation of erotic ideation. Sex Instruction in the High School. — Considering sex in- struction as one of the factors in character formation, it is obvious that the place of sex education in colleges scarcely requires consideration in this chapter. The position of sex education in the high school appears to be definitely deter- mined. As normal boys and girls have acquired a large 556 EDUCATIONAL HYGIENE measure of their sex lore before puberty, the informational character of sex education in the high schools must possess a correctional bent. The vast amount of misinformation ac- quired from the streets and the gang — pornographic literature, pathological booklets, and false interpretations of current events as described in the press — has made its impress upon adolescent minds. A careful pedagogical effort is necessary to eradicate or modify the false impressions and to give the definite and accurate information that will raise the plane of sex information far from its low level. With some limitations, sex education in the high school possesses a prophylactic value. The young adolescents, con- scious of new physical sensations and emotional stimuli, require careful guidance so that the interpretation of their physical and emotional development may be sanely directed toward high ideals. The more mature students in the high schools, even in the first year, who perchance have drifted with the current and possibly have succumbed to influences dangerous to their physical and moral welfare, need to be rescued. For them it is essential to secure a broader vision of life. The facts pertaining to sex must be placed before them in a clean manner to indicate the dignity of manhood and womanhood and to give them an understanding of their duties and responsibilities in the light of their social obligations. The possibility of developing character during adolescence so as to lessen the likelihood of immorality demands the careful instruction of high-school students in the facts pertaining to sex. This is not a difficult matter for a tactful instructor, inasmuch as most of the youths have acquired a large share of sex information, though in terms of vulgarity and obscenity. With the development of the social consciousness at puberty, it is possible to mould character on the basis of an appeal to family pride and social responsibility. The mere presentation of facts relating to anatomy and physiology will not sufiice to produce the moralizing result to be sought. In the high schools it is possible to give a few definite lectures, collating SEX HYGIENE AND SEX EDUCATION 557 the facts previously imparted in a normal way and dealing with the definite sex problems surrounding adolescence. The ethical lessons involved in sex education assume the utmost importance. Considered from the standpoint of bio- logical development, physical education, civics, and ethics, the high school may afford definite instruction upon the mean- ing of puberty and the relation of the sex instinct to personal success and physical health. The wider problems of the re- lation of chastity to family welfare, eugenics, and racial ad- vancement can be discussed without equivocation, provided that undue stress is not placed upon the venereal diseases and other pathological phases of the subject. To seek to inspire fear and to estabhsh character upon this principle is poor pedagogy. The attempt must be made constructively to create the ideal and desire for clean living and self-control on the basis of a positive knowledge of the essential values of sex facts. The dangers of sex education in the high schools are practically negligible, provided that instruction is placed upon a high biological, ethical, and social plane. Its function is to further the development of social responsibility rather than to elucidate the merely personal phases of sex prob- lems. Sex Instruction in Elementary Schools. — In elementary schools the position of sex education is different. It is desir- able to present sex knowledge to children before adolescence without drawing attention to the fact that such instruction is being given. The essential nature of puberty may be appreciated before this physiological epoch is reached. It is necessary to consider each school system as a unit in order to determine in which grades sex instruction should be given and to what extent and in what manner the facts should be imparted. The variations in classes due to numbers, differ- ences in age, nationality, and sex precocity increase the diffi- culties of definite sex education even in the upper grades of the elementary schools. If, however, sex education is re- garded as essential to the welfare of future citizens, it is man- 558 EDUCATIONAL HYGIENE ifestly important that such education should be given to the maximum number of children, and, since most pupils never reach the high schools, this becomes possible only through in- struction in the elementary schools. It is possible to lay the foundations of a rational sex education in such a manner that elementary-school children will not leave the schools, as at present, entirely ignorant of the great importance of the sex instinct in the affairs of the world. Naturally, in imparting special instruction, particularly for those who are about to leave school in order to go to work, the sexes must be segregated. Within the sexes, groupings should be made not so much on the basis of chronological age as of psychological age. The differences in sex precocity make it difficult for teachers, save those of the wisest discre- tion, to give instruction in such a manner as to preclude the augmentation of self-consciousness. The barriers of modesty and shame, having arisen in child consciousness just before puberty, increase the difficulties of sex education at this period of school life unless one recog- nizes that directness of speech, frankness, and sympathy are essential in order to overcome temporarily these barriers without breaking them down. The proper grouping of chil- dren, therefore, is imperative. For this purpose the advice of all teachers must be secured even though the instruction be given by one teacher. Frequently it is advisable to omit from the group some children whose morals are believed to be impaired in order to give them individual attention that their instruction may be gauged according to their experiences and needs. Individualized sex instruction, while theoretically desir- able at times, is practically impossible in a public-school system, save in connection with problems of discipline or in response to requests from parents for the imparting of such individual instruction. The disadvantage of individual in- struction as opposed to group instruction is that it may tend to accentuate the peculiar qualities of the instruction given, SEX HYGIENE AND SEX EDUCATION 559 whereas the group instruction makes it appear to be a normal part of education to be received by all and does not serve to build up an overweening false modesty. All steps leading to the introduction to sex education must be taken slowly in order that public opinion may constantly support the movement. The conservative position of the puolic is perfectly natural, particularly in the light of the op- position of teachers toward the introduction of this subject. Of primal importance is the education of the public as to the meaning of sex education, the necessity for its introduction into the schools, and the educational methods utilized by teachers. Secottd, it is a \dtal necessity that teachers be given a proper understanding of the purposes of sex education and receive training in the matter and methods essential for the proper teaching of the subject. Third, training-schools for teachers must organize definite courses for the adequate training of those who appear to possess special fitness for the presentation of the facts relating to sex problems. Such courses naturally must be developed on the basis of biology, natural sciences, physiology, anatomy, hygiene, zoology, and ethics. The greatest need at the present time is the prepara- tion of teachers of this subject. It has been urged by some that sex instruction by any type of teacher would be prefer- able to the present system of educational neglect. Wliile there may be some merit in this argument, it loses sight of the fact that improper pedagogical methods may do incalculable damage by destroying modesty, lessening shame, inspiring fear, and stimulating erotic desire. Dangers. — The dangers of early instruction in sex facts may arise from: (i) The Accentuation of Pathology. — To focus all atten- tion upon the venereal diseases and the resultant personal or social damage is to build up a morbid spirit and develop a phobia or encourage an obsession leading to various nervous phenomena prejudicial to mental balance, physical health, and moral stability. The morbid phases of sex should be 560 EDUCATIONAL HYGIENE relegated to the background and introduced as secondary phases of sex education. This is possible without any sacri- fice of the content of the subject and with distinct advantage in its effect upon mind and character. (2) The Stimulation of the Sex Instinct. — The method of imparting instruction should be totally impersonal. Facts should be presented in their widest relations without making it appear that any particular individual is being considered in the discussion. The sex instinct should be presented as a normal part of child nature with attributes that lead to the development of manliness and womanliness and that stand for the higher virtues. The sex instinct should not be referred to as a purely physical phenomenon whose main purpose is simply reproduction. All references to the physiology of sex may be interpreted in terms of social function rather than personal function. Scientific terms should be used wherever necessary, and all descriptions of processes should be given in plain terms similar to those employed in teaching botany and zoology. By keeping the discussions on the plane of biology and universal facts, the likelihood of stimulating the sexual instinct is decreased. (3) The Stimulation of a Morbid Imagination. — By unfold- ing all the mysteries of life in a sympathetic and dispassionate manner, all the facts pertaining to sex development are re- vealed. The imagination must not be appealed to, nor should there be any hesitancy on the part of the teacher in the ex- position of facts that will permit an appeal to imagination. Descriptions, details of processes, expositions, and reasoning should be sufficiently complete, direct, and impersonal to allow no room for imaginative processes. The present need for frank sex instruction is largely due to the fact that the erotic imagination of children receives no conscious check but is constantly stimulated through their inability to clear up the magnified mysteries. (4) The Development of Self -Consciousness. — Tactless in- struction, with personal reminiscences, or the direct considera- SEX HYGIENE AND SEX EDUCATION 56 1 tion of personal problems in the group, tends to develop self- consciousness. This is an undesirable method and creates hostility on the part of children struggling with their own emotions and unable to consider the sex facts save in terms of their own personality. At times it may create unnecessary fears and lessen self-confidence, create a feehng of self-de- preciation, and tend to offset the upbuilding value of the in- struction imparted. (5) The Breaking Down of Sex Barriers. — Among the nor- mal protective devices are certain psychological barriers, such as modesty and shame. No instruction should be given which would tend to undermine the force of these barriers. A vast distinction must be made between false modesty and false shame and the more substantial psychological attributes. To decrease modesty or belittle shame is to destroy valuable factors in conserving or upbuilding strong morals. The pres- entation of the facts relating to sex phenomena must there- fore take into consideration these barriers with a view to strengthening them instead of undermining them. (6) The Encouragement of Sex Conversations. — Obviously, at the present time matters pertaining to sex constitute no small part of the general themes of conversation of boys and girls at school. By destroying the secret nature of sex themes there is a tendency to decrease the importance of such topics of conversation. There would probably be less harm in conversations dealing with sex matters were they founded upon proper information and ideals than under the present system of vulgarity, imaginativeness, and secrecy. At the same time, every conscious effort should be made to decrease discussions of sex themes based upon misinformation, ob- scenity, indecency, and licentiousness. (7) The Creation of Curiosity. — There can be no question that curiosity is a normal attribute existing with undue force as related to sexual matters. A rational exposition of the problems of sex tends to allay curiosity and not to stimulate it. The creation of stronger self-control, founded upon basic 562 EDUCATIONAL HYGIENE knowledge, serves to relieve the pressure of curiosity and affords a valuable safeguard against its overdevelopment. Careful teaching will not create an abnormal interest in the subject, but it will simply serve to guide and direct the normal and basic interest with an array of facts and reasons which enables it to be satisfied far better than under the present system where interest is forced by secrecy, gang in- fluence, and vicious literature. Eroticism becomes subordi- nated to a healthful interest and a conscious appreciation of the meaning of sex in relation to life. Methods. — The method of instruction in matters pertain- ing to sex is practically to impart such knowledge of sex at each period of child life as may be valuable and necessary for preserving health, developing high planes of thought, and controlling conduct. Recognizing the fundamental facts es- sential for the health and morality of the community, it seeks to build up normal human beings of high ideals and good moral character with the fundamental facts enabling them to make an intelligent choice as to action. The point of departure in instruction must be the normality of sex life and the nor- mality of the sex instinct. The problems of pathology are of secondary importance. Anatomy should be dwelt upon as little as possible and embryology should be involved only in so far as may be necessary for the interpretation of the re- productive phenomena in all the plant and animal kingdom. The scientific processes are to be found in the biological in- terpretation of nature-study, supplemented by the values to be gotten from physical education, civics, hygiene, history, and ethics. In methods of instruction there is a positive phase which has to do with the development of the child and a negative phase which deals with the child's environment. It is ob- viously impossible for a school to control a child's environ- ment, nor is it within the bounds of possibihty to safeguard children from all contacts with demorahzing and corrupting influences in their environment. Instruction as to the im- SEX HYGIENE AND SEX EDUCATION 5O3 portance of bathing, correct methods of clothing, the values of physical exercises, athletics, and recreations of a whole- some character, is within the limits of sex instruction in so far as it is related to environment. Guidance as to theatres, gambling, alcoholism, debasing associates in the gang, the advantages of playgrounds, parks, libraries, the importance of religion, the necessity of cherishing home life and maintain- ing confidences with parents, properly may be included in a constructive programme of sex education involving the en- vironment of children. In the positive education of the child, character formation is the ultimate aim. Ia_lli£_stu dy of Re produ ction ^dujing the ^dolescent_period, utilizing th e facts to be gleaned. from biology,, the ethical_implications require greatest emphasis. The evolution of human lovePtEeTeTations of pareiitliQpd family welfare, and'THe- nature and importance ofme home, together with the ethical relations which should exist between parents and children, are ethical and biological concepis^pf exceedingly great value in making appeals to adolesceftts. Gradual Development. — The entire subject-matter of sex education must be developed gradually. The subject must be evolved. The spontaneous exposition of the great truths must not be permitted. Sex education must cover a long period of years and one step should be based upon pre- vious educational supports. The study of reproduction in plants and animals covers a period of years in teaching and, when based upon familiar plants and animals, affords abun- dant facts for indicating the analogies in human life. The purposes of sex education are not merely to be informational in character but to yield sufficient material for character training. Mere facts in themselves present few motives for conduct. The trend of sex education must therefore be in the direction of creating definite high motives of altruistic character. Obviously, the form of instruction given in night- schools to adults may consist of a broader treatment of the human aspects of sex problems. Among the adolescents, 564 EDUCATIONAL HYGIENE however, the inspiration of high ideals of sex conduct must form the end and aim of the instruction. Judgment, tact, sympathy, and understanding are req- uisite in order properly to balance the biological facts with the ethical concepts so that instruction may not appear to be preachment, and so that the basic facts may be presented be- fore the essential temptations of youth have begun to assail the child mind. The use of charts and illustrations merits careful con- sideration in order that they may not present more material than the child can assimilate in connection with the particular subject under discussion. The use of books relating to sex education by the children is to be deprecated until adoles- cence is well advanced. The value of sex education is en- hanced through giving adequate information without creating an inordinate interest or awakening an abnormal curiosity as to numerous questions, such as would naturally be developed through the employment of books which cannot be adapted in scope or method of presentation to fit large groups of chil- dren in the preadolescent stage. Without going into details as to the great number and variety of facts to be imparted, I may repeat that the con- notations of Hterature, history, and civics must be combined with the facts of biology, nature-study, and hygiene and. in- terpreted in terms of ethics and sociology. During the early ages, sex facts must be intellectuahzed in order not to empha- size the developing emotional phases of child nature. D uring pu bertv,_ when emotional waves are fast rushing upon the child mind7the}rnmsF5eliar^ and~Hirected mto channels^ thaTwiir^o the most good and least damage. The physical phases of sex problems should not be stressed for adolescents except in so far as they are spiritualized. The intellectual appreciation of the facts presented merely furnishes the basis of educating the emotions. The normal development of sex themes proceeds in three stages: first, the intellectual ac- quisition of facts; second, the interpretation of emotional life; SEX HYGIENE AND SEX EDUCATION 565 third, the spiritualizing of sex consciousness. These three stages are not totally dissociated at any period of child devel- opment but must be most closely interwoven in the instruc- tion during adolescence and thereafter. Education of Parents and Public Opinion. — There are frequently times during elementary-school periods when spe- cial problems arise requiring specific instruction to be given to individual children. This must be done frankly and hon- estly, whether it deals with masturbation or gross immo- rality. The frank discussion of topics involved in school discipline carries with it the obligation to discuss them also with parents in order to secure the most effective results. While parents represent the persons upon whom rests the responsibility for sex education, the school cannot ignore the fact that parents are ignorant of the best methods of peda- gogical procedure. For this reason it is highly desirable that schools, through the medium of mothers' clubs, parents' as- sociations, or general public lectures, should afiford an oppor- tunity to parents to receive instruction upon the necessities of sex education, together with pedagogical methods and the material required at different ages of child development. Particular advantage accrues from giving the instruction to mothers in connection with the clubs of kindergarten mothers during the first year of the child's attendance at school. Herein is a wide field of usefulness of the elementary school, bringing the school and home in closer co-operation and harmony in the interests of sex education of the young. In the broad problem of developing a rational public opinion that will countenance the freer discussion of the serious hygienic and moral dangers involved in the present attitude of indifference or neglect, the school has a tremen- dous responsibility. Under school auspices parents may be educated to higher ideals and to a more healthful apprecia- tion of the importance of conveying to the young a knowledge of the sacredness of human development. The school can indicate the sociological importance of sex morality. In ad- 566 EDUCATIONAL HYGIENE dition to this, the school will foster a broader concept as to the ethical import of sex education and its relation to the welfare of future generations. This may all be given con- structively without emphasizing pathology. The Need for Trained Teachers. — The crying need of the present time is the training of capable teachers in this line of educational endeavor. Training-schools must adjust their courses to the future needs of the community. The process of introducing sex education into the pubhc-school system should proceed slowly and advance no more rapidly than the education of teachers. This does not mean the creation of a new set of specialists in sex themes. It involves merely im- parting an accurate knowledge of the essential biologic facts, together with the inculcation of tact, understanding, and skill in presenting the facts in a sympathetic manner that will make an impress upon the minds of children in the course of ordinary instruction. For the presentation of specific themes in sex instruction broad vision is essential, with a clear un- derstanding of the psychology of sex, together with the varia- tions in child psychology according to the degree of physical, mental, and moral development. Conclusion. — Thus it is patent that the educational aims of sex instruction are to supply adequate information to serve as the basis of conscious reasoning with a view to stimulating the will to more effective self-control. Modesty, chastity, courage, pride, honor, and self-control are normal ends. One seeks to subordinate self-assertion in individualism by the development of social responsibility and a willingness to submit to self-disciphne. The function of sex education is to preserve health, develop right thinking, and control conduct. Its educational values are biological, physiological, psycho- logical, hygienic, and pedagogical. Sex education should de- termine the evolution of sex character on the basis of the di- rection and control of sex characteristics. V. THE HYGIENE OF INSTRUCTION CHAPTER XXX THE GENERAL HYGIENE OF INSTRUCTION The Problem. — In its application to the instruction of children, hygiene takes on a wider significance, if possible, than it does in any of its other special phases. In looking to prevention of immediate physical injury it is negative, in its care for future physical development it is positive in its view-point; but in addition it must concern itself with sim- ilar problems, negative and positive, with regard to mental health and development. It must study both the objective and the subjective results of school life. Therefore, while busied with the problem of providing conditions that make for such characteristics as strong muscles, deep breathing, erect posture, and clear vision, it must have an "ear to the ground," so to speak, for any condition that may lead to faulty habits of attention and association, hinder the development of good memory, or in any way interfere with the develop- ment or cultivation of the power to think clearly. Even the emotions must be considered, so that it devolves upon hygiene to consider the attitudes, healthful and otherwise, that are related to or that result from the child's experience in school. It is this broad, or, if you please, this multiple, view-point that determines what are the problems and what the methods of their solution in the hygiene of instruction, or, as it is termed by the editor, the hygiene of methods of teaching and management. It has been pointed out that our army of school-children in this country is now some eighteen to twenty millions strong and that throughout the greater part of the year about half the waking time of these young recruits is spent in school. 567 568 EDUCATIONAL HYGIENE They are there to receive instruction. It is for the same purpose that teachers are hired and that buildings and grounds are provided and equipped and maintained in every State. Now, the fundamental principle of instruction is that the organism of the child is immature, is still developing, and that by imposing certain conditions we are able to influence, to modify, and to mould his physical and mental development. Instruction, therefore, touches his life at its most vital points. But let us not forget that the child's response to bad may be as ready as that to good instruction. Bad environment or faulty methods may initiate abnormalities of development. This is especially true of the mental development of children who have inherited or acquired tendencies toward neuroses. In the Hght of such facts, the importance of making the instruction of this army of future citizens hygienic looms large beyond our powers of comprehension. We are intro- duced here to problems that reach nation-wide and soul-deep. They are of vital importance to the domestic happiness and the prosperity of millions of future homes, and they relate themselves to a great extent to the economic welfare of every State. Instruction is a general term and may be concerned with a wide range of activities, physical, mental, or both. A rigid classification and detailed treatment of these is out of the question here; I shall therefore only attempt to summar- ize the more important principles involved and give some of their applications, taking up first those of a more general nature and following with those that concern themselves more particularly with mental hygiene. It should be stated that in doing this I draw heavily from both published and unpublished material of Doctor Wm. H. Burnham, of Clark University, as well as from notes taken in his courses of lectures. Indeed, those paragraphs which deal more specific- ally with the characteristics of mental health do little more than to summarize his contributions in this field. THE GENERAL HYGIENE OE INSTRUCTION 569 General Hygiene Innate Ability. — Extended investigations have clearly de- monstrated that children are not all equal with respect to their abilities along certain lines. Especially is this true in case of those mental powers upon which so much of the or- dinary school instruction depends. Hygiene of instruction demands that this be recognized and that requirements be adapted to the abilities and individualities of the children. Some children are mentally defective; they should be placed at once in special classes and receive special instruc- tion by special methods. Some are merely slow in their development, constituting the type known as ''retarded"; these, too, should be placed in special classes and given indi- vidual attention. With a little care they can, without injury, be brought up to the average, in course of time. On the other hand, to attempt to drive such pupils through their classes at the same pace and in company with their more developed comrades of equal age is in many cases merely to transform retardation into arrest. Again, many a child is so unfortunate as to have inherited an unstable nervous system and thus have within him a strong tendency toward the development of some form of neurosis. Usually this is shown by such characteristics as nervousness, inability to sit still, and lack of motor control. Hygiene would demand that in such cases special care be taken to avoid overstrain from heavy work and that no tasks be given de- manding strained attention for lengthy periods. Better to modify the instruction than to run the risk of throwing the nervous organization out of balance, perhaps for life. Similarly, the unusually gifted pupil should receive some special consideration. Holding such a pupil to constant repe- tition of well-known and easy tasks that require no effort may lead to loss of interest, inattention, dawdling, and even fail- ure. An otherwise specially promising pupil is thus trans- formed into a repeater and a dullard. 57© EDUCATIONAL HYGIENE Stage of Development. — The fitting of instruction to the stage of the child's development, physical and mental, is of significance for hygiene. Length of life cannot be depended upon as a measure of the advancement a child has made in his development. Girls are some two years ahead of boys in their development at the time of puberty, and progress more rapidly to maturity. Even among children of the same sex, variations are great. Phenomena of growth, pubescence, skeletal ossification, den- tition — all these give evidence that the rapidity with which children approach maturity varies widely from individual to individual. The degree of relationship between these and the development of mental power has not been entirely worked out. A correlation is suggested, however, by such investiga- tions as those of Porter, Smedley, and Crampton, in America, and of Grazianoff , Sack, Quirsfeld, and Riez, in Germany, all of whom found a close relationship between various phases of physical health and development on the one hand and either school success or mental power on the other. As has often been pointed out, it is clear that there is a pedagogical and hygienic moral to be drawn from these facts, namely, that grading for educational or other purposes on the basis of chronological age, i. e., age in years alone, is en- tirely inadequate. Doctor Crampton has demonstrated how true this is for pubescent boys. We may therefore state as a hygienic principle that grading, implying, as it does, a measure- ment of the amount and kind of work that may properly be required of a pupil, should be based upon the mental and physical powers to which he has attained at a given stage of development, regardless of what his age in years may be. This principle becomes especially significant when applied to school beginners. As I have shown elsewhere, there is much evidence in support of the theory that a transition or "nodality" in general de\elopmcnt occurs at about this time. This is indicated by a number of phenomena, such as varia- tions in growth, second dentition, change of growth rate in THE GENERAL HYGIENE OF INSTRUCTION 57 1 certain organs, and acquisitions of certain neuro-muscular and psychical powers. These do not occur in all children at a given age. Variations are great, as is well illustrated by skeletal ossification and by dentition. The exact relationship of these phenomena to each other and to general development is not known, much less their relationship to mentahty. But, however that may be, the fact that so many fundamental developmental changes occur at this period of life is sufficient basis for the demand that, until it is past, any instruction other than that partaking of the nature of free play and allowing for natural reactions and normal physical development should probably not be given. The hygiene of instruction up to the age of seven or eight years is distinctly the hygiene of general health and normal development. Moreover, there are many indications that those children who do not begin formal school work until about the eighth year are not only not handicapped but are rather benefited thereby in the long run. The interesting and accumulating data concerning certain precocious children who at a very early age gained remarkable command of cer- tain forms of school knowledge have seemed to some to point in the opposite direction, but this is doubtful, to say the least. So much for the general statement. But, again, the above facts justify the demand that when the time for school work does arrive, entrance be based not upon the mere age in years, but upon the degree of physical and mental development. We hear much in these days about "repeaters." And truly our instruction is not hygienic when we have a high percentage of pupils in all our schools droning over again the work of last year. But, bearing in mind the great variation in development at this period, and also the general relation- ship between physical and mental development, it must follow that very many of the problems of "repeaters" in the grades would never be met if children were admitted to the first grades only on the basis of their fitness as indicated by stage of development. 572 EDUCATIONAL HYGIENE " * ' Properly, grading should take into consideration at least those special phases of development that have been mentioned and possibly some others also. It must be admitted that no standards for such grading have been established. In view of their absence, and also in view of the fact that dentition is so closely related to development as a whole and to nutrition in particular, there is much to be said in favor of taking that as an index. Unless otherwise exceptionally well developed, there is, hygienically, some question as to whether a child who has not erupted his first permanent molars should begin formal school work. Differences in the development of the sexes must be considered. At the period of life when school work is usually begun, girls are relatively more advanced than boys of equal age. The difference between them grows progressively greater up to the time of maturity, being especially significant during the pubertal years. This being true, the question is raised as to whether the instruction of the sexes should be the same from the beginning, but sufficient data are not yet available upon which to base a definite answer. On the other hand, the difference between the sexes at the pubertal period is so evident and so great that a differentiation of in- struction becomes not only a hygienic but a pedagogical de- mand also. Knowledge of mental development is not sufficiently ac- curate to admit of a close grading. Some facts of a general nature are known, however, a few of which relate themselves to our topic and may here be mentioned. Much of present-day classroom procedure very easily approximates a reaction-time experiment. That is, the child is given a question to which he must reply in the briefest possible time. This is fundamentally wrong. It has been demonstrated experimentally that the child's mind reacts much more slowly than that of the adult, as shown by the greater length of time it takes him to make associations of ideas. Quick replies should therefore be neither required THE GENERAL HYGIENE OF INSTRUCTION 573 nor expected from young children, especially when the ma- terial with which they deal is new and unfamihar or difficult. Questions should be clearly and definitely stated, and then a reasonable time for answer should be given, with some re- gard, of course, for individual differences of pupils. Driving the child to answer too rapidly is liable to result in habits of carelessness and inaccuracy, establishment of wrong reac- tions that may persist and impede thinking in the future, discouragement on account of failure, nervousness, and over- strain, or a combination of these. In any case, the result is liable to be detrimental to development of clear thinking and good mental power. In the early school years, drill for speed should only follow the mastery of the proper associations. When proper associations are firmly established, drill for speed is in place. Again, the mental imagery of the child up to about the pubertal period is concrete rather than abstract. This is the normal condition; and instruction, to be hygienic, should take account of the fact. Power of abstract reasoning de- velops late — at least as late as the adolescent years. Stimu- lation to this kind of activity at too early an age is liable to cause premature development or overstrain, either of which is injurious and should be guarded against. Doctor Hall's early investigation showed that a high per- centage of children begin school remarkably poor in ideas gained from experience. A number of other investigations have since confirmed his results. Too often the school gives no opportunity to make up for this deficiency and the result is that pupils become drilled in a "word education" and lack the power either to think clearly or deal intelligently with a concrete situation requiring tact and mental power. Hygiene has an interest in developing healthy mental powers as well as preventing injury. The meaning of all this is, therefore, that during his early years the child in the grades should be put into possession of a wealth of concrete ideas and of the ability to use them, not introduced — much less driven— to 574 EDUCATIONAL HYGIENE the working out of complicated, abstract problems like some that have found their way into our arithmetics, where the es- sential thing is a logical trick. The span of attention is more limited in the child than in the adult. Also, the span for immediate memory is shorter in the earlier years than later in life. That is, the quantity of material that can be held in mind for immediate repro- duction is considerably less. The child often does not un- derstand a long sentence, even though it be presented in simple terms, because the first part of it is forgotten ere the last part of it is heard. In presenting material, therefore, sentences should be short, definite, and clear. Enumeration of a number of conditions that must be held in mind and upon which the correct answer depends leads to confusion and serves rather to obstruct than to facilitate development of power to think. In a conversation on this topic a teacher of some years' experience recently said to me: "That's just one of the points where I used to fail. I would ask a question and then add something to it to make it clear, when in reality I was only making it the more confusing to the minds of the pupils." This is by no means a complete list of the mental differ- ences between the young child on the one hand and the adoles- cent or adult on the other, but possibly these cases will serve to illustrate the principle that a hygienic instruction is one which is fitted to the stage of mental as well as physical de- velopment of the child. Condition of Health. — Instruction in school should not proceed independently of the condition of the pupil's health. Most of the topics related to this principle belong properly in a discussion of school medical inspection and are discussed in detail elsewhere in this work. Little more than an enumer- ation of the most important ones is needed in this connection. Freedom from disease, a well-nourished condition, good posture, good digestion, ability to sleep well — all these are essentials for mental as well as physical development. There THE GENERAL HYGIENE OF INSTRUCTION 575 should be no hindrances to respiration. The child with ob- structions such as adenoid growths in his nasal passages is less able to give sustained attention and profits much less from instruction than the one that breathes freely. Kaffe- mann is reported to have demonstrated experimentally that children with artificial nasal obstructions showed a decrease in abihty to retain memory material. But more than this, it is a well-known fact that the child with adenoids is liable to be inattentive and "dull," and that he benefits both phys- ically and mentally when they are successfully removed. Attention has elsewhere been called to the relation of physical defects to school progress. Tonsilar disturbances and en- larged glands should be carefully watched for and treated when necessary. While not attempting to state which were the causal factors, Quirsfeld reports that he found among German chil- dren that a condition of lack of nourishment, weak muscu- lature, enlarged glands, and weak mental powers were very liable to be found in the same pupils. Since so much of the child's knowledge must be received through ear and eye, it is extremely important that these organs be free from defects. Special classes, if need be, should be furnished for those children who hear poorly. Meumann says that such conditions as bad hearing may go so far as to cause moral injury. Care of the eyes is equally, if not more, important. All the things that may be said re- garding hygiene of vision apply here. Good teeth, properly cared for, are essential to the health and comfort of the child and also to good school work. Numerous school dental cHnics in this and other countries are evidence that this fact is being recognized. Rose has re- ported that among German children physical development was greatly influenced by defective teeth, that poorer physical development was accompanied by poorer mental power, and that the poorer the teeth the worse on the average were the grades of the children. 576 EDUCATIONAL HYGIENE Finally, children with nervous disorders and symptoms of neurotic condition need the most careful attention. They should be free from strain of all kinds, in order to guard against nervous and mental disturbances that may be both serious and permanent. Some precaution is needed, also, to prevent the spread of such things as bad motor habits, tics, and even in many cases certain defects of speech, which may easily become "psychic contagions." The above Hst of topics is perhaps not entirely new, but the thing to be emphasized here is that these things are im- portant for instruction, also for mental development. The maxim should always be: "Health first, then instruction." Optimum Conditions for Work. — Having fitted the de- mands of the school to the child's innate ability, stage of development, and condition of health, the next step should be to look to the conditions under which the work is to be done. Sufl&cient room for work, and an abundance of light and pure air, are essential. Undue distractions should be elimi- nated as far as possible. School-buildings should be located in quiet districts. Subjects requiring strenuous effort should be studied during the early forenoon, when, as experiments have shown, the maximum of ability for the day is reached. Habit studies and routine work may come in the late forenoon or in after- noon hours. Daily application to strenuous work at a time when energy is at its ebb may be expected to result in nerv- ousness, headaches, and a minimum of acquisition of real power. On the other hand, periods of the most strenuous work should not immediately follow each other. Ability is influenced by preceding work as well as by time of day. Strenuous tasks should be followed by a period of relaxation or lighter work before other equally strenuous tasks are begun. Seasonal variations have also been noticed. Api)arently the tide of mental ability runs low during the spring and early summer, when physical growth is greatest. School work THE GENERAL HYGIENE OF INSTRUCTION 577 should be a little less strenuous at this time. On the basis of the same facts, the spring vacation finds a hygienic justifica- tion. Some attention must be paid to the social environment. The presence of the teacher, the presence of other pupils, the knowledge of their attitudes toward the work being done — all these are of significance for the healthful exercise of the pupil's mental powers. Too great variation of ability in one class is bad. The best are not stimulated to work; the poorest are too much discouraged to do so. On the other hand, abihty should not be perfectly uniform. A sHght inequahty stimu- lates the entire group to better efforts and greater develop- ment. Social environment is also a factor in the determina- tion of whether home work is good or bad. For example, Schmidt found that among the parents of children who were doing home work some could be classed as "demanding," some as "hindering," and still others as "indifferent." Hy- gienists seem to be agreed that there should be no regular home work for any of the pupils of lower grades. There is less agreement with reference to home work by pupils of the upper grammar grades, but most admit that high-school pupils may do some home work without injury. These conditions need attention if the surroundings of the school-child are to be made conducive to efficiency of work and a healthful development. School work is sufficiently un- natural and difficult at best, and injuries sufficiently numerous. Every precaution is needed to keep the child body and child mind growing and reacting normally and to prevent the fur- ther multiphcation of "school injuries." Conditions should therefore be as nearly the best as it is possible to obtain. Alternation of Work and Rest. — That the development of an organism is conditioned upon the rhythmical alternation of functioning and inactivity is a fundamental biological law. That this is true of physical development has been demon- strated by every athlete that ever went into training. Based upon this is the hygienic principle that periods of work should 578 EDUCATIONAL HYGIENE alternate with periods of rest. The old maxim that "exercise strengthens" suggests at once the classic example of the blacksmith's arm, but a similar influence from exercise is as real in case of mental as in case of physical development. On the other hand, we scarcely need be reminded that the black- smith does not use his arm without ceasing. Rest and time to rebuild tissue are essential. And if this is true for the hardened muscular cells of the blacksmith's biceps, how much more true is it for the delicate brain and nerve-cells upon which mental work depends! If such analogous reasoning does not suffice, then one needs only to observe the nervousness, the inattention, the inability to think, that are displayed by a group of pupils at the close of a long and fatiguing school session. Work is essential to development, but so also is rest; and both development and health are conditioned upon their proper balance. It is well for the child to work until he is tired, but he must have opportunity to rest afterward, not set to work immediately upon another fatiguing task. The meas- ure of this balance is the readiness with which the child re- covers. Prolonged work, whether physical or mental, is sure to result in nerve strain, and a condition of nerve strain is a condition of strength drain. When the strength thus drained is not recovered within a reasonable time, there is danger of injury. The applications of this principle are many. I mention a few of the more important. The position in which the work of the school is to be done should be natural. When the strain from unnatural positions becomes too great, the child slumps down in an attempt to ease himself — to get needed rest — and bad posture with its attendant ills results. Strenu- ous physical exercise should not follow difficult mental work, especially where movements are difficult and require close attention. This does not rest; it only increases the fatigue. Conversely, a strenuous physical exercise should never be followed immediately by difficult mental work. Exercises in THE GENERAL HYGIENE OF INSTRUCTION 579 singing, especially those in which attention to the reading of music is involved, should never be substituted for actual rest. They require attention and expenditure of energy and are more liable to produce than to relieve fatigue. Finally, by no means least in importance, frequent recesses should be given. Better work has been shown to result when recesses were fre- quent and short than when they were less frequent, even though longer. Mental Hygiene Mental hygiene as a science, the nativity of which does not date very far back in years, is founded largely upon con- tributions from psychology, normal and abnormal, psychiatry, physiology, and neurology. These sciences have in recent years contributed many significant facts regarding mental functioning and mental development and the conditions upon which they depend. It has been shown that much of the so- called abnormality, and much of the insanity even, is in great part the result of faulty mental habits developed early in life. The treatment for such conditions consists essentially in a re- education in proper habits of thinking. Now, as has been repeatedly pointed out by Doctor Burnham, it is certainly a fact of some significance that many of the patients now receiving their re-education in special institutions were only a few years ago pupils in the public schools. A properly applied mental hygiene there would have instituted correct mental habits in a high percentage of cases and thus acted, at least in many borderline cases, as a pre- ventive of much of the suffering, not to mention the expense and economic loss, to society. It is thus clear at once that the hygiene of instruction is in large part a mental hygiene, and this means that the school must pay proper attention to the cultivation of good mental habits. Of prime importance here are habits of attention, associa- tion of ideas, and emotional expression. All these are es- sential to instruction at every point. Each involves and is 5 So EDUCATIONAL HYGIENE conditioned by the others in almost every situation, so that it is almost impossible to discuss them separately. Let us there- fore turn attention for a few moments to the meaning and im- portance of each, taking up later the applications to school work and the conditions upon which they depend. Attention. — From the functional view-point, attention is that reaction by virtue of which elements in a situation be- come more or less clear in consciousness. In its simplest, most primitive form, the reaction is direct and immediate, in response to a stimulus. In its developed form it is selective in its nature; certain elements are either pushed into the background or "fringe" of consciousness or excluded entirely, while others are brought to the foreground and thus become more clear. But we must take care to interpret correctly. Conscious- ness is not static. Attention does not render its elements fixed. With a sort of panoramic sweep they change and flow, creating ever a new situation. In fact, the figure "stream of consciousness" has been very fittingly applied. There is therefore a constantly recurring readjustment, a shift of at- tention from moment to moment. Now the ability to adjust to these changes, the ability to attend in a proper manner, is at once vital to clear thinking and to mental development. The lack of this ability, on the other hand, means difhculties of thought, abnormalities of mental development, and, in extreme cases, entire loss of mental balance and a pathological condition. The whole matter is, of course, complex; but, even though such phe- nomena as emotional response and association of ideas are involved, it may yet be said that ability to attend properly is largely a matter of habit. This is the point at which the topic of attention is linked with the hygiene of instruction. It becomes the business of the school to drill pupils, so far as is possible, in healthful habits of attention. The healthful form for developed attention is suggested by the simpler, more primitive form. As intimated before, this THE GENERAL HYGIENE OF INSTRUCTION 58 1 is direct and simple, bringing one element to the foreground. The school, therefore, should drill its pupils to attend to a situation in such a way that the essentials are brought to the foreground, while unessentials, whether relating to past, present, or future, are either excluded entirely or else pushed into the background or fringe of consciousness. In ordinary terms, this means the ability to concentrate upon the essen- tials of a situation, shifting attention from moment to moment in a way to present them to consciousness from a new view- point. To the problem of how this is to be accomplished in the school we shall a little later return. Association. — Training in good habits of attention should be paralleled by training in habits of orderly association of ideas and the avoidance of interference. Briefly stated, in- terference means a struggle of ideas for possession of the fore- ground of consciousness. This problem has been dealt with in detail by Doctor Burnham, who would make the avoid- ance of interference the most general negative rule in mental hygiene. "We find interference of association," he says, "in an infinite number of forms, from the conflict of simultaneous stimuli in the nervous system and the relatively simple in- terference of incipient motor habits up to the confusion of thought in the individual who is worried or rattled or the patient who suffers from the insanity of doubt." All persons experience an occasional interference of as- sociation. For example, do you spell receive with an ei or is it ie? Was it number 368 or 836 ? Or, again, a name can- not be recalled because a similar name crowds to the fore- ground and usurps the focus of consciousness. Ordinarily these experiences last for but a moment, or at least for a few minutes, and are apparently harmless enough. Unfortunately, however, this is not always the case. Inves- tigations have shown that, especially in case of persons with unstable nervous systems, conflicts of ideas or of complex systems of ideas may under the influence of strong emotional toning finally result in serious pathological conditions such as 582 EDUCATIONAL HYGIENE obsession, dissociation, disintegration of personality, and loss of sanity. I do not mean to assume that every case is to be taken as an indication of a pathological condition. I do wish, however, to lay stress upon the necessity of proper habits of association of ideas as an essential to mental health and the development of the power to think clearly; and I insist that it is imperative that the hygiene of instruction take account of these facts, namely: (i) In extreme cases interference of association may form the basis of bad habits of thought which lead later to pathological conditions and loss of sanity; (2) interference is ordinarily a common and normal occurrence but is often ab- normal, and forms an obstruction to the free flow of ideas and to logical thinking and a hindrance to proper mental de- velopment; (3) the most successful method for treatment of pathological cases — the method of re-education — points to education in proper habits of association in the early years as the best means "for prevention of such cases ; (4) it therefore devolves upon the school, which assumes the burden of edu- cating and moulding the child to so great an extent — largely by means of association of ideas — to see that instruction be such as to avoid as much as possible the abnormal interfer- ence of these associations and that proper habits be developed. Emotions. — Habits of emotional response make up a third clement of significance for mental health. Indeed, it is im- possible absolutely to separate the child's emotional from his intellectual development — a fact, sad to say, that has not always been recognized by the schools. The influence of affective or emotional elements upon con- scious reaction has been clearly demonstrated in laboratory experiments during the last decade. Evidence of this is found in the "attitudes" that are so often to be dealt with in the working out of psychological problems. One needs but to mention a few of them, such as attitudes of indifference, prej- udice, approval, etc., to show that they are normal matters of every-day experience. But they are not always necessarily so. THE GENERAL HYGIENE OF INSTRUCTION 583 A persistent habit of assuming an attitude of disapproval may, for example, readily transform an individual into what is popularly termed a chronic grouch; certainly a habit that is not conducive to mental health. Similarly many other bad attitudes, such as jealousy, suspicion, distrust, etc., may be- come so ingrained as to become a hindrance to normal, health- ful mental reactions. But these are only mild cases. In ex- treme cases, when combined with other bad mental habits, such as interference, for example, affective and emotional toning becomes an important factor in the development of pathological conditions. Interference, emotionally toned, begets worry; worry aggravates interference; and so the evil spreads until the victim is hopelessly enmeshed in a tangle of conflicting ideas and compelling emotions from which it is impossible for him to extricate himself. It is a duty of the school to do all in its power to develop in the pupils those attitudes that are conducive to mental health. Possibly the whole secret for doing this has not yet been given to the world in full; but a large part of the secret is contained in the following expression: Freedom, Naturalness, Self-expression, Interest. Practical Applications.— Some practical suggestions as to how the principles of mental health may be applied in the schoolroom are in place here. (i) Make the instruction such as to enlist the permanent interest of the child. Faithful, energetic work on a problem of vital interest, even though it be not of long duration, will do much to develop good habits of attention and of associa- tion. (2) The injunction to guard against overfatigue is again in place here. The fatigued child is the inattentive child, or, perhaps better, the badly attentive child. It is in this condition, too, that associations go wrong and interference is liable to be initiated, and unhealthful attitudes toward work develop. (3) Make statements and questions commensurate with 5^4 EDUCATIONAL HYGIENE the limited attention span of the child. Do not "scatter" the attention and initiate interference by means of much and confusing diction. (4) Problems and tasks should not be too complex. "One thing at a time, and that done well, Is a very good rule, as many can tell." In beginning penmanship, for example, it is too much to ex- pect the young child to attend to the form of the letters, spelling of the words, holding to the line, neatness, manner of holding the pen, and posture, all at one time. (5) Take account of the kind of work to be done and use a few moments to teach the pupil how to study it. For example, a leading question or two may make the difference between a history lesson carefully studied with interest and good attention, or a history lesson which is uninteresting and "memorized" imperfectly with many a shift of attention. (6) In making assignments, give a definite task commen- surate with the child's ability, require him to do it, then give some chance for relaxation. (7) See that each child in the class or in the school suc- ceeds at something. Not to do so is to bid for discourage- ment and unhealthful attitudes on the part of some pupils. Nothing is more true than the old maxim that " nothing suc- ceeds like success." (8) Select as teachers persons who are optimistic, joyous, tactful, enthusiastic, and sympathetic; and let teachers them- selves practise good mental hygiene in the realization that most irritable, pessimistic, exacting attitudes of mind can be changed. Summary To summarize very briefly, the problems of the hygiene of instruction are those which have to do with the health and the normal development of both body and mind. The sub- THE GENERAL HYGIENE OF INSTRUCTION 585 ject is therefore broad in its scope. As a result of the solu- tion, or partial solution, of the problems concerned, the fol- lowing general principles may be stated: The demands of in- struction should be fitted first of all to the child's innate ability, stage of development, and condition of health, after which he should be given as nearly as possible optimum con- ditions in which to work; work and rest should be properly alternated in order to avoid injury from overfatigue; finally, regard should be had for the laws of mental health, so far as they are known, care being taken to develop proper habits of attention, association of ideas, and emotional response. CHAPTER XXXI THE HYGIENE OF SCHOOL SUBJECTS In this chapter the attempt is made to indicate some of the applications of the principles indicated in the preceding one to some of the most important subjects of the school curriculum. It is impossible to make a complete list, but the treatment of these most important subjects will, I hope, be of value. Reading. — The emphasis upon reading is so nearly uni- versal, both throughout the school years and throughout Ufe, the amount of time spent upon it is so great, and other sub- jects in the school depend so much upon it, that compliance with the demands of hygiene for as nearly optimum conditions as possible becomes imperative. Without attaching special significance to their order, let us turn attention to the most important of these demands. (i) First, hygiene demands that proper regard be had for the posture of the child. Suitable seats and desks, more complete descriptions of which are to be found in another chapter, are a necessity. They should be suited to the size of the pupil and so constructed as to make possible an easy, erect position, without strain; and they should support the book in a way to make reading possible without stooping and without bending forward the head or the body. Standing in Hne and holding heavy volumes in position for reading should not be required of pupils. Indeed, heavy volumes for regular use in any subject should be avoided, especially in case of the younger pui)ils. The carrying of such books is liable to be injurious. (2) In the second place, hygiene demands that oral read- 586 THE HYGIENE OF SCHOOL SUBJECTS 587 ing should have proper regard for the organs of speech. Here are involved organs of respiration, vocalization, and articu- lation, and any rules having reference to their proper care, development, and training are applicable to the hygiene of reading. In proper amounts and under proper conditions oral read- ing is a healthful exercise. Good breathing exercises and the development of good breathing habits are of value. The use of pure tone should be cultivated, but it should not be a monotone. Reading with expression brings various muscles into play, thus preventing rapid fatigue of the vocal organs. Training in habits of articulation is also valuable, since both, in school and out a little articulation is better than much loud talking for making one's self heard, and it is much less injurious to the vocal organs. Reading should never be so long nor so loud as to cause strain, hoarseness, or overfatigue of the vocal organs. Es- pecially in the early years, excessive strain should be avoided; also at the time of voice mutation, which usually occurs at about the pubertal period. So also in case of colds or sore throat, after certain diseases that affect the throat, and where there are nasal obstructions or tonsilar disturbances, over- strain should be guarded against. Bad nasal and tonsilar conditions should receive medical attention immediately. Speech defects constitute a special problem. Their causes are numerous, many of them lying outside the school, and in so far as treatment is concerned the cases belong in the hands of specialists. Within the school, however, oral work may be of value by drilHng in habits of slow, deep breathing, rhyth- mical speaking and proper articulation of words, thus pre- venting or correcting bad habits which are liable to be con- tributing factors to defects of speech. (3) Hygiene demands that care be taken to prevent school-books from becoming media for the spread of disease. Books pass from hand to hand and are liable to be thumbed by a number of individuals. Turning of pages with the tip 588 EDUCATIONAL HYGIENE of the finger moistened in the mouth should never be tolerated. Special precautions are necessary in case of supplementary readers that are handed from class to class, also library books that circulate from home to home. The same apphes to pencils and other objects, as taken up in the chapter on school sanitation. (4) A fourth demand has reference to the organs of vision. All rules regarding the care of the eyes apply here. Some of these need special emphasis. Light should be abundant, but should not fall on books and desks in a way to cause a glare. Rules for posture are important again in this connection. The distance of the book from the eyes should not be such as to cause strain of the visual organs in reading — never less than twelve inches, according to a special committee report before the American School Hygiene Association, 191 1. Near work should alternate with that giving opportunity for distance-vision, thus relieving the strain caused by ac- commodation of the eye for close vision. In the report of the British Association for the Advancement of Science, 191 2, the committee appointed to inquire into the influence of school- books upon eyesight writes as follows (p. 298) : Children who do too much close eye work suffer in various ways: some simply from fatigue, showing itself by inattention, mental weariness, temporary dimness of sight, or aching of the eyes and head; some from congestion of the eyes, as shown by redness, watering, and frequent blinking. A certain number, in circumstances which predis- pose them to the disorder, develop strabismus, or squint. Some others —and these cases are perhaps the most important of all — develop pro- gressive myopia. A special committee of the American School Hygiene As- sociation fixes the maximum time for the uninterrupted use of the eyes for near work at fifteen minutes for the first school year, increasing to one hour in the later adolescent years. Again, the undeveloped condition of the eye in the early years, the frequent lack of ability to fuse together the images THE HYGIENE OF SCHOOL SUBJECTS 589 from the two eyes, the inabiHty to hold the book at proper distance from the eyes because of the shortness of the arms, these and other facts indicate that instruction in reading should not begin too early. The British committee recom- mended that extended reading from books be postponed until the age of seven at least. Oral work, pictures, blackboard work, and wall charts are recommended for use up to this age. The "make up" of school texts is important. Author- ities are practically agreed as to the fitness of the following requirements : Paper should be white, without gloss, opaque, and sufficiently hard so that type does not press through. Illustrations should be plain and without j5ne detail, especially in the lower grades. Ink should be good black and evenly distributed over the page. Maximum length of lines should be 90 mm. (The British com- mittee gives 100 to g3 mm. — i,^^ to 4 inches.) For beginners, lines should not end in the middle of a word. Series of short lines by the side of illustrations should not be used. Margins should be sufficiently wide so that the eye does not swing off the paper, and those next the fold of the book should be wide enough to prevent printing from being hidden by the curvature of the paper. Type should be clean-cut, making lettering with clear and well- defined lines, especially in the upper half, and whites and blacks should be evenly balanced. Italics should be used very little. The committee of the American School Hygiene Association gives the following as minimum standards for type, spacing, and leading for the earlier school grades: A. First grade — (i) The height of the small letters should be at least 2.6 mm., with the other dimensions in proportion. (ii) The width of the vertical stroke should be from .4 to .5 mm. (iii) The space within the letters should be from .8 to .9 mm, (iv) The space between the letters should be about i mm. (v) The space between the words should be about 3 mm. (vi) The leading should be from 4 to 4.5 mm. 590 EDUCATIONAL HYGIENE B. For the second and third years the standard may be reduced slightly, but the letters should not be less than 2 mm. in height and the leading should be 4 mm. C. For the fourth year height and leading should not be less than 1.6 mm. and 3 mm. respectively. It would be better to re- tain the standard of the fourth year through the sixth year. The British committee is somewhat less liberal in its recom- mendations for size of type, but more liberal as regards lead- ing, or interlinear space. (5) But, after all, standards and objective material are but means to an end. These are furnished and should be properly used in order that the child may learn to read. And reading is to interpret symbols presented. It is something psychological, a series of mental processes. A fifth and per- haps most important demand of hygiene is therefore that reading should not be detrimental to the mental health of the child. Now, the earlier years are the time par excellence for play, for telling of stories, and for relating personal experiences, all of which begin the development of and furnish the basis for habits of attention, ability to concentrate upon essentials while ignoring unessentials, practise in memorizing things of interest, and in giving logical expression to ideas — all essen- tials to mental health, as outlined in the preceding chapter. On the other hand, as Doctor Fitz has pointed out, reading too early is liable to crowd out these activities and leave the child grinding over the memorization of symbols that are arbitrary and uninteresting. He develops the habit of look- ing too much at the symbols, not through them, to the thought — a habit which may retard him in his future reading when the getting of the thought is essential. The statement may therefore be repeated here with em- phasis that regular work in reading should not be required of the child in the early years. Many of the best educators maintain that reading should be postponed until the age of eight. To quote Doctor Fitz: THE HYGIENE OF SCHOOL SUBJECTS 59 1 Experience has shown, over and over again, that the child who begins to read at eight years is in no wise handicapped in his later educational progress. He has the inestimable value of the advantage of intense interest, rounded by his sense of power in unlocking the secrets of books and papers after the fashions of his elders. Increased maturity makes the slow, irksome task pleasurable and easy. The slower association time of the child makes it wrong to demand too rapid reading, especially when the material is new and unfamiliar. Ideas that should be associated with the symbols come slowly and attempts to force them are liable to cause either wrong associations or interference. To summarize briefly, then, the reading of books in the school should not be required under conditions that are lia- ble to cause bad posture or to result in injury to the organs of speech or of vision; books themselves should not be media for the spread of disease; and finally, instruction in reading should be given neither at such an early age nor by such meth- ods that it may become a hindrance to mental development and the formation of good mental habits. Arithmetic. — As one of the ''three R's" arithmetic has always had a place of great importance in the schools. Its general hygienic requirements are much the same as those for reading. The great amount of desk work that must be done neces- sitates attention to the proper adjustment of seats and desks with a view to securing good posture. Height of blackboards from the floor also should correspond to the size of the pupils. Care of the eyes makes it necessary that proper conditions of lighting be furnished and that the ''make up" of texts conforms to all the requirements given in the preceding sec- tion for reading-books in general. Special emphasis should be placed upon the requirement that diagrams and illustrative drawings be clear and that all figures, especially fractions, be in large, good type. The British committee would have all mathematical symbols in slightly larger type than other material. Blackboards should be of proper color and of good 592 EDUCATIONAL HYGIENE material, and lettering to be read by pupils in the room should be sufficiently large and clear to be read without difficulty or eye-strain. With a view to taking precautions against spread of dis- ease the use of slates may well be prohibited entirely, also the loaning of pencils among pupils. Crayons should be selected with care and pupils should be taught how to erase the blackboards properly in order to avoid as far as possible filling the air with dust. From the view-point of the child's mental development a number of things are significant. First, the age at which formal arithmetical study begins should not be too early. The power of abstract reasoning develops late, as was stated in the preceding chapter. Attempts to force its development at too early an age are liable to result in retardation or arrest. Doctor Triplett has shown that too much stress on arithmetic in the early years often results in bad mental habits, such as the incessant counting habit known as arithmomania or the fixation of incongruous ''number forms" which are liable to persist as obstructions to logical arithmetical thinking, A number of the best authorities maintain that arithmetic should be postponed until the age of eight or ten years. Finally, bad attitudes may be the result of too early stress upon the subject. Says Doctor Fitz: . . . Much of the aversion to arithmetical problems found later is undoubtedly due to the disheartening drill of this primary work. Here again the child who begins arithmetic at eight or ten years of age finds himself able to take it up quickly and has the liking for it that easy mastery always gives. Again, collected statistics show that from one-sixth to one-fourth of the time of the school is devoted to the study of arithmetic — an amount entirely out of proportion to the value of the subject for mental development. Courses are as a rule made to include too much. Topics are taught because found in the texts and Ihev are in the texts because THE HYGIENE OF SCHOOL SUBJECTS 593 they have always been in other texts before. The result of all this is, in many cases, overpressure, nervousness, and injury to mental health and development. A number of mental processes are involved in arithmetical work. Much would be gained for the hygiene of the subject if this were recognized in a practical way. For example, where mere association of ideas is involved, account of the fact should be taken and drill in formation of the proper as- sociations should always precede drill for speed. Or, again, much of the subject is merely application of a new form of expression, a new language, to a form of reasoning with which the pupil is already familiar. Thus, both ratios and common fractions are neither more nor less than unexe- cuted divisions, decimals are specialized fractions written in new form, and percentage is perfectly simple when treated as a subdivision of decimals with symbol series of its own. Doctor McDougle has emphasized the proper sequence and proper relationship of these topics for the pedagogy of the subject. The hygienic value from such a procedure would perhaps be even greater, eliminating innumerable difficulties of thought and causes of interference and unhealthful atti- tudes. Doctor Burnham has emphasized the importance of eliminating the type of complex problem which is in its es- sentials a logical trick and has little to do with reasoning about numerical relations.^ Geography. — The demands of hygiene upon geography, in so far as its influence upon physical health is concerned, have particular reference to posture and to vision. In case of the former the conditions within the school- room and the hygienic demands are practically the same as in case of reading, except in the special work of the drawing of maps. There the rules found under the discussion of drawing will apply. It may be added, however, that map- drawing should not constitute a large part of the course. ' See also Jessup's studies of eliminations in arithmetic in the 1915 year-book of the National Society for the Study of Education and in the 1914 and 1915 Proceedings of the National Education Association. 594 EDUCATIONAL HYGIENE As regards the care of Ihe eyes, also, the general rules in- dicated in the discussion of reading apply. In addition to these, however, some special precautions are made necessary by the extensive use of maps. First, the matter of the con- struction of maps is of importance. They should not be made to contain too much of detail, and should only contain such lettering as is necessary to make their meaning clear. The suggestion of Burgerstein that all the important names in wall maps be large enough to be read by the entire class is good. The special committee of the British Association for the Advancement of Science recommends that no school- atlas should use type smaller than eight-point, with a mini- mum height of short letters of 1.2 mm., and that for chil- dren below the age of nine years nothing below ten-point, with a minimum height of short letters of 1.6 mm. (yV inch) should be used. Separate maps should be used to represent physical and political characteristics. As regards the use of maps a suggestion of the British committee may be quoted: Location by reference lines should be taught from the beginning, and children should not be allowed to hunt for a name in an undi- rected fashion, as they may thus have to read fifty names in finding the one sought. In a more general way, geography may be said to be a subject of health opportunity. Outdoor excursions and trips to places of interest may do much for the general health of the pupils and are to be encouraged. From the view-point of mental development, also, geog- raphy may be said to be a study of opportunity. Pedagog- ically, the aim is to teach of the earth as the home of man. If this is done properly, with the use of concrete material wherever possible and with many properly managed outdoor excursions, the child comes into possession of a wealth of concrete ideas which, as investigations have shown, are so often lacking in school-children but which are essential to I)roper mental development. THE HYGIENE OF SCHOOL SITBJECTS 595 On the other hand, investigations have shown that unless special care is taken in the use of such material as charts, maps, and globes there may develop peculiarities and bad mental habits which may persist as obstructions to clear thinking. "When I get big I am going to move into that State, 'cause there the grass and flowers and trees — everything is all pink,'" confided a small boy to his teacher as he pointed to a bright spot on the map before him. This is a typical case. Doctor Triplett reports that no individuals asserted that map-drawing had produced inability to image places on the earth, a map being called up instead. One student reported as follows on the result of four years of study of geography, supplemented by much practise in locating places upon a large colored map: ... In consequence I still think of all States as little patches of green, red, or yellow, as the case may be. That result I do not regret so sorely, for it is a common thing. But, worse than all, the map was hung during all those years upon the south wall of the schoolroom. This reversed all the directions and I still think of Washington State, for instance, as being southeast of here, Florida as being northwest, etc. It would be almost impossible for any one who had not had a similar experience to imagine how very strong this association is. Speaking of such cases as "arrests" and commenting upon their causes and the form they take. Doctor Triplett writes: . . . The prevalent idea that one must be able to locate every place, whether of consequence or not, on the ground that it may be needed in one's reasoning appears responsible for the close memory grind of insignificant details. Overemphasis on the study of map- drawing is without doubt the strongest element in the production of the effects characteristic of these arrests. A large majority being of the visual type, extreme concentration on a symbol during the most plastic period of hfe habituates to the use of the fixed mental images of maps, globes, etc. Maps should be used to aid in the instruction of pupils concerning the things they represent, not merely as subject- 596 EDUCATIONAL HYGIENE matter, to be learned as they stand ; map questions should be used only in reviewing and summarizing, never in introducing pupils to the study of a country, except in the most general way; and care should be taken always to see that the ideation of the pupil reaches beyond the map to the actual things it represents. Writing. — The most important phases of the hygiene of writing, in so far as physical health is concerned, have refer- ence to its influence upon posture, vision, and the develop- ment of muscular control. The necessity of good seats and desks of the proper size for the purpose of securing good posture is self-evident. As regards other requirements, possibly a brief summary of those enumerated by Doctor Burgerstein would be of most value in this connection. They are as follows: (i) Body erect, without bending to the side and without a twist in the horizontal axis, and with breast not touching the edge of the desk. (2) Head very slightly inclined, eyes being as far from the paper as height of the body in good position will allow — never less than thirty centimetres. (3) Feet neither crossed nor drawn under the seat, but with soles resting on foot-rest or on the floor. (4) Arms held so that elbows are about a handbreadth from the body, forearms with about two-thirds their length on the table and almost at right angles to each other. (5) Hand with palm turned slightly to the left and resting upon the nail of the bent little finger, upon which the other fingers are sup- ported, one above the other. (6) Penholder, which should not be too short, should not be grasped too near the pen; held with upper portion pointing toward the elbow. (7) Writing periods to alternate with rest periods, gymnastic exercise, or oral instruction whenever the majority of the class begin to show signs of fatigue. (8) Copy-book so placed that it is in front of the median line of the body; lines parallel to the edge of the desk in vertical, but slanting upward to the right for slant script. THE HYGIENE OF SCHOOL SUBJECTS 597 Proper attention to vision makes necessary the following requirements : (i) Well-recognized rules for lighting should be observed. (2) The use of slates should be prohibited. (3) Writing-paper should have a good surface, being neither rough nor glaring, and should not be so transparent as to allow script to be visible through it. (4) Ink should be a good black. (5) Guide lines on the paper should be of a good black, never light blue, as is often the case, and should not be complex. (6) Script should not be too small — small letters not less than three to five millimetres in height, according to Burgerstein. Some care should be taken for the neuromuscular develop- ment. Here may be mentioned the following: (i) Strenuous drill in writing should not begin too early, as it requires too much of the accessory muscles. If reading should be post- poned until eight years, writing should be postponed until even later. (2) Script should be plain, without flourish, and should not be too small. (3) Pencils and penholders should be long and sufficiently thick to be grasped with ease. (4) Copy-book lines should not be too long. In fact, books should not be used, a few sheets of paper of proper size being better. (5) The necessity for frequent periods of rest needs re-emphasiz- ing here. Prolonged strain due to too much writing may result in what is known as "writer's cramp." (6) When first beginning to learn to write, children should be al- lowed to use coarser material, such as blackboard and chalk, thus avoiding the fatiguing finer adjustments of hand to pencil, etc. Lack of space prohibits going into the controversy of vertical versus slant script. On the whole, it may be said that investigations seem to have indicated that, from the view-point of influence upon both vision and posture, the ad- vantage is with the former, but the present semi-slant systems may easily be used without sacrifice of posture if teachers use "never-failing watch and care." So far as mental development and health are concerned, the 59S EDUCATIONAL HYGIENE problems of learning to write are those of association of the idea with the proper writing movement to produce the symbol and of the formation of habits. It should be emphasized here that learning correct forms should precede drills for speed, and that right habits should be mechanized as rapidly as possible, thus reducing the probability of interference of association.^ Drawing. — Properly employed, drawing may be a very healthful exercise. Like writing, however, a number of pre- cautions are necessary regarding it. General precautions are those against injury from poison- ous colored crayons, the use of sharp thumb-tacks, or any other material that might be injurious. Aside from these, the hygienic requirements are very similar to those of the hygiene of writing. Hygienic chairs, tables, and other furnishings are necessary to good posture. Other special requirements are given in the theses prepared by a committee of the Berlin Lehrverein, the main points of which are here enumerated: (i) Upper part of the body free and without strain, head inclined slightly forward, shoulders equal height, feet separate with soles on the floor. (2) Drawing surface directly before the middle line of the body, (3) Left forearm pushed forward on the table so that the lower part of the upper arm lies just over the surface yet so that the body may not be supported by it. Left hand holds drawing surface lightly. (4) Right forearm neither pressed close to the body nor used as a prop, but placed to make possible good free movement. (5) Right hand lightly supported on the point of the little finger. Wrist not touching surface of paper. Hand should not obscure the line that is being drawn. Proper care of eyes makes necessary these requirements: (i) Good conditions of lighting. (2) Use of white or yellow paper with good surface. 'See Freeman, " The Teaching of Handwriting." THE HYGIENE OF SCHOOL SUBJECTS 599 (3) Prohibition of drawing — especially such as map-drawing — for home work. (4) Refraining from use of fine lines and fine shadings. (5) Tests of vision, including color tests, before beginning tech- nical drawing. (6) Frequent changes from near to far vision, such as is required in drawing from models. Regard for the child's motor development makes it de- sirable that overstrain from too long periods, from use of too short or too slender pencils, drawing of too fine lines, etc., be avoided. In all the early years drawing should be free-hand, and the materials should not be too line. Tech- nical instruction should be postponed until near the pubertal period. So far as its relation to mental hygiene is concerned, drawing is of great value as a means of expression, and normal expres- sion is a condition of development. The spontaneous drawing in the early years should therefore be encouraged. Artistic expression and appreciation is a later development and should not be insisted upon in the prepubertal period. Spelling. — Outside the school one is rarely called upon to spell words except when expressing his thoughts in writing, and, especially, in letter-writing. The chief aim in teaching, therefore, should be the association of the proper letter sym- bols with each other and of these with the proper writing movements. From either view-point, pedagogical or hygienic, it is es- sential that these associations be direct and that the habitu- ation of the writing movements be carried to such a degree that they will come as little as possible into consciousness to obstruct the free flow of ideas. In brief, learning to spell should not become the cause of interference of association. For securing the results aimed at, several general prin- ciples may be laid down: (i) Wherever possible, make spelling secondary to some other activity. For example, in the early grades especially spelling should OOO EDUCATIONAL HYGIENE be taught incidentally, along with other subjects. The act of spelling is thus not made an end in itself, and the danger of too much "symbol consciousness" is reduced. Special drill classes may well be post- poned until about the fourth school year. (2) Differences in type of mental imagery make it necessary that several methods be used, appealing to visual, auditory, hand-motor and speech-motor imagery, etc. (3) Investigations of the most economical employment of time seem to indicate that about fifteen minutes per day in the upper grades is all that may profitably be spent in column drill. (4) Avoid showing the child incorrect forms. Correct errors by showing the right spelling. Never strengthen the imagery of the wrong form by making it prominent. (5) Teach homonyms separately, thus avoiding the dangers of in- terference of association. (6) Finally, make the habits of writing whole words with one impulse of the will mechanical as rapidly as possible. Methods for doing this are: copying, writing from dictation, rapid writing of familiar material, such as poems, etc. With attention fixed upon the thought or the words, the matter of spelling is left more and more to the hand.' Other Subjects. — Limits of space make it impossible to extend the list of special treatments further. Possibly the treatments here given will be sufficient to illustrate rather fully the application of the principles which were pointed out in the preceding chapter. Some of the other subjects that should be rightly included are: (i) Music, the essential hygienic considerations in which are attention to vision, to care of the vocal organs, especially at time of voice mutation, and to the development of neuro- muscular powers where the use of instruments is involved; (2) Language, in which the most important problems are those of association of ideas and formation of habits; (3) The more scientific subjects, which properly should be begun rather late, but which require special attention to the requirements of mental hygiene. In any specific case the problem will be the application * See investigations by Ayres, Buckingham, Ballou, O'Shea, and others. THE HYGIENE OE SCHOOL SUBJECTS 6oi of the general hygienic principles laid down in Chapter XXX. These will never be found to conflict with sound psycholog- ical and pedagogical principles. Freedom of expression, cor- rect habits of attention, orderly association, a lively interest in the work at hand, all are vital to both health and growth. They constitute the magic which the pedagogist must use in order not merely to preserve from injury, but to transform the immature individuals daily thronging our schools into the master minds who will solve the problems of the future. PART IV THE HYGIENE OF THE COLLEGE CHAPTER XXXII THE HYGIENE OF WOMEN'S COLLEGES It is advisable, in discussing the problem of the health provisions in women's colleges, to outline briefly the develop- ment which has taken place in the attitude of the women's colleges toward the health of their students, so that we may theorize possibly more intelligently regarding the future of this side of the college education of women. ^ The health provisions in women's colleges concerned them- selves in the early days with two phases of the girl's life — the care that was given to her in case of actual illness and the amount and kind of exercise she took. The question of the food a girl had was left entirely to the women in charge of the table, who too often had the question of expense more at heart than the wholesomeness of the food. The problem of the amount of work was left to the oversight of the faculty. The question of the amount of sleep a girl should have was sometimes decreed authoritatively, as at Smith, and some- times left to the discretion of the individual students, as at Vassar. Illness Care. — In most of the women's colleges there has been from the beginning some provision for the care of the students in case of illness. In accordance with this plan at Vassar a regular resident physician was from the beginning, ' This ( hajiter applies also, of course, to the health development of women in coeducational colleges. 6o2 THE HYGIENE OF WOMEN's COLLEGES 603 in 1863, connected with the college, and some rooms were set aside as an infirmary for the care of sick students. Other colleges, such as Smith, introduced the resident physician some years after the estabHshment of the college. The care of the students could here be intrusted to the town physi- cian until the size of the college warranted the entire services of a doctor. At Bryn Mawr there is no regular resident physician, but a physician spends two hours daily at the college for consultation. The sick student is taken for granted as a necessary part of the college to be provided for. The duties of the resident physician did not concern them- selves with the educational side of the college. She was a practising physician and in complete charge of the infirmary or small hospital where those students taken ill during the course could be isolated and properly cared for. The infir- mary was from the beginning a part of the regular equipment of the college. The doctor had no supervision over the hygi- enic conditions under which the students Hved. If the food were bad or the students suffered from its inadequacy they must complain to the heads of houses. If the curriculum were too confining for the students, so their health suffered in consequence, they must complain to the faculty. The in- dividual student's health, like her clothes and spending- money, was her own affair unless she were ill enough to re- quire medical attention or hospital care. Physical Education.— The phrase "physical education" had at this time scarcely come into existence. Education meant "mental" training, and this was to be the entire significance of the diploma awarded. Yet it was early rec- ognized that exercise was an important element in the life of the college student, as keeping her in good physical con- dition and as enhancing her mental powers. It was in the early days an adjunct rather than a distinct part of the cur- riculum. At Vassar this exercise took the form of horseback riding, where one of the prominent campus buildings is the old riding academy, now the art museum. In most women's 6o4 EDUCATIONAL HYGIENE colleges, however, as also at Vassar, the gymnasium was a part of the college from the very beginning. The work has always been "required" in our Eastern women's colleges. The matter of requirement was never, however, seriously pressed. It was a simple matter for a student to bring from her family physician a certificate of "ill health" which would exempt her from work. It was easy, too, for the- students to "cut classes" repeatedly. A number of girls in one of our large colleges, in the early days, who did not care for the work, remained away, determined not to at- tend until compelled. They were never called to account for it. In short, the students were quick to recognize that the question of the getting of a degree was in no way bound up with the question of adequate or good gymnasium work, and the latter was accordingly slighted. The gymnasium work at first was not and is not now closely co-ordinated with the work of the resident physician. Although both the gymnasium department and the resident physician are interested in maintaining a high standard of health among the students, the line is rather sharply drawn between their functions. Greater co-operation exists perhaps at Wellesley, where the gymnasium department is more truly a hygiene department. Here, as interest in organized sports grew, an athletic association came into existence. This was initiated by the student body and is controlled by them in close co-operation with the gymnasium department or department of hygiene where such exists. Resident Physician. — The resident physician has always occupied in the college a position of dignity. She was in a sense "set apart" by the character of her occupation; that is, her interests were not supposed to be and probably were not concerned with education as were those of professors and instructors. Nevertheless she ranked with the professors and took part in the faculty meetings, though merely to throw light on the physical condition of individual students. She THE HYGIENE OF WOMEN^S COLLEGES 605 would have been overstepping the mark had she ventured to take part in a discussion on any academic question or general educational policy or problem. The g}Tnnasium teacher was at first a curiously discon- nected factor in the college. Of course this was to be expected in a situation in which physical training was regarded merely as a means of keeping the students in good condition so they could accomplish their "real" education without detriment to their health. At present, however, the head of the phys- ical-training department at Vassar ranks as an associate pro- fessor with the title of "Director of Physical Training." The director of the department of hygiene at Wellesley is head of her department in precisely the same sense as that of any other department in the college and with the same powers. There has always been some effort expended by the col- lege in educating the student in hygienic ways of living. This education has consisted of a course of lectures on hygiene, usually not counting toward the degree and usually given to the freshmen by the resident physician. Subsequently in the history of the college an elective in physiology was intro- duced — open to the upper classes. Progress in Physical Education. — The principal changes that have come about in the physical education of women have been as follows: (i) Further exactions looking toward better attendance in gymnasium work. Gymnasium work in the women's col- leges is at present required for the first and second year classes in a truer sense than in the early days. At Vassar, if a student misses too many hours of gymnasium work, she is compelled to make it up before graduation. If her freshman and sopho- more work in gymnasium at Wellesley is unsatisfactory, in other words, if she is "conditioned" in her g}Tnnasium work, she makes it up in her junior or senior year. But at Welles- ley the gymnasium work and outdoor work "count toward the degree " of A.B., which is not the case in any other woman's college that I know of. This fact has always made the gym- 6o6 EDUCATIONAL HYGIENE nasium work at most colleges seem to the students of less importance than their other work — a sort of an addendum or superfluity which many of them accordingly resent. (2) Closer attention is given to the individual student on entering college and after. Careful records are now kept of the past and present histories of the students, the results of the physical tests to which they are put; and at Wellesley the condition of the backs and feet is noted. At Wellesley, also, special classes in restrictive gymnasium work and cor- rective gymnasium work are carried on for students who cannot take the regular work or who would profit by more particularly adapted work. (3) The third most noticeable change toward improving the health conditions of the college is in the increased interest in sports among women. As the colleges have grown the in- terest in basket-ball, tennis, rowing, hockey, and field-day contests has steadily increased, until at the present time en- thusiasm for sports is one of the striking features of the woman's college. This increases the interest in gymnasium work. As soon as the student can be made to feel that the gymnasium work better fits her for the competitive sports she is ready to enter more eagerly into the disciplinary ac- tivity. The interest in sports has been used to raise the standard of health and good carriage. No student at Wellesley can row on the crew unless she has a good carriage. The ''train- ing" of the students taking part in the sports also impresses upon all somewhat the value of a regular life as an aid to physical efficiency. All these provisions for the health of students are at pres- ent more developed at Wellesley than at the other women's colleges — so I shall give here a brief description of what has been accomplished at this college by its hygiene department.' The reason why this side of girls' education has been more developed at Welk'sley than at any other women's colleges is in part because of the connec- tion with the college of a normal school of hygiene. This has tended to raise THE HYGIENE OF WOMEN 's COLLEGES 607 Health Requirements on Entrance} — Applicants for ad- mission must be organically sound. A student can be refused admission if suffering from a disease which would be sufficient" handicap to make full work an impossibility. /^ Organic soundness is determined by the examining physi- cians. Every girl is examined before college opens not only as to the soundness of lungs and heart, but as to condition of throat, eyes, ears, reflexes, and even back and feet. Strength tests, which include a drawing of the torso by the aid of the Demeny thoracimeter and the anthropometric measurements, are made and each young woman is graded on her carriage. Those students who have scoliosis or exaggerated physiological curves are put into special classes in corrective gymnasium work. Those who are unequal to full work on account of heart weaknesses or recent operation or other special weak- nesses are put into a class for restrictive work. Compara- tively few are forbidden gymnasium work altogether. If a student is organically sound, but not sufficiently strong to undertake full academic work, she can be compelled to take the course in five years instead of four. By far the majority of the students are put into the regular gymnasium work — about 80 to 90 per cent — where they are given progressive work in gymnastics, dancing, games, and sports. Gymnasium work is required of the freshmen and sopho- mores during the winter months two periods a week, and an elective class is held for juniors and seniors. In some of the women's colleges gymnasium work is required four periods a week during the winter months. This is not practicable at Wellesley owing to the amount of walking necessitated by by example and comparison the standard of vigor among the college students. Also the director of the department of hygiene at Wellesley College is not the actual teacher of gymnasium work, as is the gymnasium director at most col- leges, so that she has more time and opportunity for proper organization of the department. ' The description of conditions at Wellesley College is taken largely from a paper written by Miss Amy M. Romans, director of the Hygiene Department, and read before the Fourth International Congress on School Hygiene at Buf- falo, x\ugust, 1913. 6o8 EDUCATIONAL HYGIENE the long distances between buildings. The average freshman walks from three to six miles a day. During fall or spring unorganized games are carried on for freshmen on the general playground. For sophomores, juniors, and seniors there are rowing, hockey, basket-ball, tennis, baseball, golf, archery, field and track sports. Each student participates in one of these at least three times a week during the first five weeks in the fall and last six weeks in the spring. On the theoretic side the freshmen are required to attend a course of lectures on hygiene, one a week throughout the entire year. This course counts one hour toward the degree of A.B, The practical work, two periods a week during both freshmen and sophomore years, counts one hour toward the degree of A.B. The total number of hours required at Welles- ley for the A.B. degree is fifty-nine. This makes the hygiene requirement about one-thirtieth of the total requirement. The resident physician at Wellesley attends the meetings of the academic council, and is consulted in regard to the physical condition of individual students. The question of the amount of sleep a student should have is left to the discretion of the student, the amount of work the student can carry to the faculty, the food and housing con- ditions to the officers of administration. The department of hygiene may suggest changes, but it has no authorized juris- diction over details of the housing and eating conditions. Suggested Developments. — The changes which, it seems to me, should be brought about in our women's colleges are first along those lines suggested by the changes that have already come about. Supervised exercise must be required in the real sense of the word "required." There is a strong tendency on the part of many young women not to take enough exercise, a tendency that is increased by pressure of book work. This attitude is perhaps more marked in women than in men, and should be seriously considered in planning an educational situation for women. It is due in large part to the fact that as a girl approaches maturity the restrictions THE HYGIENE OF WOMEN' S COLLEGES 609 of conventionality close in upon her far more than on her brother, limiting her exercise to such as can be taken with long skirts and propriety. She can no longer play tennis or take part in any game requiring running without change of dress. Even the bicycle has gone out of fashion in many communities. This throws the girl back upon those sports which are less simple and require more preparation and pre- arrangement — as tennis, horseback riding, dancing, or basket- ball. As a result of this many girls prefer to take no exercise regularly but walking, as tennis and similar sports cannot be played unless one have consecutive hours and opportunity for change of skirt. Moreover, all vigorous exercises are taken too intermittently, perhaps only Saturday afternoons or on holidays. Gymnasium work counteracts this tendency and is a far more important part of a girl's life at college than is generally recognized. The last one to recognize its importance is the girl herself. She seldom realizes her own physical defects, and is often more desirous to "look stylish" than to be strong and healthy. To foster bodily improvement is difficult in a college milieu where mental requirements are so strenuously urged. And this emphasis is achieved not so much by public opinion as by requirement. So many hours for the A.B. degree! These hours must be accomplished to graduate. But in the majority of women's colleges gymnasium work has no such significance. Of course it is the requirement slighted. Granting the extreme importance of gymnasium work for girls who will not take regular exercise, should not this subject count toward the degree of A.B.? Would it be such an unfortunate change for the A.B. degree to stand for a certain amount of physical excellence ? Only by a require- ment which equals in importance that of mental achievement shall we ever persuade girls of the necessity of adequate care of the body. And if the higher education of women is to be justified it must not be associated with physical inferiority. The attention to the needs of the weak student should 6 10 EDUCATIONAL HYGIENE continue through classes in corrective and restrictive work until our standards of admission are improved. Attitude of the Public. — Other changes that should be brought about are along the lines suggested by the changes that have come about in the attitude of the public toward health in general. (i) Health is no longer regarded as something a person has or has not, irrespective of the conditions of his life and modes of living. We are coming to recognize more than ever that the average person who lives wisely will be well. (2) We are recognizing also the importance of health as never before. Health is not only regarded nowadays as an asset — greater for the average person than book knowledge — but an obligation. Perhaps the period of a girl's life between the years of eighteen and twenty-one are not so important as regards her physical development as between the years of twelve and eighteen, but they are none the less a most impor- tant time, during which she should be storing up more energy than she expends, not expending more than she is storing. The strains of a college life ought not to equal those of a business or professional life. She is still in the stage of "preparation," physical as well as mental. For these reasons we believe that the energies of the health department in a woman's college should be directed constructively toward increasing the girls' physical powers and preventing rather than curing illness. There must be less illness in the college, a gradual elimination of the need of a resident physican, and the instalment of a health officer whose duties shall be twofold: (i) To see that the conditions under which the students are compelled to live are healthful. (2) To see that the students thoroughly understand their obligation to take advantage of these conditions. Healthful Conditions. — I shall take up these two points separately. And first, what conditions is a student entitled to on entering a woman's college? We maintain that a THE HYGIENE OF WOMEN'S COLLEGES 6ll Student is entitled first and foremost to work that she can carry in a way that is satisfactory to herseh" without exhausting herself. She should have time outside her work for out-of- door exercise daily, for eight hours of sleep at night, and no Sunday study. In most of our women's colleges the schedule of work is much more exacting than the school schedule, which has usually been a five-day schedule with not over six hours a day of work. The schedule in the college might very legitimately be more exacting than the school schedule, but we should never lose track of the fact that the great physical dangers in the higher education of women at the present day are: first, that under the exactions of book learning the life becomes too sedentary — girls do not get daily vigorous ex- ercise; and, second, they feel so "driven" by pressure of student and academic obligations that they acquire a neuro- muscular tension, worse for the girls perhaps than the loss of muscle power. To prevent girls from "dawdling" — also bad physically, I admit — we are in danger of increasing their required programme until there is no free time for the exercise of initiative on the part of the original or unusual student, while the average student often keeps abreast of the work only at the expense of hygienic modes of living. This does not mean that she breaks down. Too exacting a course is not to be measured by the number of breakdowns. The question is, is the student in poorer condition at the end of the year than at the beginning? Nor is increase in weight to be taken as a sign of improved physical condition, for it is not at all incompatible with decrease in muscle power and tone. There are, of course, students who can carry heavy work without injury to the health, students even who can go without sleep without great permanent injury. But the average student should not be compelled to sit up nights to study. If she does so because she is overambitious or waste? her time, that is her own affair. The health officer should also have some oversight of the students' diet or at least the planners of menus should have bl2 EDUCATIONAL HYGIENE knowledge of food values and training in dietetics. The student should have a satisfying table which would not need much supplementing at the tea-room and soda-water foun- tains. The housing conditions should be hygienic. In some col- leges there is, for instance, only one bathroom to, say, ten or more girls. This makes a daily shower impossible. Also the houses and classrooms should be properly heated and ventilated. These considerations should be under strict col- lege supervision. Personal Health Responsibility. — Having made it possible for a girl to secure enough sleep, to have good food and hous- ing conditions, the next step is to cultivate the right attitude of mind in the students. If the conditions over which the students have no control are right, it is an obligation on the part of the students to make right those conditions over which they have control. Some knowledge of the laws of health is imperative to intelligent control, and such knowl- edge should be obtained through hygiene lectures. The sense of responsibility to which the students should be edu- cated will be developed only by a change in public sentiment toward student illnesses. The hygiene lectures are usually regarded as unworthy of academic credit and in many cases probably are unworthy. In so far as a hygiene lecture consists of a set of directions pertaining to the common decencies of life, as care of the hair, teeth, general cleanliness, etc., it may be a useful lecture course for students with unsatisfactory home conditions, but it is neither fundamental nor scientific enough to merit credit. Course in Hygiene. — A hygiene course should consider those ways of living that markedly improve or seriously im- pair health, should take up problems pertaining to exercise, sleep, diet, effect of mind on body, emotional control, etc. The subject of hygiene should be presented not in the form of fixed "rules" of right living but as problems of right living. After all, each person must be an experimenter to a certain THE HYGIENE OF WOMEN' S COLLEGES 613 extent regarding his own health, though his mode of experi- menting may be to put his health in the care of another person. Hygiene lectures should, therefore, give students a knowledge of those facts which have been definitely proved by physiologists and which have a direct bearing on health. The lectures should consider also the various theories of healthful modes of living to give students some idea of the difference between sound and false physiological proof. Such a course can be made sufficiently scientific and sufficiently exacting to count toward an A.B. degree. As soon as a course counts toward the degree it assumes importance and hence an effectiveness that it cannot otherwise possess. The course should be abundantly supplemented by outside reading and should include questions of public and domes- tic sanitation. The freshmen should be able intelligently to adapt their mode of life to their physical endurance and power. Also free and abundant opportunity should be given for the students to consult the teacher regarding individual application of the points discussed in the lectures. This supplementary work would tend to make the course more effective practically and to lead to a carrying out of hygienic principles in the life. But the attitude of the college toward illness must be changed. At present, if a student is ill, she is taken care of and "no questions asked." She is not made sufficiently responsible. Has she been staying up late, overeating at tea-rooms, underexercising, or committing other hygienic in- discretions ? If she has, her illness should be treated as a con- dition due to negligence on her part, and if such conditions are repeated often she should be looked upon not as a "deli- cate" girl or an "unfortunate" girl but as an "irresponsible" girl. Perhaps some girls are delicate, are unfortunate. This possibility is, of course, always to be borne in mind. But in general the average young girl living under hygienic con- ditions will not be ill unless she has some distinct physical 6 14 EDUCATIONAL HYGIENE weakness, and that bnn;^s me to my next point. No obviously ''delicate" girls should be admitted to the regular college course. If a student is ill or weak, in such a way as to make it detrimental to her to carry full work she should be excluded on the basis of physical disability on entrance. There are an appreciable number of students who, while not "organically unsound," suffer constantly from ill health, which makes it necessary for them to miss a day here and a day there and later to work late at night to ''catch up" in what they have missed. These girls require extra time and thought from all their instructors and from the resident physician. With all this attention they often partially fail, necessitating interviewing by the dean or secretary and sub- sequently a correspondence between college and parents. If all the extra time devoted to such students were counted up it would amount to many hours. Also, they draw upon the sympathies and assistance of the students associated with them. And what do they themselves gain to offset this disproportionate expenditure of energy? Nothing that can compare with what they lose in the necessary neglect of health under pressure of work. The unhealthy student must devote a larger proportion of her time to the care of her body than the healthy student. It is entirely unjust and disadvantageous to her to put her in close competition with those physically well. Exclusion of Physical Weaklings. — Such girls should be rigidly excluded from our colleges. The physical weaklings are in a large proportion of cases the mental weaklings, not necessarily because their brains do not work so effectively, but because they cannot be subjected to any slight extra strain and because of actual classes and days missed. The presence of these students in a college hampers both instructors and other students and cannot possibly be justified on the ground of good to the delicate student. The latter usually needs to pay more attention to getting well than she can possibly do while striving to carry work which is planned without refer- ence to the constant absences necessitated by bad physical TUK HVC.IKNE OF WOMEN'S COLLEGES 615 condilions. A studciU should be icjccled on the basis of her physical condition at the discretion of the examining doctor. 'i'his regulation was not necessary in the early days of the college, because the pioneer women in the higher education of women were better physical specimens than the more pampered students of to-day. In addition to this our value of health as a business and .social asset has increased. If students were, then, excluded from college on the basis of health, the standard of health in schools would be raised. A student whose health is distinctly subnormal is a student who is as much of a drag as a badly prepared or dull student. This does not mean that the weakling cannot get an educa- tion. It means that she must "get well" before attempting average mental work. It is often the misguided ambitions of the parents which bring the physically unfit student to college. Would not the parents be educated most rapidly by being forced to pay more attention to the physical well- being of their children? Only in this way can a standard of health which shall be fair to the well students and the faculty be maintained. When a college is isolated we shall always have an in- firmary and resident physician. When, however, the college or university is in the city, a health ofHicer, whose function is to maintain a high standard of health and an rspril de corps regarding it, is more iiiii)()rt;iiit than a resident plnsician. 'Vhc emphasis more and more should be i)ut on physical education, an education to fit the student to meet the strain of life which will come to her when she leaves the college. Summary. -To sum up briefly: whiU' we are paying more and more attention to the individual student in the women's colleges, and more and more attention to sports and athletic interests among women, we have been too tolerant ot the "delicate" girl. The time has come for a complete change of attitude which shall eni|)hasi/e (1) the right of the student to hygienic conditions in its broadest sense as including satis- factory mental conditions, and (2) the responsibility of the 6l6 EDUCATIONAL HYGIENE student for her own physical condition. This change cannot be brought without its necessary corollary, the refusal on the part of the administration to receive students who cannot, either on account of inheritance or bringing up, maintain the high standard of physical excellence the woman's college must set for itself. CHAPTER XXXIII THE HYGIENE OF MEN'S COLLEGES The Health Problem and Health Provisions of Colleges. — The large place occupied by physical education, hygiene, and health supervision in the American college of to-day is in marked contrast with the conditions which existed fifty years ago. In 1855 President Stearns, of Amherst College, wrote in his annual report: "No one thing has demanded more of my anxious attention than the health of the students. The waning of the physical energies in the midway of the college course is almost the rule rather than the exception among us, and cases of complete breaking down are painfully numerous." Nothing resulted from President Stearns's recommendations in 1855, but he continued to advocate the matter in his an- nual reports. In i860 he wrote: "What we need is a pro- fessorship which shall extend over the entire department of physical education. . . . We should not only have the honor of being the first institution in the country which has ever sustained such a professorship, but we should probably save to the world a vast amount of physical and mental power which would otherwise be wasted." On August 6, i860, the Amherst trustees established the first department of hygiene and physical education in a college and appointed a physician as professor in this department. The Amherst plan provided a regular college department to control prescribed courses in physical education, voluntary athletics organized by the students, courses in hygiene, medical examinations and health supervision of all students, and sanitary supervision of dormitories and other college buildings. This department, wisely conceived and organized 617 6l8 EDUCATIONAL HYGIENE in i860, has exerted an increasing influence for good up to the present day. It is surprising that Amherst's successful in- novation was not soon followed by many other institutions, but for a period of thirty years no other college established a department of hygiene and physical education as complete as the one at Amherst. Some gymnasiums and athletic fields were built, courses in gymnastics and hygiene offered, and a few colleges provided some supervision of the students' health, but these activities were not co-ordinated in a single well-organized department. Since about 1890, however, colleges have made such rapid progress in this direction that now nearly 90 per cent have de- partments of physical education and hygiene representing many different forms of organization and degrees of efficiency. In some colleges local conditions make it impracticable to organ- ize physical education, hygiene instruction, supervision of the students' health, and sanitation in a single department, but this plan is the most economical and efficient when feasible. The principles of organization, scope, present status, and tendencies of the various college activities for the physical education and welfare of students may be considered sepa- rately. Physical Education. — Physical education includes all forms of physical exercise engaged in for health, development, the acquisition of physical accomplishments, and recreation. The physical activities carried on in the colleges to-day are usually classified in two groups, termed gymnasium work and athletics. This classification is the result of the peculiar de- velopment of these two general forms of exercise in American colleges. Gymnasium work owes its origin to the recognition by college authorities of their responsibility for the physical welfare of students, while athletics were introduced by the students in response to the natural play instinct of youth. Although Harvard College built a gymnasium in 1826 and a few other institutions provided some gymnasium facilities between 1826 and 1830, it was not until i860 that depart- THE HYGIENE OF MEN's COLLEGES 619 ments of physical education were organized on a permanent basis. With few exceptions the physical education depart- ments organized between i860 and 1890 consisted of a gym- nasium placed in charge of a professional trainer without academic rank or membership in the college faculty. Gym- nasium work was optional and attracted chiefly the strongest and best-developed students. Gradually the educational value of systematic physical training was recognized, regular courses were prescribed for all students, and in many colleges positive credit toward the bachelor's degree was given for these courses. These changes in the character of the work in physical education demanded a different type of instructor, with the result that the pro- fessional trainers of the early period were replaced by college men who fitted themselves for this branch of education and were appointed to regular positions with academic rank as in other subjects. The growth of organized physical training has progressed with such rapidity since 1890 that now over 98 per cent of the colleges have gymnasium facilities, 95 per cent offer regular instruction in gymnastics, and over 87 per cent pre- scribe physical education for graduation. The gymnasium director has a seat in the faculty in over 75 per cent of the colleges and the rank of professor in 25 per cent. The amount of physical education prescribed varies con- siderably in the different colleges. About half require two years, about one-quarter require only one year, a few col- leges require three years, and 15 per cent require four years. The number of hours required per week varies from two to five hours, the great majority requiring either two or three hours. The rapid extension in the number of colleges offering pre- scribed courses in physical education has been accompanied by a marked change in the character of the work taught. Prior to 1900 physical education courses consisted chiefly of marching, drilling with dumb-bells, wands, and Indian clubs, 620 EDUCATIONAL HYGIENE and exercises on the heavy gymnasium apparatus such as horizontal and parallel bars, horse, buck, rings, ladders, and ropes. Credits for these courses were given to all students who attended the required number of hours. No attempt was made to establish standards of proficiency or to assign grades based on examinations. The period since 1900 has been marked by extensive and intensive development of prescribed courses in physical edu- cation. The number of colleges offering regular courses in this subject has more than doubled; the scope of the courses has been extended to include swimming and all forms of athletics and games; standards of proficiency have been es- tablished and methods of examination and grading have been adopted. In those institutions where the work has reached the high- est degree of development the courses are organized on the following basis: (i) Aims. — The courses are organized to accomplish defi- nite objects. (a) Health. — A college education obtained at the expense of health is bought too dearly; the student should not only maintain his health during his college course but increase his strength, vital resistance, and capacity for hard work. Judi- cious, systematic exercise and recreation are essential to ac- complish this result. (b) Bodily Control. — Including good carriage, graceful movement, and the ability to handle the body easily and efficiently in all the circumstances of every-day life. This implies ability to handle the body on the ground, as in walk- ing, running, and jumping over obstacles; off the ground, as in climbing and other methods of handling the body by the arms; in the water, as in swimming. (c) Physical Accomplishments. — This does not imply gym- nastic or athletic skill for purposes of competition, but a knowl- edge of many forms of exercise which may be kept up for health and recreation after graduation. Personal habits and U 42 ai '-J "i 6 TH£ HYGIENE OF MENS COLLEGES 621 skill in neuro-muscular .univitios must bo acquired durinu youth; men r.vrely form habits of exercise and acquire skill in games after the age of twenty-rive. ■d^ HyiUrtk Lii^in^^.—Jhis implies a knowledge of the principles of personal hygiene and sanitation. The student who has learned these principles is competent to regulate his habits of diet. work. rest, ba tiling, and exercise, and to dis- charge his duties a>. a citizen in matters of public hygiene and sanitation. :' Contents of Physical Education Courses. — The courses usualh' include g\Tnnastic^. athletics, games, swimming, and hygiene. The tendency during the past few years has been to teach less of formal g\^nnastics and more of atldetics and games. This change accomplishes two objects: it a^ords a much bro.i " ^re interesting curriculum and makes possible a c.:... , ^^ v.nt of outdoor exercise which is always more benericial than indoor work. Where the climate per- mits, a large prop'^"' :' the work is carried on outdoors. Athletics and game- ways more interesting than formal gymnastics, and for that reason there is a tendency in some institutions to give up gymnastics altogether. There are govxi reasons, however, for believing that rational gymnastics will continue to be accorded a place in all coiiiplete and well- balanced physical education courses. The particular advan- tages of gymnastics are: .: " adaptability to individual needs by judicious selection of movements to accomplish definite objects such as improving posture, developing a flat chest, strengthening abdominal walls, regulating dosage of exercise to strengthen the heart, etc. .^^ By means of g>-mnastics large numbers of students can be handled in a room which would accommodate onl>- ten students in basket-ball or other games. .' Gymnastics exercise is available in bad weather when practically no outdoor exercise is feasible on account of rain. snow. mud. or extremely cold weather. Furthermore, manv believe that fundamental bodily training in posture. audlitv. and abilitv to handle the body under all circumstances 622 EDUCATIONAL HYGIENE of every-day life can be accomplished better by gymnastics than any other form of exercise. Dancing (esthetic and folk dancing as distinguished from social dancing) is gaining rapidly in popularity as a form of gymnastics. By a judicious selection of the more vigorous steps and proper adaptation dancing can be made a most valuable part of a rational sys- tem of physical education for men. Dancing excels all forms of exercise as a means of developing bodily control and ex- pression. ^ The inclusion of swimming in prescribed physical education courses is a recent development. It is required in about 1 6 per cent of the colleges. There is a growing tendency to include some didactic instruction in hygiene as a regular part of the physical education courses. In some colleges this instruction is given during the first ten or fifteen minutes of the physical training period, but in most institutions a regular course of one or two hours a week is offered. (3) Standards of Proficiency, Examinations, and Grades i. (a) Having accorded a place to physical education in the col- lege curriculum, it is essential to establish standards of pro- ficiency which must be attained by the students who are to receive credit for this work. Granted a rational and well- balanced course and good instruction, the student who has at- tended regularly and worked faithfully should possess health, bodily control, good posture, a knowledge of many forms of exercise, including athletic games and swimming, and a knowl- edge of the principles of hygiene and sanitation. (b) Examinations are intended to measure the degree of proficiency attained in so far as proficiency is measurable. While health is an important aim in physical education it rs not easily measured. It may therefore be assumed that the student who has taken a course in physical education has acquired at least a fair degree of health and vigor. Bodily control, posture, skill in games and swimming, and knowledge of hygiene and sanitation arc measurable by means of tests. ' Among the ancient Greeks dancing was considered one of the most valuable forms of general physical, mental, and cultural education. 3 i3 THE HYGIENE OF MEn's COLLEGES 623 Marks are assigned for proficiency and students graded as in other subjects in the college curriculum. Care of the Student's Health, Medical Supervision. — The American college is taking a prominent place in the van of the general movement for the conservation of life and health. The assembhng of hundreds or thousands of students and teachers in the college community presents problems of public health not unlike those of a town or city of the same size. These have to do, for example, with the discovery, investi- gation, isolation, and prompt treatment of all cases of in- fectious disease, and the taking of prophylactic measures, such as vaccination, etc., for the prevention of epidemics. In cases of illness or accident the students living in college dor- mitories, fraternity houses, and private houses are dependent upon their student friends for help and advice unless the col- lege provides medical supervision. In colleges where medical supervision is thoroughly organized it includes: (i) periodical medical examinations of all students; (2) medical and surgical treatment in emergency cases; (3) daily office hours by a physician for (a) consultation, (b) treatment of minor ail- ments, (c) receiving reports from students who are confined to their rooms by illness; (4) provision for treatment of medical and surgical cases either in an infirmary maintained by the college or in a local hospital. Only 10 per cent of American colleges have organizations covering all these four phases, but nearly all of them provide some medical supervision, as shown by the following figures: 80 per cent provide periodical medical examination of stu- dents; 57 per cent provide medical and surgical treatment; 26 per cent provide medical and surgical treatment in emer- gencies only; 46 per cent provide for medical consultations and advice, but without treatment. The periodical medical examination of students is the most wide-spread feature of medical supervision. These ex- aminations are in nearly all cases given in the department of physical education and required of all new students. One 624 EDUCATIONAL HYGIENE or more subsequent examinations are required in 8i per cent of the colleges and optional in the others. The chief purpose of these medical examinations is to ascertain the physical condition of each student, record all physical defects, prescribe or suggest treatment for such defects, and advise the student in matters of diet, exercise, rest, bathing, etc., with a view to improving his health and efficiency. Physical Defects Found. — The importance of making periodical medical examinations of college students is shown by the results obtained. The following table shows a resume of the physical defects found in five hundred college students: PER CENT HAVING DEFECT Eyesight, right eye 56 Eyesight, left eye 52 Hearing, right ear 9.8 Hearing, left ear 9.6 Heart 21 Lungs 18.2 Nasal fossae, right 19 Nasal fossae, left 24 . 4 Teeth 64 . 8 Pharynx 46 Tonsils 19.2 Skin 28 Head (carried forward) 57.6 Spine 92-4 Shoulders 44. 2 Chest 30-4 Abdomen 48.8 Hernia 2.2 Legs 24.6 Feet 48 . 8 General condition below normal 13 No charge is made for medical supervision except in col- leges which maintain an infirmary; in these institutions it iu:ninn.vrjii:::mz:: Sladiuni for the athletic field shown below It has been placed at the west end of the field in front of the Orphan Asylum in the background Secondary school and gymnasium of the College of the City of New York on right The stadium shown above has been erected on this field THE HYGIENE OF MEN's COLLEGES 625 is customary to charge an annual fee of three to ten dollars to all students, which fee entitles them to treatment and nursing. In some colleges an extra charge is made for board at the infirmary; in others the annual fee entitles the student to board for only a limited period. In cases of serious or protracted illness or surgical operations it is custom.ary to charge the student for medical services and nursing. There is a growing tendency for colleges to assume more and more responsibility for the care of students' health in its various phases. A competent physician who gains the con- fidence of the students can do an incalculable amount of good, not only by ministering to their physical health, but by guid- ing and advising them in many matters which affect their moral welfare. Two important phases of medical supervision which alone justify the expenditure of a physician's salary are: (i) the early detection and isolation of cases of infectious diseases, thus preventing the development of epidemics in the college community; (2) the regulation of students' absence from col- lege exercises on account of illness; all such absences should be excused only by the college physician. Sanitary Inspection of Buildings and Grounds. — Another important phase of college hygiene is the sanitary inspection of the buildings and grounds, and proper supervision of the water supply, sewage disposal, etc. The rapid growth of college communities during the past twenty-five years and the wonderful progress made in the science of sanitation dur- ing the same period make necessary a definite organization in every college for sanitary inspection and supervision. About 80 per cent of the colleges have some form of sys- tematic inspection; the responsibility is delegated to different officers or members of buildings and grounds committees. In 75 per cent of the colleges the inspection is made by a college officer (usually the director of the gymnasium or the superintendent of buildings and grounds) either as an individ- ual responsible to the trustees or as a member of a committee; 626 EDUCATIONAL HYGIENE in the other 25 per cent the inspection is made by city or State officials. Here, again, there is a tendency to correlate this branch of hygiene with the activities of the department of physical education and the care of the students' health in charge of a medically trained director. Sanitary inspection in a college community includes the following : (i) Inspection of heating, ventilation, lavatories, and clean- ing of buildings used for administration, recitation, labora- tories, etc. (2) Inspection of heating, ventilation, cleaning, lavatories, and baths in dormitories. (3) Inspection of dining-room, kitchen, refrigerators, milk and food supply, and waste disposal in commons or restaurant. (4) Inspection of gymnasium, dressing-rooms, baths, lav- atories, and swimming-pool. (5) Inspection of water supply. (6) Inspection of sewage and waste disposal. (7) Advice in planning new buildings and remodelling old ones. Hygiene Instruction. — Hygiene appears in the list of sub- jects taught in colleges as early as 1850, but very few of the institutions which offered instruction in this subject prior to 1900 gave it academic recognition by requiring it for gradu- ation or counting it as a credit toward the bachelor's degree. In most cases nothing more was attempted than to offer a few lectures on personal hygiene; attendance was optional; there were no examinations and no credits. The growing interest in health conservation and the rapid progress made in hygiene in all its branches have brought about the recognition of this subject as essential in the college curriculum. Physical edu- cation, medical supervision of students' health, and college sanitation are all valuable in protecting students' health and giving them practical instruction in healthful living, but these activities should be supplemented by some definite instruction in the principles of hygiene and sanitation. THE HYGIENE OF MEN's COLLEGES 627 Prior to 1900 only 36 per cent of the colleges offered courses in hygiene, whereas in 1914 more than 90 per cent offered one or more courses in this subject. The tendency is to include some hygiene instruction in the prescribed physical education courses as previously described in this chapter. In 76 per cent of the colleges where hygiene is taught the subject is re- quired for graduation. The topics most frequently included in the prescribed courses are: health, heredity, and environment; the modern theory of disease; the role of air, water, animals, and man in the transmission of disease; the factors in disease prevention; vital resistance, immunity, isolation, cleanliness, disinfection; hygiene of nutrition, beverages, exercise, excretion (lungs, intestines, kidneys, skin) ; nervous system (hygiene of mind, work, recreation, sex), eyes, teeth, etc.; first aid. Elective courses are offered in some large universities cov- ering such specialized branches as industrial hygiene, vital statistics and social economics, sanitary inspection, and pub- lic health administration. If our colleges are to help the people of our country to solve most effectively the principal problems of life, they will emphasize, far more than at present, thoroughgoing health education of all students. Through adequate medical super- vision, through careful supervision of sanitation, through physical education for all students, and through the practical and scientific teaching of health knowledge, health habits, and health ideals, health and normal physical development will be provided for an important part of our population. BIBLIOGRAPHY I. BOOKS Adams: " The Health Master." (Houghton, Mifflin.) Allen, W. H.: "Civics and Health." $1.25. (Ginn.) : "Woman's Part in Government." $1.50. (Dodd, Mead.) Angell, E. D.: "Play." Ayres, L. P.: "Open Air Schools." (Doubleday, Page & Co.) : "Laggards in Our Schools." Bancroft: "Games." (Macmillan.) : "The Posture of School Children." (Macmillan.) Barr, M.: "Mental Defectives." Barry, W. F.: "The Hygiene of the Schoolroom." $1.50. (Silver, Burdett.) Bergey, D. H.: "The Principles of Hygiene." $3.00. (Saunders.) Bloomfield, M.: "Youth, School, and Vocation." $1.25. (Hough- ton, Mifflin.) Bluemel: "Stammering and Cognate Defects of Speech." Bryant: "School Feeding." $1.50. (Lippincott.) Burgerstein, L.: "Schulhygiene." (B. G. Teubner, Leipzig.) : " School Hygiene," translation published by F. A. Stokes Co. Burks, F. W. and J. D.: "Health and the School." Appleton. Burrage and Bailey: "School Sanitation and Decoration." $1.50. (Heath.) Cabot, E. L. : " Volunteer Work in the Schools." (Houghton, Mifflin.) Chisholm, C: "The Medical Inspection of Girls in Secondary Schools." (Longmans.) Coleman: "The People's Health." (Macmillan.) Cornell, W. S.: "Health and Medical Inspection of School Children." $3.00. (F. A. Davis Co.) Crowley, R. H.: "The Hygiene of School Life." (Methuen & Co., London.) Cruickshank, L. D.: "School Clinics." (The National League for Physical Education and Improvement, London.) Curtis, S. H.: "Education through Play." (Macmillan.) : "Play and Recreation for the Open Country." (Ginn.) : "The Practical Conduct of Play." (Macmillan.) 629 630 BIBLIOGRAPHY Davenport, C. B.: "Heredity in Relation to Eugenics." $2.00. (Holt.) Denison, Elsa: "Helping School Children." $1.40. (Harper.) Dillaway: " Decoration of the School and Home." (Milton Bradley Co.) Ditman, N. E.: "Home Hygiene and the Prevention of Disease." $1.50. (Duffield.) Doty, A. H.: "Prompt Aid to the Injured." Dresslar, F. B.: "School Hygiene." $1.25. (Macmillan.) Ellis, H.: "The Task of Social Hygiene." (Houghton, Mifflin.) Ellwood, C. A.: "Sociology and Modern Social Problems." $1.00. (American Book Co.) Emerson, C. P.: "Essentials of Medicine." $2.00. (Lippincott.) Fisher, Irving: "National Vitality." Fitz, G. W.: "Principles of Physiology and Hygiene." $1.12. (Holt.) Forsythe: "Children in Health and Disease." Foster, W. T. : "The Social Emergency." (Houghton, Mifflin.) Gerhard, W. P.: "Sanitation of Public Buildings." (Wiley & Sons, London.) Gillette, J. M.: "Constructive Rural Sociology." $2.00. (Sturgis & Walton.) Gulick, L. H.: "The Healthful Art of Dancing." Gulick and Ayres: "Medical Inspection of Schools, 1913." (The Survey Associates.) Gulick and Jewett: The Gulick Hygiene Series. Guthrie: "Functional Nervous Diseases of Children." Hall, G. S.: "Adolescence." $7.50. (Appleton.) : "Youth." (Appleton.) Hall, W. S.: "Sexual Knowledge." $1.00. (International Bible House.) Hamilton, C: "The Blindness of Virtue." Hart, H. H.: "Preventive Treatment of Neglected Children." Hoag: "Concerning Children." Hoag, E. B.: "The Health Index of Children." (Whitaker & Ray- Wiggin Co.) : "Health Studies." 60 cents. (Heath.) Hoag and Terman: "Health Work in the Schools." (Houghton, Mifflin.) Hofer, M.: " Folk Games and Dances." Hogarth, A. H.: "Medical Inspection of Schools." (Oxford Univer- sity Press, London.) Holmes, A.: "The Conservation of the Child." : "School Organization and the Individual Child." BIBLIOGRAPHY 63 1 Holt, E.: "Diseases of Childhood and Infancy." (Applcton.) Hough and Sedgwick: "The Human Mechanism." $2.00. (Ginn.) Huey, E. B.: "Backward and Feeblc-Minded Children." Hutchinson, W.: Health Series. (Houghton, Mifflin.) : "Handbook of Heahh." $65.00. Jewett, F. G.: "The Next Generation." (Ginn.) Kelynack, T. N.: "Medical Examination of Schools and Scholars." (King, London.) Lapage: "Feeblemindedness in Children of School Age." Lee: " Play in Education." (Macmillan.) Leland, A.: "Playground Teaching and Playcraft." $2.70. Lippert and Holmes: "When to Send for the Doctor." (Lippincott.) McCombs, R. S.: "Diseases of Children for Nurses." $2.00. (Saun- ders.) Mackenzie, W. L.: "The Health of the School Child." (Methuen, London.) McKenzie, T.: "Physical Education." Mangold, G. B.: "Child Problems." $1.25. (Macmillan.) Marshall, J. S.: "Mouth Hygiene." $1.50. Mero: "American Playgrounds." MoU, A.: "The Sexual Life of the Child." fi.75. (Macmillan.) Monroe, P.: "Cyclopedia of Education." 5 vols. $25.00. (Mac- millan.) Nissen: "Swedish Gymnastics." Nutting, Read, and Stuart: "The Nurse in Education." $75.00. (The University of Chicago Press.) Oppenheim: "The Care of the Child in Health." O'Shea, M. V., and Kellog, J. H.: Health Series. (Macmillan.) Perry, C. A.: "Wider Use of the School Plant." $1.25. (Charities Publication Committee.) Rapeer, L. W.: "The Administration of School Medical Inspection." 50 cents. (Teachers College Publication Department.) : "School Health Administration." (Out of print.) : "School Health, a Handbook." (Heath. In preparation.) Richards: "Hygiene for Girls." (Heath.) Ritchie, J. T.: Hygiene Series. (World Book Co.) Rosenau: "Preventive Medicine and Hygiene." (Appleton.) Sandiford, P.: "Mental and Physical Life of School Children." Sargent, D.: "Physical Education." School of Civics and Philanthropy, Chicago. "The ChUd in the City." Schubert: "Das Schulartzwesen in Deutschland." (Voss, Hamburg.) Scripture: "Stuttering and Stammering." 632 BIBLIOGRAPHY Seller: " Handbuch dcr Deutschen Schulhygiene." $9.00. (Stein- kopff, Dresden and Leipzig.) Shaw, E. R.: "School Hygiene." $i.cx). (Macmillan.) Sill, E. M. : "The Child — Its Care, Diet, and Common Ills." 40 cents. (Holt.) Stecher, W. A.: "German-American System of Gymnastics." Steven, E. M.: "Medical Supervision of Schools." (Bailliere, London.) Still: "The Common Disorders and Diseases of Childhood." Struthers, L. N.: "The School Nurse." (In preparation.) Terman, L. M.: "The Teacher's Health." $60.00. (Houghton, Mifflin.) : "The Hygiene of Instruction." (In preparation.) : "The Hygiene of the School Child." (Houghton, Mifflin.) Tolman, W. H.: "Hygiene for the Worker." (American Book Co.) Tredgold, A. P.: "Mental Deficiency." Tuley: "The Diseases of Children." (Mosby.) Wallace, A. R.: "Social Environment and Moral Progress." Wallin: "Mental Health of the School Child." (Yale University Press.) : "Experimental Studies of Mental Defectives." (Warwick & York.) Ward, E. J.: "The Social Center." (Appleton.) Weeks, A. D.: "The Education of Tomorrow." (Sturgis & Walton.) Whipple: "Manual of Mental and Physical Tests." Whitmer, L.: "Special Class for Backward Children." Wile, I.: "Sex Education." (Duffield.) Willson, R. N. : "Education in Sex Hygiene." Wood, T. D.: "Health and Education." 75 cents. (University of Chicago Press.) : "School Sanitation." (In preparation.) Woodworth, R. S.: "The Care of the Body." $1.50. (Macmillan.) II. REPORTS AND MAGAZINES Annual Reports of the Chief Medical Officer of the English Board of Education, Whitehall, London. Annual Reports of Cities Having Medical Supervision. Bulletins of the Russell Sage Foundation. Bulletins of the U. S. Bureau of Education and the Annual Reports. Proceedings of the Fifteenth International Congress on Hygiene and Demography. Proceedings of the National School Hygiene Association. Doctor T. L. Storey, New York, Sec. BIBLIOGRAPHY 633 Proceedings of the International Congress on School Hygiene, es- pecially the Fourth, Secretary as above. Proceedings of the National Education Association. Proceedings of the National Playground Association, Proceedings and Journal of the American Medical Association. Report of the School Medical Olificer, Dunfermline, Scotland. Reports of the Chief Medical Ofl&cer of the Board of Education of Scotland, Edinburgh. Reports of the Chief Medical Officers of Bradford, Cambridge, London, etc., of England. Volumes of The American Physical Education Review. Volumes of The Playground Magazine. Volumes of The Psychological Clinic. Volumes of Zeiischrift fur Schulgesundheit. Extensive bibliographies and lists of bulletins obtainable from the U. S. Bureau of Education. Bibliography on educational hygiene, published by Teachers College, Columbia University. Many of the popular magazines, especially The Popular Science Monthly, and most of the educational magazines now publish articles on various phases of educational hygiene. The surveys of many cities and States or parts of States have sec- tions devoted to educational hygiene; e. g., the Portland, Ore., the Springfield, 111. (Russell Sage Foundation), the Ohio, the Pennsylvania, Wisconsin, Butte, Mont., etc. Some of the most helpful bulletins of the U. S. Bureau of Education. Along this line are those on rural schoolhouses and grounds, open- air schools, the health of school-children, sanitary surveys in several parts of the country, school architecture, bibliographies, exceptional children, consolidation of schools, the Gary system of education, and digests of school-health literature, etc. Bulletins of the Smithsonian Institution, such as Hill's " The Relation of the Atmosphere to Our Health." U. S. Mortality Statistics. Reports and bulletins of U. S. Public Health Service. Bulletins and reports of several State boards of health, c. g., New York. Bulletins of several city boards of health, e. g.: Providence, R. I.; Cincinnati, Ohio; and New York City. Bulletins of several life-insurance companies, and of the Life Extension Institute of America. APPENDICES APPENDIX I HEALTH AND SCHOOL PROGRESS The Relation of Health to Economy in Education and to Physical and Mental Progress All persons realize that there is some general relationship between health and ability to study and to progress in school activities. We find some children, however, who seem to be in rather feeble health or who have physical defects that would seemingly hinder them seriously in their school work, but who, nevertheless, make fair or superior progress in their studies. That this is not a general rule we are from the facts fairly sure, and that such children may succeed in school at the cost of future vitality and normal physical development is certain. But just what the correlation is must be determined by scientific investigations of a medical, pedagogical, psychological, and statistical character. Some of the principal questions which confront us in this important field are as follows: 1. How much of non-promotion, retardation, elimination, and other phases of school pathology are due to the ailments and defects of pupils ? 2. What ailments or defects seem to be closely correlated with school failure or inefficiency? 3. What ailments and defects seem to have little or no bad effect on school progress? On physical development? 4. What ailments and defects of teachers are correlated with teaching inefficiency? 5. What is the relationship of absence due to ill health to pupil inefl&ciency ? 6. What are the effects of cures and corrections of ailments and defects on pupil or teacher efficiency? 7. To what extent does the degree of defect or seriousness of an ailment correlate with pupil efficiency? 8. What is the correlation between ailments and defects in school life and early death? g. What is the relation of certain sanitary improvements to school progress of pupils? 63s 636 APPENDIX I 10. Do schools which have all-round and thoroughgoing educa- tional hygiene prove in any educational ways superior to others not having such provisions? The principal summaries of investigations in this field are to be found in Gulick and Ayres's "Medical Inspection of Schools" and Rapeer's "School Health Administration" (out of print). "The Re-a lation of Health to School Progress " would at this time be an admirable'^ problem for a doctor's dissertation. Not only to provide arguments for the extension of educational hygiene in schools but as a means of better scientific control of the educative process, such investigations have much of value to offer. In the briefest manner possible and with little critical comment we consider it desirable to record here several investigations and the results reached. First are given summaries of data ofltered by Gulick and Ayres. Doctor Cornell found among 1,594 children in five schools that but 28.8 per cent of the "exempt," or passed-without-examination, pupils were physically defective, while of those with less satisfactory scholarship, the non-exempt, 38.1 per cent were defective. Of course, we may account for this difference in scholarship in relation to phys- ical defects on the ground that the children with a greater percentage of physical defects and ailments had poorer home conditions and possibly poorer heredity as a basis for school work. Reavis and others have shown that there is a fairly close correlation between poor conditions for home study and poor scholarship, and several studies show that the grosser physical defects and ailments are more common among pupils with poor home conditions.' Doctor Newmayer also found the percentage of cases, among 5,005 exempt and non-exempt pupils, 50 for the first and 66 for the second group. The actual percentage differences for the two groups in eight classes of defects are surprisingly slight, and the correlation here could be partly accounted for on other grounds than the defects. Superintendent Bryan in 1906 compared the percentages of hearing and vision defects of pupils retarded in the schools with the percent- ages of those who were not. There were 8,110 normal children and 2,020 retarded. The retarded had 50 per cent more hearing defects; the percentages for the two groups being 4 and 6. The retarded children had a slightly higher percentage of vision defects, but the difference was sHght, 27 and 29 per cent. The difficulty here seems to be that the standard for defective vision was set too low, at 20/20 probably, instead of at 20/40. According to the writer's studies there were probably not over 10 per cent of the children who were actually 'See Parker's "Methods of Teaching in High Schools," chapter on Super- vised Study, p. 396, and the reference at the end of this section. APPENDIX I 637 defective enough to require glasses. Had this seriously defective group been picked out, the differences might have been greater. In this study the number of children of normal age (1,279) who had failed of promotion was compared with another group (573) who had failed and were retarded, or over age, for their grades. The two rroups were about the same in defectiveness of vision and hearing; ine same percentages were found having bad health; and the retarded children were worse than the other children only in greater irregularity of attendance. For these two defects and general health at the time of examination there seems to be little relation to school progress. Irregular attendance was positively correlated, and, since irregular attendance is closely correlated with infectious and other ailments which keep children at home, these two defects and state of health at the time of examination may not be as closely correlated with school progress as are the illnesses which keep children at home. GuUck and Ayres also report Superintendent Verplanck's find- ings among 1,093 children promoted and 303 children not promoted. Seventy-seven per cent of those not promoted were defective, while only 60 per cent of those promoted were defective. The figures show that for adenoids and defective teeth the percentages were consid- erably greater among the not-promoted group, while the other dif- ferences are too slight to be significant. Superintendent D. C. Bliss also made similar studies in 1909-10 while he was at Elmira, New York. He tabulated the physical defects among 449 children, of whom 345 had been in the first grade two years, 86 three years, and 18 four or more years. The cases per hun- dred children having six separate defects for these three groups were respectively: 134, 139, and 217. The correlation between retardation and defectiveness is here positive, and especially so for those chil- dren who had adenoids, anemia, and rickets, while tonsils, enlarged glands, defective vision, and defective hearing all show a larger num- ber of cases among those who had been four or more years in their grades over those who had been held for two years in these grades. Ayres's own findings for 7,608 children are also reported. Only 75 per cent of the retarded children were defective and 80 per cent of the normal children. Analysis of these unlooked-for results showed that most defects and ailments fell off in numbers as the children advanced in age, with the exception of defective vision. When these data were studied from the standpoint of each age group for six defects, namely, those of enlarged glands, defective vision, breathing, teeth, tonsils, and adenoids, and from the standpoint of the mentality and school progress of the children, the bright children had an average percent- age of 16 defects, the normal 19.6 defects, and the dull 23.6 defects. 638 APPENDIX I The average loss in school progress of children with defects over those without defects is given as q per cent, which would mean a loss of over a year in passing through the eight grades of an elementary school. The defects are also given in the order of their retarding effect, enlarged glands being most closely correlated with school failure: enlarged glands, adenoids, enlarged tonsils, defective breathing, defective teeth, and defective vision. According to these data the children of the elemen- tary schools who have defective teeth (at least half of them) require about a half-year more in completing the eight grades than the nor- mal child. The child with enlarged glands requires one and two-tenths more years to get through the eight grades. For the third or more of American elementary-school children who have two or more defects the retarding influences have not been de- termined. We might infer that they would be much greater. However, it has been found that in perhaps a majority of cases these defects are symptoms of bad heredity and bad home conditions. If by some means we could get all these defects corrected, we might find with no further data than here given that the children would remain just as backward after correction. We must have the results of correction followed up more closely in order to eliminate the other retarding forces from unduly influencing our inductions. If we find in general that children make much more rapid progress after the correction of defects (and the elimination of absence by disease prevention, not here included), we may justly infer that the defects and diseases were prob- ably the causes of school backwardness and not heredity and not home and other environment. Such measures of school progress for such purposes should, if possible, be made by objective scales such as the Stone and Courtis scales for arithmetic, the Ayres and Thorndike scales for handwriting, the Hillegass, Ballou, Courtis, and other tests of composition, the Thorndike scales for reading and drawing, the Buckingham and Ayres tests for spelling, and others. The use of the objective scale eliminates the often erroneous and non-comparable results of teacher's examinations. The general result of the investigations summarized by Gulick and Ayres is that there seems to be a definite correlation between physical defects and retarded school progress. The extensive survey of data along this line given in the writer's volume on "School Health Administration" shows the same correla- tion appearing in many investigations. A study of the reports of the visits of attendance officers to the homes of absentees from school shows that on the average from 40 to 70 per cent of such absences are caused by the illness of a pupil him- self or of some one else in the family. This is especially true in cities APPENDIX I 639 and in rural regions and villages where school attendance has become from one cause or other an established habit. Keyes shows in his study of the "Progress through the Grades of City Schools" that a close correlation exists between absence and non-promotion and that absences under a month retard 25 per cent of the pupils sustaining such loss; that absences from one to two months, as in the case of quarantine, retard 50 per cent of the children; and that absences exceeding forty-nine days retard about 75 per cent of the children absent. Doctor Bachman corroborates these results in his investigation of the New York City schools. In this volume also the reports of many city superintendents and health officers are analyzed. They all indicate a rather close connec- tion between physical defects, illness, and minor ailments and in- efficiency in school work. The final rough conclusion is: these data seem to show that illness and physical defects in school-children are the cause of almost 15 per cent of elimination, 16 per cent of non-pro- motion, and 17 per cent of retardation (p. 52). Doctor Terman furnishes some further data in his book on "The Hygiene of the School Child." In his chapter on "The Hygiene of the Nose and Throat" he summarizes Bonassola's findings that of 141 out of 400 school- children who displayed symptoms of aprosexia, inability to give attention, 117 had adenoids and the remaining 24 all had some kind of nasal obstruction. These, of course, must not have all been cases that should have surgical removal. In a school of 375 boys Wilbert found that 22 of a group of 26 described as bad scholars had adenoids. Terman also summarizes Barr's findings in Glasgow, Permewan's studies in Liverpool, Gelle's study in Paris, Zhermunsky's investigations at St. Petersburg, Kobrak's study at Breslau, Wanner's study in Munich, and others, all of which show a fairly close correlation between school progress and defective hearing, from only slight difficulty of hearing in one ear up to deafness in both. We cannot translate their results into a general standardized state- ment of the percentage effect of such defects upon retardation, but it is evident that it is one of the serious factors. One or two per cent of American elementary-school children are seriously affected. We shall soon be able to say what percentage of this group is retarded by the defect. Retardation effects of malnutrition are also given by Terman. Macmillan and Bodine in Chicago, Harrington in Boston, Doctor Warner in London, Bean, and others give data from which we may estimate that from 20 to over 50 per cent of retarded children suffer from malnutrition. For example, Macmillan and Bodine found 640 APPENDIX I thai 54.6 per cent of 2,100 retarded children suffered from malnu- trition. Doctor Wallin's study of the relation of defective mouth con- ditions and retardation in Cleveland is reported by both Terman and Rapeer. It seems to show that a close relationship exists between defective teeth, as Ayres found, and retardation. Kohnky's more recent study, using a control class, seems to verify his general con- clusions without such a check. In The Psychological Clinic for January, 191 5, Doctor W. L. Foster gives interesting tables and graphic representations of the relation of defective teeth to scholarship. Far more pupils with good teeth passed in certain schools than did those with poor teeth, ranging from 50.6 per cent passing in all subjects who had but one decayed tooth, down to 3.2 per cent of those with five or more decayed teeth. He also shows incidentally the influence of giving school marks for con- dition of the teeth. Based on the number of decayed teeth, the dental condition of the pupils given this incentive improved 41 per cent in passing through the grades. Doctor Felix Arnold, in the same number of the magazine men- tioned above, shows the results of a study of the relation of obstructed breathing (commonly adenoids) to memory work in school. He used cotton and paper plugs for the nostrils, and gave memory tests. Pupils with such artificially obstructed breathing did poorer work than the others. He concludes: "In terms of classroom practise, obstructed breathing prevents any progress through drill, and hinders assimila- tion of new matter sufiiciently to cause non-promotion of the pupils concerned." Similar critical questions will arise in reviewing these investiga- tions as with others mentioned, for example: Was it the condition of the teeth, or other factors associated with bad teeth, such as poor home conditions, and possibly heredity, that caused the lower promotion rate? How much more did these pupils give attention to going to the dentist under this incentive as they grew older than would be found in other schools not using this incentive? Were not the irri- tation of the plugs used, and the conditions of the test, for the second group of children, suftlcicnt to account for their poor attention or memory work ? Did such plugs function at all as do ordinary enlarged adenoids? These questions are not answered satisfactorily, and we can only conclude that these experiments seem to bear out the general conclusion that there is a positive and probably close correlation be- tween physical defects and ailments on the one hand and school progress and mental (and i)hyslcal) efliciency on the other. Terman points out indirectly that school progress is more than mental progress, that education also includes physical education and APPENDIX I 641 development; and gives the results of many studies, showing the evil effects of physical defects and illnesses on physical development, growth, and health. All who realize that the schools are responsible for an all-round education of the nation's future citizens must appreci- ate the fact that children sometimes pull through with their mental work when sufTering from defects and ailments, and that thousands drop by the wayside in early life from many diseases which are very largely preventable through a socialized education and which have been actually encouraged by bad school-life conditions. Malnutri- tion, adenoids, enlarged tonsils, defective teeth, measles, scarlet fever, tuberculosis, and the like make for a far inferior citizen to the one which the school is responsible for developing. National degeneracy has already greatly alarmed some of the older nations, and its spectre is already abroad in our land, as many valid data, such as mortality, insurance, and life-extension statistics, show. We could fill a volume with the physical evil effects of ill health and physical defects. Rheumatism usually affects the heart; scarlet fever, measles, and such diseases quite frequently have a bad effect on the eyes, on hearing, and on the general constitution. Medical books and papers are filled with data along this line. The physical- educationist can find plenty of data to prove that his work is largely nullified by preventable ailments and remediable defects — that a nec- essary foundation for physical education must be the prevention, treatment and correction of ailments and defects. It is possible to estimate in a general way the effect of illness and defects on retarda- tion and to estimate the cost of retardation in money and lost edu- cation. Sordidly and financially considered, many superintendents and teachers will find it possible to show that the general saving to the parents and to the schools in money each year will far more than pay for elaborate systems of educational hygiene. The need is for more careful records and for patient study of such data in the way, for example, that Mr. Reavis has recently investigated "The Relation between the Physical and Health Conditions of Children and Their School Progress" {Elementary School Journal, October, 1Q14) and Professor Baldwin has studied "Physical Growth and School Prog- ress" (Bulletin of the U. S. Bureau of Education). APPENDIX III PHYSICAL-RECORD CARD, GIRLS' HIGH SCHOOL, PRO- VIDING FOR FOUR ANNUAL EXAMINATIONS WEST PHILADELPHIA HIGH SCHOOL FOR GIRLS MEDICAL INSPECTION CARD me; (G Mua D„^ PudCTfAi Signs asd Sntproiis ".^^'.l' ExcLUsiOK raoM School DutAnox oi Exo-csioiii raoti Dire or Omsct K„„„ Ktient "".=0*;^' °^^'' PaUent — "S^™T' ^''"tr^hSr*^ .t= ,;^= Jit. i„ Other children of -tsr ^S'S" Sometime* liegiiu mth reveriihncM but » usually very KCond d»r u afoall pimples, which in about a day Oniet iuidious, may be rapid or ciadual. Typicallv wie throat, great weakncM, andtwclling of lymph nodes in the neck, about the angle of the jaw. Tlie back of the throat, tomiU, or palate may ibow patches likepicccsofgiayiih-whitckid. The moit proooUDced in i^ty''l4fyo«cal diphtheria P «q y Mouth spray and crmt of spots. -v^r ^■^ -y^ "tar iithtnudday returns- A mild di^nM and seldom any after charges from nose. no diphtheria ported nega- showing diph- theria bacilli *houU be tm- has been raised and two sucwv wltureflub^ ?aj,y."'°'' from no»e and throat are reported [ after cStcls Whrn diphtheria ii^curv m i negative .'^'ose showing dipb- | school, all children luffcrinf from ^it thrnai Begin* like cold in the bead, with fcvenshneas, runnins nooe. inlUmed and watery tya. and soeaing: imoll creaccolk croup* ol mulberry -tin led (pots appear about the lliird day; nsh fint seen on forehead and face The rsah vans with heat; may almou disap- pear i( the air i» cold, and come out again with thing bi"". ■i'"" llani^omriwliilrn ,.nJ l^ndrr .Vn,^li"...'^.V^ uiff! yea. No. ' Until rtcovcry and 1 disinfection ot pcnan: at least Eidude untQ isih day aftei child bat nw patient. school during 1 risk of infection first three or four diy*. Uforc 8th to i!th day the rash appeaii. Great variation in type of after child lo^t di»ase- l!iaDgerou> in childien under > years (German) ""SS"'"^ No. Until recovesy and S days.' Exclude unta iid day after chih] laat mw p«lieai. school during frequently confuted with scarfet fever. iithtoijd^y .^ Ye*. ~Ve^ ^Hfvi-S- Exclude ijtb to aid day after child lost taw patient. to I id day after chUd last saw 'Stir;^'""'^^- ^'"''""-^ FEVER fweruhDe«fc mtc thioat. and often vomiting. Vi^. ally within twenty-rour houra the raah appcan. fineljr ipolted. evenly diffuied. and bright red ^e ^ Wuthw to^Wn da^ when il^Sy^d'tbe sS'n P«*» '1^^- ^^: "". f*"™. I*^ !"««■ ''T" ehantes from sup- •''airu?'^' Seven days from MwyiiUt. Until Mven dxy« j Seven days from time child lost saw afterquoranlmc, patieltt. Dangerous both during attack and from after Many mild cases not diajcnosed and many con- cealed. The peeling may bit six to eiKbtwwks A aecond attack is rare. When scarlet fever nas About third day a ^ mih nl shotlik'e pimS. fell bdow the »kin, and seen fir«it about tbe lace and wn*U: spot! develop in two days, then form little bliMen. and alter two daya more become yellowish •cabs. " *" Recovei^ and dis- Exclude until iid day af^er child infection of per- days after ouar- \ day after child Exclude iidoys or 7 days after iuc- c^ul vaccina- tion, untewtb^^ ccMfuUy vatti- year. in which case they may connection with s vl... i ■ ■ tohavealljKnons^.i" i SEPTIC reddened and may thow patches like dtphlberio. Mouth spny and dis- chMges Horn nme -v=r ^ "IBr No. Until recovery. kidneys, etc. Very apt to cause epidemics if *?Wh"^ lo™ "in"y ' t^fiw "h^'^'li* ""i^d"' 'c^'i;ct^.^tJ^ ■5Sr^ No. EiKbi weeks or 1 alter lAt char, .icteristit couitb Fourteen day». provided no cough develops raeontune. After cflecU often very severe and di>ea*c caus* great drtiility. ReUpies arc apt to occjir. Second attai rare. SpecialK- mfetUous (or c .n..o,_,ora.ha..e.ond.„„_.r.a..nd._o,the.o,er^^ APPENDIX IV THE SCHOOL COMMITTEE OF THE CITY OF BOSTON. DEPARTMENT OF SCHOOL HYGIENE To Parents and Guardians: Diseases of the teeth have been named "The Disease of the People." The wide-spread existence of this disease and the great injury it does to the health of the child make it one of the greatest factors in deciding the child's future. The cure of the disease calls for the strong, united action of all persons having the care of children. Good Health Depends upon Good Teeth — Because 1. There cannot be health without nourishment. 2. There cannot be nourishment unless the teeth break up (chew) the food so that the body can digest the food. 3. There cannot be good digestion unless the teeth are able to break the food, and bad teeth cannot do good work. 4. If there is not good digestion, there cannot be good health. Medical investigations show that much of the disease of the teeth can be prevented ; also that the younger the child when the teeth are cared for, the greater the benefit. All this means that if the first, or temporary set of teeth, could be kept free from disease, the second or permanent set of teeth would be practically sound. Children enter school life just before or during the most impor- tant dental period; namely, the cutting of the sixth- year molar tooth. This is the first permanent tooth. This first tooth of the second set will not be healthy and sound if the first set of teeth is decayed or neglected. The other teeth of the SECOND set will not be healthy if this first molar is decayed. The one great cause in all decay of teeth is the failure to keep them clean. There was a time when the wheat used for flour was not so finely 643 044 APPENDIX IV powdered as it is to-day, and when modern inventions had not robbed l)rc'acl of a coarseness that made the teeth dean and strong by chewing. The finely powdered wheat-flour bread clings to the teeth and sets up fermentation. This causes decay of the teeth. This decay goes on faster during the night than during the day. Teeth should be cleaned after each meal but must be cleaned before going to bed each night if decay is to be prevented. Teeth can be cleaned by brushing or by passing silk floss between the teeth. Many children neglect to do this; then it becomes necessary to have the teeth cleaned and repaired by a dentist. The School Committee has gone over the whole problem of the care of the children's teeth and has prepared a plan which, it believes, will aid the children greatly in promoting good health. The task is a big one and requires the co-operation of parents and teachers if the best results are to be gained. Each parent or guardian is asked to assist in this work which means so much for the future of the children. 1. You are asked to buy a tooth-brush for each child in the family. 2. You are asked to see that the child uses this tooth-brush DAILY, especially before going to bed at night. 3. You are asked to fill out and sign the attached form so that the school nurse may give any assistance required in any case. This will be regarded as confidential. 4. You are asked to attend the Free Lecture and Demonstration to be given by dentists at the school your children attend. 5. You are requested to take your child to your family dentist for examination and for treatment. If circumstances do not permit consulting a dentist at his office, the child may be treated, at a small cost, or free, at one of the following dental clinics. You are asked to do this NOW. Boston Dispensary, Bennett Street, 5 dentists, 9 a.m., daily. Harvard Dental School, Longwood Avenue, 55 dentists, 9 a.m. to 2 p.m., daily. Tufts Dental School, Huntington Avenue, 80 dentists, 9 a.m., daily. Massachusetts General Hospital, Blossom Street, 4 dentists, 8.30 a.m., daily. Mt. Sinai Hospital, Staniford Street, i dentist, 9 a.m., daily. Hull House Dispensary, Hull Street, i dentist, 9 a.m., daily. APPENDIX IV 645 Grace Hospital, Kingston Street, 4 dentists, 9 a.m., daily. Maverick Dispensary, Maverick Square, i dentist, 10 a.m., Tuesday and Thursday. Respectfully, Thomas F. Harrington, M.D., Director of School Hygiene. Fill out and tear off this slip and return it immediately. 191 • To the Principal of School. A a pupil in Grade is receiving treatment at Dr or at Hospital, or B. I desire a pupil in Grade to receive dental treatment at Hospital. I assume the responsibility of such visits. I ^ pay minimum ^ ^ cannot ^ •' cost of treatment Parent or Guardian. INDEX Abt, Doctor I. A., 62 Administration of educational hygiene, 134 Ailments in order of frequency, 228 Ailments of pupils, 223 Aims of physical education, 620 Alderman, E. L., 181 Allen, VV. H., loi American Medical Association, 4, 5 Andrews, J. B., 28 Apparatus, play, 405 Arithmetic, hygiene of, 591 Association, 581 Athletic games, 401 Athletic test, 464 Athletics in high school, 439, 453 Attention, 580 AjTes, L. P., 17, 120, 296 Babbitt, Ellen C, 36 Badge for athletics, 418 Biotype, 47 Blackboards, 350 Bliss. D. C, 173 Blind children, 436 Boy Scouts, 468 Brown, E. F., 283 Building rules, :i^^ Bureau of Municipal Research, 92 Cabot, Ella L., 84 Camp-Fire Girls, 469 Cancer, 26 Carnegie Foundation, 85 Carney, Mabel, 112 Charitable societies, 96 Child development, stages of, 551, 570 Child-welfare exhibits, 91 Children's Aid Society, 244 Chorea, 64 ChurchiU, J. A., 184 Classification of mental defectives, 296 Classroom, standard, 338 Cleanhness and cleaning, 89, 185, 351, 364 Chnics, school, 137, 253 Codes, 223, 234 College credit, lack of, for health teaching, 504 College hygiene, 602, 617 CoUi^r, Price, i Communicable ailments, 41, 224 Consolidated rural school, 323, 459 Contagious diseases, 41, 224 Co-operation, public, 82, 245 Cornell, 17 Country school farm, 323 County superintendents, 194 Crippled children, 436 Criticism, service of, 83 Crowley, Doctor Ralph, 311 Cruickshank, L. D., 225 Curtis, S. H., 123 Dancing, 447 Deaf children, 436 Death losses, i, 7, 8, 10, 11, 14, 15, 16, 25, 26, 27, 28 Death-rates at various ages, 14, 15 Defects of pupils, 223 Degenerative diseases, death-rates of, 26 Denison, Elsa, 88 Dental chairs, 237 Dentists' organizations, 95 Desks, 351 Determiners, 50 Devine, 13 Dewey, John, 381 647 648 INDEX Diagnosis of mental defects, 304 Diagnostic chart, 113 Diet, 68 — .--'^' Dietaries, 290 Diphtheria, 39 Diseases of pupils, 223 Disinfection, 40 Ditman, 59 Divisions of educational hygiene, 130, Drawing, hygiene of, 598 Dresslar, F. B., 5, 86, 121, 124 Drills, physical, 429 Dunn, 31 Educating the public, 100 Educational hygiene, meaning, 4 Educational psychology, 5 Ellis, Professor Caswell, 348 Emergency outfit, 486 Employers and health, 543 Equipment, play, 405, 462; dental, 254 Eugenics, 3, 48, 55 Eugenics Record Office, 56 Examinations, 156, 216 Exceptional children, 204 Exclusion form, 208 Excursions, 467 Exhibits, 90 Expenditures for health work, 43 Eyes, ears, nose, and throat, disorders of, 79, 80 Fatigue, 67 Fears of children, 66 Feeble-minded children, 302 Feeding of school-children, 76, 273 Festivals, play, 466 Fire-proofing and fire laws, 335-7 First-aid supplies, 486 Fisher, Irving, 7 Fisk, E. L., 27 Folk dances, 416 Foods for school-children, 70-77 Forms for medical supervision, 205-8 Forsyth Dental Infirmary, 252 Freeman, R. G., 34 Games, 447, 460 Gamete, 48 Geography, hygiene of, 593 Girl problem, 396 Girl, the working, 541 Girls' athletics, 422 Goldwater, S. S., 199 Green, F. R., 22 Grounds, 359 Gulick, L. H., 88 Guthrie, L. G., 60 Gymnastics, 444 Habit spasms, 64 Habits, health, 482 Harriman, Mrs. E. H., 56 Headache, 78 Health agencies, 150 Health almanacs, 182 Health census of school-children, 197 Health grading of the school-child, 114 Health and heredity, 51, 52, 53, 60 Health programme, 491 Health surveys, 112 Heating and ventilation, 343, 360 Heredity and environment, 3, 45, 46, 47, 60 Hill, L. P., 345 Hoag's diagnostic chart, 113 Home hygiene, 531 Hospitals, 96 How to start open-air schools, 271; clinics, 253; medical supervision, etc., no Hutchinson, Woods, 67 Hygeia, 499 Hygiene of instruction, 567 Hygiene of methods, 124 Hygiene, teaching, 472 Hygrometers, 349 Ideals of health, 489 Illness and physical defects, losses, 9, 17, 18, 19, 20 Individual differences, 46-53 Industrial hygiene, 538 Infant mortality, 8, 14, 15, 18, 19, 32, 33, 34, 35, 36 INDEX 649 Infant welfare organizations, 259 Inspection of pupils, 204 Jaffa, Doctor Adele, 68 Janitors, 326 Johnston, Charles H., 56 Jordan, D. S., in Kennard, Beulah, 381 Kentucky sanitary privy, 369 Kerschensteiner, Doctor, 542 Kirk, John R., 356 Kohnky, Emma, 19, 249 Life Extension Institute, 132, 543 Life-insurance agencies, health work of, 2 Lighting, 339, 359 Little mothers' classes, 236 Longevity and heredity, 55 Lunches and food values, 75, 275, 277 McMurry, Professor Frank, 473 Malnutrition, 286 Manhattan Trade School, 542 Manual training, 159 Measles, 38 Measuring the efficiency of medical supervision, 226 Medical inspection laws, 187 Medical supervision forms, 205-8 Medical supervision, phases of, 202 Men's colleges, 61 7 Mental development and heredity, 53 Mental hygiene, 579 Mentally defective children, 204 Methods of teaching hygiene, 481 Milk stations, 33 Mimetic exercises, 416 Moral development and heredity, 55 Morse, Doctor J. L., 40 Mortality statistics, 9, 10, 11, 25 Moving-picture show, 402 National vitality, 7 Nervous disorders, 61, 63 NewTnayer, S. W., 36, 88 Newspapers, 91, 112 Nose-blowing drills, 235 Notices to parents, 220, 222 Nurse as attendance officer, 215 Nurses, school, 145, 161; qualifica- tions, 237 Nurses settlements and societies, 93, 97 Nurses, training of, 527 Nuttall, G. N. F., 24 Open-air school children, feeding of, 284 Open-air schools, 256 Parents' health responsibilities, 59 Parent-teacher associations, 98 Pasteur, Louis, 16 Pearson, Karl, 42 Pennsylvania Rural School Survey, 20, 121 Philanthropists, 99 Physical defects, 17, 18, 19, 20; and heredity, 51 Physical defects of college students, 624 Physical education, 123, 410 Physical education, aims of, 441 Physical status of high-school pupils, 500 Physical training, 410 Play and playgrounds in cities, 380 Play equipment, 462 Play instincts, 392 Playground Magazine, 123 Polyclinic, 244 Prenatal health work, 34 Preventability of deaths of school- children, 16, 17 Preventive medicine vs. curative medi- cine, 2, 23, 24, 510 Prolongation of life, 24 Psychological examinations, 307 Public-health services, 4 Public opinion and sentiment, 87, 88, no, 124, 518 Publicity, 89 Pupil's Health Record, 206 Pure food, 30, 31, 32 050 INDEX 1 Reading, hygiene of, 586 Record cards, health, 205-9 Records, physical training, 432 Recreative exercises, 415 Reesor, Mary, 124 Registration of deaths, 1 2 Relief organizations, 236 Reports of medical supervision, 2 lo-ii Research in educational hygiene, 172, 247 Resistance to disease, 54 Retardation and health, 17, 18, 19, 20, 165; Appendix I. Rittenhouse, 26 Rockefeller Institute, 85 Roller towels, 22 Rosenau, 51 Rucker, Doctor, 40 Rules and regulations, 239 Rural hygiene working forces, 193 Rural play, 456 Rural school sanitation, 355 Sage Foundation, 83 Saint Vitus's Dance. See Chorea Salaried medical profession, need of, 2 Sanitary commandments, 379 Sanitary survey forms, 216 Sanitation forms, 121, 122, 123 Sanitation of schools, 312 Saturday half-holiday, 470 Scarlet fever, 39 Schaeffer, N. C, 20 School examinations and adult exam- inations, 199 School health problem, 13 School medical supervision, 37 Seating, 187 Sewage disposal, 371 Sex education, 547 Sex instruction in the high schools, 555; in elementary schools, 557 Sites for schools, 333 Social centre as a health agency, 103, 108, 471 Spelling, hygiene of, 599 Stammering and stuttering, 67 Standardization clinic, 203 Standards : of sanitation, 330 ; for classroom, 338; for rural schools, 372; for playgrounds, 404; for ath- letics, 464; for teaching hygiene, 475; for professional training of nurses, 533 State co-operation for school health progress, 147-8 State health examinations, 2cxj Supplies, 233 Survey, health, 112, 317 Symptom chart, 113, 214 Teachers' meetings, 180 Teaching health, status of, 503, 522 Teaching hygiene, 123, 472 Teeth and mouth conditions, 80, 245 Terman, L. M., 66 Texts in hygiene, 477-8, 488, 544 Thorndike, 46 Toilets, 353, 368 Training school-health workers, 135 Treatment of pupils, 225, 232, 251 Tuberculosis, 38, 257 Typhoid fever, 28, 29 Vaccination, 41 Van Sickle, J. H., 296 Ventilation, 79, 325, 331, 343 Voluntary assistance, 100 Wald, LilUan D., 231 Wallin, 19, 20 Warner, Doctor Francis, 61 Water supply for schools, 350, 365 Whooping-cough, 37 Wider use of the school plant, 91 Winslow, C. E. A., 2, 3, 14, 30 Witmer, Professor L., 296 Women's clubs, 88, 98 Women's colleges, 602 Wood, T. D., 113 Work, optimum conditions of, 576 Workers and health, 539 Writing, hygiene of, 596 This book is DUE on the last date stamped below OCT 1 7 1932 APH 121931 APR 141937 MAY I M» vm , 1 EB 161938 f-!- [JUL 2 3 1941 ^ 121936 '—