CENTRAL CIRCULATION AND BOOKSTACKS The person borrowing this material is responsible for its renewal or return before the Latest Date stamped below. You may be charged a minimum fee of $75.00 for each non-returned or lost item. Theft, mutilation, or defacement of library materials can be causes for student disciplinary action. Ail materials owned by the University of Illinois Library are the property of the State of Illinois and are protected by Article 1 6B of Illinois Criminal Law and Procedure. TO RENEW, CALL (217) 333-8400. University of Illinois Library at Urbana-Champaign FEB 2S2M5 When renewing by phone, write new due date below previous due date. LI 62 Digitized by the Internet Archive in 2017 with funding from University of Illinois Urbana-Champaign Alternates https://archive.org/details/schoolhygieneinmOOmart i J al School Hygiene in Massachusetts BY GEORGE H.' MARTIN, Secretary ^’ieprinted from the Seventy- second Report of the Massachusetts Board of Education SCHOOL HYGIENE Containing a Statement relating to the Present Condition of Medical Inspection in the Schools of Massachusetts ; Disclosures by School Inspection; Limita- ^ tions on School Work ; the Teeth also Tuberculosis; Suggestions to Teachers regarding Tubercu- losis and its Prevention ; Printed Rules of Health; Out-door Class in Boston BY GEORGE H. MARTIN Secretary State Board of Education BOSTON Wright & Potter Printing Company, State Printers 1 8 Post Office Square 1909 MEDICAL INSPECTION. MEDICAL INSPECTION. The law requiring school committees or boards of health to appoint school physicians was amended during the legislative session of 1908 by repealing the section which limited the ex- penditures to a specific appropriation for the purpose. This leaves the law mandatory upon all school committees in towns and upon all school committees in cities where the work has not been taken up by boards of health. Reports received show that in 294 of the 321 towns and in 32 of the 33 cities school physicians have been appointed and are now at w^ork. In one or two towns it appears that the inspection is under the direction of the board of health. This is not in accordance with the law. Boards of health are authorized to appoint school physicians only in cities. In a majority of cases the physicians report in writing to the committees, and their reports are printed in the annual school reports. This should be required in all cases. The reports now in print are most gratifying. With great unanimity they show that the physicians have accepted their appointment in the highest professional spirit; that they have entered on the new work with interest; that they have inter- preted the law broadly; that they have dealt with delicate situ- ations with tact and wisdom, thereby winning the confidence of parents and teachers; and finally, that the service which they have rendered is in most cases far in excess of their pecuniary compensation. The following statement, from the report of the superin- tendent of schools of Northampton, is typical of many : — Medical inspection in the Northampton schools is an unquahfied success. This is largely due to the energy, tact and practical experience in school matters of our school physician, Dr. J. G. Hanson, supple- mented by the cordial co-operation of parents and teachers, and, most important of all, the professional support given him by the physicians, dentists and oculists practising in this city. 4 A part of the work, which was less prominent in the minds of those who framed the law, may yet prove to he of prime importance. This is the inspection of school buildings and premises. In many of the reports the inspection is shown to have been thorough, and the conditions as to light, heat, venti- lation and sanitation are described in unmistakable terms. Im- provements which neither teachers nor superintendents nor State agents have been able to secure may yet be brought about through the fearless exposures by the school doctors. The possibilities in this direction are shown in the Ameshury report : — By virtue of a law passed by our Legislature of 1906, a new office in the management of our schools was created. Several conditions, which had existed some time, confronted your inspector, and needed immediate attention. The work of the year has been looked after thoroughly. We will be excused of any egotism if we say the results have been exceedingly gratifying. Of course only a beginning could be accomplished where there is so much work to do. ^ The first and foremost thing to do was to remedy the condition of things at the Bartlett school. Here was a menace, in the minds of the parents, and the school committee was at a standstill as to what to do. When the superintendent wanted to transfer pupils from one school to another, he had to respect the arguments against the bad health condi- tions at the Bartlett. Diphtheria had made its appearance there so often (ten or twelve cases) that many sessions of school were lost, the full attendance lessened and the school efficiency materially inteiTupted. The drainap from the sink was found to be bad, — absolutely no idea of health in its construction. A cesspool was sunk, plumbing established in ac- cordance with the regulations of the board of health, house cleaned, fumigated, and then a liberal coat of oil applied to all the floors. Theie have been no contagious cases from that school since. For years (always, for that matter) contagious diseases have occa- sionally broken out in some of the schools, so that the board of health had to destroy many dollars’ worth of books and other school property, discontinue the school sessions, clean, wash and fumigate, all of "which entailed many dollars of expense to the tax payer. During this year not a single case of contagious disease has made its appearance, not a cent’s worth of property has been destroyed, not a session of school has been omitted, and the board of health are strangers to us. The reports also show that an increasing nnmher of children are cared for by the parents in accordance with the notification 5 cards sent from the school. Yet parental neglect still stands in the way of securing the hoped-for results. Where school nurses are employed, the children are cared for more quickly and better, and the loss of school time is reduced to a minimum. All signs point to the fact that the school nurse will ultimately be considered an essential factor in the school system of all cities and large towns. Eye ato Ear Tests. The second annual tests of sight and hearing of school pupils have been made by the teachers, and the results included in the school returns. Only one town, ETantucket, reports that the examination was not made. The results are as follows : — Eye and ear tests. Counties. Number of PUPILS EXAMINED. Defective eyes. Defective ears. 1907. 1908. 1907. 1908. i 1907. 1908. Barnstable, .... 4,562 4,529 770 539 276 143 Berkshire, .... 14,343 14,653 2,614 2,470 786 593 Bristol, .... 38,210 37,957 7,683 6,700 2,450 1,802 Dukes, .... 678 752 162 162 32 43 Essex, ..... 54,088 53,252 11,984 9,308 3,240 2,326 Franklin, .... 6,546 6,925 1,343 1,077 520 397 Hampden, .... 26,749 27,458 5,275 4,761 1,749 1,750 Hampshire, .... 8,807 8,650 1,626 1,510 535 407 Middlesex, .... 92,688 93,567 19,975 16,839 5,495 3,902 Nantucket, .... - - - - - - Norfolk 26,525 27,800 4,498 4,342 1,465 1,254 Plymouth, .... 20,818 21,1651 3,295 2,9341 911 8191 Suffolk 93,920 92,463 28,853 21,950 7,324 6,805 Worcester, .... 44,530 48,264 8,529 8,566 2,604 2,360 State, .... 432,464 437,435 96,607 81,158 27,387 22,601 1 Exclusive of Hanson. While the number of children examined in 1908 is slightly larger than the number in 1907, the number found defective appears to be decidedly smaller. In 1907, 22.3 per cent, of those examined were found to be defective in vision and 6.3 6 per cent, in hearing. The number reported in 1908 as defective in vision is 18.5 per cent, and in hearing 5.1 per cent. It is impossible at present to account for this apparent re- duction. Whether it is dne to more careful testing, or to a different basis for reporting, or to counting children wearing glasses as normal, no one can tell; hut it is interesting to note that there appears to he a reduction in every county. The figures for another year may throw some light upon the subject. Disclosuees by School Inspection. The number of children suffering from some physical ailment is shown to he much greater than any one had supposed. This is true of the country towns as well as of the cities. In a small country school were found an epileptic child, one with serious spinal curvature and one with quite pronounced chorea. A school physician, who has inspected 330 children in two country towns, reports : — Of these, 217, or 65 per cent., had decayed teeth; 65, or nearly 20 per cent., had adenoids and chronically enlarged tonsils; 9 had decided eczema ; 5 had valvular lesions of the heart ; 7 had head lice ; and 1 had spinal curvature. In view of these facts, the statement frequently made as an excuse for non-action on the part of school committees, Our children are all healthy,’’ is evidently founded on ignorance. In the cities the number of children affected and the variety of ailments is large. In AVorcester the school inspectors found the following : — Diseases. Cases. Specific infectious diseases, ...... 269 Diseases of the oral and respiratory tract, 1,974 Diseases of the ear, ...... 75 Diseases of the eye, ....... 223 Diseases of the skin, ....... 2,109 Miscellaneous diseases, ...... 1,4J02 In Boston the inspectors found : — Diseasks, Ca.se.s. Specific infectious diseases, ...... 408 Diseases of the oral and respiratory tract, 1,932 Diseases of the ear, ....... 213 Diseases of the eye, ....... 1,067 Diseases of the skin, ....... 4,497 Miscellaneous diseases, ...... 1,368 I have used these two cities as types. one would be willing to vouch for these figures as showing the exact physical condition of all the school children in these cities. The inspec- tions vary in their thoroughness, the physicians vary in their diagnoses, and the categories used in classification are not ex- actly alike in their content. But what the figures do show is, that a large number of children are in school who were not at the time of inspection well. Limitations on School Work. There is always in the public mind a feeling of dissatisfaction with the results of educational work. Such feeling finds voice in private circles, on public platforms and in periodical litera- ture. The voices are more numerous and more strident at some periods than at others, but the feeling always exists and has always existed, and lies at the foundation of all educational reform. The dissatisfaction has not been without justification. The schools have not secured all the results desired. The money expended has not brought the return which the public had a right to expect. These facts cannot be concealed nor truthfully denied. In looking for the cause or causes of the inadequate returns yielded by the schools, most of the speakers and writers have gone far astray. They have almost without exception confined their view to the schools as institutions, — that is, to the admin- 8 istration, to the teaching, or to the curriculum. J^ever has one of them taken account of the fundamental factor in the prob- lem, — the children themselves. The assumption in all these discussions has been that children, being children, are equally susceptible to education ; that they will take ’’ learning as they take diseases peculiar to children, if they are properly “ ex- posed ” to it. Medical inspection has given a rude jolt to this assumption. It has shown that in the cases of large numbers of children there is no reasonable ground for expectation that they will come out of the schools scholars. In the cases of many we have no right to expect to develop a high degree of intelligence. One phy- sician’s report says, I found fourteen children who were men- tally deficient,” that is, too weak minded to profit by school instruction. But of children of normal mental powers the num- ber of children suffering from physical ailments is large enough to lower the standard of attainment of the whole school popula- tion. Take, for example, some of the cases classed under mis- cellaneous diseases. According to the Boston report for 1906, the inspectors found 208 cases which they called anremia. If there had been so many cases of diphtheria, everybody would have been alarmed, • — teachers, parents, doctors and the public. But only anaemia, — merely pallor and weakness and languor, — and, perhaps, some functional disturbance, no one makes much account of these, and the school machinery grinds on. If the study of physiology has taught anything, it is that for all mental activity one thing is essential, — an adequate supply of good red blood. Fancy an anaemic girl sitting down at night to a difficult lesson in arithmetic or geometry or Latin, trying to concentrate her thouglit, summoning powers which cannot respond to her call. Her inevitable failure is not a failure in the teaching, or in the curriculum, or in the disposition of the girl ; it is simply a failure to coerce nature to a reversal of her laws. AVhat is true of anaemic pupils is equally true of huudreds reported as suffering from neuralgia. There is no possibility of successful and continuous intellectual effort. In view of what medical inspection has already shown, we have a right to insist that Avhen the results of school woi‘k arc 9 measured, men should judge righteous judgment. There is much popular clamor for the essentials ” in public schools. Modern business has become so highly systematized and special- ized that the business man expects every employee to work with the promptness and unerring accuracy of a standardized ma- chine ; anything less than this causes annoyance. If the schools could receive from the homes children sound in body and clean in personal habits, these children would go out able to read and write and spell and cipher to everybody’s satisfaction, without leaving out anything from the present curriculum. The essential which is lacking is a condition of body which makes concentrated and sustained mental effort not only a possi- bility, but a delight. As this condition is approximated, the schools will have approximate success. The whole situation is aggravated by the facts which a recent investigation in Hew York has shown, — that the physical de- fects are most numerous in the earlier years of school life. Children outgrow many of their troubles. While there is some comfort in knowing this, school people will at once see that the period when defects are most numerous is the period when in the lower grades most of the mechanical work is done, which is the foundation for all subsequent study. This is the time when children are learning to read and to write and to spell and to handle numbers, — the time when habits of accuracy are formed, if formed at all. It is the time for drill. The facts shown in the chapter on Retardation and Physical Defects,” in the book, Medical Inspection of Schools,” pre- pared by Dr. Luther Hasley Gulick and Mr. Leonard P. Ayres, and published by the Hew York Charities Publication Com- mittee, are most significant. The Teeth. Examinations of the teeth of school children in different places throw light upon the primary cause of many of the dis- abilities under which children suffer. A paper read by Dr. C. Edward Wallis at the London Con- gress of School Hygiene in 1907, and published in the second volume of the proceedings, contains a table showing the results of an examination of 245 children between the ages of seven and 10 twelve in an elementary school in one of the poorer districts of London : — Totals. Number examined, . . . . 245 children. Number of decayed temporary teeth, 952 = average per child, 3.9. Number of decayed permanent teeth. 685 = average per child, 2.8. Alveolar abscesses and fistulae discharging pus, 23 = 9 . 3 per cent. Chronic pharyngitis, .... 40 = 16.3 per cent. Chronic enlargement of tonsils, 71 = 29.0 per cent. Chronic submaxillary lymphadenitis (en- larged glands under the jaw), 150 = 62.2 per cent. Enlarged glands in neck, 16 = 6 . 5 per cent. ‘‘Mouth-breathers,’^ . . 6 = 2 . 4 per cent. Ansemia (22 boys, 66 girls), . 88 = 37 per cent. (13.4 boys, 81.4 girls). Strasburg was the first city in the world to maintain a munic- ipal school dentistry. Dr. Jessen, in a paper read at the London Congress, reports of this work ; — In no part of the public medical service have such results been ob- tained with such small expense. The experience of the Strasburg and other experiments has proved beyond doubt that the health of the children has been gTeatly raised by dental treatment. The care of the teeth has guarded against infectious diseases, and been a most valuable factor in the struggle against the spread of tuberculosis. . . . The report of the government inspector laid stress on the following facts : — School absences caused by toothache had greatly diminished. The work of children hitherto suffering from their teeth had greatly improved. The general health of children who occasionally suffered from tooth- ache had greatly improved, as a consequence of dental treatment. Very little school time had been lost by children attending school dentistries, as they went out of school hours. . . . The children took the greatest interest in the instruction given to them about the care of their teeth. The children like to be treated by the dentist, and no objections whatever had been experienced on the part of the parents. Dr. Jessen made this statement: In Germany at the present moment at least 90 per cent, of all elementary school children suffer from decayed teeth.” That conditions are not much, if any, better in Massachu- setts, seems probable, judging from some reports recently made. 11 The school physician of Ashby reports that 95 per cent, of school children have decayed teeth. The school physician of ISTorthampton reports as follows: — The most deplorable fact elicited from the examination was the almost total lack of care given children’s teeth. Out of 600 children whose teeth were examined, only 74 had received any attention, and the larger number of the 526 exhibited most uncleanly and unhealthy mouths. Dr. Willard C. Crocker, medical inspector of the schools of Foxborongh, gives in his report a table of the results of inspec- tion in all the schools of that town : — School. Number examined. Teeth needing to be filled. Teeth to be extracted. High, 69 268 141 Grade IX., 43 147 26 Grade Vm., . . . . 48 166 25 Grade VII., 51 162 31 Grade VI., 31 81 11 Grade V., ..... 36 103 45 Grade IV., ..... 36 47 20 Grade III., 39 71 8 Grade II., 31 38 - Grade I., .... . 40 8 3 Cary school, ..... 30 38 6 Quaker Hill school. 24 33 2 Everett school, .... 14 26 1 Plimpton school, .... IS 31 - Pratt school, .... • 26 48 5 Paine school, ..... 36 36 10 Totals, ..... 572 1,303 334 j 12 A striking feature of this exhibit is the condition of the teeth of the pupils in the high school. There is no reason to think that the condition is worse in this town than in others. It would be easy to satirize a condition which keeps boys and girls in high school at work five hours a day for four years on Latin and French and algebra and chemistry and a dozen other subjects, and leaves them ignorant of the elementary prin- ciples of health and without habits of personal cleanliness. That faithful inspection and frank reporting of the results will bring relief is evident from Dr. Crocker’s report : — Though the examination and report sent to each parent showed the defects of the milk teeth, the above summary refers only to the adult teeth, and does not include teeth already filled or missing. . . . All agree on the necessity of checking the decay that is started; and we are pleased to announce that the dentists of Foxborough have united in granting a discount of 25 per cent, from the regular prices upon all work for the school children as outlined in this examination, and that in some cases a special discount may be arranged on recom- mendation of the medical inspector. It looks as if through dental inspection we were getting nearer the root of many of our school difficulties. For this reason the propaganda started by the Massachusetts Dental Council is most welcome. The travelling exhibit which has been prepared and the popular lectures which accompany it are proving effective means of arousing public interest. Tuberculosis. The Legislature of 1908 (chapter 181) added ^^tuberculosis and its prevention ” to the legal requirements for school instruc- tion, so that the law now reads: — In each of the subjects of physiology and hygiene, special instruction as to the effects of alcoholic drinks and of stimulants and narcotics on the human system, and as to tuberculosis and its prevention, shall be taught as a regular branch of study to all pupils in all schools which are supported wholly or partly by public money, except schools which are maintained solely for instruction in particular branches. . . . In order that the teachers might have some authoritative guide in carrying out the provisions of the law, the secretary of tlie ( 13 Board of Education through the courtesy of Dr. Kobert W. Lovett of Boston was able to confer with several prominent specialists in pulmonary diseases, who agreed to prepare a simple booklet of suggestions to teachers. This was done, and copies have been furnished to all the teachers of the State. The con- tents are as follows : — Suggestions to Teachers regarding Tuberculosis and its Pre- vention. The suggestions to teachers contained in this booklet have been pre- pared for the Board of Education, as a matter of public service, by the following eminent specialists of Boston : — Arthur T. Cabot, M.D., Chairman Massachusetts Commission on Hos- pitals for Consumptives. Herbert C, Clapp, M.D., Professor of Pulmonary Diseases, Boston Uni- versity School of Medicine. Edward O. Otis, M.D., Professor of Pulmonary Diseases, Tufts College Medical School. Horace D. Arnold, M.D., Professor of Clinical Medicine, Tufts College Medical School. Cleaveland Floyd, M.D., Director, Out-patient Clinic, Boston Consump- tives’ Hospital. John B. Hawes, 2d, M.D., Secretary Massachusetts Commission on Hos- pitals for Consumptives. George H. Martin, Secretary. Introduction, Chapter 181 of the Acts of the Commonwealth of Massachusetts of 1908 provides that tuberculosis and its prevention shall be taught in all grades of the public schools of this State in which instruction is given in the subjects of physiology and hygiene. This pamphlet is not in- tended as a text-book for teachers of this subject, but is merely to suggest certain lines of instruction and to emphasize certain points to be dwelt on with particular emphasis. At the end of this pamphlet will be found references to various standard works on this subject, some of which will be within the reach of every school teacher, or which can be secured at a nominal price. It is manifest that the methods of teaching and the subjects which are taught must vary a gTeat deal, according to the age of the pupils. Among the primary grades, for instance, it should be made clear in the first place what consumption is, and why it is necessary to know some- thing about it; and then particular emphasis should be given to the question of home hygiene, fresh air, open windows at night, bathing, care of the teeth, proper clothing, proper food, the avoidance of tea, coffee and tobacco, etc. Pupils in the grammar schools should be taught J 14 more than this, — they should be given some idea as to what this disease is doing in our midst, what causes it, and the methods which are being taken to combat it. In the high schools and normal schools instruction should go still further, and it is possible that the teachers or head masters can make arrangements with the school physicians, or with physicians of local anti-tuberculosis associations, to give a series of short talks on this subject. Students of this age should not be allowed to finish their training without having a very clear idea in regard to consumption, its cause, the methods of prevention and cure, the present campaign against it, the methods of treatment in the sanatorium and especially in the home, and, most important of all, the early signs and symptoms of this disease, as well as a thorough knowledge of the ordinary laws of health and hygiene. It would be well if every such pupil was required to read Dr. Knopf's excellent essay, entitled “ Tuber- culosis as a Disease of the Masses, and how to combat it," which can be bought for 25 cents, or which can be secured in the local library. Every teacher should realize her opportunity in thus directing her pupils in the way of wholesome living. A healthy mind requires a ♦ healthy body. The interest of the scholars will be aroused in this matter only in so far as the instructor stimulates or develops this interest. Outline. I. What tuberculosis is. What consumption is. What the tubercle bacillus is. When discovered, and by whom. Methods of growth. Things favorable to its growth. Things unfavorable to its growth. IT. Outline of history of tuberculosis: (1) ancient times; (2) dark ages; (3) present. III. What tuberculosis does: (a) in the world; (b) in this country; (c) age at which it kills; (d) compared with other great disasters, — yellow fever, Slocum disaster, San Francisco fire. Civil War. IV. How tuberculosis is spread. Sputum ; milk ; anti-spitting laws. V. Tuberculosis is preventable; it is curable; it is not hereditary. How pre- vented: (a) by living so as to keep health, — fresh air, — exercise, — food, etc.; (b) non-spitting. VI. How cured, — sanatoria. Home treatment. Methods of getting fresh air. A cure possible in any climate. A tendency and not the disease is hereditary. ( o 15 VII. Early signs and symptoms of consumption. Importance of other things besides a cough, — pallor, angemia, loss of weight, weakness, listlessness, uncleanliness, glands, etc. VIII. The campaign against consumption in Massachusetts. Every one must do his share. Tuberculosis exhibits, societies, hospitals, etc. IX. Reference to standard works on the subject. Tuberculosis and its Prevention. I. Tuberculosis is a disease caused by a very small germ or microbe called the tubercle bacillus. This is so small that it takes three thou- sand put end to end to measure one inch. This germ does not readily grow outside of living bodies, but when it gains entrance into the body it grows and multiplies, and finally destroys the tissues, and thus causes the disease tuberculosis. Consumption is tuberculosis of the lungs, otherwise known as pul- monary tuberculosis, pulmonary consumption, or phthisis. Tubercu- losis of other parts of the body is known by different names, such as humpback, or PotCs disease, which is tuberculosis of the spine; hip disease, tuberculosis of the hip; white swelling of the knee or of the ankle, which is tuberculosis of the knee or of the ankle; scrofula, which so many children have, characterized by lumps in the neck caused by enlarged glands, which is nothing but tuberculosis of these glands; lupus, a skin disease, tuberculosis of the skin. So it is possible for this tiny genn to cause tuberculosis or tuberculous disease of any part of the human body. Although this germ cannot grow outside of the body, yet it will survive and keep its vitality for a considerable time after it is cast out. Darkness* and damp favor its survival. Dryness, fresh air and sunlight tend to destroy it. Direct sunlight will kill any germ of tuberculosis in twenty minutes. The organism which causes this disease was discovered by a famous German physician. Dr. Robert Koch, in 1882. Up to that time nobody knew what Tvas the cause of this terrible affliction. II. Tuberculosis is a very old disease. Indeed, in the old Egyptian mum- mies evidences of tuberculosis have been discovered; and the famous writei's of the old days, whose wulting-s are still in existence, described this strange .condition, in which their patients developed a cough and gradually wasted away. The disease was known then, as it is now. ) 16 as the “ Great White Plague.’’ There was not much which they could do for it. A few of the wiser doctors advised their patients to go to the mountains or to take a sea trip, although they could not explain why this should be beneficial. Later, in that period in the history of Europe known as the dark ages, — the tenth, eleventh and twelfth centuries, — even the little knowledge which men possessed about tuberculosis was forgotten, and the disease swept through Europe, destroying people by thousands and sometimes wiping out whole families. Those suffering from this disease were shunned and avoided as if they were lepers, and were confined in rooms wuth the windows and doors closed, shutting out fresh air and sunlight, — things which we now know are so important in curing the disease. In the first half of the nineteenth century people began to realize that consumption was curable. In Germany they began to build hos- pitals or sanatoria for consumption, where those suffering from this disease could be sent and undergo the out-door treatment, remaining in the fresh air all the time, eating proper food, and thus have their disease cured. This plan of the open-air treatment has spread over the entire world. Now a person with consumption is no longer given up as hopeless, but in the various hospitals and sanatoria which are scattered all over our country, and especially in Massachusetts, — the leader in this movement, — as well as in the homes of the people, con- sumption is being cured. III. While consumption, then, is curable, it is still a very prevalent disease and is causing incalculable suffering and loss, chiefly because it is greatly neglected. It has been found that of all people who die every year, about one-seventh die from consumption. When we consider the terrible carnage in the destructive battles in the eighteenth century we are rightly shocked, and yet during that same period nearly twice as many died from tuberculosis. In this century, during the four years of the civil war there were killed some one hundred and fifty thousand men, which causes one to realize the terrible nature of war; and yet evei-y year in the United States there are more than one hundred and fifty thousand people destroyed by this one preventable disease, — con- sumption. The combined sum of all those who die of typhoid fever, appendicitis, scarlet fever, measles, diphtheria and cancer does not begin to equal the number that die from consumption alone. Such comparisons as these bring us to a realizing sense of the part played by consumption in producing misery and suffering in the world. Most important of all is the fact that this disease attacks people when they are in the prime of their life, and when their services are worth most to their families and to the community in which they live; for the mortality from consumption is the greatest during the most active period of life, — from fifteen to thirty-five or forty years. It spares ( 17 no one, neither the child, the youth or the adult, the weak or the strong. Compare this with the infectious diseases of childhood, such as diph- theria, scarlet fever, etc., which are most prevalent and fatal in the early years of life, and with cancer, which is rarely fatal before a person is fifty years old, when one has lived longer than the average length of human life. During the past five or six years there have been certain great disasters which have aroused the sympathy of the entire country, and for which relief funds have been raised amounting to thousands of dollars: for instance, the yellow fever epidemic in Louisiana some years ago; the terrible Slocum disaster in New York harbor; and the San Francisco earthquake and fire. And yet, terrible as these events seemed at the time, when they are compared with what consumption is doing silently and quietly in our midst, their importance sinks into insignificance. IV. When the germ of consumption attacks any person, it gets into his lungs and there grows and multiplies. As the disease becomes active a cough develops, and the person afflicted raises a certain amount of sputum. In this sputum are an innumerable number of the tuberculosis germs, which, if they are inhaled by people run down or otherwise in a poor condition to resist disease, may cause the disease in them also. This sputum must be destroyed in every case. If all sputum from con- sumptives were destroyed, consumption would soon die out. The disease is spread by carelessness or ignorance on the part of the consump- tives, who do not realize that every time they fail to destroy the sputum, or spit on the floor, or on the sidewalk, it will dry, be ground up into a powder, fly through the air as dust, and be inhaled by some person who is in a condition to receive the disease, and so cause the disease in him. It has been calculated that in the sputum of one consumptive in the course of twenty-four hours there may be more than twenty-four mil- lion of these germs. It is for this reason that a law has been made forbidding spitting on sidewalks, in public buildings, in cars, etc. It is then most important that every one, young or old, should realize clearly the dangers of indis- criminate spitting, and one’s duty in seeing that this disgusting habit is stopped. Tuberculosis may be spread in a small measure in other ways: by means of germs from tuberculous cattle, which find their way into milk or meat; but this factor is such a small one that it may properly be passed over with a very few words. While we should realize that an untrained, ignorant and careless consumptive is a danger to the community, we should also remember and constantly teach that the trained consumptive who is careful about his sputum and cleanly in his habits ceases to be dangerous, and may live among us without jeopardizing the health of others. It is very important that this distinction should be made clear, and that every J 18 effort should be made to eradicate the stigma which in present times often rests upon the consumptive, no matter how careful and well trained he is. Y. Tuberculosis is not hereditary; it is the tendency which is inherited, but not the disease itself. In other words, consumptive parents may have children who are naturally of a poor constitution, with weak lungs, flat chests, and little or no power to resist infection. Children in such families should be brought up with the utmost care, and should be given the maximum amount of fresh air and sunlight. The training of their minds should be sacriflced, if need be, in order that their bodies may be developed to the highest possible standard of health. It is for such children as these that there have been founded in Germany the so-called “ forest schools,” where the children of tuberculous parents and all those children who are weak and run down and liable to con- tract this disease are sent. There they go to school practically out of doors, and are trained in the best habits of hygiene and proper living. Such a school as this has recently been opened in Providence, R. I., and others are planned for this State. We should endeavor to teach children, first, that spitting is a dan- gerous as well as a disagreeable habit; and second, that the best way to avoid consumption is to so live that we are always in a healthy con- dition, so that we can resist the haiinful action of any germs that may find their way into our lungs or stomachs. We should teach children the importance of fresh air, good food and cleanliness, and a proper amount of sleep. In regard to fresh air: m far too many instances mothers have a positive dread of open windows and of draughts. It is, however, very important that rapidly growing children should have as much fresh air as possible. This should be taught in a practical way in the school- room itself, by using every possible means for good ventilation, by opening the windows wide during all recess intervals, and by inteiTupt- ing hours of study by short intermissions during which the children are given breathing exercises with the windows wide open. The fact should be emphasized that night air is not dangerous. The fact that we are all spending one-third of our lives in sleep, and that during this one-third, which is the period used for building up the body and making good the losses sustained during the day^s work, it is most important that the body should have fresh air in large amounts, should be taught. A large amount of sleep in the growing period is important. All this should be emphasized. The question of proper food should be considered. The use of tea and coffee and other stimulants among children, especially of the poorer classes, is extremely common, and does a great deal of harm. Tlie dan- gers of this should be taught. The importance of bathing should be made clear. Children, and < 19 through them their parents, should be made to see that the morning bath is not only for cleanliness, but also to stimulate the body and mind for the work of the day. Every child should be faught as soon as possible to take a sponge bath in a warm room every morning. The proper care of the teeth should be emphasized, and the dangers of neg- lecting to care for the teeth constantly impressed upon the children. There should, whenever possible, be active co-operation between the teachers and medical inspectors; for the teacher, who sees the children constantly, can note the signs of failing health far more accurately in many cases than the physician, who sees the child only occasionally. VI. The treatment of consumption first of all is by so living that the body does not acquire the disease; therefore, the ideal method of treat- ment is by prevention. This, however, is not possible in every case, and there are unfortunately a great many people, as has been shown, who have this disease, for whom active measures in curing it or stopping its progress must be taken. Treatment is not by means of drugs or medicines. Especially one should avoid patent medicines and advertised cures of all kinds. Treatment consists in giving the patient fresh air day and night, proper food at the proper time, and rest. This is done either in the home or in institutions built for this purpose, called tuberculosis sanatoria. Massachusetts was the first State in this country to have a State sanatorium. The Massachusetts State Sanatorium is a large institution, which holds three hundred and fifty patients, situated in the center of the State, in Rutland. Here patients in the early stage of consumption, which is the curable stage, are taught how to live out of doors in comfort; how to sleep out of doors at night, or in open-air wards or rooms winter and summer; what food they must eat; the amount of exercise or rest they must take; and the precautions they must use in earing for their sputum, to avoid giving others this disease. Such sanatoria exist in most civilized countries to-day, and more are being established every year. The average length of stay is six months to a year. From sixty to seventy per cent, of those in the early stage of the disease leave the sanatorium at the end of this time apparently cured. The fact should be emphasized that it is no longer considered neces- sary for a consumptive to go to a different climate or to some distant place in order to get cured of the disease, for, although certain climates are of value, consumption is being cured in New England every day. It is important to remember, however, that but a small percentage of these consumptives are in a position financially or otherwise to go to a sanatorium for treatment. A gTeat majority of sufferers from this disease must be taught how to live in their own homes; and at present the so-called home treatment of consumption is meeting with a great deal of attention. ) 20 Teachers of our public schools have a great opportunity to instruct the children with whom they come in contact, young and old, in the principles of tliis treatment ; and it is important to always bear in mind that fresh air night and day, sunlight, cleanliness, bathing, plenty of plain, nourishing food, are the things on which the treatment of con- sumption is based; and, further than this, that these are the essential conditions in obtaining and preserving good health and in avoiding a gTeat many other kinds of diseases. The actual details of the open- air treatment of consumption may well be left to the physician or nurse. VII. It is important that teachers should realize that the earliest sign of consumption is not necessarily the so-called hacking cough, hemor- rhage from the lungs, or the presence of night sweats and fever. These frequently do not appear until comparatively late in the disease. The earliest signs, in children especially, are those of failing health, from whatever cause. In the first place, the teacher should be told or should find out what children in the class have consumption in their family, and should give special attention to these children. Loss of appetite, weakness, languor, listlessness, are among the early signs. Pallor, marked anaemia, loss of weight, excessive emaciation, the presence of enlarged glands in the neck, are indications that there is something wrong. If in addition to this there is a cough, with or without any sputum, the child should most certainly be examined by a physician. VIII. The campaign against tuberculosis in Massachusetts is along two lines ; first, that which is being done by sanatoria and hospitals; second, that which is being done outside of these institutions by physicians, boards of health, anti-tuberculosis associations, etc., in teaching people how to live in their own homes. At present Massachusetts has certain State institutions, such as the State Sanatorium at Rutland for early eases, the three hospitals for ad- vanced cases which are being planned by the Massachusetts Commission on Hospitals for Consumptives, and numerous private institutions. In addition to this, and of still more importance, is the work which is being done by the medical profession throughout the State and by the various anti-tuberculosis associations, lay and medical, which have been formed in all of the large cities and in many of the smaller cities and towns of Massachusetts. It is by these agencies that the prevention and control of tuberculosis is being accomplished. By means of tuberculosis clinics and district nurses we are finding out the innumeral)le cases of consumption in the homes, in the tenements and in the factories of our State. The early cases are urged to go to the State Sanatorium at Rutland ; projier hospital accommodation is ol)tained for the advanced cases, or they are taught how to live in their own homes. The masses of the people 21 are educated by means of lectures, exhibits, cards and signs, etc.; boards of health are stimulated to take proper measures as regards disinfection; and physicians are persuaded to report their cases of consumption as they do their cases of scarlet fever. Most important of all, the general public is aroused to realize the importance of the subject. One of the most efficient means of instructing the public, and school children as well, in regard to tuberculosis, is by means of the travelling tuberculosis exhibit which goes from city to city throughout the State. It is very important that when this exhibit appears arrangements should be made by which teachers and school children of all grades should attend, and receive definite instruction as to what the various charts, photographs, models, etc., mean. Such an exhibit will be found an ob- ject lesson of verj^ great importance, and a means of emphasizing the points which have been given in previous instruction in the schools. IX. The following books, or most of them, can be found in the public libraries, in the travelling library of the Massachusetts Federation of Women^s Clubs, or should be provided by the local anti-tuberculosis association, and some at least should be provided by the school com- mittees for the use of the teachers. Further information can be ob- tained at any time by applying to the Massachusetts Commission on Hospitals for Consumptives, 3 Joy Street, Boston, or to the Boston Association for Relief and Control of Tuberculosis, 4 Joy Street, Boston. In almost every ease local physicians can give additional in- formation. List of Books. “ Tuberculosis as a Disease of the Masses, and how to combat it,” by Dr. S. A. Knopf. (This can be obtained from “ Charities and the Com- mons,” 105 East 22d Street, New York, at 25 cents a copy.) “ The Cause and Prevention of Consumption,” a circular issued by the niinois State Board of Health. “ Consumption and Civilization,” by John B. Huber, a large book, going into very minute detail on this subject. (It can probably be found in the public libraries, and can be bought at any large book store.) “ The Prevention and Cure of Tuberculosis,” a collection of articles of a popular character on the subject of tuberculosis, by the leading men in this subject in this country; compiled by Joseph R. Long; published by H. M. Brinker, Denver. This is an excellent series of essays, covering the whole ground very completely, and can be secured of any bookseller. Pamphlet of information on the subject of tuberculosis, issued by the Boston Association for Relief and Control of Tuberculosis, which can be obtained on application at the office of the Association at a nominal price. Several school text-books on physiology and hygiene contain valuable chapters on tuberculosis. Information concerning these may be ob- tained from the publishers. 22 c Printed Pules of Health. The following rules of health have been prepared bj the Edu- cational Department of E'ew Jersey, and furnished to all the schools : — How TO KEEP WELL AND PREVENT CONSUMPTION. Air. Fresh air and sunshine are necessary to good health. Cold or damp fresh air does no harm if the skin is kept warm. Night air is as good as day air. Breathe only through your nose. Avoid hot, .crowded, dusty, dark or damp rooms. Breathe deeply and throw back the shoulders frequently. Food. Live on plain food, and eat regularly. Eat slowly, chew thoroughly, and avoid fried food. Drink water freely (not iced). Have your own cup if drinking fountains are not provided at school. Exercise and Rest. Regular exercise is. essential to good health. Go to bed early, and sleep with the windows open. Never sleep in a damp bed. Clothing. Wear only loose clothes. Wear no more clothing than you need for warmth. Never sit with wet feet or in damp clothing. Cleanliness. Consumption and other diseases are spread by careless spitting. Spittle on the floors of rooms, halls, stores and cars will certainly be breathed in the form of dust. Keep clean. Wipe and dry the body quickly every day. Keep your finger nails clean, and wash your hands and face before you eat. Clean your teeth after each meal and before going to bed. Never hold money, pencils, pins or other things in your mouth. Never lick your fingers while turning the pages of a book or count- ing money. All children should obsen^e the preceding rules, both for their own sake and for the sake of others. They are necessary safeguards against ( 23 other dangerous diseases besides consumption. Nearly all children’s diseases are infectious. The foregoing rules have been approved by the State Board of Health and the State Board of Education. Teachers are requested to make them as effective as possible. C. J. Baxter, State Superintendent. Trenton, N. J. More specific than these are the rules prepared by Dr. S. A. Knopf of Kew York City, entitled Simple Rules for School Children to prevent Tuberculosis.’’ Do not spit except in a spittoon, a piece of cloth or a handkerchief used for that purpose alone. On your return home have the cloth burned by your mother, or the handkerchief put in water until ready for the wash. Never spit on a slate, floor, playground or sidewalk. Do not put your fingers into your mouth. Do not pick your nose or wipe it on your hand or sleeve. Do not wet your fingers in your mouth when turning the leaves of books. Do not put pencils in your mouth or wet them with your lips. Do not hold money in your mouth. Do not put pins in your mouth. Do not put anything in your mouth except food and drink. Do not swap apple cores, candy, chewing gum, half-eaten food, whistles, bean blowers, or anything that is put in the mouth. Peel or wash your fruit before eating it. Never sneeze or cough in a person’s face. Turn your face to one side or hold a handkerchief before your mouth. Keep your face, hands and finger nails clean. Wash your hands with soap and water before each meal. When you don’t feel well, have cut yourself, or have been hurt by others, do not be afraid to report to the teacher. Keep yourself just as clean at home as you do at school. Clean your teeth with tooth-brush and water, if possible, after each meal; but at least on getting up in the morning and on going to bed at night. Do not kiss any one on the mouth or allow anybody to do so to you. Learn to love fresh air, and learn to breathe deeply and do it often. Out-door Class in Boston. The following account of an effort to provide healthful con- ditions for school children exhibiting signs of incipient tuber- culosis has been furnished by Mr. Walter E. Kruesi, secretary ) 24 of the Boston Association for the Belief and Control of Tuber- culosis : — Examination of the families of persons applying at the Tuberculosis Clinics in Boston was started at the instance of the Boston Associa- tion for the Relief and Control of Tuberculosis in January, 1907. The first 1,200 children examined revealed 100 cases of tuberculosis, mostly incipient. These children were attending the regular public schools. As the incipient cases are not contagious, they were not a source of danger to their schoolmates, but their school records show that they were too unwell to absorb the education which was provided. This, therefore, represented a waste of thousands of dollars per year. FurtheiTuore, the average school ventilation conditions and the pres- sure of the school work was distinctly detrimental to them. There was absolutely no institution or other provision for such children in this State. Turning to find out what others were doing, the Boston Asso- ciation studied the forest schools provided for this class of cases by many of the German cities and the outdoor schools provided in England. In these schools the children admitted are sent every day to the open country nearest their homes, and are there provided with proper clothing and school benches set down in the open. During storms the benches are moved under a canopy roof. There is no further shelter The children are properly fed during the day, and the curriculum is modi- fied by the introduction of therapeutic exercises, rest periods and otherwise, as indicated by scientific study of the needs of the group. The association’s secretary proposed last winter that a similar school should be organized in Boston. Finally on the 16th of July it was opened as a day sanatorium and school of outdoor life on the grounds of the proposed Robert Brigham Hospital, Parker Hill, Roxbury. This situation had been previously used to good effect for an adult day san- atorium. A simple building was built, containing two dressing rooms and lavatory with a large shower bath between, an open kitchen, pantry, and platform for a large tent to be used for a shelter in storms and as a dining room. Three 10 by 12 tents were provided for the cook, handy man and tools and supplies. A garden 3 by 7 feet was laid out for each team of two children. There were also three central flower gardens. In these were planted seven varieties of vegetables and ten varieties of flowers. Small plants were put in because of the late- ness of the season, and in order to give the children an encouraging start. The schedule of the day began with assembly and the raising of the national and health flags, then ablutions, breakfast, brushing of teeth. After an hour’s work in the garden and an hour’s class in study of the lessons of the need of living things for oxygen, good food, sunlight, elbow room, etc., they again became active in free play. Washing up for dinner quieted them, and after again brushing < the teeth, all were required to rest or sleep for an hour. The after- noon routine was similar. At the end of eight weeks all of the chil- dren had gained in weight, had made marvelous improvement in ap- pearance and manners, while the tuberculosis of 8 had been definitely arrested. Every garden had succeeded in every crop. One child’s family had moved out of the worst part of town to good quarters, while others had materially improved their surroundings. Lest the gi’eat gain which had been made should be lost, the school board was requested to organize a special class, made up of these children and others admitted to take the place of the discharged. An especially fitted teacher was selected for the work, and is now con- ducting it in the unheated tent. To provide against the exposure, every child is given a waterproof canvas bag lined with blanket. Each child has also been provided with an especially warm overcoat and other necessary clothing. The teacher reports that the children are making satisfactory progress in keeping up with the work which they ought to do were they in the regular school. The city of Boston is mak- ing an effort to provide the school with a proper building for shelter duiing bad weather, and in order that the efforts already so well begun may be placed on a safe basis for continued development. Playgrounds. The playgrouiid movement is a part of the general effort to improve the conditions for the physical and mental growth of children, and it seems now to be the most popular part. In 1908 the Legislature passed the following act, knotvn as chapter 513, Acts of 1908 : — An Act to provide for public playgrounds in certain cities and TOWNS. Section 1. Every city and town in the commonwealth having a pop- ulation of more than ten thousand, accepting the provisions of this act shall, after the first day of July in the year nineteen hundred and ten, provide and maintain at least one public playground conveniently lo- cated and of suitable size and equipment, for the recreation and physical education of the minors of such city or town, and at least one other plaj^ground for every additional twenty thousand of its population. Section 2. Cities and towns may appoint, and determine the com- pensation of, a qualified supervisor of each playground, who shall direct the sports and exercises thereon. Section 3. In cities and towns where the provisions of this act are not already satisfied, land for the purpose aforesaid may be taken, and the money necessary to pay for such land may be raised in accordance with sections nineteen, twenty and twenty-one of chapter twenty-eight 26 of the Revised Laws; and any land owned by the city or town may be set aside by vote of the city council, or of the board of selectmen, for the purposes of this act. Section 4. In cities and towns which have a population of more than ten thousand, and which have not already satisfied the provisions of this act, the following question shall be placed on the official ballot at the next city or town election : — Shall chapter of the acts of the year nineteen hundred and eight, requiring certain cities and towns to provide public playgrounds, be accepted by this (city or town) ? Section 5. This act shall take effect in any city or town to which it applies upon its acceptance by a majority of the voters voting as aforesaid. Under the referendum provisions of this act it was subjected to popular vote at the December elections in 25 cities. The vote was as follows : — Yes. No. 1 Yes. i No. ! Beverly, 2,139 703 Melrose, 1,386 452 Brockton, . 7,468 1,046 New Bedford. 7,107 1,187 Chicopee, 1,445 754 Newburyport, 1,746 770 Everett, 2,102 248 North Adams, 1,217 1,383 Fall River, . 10,940 1,484 Northampton, 1,140 1,236 Fitchburg, . 3,539 761 Pittsfield, 3,783 727 Gloucester, . 2,489 920 Quincy, 3,002 933 Haverhill, . 4,825 1,116 Salem, 5,129 606 Holyoke, 5,047 787 Springfield, 10,342 1,006 Lawrence, . 7,533 1,406 Taunton, 4,181 910 Lowell, 10,283 2,424 Woburn, 1,994 437 Lynn, 11,122 1,083 Worcester, . 13,626 4,557 Marlborough, 2,064 463 These figures are mainly from newspapers, and subject to slight errors. The acceptance of this act is only the beginning. There will be needed a campaign of education to secure under tlie law a sufficient number of grounds suitably located, adequately equipped and properly supervised. The supervision should be by the school authorities or some other non-political organization. 27 School Instruction in Hygiene. While the public under the medical inspection law is doing so much for the schools, the question is a reasonable one, What are the schools doing in return ? ’’ It were foolish to go on year after year hunting for troubles and always finding them, spending public and private money in curing defects, without undertaking to go deeper and strike at the roots. We ought to be able to look forward to a reduction in the number of disabled children, and to the eradication of many if not of most of the diseases and defects. The physical defects and disabilities from which the children are suffering are in the main due to ignorance of the laws of health. Parental neglect is not wilful. The relation to health of personal cleanliness and household sanitation, of food and air and light and sleep, is very imper- fectly understood. Public education can have no worthier end than to promote public health. To do this effectively, the much-neglected and much-abused study of physiology and hygiene will have to be given a more prominent place in the curriculum of all schools. Even the three P’s ” are not more essential. To the prejudice created by the unwise efforts to confine all the school instruction in physiology to the effects of alcohol and tobacco is due much of the neglect. There is needed everywhere an increased amount of time for the study, more sympathetic and judicious instruction, and a more studied effort to bring the schools and the parents into co-operation for the forming of better habits by the children, and for more sanitary conditions in the homes. 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