Glass. Book- COPYRIGHT DEPOSIT HEALTH AND THE SCHOOL A Round Table BY FRANCES WILLISTON BURKS AND JESSE D. BURKS DIRECTOR, BUREAU OF MUNICIPAL RESEARCH, PHILADELPHIA WITH AN INTRODUCTION BY FRANK M. McMURRY PROFESSOR OP ELEMENTARY EDUCATION TEACHERS COLLEGE, NEW YORK D. APPLETON AND COMPANY NEW YORK CHICAGO .^'^I'J'^ v^ ^' Copyright, 1913, by D. APPLETON AND COMPANY -n )CI.A3 512 26 '1 TO AMERICA'S MOTHERS AND TEACHERS GUAHDIANS OF A NATION'S STRENGTH INTRODUCTION Recent years have witnessed notable advances in our comprehension of the conditions governing the health of children. We have been astonished at the number of de- fects found among them; we have received new convic- tions in regard to provision for air and play ; and we have become acquainted with better methods for warding ofif disease. Nor is our attitude on this whole matter by any means so theoretical as it was even a few years ago. Indeed, the extent to which all this knowledge is finding applica- tion, in communities of all sorts, is striking. Herbert SpcLci . charge that people were generally far more in- terested in the health and general care of their horses, cattle, and hogs than in that of their children will hardly hold much longer. And it seems likely that good health will soon rank £rst, in the minds of teachers and parents, among the things that make up a good educa- tion. The realization of this promise will mark a revolution in the practice of the schools ; for, in times past, they have really, if not consciously, sacrificed health for the acquisition of knowledge. Training institutions for teachers have even been among the worst offenders in this respect. But observation is teaching us that, while neither knowledge nor health can be wholly neglected, the former is far inferior to the latter as a condition of vii viii INTRODUCTION success. School instruction in physiology and hygiene is still almost a farce, to be sure; but a better time is in sight. In consequence of the striking advances in this field, there is pressing need of literature that summarizes both the theory and practice at present accepted, and in a style making the facts thoroughly clear and interesting to the ordinary reader. The present volume helps to meet this need in a most effective way. It accomplishes three things : From widely scattered sources it brings together the theoretical facts pertaining to health, that seem well established, and that are most valuable ; it suggests how these facts have been applied, and, to some extent, shows the extent of that application up to the present time; and it presents all this matter in a surprisingly simple and attractive man- ner. While excellent judgment seems to have been shown in determining what should be presented, the style of presentation is specially worthy of attention. The method is conversational, the subjects of conversation being just such questions and objections as the thought- ful, really interested, but perhaps skeptical person would desire to ask; and these are answered in a remarkably direct and convincing way. F. M. McMuRRY. Teachers College, Columbia University, New York City. PREFACE The present widely aroused interest in matters of health has developed a great need among teachers and parents and public officials for practical guidance. The sickness and health of children are not really controlled by fate and the doctors, as many parents and teachers as- sume, but by those who regulate the daily conditions un- der which children live — parents, teachers and govern- ment officials. If these controlling powers are not thor- oughly informed and intelligently alert, no amount of national agitation and legislation will secure the health of children. It is comparatively easy for people with no technical training to learn a few fundamental matters concerning health — what normal health is, the conditions essential to its maintenance, the detection of many organic defects, the approach of acute diseases, and the effect upon indi- vidual children and their associates of allowing remov- able defects and diseases to continue. This book sets forth the health problems which must be met in every school and family, and furnishes a work- ing program for parents, teachers, school boards and boards of health. The material has been put in the form of conferences such as might take place in any town which is success- fully solving the problems connected with the health of its children. While most of the problems under discus- sion are focused in the school and the home, the people X PREFACE taking part in the conferences are not limited to teachers and parents. The health of children is a concern not ex- clusively of anxious parents or faithful teachers, neither of which groups has yet been very successful in securing it. Healthy children are vitally needed by the whole community which has to exert its highest intelligence and power to produce them. In the following conferences the zeal of teachers and the solicitude of parents are supplemented by the scien- tific knowledge of a physician, the experience and sym- pathy of a social worker, and the practical sense of a suc- cessful business man. The characters are not of course transcribed from life, nor is it claimed that the investigations and reforms cred- ited to them have as yet all taken place in a single town. Each one, however, has taken place in some town. Every statistical item reported has been secured through actual investigation, in various cities and states. The time has come for such scattered investigations and reforms to be included in the health program of every town. Many communities realize this, but are un- certain how to begin their novel task. It can only be accomplished through groups of active citizens for whom the conference method in this book may serve as a sug- gestion for procedure. ACKNOWLEDGMENT Grateful acknowledgment is made to the following persons for criticism and constructive suggestions in the preparation of this volume : WilHam H. Allen, Director, Bureau of Municipal Research, New York, Author of Civics and Health. Frederick Almy, Secretary, Charity Organization Society, Buffalo. Ellen C. Babbitt, Child Helping Department, Russell Sage Foundation. Alice C. Boughton, Superintendent of Lunches, Home and School League, Philadelphia. Martin G. Brumbaugh, Superintendent of Schools, Philadelphia. Richard C. Cabot, M. D., Assistant Professor of Clinical Medicine, Harvard University. Arthur D. Dean, Chief, Division of Vocational Schools, State Education Department, New York. James Mapes Dodge, Chairman, Link-Belt Company, Philadelphia. Samuel T. Dutton, Superintendent, Horace Mann School, Teachers College, New York. Edward C. Elliott, Director, Course for the Train- ing of Teachers, University of Wisconsin. Luther H. Gulick, M. D., Director, Department of Child Hygiene, Russell Sage Foundation. xii ACKNOWLEDGMENT Samuel McC. Hamill, M. D., Professor of Diseases of Children, Philadelphia Polyclinic Hospital and College for Graduates in Medicine. W. W. Keen, M. D., Professor Emeritus of Surgery, Jefferson Medical College, Philadelphia. Frank M. McMurry, Professor of Elementary Edu- cation, Teachers College, New York City. Rudolph R. Reeder, Superintendent, New York Orphanage, Hastings-on-Hudson. Ella Flagg Young, Superintendent of • Schools, Chicago. Acknowledgment is also due to the following, for the use of illustrations : Board of Recreation, Philadelphia; Bureau of Health, Philadelphia ; Bureau of Municipal Research, Philadel- phia; Child Hygiene Association, Philadelphia; Depart- ment of Health, Chicago; Home and School League, Philadelphia ; Horace Mann School, New York City ; National Cash Register Company, Dayton, Ohio; New York Orphanage, Hastings-on-Hudson; Playground and Recreation Association of America ; Review of Reviews, New York ; Russell Sage Foundation, New York ; Sey- bert Children's Village, Meadowbrook, Pa. ; Society for the Relief and Prevention of Tuberculosis, St. Louis ; State Board of Health, Virginia ; Taylor Instrument Companies, Rochester, New York ; The Detroit Saturday Night, Detroit, Michigan; World Book Company, Yon- kers. New York. CONTENTS PART I THE BREAKDOWN OF THE SCHOOL IN ITS HEALTH PROGRAM PAGE I. Are Education and Health Incompatible? Are our schools and homes producing healthy or defective children? — Should the schools add responsibility for health, and thorough training in hygiene, to their al- ready numerous obligations? — If the aim of education in school or home is to prepare adequately for the efficient life of which health is an indispensable factor, is not the home or school that does not secure the highest possible degree of health and vitality for its members a failure? ......... i II. Health Census of a School Astounding number of pupils found with removable defects, — adenoids, enlarged tonsils, decayed teeth, impaired vision, spinal curvature, anaemia, malnutrition, etc. — An account of these defects and the resulting func- tional derangements — poor assimilation, nervousness, fa- tigue 12 III. Sanitary Inspection of a School Building Sanitary conditions described, — ventilation, heating, lighting, drinking and toilet arrangements, cleaning of building, adjustment of desks, etc. — Means of correcting faulty conditions. — Standards of sanitation summarized . . 29 xiv CONTENTS IV. A School Child's Day PAGE A study of the daily program: number of hours of work, rest, exercise, and recreation desirable. — Necessary alter- nations of kind of work and of work and rest . . 55 PART II THE OPPORTUNITY OF THE SCHOOL FOR PRO- MOTING HEALTH V. Cooperation with Parents in Securing Medical Aid Cooperation between school and home indispensable. — School and health boards in need of authority to re- quire necessary treatment. — General education a more fundamental corrective than general coercion. — Meth- ods by which health officers, teachers, and enlightened parents can enlist the cooperation of ignorant or indif- ferent parents, — home and schools associations, public lectures, bulletins, exhibits, personal visits . • • 77) VI. Provision for Medical Aid Really expert medical service now available only for the very rich and the very poor. — Dangers of mediocre medical service and the need for adequate expert service for families of moderate income. — Experience of life insurance companies in furnishing free medical advice and treatment. — Plans for cooperation in securing com- petent medical, surgical, and dental service. — Drift toward public medical service ..... 84 VII. Teaching Children the Art of Health Training children in the knowledge and practice of health laws and safeguards one of the most important func- tions of the school. — Scope and methods of instruction CONTENTS XV PAGE in hygiene and sanitation. — Sex instruction essential. — Psychological factors involved in successfully estab- lishing health habits, — example, motive, practice . . 103 VIII. Health Supervision in Schools Five functions included in school health supervision, — medi- cal inspection, examination, and treatment; sanitary su- pervision of school buildings and homes ; hygienic regu- lation of school and home activities; health instruction of pupils and parents; physical education of children. 128 IX. Scientific Management in Health Supervision Study of an actual medical and sanitary inspection system, and applications of efficiency tests. — Competent physi- cians and a well-devised plan not sufficient guarantees of effective work. — Accurate information regarding work done and results accomplished the basis for effec- tive supervision . • 147 X. Red Tape Plan and forms for recording and summarizing facts re- garding physical examinations, recommendations for treatment, treatment obtained, inspection of school plant. — Method of using such records for directing and controlling inspection service ..... 174 PART III A PROGRAM OF CHILD HYGIENE XI. Health Begins at Home The home as active as the school in producing physical de- fects of children. — Children in a large proportion of homes defective. — Parents generally unaware that it is necessary to study and practice child hygiene in bring- ing up children. — Account of actual cases typical of the xvi CONTENTS PAGE common failure of parents to realize that what seem grave constitutional defects are merely the result of vio- lation of health laws, — ill-selected or superfluous diet, imperfect mastication, bad ventilation, insufificient exer- cise or rest. — Responsibility of the family physician for teaching hygiene to his patients. — The underlying prin- ciples of wholesome living, simple and few . . . IQi XII. Air Air the most vital of physical necessities. — Much fatal illness due to unwholesome air. — A fresh-air regime necessary for the health of children. — How to secure it — sleeping porches, window tents, outdoor schools, proper house ventilation 203 XIII. Food A specially selected diet necessary for children. — Necessity of making this highly nourishing and digestible. — Proper balance of food elements. — The value of various common articles of food. — Suggested menus providing food elements in proper proportions .... 217 XIV. Clothing Comfort and cleanliness the two main considerations. — Clothing that protects sufficiently but neither constricts nor oppresses. — No arbitrary standard of children's clothing possible. — Choice to be intelligently made ac- cording to climate and vigor of children. — Use of the thermometer in regulating dress 233 XV. Playgrounds Excessive housing, a danger of modern civilization. — Out- door play essential to children's healthy growth. — How to secure it. — Provision made for playgrounds in vari- ous cities. — The playground movement .... 243 CONTENTS xvii XVI. Health Habits PAGE Habits that promote personal health. — Physical habits : breathing, eating, elimination of waste, exercise, pos- ture, cleanliness, rest. — Mental habits : cheer, courage, self-control. — Habits that promote community health : practices that prevent the scattering of unclean matter and disease germs ....... 259 XVn. Calling the Doctor How to choose a physician. — Choice to be based upon the adequacy of his training, his professional standards, methods, and activities, and his acknowledged success. — — When to call a physician. — The meaning and gravity of certain symptoms ....... 283 XVni. Health Problems in Children's Institutions The discussions in the preceding chapters all applicable to conditions in children's institutions or boarding schools, — additional problems involved in such institu- tions. — Methods of counteracting the undesirable efifects of herding children together night and day. — How to avoid contagion and the devitalizing eflfect of routine. — Institutional diet, clothing, and recreation . . 298 PART IV SOCIALIZED HEALTH: A FORECAST XIX. The Relative Cost of Health and Disease Every step in the conquest of disease attended by an enor- mous saving in money and in human happiness. — Money efficiently spent for health conservation a highly paying investment. — Economics of disease prevention 2 xviii CONTENTS PAGE illustrated in Panama. — Health supervision in schools a fundamental and economical means of developing good health, and standards of healthy living, among all the people ......... 316 XX. Compulsory Health Health important not merely to the individual and his fam- ily but to the community ; therefore a civic obligation as well as a right. — The work of home and school often undone by the failure of health officials to pro- tect the community from contaminated water and milk, unsanitary streets, sewers, public conveyances, smoke, etc. — The health problem of a community, of which school health supervision is but one part, to be consid- ered as a whole, each activity to be supplemented and supported by all the others. — A forecast : Every child with a sound physical inheritance and, from babyhood up, kept free from preventable defects and diseases. — Extermination of contagious diseases. — Sanitary school- houses, playgrounds, gymnasia, and swimming pools for 100 per cent, of the children. — Municipal nurses, dentists, and physicians always available to give expert advice, instruction, and treatment as desired. — Dispensaries and hospitals adequate to the entire need. — Each school a center for health instruction not only for children but for adults. — Public and private agencies working to- gether in effective cooperation. — An educated and exact- ing public sentiment demanding thorough public en- forcement of the best sanitary standards . . . 340 FULL-PAGE ILLUSTRATIONS FACING PAGE / "Health and Happiness" ....... 52 "There's No Fun Like Work" and "What Are They Rais- ing?" 60 "Baby Saving Show, Philadelphia" ..... 200 "Good Cheer and Health at Three Cents" . . . 218 '■' "Hitting the Health Trail" and "A Winter Prescription" 2,^6 - "The Eternal Spirit of Play" and "The Most Effective Argument for Playgrounds" ..... 252 "On the Toboggan to Health" and "Bringing the Beach to the City" ......... 256 "Every House a Home" ... ... 314 / PERSONS TAKING PART IN THE CONFERENCES Mr. Young. Superintendent of schools. He is trusted and admired by the whole town, and is regarded by his school board as a model of progressive efficiency. Mr. Martin. A member of the school board, also a widower with many cares. He is unenlightened, but eager to learn. • Mr. Ross. A self-made business man, satisfied with his work and with society. He is constrained by his su- perior wife to assume an active interest in all social wel- fare movements. Mrs. Ross. An awakening woman, whose husband's money has given her leisure to look around. This has aroused in her a sense of social responsibility. Miss Parsons. A social worker, whose active sym- pathies and penetrating mind command a following wher- ever she moves. Dr. Latta. a physician, new in the town. His elab- orate and spotless office equipment is the scorn of most of the old practitioners who view his new-fangled meth- ods and notable successes with jealous alarm. Health and the School ARE EDUCATION AND HEALTH INCOMPATIBLE? Mr. Young. — A profound movement, destined to ac- complish great results, is stirring our entire country. On every hand we hear the question, "How can we bet- ter our schools ?" As a people, we are finding out that popular education has not kept up with the procession. We see every day the last miracle of science or invention instantly appropriated by the industrial and commercial world. We see the efficiency of industrial institutions keyed daily to a higher and higher pitch. Why is it not so with our schools? Why do they not profit by the last scientific discovery or invention as do our rail- roads and factories and department stores? Is there no branch of science which can specially serve our schools, and whose every advance means equal ad- vance in our system of education? Though the schools have been slow to realize it, there is evidently one science, the most important of all, that is intimately con- nected with their efficiency. This science in its recent unprecedented development has benefited humanity far more wonderfully than any other. It is the science of medicine, the knowledge and control of health and dis- ease. Its discoveries lie at the service of our schools. 2 HEALTH AND THE SCHOOL Healthful schools and healthy children have suddenly become the demand of the day. I believe we can have both, if we determine to; if we are willing to act on even a part of the modern medical knowledge that is ours for the asking. Like most school men, I have been long in waking up to this vital matter, which a recent experience revealed to me with sudden force. Last week my youngest little girl came running to me to know when school was to open. As she eagerly questioned the number of days before she was to enter school, and with forty other children be crowded into a classroom for long hours of weary work for young brains and little fingers, I wondered how long her cheeks would stay rosy and the spring in her step remain. I confess to my shame that I began to question whether I could not arrange to get her into some private school, where her physical comfort and welfare would receive more careful attention than her class standing. Then an accusing thought struck me. If I could not trust my own child's precious body to the schools that are under my direction, what about the 5,000 other young bodies that are gathered in these schools every day ? As the sense of this overwhelming responsibility came upon me I was stung with remorse, for I reflected that the most we had ever done for the physical welfare of these 5,000 children was to see that the school buildings were sufficiently heated, and that contagious diseases were somewhat guarded against. While we have been patiently studying new ways of directing our long-suffering children's minds, we have never thought to find out whether the avenues to their minds were open; whether their eyes and noses and mouths and ears and brains were in shape to do business ; whether the physical conditions under which the chil- EDUCATION VERSUS HEALTH 3 dren were working were the best possible ; whether the home conditions were wholesome; whether the children were learning habits of health. We school people have already far more educational theory than we practice, but do we know anything about the theory and practice of children's health ? I would not trust my little girl's physical care to any one who knows as little about it as I do. I have always left it to her mother and the doctor; but, heaven forgive me, for eight years now I have been partly responsible for the health of 5,000 boys and girls, and what have I been doing? What have we all been doing? Leaving the matter to Providence and the parents, many of them more ignorant than ourselves. We have calmly taken for granted that the general health of the children should decline through the win- ter, and that coughs and sneezes should punctuate all the recitations from autumn to spring. We have ac- cepted as inevitable the fact that June finds the children pale and nervous and worn, as they issue from the school mill which they entered so buoyantly in September. Now, I want to know whether this physical deterioration is a necessary price of education. I wish to lose no time in finding this out, for, if it is really so, I am not willing to continue in a business that actually damages children. I need help in investigating this question. I therefore propose that we devote the year's study to the health of children, in school and home; and that to-night we try to arrive at some conclusion concerning this question : Are education and health incompatible? Mr. Martin. — If Mr. Young's earnest words were not so evidently prompted by deep conviction, I should suppose he intended his gruesome question as a joke. Are education and health incompatible? How can they 4 HEALTH AND THE SCHOOL be? Have not improved health and longer life followed step by step Mrith increasing education? Dr. Latta. — They have followed step by step with a certain form of education, that of the scientific labora- tory, which has indeed diminished disease and lengthened life; but our common schools are still producing quite reverse results, as they have always done. Mr. Martin. — I find it hard to follow you, sir; but if there is actually any ground for doubting the whole- someness of our schools, as a member -of the school board I want to know it. If my five children are likely to be physically handicapped through the very process of education I want a chance to think that over, too. Mr. Ross. — Now, before we let ourselves be carried ofif our feet by Mr. Young's enthusiasm, let us question a little the purpose of our schools. It is to teach, isn't it? Is it not stretching matters a little to demand that the schools should add to their already great responsi- bilities the care of the children's health ? Let the schools stick to their task of teaching which, with no disre- spect to anyone present, I may say they do none too well. Mr. Young. — Does Mr. Ross realize that one of the greatest single factors in keeping down the efficiency of our schools is the never-ending stream of absence, from which no class is free, and that absence in turn is largely due to sickness? If we are teaching none too well, which I grant, it is, partly at least, because we are teaching none too likely children. The sick absentees and the ailing children present are too often the pacemakers for their classes. It is not an inspiring idea. If, as Mr. Ross says, the business of the schools is merely to teach, our town will certainly not get its money's worth of teaching until the schools demand that the EDUCATION VERSUS HEALTH human material sent to them to work on is in as good condition as modern science knows how to make it. Dr. Latta. — That is far from being the case at pres- ent. Investigations under the Russell Sage Foundation - ■ ■ ■ ■ 8 YEARS 8.5 YEARS 8.6 YEARS 0.7 YEARS 9.1 YEARS 9.2 YEARS NO DEFECTS DEFECTIVE TEETH DEFECTIVE BREATHING HYPER- TROPHIED TONSILS ADENOIDS ENLARGED GLANDS THE HANDICAP OF PHYSICAL DEFECTS. The diagram shows the number of years required by defective and non-defective children to complete the eight elementary grades; according to data collected and published by the Russell Sage Foundation. indicate that not less than 6o per cent, of American school children are handicapped by removable physical defects, and that, as a result, they are making 9 per cent, slower progress in their studies than they should. Children with seriously defective teeth, according to these investigations, fall six months behind in eight 6 HEALTH AND THE SCHOOL years. Half the school children of the nation— ten mil- lion — have bad teeth. Children with adenoids require a year and a month of extra schooling to complete eight grades. One-eighth of our twenty million children have adenoids. Children with enlarged glands require a year and two months over time. Nearly half of our chil- dren have enlarged glands. How much longer are we going to tolerate this enormous and unnecessary waste of time and educational effort, to say nothing of the vitality of the children? Mr. Ross. — Oh, doubtless children attending school ought to be kept in sufficiently good health to prevent them from wasting their time or that of their teachers and classmates ; but it is for parents and health boards to see to this, and not for the schools. Give teachers any discretion in these matters, and they will begin to usurp the authority of the home. They will soon be directing us when to put flannels on our children and what to give them for breakfast. Mrs. Ross. — I, for one, should not object to such consultations with my children's teachers. They care for the children through as many waking hours as I do myself. If they do not understand the physical care of children they ought to, for the children don't leave their bodies at home. Miss Parsons. — I think that all these vexed details of what is to be expected of the schools and the teachers will clear themselves if we return to the question Mr. Young proposed, "Are education and health incompat- ible?" I haven't the least idea that they are, if we have the right idea of education. But if, as I suspect, our present form of education is not compatible with health, must we not ask what is the great purpose of education, and how are our schools failing to serve it? EDUCATION VERSUS HEALTH 7 The schools, as our special instruments of education, should undoubtedly provide or insist upon whatever makes for the best education, whether the necessary fac- tors are arithmetic books, baths, soups, or surgical op- erations. Mr. Ross. — What is the best education nowadays? It used to be a thorough knowledge of the three R's, the purpose being to enable children to get along. Miss Parsons. — Is not the purpose of education far more than that? Is it not to bring a human being to his highest possible state of healthful vitality and effi- ciency and human sympathy for the sake both of his own welfare and happiness and that of the community? Mr. Ross. — That is a beautiful thought. Miss Par- sons, but it is too much for a school to undertake. It requires educated ancestors and parents and money even to approximate such a product of sweetness and light. Neither physical nor spiritual perfection can be turned out by the gross from a public school. Miss Parsons. — But at least the product should not fall short of the Maker's pattern. If our schools cannot produce saints, or Samsons, they should, at any rate, graduate well-disposed, intelligent children, who are healthy. Mr. Martin. — Who knows that they do not? We are ready for some facts in this interesting discussion. Does our form of education damage our children, or does it not? Dr. Latta. — It does damage some of them, sir. Be- sides tolerating defects that could and should be re- moved, it produces certain ones. The impairment of vision, for instance, begins everywhere in the lower grades and continues increasingly to the top. These im- perfect eyes which the schools are making are the source 8 HEALTH AND THE SCHOOL of many constitutional ills that are not taken into account in public health reports. Headache, indigestion, nervous- ness, lassitude, and general misery are the price that a large number of our children are paying for the privi- A PUBLIC SCHOOL MAY BE A CENTER OF INFECTION AS WELL AS A CENTER OF INSTRUCTION. Every one of the twenty-two cases of scarlet fever indicated by the small circles was associated with the same school. Other schools in the same neighborhood were free from infection. This epidemic in Philadelphia was stopped when medical in- spectors located the scarlet fever carriers in the Thomas May Pierce school and put them under quarantine. lege of going to school and abusing their eyes. The eyes, moreover, are not the only organs that are injured in school, though the unscientific health inspection re- ports of many cities indicate nothing else. EDUCATION VERSUS HEALTH 9 The backs that are twisted and bent by false positions and ill-adjusted desks are not usually mentioned. Nor is the connection often admitted between the annual crop of acute diseases and the schools that cause and foster them ; the fatal diseases of the respiratory organs, caused by bad ventilation and wrong systems of heating, and the inevitable contagious diseases that every mother ex- pects to invade her home as soon as the eldest child enters school. Do you know why I aim to be back in my ofifice every year at the opening of school ? For the reason that then the harvest begins, to keep up with little abate- ment till school closes in the summer. Mrs. Ross. — Has not the cold weather of these months as much to do with the increased sickness of the chil- dren as their school attendance. Dr. Latta? Dr. Latta. — Only in this way — that, as soon as frost comes, the windows in the schools, and in many of the homes, too, are practically sealed up. The children are forced to breathe unwholesome air, and the germs do the rest. The winter months should be the most health- ful of all the months in the year. The cold, clear air, free from many of the summer germs, is the best tonic we know, but we grudge it to our children both in school and home. At this point let me say that we must not lay all the ill health of our children to the school. The home is quite as responsible for it, and should come in for its full share of investigation; for, if there is one place less scientific than the school, in the care of children's health, it is the average home. Mr. Martin. — Returning to what Dr. Latta said of the medical inspection reports, his remarks seem to me to have little bearing on our local health question, since lo HEALTH AND THE SCHOOL we have no medical inspection in our town. For aught we know the condition of our school children is better than that of children in other towns. Mr. Young. — True — and, for aught we know, it is worse. We ought to know whether it is or not. We cannot let civic pride take the place of information on this subject. Miss Parsons. — Is not the purpose of our club to gather and use just such information? Shall we not arrange with the help of competent physicians to find answers to the following questions : 1. What is the present physical condition of our school children? How can it be improved? 2. What are the conditions under which the children are living and working in home and school? How can these conditions be improved? 3. How can we enlist the teachers, the parents, and the children of this town in a children and health for- ward movement? Mr. Young. — You have offered us a valuable pro- gram, Miss Parsons. In carrying it out our club will render a great service to the town. As our time for closing is at hand, I will sum up in a few words the result of our evening's discussion : Dr. Latta has made it clear that education, as it is now conducted in the public schools, is actually incom- patible, at many points, with the health of our children. Not only are the schools failing to foster and develop health, but to some extent they are undermining it. There seems further to be an agreement on these fundamental matters : That the aim of education in school or home is to prepare adequately for an efficient and well-poised life. That health is an indispensable factor in such a life. EDUCATION VERSUS HEALTH ii That there is no duty more pressing in the school or home than that of securing the best health possible for children. Suggested Reading Allen. Civics and Health. American School Hygiene Association. Proceedings OF THE Fifth Congress. What Our Cities Are Doing for the Health of Our Children. GuLiCK and Ayres. Medical Inspection of Schools, 1913- Hogarth. Medical Inspection of Schools, Chapters HI- VI. Russell Sage Foundation. Money Cost of Repetition Versus Money Saving through Acceleration. The Relation of Physical Defects to School Prog- ress. II HEALTH CENSUS OF A SCHOOL Mr. Young. — "The schoolboy with his shining morn- ing face" has stood for generations as a symbol of the happiest, healthiest life in the world. How does this child of the poet's fancy stand up under scientific in- vestigation? What is his status in our town? We have been making a few inquiries about the shining appari- tion. Miss Parsons will report the result. Miss Parsons. — I shrink from saying anything to take the shine off; and were it not for the hope of convert- ing the poet's fancy into actual truth I should much prefer to cherish, undisturbed, the illusion of his highly vitalized schoolboy. As a matter of fact, however, we have found few traces of this boy. Eight or nine in every ten of our school children need either the doctor or the dentist or the oculist. Mr. Ross. — Impossible ! Miss Parsons. — So I should have said a month ago-, but our investigation has left no room for question. It is true that we have thus far investigated only one school, our purpose being to develop experimentally a model for further work in the entire school system ; but the Washington school which we chose is typical of all the other schools in town, apd for that matter probably of schools throughout the country wherever communi- ties have been as backward in school health matters as we have. 12 HEALTH CENSUS OF A SCHOOL 13 Dr. Latta. — That means almost sixty per cent, of our cities, and even more of our country communities. Miss Parsons. — The actual work of examining the children was done by three of our best known and most trusted physicians. After careful con- sultation they de- cided exactly what standards of health to follow, just what defects to look for. In a number of cases all three phy- sicians examined the same child, to make sure that all were accurately observing the same standards. I mention the con- scientious care taken by these phy- sicians to make it possible for you to believe their incredi- ble report. PHYSICAL RATING OF 20,000,000 SCHOOL CHILDREN IN THE UNITED STATES. The dark section represents 12,000,000 children (60%) who have defects so serious as to interfere materially with their physical growth and to retard their school progress by from 6 to 15 per cent. The shaded section represents 4,000,000 children (20%) who have less serious defects. The white section represents 4,000,000 children (20%) who are physically sound. [According to data published by the Russell Sage Foundation.) The general; re- sult of the investigation you have already heard. Almost nine out of every ten children in the Washington school were found in need of treatment. There is, however, a very hopeful side to this dark picture. Most of the de- fects we found can readily be corrected. Intelligence in their detection and treatment, and, most of all, in their 14 HEALTH AND THE SCHOOL prevention, can easily free the children from them, and keep them free. That makes our duty toward these chil- dren very clear. Of the 468 children examined 412 needed treatment for one or more defects. The defects themselves num- bered 879, which showed an average of 2.13 defects to each child needing treatment. The distribution of defects was as follows : CHILDREN FOUND NEEDING TREATMENT * 468 CHILDREN EXAMINED DEFECT Defective Vision Defective Hearing Defective Nasal Breathing, including Adenoids Hypertrophied Tonsils .... Enlarged Glands Pulmonary Disease Cardiac Disease Nervous Diseases Orthopedic Defects Anaemia Malnutrition Defective Teeth Defective Palate NUMBER OF CHIL- DREN NEEDING TREATMENT PERCENTAGE OFWHOLE NUM- BER EXAMINED 144 30.7 6 1.2 138 29.4 116 24.7 I 0.2 12 2.5 I .2 22 8.9 n 16.4 21 4-4 318 67.9 3 .6 Mr. Ross. — May I interrupt the proceedings to in- quire whether having all these modern defects is as * Based upon a report of the New York Bureau of Municipal Research : A Bureau of Child Hygiene, September, 1908. i HEALTH CENSUS OF A SCHOOL 15 bad as it sounds ? Why should we be so concerned about them? Toothaches and growing pains and other such uncomfortable things are necessary incidents to child- hood. We all had them once, but they soon passed by without any medical treatment. Dr. Latta. — Too many of our childhood friends passed by, too, without medical treatment, Mr. Ross. The graveyards are full of them. Mr. Ross. — But the children who died had something the matter with them, Dr. Latta. It took a fatal disease to remove a child in my day. Little walking defects that don't keep children home from school aren't going to carry them to the churchyard, are they? D'R. Latta. — Not at once, Mr. Ross, but they lead the way. Scores of children will die this year in our town, and most of them will have a record of little de- fects neglected. A decayed tooth is not so bad as a decayed appendix, but it is constantly filling the whole alimentary system with putrefactive germs. An adenoid is not so deadly as pneumonia, but it does reduce the air supply, which prevents the blood from discharging its poison. It thus invites pneumonia and the whole collection of respiratory diseases. When the fatal disease you spoke of is look- ing for a victim, what likelier one can it find than a young constitution struggling under the handicap of un- aerated blood or an alimentary canal full of decay? Mr. Ross. — That is the sort of thing I wanted you to bring out. Dr. Latta. Do you actually believe that there is a very close connection between these slight defects and the serious diseases? Dr. Latta. — I know it, sir. Mr. Ross. — Then let us hear more about them and how to rid the children of them. i6 HEALTH AND THE SCHOOL Miss Parsons. — How to rid the children of their physical defects is, of course, one of our great problems. How to prevent defects is a still more important one. We are beginning with the first problem in the Wash- ington school, and succeeding beyond our hopes. At a later meeting we shall tell of our methods and results. You will now want to hear something about the nature of the defects that were found. Dr. Latta will give us a brief account of them and of their constitutional results. DEFECTIVE TEETH Dr. Latta. — You see by the table which Miss Par- sons has just shown you that the greatest number of defects found are in the children's teeth. Defective teeth are of two kinds, malformed and decayed. I might add a third kind, missing teeth, which are piti- fully numerous. Whatever is wrong with the teeth, whether it be malformation, decay, or absence, inter- feres with their prime business, which is to chew food, and with the aid of the saliva partially to digest it. To swallow food that is not thoroughly masticated imposes an enormous strain upon the digestive organs, which never fail at some time to exact their reckoning. The first mentioned tooth defect, malformation, often does more than interfere with chewing. Protruding teeth, which keep the mouth from closing, besides mak- ing proper mastication out of the question, prevent nasal breathing — the only right way of breathing. Aside from hygienic considerations, deformed teeth are an in- tolerable social oflfense as well as a mortifying and un- necessary handicap to their possessors. We should not compel our children to view such unsightly defects HEALTH CENSUS OF A SCHOOL 17 among their companions, and we should certainly save the unfortunate children who have them from their so- cially demoralizing' effects. Mr. Martin. — Is there any help for bad cases of pro- truding teeth? Dr. Latta. — Assuredly. A good orthodontist can completely make over the shape of a mouth ; but unfor- PHYSICAL COMELINESS A PERMANENT ASSET. Every child has a right to be relieved of the unnecessary handicap of removable physical defects such as distorted jaws and teeth. The drawing shows results actually brought about by an ex- pert dentist. tunately the technique of teeth-straightening is not given much attention in most of our dental colleges and there are few men really skilled in the art. On the other hand there is no defect in teeth that is easier to avoid by pre- ventive measures than the unnatural protrusion of the upper teeth. I shall say more about this matter when I speak of adenoids. i8 HEALTH AND THE SCHOOL Decayed teeth need little description. When the decay is advanced, they proclaim themselves by their offensive odors and are easily recognized by any one who takes the trouble to look at them. I have already alluded to them as serious sources of intestinal infection. Few people, however, realize that they are. Everybody is a little careful not to eat decayed food if he can help it, but what earthly good comes of this precaution when decay is already present in the mouth ? Mr. Ross. — Only today I happened to hear that the best professional ball players put the same value on sound teeth that you do. The manager of one of our leading teams has announced that he intends to take a dentist along with him on his annual Southern training trip. He says he has found that most of the stomach troubles which bother young players are entirely due to poor teeth. Dr. Latta. — Those men know they can't play good ball with poor teeth. Let us see now what happens when decay goes so far as actually to destroy the teeth. When a deciduous or baby tooth goes prematurely, the result is often shown in a malformed jaw and imper- fect second teeth. That is bad enough, but when a per- manent tooth is lost its owner has parted forever with a good-sized block of his vital securities. Undue work is thrown on his other teeth, the teeth in his impaired jaw are thrown out of bearing, his whole mouth is crippled, and he limps when he chews. The stomach complains at this unfair arrangement and retaliates in the form of dyspepsia. "If I were asked to say whether more physical de- terioration were produced by alcohol or by defective teeth, I should unhesitatingly say defective teeth." This is the declaration of Dr. Osier, a world-wide medical HEALTH CENSUS OF A SCHOOL 19 authority. Sixty-eight per cent, of the Washington school children are now suffering such physical deterio- ration. Bad teeth should be tabooed in our schools, as is the presence of head lice. The latter infection is counted a disease and disgrace; but does it compare either in offensiveness or danger with the disease and disgrace of rotten teeth that are poisoning their pos- sessors and filling the air with intolerable odors ? Mr. Martin. — Your words give me great concern. Dr. Latta. I shall send all my children to the dentist to-morrow, and yet, if I were to do that every time their teeth bothered them, I couldn't afford to keep them in shoes. Dentists are too great a luxury for most people. How are the unfortunate 68 per cent, in the Washington school going to have their teeth attended to without cutting down their supply of oatmeal and overcoats? Mr. Young. — You have brought up a very serious problem, Mr. Martin. The present cost of dental work is indeed prohibitive for the great majority of people. It will have to be adjusted before vv^e can expect our school children all to have good teeth. It is a question with which our club must some day grapple. Dr. Latta. — In the meantime children can help them- selves out wonderfully by keeping their teeth clean. If the teachers and the parents had seen that they were doing this every day, there would not have been 68 per cent, of children with bad teeth in the Washington school. DEFECTIVE EYES Dismissing the question of teeth for the present, we will turn our attention to eyes, which you noticed stood second in the list of defective organs found. Many of 20 HEALTH AND THE SCHOOL these eye defects are very simple, easily detected and corrected. The inconvenience and misery that they cause are indeed out of all proportion to the ease with which they can be removed or prevented. There are four main defects of vision that give almost all the trouble. These are: short-sightedness (myopia); far- sightedness (hypermetropia) ; astigmatism, an irregular- ity in the cornea, resulting in uneven and blurred vision ; and weakness of the eyes, due to over-use, or poor light- ing and print, or low constitutional vitality. These are all alike in their results on the children. They all cause a nervous strain which shows itself in various ways — headache, stomach trouble, lassitude, irritable temper, and general nervousness. The effect of correcting eye troubles is almost magical. It is not unusual for a disposition which has been the parents' despair to be completely transformed, simply by lifting the unconscious strain from the long- suffering child. There is no treatment that can be given to school children with such ease and at the same time with such valuable results as correcting and preventing eye de- fects. ADENOIDS AND HYPERTROPHIED TONSILS Next on the list, only i per cent, below defective vision, comes defective nasal breathing. This in most schools reaches a higher percentage than does defective vision, and it is even more serious in its consequences. Defective nasal breathing is almost always due to the presence of the much-talked-of adenoid; and that in- truding nasal growth, along with the hypertrophied ton- sil, is the bane of the primary schoolroom, afflicting the younger children far more generally than the older ones. HEALTH CENSUS OF A SCHOOL 21 You observe in the table that the cases of hypertrophied tonsils were only slightly fewer than those of defective nasal breathing. The two defects very often go together, and when they do they keep their victim half stifled. This is the day of fresh air agitation. We hear much about sleeping porches, open-air camps, and even out- door schools, but the child with adenoids cannot breathe the fresh air when it is offered to him. The adenoids in the nasal cavity partly or wholly cut off the supply of air through the nose, which throws the business of in- haling air upon the mouth, a function for which the mouth was never intended. Mr. Martin. — Why not? I've heard much about the evil of mouth-breathing, but why is it really so bad ? Dr. Latta. — In the first place, it is a constant strain and discomfort to force air through the mouth, and the inhalations are ordinarily not so deep as wh^n taken through the nose which, of course, means a reduction of the air supply. Put a clothes pin on your nose for five minutes and find out for yourself some of the dis- comforts and limitations of mouth-breathing. The most tangible evidence of the harm of this practice is the surely resulting distortion of the jaws, especially the upper jaw, and indeed the entire face. The unfortunate children and grown people, too, whom you see with pro- truding upper teeth and jaws, are almost invariably vic- tims of the mouth-breathing habit. Mr. Martin. — How can such a simple thing as hold- ing the mouth open cause a change in bony structure ? Dr. Latta. — Very easily indeed. A little pressure con- stantly applied to a growing bone can modify its shape greatly. When the mouth is closed the cheeks and tongue and lips are all exerting normal and balanced pressures upon the jaws. When the mouth is open the pressure 22 HEALTH AND THE SCHOOL of the lips and the tongue is removed, the cheeks only continuing to press from either side. This results in the narrowing and protruding of the upper jaw, and to some extent, of the lower jaw, a phenomenon with which you are all painfully familiar. To continue now with the causes of defective breath- ing, when enlarged tonsils are also present they further obstruct the inhalation of air, and the process of breath- ing, which should be a delight when it is conscious at all, is a dull chronic misery. Children with breathing thus impaired show all the symptoms of partial suffocation, sluggishness of mind and body, pallor, nervousness, and a general feeling of ill will toward their companions and surroundings. Normal growth cannot go on when the blood lacks the normal amount of oxygen, and unless the obstruc- tions to breathing are removed or outgrown their vic- tims never reach full stature. In addition to those se- rious constitutional derangements, adenoids and enlarged tonsils bring about definite diseases. Their congested tissues are excellent pastures for germs. Colds and sore throats in steady procession visit the adenoid child, who is thus a constant source of infection to his school mates. While all these results seem bad enough, perhaps the very worst effects of obstructed breathing appear in the minds and characters of the affected children. It is hard for children with obstructed breathing to be good. In fact, the proportion of nose and throat defects among delinquent children is invariably much higher than among well-disposed children. One school principal of my acquaintance, when a child was sent to his office for discipline, made it his regular practice to look first into the child's mouth. He rarely failed to find the tell-tale tonsil. He does this no more, however, for, HEALTH CENSUS OF A SCHOOL 23 by enlisting the interest of the parents, he succeeded in ridding his school of both adenoids and enlarged ton- sils. The problems of discipline were removed at the same time. The four kinds of defects we have thus far discussed, those of teeth, eyes, nose, and throat, not only on ac- count of their seriousness, but on account of the great numbers in which they occur, are those of the greatest importance from the standpoint of the school. They moreover come easily under the control of school author- ities, as their corrective treatments are in general simple, and not likely to be much hindered by parental oppo- sition. It would be well to add the caution, that, while the removal of adenoids and tonsils involves but simple operations, it is of the utmost importance that these be skillfully done. No operations should be urged upon school children unless it is made sure that they will be in charge of competent specialists. The other defects in our list, while much fewer, are not slight ones either from the standpoint of the school or of the afifected children. The school cannot afford to drag along one child whose power is impaired through needless disease, and not one child can afford the un- necessary burden. ANEMIA The next disease on our list, anemia, is a scanty or impoverished condition of the blood, which shows itself by an unnatural pallor. It produces constitutional symp- toms like those caused by adenoids and defective eyes. Weakness, pains in the head, poor sight, and impaired digestion are the trials of anemic children. Work and play have little joy for them, and mere living is an ef- fort. Cases of anemia that are not caused by organic 24 HEALTH AND THE SCHOOL disease can be cured and prevented by supplying the right Hving conditions — proper food, air, and rest. ORTHOPEDIC DEFECTS The orthopedic defects come next, with a record of 9 per cent. Curved spines are the chief orthopedic AS THE TWIG IS BENT. School desks that are too high or too low cause mishapen spines. troubles that appear in schools. Many of these twisted backs are caused by wrong school conditions, ill-fitting desks, over-prolonged desk work, carelessness of posture, and neglect of exercise. The school should give special regard to orthopedic defects, with a view not only to their cure, but more particularly to their prevention. The school years, which are the growing years, make or mar the body. Like a young tree, a child's back is taking on its permanent shape. It can easily be modi- HEALTH CENSUS OF A SCHOOL 25 fied at this time, and to let it settle into a false curve is to do the child irreparable injury. He loses not only the possibility of ever attaining a fine posture and bear- ing, a most important factor in his future success and happiness, but he suffers a permanent impairment of health. No vertebra can remain turned or slipped from its proper place without setting up an irritating pres- sure on nerves or organs, which results in a life-long nervous strain, if not in actual organic disease. Defects of feet, particularly flat-foot, due to a weak or broken-down foot arch, are a condition too seldom recognized among school children. So-called growing pains in instep, sole, ankle, knee, or hip are often symp- toms of flat-foot. The condition requires thorough in- vestigation and the advice of a specialist, as chronic discomfort, stiffness, and weakness, with attendant nerv- ous strain, are the consequences of neglecting or wrongly treating this defect. MALNUTRITION Defective nourishment is next on our list. Our schools as now organized cannot be held accountable for this trouble, as they can for orthopedic and eye defects, but they should take note of all cases and set the proper agencies at work to cure them. Some cases of malnutri- tion are due to actual disease, and should be kept in the hands of doctors. Many are due to poverty, and these should be handled for the time being by charity organizations. Many, however, are due to mere igno- rance of parents as to the right diet and hygienic habits for their children. It is with such cases that the school could and should wield a strong and beneficial influence. 26 HEALTH AND THE SCHOOL CARDIAC DEFECTS Heart troubles are found in small numbers in most schools; the proportion in the Washington school being 2.5 per cent. Children having such defects should be pronounced upon by an expert and have their activities regulated under his advice, as certain forms of play and exercise, normal enough for normal children, often cause the affected children great harm. DEFECTIVE HEARING Deafness we found in 1.2 per cent, of the children. This trouble is often caused by catarrh of the middle ear, which, if neglected, may develop into mastoiditis, a dangerous inflammation in the bone behind the ear. Deafness is also caused by the presence of adenoids, and may be corrected by their removal. Nothing should be left undone to relieve children of defective hearing at the earliest possible moment. It may soon become too late. DEFECTIVE PALATES Cleft palates were found in three children, these being 0.6 per cent, of the entire number. Skillful surgical treatment is the only help for unfortunate cases of this kind, and little can be done even by surgeons after in- fancy. PULMONARY AND NERVOUS DISEASES Any form of either pulmonary or nervous disease is serious and difficult to handle. Children suffering from such a disease should remain away from the ordinary school until cured. HEALTH CENSUS OF A SCHOOL 27 ENLARGED GLANDS Swollen glands were among the defects we looked for. Though we found many cases of slightly enlarged glands, none was serious enough to report. In most cases enlarged glands are symptoms of other defects, such as bad teeth, hypertrophied tonsils, and pediculosis (head lice). The glands return to their natural size and condition as soon as the causal defects are removed. Glandular enlargement must never be overlooked, how- ever, as it is always an indication that the bodily nutri- tion is being interfered with, and that the poisons which accumulate in the tissues are not being properly dis- posed of. This state of the glands furnishes exactly the right soil for tuberculosis. When glandular enlarge- ment continues and increases it usually means a serious case of this dreaded and dangerous disease. SUMMARY This completes the list of physical defects which we selected for the test of the Washington school children. The list is extremely conservative. To avoid opposition to the experiment, we omitted several defects which should properly have been included in it, such as mental deficiency, defective speech, non-infectious skin diseases, hernia, and phimosis — a constricted condition in boys, curable by circumcision, and likely to produce nervous derangements as well as hernia if neglected. Our survey also took no account of the minor contagious diseases which we incidentally met in great numbers — pedicu- losis, ringworm, scabies, impetigo, — nor of the venereal diseases sometimes found among school children. All 28 HEALTH AND THE SCHOOL these defects and diseases of school children, together with the best ways of discovering- and handling them, have been described with great clearness in several re- cent works to which I shall refer you. The list of defects which we have considered to-night, though only partial, is long. You have seen the se- rious consequences involved in letting them go uncor- rected, and at the same time you have seen how easily removed or prevented many of them may be. Do you think the school, which is responsible for many of them and handicapped by all of them, can any longer afford to ignore them? Must it not use all its influence and authority to secure their rernoval and prevention? • Suggested Reading Allen. Cizncs and Health, Chapter VI. American School Hygiene Association. Proceedings OF the Fourth Congress Contagious Skin Dis- eases in Relation to Schools. Hoag. The Health Index of Children. Hogarth. Medical Inspection of Schools, Chapter XVL National Society for the Study of Education. The Ninth Year Book. Part I, Health and Education. Ill SANITARY INSPECTION OF A SCHOOL BUILDING Mr. Young. — What ails our children? When we heard that question answered at our last meeting we were all thoroughly shocked. There is another ques- tion fully as urgent. Its answer is no less shocking. What ails our school buildings? Mr. Martin will ex- plain. Mr. Martin. — It is a penance for me to give an an- swer, for I am in a measure responsible for the condition we found at the Madison school. For five years I have been on the school board, and not till last month did I know, or know enough to care, what condition our buildings were in. It is true that I did not chance to be a member of the committee on buildings, but that was no excuse. When we came to examine the Madison school build- ing, outside and inside, with respect to its site and sur- roundings, its heating, ventilating, lighting, sanitary ap- pliances, and care, we made the following discoveries* : The building is a two-storied frame structure with no fireproofing, but with ample outside fire escapes. Its location is bad, being near a gas plant which constantly fills the air with unwholesome odors. * Based upon an investigation of the sanitary conditions of a school building, by W. E. McGowan, reported in the Pedagogical Seminary, December, 191 o.^ 4 29 30 HEALTH AND THE SCHOOL The ground on which the building stands is low and ill-drained, which makes the fair-sized yard unfit to play in during much of the year. Part of the yard is fenced ofif for lawn and shrubbery ; the ornamental effect thus secured being paid for by the children in narrowed space for play or gardening. The heating of the building is by means of the hot- air gravity system, the warm air inlets being in or near the floor. We found the heating system to be effective, so far as temperature was concerned. The thermometer stood at about 70 degrees in all the schoolrooms, and the teachers reported little trouble, even in zero weather. Getting air heated, however, seems to be a far less important matter than keeping it sufficiently fresh and moist. It is an easy thing for children to exercise or put on wraps if they are cold, but they have no protec- tion against air that is poisoned, or so dry from heating that it blisters the delicate membranes of nose or throat. It was in its failure to assist the ventilating system that the heating system in the Madison school broke down. Ventilation has been a general theory for many years ; a general practice never. We found it in its theoretical state in the Madison school. At one time a ventilating system had been installed and then forgotten. This sys- tem still stands as our fathers left it. It was not work- ing when we saw it, never had been working, and the janitor did not know of its existence. The system included an outlet flue in each room. These flues were for conveying foul air into a central chimney — too small for the purpose — which had been used as a smoke flue when the building was heated by stoves. . Our anemometer tests, taken with windows both open and shut, showed that no foul air was being con- veyed through the outlet flues to the central chimney. SANITARY INSPECTION 31 We discovered the reason for this total failure of the outlet flues when we inspected the bottom of the chim- ney in the basement. Set in the base of the chimney- was a stove which once had been put there to furnish an upward current of air. The stove had never been used; the janitor did not know what it was for. In many rooms we found slightly opened windows, which gave an appearance of good ventilation, but an appearance only. Our anemometer tests showed that the quantity of fresh air admitted into the rooms fell far short of the amount required by our State school regulations governing the construction of new buildings. This is 1,800 cubic feet per hour per pupil. The greatest amount of air admitted in any room in this school was 1,100 cubic feet. With the ventilating system in the dormant condition just described, the only way that good, as well as warm air could have been provided in the building would have been through a miracle. No miracle had taken place when we visited the school, and the air was what might have been expected — intolerable. Mr. Ross. — I should like to ask just how you were able to find that out. Was it by the odor of the air? There is, of course, always an odor in schoolrooms and children's institutions. This seems harmless enough, and it cannot be avoided where you have so many children together. Mr. Martin. — I do not agree with you there, but the odor in this case, I assure you, was quite sufficient to indicate the bad quality of the air. We did not depend upon that, however. Our conclusions regarding the amount of organic matter in the air were based upon the amount of carbon dioxide (CO2) which it contained. The excess of CO2 in air that has been breathed is a very 32 HEALTH AND THE SCHOOL accurate index of the amount of organic matter that has been exhaled. We measured the proportion of CO2 in the air very carefully by the Petterson-Palmquist ap- paratus, which registered an amount greatly exceeding the present generally accepted limit for health ; i. e., 10 parts in 10,000 of air. Our tests showed that the pro- portion of COo in the school air increased steadily after the opening of school to 20 or 24 parts per 10,000. The pupils were breathing what would be technically ranked as bad or very bad air throughout their school day. As these tests were conducted in weather moderate enough to allow of the windows being partly open all day, it is interesting to consider what condition the air of that school reaches in really cold weather. At this point I must admit, however, that, according to recent experi- ments, the COo test is not an altogether infallible index to the wholesomeness of air. We will discuss this ques- tion more fully later.* There is a further factor necessary to air that meets modern standards and as to this the experts leave us in no doubt. It is moisture, a condition fully as important as purity. Heated air has to be humidified. Mr. Ross. — Oh, come, Mr. Martin, isn't that carrying a fad too far? They will want us to perfume the school children's air next. We all know that damp air is deadly. Dr. Latta. — Not so deadly as air that is too dry, Mr. Ross. Mr. Martin. — I confess that when humidity as a fac- tor in ventilation first came to my attention I thought the emphasis which some of the school agitators placed upon it was rather far-fetched. Why good, dry air should be made artificially damp was more than I could see. When scientific facts clash with opinions, however, * See page 46. SANITARY INSPECTION 33 it is the opinions which have to give way, as mine have now done. I learned that eggs in an incubator never hatch unless the air is humidified to the right degree; that even cactus plants succumb to the air of our furnace- heated houses. I noticed that my children wilted like cut flowers when they were kept indoors a single whole day in the winter, though the air in our house is fresh. Then I concluded that there was some point to all the recent humidity agitation. Mr. Ross. — I don't understand this at all. How can house air in the winter be so much drier than outdoor air? The air we have in the house all comes in from outdoors, doesn't it? Why doesn't the moisture stay the same? Mr. Martin. — When air is heated its capacity for moisture increases enormously. Unless additional mois- ture is supplied artificially the relative humidity becomes very low, and the air absorbs whatever moisture comes in its way. In our houses such moisture is supplied principally by the membranes of our noses, throats, and lungs. Not being constructed for this purpose, the mem- branes become parched. The results are colds, sore throats, and universal catarrh. My children have never been free from these troubles during cold weather. Ex- periments have conclusively proved that it is not the winter weather but the roasted indoor air of winter that gives the germs their chance. Humidification of air was a foreign thought to the janitor of the Madison school, and we accordingly found nothing of the sort being done. The lack of moisture in the air was made evident by our hygrometer tests, which showed the amount to be only 24 per cent. Ordinary outdoor humidity is not far from 60 per cent. Indoors it cannot go below 40 per cent, without serious 34 HEALTH AND THE SCHOOL harm resulting. What do you suppose is the effect when the percentage of moisture has shrunk to about half the minimum limit for health? HYGROMETER. This instrument for measuring the amount of moisture in the atmosphere should be part of the equipment of every school. Noisome and parching air was what we found in this school. School children in all parts of our country are breathing the same kind of air. The lighting arrangements had been fairly well planned in the construction of the building, the ratio of glass SANITARY INSPECTION 35 to floor space being within the very moderate i to 6 ratio prescribed by law. The placing of the desks was also proper, except in one room, where the light came from the back instead of from the left, or the back and left, with a preponderance of light from the left. Aside from these general arrangements, however, no thought seemed to have been given to the important matter of illumination. Though the seats for the most part were rightly set, the children were assigned to them with no regard to the lighting. There were empty seats in the best lighted places, and no effort had been made to seat children with respect to any visual defects they might have. While the ratio of window space to floor space was within the legal limit, we found that the light which should have been admitted was reduced in several ways. Large trees in the school yard stood near some of the windows, cutting off the light. The windows themselves were all dirty, which materially reduced the illumination. The shades were carelessly adjusted, some being broken and impossible to raise. Some of the windows were filled with plants which absorbed about a quarter of the light. You may wonder how plants could live in the abnormally dry air we found. It was, indeed, only by being con- stantly soaked with water that they did survive, and this constant soaking of the plants actually increased the humidity of the air in the rooms where they grew. The sanitary appliances and practices in this building we found as follows : The toilet rooms, which were unheated, were placed in a well or shaft inside the building, and illuminated only by skylights at the top of the well. The ventilation was supposed to be carried on through swinging sash windows. 36 HEALTH AND THE SCHOOL Now, there are four prime requisites for proper sanita- tion of toilet rooms. These are cleanHness, direct il- lumination from the sun, ample heating, and a continu- ous supply of air, preferably by a special system of as- pirating chimneys and exhaust fans. These well-known principles of hygienic construction were all being vio- lated in the Madison school building. There was no sun, no heat, no ventilation. The odor from the toilets permeated the whole school. The drinking and washing facilities evidenced strik- ing disregard of sanitation. The common drinking cup and towel were still in use as they were a generation ago, though it is everywhere known what spreaders of contagion these filthy things are. A recent test made on a common drinking glass from a school showed lOO,- Goo bacteria to a square inch of glass surface, and the upper third of the glass so thickly strewn with skin cells from the lips of the children that a pin point could not be touched to any part of the glass without coming into contact with several bits of skin. The manner of cleaning a school is of great impor- tance from a sanitary point of view. This can be so done as to result in greater harm than benefit, and so we found it in the Madison school. The floors were bad, rough and full of wide cracks. These collected quantities of dust which came forth in clouds at each sweeping. The janitor was aggravating the trouble by dry-sweeping the halls during school hours, and filling all the classrooms with fine dust. In the mornings before the opening of school he stirred up fresh dust in every room by going over the desks with a feather duster. Comfortable and proper seating for the children is an important item among the hygienic arrangements of a school. It is a necessity of every school which keeps SANITARY INSPECTION 37 up the use of the old-fashioned desk that adjustable desks be provided for the exceptional children who are present in every class. We found no adjustable desks in the Madison school, but we did find tall boys and girls doubled up in little seats, and little children with shoul- ders and arms uncomfortably propped up by desks too high, and with legs dangling from high seats all day. Mr. Ross. — What do you mean by your reference to the old-fashioned desk? How can school children get along without desks? Mr. Martin. — By having light movable tables and chairs. This arrangement, in the primary rooms at least, has every advantage over the regimental rows of desks which have always been a notable hindrance to the clean- liness of schoolrooms as well as to the comfort and free- dom of the children. It is hardly possible to keep a schoolroom floor clean around the legs of stationary desks, which collect dust and germs in every crack and corner; and it is even less possible for children to have any natural physical or social life in a room which is so filled with furniture that they cannot exercise freely or occasionally form little groups. Tables and chairs that can easily be moved aside at any time meet the triple need of a schoolroom — sanitary, hygienic, and social. I could easily go into greater detail in my report, but the items I have mentioned cover in a general way the extent of our investigation. Our findings I think prove beyond a question Mr. Young's contention, uttered at our first meeting, that the schools are damaging the health of our children. Mr. Ross. — The conditions you report, Mr. Martin, are scandalous. I should like to know who is to blame for them. Mr. Martin. — I am to blame, Mr, Ross, and you are 38 HEALTH AND THE SCHOOL to blame, and every one in this room is to blame, as well as every citizen in this town. The Madison school is a public school. The public is responsible for it. If the school board has failed, as it certainly has, to maintain a decent school building, why haven't the 600 parents LEGAL REGULATION OF SCHOOLHOUSE CONSTRUCTION (1912). The states in white have complete regulation; those in light shading moderate regulation; those in dark shading deficient regula- tion; those in black have no regulation at all. [From Russell Sage Foundation]. who are interested in it insisted on proper arrangements for their children? Why have the doctors in this town, who are supposed to guard our health, allowed these dis- ease-breeding conditions to continue? None of us can escape the blame, which is written large in our deficient laws regulating schoolhouse construction. Miss Parsons. — Now, however, that the light has been turned on, Mr. Martin, may we not hope to have school conditions improved? When people really find out how SANITARY INSPECTION 39 bad things are, they are usually eager to do all they can to right them. Mr. Martin. — We have found that to be true, Miss Parsons, and I am glad to report that radical improve- ments have already taken place in the Madison school. When the principal and I realized what the sanitary conditions and practices in the school really were, we could not rest till we got some changes started. The principal organized his teachers into a kind of sanitary vigilance committee. He persuaded a children's specialist to show the teachers how to give simple eye and ear tests, and how to seat the children according to the results of these tests ; also how to avoid eye-strain from unchanging light conditions by simply having each pupil sit in different parts of the room every day. This physi- cian also taught the teachers how to adjust seats and desks to the size of the children, for I am happy to say that, though chairs and tables are still out of our reach, we have finally persuaded the school board to place 8 or 10 adjustable seats and desks in each room. After we had the teachers enlisted, we attacked the building. The most desirable treatment for that, obvi- ously, was to tear it down and build a new school house on a new site. That being out of the question, we satis- fied ourselves with accomplishing the following results : Grounds. — We have contracted to have the school yard drained, during the long vacation, and part of it treated with a durable and elastic dressing especially adapted for playgrounds.* The section now covered with lawn and shrubbery will be used for school gardens. Ventilation. — i. The fire at the bottom of the aspirat- * For description of surface dressing, see The Reorganised School Playground. United States Bureau of Education, Bul- letin No. 16, 1912. 40 HEALTH AND THE SCHOOL ing chimney has been started and ordered to be kept going whenever windows cannot be kept well open. 2. The janitor and teachers are instructed to have the outlet flues always open and clear. 3. A complete change of air is secured in each room at the end of every hour by opening all windows for a few moments. 4. A number of recitations are held daily as fresh- air classes, and a fresh-air room has been inaugurated, to which anemic children from other schools are ad- mitted. 5. Apparatus for humidifying air has been installed at moderate expense. LETTING IN THE AIR AND SUNSHINE. Almost any old building can be transformed into an open air school simply by removing part of its wall. SANITARY INSPECTION 41 Lighting. — i. The trees in the yard have been trimmed. 2. The windows are kept thoroughly clean. 3. No plants are allowed to interfere with the illumi- nation. 4. The window shades are all in working order and intelligently manipulated by the teachers. 5. The children are seated, with reference to simple eye tests, in such a way as to secure their greatest com- fort, those with defective vision next the windows, those with myopic or short-sighted eyes in the front seats. 6. The seats that were wrongly placed with respect to the light have been set so that the light falls from the left. Sanitary Appliances and Practices. — i. The janitor is now required to wash closets and urinals daily with brush and hot water, and at least twice a week with a germi- cide. SANITARY DRINKING FOUNTAINS. Fountain heads can be installed at small expense in place of the old-fashioned faucets and chained cups. 2. Enough artificial light has been installed in each toilet room to allow the cleanliness of the appliances to be inspected. 42 HEALTH AND THE SCHOOL 3. It is planned during the short vacation, to install systems of heating and ventilating in the toilet rooms. Warm air will be used for heating, as this will assist the ventilation. For mild weather a number of inexpensive electric fans will be provided. 4. The common drinking cup has been abolished, and fountain jets put in its place. 5. For the common towel inexpensive Japanese paper towels have been substituted. 6. The floors, in the vacation, will be cleaned, scraped, filled, finished, and waxed. In the meantime the janitor has been prohibited from doing any dry sweeping or feather dusting, or from sweeping any floor dur- ing school hours. He is required to have the whole building dusted with damp cloths every day before the morning session, and to have all the floors scrubbed on Saturday. 7. Adjustable desks have been assigned to all the chil- dren who needed them, and it is now possible for every child in the school to work with his arms resting in com- fortable positions, and with his two feet set squarely on the floor. Finally, the principal makes a careful and thorough tour of inspection throughout the building each day, to see that the daily sanitary routine is maintained in all these essential particulars. The greatest result of our two months' work, however, has not been the partial rehabilitation of the miserable old school building. It has been in the improvement of the school children themselves. Miss Parsons and her committee may justly claim to find results from remov- ing the defects of the Washington school children ; but it is evident that removing merely the defective condi- tions in the Madison school has gone far toward trans- SANITARY INSPECTION 43 forming its children. Thanks to the fresh, clean, and sufficiently moist air that the pupils are now breathing, and the better light provided for their eyes, the principal is able to report marked increase in energy and success in school work, and problems of discipline reduced about 75 per cent. Mr. Ross. — We owe Mr. Martin a vote of thanks on behalf of our club, and on behalf of the whole town, for the valuable pioneer work he has done in our school sanitation. His work has shown sanitation to be a very fundamental department of school administration. I for one should like to know much more about it. May I not ask Mr. Martin, in concluding his report, to give us a brief summary of the general standards to be attained in school sanitation, together with a few suggestions as to the best methods of attaining them? Mr. Martin. — In our limited time I can hope only to give the most condensed outline, but it will doubtless clear up the subject in our minds to review systemati- cally, though briefly, the general principles touched on in the report just described. SITE The site of the schoolhouse should be chosen ivith a view to obtaining pure, dry air, good light, reasonable quiet, and sufficient outdoor play space. It should, there- fore, be on "dry, porous ground, well-drained, free on all sides, distant from any buildings, far from factories, offensive trade establishments, markets, boiler shops, saloons, and elevated railroads, far from anything creat- ing noise, smoke, smell, gases, or fumes." Mrs. Ross. — May I ask what is regarded as sufficient play space? 44 HEALTH AND THE SCHOOL Mr. Martin. — The standard is necessarily a flexible one. London, the most congested city in the world, allows each child 30 square feet of school yard. That permits each child to do little more than swing his arms about him. Many of our large cities do not observe even this standard. In one of our greatest cities 168 of the schools fall below the 30-foot limit, one school in the list having only 1.3 1 feet per child. At least 145 square feet per child, or an acre for 300 children, is required for active play. Even this apparently liberal allotment falls far short of the need of active boys, who cannot play their favorite running games if more than 70 are allowed on one acre. CONSTRUCTION The main concerns in the construction of a building are: safety, light, heating, ventilation, cleanliness, and convenience. While safety and sanitation are quite dis- tinct items and are, indeed, conducted by separate mu- nicipal departments, school authorities should keep as close watch on arrangements for safety, especially those bearing on fire prevention, as on those for sanitation. Wood should be avoided as a material for construction, except in the smallest rural schools. The height of the building should never exceed five stories, and wide stair- cases — 44 inches for two files — should make it possible for children to reach the different floors comfortably and rapidly, without the use of elevators. Ample fire-escapes should also be provided, though these should never be regarded as the main dependence of the children against the danger of fire. Fire prevention, not fire escape, is the ideal of the modern school, which should be equipped with fire walls and doors to prevent the spread of a fire SANITARY INSPECTION 45 that has started; wire glass to prevent the breaking- in of windows by flames, and automatic sprinklers in places where fire is likely to start. For the sake of insuring not only fire security, but quiet, cleanliness, and whole- some air ; "the walls, floors, ceilings, and partitions should be sound, damp, fire, vermin, and dustproof. The junctions of ceilings and floors with walls should be concave, and all projections, moldings, etc., where dirt and dust may lodge should be eliminated whenever pos- sible." * Ample provision should be made for dressing-rooms, library, study rooms, auditorium, bathroom, teachers' room, and nurse's room. The further items of construction afifecting heat, ven- tilation, light, and cleanliness we will take up separately under those heads. HEATING The heating system should provide a temperature which insures a maximum of comfort and energy to the pupils. Such a temperature, when air is fresh and suffi- ciently moist, is reached, for ordinary school work, at the comparatively low point of 65 degrees. The perfec- tion of modern heating systems makes the meeting of this temperature requirement an easy matter. It is in relation to ventilation that the heating system becomes an item of very critical determination. VENTILATION A satisfactory ventilation system provides for the in- troduction and adequate circulation of good clean air in sufficient amount for all the individuals who occupy a * Hygiene and Public Health. Price. 5 46 HEALTH AND THE SCHOOL school. The present accepted standards of good school- room air are : CO2 content, 4 to 10 parts in 10,000 ; hu- midity, 40 to 60 per cent. ; temperature, 65 to 68 degrees ; amount, 1,200 to 1,800 feet per pupil per hour; cleanli- ness, freedom from dust, smoke, poisonous gases and odors. As I stated before, the proportion of CO2 that can exist in air without rendering it harmful is a matter of present controversy. Recent careful experiments have indicated the surprising fact that the COo content in air, instead of reaching the maximum for health at 10 parts, can rise as high as 150 parts in 10,000 and even higher without resulting in physical discomfort or disturbance, provided that the air is circulating freely and does not become too hot or moist. Mr. Ross. — Then what value had the CO2 test that was applied in the Madison school? Mr. Martin. — As a test for the contamination of the air alone it had little significance; as an indication of the stagnation of the air it was important. Stagnant air has been shown to be uncomfortable and unwhole- some, even when it is pure. Mr. Ross. — I can't see how pure air can be either un- wholesome or uncomfortable. Mr. Martin. — We have all experienced the condition on a sultry, summer day, when no breath of air was stir- ring. The outdoor air, though pure, was just as bad as the indoor air. The lack of a breeze was the whole trouble. The body envelope of air which immediately surrounds the body, becomes overcharged with heat and moisture, unless it is being constantly changed by a mod- erate current of air. A stagnant condition of the air, whether outdoors or indoors, brings on the characteristic symptoms that are caused by bad ventilation. These SANITARY INSPECTION 47 seem beyond a doubt to be due to the discomfort of the skin and possibly the lungs, but not to inhaled poison.* Mr. Ross. — If the skin is all that is to be considered in ventilation, why not simplify matters by installing a lot of electric fans in schoolrooms, and letting the elabo- rate contrivances go? Mr. Martin. — To add electric fans to the schoolroom equipment would undoubtedly contribute greatly to the comfort of pupils, if the fans were so placed as to avoid strong drafts on anyone. I have, in fact, tried the effi- cacy of the electric fan in "freshening" the air in a room. My stenographer had decided she could no longer endure the oppressive air of my office. Daily headache and lassitude, she felt, would compel her to give up her work. I determined to try the fan. From the first day it was installed, though no other change in the ventila- tion was made, the stenographer's bad symptoms disap- peared, and now, after several months, she is comfor- table and full of energy. To substitute fans, however, for the standard methods of ventilation would be an unwarranted step in the pres- ent experimental stage of the subject. Recent experi- ments in the Harvard Medical School indicate strongly that there are actual poisonous substances in expired air. The combined plenum and vacuum methods for large buildings, gravity and exhaust system for smaller buildings, and the jacketed stoves with an air flue from outside and a vent, for one-room schools, must be re- garded as the approved methods until practical devices have been demonstrated which meet the condition bet- ter than do the best ones now in vogue. It must be remembered that, no matter how perfect a ventilating system may be, it is never the substitute for * The Heating and Ventilating Magazine, February, 191 1. 48 HEALTH AND THE SCHOOL direct outer air that its advocates often claim. If win- dows must be closed to assist the operation of a ventilat- ing system, these should be opened top and bottom at least once an hour to secure a thorough blowing out of the schoolroom. A sudden drop in temperature is no obstacle to the plan. Children are refreshed by cold that does not last long enough really to chill them. Two more points must be emphasized with respect to air introduced into schoolrooms. It must be clean, and it must not be overheated or "baked." Outer air that is charged with dust should be filtered or washed. Pass- ing air through a wet gauze screen at the opening of the fresh-air flue is a simple and fairly effective way of cleansing it. Air used for warming as well as ventilat- ing purposes should never be heated to over loo degrees, as a higher temperature makes it injurious in several ways. Carbon monoxide, a deadly poison, penetrates red- hot iron and enters the air chamber of an overheated furnace. Burning particles of iron and dust contribute disagreeable odors, and other factors not yet plain cause baked air to be harmful. Consequently, hot-air systems not reinforced by direct radiation should be confined to climates that do not require forced heating. The best standards for good air we may now sum up in a word. Keep air clean ; keep it cool ; keep it moist ; keep it moving. LIGHTING In the lighting of a schoolhouse the aim is twofold: to secure as much natural sanitation through sunlight as possible, and to provide enough light to make all eye work comfortable and safe. Every room should be so placed as to allow the sun to enter at some time during SANITARY INSPECTION 49 the day, a southeast exposure being the most desirable for this purpose. The main hght should come from the left. The proportion of the area of windows to floor space should not be less than i to 5. Windows should have square corners, with tops not more than 6 inches from the ceiling, and bottoms not more than 3 feet 6 inches from the floor. When outside light is obstructed window glass should be ribbed or prismed. Windows should be fitted with two opaque shades, rolling respec- tively up and down from the middle. Ceilings should be white or light bufif, and the walls light green or buff. Windows should be kept clean and unobstructed. For artificial illumination electric light is best. PLUMBING AND DISPOSAL OF WASTE The purpose of plumbing and the various methods of waste disposal is cleanliness, through the supply of water for cleansing purposes and the removal of offensiz'e and dangerous matter. "There should be ample provision for washrooms, basins, shower baths, urinals, water- closets, all situated conveniently in well-lighted, heated, and ventilated apartments ; the fixtures made of porcelain or enameled iron, the floors, walls, and ceilings con- structed of stone, tile, or pressed glass. Water-closets should be provided with automatic flush apparatus." * When plumbing cannot be installed and no running water is at hand, the dry earth closet is the most sanitary toilet arrangement. This must receive constant, intelligent care, and should be situated not less than 40 feet from the schoolhouse. When running water is available the septic tank system is a safe and inexpensive method of waste disposal. * Hygiene and Public Health. Price- 50 HEALTH AND THE SCHOOL DRINKING FACILITIES Wholesome drinking water should be provided to school children by methods which do not permit the spread of contagion. Unless drinking- water comes from an artesian or other thoroughly certified well, it should invariably be fil- tered. If the pub- lic water works do not provide fil- tration, the schools should do this by means of properly adjusted and fre- quently cleaned filters. In case of demonstrated con- tamination, water should be boiled COVERED CAN AND INDIVIDUAL CUPS. ^Q miuutCS The Sanitary substitutes for the disease-breeding rnmmon drinkinP" open water bucket and common cup. , ° cup must give way to the drinking fountain, when there is running water; or, when water is restricted, to sanitary paper cups or individual cups under the care of the teacher. Water receptacles should be kept closely covered to pre- vent the contamination sure to result from the use of open pails. FURNITURE School furniture shoidd minister to the ease and com- fort of school work, and be so chosen and cared for that it cannot produce injury to the pupils through contagion or strain. Desks and seats and tables should be care- SANITARY INSPECTION 51 fully adjusted to pupils. They should not be perma- nently attached to the floor. Blackboards should be of slate, and placed where they can easily be seen by all pupils. The common towel should be replaced by the cheap paper towel which is destroyed after being used once. Pictures, charts, globes, models, and instruments should be coated with varnish, and should be smooth and easily cleaned. Pens, pencils, and books should be used as individual property and disinfected before going into the possession of other pupils. The last-named articles, and many others like them, while they may be regarded as school furniture, are really materials of instruction, and their control, except as regards their sanitary cleanliness, falls more properly under the hygienic regulation of school activities. Such regulation is a much-needed branch of health supervi- sion. Until the time comes when school activities are regulated hygienically, which is far from the case at present, sanitary authorities must do what they can to secure a wholesome school equipment. It is altogether likely in the future, however, that a department for the regulation of school activities will take over the chief responsibility for school furnishing, as these present many problems quite distinct from those of ordinary sanitary requirements. CLEANING Schools are cleaned for the purpose of keeping them free from dust, germs, refuse, and bad odors. Dust is the main point of attack, and prevention of dust is the first move to make. The building itself and the articles in its equipment, as we have seen, should all be devised so as to catch and hold the least possible dust. Dusty 52 HEALTH AND THE SCHOOL outer air, we have already stated, should be cleansed before it is introduced into the ventilating flues. The most effective method of all for excluding dust, dirt, and germs from schoolrooms, though as yet it is least recognized, is to prevent children from distribut- ing the mud and filth of the streets over schoolroom floors by means of their shoes. The Japanese people, who have adopted our best sanitary standards and re- tained the best of their own, do not permit street foot- wear to be worn within their buildings even when these buildings are on European models and their occupants wear European dress. As a consequence of this rule, the floors of houses, hospitals, and schools, when not covered with matting, present the appearance of polished table tops. Mrs. Ross. — What an enviable condition! Surely dirty shoes are the chief source of dust in our schools and pubHc buildings, not to say private dwellings, but how could you ever arrange to have 500 children take off their shoes before entering a school building? Mr. Martin. — The Japanese provide a roomy vesti- bule where this is done. We could easily solve the diffi- culty if we became convinced of the sanitary importance of such an arrangement. In the meantime the warfare against dirt, both pre- ventable and unpreventable, must go on vigorously and continuously. The first requirement in sanitary cleaning is to avoid the raising of dust. The vacuum cleaner answers this requirement most satisfactorily. Sweeping and "dusting" can be made fairly dustless operations, however, by the use of wet sawdust scattered over floors for sweeping, and damp cloths for use in wiping furni- ture and floors. These should be wiped up every day when rooms are in use. A disinfectant should be used SANITARY INSPECTION 53 not less than once a week. Strong soapsuds alone make an excellent disinfectant. Floors, to be kept clean, must present smooth surfaces ; if they are made of soft wood they should be treated with hardening preparations. Oil as a floor dressing does not deserve the vogue into which it has recently sprung, as, instead of eliminating dirt, it binds the dust on the floor, where it sticks. In fact wood, unless polished and waxed, does not make the most sanitary floor for schools, and we cannot hope to have really first- class wooden floors until we stop the habit of grinding dirt into them with our shoes. Many English schools have floors of small stone blocks set in cement, which are easy to scrub, comfortable, and soundproof. Window Cleaning. — Window cleaning, as we have seen, is of great importance. The frequency with which this is needed varies much, according to location, cli- mate, and season, but a schedule should be followed which is carefully regulated with a view to keeping the glass constantly clear. This finishes the list of general items to be considered in the sanitation of school buildings. Two main pur- poses are back of the entire program, determining every item on the list. They are comfort and cleanliness. Mr. Young. — After hearing this excellent summary of modern sanitary standards and realizing the distance -which most of our schools must travel to reach them, I am tempted to paraphrase Portia's words — If to do were as easy as to know what were good to do, chapels had been churches and poor men's cottages sanitary schoolhouses. Miss Parsons. — And why shouldn't they be? The twentieth century man does not spend his life in wistful desire. To know what were good to do is the modern 54 HEALTH AND THE SCHOOL signal for doing it. As soon as the American people find out that they need sanitary schoolhouses they will get them. Two states — Virginia and Wisconsin — are now conducting state-wide campaigns of sanitary edu- cation through their Universities ; and Wisconsin is sub- sidizing her country schools for the purpose of equipping buildings with proper heating, ventilating and sanitary devices. Will it be long, do you think, before the reproach of sending children to unsanitary schoolhouses will be lifted from every state in the Union? Suggested Reading American School Hygiene Association. Proceed- ings OF THE Second Congress. Schoolhouse Con- struction as Affecting the Health and Safety of Children. Proceedings of the Third Congress. An Inquiry Into the Problem of Desks for Children. Proceedings of the Fifth Congress. Proper Sani- tation of the Schoolroom. Ayres. Open-air Schools. Denison. Helping School Children, pp. 145-160. Search. The Ideal School, Chapter V. Shaw. School Hygiene, Chapters I-VH. United States Bureau of Education. American Schoolhouses. Rural Schoolhouses. IV A SCHOOL CHILD'S DAY Mr. Young. — In our last two meetings we have been shocked to hear that our town is every day sending thousands of physically defective children to spend five hours in a dozen school buildings that are violating many of the simplest rules of sanitation. What do these defective children do when they get to the unsanitary buildings? How do they spend their time? Our school children's daily programs still wait to be scrutinized. Mrs. Ross will guide us in this task. Mrs. Ross. — The task would be a most ungrateful one if it were not a necessary step toward an improved sched- ule for the children. We cannot, of course, hope for the immediate correction of all the abuses that are going on in our schools. ]\Iany of these are in accordance with general school practice, and must wait until an enlight- ened public sentiment puts a stop to them. It will be a great advance for us, however, to understand the abuses clearly. Mr. Martin. — It seems to me that the word "abuses" is remarkably strong language to apply to the efforts of the public schools, the most altruistic of all our institu- tions. Mrs. Ross. — I can think of no other word that de- scribes so accurately certain things that are taking place in our schools, for the reason that many of our edu- cational leaders have not yet learned to gauge school 55 56 HEALTH AND THE SCHOOL requirements according to such non-academic matters as the capacities of httle children's eyes and stomachs and nerves. Our schools at present set a far higher value upon a child's ability to pass a set examination than upon his ability to digest a dinner. That a school curriculum should be arranged with reference to such arbitrary tests as examinations, or to some possible future needs of grown-up citizens, and not first and always with refer- ence to what young eyes and stomachs and nerves will not only endure but thrive under, seems to me the most comic anomaly of all our highly intelligent modern life. Like all things humorous, the school comedy has its tragic aspect. This appears in the spent eyes, ruined stomachs, and shattered nerves that often pay for the successful examinations and the preparation for future citizenship. Mr. Martin. — Are we guilty of bringing such disas- ters upon our school children here? Mrs. Ross. — Guilty is the word, Mr. Martin, though our school authorities can shift part of the responsibility to other shoulders. The curriculum of the high school, for instance, is largely dictated by the colleges and their arbitrary entrance requirements ; the work in the ele- mentary schools, in turn, is determined by the high school entrance requirements and the state examinations. Our schools devise their own weekly and daily programs, to be sure, but these must be in strict accord with college and state demands. Before going into a detailed criticism of our school program I wish to make it clear that my report is not based upon opinion but upon evidence. The criticisms and suggestions advanced are made entirely with refer- ence to a few scientifically established facts regarding the A SCHOOL CHILD'S DAY 57 endurance, liability to fatigue, and the recuperative pow- ers of children. The facts so far established are un- fortunately few and little known, but they have the im- mense advantage of being facts, and consequently out- weigh the total enormous output of professional opinion up to date. Until about 1910 one school superintendent's guess was as good as another's in answer to such ques- tions as these : How many hours of purely mental work in a day can children of certain ages stand? How much exacting eye work is it safe to require? What is the best number of pupils for classes of various kinds? What subjects are most fatiguing? What is the result in fatigue or stimulation of formal physical exercise? Of what lengths should recitations be made? How fre- quent and how long should recesses and vacations be? For many years the discussion of these questions and many others like them has produced great heat and little light. Discussion does not develop physiological law. There is only one method that can show just how school work affects children. This is psychological and physio- logical investigation which is based upon a thorough analysis of school conditions, and extensive, accurate measurements of the results of these conditions on school children. Practical work of this sort is new. Many problems of the school program still remain to be solved, but the few results thus far established are sound, and they are sufficiently revolutionary to keep us well occupied for a time in applying them. With uniform consistency the facts that have been worked out show (a) that our schools are requiring far more book work, that is, work unconnected with muscular activity, than children can profit by or even safely endure; (b) that they are giv- ing too short and infrequent recesses between hours of 58 HEALTH AND THE SCHOOL study, including an insufficient pause for the noon meal ; (c) that their systems of home study, examination, and competition impose on the children dangerous strains which teachers have no means of measuring or regulat- ing. Mr. Martin. — I should be much interested to know how the scientists are able to arrive at these sweeping conclusions. Mrs. Ross. — They have done so by the study and comparison of records of thousands of children. They have measured accurately the work accomplished and the fatigue incurred under various sets of conditions, such as short hours and long hours, with and without in- terposed recreation periods, at school and at home, be- fore and after heavy meals, before and after vigorous exercise, in large classes and small classes, when the subject was stimulating and when it was dull. Mr. Martin. — Results based on such thorough work as you describe evidently admit of no contradiction, but I should like to know, nevertheless, just how it is pos- sible to measure fatigue. Do the investigators depend on the children to say when they are tired? Mrs. Ross. — Not by any means. Children who are not in the least fatigued often declare they are weary, and no less frequently children on the edge of nervous exhaustion are keen for more work. Objective tests are the only reliable ones for determining fatigue. Those that have been found most accurate are measuring the changes in the action of the muscles of accommodation of the eye, the varying sensitiveness of the nerves of touch, and the speed and accuracy of performing cer- tain mental and muscular processes, such as the written addition of numbers and the copying of letters. There are also general symptoms that indicate chronic fatigue. A SCHOOL CHILD'S DAY 59 These are uneasy and insufficient sleep, loss of appetite and weight, lack of mental concentration, restlessness, irritability, and languor. These symptoms invariably ap- pear among a large proportion of children during term examinations and prize contests, which is quite enough to condemn these practices. Now let us examine in detail the amount and kind of work our own schools are requiring, and compare these requirements with the soundest modern standards. We find that our primary grades are spending four- fifths of the school session in formal work, that is, four out of five hours are spent in book study and arbitrary drill in reading, writing, arithmetic, and geography. This arrangement is in direct opposition to the best school usage, which provides that at least half the time in the primary grades be devoted to physical activity of various kinds : singing, educational games and dances, and constructive work, such as weaving, sewing, cutting, building, modeling, and gardening; and that the remain- ing half of the session be spent in intellectual work which requires a minimum of fine nervous and muscular adjustment for eye or hand. During this time subjects in history, geography, and science may be presented through stories, by pictures (lantern pictures if possible), and by various other materials ; and these demonstrations may be made the basis for discussion, description, and reproduction in speech, dramatic representation, construc- tive activity, and, to a limited extent, in writing and drawing. Such a program allows little more than an hour a day for drill in reading, writing, and arithmetic, but this brief hour is spent in eager, intense work, which accomplishes as much as the three or four unrelieved hours that our schools ordinarily require. Mr. Young. — This program allows for a very limited 6o HEALTH AND THE SCHOOL amount of eye work. Has it been determined just how much of it primary children can endure? Mrs. Ross. — The question has not yet been completely determined, but it has been very thoroughly demon- strated that they cannot safely use their eyes the number of hours we now require them to do so, and it is equally evident that one hour, distributed through the day, does the average child no harm. The varying capacities of individual children must, of course, be taken into account in considering any general rule. Mr. Martin. — Is such an ideal program as you de- scribe in actual operation in any primary school? Mrs. Ross. — Such programs are being followed in several of our leading schools with convincing results; conspicuous examples being the Horace Mann School in New York, the University Elementary School and the Francis W. Parker School in Chicago. Mr. Young. — Such a holiday atmosphere as you ad- vocate for the primary grades must, of course, give way to sterner methods in the grammar grades and high schools. How much purely mental work is it con- sidered desirable to impose in these years? Mrs. Ross. — The capacity for such work increases rapidly in children who are intellectually gifted, but these w^e must remember are only a very small propor- tion of our children. The great majority never develop the power of sustained intellectual work, and are forced to protect themselves against the fatiguing effort of do- ing it by sitting unresponsive during classes, or leaving school. By the 6th grade the children should be sorted out according to their aptitudes, and the "book-minded" ones given two to three hours a day of purely intel- lectual work, the others not much more than half that time. In the high schools intellectual work for those THERE S NO FUN LIKE WORK. These New York school children bring unbounded energy and per- severance to tasks which are adapted to their capacities and needs. Mi i>iiiiwiiliiifi-ate^aa m ' v.--^ k"' p:):"': W^\^m^ mM V'^M .-teS^KfSpgl «--.«^s-.^:;j«^ii.^ ■ :..^^^ WHAT ARK TXIKV RAISING? Active minds and vigorous bodies are conspicuous items in the crop reports from the boys' gardens in Dayton, Ohio. A SCHOOL CHILD'S DAY 6i adapted to it can be carried on three or four hours a day. A very successful attempt to adapt the work of the three upper elementary grades to the aptitudes of pupils has lately been carried out in some of the Chicago ele- mentary schools. The motor type of children who have been given hand work for half the school day, and book work for the other half have developed ability hardly before suspected. It is not an uncommon thing now for nine out of ten children in a class thus trained to enter the technical high school, though they come from elementary schools which, before this change in curriculum took place, sent almost none of their children to high schools. The schedule, however, for both elementary and high schools is not to be considered as hard and fast. There are certain ages when tendency to fatigue is especially pronounced, and the school requirements must take this into consideration. At the age of eight, for instance, most children show a distinct decline in nervous endur- ance, as a result of the double strain of second dentition and the unusually rapid growth which sets in at this year. Their tasks should accordingly be no heavier than the tasks of six-year-olds. Five or six years after this early nervous check comes the period of puberty, which invariably makes unusual demands on the nervous systems of both boys and girls, and greatly increases their tendency to fatigue. The school requirements should be lightly and flexibly ad- justed during this critical period, which with girls ar- rives between the thirteenth and the sixteenth years, and with boys between the fourteenth and the seven- teenth. The fact that boys and girls reach sexual maturity at different ages, and accordingly need their school work lightened at different times, constitutes a rather forceful 6 62 HEALTH AND THE SCHOOL argument for educating the two sexes separately from the thirteenth to the seventeenth years. Mr. Young. — I should like to hear how the total num- ber of school hours which you have indicated as desir- able should be divided. Have any general standards been established for length of lessons and recreation pauses in elementary and high schools? Mrs. Ross. — Yes, and these vary widely from com- mon practice. The German scholars with their pains- taking thoroughness have worked out the pauses neces- sary for a combination of maximum efficiency and min- imum fatigue. For the lower primary grades purely in- tellectual work should be limited to fifteen-minute pe- riods, and a pause for rest and informal relaxation should follow every half hour of such work, which should then be succeeded by hand work or directed games. In the upper primary and elementary grades classes should not be held longer than half an hour, and a recess from ten to twenty minutes in length should be granted once an hour, the recess period being lengthened as the school session proceeds and the children's tendency to fatigue increases. This recreation schedule applies with equal urgency to high school work, though recitations there can be extended to advantage to forty or fifty minutes if the classes are large, that is, numbering forty or more. If classes are smaller the length of recitation should be proportionately shortened, as fatigue develops more quickly in small classes than in large ones, owing to the closer attention they demand. Shortening the time for small classes has its obvious economic advantage also, for a given amount of work can be covered in a shorter time in a small class than in a large one, and the energy of the teacher spared as well as that of the children. A SCHOOL CHILD'S DAY 63 Mr. Young. — I suppose some of the rest periods may well be taken for gymnastic exercises. Mrs. Ross. — That is a thing very commonly done, but the practice is wrong. The recesses cease to be rest periods if they are taken up with gymnastics. Formal gymnastics are proven to be fully as fatiguing to brain and body as the most exhausting of all studies, arithmetic. They are doubtless necessary for the health of school children if the schools lack space and equipment for active games and play, but they must rank as one of the fatiguing though desirable school exercises and not masquerade as either rest or recrea- tion. Mr. Martin. — In connection with the matter of rest pauses, I have a grievance against our present school schedule. Mrs. Ross hinted at the beginning of her re- port that the noon intermission was not long enough. This period is certainly not a time of rest in our family, as it undoubtedly should be. The children hurry home, bolt their dinner, and are ofif again in a rush for their two afternoon hours of school work. Mr? Ross. — You have brought up one of the most radical of all the changes which our schools ought to make. The present noon pause of an hour and a half is too short by at least an hour. The noon meal for children should be the heartiest in the day, and should be well digested before further work is demanded. It should be leisurely, and followed for at least half an hour by actual rest or the lightest occupations. Exact- ing school work should not be resumed for at least two hours after the noon meal. By that time children as well as teachers are able to do as exacting work as in the morning hours. Mr. Young. — So long a noon intermission would re- 64 HEALTH AND THE SCHOOL quire the afternoon session to extend till 4.30 or 5 o'clock. Do you think parents would agree to that? Mrs. Ross. — German parents do. Those hours are in common favor in Germany. Mr. Martin. — But such late hours would make it harder than ever for the children to do their home study. Mrs. Ross. — Why should they do any home study? Mr. Young. — I doubt whether a schedule can be de- vised to avoid it. Mrs. Ross. — I agree with you, if we are to leave the school requirements and the length of the school session just as they are. One or both of these factors in the school schedule can be changed, however, and will be changed as soon as we wake up to the fact that ordinary "home work" for elementary school children is a bar- barism. In the first place, the home preparation of lessons is often a farce, being done for the edification of teachers by sympathetic parents. I confess my own frailty in this matter, as I never scruple to help my children all I can when I see their nerves strained by home lessons. My scruples develop the next day, however, when the children have taken their neatly done exercises to school, and I pause to reflect that the overworked teachers will use their limited time and strength to' mark me 100 in arithmetic. The school board would really economize its resources by delivering parents from the temptation of the "lesson graft." The other objections to home work have direct refer- ence to health, and are even more serious. In the aver- age home, lessons are studied immediately after supper, with poor light and in the midst of a sociable family. The direct consequences of this arrangement are indi- gestion, eye troubles, and general nervous strain. A SCHOOL CHILD'S DAY 65 Mr. Martin. — I fear my own children are inviting some of these disorders, but how to prevent their doing it is a puzzle. Mrs. Ross. — Do you not sometimes question whether your children might not be better ofif, mentally as well as physically, with certain of their studies completely dropped ? Why do we continue to let the schools pile their dead languages and higher mathematics and fantas- tic forms of arithmetic upon the children ? The disciplin- ary value of these studies, the psychologists tell us, has been grossly over-rated. And, again, why do we not insist that the schools shall make their sessions long enough for the children to learn the lessons they are sent there to be taught ? We seem hardly to realize that we are all part owners of the public school and that our convictions with respect to it can shape its policy. The curriculum is not a changeless entity, incapable of being adapted to the needs of the children, for whom it exists. Let us have it rearranged and prolonged, if necessary, so as to make sure that the children shall go home free from care for their short evenings of social recreation. Mr. Young. — I am greatly impressed with the case you make out against home work. Would you try to abolish it for the high schools as well as for the ele- mentary schools? Mrs. Ross. — It probably cannot be altogether avoided there, though much of the lesson preparation could be done to the best advantage in the school building after the regular session. In cases where lessons must be studied at home there should be a regular home schedule approved by the teacher, indicating the time, place, and conditions under which the work is to be done. To en- courage work in the schools the buildings should be kept 66 HEALTH AND THE SCHOOL open all day, and a certain number of teachers be in at- tendance to look after the needs of pupils. Mr. Young. — Wouldn't there be a great outcry if we were to keep the children in school more than the five hours they are already held there? Mrs. Ross. — There undoubtedly would, if we kept them doing the same formal tasks to which they are already giving too much time ; but not if we gave them a chance to play and work with their hands and make things, as children long to do, out of wood and cloth and metal and flour. Mr. Martin. — Are any schools actually doing this sort of thing? Mrs. Ross. — Most assuredly. In Gary, Indiana, for instance, where the compulsory school session is only a little over five hours, half to three-quarters of the children voluntarily spend from six to eight hours a day, Saturdays and vacations included, under the super- vision of teachers, in the schoolrooms and grounds and swimming pools. Of the five hours' session itself only one-quarter of the time is devoted to formal class work. The children, probably not more than 5 per cent, of whom are "book-minded," are getting what they want and need in the shops and playgrounds as well as in the classrooms, and are making progress that abashes the conventional schools. Mr. Young. — How much recess or play time do the Gary children have? Mrs. Ross. — One-fourth of their session is devoted to play, which, however, is often led to have a very close relation to their school work. There are certain games, for instance, which require a knowledge of addition, and these serve as a powerful stimulus to the arithmetic classes. A SCHOOL CHILD'S DAY 67 Mr. Martin. — If the schools are to absorb so much of our children's time, how are we going- to squeeze A SCHOOL CHILD'S DAY IN GARY, INDIANA Note the liberal provision for directed play and hand work FOURTH GRADE 8.45 Arithmetic, Geography, History 10.15 Play and Physical Training 11.00 Reading, Writing, Spelling, and Language 11.45 Noon Intermission i.oo Nature Study, or Manual Training and Drawing 2.30 Play and Physical Training 3.15 Music and Literature 4.00 Close of Day's Work FIFTH GRADE 8.30 Arithmetic, Geography, History 10.15 Manual Training, or Science 12.00 Noon Intermission 1.00 Reading, Writing, Spelling, and Language 2.30 Physical Training 3.15 Music and Drawing 4.00 Voluntary play until 5 o'clock in the private lessons in music and dancing and the other extras? Mrs. Ross. — That is a rather special problem, as most children have neither music nor dancing lessons beyond what the schools provide. The question is not to be ignored, however, and should be frankly taken up with the school authorities. Parents and teachers must con- fer in making out the complete daily schedule, and, if it seems wise to make heavy demands on the children 68 HEALTH AND THE SCHOOL through private instruction, the public school demands should be correspondingly lightened. Mr. Young. — I welcome as a relief from the heavy charges which Mrs. Ross has brought against the schools her reference to the responsibility of parents. Is there not as much juvenile fatigue induced by late evening hours and social thrills as by too heavy lessons? If parents demand that we devise hygienic school sched- ules, which I admit we have not yet done, they must heed our demand for hygienic home schedules. Mrs. Ross. — Nothing could be more desirable, Mr. Young. A child's daily program from waking to sleep- ing, at home and at school, should be judiciously worked out by teachers and parents together, and then adhered to, unless it is proving too fatiguing. Aside from the hygienic value of such an arrangement, the established habif of the methodical disposition of time is a priceless one. In arranging the daily program teachers and parents must both remember that each child has his own in- dividual limit of endurance, and that even this varies from time to time, as in the ninth year and later at puberty. The eight-year-olds, for instance, should be spared their piano lesson for two years more, unless the school tasks are distinctly lightened to permit of this special nervous tax. When the daily program is once agreed upon, teacher and parent must still be on the alert for symptoms of chronic fatigue, and warn each other when either sees them. Mr. Young. — Are we to understand that all fatigue must be eliminated from the experience of school chil- dren ? Mrs. Ross. — Not at all. Fatigue cannot be avoided A SCHOOL CHILD'S DAY 69 for children, nor is it best that it should be. Now and then children should be made to work a little when they are fatigued. They recuperate rapidly and are all the hardier for their exertions. This Spartan prescription applies only to occasional spurts, however, and should never become habitual. Chronic fatigue is to be avoided like the plague. Children's sleep should be long and sound, and restore their nerves completely each day. If the mornings find children unrefreshed there is certain trouble brewing. Nervous exjiaustion in any human be- ing is a scandalous condition. To permit a child to suf- fer it should be regarded as a crime. Mr. Martin. — I should like to know just how long a child's night should be. Our family rules for bedtime have been based altogether on guesswork. Mrs. Ross. — That seems to be the case in most fam- ilies, and it is aniazing to see how the guesses vary. There are established standards, however, which parents cannot afford to ignore. SLEEP REQUIRED FOR CHILDREN OF DIFFERENT AGES Recommended by Dr. T. D. Wood in Health and Education. AGE HOURS OF SLEEP TIME IN BED 5-6 13 6.00 p.m. to 7 a.m. 6-8 12 7.00 p.m. to 7 a.m. 8-10 iiy2 7.30 p.m. to 7 a.m. 10-12 II 8.00 p.m. to 7 a.m. 12-14 103^ 8.30 p.m. to 7 a.m. 14-16 10 9.00 p.m. to 7 a.m. 16-18 9^ 9.30 p.m. to 7 a.m. 18-20 9 10.00 p.m. to 7 a.m. 70 HEALTH AND THE SCHOOL Here is a table which shows the number of hours chil- dren of different ages should be in bed. The estimate is a liberal one, and with certain vigorous children could be reduced half an hour without harm. It may also be remembered that the amount of sleep needed in summer is somewhat less than that needed in winter, very pos- sibly because of the greater amount of fresh air most children get in their sleeping rooms in warm weather, Mr. Martin. — I should be much interested to know how you would lay out the hours of the day for a ten- year-old child. Mrs. Ross. — Supposing that the time and length of the school session were to be modified, as we have sug- gested, and the school occupations properly adapted to the children, a daily program such as this would be wholesome for a ten-year-old child : 7.00 — 7.30 a.m. Dress 7.30 — 8.00 a.m. Breakfast 8.00 — g.oo a. m. Light household duties and trip to school 9.00 — 12.00 a. m. School 12.00 — 12.30 p.m. Return home. 12.30 — i.oop. m. Dinner i.oo — 1.30 p.m. Rest and light occupations 1.30 — 2.30 p.m. Outdoor play and return to school 2.30 — 4.30 p.m. School 4.30 — 5.00 p.m. Return home 5.00 — 6.00 p.m. Piano practice, entertaining. Younger chil- dren: housework or other useful employ- ment 6.00 — 6.30 p.m. Supper 6.30 — 7.30 p.m. Household fun 7.30 — 8.00 p.m. Preparation for bed 8.00 — 7.00 a.m. Sleep Mr. Young. — As our closing time has arrived, we can take but a moment to sum up the many important points which the evening's report has brought out. A SCHOOL CHILD'S DAY 71 Physical zvelfare and groziHh the chief consideration. — The underlying principle, as I take it, in laying out the day's occupation for a school child is that every item in the program shall be scientifically adjusted to his physical capacity and wholesome growth, and that, even when this adjustment has been made, constant guard must still be kept by both parents and teachers to make sure that the demands of the daily program are not causing strain. Allowance for abundant physical activity essential for good health and good school work. — In the planning of a wholesome school schedule, abundant allowance must be made for muscular activity, as this is the most natural form of activity for children, and the means which brings their brains into the most energetic play. Frequent rest and recreation necessary to avoid fatigue and insure good digestion. — As children become fatigued very easily it is necessary to make their hours of work short and diversified, and followed by frequent pauses for rest and play. Two periods in the day should be especially dedicated to rest and recreation — the times following the noon and the evening meals. Digestion is evidently one of the chief concerns of childhood, and should not only be protected from interference by school demands, but carefully promoted by an opportunity for ease and pleasure after each important meal. No less important than nutrition is sleep, which must also be guarded from the encroachments of school work and of social diversion as well. As compared with the needs of the child, it appears that the demands of the school have been given scant consideration this evening. The latter must, forsooth, make way at every turn for some demand of the child's mere body — his digestion, his sleep, and even his play! 72 HEALTH AND THE SCHOOL To what measures shall we teachers be driven? How can we get together our school exhibits and gather our fine files of examination papers if we aren't to put on the screws when occasion demands? I see only one way out of the difficulty. We must change our idea of what the product of the school should be. The torturing displays of midnight work done by pupils and teachers will no longer answer. Our rever- ently prepared and marked examination papers will have to go. What will there then be left to show what we've been teaching? Nothing but wide-awake, well-developed boys and girls ! Suggested Reading Arnold. School and Class Management, Part H, Chap- ter L Francis Parker School. Year Book, 1912. Holmes. The Conservation of the Child. Search. The Ideal School, Chapter VH-X. United States Bureau of Education. Provision for Exceptional Children in Public Schools. Wither. The Special Class for Backward Children. V COOPERATION WITH PARENTS IN SECURING MEDICAL AID Mr. Young. — Four weeks ago, when we learned that 87 per cent, of the Washington school children were in need of medical treatment, we were told that prelimi- nary steps had already been taken toward securing the treatment. To-night the committee having this matter in charge will report to us the result of six weeks' work. Miss Parsons. — Before beginning our campaign we investigated the various methods of securing medical aid which were employed by cities having school med- ical inspection. We were astonished to find in many instances how little follow-up work was being done, and how small was the proportion of defects treated to the number discovered. Many reports placed great em- phasis on the large number of defects found, and these discoveries were apparently regarded as sufficient evidence of the usefulness and efficiency of the inspec- tion system. In one large city, for instance, the depart- ment of health could not show evidence that, of 65,000 children whose parents had been notified of their de- fective condition, more than 8.5 per cent, had been treated. To avoid the danger of any such fractional result from our work, we realized that we must have the actual interest and cooperation of the parents. Parents of all 73 74 HEALTH AND THE SCHOOL kinds and conditions, when convinced that a certain course is for the good of their children, will do almost anything and suffer almost any sacrifice to accomplish it. A formal official notice, however, which invites a parent to have his child treated for a defect of which he has never before heard, does not carry much convic- tion, and in the great majority of cases is ignored. Most parents know little of pathological conditions, and are very properly timid about trying experiments on their children's bodies. Our problem, then, was to gain the confidence of the parents and to teach them how their children's health could be improved. We accordingly decided to reinforce the usual formal postal card notification with a little personal influence.* For this purpose we employed two nurses, to whom we gave records of the physical exam- ination and the recommended treatment for all the de- fective children. A few days after the formal notice of a child's defect was sent to the parent one of the nurses either visited the home or invited the parent to consult her at the school. In these personal interviews the nurse was able to make parents understand the nature of the defects from which the children were suffering and the necessity for having them treated. In most cases she advised the parents to consult the family physi- cian. When a family had no regular physician and no means to pay one, she suggested a dispensary. When the parents were unable to take children to a dispensary, she took them herself at their written request. The results of this personal work, which has thus far been carried on only six weeks, are very remarkable * Based upon an investigation in New York City by the Bureau of Municipal Research in 1908; reported in A Bureau of Child Hygiene. COOPERATION WITH PARENTS 75 — 90 per cent, of the children who needed treatment hav- ing already been treated by either doctors or dentists. Of the 412 children who needed treatment 227 have been treated for all their defects; 144 for one or more defects, the remaining- defects to be treated as early as it is possible; while 34 children are waiting for treat- ment, which will be given as soon as it can be arranged for. This accounts for all but seven of the 412 children. In these seven cases, constituting less than 2 per cent, of the entire number, the parents would not consent to treatment for their children. You see by these figures that we have gained the active cooperation of more than 98 per cent, of the parents, Mr. Ross. — Such a high percentage seems to me al- most incredible. Your nurses must have spent more time on each case than the ordinary school board could afford to allow. Miss Parsons. — On the contrary, I think you will see in a moment that our methods can be actually dupli- cated in the ordinary school, and that 98 per cent, of co- operating parents and even 100 per cent, is exactly what may be generally hoped for. As you know, our experi- ment has been carried on for the sole purpose of estab- lishing for all our schools an effective and economical method of following up cases needing medical treat- ment. The fact that our methods have been new, the nurses untried in this educational work, and the dis- pensaries unprepared to handle the unusual number, has made our work considerably slower and correspondingly more costly than it need be when it has become estab- lished. In spite of this handicap the cost of the nurses' service per child treated was only 60 cents. The amount of work done was really small, compared with the im- portance of its results. It required but one interview 76 HEALTH AND THE SCHOOL with parents, half of whom came to the school, to bring about the treatment of 61.6 per cent, of the children; two interviews per case resulted in the treatment of 28 per cent, of the children; in only one case, which was 0.2 per cent, of the whole number, was a third interview required. The result of our experiment has brought out the fol- lowing facts : 1. Parents who have been made to understand the se- rious nature of their children's defects gladly respond to advice concerning treatment. 2. The cost of personally enlisting the parents' inter- est through the work of nurses is not prohibitive. It can be made materially lower than 60 cents per child treated. 3. The securing of facilities for treatment is still a problem. There are no agencies in our town for pro- viding reliable treatment, between the two extremes of the expensive practitioner and the charitable clinics and dispensaries. Some means must be devised either by our city government, our charitable agencies, or some other organized groups of citizens, for providing skillful medi- cal, surgical, and dental treatment for children at mod- erate cost or possibly at no cost at all. Mr. Young. — These conclusions have so important a bearing on improving the health of our school children that I should like to hear them further discussed. Miss Parsons had left us with no doubt that parents who are properly informed as to their children's defects will do all they can to correct them. She has also shown us that a very effective way of educating parents is through the work of school nurses. Their assistance is evidently in- dispensable for the following up of cases. Nurses, however, are far from being the only means COOPERATION WITH PARENTS 77 of rousing parents to an active responsibility for their children's health. The educational possibilities of even formal official notices to parents have not been generally realized in this country, though excellent use is made of such notices by many cities in Germany. The city of Wiesbaden first devised a letter now in use in forty Ger- man cities, which is sent to parents before any physical examinations are made. It invites the cooperation of parents as follows : "For the better protection of the health of children attending the public schools, school doctors have been engaged to undertake the medical inpection of children on entering school, to be re- sponsible for their health as long as they attend the school, and responsible, too, for the school building from the point of view of the pupil's health. "These provisions will be of great use, both to the children and their parents. In the course of his education much will be learned with regard to the health and bodily conditions for each child, and this new knowledge, which is being gained now for the first time, the school doctors will put at the disposal of the parents, with whom henceforth they will work in the interests of the children. "Parents who, however, do not wish that their children should be examined by school doctors have a right to exempt them, as the nevr provisions do not refer to educational matters that are in any way compulsory. Such parents, however, must furnish the necessary information from their own doctor." Accompanying this letter is a request that in case the examination is agreed to, the father or mother or guar- dian of the child shall be present at the examination. This insures the immediate understanding of their chil- dren's defects. Mr. Ross. — Is this letter generally well received ? Mr. Young. — So well that 96 parents in 100 agree to the school examination. In Leipzig three-fourths of 7 78 HEALTH AND THE SCHOOL the parents of defective children act at once on ad- vice offered. Only 3.5 per cent, neglect a second warning. Miss Parsons. — While we are waiting for equally ef- fective systems to be established in the schools of our country, a strong educational influence can be exerted upon the home by principals and teachers through the children themselves. An observation recently made in Philadelphia shows how effective the sympathetic co- operation of a school principal may be in securing treat- ment for children. Two schools having the same inspecting physician and school nurse showed a difference of 50 per cent, in the number of defective cases treated during three months. The only radical difference between conditions in the two schools was that in the one the principal was indifferent to the work of the medical inspector, while in the other school the principal used active influence to carry out the inspector's recommendations. The methods employed by the cooperating principal were personal in- terviews, talks to classes, and addresses at parents' meet- ings in which he explained the children's defects and urged their treatment. Mr. Ross. — The second principal took a very impor- tant step when he called the parents together. In addi- tion to the excellent methods already proposed, I was about to suggest an association of parents and teachers whose object would be the promotion of children's wel- fare. Notable work has already been done by such or- ganizations in many cities, conspicuous among which are Boston and Philadelphia. Meeting at the school, the members of these clubs join with the teachers in considering the best ways of fulfilling their common task — the building up of citizens. COOPERATION WITH PARENTS 79 The organization provides a center where advice can be sought and found and where study courses and lectures on health are made the means of presenting systemati- cally the knowledge that most parents sorely lack for the wholesome up-bringing of their children. Not only are such clubs potent means of educating their own members, but they are powerful agencies for securing wholesome school conditions for the whole community. The problem of persuading parents to give their children necessary treatment does not exist among members of an efficient parent-teachers' organization. Mr. Martin. — I have just been thinking that means ought to be found for doing away with this problem altogether. Though our discussion to-night has centered around the main question of how to persuade parents to give their children needed medical attention, and we have learned a number of effective means for accomplishing such persuasion, it seems to me that any system of per- suasion should be regarded only as a temporary make- shift. Must society always remain dependent on the mood or will or intelligence of individual parents for the health of its growing citizens? A child belongs to the state more absolutely than to its parents. The security of its health is of more material importance to the state than to the parent. Should not the state, then, have authority to coerce a reluctant parent and compel him to do all that is necessary for his child's health? Must we not have compulsory health as well as compulsory education? Miss Parsons. — You have brought up a tremendous issue, Mr. Martin. There can be no doubt that compul- sory health will some day — and that not a very distant day — be as firmly established in our country as compul- sory education now is. The day, however, waits upon 8o HEALTH AND THE SCHOOL two things — a popular demand for compulsory health and facilities for its enforcement. We are all working" toward it now when we are edu- cating and persuading parents to have their children treated. Those cities that are beginning to have school and municipal dispensaries of various kinds are building up means for its enforcement. Indeed, there has already been one actual attempt made in one of our states to secure a law looking to the compulsory health of school children. In the winter of 191 1 a bill was introduced in the California legislature providing for the mandatory extension of "health and development supervision" to all the schools in the state, including the various state institutions for delinquents and defectives. Not content with the services of medical inspectors, the bill demanded that there should be "educators," experts in physiology, hygiene, and practical psychology, who could make a skillful diagnosis of the defective conditions of growth and development of school children. Such educational health experts who work side by side with skilled physi- cians are already employed in several California cities, notably in Los Angeles. The bill further provided for a State Bureau of Health and Development, whose function was to be the organ- ization and supervision of the state work, and the prose- cution of state wide investigation of the problems of hy- giene. The public schools were to serve as laboratories for the study of child hygiene; the normal schools were to train their students in educational hygiene; and the state university was to ofifer training for experts in hy- giene. The bill was splendidly conceived for uniting all the educational forces in the state for a sound and effective health program. It was warmly hailed by people who COOPERATION WITH PARENTS understood its promise of welfare for the next genera- tion, but, nevertheless, it met defeat without ever being brought to a vote in the House. So loud was the popu- lar clamor against it that the assembly committee to which it had been referred felt obliged to smother it. Mr. Young. — The popular clamor against such a valu- able measure can only be accounted for in one way. The people did not understand its significance and value. The defeat of that bill emphasizes the lesson that many ^OICNOEin) Location of Adenoids SHOWN X Adenoids cause mouih- breaihiirg. ■) \;p^ freouentcolds, i\yA^^^^^^^ and deformilv of Ihe jaw and chesh TTiev induce slupidilv and c^ko^ siunt mental ahd physical grovlh. DON'T LET Y0UR.CH1LB BE. ^O HANDICAPPEX1>. Removal of Adenoids 15 a simple and brief operation. GIVE. YOUR CHILD A CHANCE TO BRJE-ATHE PARENTS WILL HELP WHEN THEY KNOW HOW. Such graphic appeals as these will go far toward enlisting the in- telligent and active support of parents in a constructive program of child hygiene. From the Weekly Bulletin of Sanitary In- struction published by the Chicago Department of Health. 82 HEALTH AND THE SCHOOL reformers are slow to learn. It is useless for legislation to attempt to outrun public opinion. That same bill or one equally sweeping will yet pass in California, as in all our other states, but not till we get enough voters enlisted for it. Dr. Latta. — This work of enlistment is going stead- ily forward under the leadership of able officials who are demonstrating the value of health laws as they exist to-day. For example, in Rochester the health officer, by thoroughly enforcing the present health requirements, is constantly educating the whole city to insist on health rights not yet provided for by law. Convinced of his interest in their children's welfare and his knowledge of the best means to secure it, the parents of Rochester al- lowed him, even before he had the legal right to do so, to impose his own restrictions in granting working papers. Ohio in 1910 passed a law providing that a working certificate must certify that the child is in proper physical condition to do the work he is employed to do. This law is being strictly enforced in Cincinnati, where it is interesting to note that about 50 per cent, fewer working certificates are now being granted than there were five years ago. Mr. Young. — Rochester and Cincinnati are evidently solving the problem which we have had under discussion this evening — how to win the cooperation of parents in promoting the health of their children. Our discussion has brought out a number of important points which we may sum up briefly as follows : Under present laws school children cannot receive nec- essary medical treatment without their parents' permis- sion. Parents readily grant such permission when they un- derstand the necessity. COOPERATION WITH PARENTS 83 Parents can be successfully instructed by means of official bulletins; by the personal influence of nurses, teachers, principals, and children; by lectures, exhibits, and study classes given under the auspices of school boards or associations of parents and teachers, or any other organization whose object is the promotion of chil- dren's welfare. There is evidently no more hopeful field of endeavor in connection with children's health than educational work with parents. The success of such work, where it has been fairly tried, shows clearly that the real solu- tion of the problem of securing health for children lies in an enlightened parenthood. Suggested Reading American School Hygiene Association. Proceed- ings OF the Sixth Congress. The School Nurse as a Link in the Chain of Preventive Medicine. Health Problems Encountered in Home Visits to School Children. Denison. Helping School Children, Chapters VI-IX. Grice. Home and School. National Society for the Study of Education. Ninth Year Book, Part II. School Nurses. VI PROVISION FOR MEDICAL AID Mr. Young. — We have found that parents are eager to secure medical and dental service for their children when they realize the need for it. But how are they all to secure it? We met abundant difficulty in provid- ing treatment for even the 412 school children whose cases we reported last week. How can we get the re- maining 4,600 children looked after? Mr. Ross. — I think that burdensome question should not fall on the school to answer. Let the parents solve it individually. Mr. Young. — If they could, that would certainly be the simplest way. But many of the parents have not the time, intelligence, or money to seek out or to pay doctors and dentists who are qualified to treat their chil- dren. The average parent of restricted means is in a rather helpless situation. He is neither rich enough nor poor enough to command very good medical, surgical, or dental service. Mr. Ross. — What can you mean? Mr. Young. — Exactly what I say. I have the word of a prominent New York physician to the effect that only two classes of people in our country are at present getting the best medical service. These two classes are paupers and millionaires ; and, on the whole, the paupers 84 MEDICAL SERVICE 85 seem to come off best, because they are invariably treated in hospitals, where doctors demonstrate the latest meth- ods and every modern appliance is at hand. If our school children could be reduced to beggary the problem of providing them with medical treatment would be much simplified. As most of them, however, belong to self- respecting families who can afford to pay something, but not much, for medical service, the problem presses. Mr. Ross. — Won't the free dispensaries accommodate those who can't pay ordinary doctors' fees? Mr. Young. — Certainly, so far as their resources al- low. The charitable dispensaries were of great service to us in getting the Washington school children treated, but they would be swamped if all the needy school chil- dren in town were to apply to them. Mr. Ross. — What alternative is there, then? Mr. Young. — There is only one logical one. If our town is to make the health as well as the education of its children compulsory, as it doubtless will before long, it must supply means for the enforcement of health as well as education. Free professional aid, which includes not only diagnosis and treatment — medical, surgical, and dental — but advice as to daily hygienic living, regulation of diet, and necessary nursing, will have to be supplied to all children who need it or who prefer it to private treatment. Mr. Ross. — But that is socialism. Mr. Young. — Is it socialism any more than to supply free schools and textbooks? The community expends enormous sums on education to protect itself against ignorance in the coming generation. Can it invest fur- ther sums more profitably than in guarding itself against the burden of ill health in the next generation? Free medical treatment supplied by town or state for the sake 86 HEALTH AND THE SCHOOL of securing sound citizens is no more a charity than is pubHc school education. The safeguards to health that our community is al- ready providing are nowhere considered socialistic or as exploitations of rich taxpayers for the benefit of poor ones. Our sewers, our garbage collection system, our street cleaning, our present expensive draining of the outlying swamps, and all our other sanitary enterprises are being cheerfully supported by the taxpayers for the sake of fostering the health of the whole community. When, in spite of such general sanitary precautions, the health of any individual fails, is it not for the best in- terest of the public to supply prompt and effective rem- edial measures? Dr. Latta. — England has certainly concluded that it is. Who would have believed a short time ago that the year 1913 would see a free public medical service thor- oughly established in England? Mr. Young. — Personal medical treatment at public expense, and public sanitation are really not different in principle. The health of every person in the community is the thing sought for in each case. Since the burden of ill health of any of its members falls on the whole com- munity in the long run, it is far more economical for the town or state to pay whatever sums are necessary for preventing or checking sickness than to suffer the back- breaking cost of unchecked disease. The present free distribution of vaccine and the various antitoxins for diphtheria, tetanus, meningitis, and typhoid is notable evidence that society has already found out the profit there is in laying out money for the prevention and cure of these formidable "catching" diseases. It will not be very long before it is recognized to be worth while for public medical officers to treat, at public expense, any MEDICAL SERVICE 87 form of sickness that may arise in the community, or at least to exercise supervision over the cases where pri- vate treatment is preferred. Mr. Ross. — What about the private doctors? Will they ever consent to letting their patients slip out of their hands in any such wholesale fashion? Dr. Latta. — Not just yet, certainly. Bellinzona, a town in Switzerland, not long ago tried to municipalize its medical service, with the result that 56 of the 58 private doctors went on strike. Lloyd-George in Eng- land has also encountered some difficulty in securing medical care for the beneficiaries of his new social in- surance system. The British Medical Association was incensed at the medical provision in the act and threat- ened a general boycott. In a war between doctors and patients, however, the latter have the unconquerable advantage of numbers. The handwriting has already appeared on the wall, and the shrewdest as well as the most public-spirited of the younger men are preparing themselves for the field of public health service, where the greatest usefulness is to be attained, and the highest laurels are to be won. Mr. Martin. — While we are waiting for the enlight- ened day of free medical service, what can we do to meet the immediate exigencies of our school children? Mr. Young. — The most effective course that has been found in attacking such a wide public need is to call together city officers and representatives of as many private welfare organizations as possible for the purpose of formulating a concerted campaign. Until this most important step is taken it is impossible for a town to estimate its resources. A study recently made in New York City has revealed an amazing number of agencies (119) whose energies can be used for the welfare of 88 HEALTH AND THE SCHOOL SOME OF THE EXISTING AGENCIES, PRIVATE, PUBLIC, AND SEMI- PUBLIC, WHICH CAN BE UTILIZED FOR IMPROVING THE HEALTH OF CHILDREN Adapted from a Compilation by G. Stanley Hall I. Hygienic ' Fresh Air Work Milk Commission or Depots Public Baths and Gymnasia Societies for the Prevention of Tuberculosis II. Recreational Boys' Clubs and Camps Girls' Clubs and Camps Park and Recreation Commissions Playground Associations Shut-in Societies Vacation Schools III. Relief for Sick Children Children's Hospitals, Dispensaries, Convalescent Plomes Diet Kitchens District Nurses Free Dental Associations Institutions for Crippled, Epileptic and Nervous Children IV. Child Welfare Children's Bureau Medical Inspection of Schools Open-air Schools Parents and Teachers' Associations Public Education Associations Visiting Nurses V. General Welfare Conferences, Surveys, and Exhibits Relief and Aid Societies Women's Clubs MEDICAL SERVICE 89 school children. The amount of money these agencies spend for the direct help of the schools is not less than a million dollars. Seventy-six of them offer direct, con- tinuous, and gratuitous cooperation with the schools. The report on this study shows further how by cooper- ation and central supervision of some kind the efficiency of these private agencies can be enormously increased. I recommend this report, as well as a further study re- cently made, which covers communities throughout the country, as most instructive examples of how to make every possible agency count for its maximum in carrying out any welfare program.* We have in our own town a number of charitable societies, social improvement clubs, home and school as- sociations — lately formed — and medical organizations of various kinds. Each one of these societies is interested to see a health program for our school children carried out. By uniting their efforts they can go far toward doing it. At an informal conference which we have al- ready held, the officers of these various societies pledged their influence to forward the school children's health movement and particularly to gain the cooperation of their clubs in securing the treatment which the children now need. The plan is as follows : The Woman's Club is to pay for three nurses who will treat the children's minor ail- ments, give home instruction, and assist in surgical cases. The Dental Society is to provide free service three af- ternoons a week until the needy children now requiring attention are cared for. The Society of Physicians and Surgeons is similarly to guarantee medical and surgical * Outside Cooperation with the Public Schools of Greater Neiv York, Bureau of Municipal Research, New York. Helping School Children, Elsa Denison. go HEALTH AND THE SCHOOL treatment; the Home and School League is to bear the cost of medicines and dental and surgical appliances, and the town hospital to accommodate, free of charge, the children whose cases call for more than a day's nurs- ing. While this plan is not an ideal one, making as it does so many of the children dependent upon charitable en- terprise, it is, nevertheless, an enormous step in advance for us. Not only will our children get the treatment they need, a great good in itself, but, owing to the wide publicity that will be given to the work of the various clubs, the whole town will be impressed with a striking lesson in the public's responsibility for the health of its growing members. Mr. Ross. — Is such a program as you describe in actual operation anywhere? Mr. Young. — To be sure, with many local variations of course. In a number of communities philanthropic efforts, which are the conspicuous feature of our pro- gram, have already served their temporary purpose and been succeeded by public enterprises. The inauguration of free dentistry in the schools of 48 of our cities is one of the direct outcomes of initial charitable work; so is the appointment of over 500 school nurses in more than 150 cities, as well as of many public nurses in rural com- munities. The recent establishment of divisions of child hygiene in New York and Philadelphia, as outcomes of philan- thropic endeavor, is the most notable step yet taken for the physical welfare of children by any cities in our coun- try. With an annual outlay of over $500,000, the bureau provides for the physical examination of all the school children, and aims to supply treatment to all children who require it and are unable to pay for it. In addition to MEDICAL SERVICE 91 these concerns it watches over the sanitary conditions of both home and school, gives home instruction in the care of children, and provides milk stations where pure milk can be bought at moderate cost. This pioneer work is of great significance ; it will exert a profound effect on all our American cities. In many cities which have not yet taken the advanced position of New York, philanthropic societies are co- operating effectively with the school authorities in secur- ing medical treatment for children. Los Angeles, in the arrangements which it completed in 1912, has developed a combination that is giving great satisfaction for the present. The school board of that city, with the aid of the Children's Hospital Association and the Parent- Teachers' Association, stands prepared to give freely to needy children whatever expert medical attention they require. The treatment is given in two perfectly ap- pointed buildings erected by the School Board on land belonging to the Children's Hospital, the salaries of doc- tors and nurses being paid by the Parent-Teachers' As- sociation. One of the buildings is equipped to accom- modate various kinds of cases that can be treated in a single day. Here the children's eyes, ears, noses, throats, and teeth are treated by both men and women doctors and dentists. Circumcision is also provided for. In the second building, which is a carefully conducted hospital, children may remain as long as necessary, the Parent- Teachers' Association paying the bills. Miss Parsons. — Los Angeles may well regard this thorough provision for its children's health with pride. The plan indicates an advanced sense of public duty with respect to children, but the arrangement, liberal as it is, has not yet reached its final form. Eventually all the school children will be free to come for treatment 92 HEALTH AND THE SCHOOL and the city will pay all the bills. Los Angeles, as well as other similarly disposed cities, will in time shake it- self free from dependence on any charity, such as the Children's Hospital Association, for the care of its chil- dren, and it will furthermore cease to single out un- fortunate children to become recipients of special town benefactions. Mr. Ross. — But why shouldn't the poor children be the ones to receive these benefits? They certainly need them, and the others don't. Mr. Young. — Such an arrangement is essentially un- democratic. All children have a right to health as well as education, and none should be humiliated by securing it under conditions of special dependence. Many so- called charities, both private and public, are a constant confession of injustice in our social and industrial sys- tem. Mr. Ross. — That's a queer sounding remark, Mr. Young. What would become of the social order with- out the leaven of charity? Mr. Young. — We don't want to part with chanty, Mr. Ross, but with certain injurious forms which it now takes. Some of our charities actually encourage social injustice by alleviating and hiding distress which should be heralded abroad as indications, for example, of impossible living wages or deadly housing conditions. Mr. Ross. — The charity that provides medical treat- ment for poor school children can hardly be charged with shielding greedy employers and landlords. Mr. Young. — Possibly not — but, however that may be, the children of a community should not be dependent for their health on the voluntary offering of certain citi- zens. To be sure, with the many forms of injustice still operating in society, we cannot as yet spare the MEDICAL SERVICE 93 direct benefactions of generous men and women who are blazing the way for pubHc benefactions that will be received as a right. Universal justice, when it comes, will mark a far higher stage of social evolution than is possible under a regime of private charity, however princely. Justice, for instance, demands that every hu- man being shall have health as a right and not as the voluntary offering of his neighbor. Miss Parsons. — And is not this view daily gaining wider acceptance? Cooperation among those concerned, and not dependence on an outside agent, is proving to be the only sound basis for any permanent social better- ment. In our war on disease we are beginning to real- ize the tremendous power that lies not only in organized philanthropy, but in organized common effort that is not dependent on philanthropy. The valuable health measures that many of our states and cities are adopting, such as the suppression of com- municable diseases and the care of tuberculous cases, are activities, democratic in the sense that they are not de- pendent on philanthropy, but not yet democratic as re- gards the distribution of benefits. The free public care of the sick and the distribution of remedies and prophy- lactics are still limited largely to actual dependents or impostors. To be thoroughly democratic a general tax for the treatment of disease should carry with it the right of every taxpayer to profit by it. Dr. Latta. — Such a democratic scheme, carried on privately, it is true, is proving remarkably successful in the University of California, where 4000 students receive expert medical care, minor surgical treatment, and pre- ventive advice for a flat fee of $3.00 a year. The doctors and surgeons, employed in this cooperative service, are very able men, receive good salaries, and are highly 8 94 HEALTH AND THE SCHOOL pleased with the opportunity of pursuing their profession, free from the harassing consideration of fees. Mr. Young. — On even a larger scale has been the work of certain semi-public cooperative societies, notably the very successful sickness insurance companies of Germany. In our own country the life insurance companies have been the most conspicuous leaders among non-charitable organizations in a nation-wide campaign against disease. To take a single example, in 1909 one of our leading in- surance companies launched the novel plan of nursing its sick policyholders and destroying the diseases that threatened them. Though the contract of the company calls only for the payment of a death benefit, the directors believe it is profitable as well as humane to postpone the death of policyholders by laying out money to keep them well. To this end they inaugurated a thorough educational campaign, as well as an actual nursing sys- tem by which nurses' services are supplied promptly and without cost to sick policyholders as long as there is need. The records of the company already show innumerable cases where distress has been relieved, lives saved, and earning capacity restored by the work of the visiting nurses. The extent of the service has been enormous. In the first six months of 191 1 there were over 320,000 visits made by nurses in 473 cities and towns. The company is planning to extend its work over the entire country at an annual cost of over $500,000. In addition to providing nurses' care for the sick, this company distributes health bulletins that reach regularly about 15,000,000 people. When tuberculosis is found the sufiferers are given every practical direction that modern science offers for a successful fight against this disease. Suggestions for diet, clothing, and daily habits MEDICAL SERVICE 95 are plainly set forth, along- with photographs, designs, and specifications for inexpensive sleeping porches and all other arrangements for open air living. Simple and thorough directions are also supplied for preventing the spread of disease. It is in the line of prevention that the company is probably doing its most remarkable work. Realizing the immense economic ad- vantage of preventing disease rather than curing it, the officers provide policyholders with sound and practical directions for the sanitary care of their homes and fam- ilies. Even the children holding policies have been or- ganized into a Health and Happiness League, whose pledge is a series of promises that make for the health and happiness of the members and all whom they meet. Miss Parsons. — The health campaign of this life in- surance company, conducted as it is on a gigantic scale and by the most expert methods, is a profoundly signifi- cant thing. Here we have open to 6,600,000 men, women, and children in one organization alone, a great benefaction, whose basis is not charity but business pol- icy. The benefaction is regarded not as a privilege but as a right, for the cost of it is maintained by the people who are benefited. Such thorough work as this insur- ance company and others are doing will undoubtedly serve as a model for whole communities that are begin- ning to realize the economy of promoting health. Dr. Latta. — In the meantime the full resources of the life insurance companies should be brought into play in the work of health education. The extent of their influence is enormous. Our leading companies have a trained force of 80,000 medical examiners — a greater force than our standing army — as well as 20,000 agents, all of whom are constantly at work among 20,- 000,000 policyholders. The educative power of these 96 HEALTH AND THE SCHOOL great organizations has as yet hardly been tapped. In fact, we must turn to the fire insurance companies to gain a really adequate idea of the incredible saving from loss that can be accomplished by a scientific course of prevention. Let me quote Professor Irving Fisher in this connection : "The fire insurance companies maintain a laboratory at Chicago, where building materials are tested as to fire resistance, and they have done so much in the way of fire prevention that the insurance rate on cotton and woolen mills, for instance, has fallen from $3.00 to $4.00 per $1,000 to 7 cents! The life insur- ance companies can do as much to prevent disease as the fire insurance companies have done to prevent fire." Mr. Ross. — I should like to know whether the experi- ment of the life insurance company which Mr. Young has cited has paid financially. Mr. Young. — That cannot be definitely determined for some years, though there are already strong indica- tions that it has. In a number of cities, for instance, where the nursing service has been conducted, the death rate has decreased much more than it has done in other cities of the same size and similar industrial conditions but unprovided with nurses. The managers are confi- dent that events will prove the economy of their course, which they declare is the only practical way of meeting the responsibility they owe to the people who support the company. They believe that a life insurance com- pany must actually insure life, if it is to prosper in the end, and that the time is passing when the people will tolerate the grim irony in the term life insurance which is now taken to mean death insurance. Dr. Latta. — There is little reason to doubt that re- MEDICAL SERVICE 97 ducing death losses through health conservation will prove highly profitable to insurance companies. Certain insurance statisticians have calculated that an outlay on health of only i per cent, of the annual income would save enough lives to give the companies a profit on the investment of at least 100 per cent. Mr. Young. — Some such organized protection of health as the insurance companies are developing will in time gain general adoption. Whether the protection can best be provided by private insurance companies, or such government-supervised societies as are now flour- ishing in Germany, or through direct public administra- tion by state, as in England, are questions of method that will gradually be adjusted. Whatever final form these organizations may take, they will necessarily be established and conducted according to two fundamental principles which have already made themselves very clear. These principles have as vital application to our own lit- tle question of treating the town school children as to the largest health problem before the human race. It will be worth while to state them. I. The best and most economical machinery for con- serving health can he operated only by strong organiza- tions which can command the services of experts in medicine, education, and scientific management. Since it is to the interest of all society as well as to the individuals directly concerned that the most effi- cient and economical machinery be employed for keep- ing every one in health and exterminating every disease, society for its own protection will be compelled to de- vise means not only for bringing organized methods of treating and preventing disease within the reach of all, but of compelling their use. General health taxation of 98 HEALTH AND THE SCHOOL one kind or another, and general free treatment of dis- ease, will be the final result of this necessity. The first public step in this direction will be medical aid for school children at public expense. Mr. Ross. — I can't see why they should have it. It isn't at all democratic to make one set of people help pay the bills resulting from the indiscretions of another set of people. Miss Parsons. — You cannot dismiss the causes of children's diseases by calling them indiscretions. They have far more sinister names than that. These are poverty, vice, ignorance, and mismanagement. The pub- lic schools themselves, we have found, are among the agencies that are needlessly injuring the health of our children. Should not the town and state that control the schools, and which have compelled the children to attend them, at least be required to repair the untoward damage inflicted through compulsory school attendance? And, further, should not society as a whole pay the cost of the poverty, vice, and ignorance which it peniiits to prey on the health of its weakest members, and through these on the health of all? Those who suffer most from such afflictions have least power to remove them. The curse can never be lifted unless the whole of society gets under the load. Mr. Young. — Taxation on account of the preventable sickness of others, in addition to being fundamentally just, has the further advantage of serving as a power- ful stimulus to the stronger members of society to re- move the causes that are dragging the whole structure down. It is only by bringing the handling of disease under public administration, making the cost of it a public burden, and, furthermore, the reduction of it the chief motive to those who treat it, that we can hope to MEDICAL SERVICE 99 reduce sickness to a minimum. This brings us to the second principle which must govern the effective con- trol of disease. 2. Si7ice the stamping out of all preventable sickness and the upbuilding of health are aims of far greater consequence in any organized health program than the mere treating of such sickness, it is necessary to provide physicians tvith sound economic motives for giving their best endeazror to positive health culture and to the pre- vention rather than to the cure of disease. Our present method of employing doctors merely to attend us in illness, and not to keep us from contracting it, is an appalling handicap to the usefulness of the profession. The ordinary private physician is in a hope- less dilemma where his professional zeal for reducing the sickness of mankind conflicts vitally with his very real need of patients. In spite of this clash of inter- ests many of our physicians, led by high ideals of public service, are taking time from lucrative practice to give unpaid help to the various health movements. How much more might these men accomplish if such public work were made their actual profession and not the efforts of a few stolen minutes ; if their highest public service were made to harmonize with their own private interests. Mrs. Ross. — In that case the children's specialists would win their laurels not from the number of desper- ate cases they had snatched from death, but from the number of children they had kept from sickness alto- gether. Dr. Latta. — Exactly. Our greatest children's doctor would be the wisest counselor in child hygiene, and not necessarily the most skillful wrestler with mortal dis- ease. Where the "treating" physician at his best can lOO HEALTH AND THE SCHOOL save but a hundred lives, the efficient hygienist may save ten thousand. The pubHc does well when it captures the best pri- vate physicians for the wider field of public service and rewards them appropriately, with both honor and in- come. If the health of society were in the hands of wise public physicians who were free to put into prac- tice all the sanitary knowledge now available, and whose salaries were to be increased as the number of patients diminished, sickness would flee from the earth at a pace we can never hope for under our present benighted sys- tem of paying a premium on it. Mr. Ross. — I can't see where you will stop if you begin to give free medical care at public expense. Why not nourishing meals and airy bedrooms as well? Miss Parsons. — Why not, indeed, if that were the most efifective way of obtaining these prime necessities? Society can ill afford to let any of its members lack them. Since they are universal daily needs, however, they can be obtained only by universal daily effort. No insurance organization can be devised to feed all its members every day. The treatment of the sick, on the other hand, is an occasional burden pressing heavily on but a few individuals at a time. A slight general tax, which would burden no one, would insure all against the risk of disease. Sick benefits are absolutely different in principle from daily dispensations of bread and butter. Mr. Young. — The question of good food and hous- ing which Mr. Ross brought up is not, however, out of place in our discussion of the treatment of defective children. While, as Miss Parsons says, there is no way for the ordinary man to dodge the responsibility of working for the reasonable necessities of life, it is fur- ther true that thousands work hard for them and never MEDICAL SERVICE loi get them. In fact, the problem of securing healthful living conditions is far less simple than the question of medical care. It involves the government regulation of wages, of trusts, of food preparations, of housing conditions, of unemployment, of child labor, and nu- merous other economic puzzles. Mr. Ross. — If the w^hole matter is so involved as you indicate, what good will a little free medical treatment do, anyway? If the cause of school children's ill health lies in bad living conditions, seeing the doctor isn't go- ing to help. Why shouldn't society solve its funda- mental problems instead of going to a lot of expense in patching up mistakes? I must confess that I can't see why free medical service for the public in general, and for school children in particular, is a whit more im- portant than scores of other benefits which every one would like to have but can't. Mr. Young. — The health of the public in general and of school children in particular is the very core of the nation's life. We cannot wait for the social readjust- ments to take place that will insure healthful conditions for all. The school children are suffering now; the coming generation is threatened now. It is not a ques- tion of pauperizing individuals ; it is a question of sav- ing the strength of the state. This lesson has just been dearly learned by England. The Boer war revealed an appalling decline in the vigor of her manhood. Why? Because for three generations she was indifferent to the physical welfare of her children and their working par- ents, who were wearing out their lives in the mills. Our own country is as yet full of fresh life. How can we best preserve it? By giving a free hand to our doctors, who should be our public servants, responsible to the public not only for the cure and prevention of I02 HEALTH AND THE SCHOOL our diseases, but for the upbuilding- of our national health. Suggested Reading Bureau of Municipal Research^ New York. Outside Cooperation with the Public Schools of Greater Nezv York. Dawson. Social Insurance in Germany. Denison. Helping School Children, Chapters HI, IX, XHL GoRST. Children of the Nation. Hall. Educational Problems, Part H, Chapter XI. Seager. Social Insurance, Program of Social Reform. VII TEACHING CHILDREN THE ART OF HEALTH Mr. Young. — Our last two discussions have con- vinced us that the chronic diseases and defects of school children which have until very lately been ignored can be properly treated only by the schools taking a hand. Provision for necessary treatment and enforcement of it are evidently among the greatest responsibilities of public schools to-day. There is one responsibility still greater. This is to teach children how to be well. Medical treatment, while indispensable, is only repair work. Much that is now needed would be unnecessary if the children had lived under proper conditions and practiced healthful habits. Far more important, then, than the patching up of im- paired children is the duty of teaching children how to keep out of the repair shop altogether. To give sound health training is the most important educational work of the schools. We have been teaching hygiene for many years, but have we ever succeeded in developing hygienic habits among our children? Why haven't we? Because we have presented the subject as a theory of health and nothing more. What our children need to learn is the art of health. How to convert the theory into practice is what we wish now to consider. 103 104 HEALTH AND THE SCHOOL SCOPE AND METHOD OF HEALTH INSTRUCTION With a view to getting new life into our health in- struction, both at school and at home, I wish to submit to your approval a few recently developed standards as to matter and method in teaching hygiene. Let us first consider the amount and kind of the instruction that should be given, together with the relation this should bear to the rest of the curriculum. We will then discuss special methods for enlisting the cooperation of the chil- dren in practicing what they learn. CONSTANT INSTRUCTION WHICH IS CORRELATED WITH OTHER STUDIES So important is it for everyone to have as thorough and practical a knowledge of hygiene and sanitation as possible that these subjects should be kept before pupils throughout their school course. This should not be done by presenting them as isolated studies. Since daily prac- tice, and not the storing up of theory, is the great object in view, it is necessary to bring the principles of health- ful living into closest possible connection with all the interests and activities of children. These principles can be brought in naturally with a score of school oc- cupations and studies : weather observations, games, and festivals, nature study, primitive life, industries, and discussions of social and ethical questions. Mr. Ross. — Do you think such incidental attention to these subjects would be enough? Is it not necessary for the children to make some separate textbook study of them? Mr. Young. — To be sure, children need a certain HEALTH INSTRUCTION 105 amount of book study to focus and coordinate the ideas which they should be receiving constantly through other sources. Good primers of hygiene and sanitation are indispensable aids in health instruction. Their contents should, moreover, be largely mastered before the sixth grade is reached, in order that the school deserters, who flock off at that year, may be included in this instruc- tion. Textbook study, however, should never be regarded as an end in itself. Books on hygiene and sanitation are most valuably employed when used as reference books in studying subjects of more vital appeal than abstract health. The stuSy of home life or town and country industries, for example, offers many interesting problems which can be solved only by acquiring a fairly thorough knowledge of certain phases of hygiene and sanitation. The children consequently consult books on health to find out facts that they are eager to know in their broader connections, and thus receive a strength of impression quite impossible were the same facts to be arbitrarily set before them as lessons to be learned. Mr. Ross. — Has everything in the schools got to be dressed up so that children shan't know they are work- ing? Mr. Young. — We are not trying to beguile the chil- dren into work, Mr. Ross. We are merely offering them sound motives for putting forth their efforts. Do grown people work without good reason? Why should children? It is a profoundly immoral thing to make children perform what seem to them irrational tasks. Is not the wisest and most reasonable disposition of his time the thing that marks the man of highest de- velopment? Is not the hopeless misdirection of his ef- forts the mark of the inefficient man? Are we teachers io6 HEALTH AND THE SCHOOL to dull the natural discrimination of children and train them to inefficiency by setting them at work which to them has no value? Surely the more important a sub- ject of instruction is, the more important is it that this should be presented in a way to appeal to the children's active interests. TECHNICAL STUDY IN THE HIGHER GRADES After the fundamental principles of hygiene and sani- tation have been acquired in the earlier grades, the up- per elementary and high school grades may offer more technical study through manuals dealing with first aid, care of young children, methods of public sanitation, and prevention of disease, but this more special study should be conducted for the most part like the earlier health study. It should still be made incidental to broader in- terests, such as history and civic life. Mr. Ross. — Your scheme may be ideal, but is it prac- tical? I should fear that teachers and pupils would get so hopelessly tangled up in trying to weave all their strands of knowledge into one garment that their minds would be in great danger of going bare. Have these extraordinary theories ever really been put into practice ? Mr. Young. — They have, indeed. I was about to re- fer to a detailed outline of just such health instruction which is now being successfully carried on in Speyer School, New York. I have here, in fact, a brief outline for work in the eighth grade of this school. The whole program, which is published in Teachers' College Record, May, 1912, will prove immensely suggestive to teachers who are trying to put life into health instruction and don't quite know how to do it. HEALTH INSTRUCTION 107 HEALTH IN ITS RELATION TO LIFE Approach : Interest in Community Life Through the Study of History and Civics General Scheme I. The meaning of health. (October) I. The relationship of health to citizenship. II. How does it pay to be well? (November) 1. A personal consideration. 2. A civic interest. 3. Why good health pays. III. The value which the school places upon health. (December) IV. How the city protects its citizens. (January) 1. Health protection. 2. Protection of property and rights. 3. Protection against accidents. (February) 4. Protection against disease. V. National protection. (March) VI. What keeps people from being well? (April) 1. Accidents. 2. Disease germs. 3. Unhealthful work and surroundings. 4. Bad habits. VII. Some personal and civic problems. (May) OUTLINE OF HEALTH STUDY FOR THE EIGHTH GRADE IN SPEYER SCHOOL, teachers' COLLEGE, NEW YORK. Mr. Ross. — I shall try to reserve my judo^ment until I have seen this publication. In the meantime may I io8 HEALTH AND THE SCHOOL ask why you have made no mention of physiology? Has it "gone out," too? Mr. Young. — Physiology presented as an isolated de- scription of the body and its functions has gone the way of Greek and certain forms of mathematics. It does not serve the purposes of a common school education. A detailed knowledge of physiology has about as much bearing on ordinary health practice as a mastery of cal- culus has on bookkeeping. Physiology as a separate study is a subject for specialists. If the high schools wish to offer a course in this subject they should make it elective. The limited amount of physiological infor- mation necessary to give force to the principles of hy- giene can easily be introduced as illustrative material in the study of the latter subject. It must always be remembered that the actual test of successful health instruction is not the passing of exam- inations on scientific textbooks. It is in the wholesome condition of the children. Clean teeth, skin, hair, nails, and clothes make up some of the evidence. New York City sets these items as its first requirements for credit in hygiene, which is now necessary both for graduation and for promotion from grade to grade. SEX INSTRUCTION As opposed to physiology there is a natural science which has generally been reserved for high schools and colleges, but which, in simplified form, can be brought down to the elementary grades with great advantage. This is the science of biology, which serves more ad- mirably than any other means to give children a sane and reverent attitude toward the supreme function of all living things, the imparting of life to others. In this HEALTH INSTRUCTION 109 study, which begins with the simplest living forms, chil- dren come to realize deeply the wonder and the beauty of the universal natural provision for extending life through sex and parenthood. Such an attitude is essen- tial for a proper reception of the specific sex instruc- tion which the schools are beginning to recognize as their duty to offer. Preparation for family life and parenthood should un- doubtedly be one of the chief concerns of the school, and this responsibility rests in part, though not wholly, upon those responsible for health instruction. "Thus, in connection with lessons upon filial duty, self-respect, personal dignity, patriotism, obligations to posterity and to the race, conscience, purity, and religion, the facts of sex life have their proper place." * Mrs. Ross. — May I inquire as to the extent to which it is considered wise to carry sex instruction into schools ? Mr. Young. — That is a hard question to answer, Mrs. Ross, because much that is desirable to bring into the schools is it not yet wise to introduce. Instruction by outsiders throws undue emphasis upon the subject; and few teachers at present have the experience and training or the natural fitness to carry out the delicate task of leading children to think frankly and wholesomely about sex matters. That does not mean for a moment that we may not yet develop teachers fit for this task. The normal schools have a great responsibility in this matter. It is within their power to fill the schools in a few years with teachers who have the necessary information and the right attitude concerning sex facts to be helpful guides to growing children. Until such teachers are generally provided for our schools, however, it will be impossible * C. R. Henderson, Education with Reference to Sex. 9 no HEALTH AND THE SCHOOL to lay down any set program for such instruction. As much harm may come from forcing it as neglecting it. At present each school system will have to be guided by its own limitations and opportunities, bearing in mind, of course, constantly the program that, under ideal con- ditions, should be carried out. As to what this program should contain, there is a fairly general agreement among our educational leaders who have seriously studied the question. This is well summarized in a set of recommendations sent out by the Society of Sanitary and Moral Prophylaxis. These are as follows : ITEMS WHICH SHOULD BE INCLUDED UNDER SEX INSTRUC- TION Every boy and girl has a claim to knowledge : (i) Of the functions and hygiene of the chief organs of the body, including the reproductive system. (2) Of the meaning of sex, marriage, home-making, of the sacredness of the prenatal life, the influences of heredity and the consequent duty of right living, even when young; of the re- sponsibilities of parenthood. (3) That handling the organs of reproduction, except as necessary for cleanliness, injures sometimes health and always mind, character, and sense of honor, causing greater mental and moral harm as one grows older. (4) Of the most prevalent contagious diseases, such as tuber- culosis, syphilis, gonorrhea; their danger as indicated by stat- istics of wide prevalence ; their many methods of communication ; including the fact that syphilis and gonorrhea exist almost universally among those leading immoral lives ; a reason for avoiding such men and women as one avoids those with diphtheria and smallpox ; that they are more difficult to cure than any other contagious disease and that their harm is more far-reaching. (5) Of the normal phenomena of adolescence; the physi- ologic influences on health, mind and morals of clean thoughts, reading, conversation, entertainments, companions ; the value of occupation and physical exercise in keeping thoughts and habits HEALTH INSTRUCTION iii and health good ; the avoidance of tobacco, alcoholic drinks (in- cluding patent medicines, many containing alcohol), the adver- tisements of "doctors" and "remedies" found in newspapers, magazines, etc. Every girl has a claim to instruction concerning the hygiene of menstruation, the function and sacredness of motherhood and the care of infants. Every boy has a claim to instruction concerning the value of conscience, and avoidance of ignorant and evil advisers in this matter; the sacredness of fatherhood, and the duty of protecting all girls and v^^omen from evil as he would his sister or his mother. The physiology and hygiene of sex, when successfully taught, is an essential part of the course where it logically belongs. It must not be interjected. Mr. Martin. — I must say that this list of items strikes me as a rather overwhehning array of facts to set before our children. Must we part with all idea of youthful innocence ? Mr. Young. — Have you any idea how many of our public school children over eight or ten are youthfully innocent? Probably not one in twenty. They know the things they should not know and they don't know the things they should. Can the school any longer evade the responsibility of directing their natural and irrepres- ible interest in sex matters along proper channels? Miss Parsons. — We must bear in mind that if chil- dren do not get proper sex instruction in the elementary schools, 93 per cent, of them are likely to get it nowhere. The elementary school is the only school that this vast majority of American children ever attend. HOW TO MAKE SEX INSTRUCTION COUNT May I add a word also about the program for sex in- struction which Mr. Young has just read. It perhaps 112 HEALTH AND THE SCHOOL seems somewhat bald and over-emphatic with regard to the repulsive and negative side of the subject. This side cannot be ignored, of course, but it need not be unduly emphasized and indeed, as I happen to know, it was far from the intention of those who framed this program that it should be. The matter of emphasis is in the hands of the teacher as is also the entire success of such a pro- gram which requires to be carried out with careful wis- dom. . In order to succeed, the teacher must be con- stantly guided by two fundamental considerations. The first is that high and beautiful ideals, such as are most vividly embodied in some hero, are far stronger incen- tives to right action than anticipated punishments. The pathology of sexual misdeeds should accordingly not re- ceive as much emphasis as should the high satisfaction and honor which come from following a difficult but self-respecting course. The second consideration is that injunctions as to right conduct cannot possibly result in right conduct unless opportunity is given to carry them out. A course of action must accordingly be opened to boys and girls which will make it possible for them to put into operation the difficult instructions that have been laid upon them. If girls are told to guard their health during menstru- ation, the schools must help them do it by relaxing de- mands of attendance and preparation of lessons when necessary. If boys and girls are instructed to be modest and restrained in each other's presence, the schools must give them the chance to meet and practice those virtues in parties and dances held under favorable auspices. Many schools in New York City and elsewhere are al- ready doing this for their young people. If boys are ad- vised to check their sexual desires they should be pro- vided with other exciting outlets to their growing ener- HEALTH INSTRUCTION 113 gies. Wholesome fads of all kinds, such as airships, electrical experiments, boat-building, and photography, should be encouraged by the schools, in addition to the valuable standby, athletics. COOPERATION OF PARENTS NECESSARY Dr. Latta. — Making such wholesome provision for boys and girls as you indicate gives an opportunity for the closest kind of cooperation between school and home. There is no point in health instruction or moral instruc- tion — the two are inextricably associated — where it is so indispensable that the efforts of parents and teachers shall be mutual. Parents are unable to meet the respon- sibility alone — so are the schools. Parents, as a rule, are not well enough informed themselves to give their children all the instruction they need ; on the other hand, the schools cannot know as parents can when individual inquiries as to sex facts begin. The first question very certainly marks the time for the first instruction, which should be given frankly, ten- derly, but briefly by parents in prompt answer to specific questions put spontaneously by their children. It is not at all necessary to go into physiological detail in the early years. Children do not demand this, but they do insist on having the fundamental mysteries cleared. If they cannot persuade their parents to enlighten them they go to the turbid fountain of information, the street, where they acquire the most sacred facts of Hfe in a solution of poison. Definite school instruction even in the first grade cannot be sure of anticipating street in- struction. The cooperation of parents in this matter is vital. It is necessary that they end once for all the sense of forbidden mystery which at present makes 114 HEALTH AND THE SCHOOL school instruction in the physiology and hygiene of sex a self-conscious and uncomfortable thing. Mrs. Ross. — How are parents to be persuaded to break their habitual silence on these matters? Dr. Latta. — We cannot hope, I suppose, to revolu- tionize the practice of all those who are now parents, though parents' meetings with frank instruction and dis- cussions have already resulted in a partial change of sentiment. Many fathers and mothers are beginning to appreciate the wonderful opportunities that the first in- nocent inquiries offer them for cementing the love and confidence already existing between themselves and their children; and, on the other hand, to realize the grievous blow which they strike both at themselves and their chil- dren if they repulse the childish confidence which prompts the early questionings. Before a complete change in parental feeling can be effected, however, a new generation of parents must be reared, and this fact gives the schools a present respon- sibility of double weight. For the best thought on sex instruction, which com- bines a rare ideality with a close practical knowledge of needs and methods, I recommend to your further study Professor C. R. Henderson's report on Education with Reference to Sex.* ESTABLISHING HEALTH HABITS Mr. Young. — Miss Parsons' appeal for the school to afford means for boys and girls to practice the moral and hygienic precepts they have been taught brings us to the question of how to convert health instruction into * Eighth Year Book, Part II, of the National Society for the Study of Education. HEALTH INSTRUCTION 115 health habits. To do this successfully we must recog-- nize the three forces which are most powerful in direct- ing conduct, and consequently in establishing- habits. Briefly stated, these are (a) example, (b) motive, (c) continuous practice. The teachers and parents who do not constantly heed these fundamental springs of action will not proceed far in their critical task. Example. — Dr. Latta startled me last week by telling me that if I wanted the school children to stand straight I'd have to stand straight myself. I had inadvertently failed to apply what I knew well enough, that example was the most potent of all educational influences. Al- though we hear much rhapsodizing about the true edu- cation being an unfolding from within, and a leading out (e-ducing) of one's inner gifts, the fact remains that education is largely a laying on from without, and a drawing in to one's self of the knowledge and ways of ethers. Since this process is the main business of the forma- tive years, it is a most fortunate coincidence that chil- dren want more than anything else to be as other people are and to do as others do. Their natural tendency to imitate other people is immensely increased by admira- tion, and when children are lucky enough to admire their parents and teachers they strive to imitate these heroes and heroines in every possible way. All the personal tricks are faithfully reproduced, posture, breathing, chewing, smoking — in fact, every act on which the ob- servant youngsters can get any data. While this ten- dency is in full swing parents and teachers have no diffi- culty in persuading children to adopt healthful habits if they show their own respect for them by consistent observance. Mr. Ross. — That puts a mighty burden of responsi- ii6 HEALTH AND THE SCHOOL bility on us all, doesn't it? Must our children's desirable habits be limited to those they see us practicing? Haven't we a right to expect the new generation to be an improvement on the last? If not, how does social evolution operate? For instance, it is too late for me to make over my own habits of eating, but I don't in- tend to have my children bolt their food as I do. Mr. Young. — You have expressed very frankly an attitude of parents and teachers that is a perpetual stumbling block to children and that keeps social evolu- tion from operating more rapidly than it does. Parents and teachers are not necessarily finished human products. Should not they and their children struggle on, hand in hand, to conquer the difficulties and win the rewards of life? Mr. Martin. — If, among the difficulties, you include that of thorough mastication, I can commend Mr. Young's plan. We have adopted chewing reform in our family with pronounced success. My sister and I entered into the game with the children, and we all vied with each other in making record chews. It is far sim- pler to socialize a reform like this, making it a family or class effort, than to attack the difficulty individually. Our youngest child, it is true, was now and then careless about the rules of the game, but one punishment, an impressive one, was all the help he needed. He was not allowed to finish his supper. Though he was almost through with it, the effect was as thorough as starva- tion. He has been our star chewer ever since. Mr. Young. — The measure which impressed Mr. Martin's small son with the advantage of mastication illustrates the second influence we noted as leading chil- dren to form good habits. Motive. — If a dog performs his trick nicely you give HEALTH INSTRUCTION 117 him a caress or a biscuit. By a system of rewards and discouragements you easily lead him to acquire all kinds of habits, which are known to you as tricks and to him merely as certain evolutions that bring about desirable results. This simple and thoroughly effective method of estab- lishing habits works just as well in the school or home as in the kennel. Children, like dogs, have a prefer- ence for doing things that are worth while. When they once become convinced that healthful habits are desir- able they will practice them to the end of their days. Mr. Ross. — Now what do you mean by desirable? It seems hardly fair to use arbitrary punishments and rewards to induce children to form good habits. If good and bad habits don't bring their own rewards and pun- ishments in good health and ill health, what do they amount to at all? Mr. Young. — To be sure. Children should be led as soon as possible to realize the tremendous profit that healthful habits yield, but before they are old enough to appreciate this they sometimes require very tangible evi- dence. A three-year-old hasn't had enough scientific training to realize the causal relation between imperfect chewing and dyspepsia. When he is deprived of his supper, however, he meets a concrete and instructive experience which is a symbol of what actually happens to some extent to every food bolter. Such expedients are, of course, necessary only in the very early years. Children are soon able to appreciate the priceless blessings that good health confers — beauty, prowess, fun, usefulness, earning capacity, friendship, happiness. This list makes a powerful appeal to grow- ing boys and girls, who do all in their power to win such prizes when they believe they know the way. ii8 HEALTH AND THE SCHOOL The Speyer School plan of hygiene instruction takes full account of these social motives. It is qualified at every step to arouse a desire on the part of children to keep themselves and their surroundings wholesome. I am confident that we cannot do better than to adopt a similar method for use in our schools. For the present, however, I believe we need to sup- plement this general plan with a certain amount of in- tensive work on health subjects. Since the Speyer School course is developed as a unit from the kinder- garten to the eighth grade, it will evidently be many years before all our children are able to receive the full benefit of such a course. It therefore has seemed es- sential that for a time we provide more special and striking opportunity for health study, so that the older children may not leave school without having gained a clear impression of its immense importance. The special program which we have already intro- duced takes account not only of pupils, but of parents and teachers, among whom it is highly necessary to arouse a new interest in health matters. A serious and practical attitude toward these concerns, I regret to say, is a rather new thing for us all. It is, therefore, highly important that we direct widespread, earnest, and im- mediate attention to them. The only way to do this is to disregard temporarily certain ideal pedagogical con- siderations and frankly resort to successful advertising methods. This is exactly what we are doing. Our problem is to make all our children and their teachers and parents see as promptly as possible that wholesome habits are desirable. The only way to do this is to prove it to them. Lectures, exhortations, and pictures of drunkards' stomachs do not prove anything. Demonstrations do. Therefore, we are demonstrating. HEALTH INSTRUCTION 119 We are using our schoolrooms now not merely as lecture halls for teaching hygiene, but as laboratories, and the children themselves are serving as their own subjects of experiments. Our first step was to take the pupils and their parents into our plan and make them see what a valuable thing it would be for us all to find out surely whether hygienic habits bring about the good results that are claimed for them, and we showed them further that schools of sev- eral hundred children each furnish the best possible means for making such an investigation. As a first step we asked the children with the help of their par- ents to fill out forms, setting down their daily physical habits, their hours of sleep, frequency of baths, opening of windows at night, thoroughness of mastication, tea drinking, cigarette smoking, etc. Both children and parents responded to this request with surprising promptness and earnestness. When the reports were all in we held a few early evening meet- ings for both parents and children, at which physicians gave short talks on the laws of health. We then ex- plained that we wished, if possible, to establish the value of each one of these health laws, and that in doing this we should be greatly aided if every child who was found to be neglecting any of them would, with the aid of his parents, correct some single practice desig- nated by his school principal. Consent to this plan was heartily given and the experimental work began. On the basis of their reports the children were formed into groups, according to the single habit which varied most widely from standard. The flagrant tea drinkers, the short sleepers, the food bolters, even the cigarette smokers, agreed respectively to reform their one worst habit, leaving the other habits unchanged during the I20 HEALTH AND THE SCHOOL time of experiment (six weeks). I may say parentheti- cally that in rounding up the cigarette smokers we did not depend entirely on their own confessions. A little judicious detective work arranged between teach- ers and parents had been necessary both for discover- ing the smokers and for holding them to their prom- ises. One boy, who disregarded his promise, immedi- ately lost his place among the army of investigators. The school sentiment was so overwhelmingly against this deserter that no one has since ventured to break training. The children are immensely in earnest and will tolerate no insincerity or "faking" among their num- ber. Mr. Martin. — How are you expecting to show the benefits resulting from this six weeks' experiment? Mr. Young. — By two series of measurements taken at the beginning and at the end of the six weeks. These measurements include weight, height, lung capacity as tested by the spirometer, and nervous energy as indi- cated by a hand dynameter. These methods of testing the children's physical con- dition have been chosen because they are thoroughly practical for dealing with large numbers. They are somewhat crude, of course, and even with our closest care will doubtless permit a certain amount of error to appear in our results. It has already been a little dis- concerting to observe that some members of our "mas- tication squad" have lost weight since they began to chew more thoroughly, and that a few of our tea drink- ers are showing increased nervousness since they dropped their tea. These cases are due to exceptional causes, however, such as sickness, toothache, and domestic up- heavals of various kinds. They will not seriously mar the success of our experiments, since the number of chil- HEALTH INSTRUCTION 121 dren taking part in them (5,000) is large enough to make an average result contain but a small percentage of error. The children understand that they cannot ex- pect to see a miracle performed in every child or in every class. They are accordingly waiting with great in- terest for the returns from the other schools, where chil- dren of the same age are cooperating in the same experi- ment. Mr. Ross. — I must confess that Mr. Young's scheme strikes me as very interesting. I should fear, though, that the unusual excitement brought about in the schools by this novel experiment would entirely demoralize the ordinary school work. How has that been going for- ward since the "training" began? Mr. Young. — Your question brings up one of the most interesting facts in connection with this experi- ment. The school work during this time has been car- ried on with a vigor and enthusiasm quite unknown in my previous experience. Realizing that the health experiment, as long as it lasted, would be the consum- ing interest both in the schools and the children's homes, we have related most of our school work to it. First of all, we have provided for a considerable amount of direct study of hygiene, based on recent excellent textbooks in that subject. In addition to this, the other studies have all been connected with the present pre- vailing interest of the school. The arithmetic work has been based upon the numerical aspects of the laws of health, such as amounts and proportions of food and hours of sleep, and upon tabulations and calculations of the various measurements made on the children. Much of the actual measuring and recording has, in fact, been performed under supervision, by the children themselves. The reading and composition work has centered on 122 HEALTH AND THE SCHOOL health matters, and even the history and geography have been brought into hne by being made the occasion for studying the Hving conditions of other times and cHmes. It is the first time we have ventured in our schools to depart from formal tradition and to carry out the modern idea that school work should be inspired by a vital and immediate motive. So successful is our ex- periment proving, however, that we shall later arrange some such general program for a thorough study of home, school, and town sanitation. We shall not confine this instruction to what the books declare ought to exist. We shall supplement such theoretical knowledge with a scrutiny of the actual con- ditions in our town, including our schools and homes. The children will look into the matter of how their own homes are ventilated ; they will find out whether their schools are cleaned by dry or wet sweeping; they will discover the mosquito-breeding places in their neighbor- hoods, and they will be made responsible, whenever pos- sible, for looking after certain sanitary details in their homes and schools and neighborhoods. They will study public sanitation by seeing how the trolley cars in which they ride are ventilated, how the town streets are cleaned, how the color of the water in the river changes at the points where the sewage flows in ; and by comparing local sanitary provision with the best methods in use elsewhere for securing the people's health. They will learn what "bacterial count" means and how it indicates the purity of our water and milk supplies. They will conduct bacterial experiments them- selves, and see how the conditions of our milk and water compare with safe standards. Some of the children will make excursions to the filter plant of the neighbormg town and bring a report of it to their schoolmates. In HEALTH INSTRUCTION 123 a hundred ways they will learn what sanitation really is and how it pays. Mr. Ross. — This is all very excellent, but it seems to me that you have made an unwarranted assumption in taking for granted that children really value health much, and that they will adopt sanitary practices when they are convinced that these will result in health. They certainly will not if they are like my boy. His health is the last thing he ever thinks of. Except as his mother controls him, he is absolutely reckless of it, as indeed most boys are. Mr. Young. — I don't doubt it, but it is not because he doesn't like to be well. When the actual possibility of pain and disease confronts children their bravado van- ishes. Have you ever seen a panicky youngster holding his breath, gallop by a quarantined house in mortal fear that a germ would catch him? Children do not need to be convinced that health and strength are things they want. Their skepticism is usually directed against the means for securing these blessings. In impressing the desirability of health habits on the children we are not confining their attention to the profits they themselves derive. We are making it clear to them that the benefit is shared by many others, those in their families and schools, and, in fact, the whole town. They see that the less sickness each child has, the less of the family income melts into the hands of the doctor, the less the work of his class is interrupted, the less strain and possible sickness his mother and brothers and sisters and neighbors suffer. The moral obligation of keeping one's health, the chil- dren are discovering, is as soundly based as that of any other virtue. Truth telling and honesty are accounted virtues merely because they contribute to the general 124 HEALTH AND THE SCHOOL good. Individual good health, they see, contributes to the general good no less than these. To fail in health when others depend on you is to break a promise; to spread contagion is to steal. Good health, like honesty, is the best policy. Continuous Practice. — The best examples and the most powerful motives, while they are effective aids in initiating habits of health, are not always sufficient to fix them. There is only one swift, sure way to do this. I will ask Miss Parsons to discuss it. Miss Parsons. — Parents and teachers who really want results must resort on occasion to the military method of obtaining them. They must not allow lapses in conduct. Mr. Martin. — But how can they prevent occasional lapses? Children aren't under observation all the time. Miss Parsons. — They ought to be. Mr. Ross. — What ! Do you mean that our poor chil- dren are never to have any rest from supervision, or the patient teachers and parents from incessant super- vising? Miss Parsons. — You put it rather unsympathetically, but that is just what I mean. A thoroughbred race horse is never left to his own devices. He is too valu- able a creature. What about a child? Until he has ac- quired a reliable bent it is the most reckless folly to turn him absolutely loose. An hour of unsupervised play can make mischief for a lifetime. Mr. Martin. — Your idea is so novel that I hardly grasp it. Do you actually mean that all children, rich and poor, should be watched and guided all the time? Do you believe for a minute that such an arrangement is possible? Working parents cannot keep their eyes on their children much of the time, and, as for the HEALTH INSTRUCTION 125 teachers, they already have more work than they can do Miss Parsons. — Let us have play leaders, then. There are various ways of giving children more super- vision than they now have. Lengthened school hours, which provide for directed play as well as work, super- vised playgrounds and recreation centers, these all tend to increase the time that children are wholesomely em- ployed under responsible guidance. Mr. Martin. — I find it hard to give up the idea that the rough and tumble treatment which children give each other free from their elder's scrutiny is the best part of their education. Miss Parsons. — That cherished conviction is very widely held, but it has no basis in fact. Unsupervised play among boys of different strengths always crowns the bully who has the muscle to support his claims. It is also in their unwatched moments that children give each other liberal instruction in vice, which is a part of almost every public school child's present education. Mr. Martin. — I fear that this is undeniable, and yet, won't all this supervision take the spontaneity out of our children? Miss Parsons. — Far from it, if the supervision is of the right sort. A good play leader encourages all the wholesome impulses of children. By enforcing fair play he actually liberates unsuspected powers in the more timid children, who would stand no chance at all in the* free for all scramble of unsupervised play, Mrs. Ross. — Children's play has an effect on character no less marked than upon physique, and if we do not make sure for the children that their play shall be right- minded and friendly as well as physically safe, we may be wronging them more deeply than if we were to ex- pose them to physical danger. In Gary, as you remem- 10 126 HEALTH AND THE SCHOOL ber, the schools and grounds are open under supervision all day for the special purpose of saving the children from the demoralizing street and alley. The Gary chil- dren so far have lost none of their spontaneity, but they have been spared a great deal of viciousness and cigarette smoking. Mr. Young. — Our discussion seems to have wandered to the question of enforcing moral as well as health hab- its, but after all, these two sets of habits are intimately associated. The method of enforcement, eternal vigi- lance, is the same for each. When parents wake up to the truth that habits, not half-forgotten facts, are the actual fruits of education, and that children's habits are being formed every minute of the day, they will manage to work out some plan whereby every one of these min- utes shall be wholesomely directed. In closing, let me call your attention to the valuable training in health habits that is being carried on through the Public School Athletic League in New York. Ten thousand school boys in the spring of 1913 were prepar- ing to take part in the great demonstration of the league to be held in June. To a man, they voluntarily adopted and rigidly kept the following set of health rules : Go to bed at 8 P. M., after a thorough wash. Scrub the teeth and gums thoroughly. Have your clothes and books ready for the next day. Keep your bedroom windows open top and bottom. Rise not a minute later than 7 A. M. ; take two minutes for drill and hygienic exercise. Clean face and neck and scrub hands. Finish with a cold splash all over. Rub yourself hard all over. No cofifee ; no tea ; drink milk, a little at a time. Chew your food to a pulp. No smoking. HEALTH INSTRUCTION 127 Then look yourself over and ask yourself: Am I clean from head to foot? Do I stand up like an athlete? Suggested Reading American School Hygiene Association. Proceedings OF the Third Congress. The Problems of Hygiene and the Province of the Normal School. The Teaching of Hygiene. Proceedings of the Fourth Congress. New Principles in the Teaching of Hygiene, The Teaching of Sex Hygiene. Proceedings of the Fifth Congress. The Consecra- tion of the Affections, Often Misnamed Sex Hygiene. Some Suggestions for a Course of Study in Hy- giene. Denison. Helping School Children, pp. 233-246. Health Education League. Health Education Series. Journal of Educational Psychology. Hygiene Num- ber, October, 191 1, Nature Study Review. February, 1910. Teachers' College Record^ May, 1912. VIII HEALTH SUPERVISION IN SCHOOLS Mr. Young. — In 1890 the little western city of San Antonio established a system of so-called school medical inspection. Four years later Boston, with its neighbor- ing towns, Brookline and Cambridge, took this step. In 1902, twenty-three cities had taken it; in 1912, four hun- dred and forty-three cities were conducting some form of medical inspection * and in 1913 it is estimated that eight hundred cities were doing this. The health super- vision movement is sweeping the country, and is about to capture our own town. The work which our club has been directing for the health of the school children has aroused the citizens, and they are demanding that public measures be taken for accomplishing in all the schools what we have done experimentally in two of them. These measures cannot be arranged overnight. We must plan them with closest care if we would escape the blunders already made by scores of cities which have rushed uninstructed into the health business. While health supervision is a vital improvement that has come to stay in the schools of our country, it has not yet passed the experimental stage. It has still no general standards. Each city evolves its own method, which is * What American Cities Are Doing for the Health of School Children. — Russell Sage Foundation. 128 HEALTH SUPERVISION 129 12 10 09 08 07 06 05 02 nn 1 4 5 8 9 11 17 23 28 37 55 77 111 167 263 400 411 443 THE RISE OF SCHOOL HEALTH SUPERVISION. often SO inadequate that its chief benefit seems to be the air of progressiveness which its name imparts to the town. A preliminary survey of this field has been made by Miss Parsons. We shall hear her report to-night. Miss Parsons. — Without in the least discrediting the health supervision movement, I must admit that the fruits it has so far borne are not yet commensurate with the stir it has made. The towns we have visited have displayed a wonderful variety of systems which, with a few most hopeful exceptions, are so rickety that they would not be tolerated at all under any private business management. The main trouble is that most health su- I30 HEALTH AND THE SCHOOL pervisors have not yet found out just what they want to do or how they want to do it. Their program is vague; their methods more so. There is only one proposition on which all are united. No one disputes that the purpose of health supervision is to promote the health of school children. From this point on we encounter amazing divergence. There are no generally accepted standards of what constitutes health in school children ; of what are the best means of preserving and building up their health ; or of restor- ing it when impaired. Such problems of technique have been largely overlooked. Notwithstanding this temporary maladjustment be- tween purpose and method, the prospect for sound health supervision throughout the country is bright. Within the year all our largest cities have made distinct ad- vances in the efficiency of their systems, and here and there, in various states, smaller cities and coun- try communities have forged out excellent devices for meeting special problems. By coordinating the best experience thus far available we shall be able to establish a very effective system for our own town. To-night's discussion will be devoted to our projected health supervision program; our next discussion will be given to the best methods of carrying it out. The general aim of health supervision in schools is to guard and develop the health of pupils. The means for carrying out this aim are fivefold : 1. Medical inspection, examination, and aid. 2. Sanitary supervision of school buildings and homes. 3. Hygienic regulation of school and home activities. 4. Health instruction of pupils and parents. 5. Physical education of children. HEALTH SUPERVISION 131 MEDICAL INSPECTION^ EXAMINATION, AND AID The distinctively medical division in a system of health supervision should be responsible for the standing as well as the progress in health of all pupils. To this end, it must provide for the periodic physical examination of pupils in order to determine what form of physical de- velopment or corrective treatment they may require. It must also provide for inspection for contagious disease at stated intervals, as well as at such other times as cir- cumstances may call for, and it must fix and enforce quarantine in cooperation with the board of health. Finally, it must not only keep a thorough current record of the health condition of all pupils but enforce and pro- vide, when necessary, the proper treatment of all disease and removable defects discovered. The necessity for guarding against contagious dis- ease in schools is so apparent that, when a school sys- tem begins to take any special measures for its chil- dren's health, its first step is invariably to establish some form of inspection for such disease, the main purpose being to discover each case as promptly as possible in order to exclude it from school. The motive of such inspection work is merely commu- nity protection, and is not based upon a concern for the sick children themselves. This necessary precautionary work is as much as many systems up to the present have undertaken. Some cities, however, recognizing the need of attend- ing to the individual health of children, now require, in addition to the regular inspection service, a partial or thorough examination of every school child, to deter- mine his state of health and development. A little more 132 HEALTH AND THE SCHOOL than half of the cities which require examinations are satisfied with a record of eye and ear difficulties. The examination work that we have done experi- mentally in our own town has left us in no doubt, how- ever, of the tremendous importance of finding, with a view to their correction, all the chronic defects which are handicapping our children. The need of correcting the defects thus discovered, and, indeed, of treating properly all illness, slight or serious, which affects school children, indicates the third demand that rests on the medical division of a health supervision system. This is either to arrange for or actually to give medical, surgi- cal, and dental treatment to all the children who need it. Mr. Martin. — Aren't you talking revolution. Miss Parsons? If there is one regulation on which our com- mittee has found practically all medical supervision sys- tems united, it is the emphatic order that school physi- cians shall not only give no treatment, but offer no advice as to treatment. Miss Parsons. — ^Was there ever a more short-sighted policy? Why waste these doctors so? The one big thing that most of them are as yet trained to do is to treat disease. All the medical schools still lay their chief stress upon this function. Why should we deprive the doctors of opportunities for service, compelling them to eke out their incomes by doing nurses' work — you will see next week that inspections and, to some extent, examinations are nurses' work — when the best use they can make of their time at present is to treat the school children? Mr. Ross. — Would not such a course tread on the toes of the family physician? Miss Parsons. — That is one of the theories, to be sure, on which school treatment is so vehemently op- posed, but the theory doesn't hold water. It has been HEALTH SUPERVISION 133 overwhelmingly demonstrated, in our country and abroad, that private practitioners are not called upon widely to treat school children, even when the schools have discovered the need. Dr. Latta. — We must admit, however, that New York City in 191 1 made an exceptional showing in this regard. Fifty-eight per cent, of school children treated there received treatment at the hands of private physi- cians, the remaining forty-two per cent, depending on hospitals and dispensaries. Miss Parsons. — But even when private doctors are extensively called upon, which is not often, a large pro- portion of them leave the children in worse condition than they found them. Have the schools a right, do you think, to send the children off to practitioners who are likely to harm them ? Mrs. Ross. — What an extraordinary idea. Miss Par- sons. You have made an appalling statement. Does Dr. Latta hold the same opinion? Dr, Latta. — Unfortunately, I do. The fees that physi- cians receive are, to some extent, an index of their com- petency. Can you expect a man who earns his living by making bedside visits for twenty-five cents to handle cases as competently as the two or three-dollar man ? Mrs. Ross. — But the poor can't pay more for medical service for their children. Dr. Latta. — Exactly, but can society afford to let the majority of its young citizens — the poor are always the majority — depend upon the kind of medical treatment poor parents can afford? Miss Parsons. — Fortunately, perhaps, the poor par- ents, as we stated, do not call widely on private physi- cians when their children's defects are discovered. Dis- pensaries and clinics of some kind must invariably be 134 HEALTH AND THE SCHOOL pressed into service to secure anything like an adequate amount of treatment for the mass* of school children. The confusion, delays, difficulties, and often the impos- sibility of providing treatment in such institutions which are under the supervision of neither school nor health board, make the arrangement extremely unreliable. On the whole it has proved a failure. A medical inspection and examination system that, in spite of proved experience, continued to trust to the hazardous cooperation of outside agencies or irrespon- sible physicians for carrying out its own recommenda- tions comes pretty near to being a farce. Most of the systems in our country, until very lately, have been of this order. If ours is to take higher rank it must pro- vide for the treatment as well as the examination of the children. Dr. Latta. — We shall not be absolute pioneers in such an undertaking. The schools are everywhere be- ginning to realize the necessity for providing prompt and proper treatment for pupils, not only for the benefit of the children, but for the sake of raising their own efficiency through the resulting improvement in the at- tendance and the energies of the children. True, not many American cities have as yet developed satisfac- tory arrangements for providing treatment, but the number of those making a start in this direction is in- creasing every day. The day is even now in sight when school dispensaries will be general. Miss Parsons. — The largest cities are already pro- viding nurses' rooms, where slight accidents and ail- ments are treated by the nurses. This arrangement alone is an immense advantage to the schools, obviating as it does the necessity of wholesale exclusion for minor contagious diseases, which formerly were a fertile source HEALTH SUPERVISION 135 of truancy and often resulted in the complete demoral- ization of the school. In New York City, school exclu- sions have been reduced from 57,000 in 1903 to slightly over 3,000 in 191 1, and this in spite of the great in- crease in the number of school children in that time. Forty-eight cities have school dentists and a few have dental nurses whose business it is to give prophylactic care to the children's teeth. New York City is conduct- ing eye, ear, and dental clinics and is considering the es- tablishment of dispensaries for the treatment of other de- fects. A few cities, among them Los Angeles, as you remember, are conducting polyclinics where all non-in- fectious ailments and defects can be treated. The tech- nique of the whole problem of children's clinics and dis- pensaries has been well worked out both in Europe and in our own country.* Mrs. Ross. — You would not, I suppose, advocate com- pulsory school treatment? Miss Parsons. — Certainly not, unless parents failed to secure necessary and satisfactory private treatment for their children. The determination by the school au- thorities of what may be called satisfactory treatment is, of course, a matter for very wise adjustment. How- ever that may be arranged, I would at any rate advocate a more extensive follow-up system on the part of nurses than is commonly practiced. If it is worth while to follow up any case of sickness or defect, it is worth while to follow up every case. The little illnesses that ordi- narily pass off without the attention of a physician — ■ the short "bilious spells," the digestive upsets, the slight colds, the headaches — all of which play havoc with school attendance and school work, should be subjects of special attack on the part of the school nurse, who * Medical Inspection of Schools, Chapter XV. A. H. Hogarth. 136 HEALTH AND THE SCHOOL can do much by tactful home instruction to prevent their future occurrence. The more serious cases should, of course, also be recorded, and the school authorities satisfied through the inspecting nurses that proper treat- ment is being provided. Mr. Ross. — Are you not introducing too much pa- ternalism into your system? Miss Parsons. — No paternalism at all, Mr. Ross. Would you say that our democratic system of public education is paternaHstic ? Why, then, should you regard the enforcement of health as a less democratic procedure than the enforcement of learning? If the school is to carry out its essential purpose of developing useful citi- zens, it cannot afford to take any chance on their health. It is the business of the medical corps to see that no chances are taken. sanitary supervision of schools and homes Sanitary supervision of schools has for some time been recognized as an essential safeguard to the health of school children. It will not be necessary for us to- night to review the program of school sanitation, having discussed this at some length in an earlier meeting * I wish, however, to emphasize the need of fixing definite standards of home sanitation, and of extending the sys- tem of sanitary inspection to include homes as well as schools. Unless wholesome surroundings are to be regarded as luxuries merely for school hours, supervision of home sanitary conditions is fully as important as the super- vision of school conditions. Efforts to improve home conditions have already been made by visiting nurses * See Chapter III. New Britain Spotless Town Crusade ''^"conn:^ Does your back yard look like this? If so, why not clean up before Easter Sunday ? Dirty yards cause tiles, sickness, death. Old tin cans hold water; water breeds mosquitoes. Rotten garbage makes bad air, bad air makes weak bodies, weak bodies make big doctor's bills. What you can do to help make New Britain a Ciean City Take away all the ashes and dirt from your back yard immediately. Send your rubbish to the dumping ground. Clean out your cellars, stables and sheds. Whitewash your cellar walls, fences and hen-houses. Bum all rubbish that will bum. Clean your vacant lots and alleyways. Avoid mi.xing ashes and garbage. This is against the law. You may be fined five dollars. Refrain from throwing old paper, banana or orange skins into streets. Plant some grass and flower seeds to make your home beautiful. Every house should have a little green grass and a few trees. When you have cleaned up for Easter, KEEP YOUR YARD CLEAN ALL THE TIME. The Board of Public Works, City Hall Telephone 77, will furrish informa- tion concerning teams and dumps. This Is the Program April 8 to IS, Spotless Town Week; everybody clean up. April 9, Palm Sunday; all dirt from the winter carried away. April 14, Fast Dav, Holldav; all dirt carried away. April 16, Easter Sunday: let us make New Britain a city that is "AS CLEAN AS AN EASTER LILY " TOSEPH M. HALLORAN. Mayor. ■dr. henry T. bray. Health Officer. AUGUST BERGSTROM. Sanitary Inspector. HERBERT A. JUMP. Sec'y of Spotless Town. CIVICS AND HEALTH. The "Spotless Town League," composed of ten thousand New Britain school children, distributed this appeal and enlisted the entire population of 45,000 in a clean-city crusade. The appeal was printed on yellow paper in six languages. 137 138 HEALTH AND THE SCHOOL and teachers in many communities, but such work has thus far depended largely upon voluntary personal zeal or the occasional appeal of an especially needy case. Home inspection should be put on as sure and system- atic a basis as school inspection; for the school has a right to know the home conditions of all its pupils, and to insist, either through its own authority or that of other public agencies — health boards, housing officials, or. nuisance inspectors — that the children's physical sur- roundings shall not fall below a minimum standard for healthy growth. The actual records of home and neigh- borhood inspections, including such items as the condi- tion of streets, alleys, and vacant lots, and the drainage of pools and gutters, can be made of great direct value to the school children by serving as practical material for their own study of hygiene and sanitation. In a number of towns children have been successfully enlisted in a town-cleaning crusade. They take great pride in bearing a recognized part ir; a real town move- ment. The beneficial effect both on the town and on the children is quite incalculable. In this connection the achievements of Mrs. Caroline Bartlett Crane, of Kala- mazoo, "the Mother of Spotless Town," are well worth consideration. The success of this remarkable woman's work is due as much to her ability to educate citizens in the purpose and methods of public sanitation as to the actual sanitary work which she directs in their towns. HYGIENIC REGULATION OF SCHOOL AND HOME ACTIVITIES Questions of the relation between health and the ac- tivities and conditions of school life as well as the home life of school children, present almost a virgin field of school health supervision. Certain items which HEALTH SUPERVISION 139 belong under such general heads, as health of teachers, recess periods, and home study, have now and then re- ceived desultory attention, but these items and many others like them are fast shaping themselves into the whole general problem of securing a healthful round of twenty-four hours of activity, rest, and recreation for children. This is actually the most fundamental of all the questions involved in the health of children at school. When the contagious diseases are brought under con- trol, as they will be, and the school houses and homes cleaned up, as they will be, and a proper food supply secured, as it will be, the one great factor influencing the health of children will be the manner and conditions of their pursuits. We touched on a few of the most important matters under this head when we discussed a school child's day, the distribution of his hours of study, play, and rest, but our discussion, thorough as it seemed, dealt only with the fringe both of what is known and what is yet unknown in this comprehensive field. Though a hundred questions still wait for scientific determination, there are scores of facts thoroughly at- tested, which it should be someone's business to push through the hard-set doors of our schools. It is a fa- vorite pastime of school experts at present to contem- plate the unknown, and to formulate brilliant lists of questions still waiting answer in connection with the hy- giene of child life. It would be an even more brilliant exercise of their wits to secure the recognition of what is already known, and to make it the basis of school practice. Every one knows, for instance, that a cheerful, friend- ly schoolroom atmosphere is an essential condition for health, and that healthy, cheerful teachers are in- dispensable to this arrangement, and yet how many I40 HEALTH AND THE SCHOOL schools are taking measures to keep their teachers well and happy? Every one knows that it is an unnatural strain for little children to be kept sitting in repressed silence for hours every day, but the schools aren't let- ting up much on this curious method of developing citi- zens. Every one knows that work which gratifies the in- stinctive desires of children draws out their most joyful and vigorous endeavor, and yet the schools are either ignoring entirely or recognizing in very grudging mea- sure the passion of children for constructive work and dramatic expression, while continuing to ply them with premature formal studies that would later present a vital appeal and be covered in far less time, at far less cost of energy both to teacher and pupil. In short, every one knows that the highest physical well-being requires that work shall not only be free from strain, but a source of interest and joy ; and yet how many schools see to it that the yoke does not rub? How many are prescrib- ing work for little children according to its joy-giving capacity ? We need some authority in our schools to enforce the principles already known that relate to the healthful activities of children. Mrs. Ross. — It is a new thing to me, and most en- lightening, to hear these matters grouped together, as they evidently should be. Could you give us further items that come under the general head of hygienic activities ? Miss Parsons. — Plenty of them. Protection of chil- dren's eyes by every possible means — books printed on unglazed paper, in large, distinct type ; clean, unglazed blackboards on which large characters are used ; coarse writing pens and soft pencils ; the abolition of slates ; regulation of the amount of close eye work to fall short HEALTH SUPERVISION 141 of the fatigue limit ; requiring of proper illuminating fa- cilities in homes ; protection from nervous fatigue by fit- ting school demands to individual capacities — allowing for physiological age, and the manifest aptitudes of chil- dren in the assignment of their work; separating chil- dren who show widely different rates of progress, thus removing a general and constant source of discourage- ment or irritation. Finally, persistent inquiry and in- vestigation as to matters not yet determined, such as the effect of long hours of sitting on heart action, of indoor school work on the number of red corpuscles in the blood, of hours of study on gain in weight. These are only a few of the vital questions which must be brought under regulation by experts in the hygiene of education. Mrs. Ross. — I don't see how our little town can hope to command the services of an expert able to speak with authority on all these critical matters. Miss Parsons.' — It ought not to be necessary for each little town to employ actual authorities on educational hygiene. If we can only be supplied with approved standards from an authoritative source, our local au- thorities can put them into execution. The best infor- mation on these subjects should be made available to all our schools by the state education department or the national bureau of education or the children's bu- reau. A number of our states which are most progres- sive in health matters are already doing valuable edu- cational work of this kind, issuing frequent bulletins to health officers, and holding health institutes ; but the in- dividual efforts of these states, however valuable they may be, are likely to be sporadic and variable. The standardization of educational hygiene is a national con- cern. The states require national guidance and help in this work. The Washington bureaus should focus the 11 142 HEALTH AND THE SCHOOL knowledge that is being gained through our nation-wide experiments in the hygiene of education, and they should be equipped to give out to every school in the country, either directly or through state departments, authori- tative information as to the best standards achieved to date. LEGAL PROVISION FOR SCHOOL MEDICAL INSPECTION (1912). States in white have mandatory laws; shaded states have permissive laws, states in black have no laws at all. [From Russell Sage Foundation.! HEALTH INSTRUCTION OF PUPILS AND PARENTS A system of health supervision should include general oversight of the hygiene and sanitation that is taught to school children and their parents. The methods and details of such work should, of course, be developed with the cooperation of the educational staff of the schools, but it should be the special province of the health supervisors to give constant power and direction HEALTH SUPERVISION 143 to this important instruction, which tends to become hopelessly weak unless it is under expert control. Teach- ers, owing to the character of their training, know less about hygiene and sanitation than about any other sub- jects they are expected to teach, and, until normal schools wake up to the need of giving generous train- ing in these subjects, health supervisors will have to make up the deficiency by supplying teachers with in- formation as well as enthusiasm. PHYSICAL EDUCATION The term physical education is often loosely used as applying to all the educational factors that affect the health of children, but it is more properly employed to mean the cultivation of physique as a basis for the highest possible vitality and efficiency. To build up the physique of children is a far more fundamental way of securing their health than to treat defects which should never have been allowed to de- velop. It is no less fundamental a way of securing their successful progress in school, as has been repeatedly shown by scientific tests taken among school children. Dr. W. T. Porter of the Harvard Medical School in 1893 first showed in a study of 30,000 children that the majority of those who were physically advanced beyond the average showed proportionate mental advance, and correspondingly, the majority of children who were phys- ically retarded, gave evidence of mental retardation. To illustrate, he found that among pupils of the same age, ranging from 6 to 18 years, the average height and weight of those who were in the higher grades were greater than of those who were in the lower grades. With the increasing light that is being thrown from 144 HEALTH AND THE SCHOOL many sides on the whole subject of physical education, it is no longer possible to dismiss its claims with a few perfunctory calisthenics rung in at recess or between classes. While we cannot to-night go into a detailed study of the modern conception of physical education, I can call your attention to at least two underlying prin- ciples which will convince you of the importance of hav- ing this work under the control of experts, who can make it a dominant factor in a school system. 1. The most pozverful impressions which children re- ceive are connected with their physical activity. — This suggests the great educational value of active games which not only give heart, lungs, muscles, and nerves their needful exercise, but present rich opportunities for mental and moral training. Physical education should be regarded as anything but an arbitrary system of muscle hardening and lung stretching. It is a process which makes use of children's fundamental instinct for active play to cultivate in them both mental and bodily vigor ; both moral and nervous poise. The physical edu- cation program should be in complete harmony with the entire school program, providing whatever necessary ex- ercise is not supplied through other school work; and through such exercise adding further instruction and life to the other school interests. This is often done successfully by employing historic dances, folk dances, and pantomimes to lend interest to the various festivals through the year — harvest home, Christmas, May Day, historic anniversaries, etc. We see that the successful physical director must be an educational expert. He must be no less a medical expert, for the educational aspect of physical training is no more important than its physiological bearing. 2. Physical training must he hygienically adapted, not HEALTH SUPERVISION 145 only to the age and sex of children, but to their individ- ual needs and limitations. — No one disputes this self- evident proposition, but how often does one see it in practice? How often are children with weak hearts under observation and suitable restriction in the school playground or gymnasium? How often are girls guarded from exposure or strain during days of special susceptibility? Such necessary personal supervision can indeed be carried out successfully only when the re- sponsibility for physical education is in capable hands, and the needs and limitations of individual children are carefully determined by a thorough system of physi- cal examination and inspection. This concludes the outline of the five specific needs for which our system of health supervision should pro- vide. Compared with what most other cities are as yet undertaking, our program appears highly ambitious; viewed from the standpoint of our actual needs, it evi- dently contains not one vmnecessary item. Mr. Ross. — I must confess that Miss Parsons' words have carried conviction, but there is one difficulty that I see looming large in the way of her program. It will cost too much ; it can never be carried out. Mr. Young. — You forget that the public is with us. It is the people who pay the bills. With public senti- ment in our favor, our success waits almost wholly upon the degree to which we apply the principles of scientific management to our health supervision. Few cities yet suspect the enormous increase in efficiency which the installation of scientific management would mean to their systems. High expense and low efficiency are the rule to-day. We intend to reverse this order. With this end in view we shall devote our next meet- 146 HEALTH AND THE SCHOOL ing to a discussion of the principles of scientific man- agement as applied to health supervision in schools. Suggested Reading American School Hygiene Association. Proceedings OF the Fifth Congress. What Our Cities Are Doing for the Health of Our Children. Proceedings of the Sixth Congress. Problems of School Hygiene in Massachusetts. Denison. Helping School Children, Chapters VH, IX. GuLiCK AND Ayres. Medical Inspection of Schools. HoAG. The Health Index of Children. Hogarth. Medical Inspection of Schools. Kelnyack. Medical Examination of Schools and Scholars. National Society for the Study of Education. Ninth Year Book, Part L Health and Education. IX SCIENTIFIC MANAGEMENT IN HEALTH SUPERVISION Mr. Young. — When two people or more unite to se- cure a common end they are instantly confronted by the following questions: What steps must we take to gain our end? How can we best take these steps? Which of us can best take this step and which of us that? It matters not what the enterprise may be, whether it be to establish or conduct a church, a factory or a school system, these fundamental questions must be answered in some fashion before anything can happen. In other words, there must be agreement on some plan, some method of administration, and some form of organiza- tion. The degree of success which an enterprise reaches, provided the human element is constant, is in proportion to the adequacy of its program, its organization, and its administrative procedure. The organization and ad- ministration of an enterprise constitute its management. To bring these two factors to their highest possible effi- ciency is the aim of scientific management. It is this form of management which we propose to install in our system of health supervision. Our committee, after making a wide study of the kinds of management now current in health supervision systems, has certain plans and methods to propose, which 147 148 HEALTH AND THE SCHOOL are based upon a scientific analysis of the organization, methods, and results they have observed. Miss Parsons will present the report. Miss Parsons. — Scientific management has lately be- come a phrase to conjure with, but it stands for no sys- tem of magic. It stands rather for the application to any kind of human employment of two simple common- sense principles, which any normal mind can grasp at the first hearing. Mrs. Ross. — Then why has the world waited so long for business management to become a scientific art? Miss Parsons. — Because rule of thumb is hard to dis- place by scientific law. It has been no easy matter to abstract the principles underlying scientific management from the mass of details involved in practicing them. You remember Lamb's account of the origin of roast pig. It has taken the race a long time to discover the most economical and efficient way of roasting its pig. The recipe is a twentieth century discovery, fraught with tremendous importance, for it means that in time the pork barrel will hold enough for us all. Let us now examine the two underlying canons of the "gospel of efficiency," as Mr. Taylor, the chief apostle of scientific management, calls the system, and let us see how they can apply to our system of health super- vision. The first has to do with organization ; that is, with the distribution of duties, or "functions," as they are called in technical parlance. I. Duties must be so apportioned as to make each in- dividual in the whole body count for his maximum. — Such an apportionment obviously requires that each per- son be allowed to do only such work as he is best fitted to do. This means that he must be relieved of those duties which can be performed as well by some one SCIENTIFIC MANAGEMENT 149 whose time is less valuable, and that he be prohibited from performing duties which can be better done by some one else. In a system of health supervision the application of this principle would affect the functions of the school physician as follows : He would be required to use his energies in finding means to promote the health of the children and in diagnosing and treating such diseases and defects as might develop in spite of his preventive efforts ; he would be relieved from making inspections, first examinations and clerical records, as nurses and clerks, whose time is less valuable than his, can perform such work under his instruction, as well as he ; finally, he would be prohibited from determining his own methods of diagnosis and treatment, as such decisions are best made by medical specialists. Dr. Latta. — Miss Parsons has proposed some very daring innovations. She can't match them all in a single city in the United States to-day, but in time every one of the cities will come around to them, for the scheme is fundamentally sound. Mr. Ross.— But Miss Parsons. — Pardon me just a moment, till we set before ourselves the second principle, the one which has to do with methods of administration. 2. Duties and tasks must be so regulated that each effort shall secure a maximum result; to this end every process and material used must conform to standard. Mrs. Ross. — What is meant by "standard"? Miss Parsons. — The term "standard" is applied to the most scientifically determined methods or specifications which have been reached at the time the standard is drawn. A standard represents neither perfection nor finality, but it does represent the best that has yet been I50 HEALTH AND THE SCHOOL devised, and should therefore be strictly enforced until expert scientific study justifies changing it. Mrs. Ross. — Do these two principles which you have stated actually stake out the whole field of scientific management? If so, it seems to me that it is merely a wonderful system of mechanics with the human element practically eliminated. You fit your man to his groove, gear him up to the highest speed, and then press the but- ton. I should fear that our health supervision system would turn out to be merely an automatic mechanism. We want the nurses and doctors to remain human, to be interested in the children themselves. Isn't there danger that their judgments will be paralyzed by too much over- head regulation? Miss Parsons. — There is no danger of this. It is true that the principles, in the simple form stated, sound harsh and mechanical. That is merely because they had to be put abstractly. As a matter of fact, the human element, i. e., the interest, enthusiasm, cooperation, and prosperity of each man in the system is the very highest concern in scientific management. Mr. Martin. — I thought the highest concern was in- creased profits. Miss Parsons. — Increased profits of one kind or an- other — wealth, leisure, human comfort, health or happi- ness — are undoubtedly the greatest motives for develop- ing scientific management, but the chief concern in achieving this end must be to develop first-class men and women among the workers. This is one of the duties, the most fundamental of all, which was referred to in the bare statement that every process and material used in discharging a duty should conform to a standard. To arouse the best efforts of workers, to enlist their interest and initiative, is a critical task, which can sue- SCIENTIFIC MANAGEMENT 151 ceed fully only when based upon the results of an accu- rate study of the motives which influence men and women ; in other words, upon psychologically sound standards. Not all supervisors can be expert psycholo- gists, but they can increase their efficiency greatly by adopting standards set by experts in human nature. MEDICAL INSPECTION IN SCHOOLS Let us consider now in some detail the bearing that these principles of scientific management have upon our proposed system of health supervision. I shall not at- tempt to outline a complete set of regulations for organi- zation and procedure. We could not possibly cover so much ground in one evening, but I wish to bring out certain points where the application of these principles will give our system an advantage over any single sys- tem that we have yet observed. We will first take up the medical department, which at our last meeting we agreed should be responsible for inspection, examination, and treatment of school children. Medical inspection is almost everywhere carried on at enormous waste of the physician's time and the public's money. This is due, in part, to unscientific organiza- tion ; in part, to unscientific method. ORGANIZATION OF MEDICAL INSPECTION Let us consider first the organization. When doctors are assigned to make inspections and first examinations of school children, as is usually the case where these steps are taken, they are often required to perform a 152 HEALTH AND THE SCHOOL great deal of work that can be done as well by nurses and even teachers and clerks. Such an arrangement violates the first canon of scientific management, which prohibits an individual from doing work that can be done as well by some one else whose time is less valuable. Mrs. Ross. — Do you mean that much of the work of inspection and examination can be carried on without doctors ? Miss Parsons. — Exactly. Mrs. Ross. — Then what becomes of the doctor's divine right of diagnosis? Miss Parsons. — That remains quite intact. The doc- tor is still needed to pronounce the authoritative word upon conditions of the body, but he can be immensely re- lieved in the routine of physical examination and inspection work by trained assistants who do not happen to possess the mystical power inherent in the symbol M. D. Let me illustrate by citing a very inter- esting experiment which has just been carried out in New York. In 191 1 the Bureau of Municipal Research made a test which brought out the fact that the cost in New York of physicians' inspection for contagious diseases was 58.1 cents per 1,000 children per day, while the cost of nurses' inspection was 36.96 cents, a difference of 22.14 cents, or 38 per cent. Think what the saving to New York would be if its 750,000 children were to be in- spected for 22.14 cents less per thousand per day than under physicians' inspection. This amount, which would be about $33,000, would provide for a year all necessary treatment for the chronic defects of about 60,000 chil- dren; 45,000 of whom would require attention for their teeth, 30,000 for verminous conditions, 12,000 for defec- tive vision, 6,000 for mouth breathing, deafness, and dis- SCIENTIFIC MANAGEMENT 153 charging ears, and 3,000 for diseased scalps, chronic eczema, and ringworm.* Mrs. Ross. — Might not the children be getting all this treatment at the expense of those inspected by the nurses? Economy is good, of course, but efficiency is better. Did the nurses really perform the inspection work as well as doctors would have done it? Miss Parsons. — Precisely as well. In the four schools where the nurses handled all the work of inspection and exclusion, not one of the forty-one exclusions which they made was found to have been unnecessary, nor was there one case found of a child passed over who should have been excluded. The Bureau of Municipal Re- search, which carried on this experiment, recommended that the inspection and exclusion of contagious diseases for the entire city be given to the nurses. Mrs. Ross. — Was this done? Miss Parsons. — It was in 1912, and the results have already shown the wisdom of the arrangement to be past argument. Though the force of school physicians was reduced between one-half and one-third, and the num- ber of nurses not proportionatey increased, there has been a marked increase in the number of physical exam- inations, inspections, and corrections of physical defects of the school children. Owing to time saved from in- spection work the school physicians have averaged an increase of about 100 per cent, in the number of physical examinations they have made. As a result of the greater number of nurses employed, the number of inspections has been 25 per cent, larger than in the previous year, and the number of cases receiving treatment about 10 per cent, greater. Furthermore, this added efficiency has been * Based upon a study of cost of school clinics in Medical In- spection of Schools, by A. Hogarth, Chapter XV. 154 HEALTH AND THE SCHOOL brought about at an outlay of $4,800 less than the outlay of the previous year under the old regime.* Mrs. Ross. — Has the new plan in New York proved popular among those engaged in the work? Miss Parsons. — Not altogether. Some of the doctors feel abused at the curtailment of their duties, and some of the nurses object to the burden of their new respon- sibilities. A little friction at the beginning is quite in- evitable when such a radical change is being put into force. Prejudices will gradually yield, however, for the nurses' capacity both to inspect and even to examine chil- dren to a certain point has been demonstrated over and over again, not only in experiments but in actual practice. In Cambridge, England, in 1906, the school nurse was given authority by the medical officer to exclude cases, issue return certificates, and even to treat certain minor afflictions on her own initiative. Her service has proved eminently satisfactory. Massachusetts, the only state up to 191 1 to require school physicians in every town and city, has also demonstrated the fitness of the school nurse both for the inspection of contagious diseases and the examination for defects. The smaller towns, after the mandatory legislation went into effect, had at first great difficulty in arranging for school physicians on account both of the expense and also of the professional jeal- ousy of the private practitioners, who naturally objected to having their own young patients pronounced upon by a rival physician and a political appointee at that. By a liberal construction of the law a nurse was ap- pointed in Canton, Mass., in 1908, to perform for the school children what would have been expected of a physician. She made inspections for contagious diseases, * A Report upon the Health Conditions in the Public Schools of New York City, The Medical Record^ August 31, 1912. SCIENTIFIC MANAGEMENT 155 examined children for physical defects, sent sick and defective children to their family physicians for treat- ment, and saw that they received it. Those too poor to pay for treatment she took to a free dispensary in the nearest large town (Boston). In addition to these duties she carried on educational work in hygiene with both parents and teachers. This nurse proved so efficient as a school health officer and gave so much satisfaction to the whole town, including the doctors, that one small place after another in Massachusetts has followed the example of Canton, leaving the health supervision of the school children entirely to a nurse. Massachusetts has not been alone in this experiment. Among other states, California is demonstrating the ability of nurses who, in San Francisco and Oakland, conduct practically all the routine of examinations. Mr. Ross. — You spoke of school physicians at present being assigned to do teachers' and clerks' work as well as nurses' work. How does that come about? Miss Parsons. — Much of the routine of physical ex- amination, such as taking weights and measures and setting down records, can actually be performed by teachers and clerks and even pupils, saving not only the physicians' time but the nurses' as well. There is no justification for the costly combination of doctor and nurse now in vogue, by which the doctor plays nurse and the nurse plays clerk. Mr. Ross. — It seems to me your nurse-teacher-clerk combination must necessarily lessen the value of the examination. Miss Parsons. — Not at all. The clerks or the older pupils are as efficient as doctors or nurses for taking down records; the teachers as reliable as doctors for making preliminary eye and ear tests ; and the nurses 156 HEALTH AND THE SCHOOL themselves, as we have seen, are as competent as ordinary physicians to detect other physical abnormalities which should be referred for expert medical advice. Dr. Latta. — No doubt many physicians would ques- tion Miss Parsons' last statement regarding" the diagnos- tic abilities of nurses. As a matter of fact neither a nurse nor an ordinary doctor is qualified to say that a child is really sound. The powers of an expert diagnos- tician are required to secure any sort of certainty in such a matter. Occasionally we find a most healthy appearing child who is really suffering from a fatal disease. The symptoms of kidney disease, for instance, are likely to escape any but expert methods of detection. Such cases are rare, however, and while over 50 per cent, of the nation's children even now are having no physical ex- amination whatever, are we not wasting time to discuss impracticable refinements of methods for eliminating all error in examination? What we want now is to find means of giving all our 25,000,000 school children the advantage of at least some sound health supervision. To have expert physi- cians examine every member of this enormous army is manifestly impossible ; but nurses under physicians' direc- tion are likely to prove equal to the task. Mr. Ross. — May I ask whether a distribution of physi- cal examination work between teachers and nurses, such as Miss Parsons described, has been tried anywhere? Miss Parsons. — It has. Massachusetts, the leading state in providing for the physical welfare of children, leaves the preliminary eye and ear tests to teachers, with the thorough endorsement of the oculists themselves. There is really nothing, they say, in the training of an ordinary physician that makes him a better tester of vision and hearing than an intelligent teacher. Minne- SCIENTIFIC MANAGEMENT 157 sota is even training her teachers to make general physi- cal examinations, the claim being that trained teachers can recognize 90 per cent, of the defects of children, Mrs. Ross. — I was interested to learn, not long ago, that Swarthmore College, recognizing the direct responsi- bility of teachers toward the health of children has ac- tually added a course of medical inspection to its teach- ers' preparatory course. School children are brought to the college every week and the students under the super- vision of the physical director are taught the methods of inspection and examination. Mr. Martin. — This is all very bewildering to me. It seems to me that such innovations will tend to unseat the doctors entirely. Dr. Latta. — Oh, not at all. The effect will only be to seat them higher up. The whole purpose of this sharply economical distribution of duties is, as you remember, to make each individual count for his maximum. The or- dinary physician, as now trained, is working at his maxi- mum when he is diagnosing and treating disease, not when he is sorting out healthy from unhealthy children. We must save him for his function as a healer, a neces- sity which was thoroughly discussed at our last meeting. Mrs. Ross. — I am rather surprised to hear you empha- size so strongly the healing function of the school doctor. I thought the modern doctor was to keep children well and develop their health. Dr. Latta. — So he is ; but, while our schools still con- tain between 60 and 80 per cent, of defective children, there is much old-fashioned treating to be done, and the old-fashioned school doctors can't employ their time better than by doing it. In the meantime, not a moment should be lost, of course, in developing a new breed of doctors and nurses who shall be hygienists first of all, 12 158 HEALTH AND THE SCHOOL rather than healers. Children under their care, from birth and before, will not develop the hideous array of defects and diseases now prevalent among all the chil- dren of the nation, regardless of wealth or station. To return to the question of substituting nurses for doctors in inspection work : I regret to admit that some of the motives which prompt resistance to this plan are not entirely concerned with the welfare of the children. It is a disconcerting thing, for instance, to a politically inclined medical chief to see $75,000, more or less, about to be diverted from the support of a body of male medi- cal inspectors who on occasion can serve as a forceful political instrument. It is also disconcerting to the in- spectors to contemplate losing their jobs. I am far from implying that all doctors who oppose the inroad of the school nurse do so with any sordid motive. Many of them are honestly imbued with faith in their own mystic powers. I merely say that the economic motive strength- ens the conservative element in the medical profession which has always resisted innovations, tooth and nail, since before the day when Hippocrates horrified society and called down the anathemas of his fellow doctors by announcing that fits developed from natural causes and were not malign gifts from the gods. Magic and common sense have waged immemorial combat in medi- cine, but we trust that common sense, with her powerful handmaid — modern science — will, from now on, hold the upper hand. Miss Parsons. — Let me call your attention now to the second weak spot in the organization of most in- spection systems. The change involved, contrary to the one just discussed, will require a greater outlay, but will also -increase the efficiency of the service. I refer to the common practice of leaving to untrained teachers SCIENTIFIC MANAGEMENT 159 the actual detection of contagious diseases. This is in direct violation of the principle we stated ; that individuals should be prohibited from performing duties which can be better done by some one else. "What is called physicians' inspection is primarily teach- ers' inspection, the physician inspecting only such cases as the teachers select. The result is that many a case requiring expert advice misses the untrained teacher's eye, and never passes under the physician's. On the other hand, much of the physician's time is wasted in sifting out cases unnecessarily sent by teachers. A physician's class-room inspection made in 1910 among 1,784 school children of Philadelphia showed that about 12 per cent, of those needing treatment for minor con- tagious diseases had failed to be observed by the teach- ers. On the other hand, in a single month of the same year, one inspector had 569 pupils sent to him by teach- ers, only 14 of whom (2.4 per cent), in his judgment, were proper cases for his attention. Medical inspection is surely a curious misnomer for teachers' inspection of this sort. Mr. Ross. — What better plan is there? Miss Parsons. — The children should have periodic in- spection by people who know how to give it. Teachers, unless specially trained for it, do not know how. Nurses do. New York and a number of other cities are now requiring a direct monthly inspection of all children by nurses. The results have already far more than justified the wisdom of the arrangement. In this brief discussion of the organization of medical service we shall not need to take up the duties of super- visors. Most systems are already well supplied with these functionaries. Their methods rather than their functions call for scrutiny, and these are of so much i6o HEALTH AND THE SCHOOL importance that we shall have to give a separate evening to their consideration. METHODS OF MEDICAL INSPECTION In considering methods, we must hold carefully before us the principle that duties should be so regulated that each effort shall secure a maximum result, and that to this end every process and material used must conform to standard. It is at this point in current medical inspection that we encounter chaos. The conception of a standard as being the only means for securing both the greatest effi- ciency and economy has exerted no influence on most of our systems. We find almost nowhere scientifically fixed regulations concerning many of the following items : kinds of communicable diseases and symptoms for which inspection is necessary; kinds of defects and symptoms for which examination is necessary; manner and fre- quency of inspections and examinations ; character of treatment required ; time, place, and manner of giving it ; length of quarantine for various diseases; following up of excluded cases to insure proper treatment and quar- antine; further precautionary measures against conta- gion ; disinfection, exclusion, and treatment of exposed children; making, filing, and using records and reports. After a discouraging search for a scientifically man- aged system of medical inspection we at last came upon one which had recently been organized by management experts in one of our larger cities. This particular city had suddenly waked up to the fact that its medical in- spection service, on which it had long prided itself, was not making good; and it had promptly called in experts SCIENTIFIC MANAGEMENT i6i to set the system on its feet. Like many another city, this one had assumed that its medical inspectors were carrying out the following important steps : 1. Inspection for contagious disease. 2. Quarantine for contagious disease. 3. Treatment of minor contagious disease. 4. Yearly physical examination of school children. 5. Referring of cases demanding treatment to proper authorities. 6. Following up of cases referred. 7. Consideration of special cases. 8. Making of prompt and accurate reports. 9. Directing and coordinating efforts under central supervision according to information from records and reports. Bearing in mind these points, you will be interested to note, item by item, the contrast between what medical inspection in the city under discussion was assumed to be and what it really was. This is v/hat the investigators found : I. Inspection for Contagious Disease. (a) Inspection work was carried on with enormous waste of time. During the year, routine visits to all schools every day had occupied 60 per cent, of the medical inspectors' time, with no greater result than the finding of 25 cases of major contagious disease among 174,000 children. Major contagious diseases are seldom found in schools, for the obvious reason that their sever- ity from the first onset usually keeps children at home. Mrs. Ross. — Isn't this large expenditure worth while to discover even a few cases? The 25 cases which Miss Parsons cited might have multiplied to 2,500 cases if the doctors hadn't caught them in time. Miss Parsons. — To be sure; but it needn't have re- i62 HEALTH AND THE SCHOOL quired 28 doctors working for a year to do it. We have already seen that nurses could have done the inspection work ; but quite apart from that consideration, the doc- tors were wasting quantities of time by their methods of inspection. They were constantly paying hundreds of visits to schools where there was nothing for them to do. This waste of their time made the cost of the discoveries that they did make many times as great as necessary. Mr. Ross. — How could this cost have been reduced? Miss Parsons. — By so simple a method as the use of the telephone. Since the physicians, in all cases, in- spected only those children whom the teachers picked out, they would have saved an immense amount of time by confining their visits to those schools where the> were needed to pronounce on suspicious cases. Tele- phone calls could have brought them at any time. This point introduces us to the next defect which the experts noted in the system. (b) The system did not provide for periodic inspec- tion of all school children. Only those children who were selected by teachers, as occasion arose, were seen by the inspector. 2. Quarantine for Contagious Disease. (a) Pupils were often allowed to return to school before the expiration of the exclusion term specified in the state law. (b) There was wide variation among inspectors, as to exclusion for similar diseases, with the result that there was much friction between the department of con- tagious diseases, on the one hand, and principals and teachers on the other. For instance, in the handling of suspected diphtheria cases, some inspectors excluded pu- pils immediately upon beginning the test of cultures from SCIENTIFIC MANAGEMENT 163 the latter's throats; others waited until the presence of the disease was determined by the diphtheria baciUus de- veloped in the culture. In the handling of minor con- tagious diseases, exclusion authority was often abused. For example, of two inspectors working in similar schools having nurses, one was found rarely to exclude a child who could be treated by the nurse, the other ex- cluded almost all the children, thus depleting the school enrollment and preventing proper treatment by the nurse. Eighty-nine per cent, of the total number of exclusions were for causes other than acute diseases. Arbitrary wholesale exclusion for lack of evidence of recent vacci- nation was one of the contributing factors to this high percentage. 3. Treatment of Minor Contagious Disease. — There was no uniform practice in school or home treatment for minor contagious diseases. 4. Yearly Physical Examination of School Children. (a) Instead of each child's receiving an examination every year, as was called for, an investigation among 5,910 children in attendance during five years showed that 9 per cent, had never been examined, 36.1 per cent, had been examined only once, 39 per cent, twice, 15 per cent, three times, 9 per cent, four times, and none five times. (b) There were no definite standards as to what should be considered physical defects. Inspectors who were specialists in private practice were accordingly found to discover their "specialties" in undue proportions to the neglect of other defects. (c) There were no working schedules or uniform methods provided for the examination of pupils. Each inspector, therefore, chose his own method of making eye and ear tests, which, in many cases, were inaccurate. 1 64 HEALTH AND THE SCHOOL (d) There was wide variation in the time given to single examinations. This varied from six seconds to six minutes. A careful test has demonstrated that an examination, exclusive of any clerical work, cannot be properly given in less than seven minutes. (e) Inaccuracy of examinations was shown by the re- examination of 200 children representing twelve inspec- tors. The inspector who was detailed by the chief of the division to make a reexamination found 145 defects undetected in the first examination, and 57 previously recorded that were unworthy of notice. 5. Referring of Cases. — Cases were not systematically referred to nurses, parents, and doctors. Cards were often filled out with recommendations that were not specific and given to children only. 6. Following Up of Cases. — Cases were not followed up, but lost sight of. There was no standard of what a treatment should be. Pupils with errors of refrac- tion were reported "treated" when supplied with an eye- wash ; those with adenoids, when they began to use a gargle ; those with defective teeth, when they were given tooth brushes. A questionnaire test showed that, out of 1,013 pupils recommended for treatment for defective vision during five years, only 14.9 per cent, were pro- vided with glasses; of 615 having enlarged tonsils or adenoids only 11.2 per cent, had received adequate treat- ment. 7. Special Cases. — Special cases referred by principals and teachers were incompletely reported, neither uni- formity nor system being used in the reports. 8. Reports. (a) Great variation and laxity were shown in filling out and turning in reports of contagious diseases. It was a common practice for an inspector excessively zeal- SCIENTIFIC MANAGEMENT 165 ous to show a very large number of exclusions, to report the same pupil excluded for the same cause several times during one period of exclusion. (b) Reports of examinations, reexaminations, and re- sults of recommendations for treatment were not made promptly to the chief medical inspector. Their ijiac- curacy, moreover, made them practically useless. An in- vestigation of 200 children, representing 227 physical defects reported by thirteen inspectors as treated, showed that only 43 per cent, of the defects were treated in any proper sense. 9. Administrative Control and Information. (a) There was no central control and supervision of exclusions and readmissions of pupils. (b) There was no adequate administrative control of the inspection system as a whole which was indicated by the fact that the inspectors were found to be averag- ing in the time given to their work less than one-half of the five hours a day they were expected to give. (c) No accurate information could be obtained for the entire city as to school days lost through exclusion, because the case records at the central office were either incomplete, inaccurate, or altogether lacking, and be- cause no provision was made in the records at the schools for currently recording the causes of absence. (d) The records in the central office were not kept up ; cards were missing or left unfiled for more than six months at a time. In April, 1909, there were 3,063 re- port cards relating to the school year 1908, still tied up in the bundles in which they had been received. I have thought it worth while to run over the short- comings of this system in some detail because similar ones are bound to crop out in every town that doesn't specially guard against them. Even a small town, like i66 HEALTH AND THE SCHOOL our own, which presents no great administrative prob- lems, needs precisely as good a plan and as clear-cut methods of management as the largest city. Good inten- tions and fine ideas about the health of children do not automatically result in healthy children. Mr. Ross. — Those people didn't know how to do busi- ness. I could have run their system better myself, and I don't know an adenoid from a potato. Miss Parsons. — It was just such administrative knowledge and experience as you have, Mr. Ross, that they needed and fortunately obtained. Let us now go over the items as they stood after the experts put the system on its feet. 1. Inspection (a) and (b). — Much time formerly wasted is saved by substituting for a daily visit by the inspector to each school a weekly visit to each school room. The teacher is thus no longer responsible for detecting contagious diseases, nor are any children left uninspected. Any day, however, that the teacher notices suspicious symptoms, she can secure an inspection by telephoning to the school inspector at a specified time. The weekly schedule is subject to change in case of un- usual stress, as in epidemics. (Form 4, page 184.) 2. Quarantine for Contagious Diseases. (a) The legal length of quarantine is now observed, as prompt records, carefully supervised, check laxity and irregularity in this matter. (b) Conditions warranting exclusion are accurately stated in the regulations and an inspector is now not permitted to exclude a pupil for a minor contagious dis- ease more than one day without the permission of his immediate superior. Exclusion for vaccination is also obviated by requiring the inspector to gain satisfactory evidence before pupils are enrolled. SCIENTIFIC MANAGEMENT 167 3. Treatment for Minor Contagious Diseases. — Minor contagious diseases are now treated at school whenever possible. 4. Yearly Examinations. (a) Every child is now examined when he enters school, and regularly every year thereafter. If need arises in special cases for an earlier examination, this is given. This regulation is enforced by a system of prompt reports and close supervision. (b) and (c) Examinations and inspections are made according to a prescribed schedule, which definitely de- termines what defects to look for, how to look for them, when and how to treat them, and how to record the re- sults of examination. (Form i, page 179.) (d) and (e) To secure the greatest possible uni- formity in standards and methods, stafT conferences and clinics are held at regular intervals. 5. Referring of Cases. — Carbon copies of records are now sent promptly to all parties interested — central of- fice, teacher, and nurse ; the inspector retaining a copy. The nurse is responsible for informing parents and see- ing that the treatment recommended is carried out ; the teacher for giving what special consideration the case may require ; the inspector for bringing the case to a conclusion, and the central office for exercising a general supervision until the completed record is received. (Form I, page 179.) 6. Folloziing Up of Cases. — Cases are now easily fol- lowed up, as a record is in the hands of the four parties interested. A definite standard for the necessary treat- ment, and the result necessary to warrant the discharge of the case, makes the procedure for each case clear. 7. Special Cases. — Thorough examinations of special cases referred by principals and teachers are now given i68 HEALTH AND THE SCHOOL at the weekly visits of the inspectors, and are reported at once, as in the case of regular examinations. 8. Reports. (a) Accurate card reports of inspections are promptly sent to the central office, where they are kept on file. (&) Accurate reports of reexaminations and results of treatment are made on the card that recorded the orginal examination, and as soon as the cases are dis- missed are sent to the central office, where they are filed. 9. Administrative Control and Information. (a) and (b) The central administrative control has been greatly strengthened by the establishment of stand- ards of procedure ; a system of simple records, including time reports (Form 2, page 181), which are turned in promptly and used ; and a program of stated staff con- ferences and clinics for securing the greatest possible uniformity in standards and methods. (c) and (d) Complete records, intelligible to the pub- lic, of the physical condition of the school children, as well as of the results obtained through recommended treatments, are now available in the central office. These records include a monthly summary of all cases handled during the month (Form 3, page 183) ; new cases, those still pending, and those dismissed as cured. This sum- mary is published in health news columns of the news- papers every month, together with statements regarding the cost of handling the various items. Mr. Young. — Those people are certainly getting their money's worth now, but will they continue to? How long will it be before the varnish wears off their sys- tem? It sounds too good to last. Miss Parsons. — If it doesn't last it will be due to the grossest neglect of city officials and citizens. In SCIENTIFIC MANAGEMENT 169 ordinarily honest and efficient hands this system will stand wear. Mr. Ross. — I believe you are right, Miss Parsons. When we installed scientific management in our factory we didn't change a single important manager or fore- man, but the new system doubled our profits in a year. Miss Parsons. — Double profits in health are what we are figuring on in this medical inspection system. Let us turn now to what scientific management has to say in the department of sanitary supervision. SANITARY inspection OF SCHOOLS: ORGANIZATION AND METHODS Sanitary inspection is usually carried on in connec- tion with medical inspection, owing to a curious tra- dition that it takes a doctor to determine whether enough air is entering a room, whether children are us- ing sanitary drinking cups or the thermometer stands too high. These items have not the remotest connection with surgery, obstetrics, materia medica, or with any of the other arts which go to make up the doctor's distinctive repertoire. The smattering of sanitary knowledge that is offered in an ordinary medical course, and which con- stitutes the physician's only claim as a sanitary authority, is distinctly less than what is included in a good course in domestic science. However, it is often convenient for the medical in- spector, physician or nurse, to examine children and buildings at the same time, and there is no harm in this arrangement if the sanitary standards are not left to the determination of these inspecting officers. Modern sanitation has developed into a fine art. Experts only I70 HEALTH AND THE SCHOOL are qualified to set standards, and the inspecting officers for schools or homes, whoever they may be — doctors, nurses, or policemen — must make their reports on the basis of standards set or ratified by expert sanitarians. Moreover, the form for inspection records must be so devised as to provide for a thorough and accurate report on every item. It is an evidence of the extreme youth of the inspection systems in this country that most of them have not yet discovered these two simple and self-evident requirements. Prevailing methods of sanitary inspection are well illustrated in the report on the city system we have been considering. The duties of the sanitary inspectors in this city were as follows : 1. The exact determination of the sanitary construc- tion and equipment of each school building, as a basis for a permanent record. 2. Systematic and periodic inspections to guard against new conditions harmful to health. These duties, it was found, were being carried out in the following manner : 1. Permanent Records of the Sanitary Construction and Equipment of School Buildings. — There were no such records. 2. Periodic Inspections. (a) Periodic inspection, which was made at the open- ing of the year, was insufficient to tell the whole story of conditions that vary through the year : e. g., heating, ventilation, sanitation. (&) No sanitary standards were prescribed for use in reports, each inspector being allowed to establish his own standards. The making of reports was regarded as a mere form by inspectors, who based their state- ments concerning capacity of rooms, size of windows. SCIENTIFIC MANAGEMENT 171 etc., on general estimates, and who frequently omitted salient items. For example, among all the reports, only five recommended better ventilation, while the depart- ment of buildings admitted that there were 162 buildings whose ventilating systems furnished less air than the law required. Similarly, only fourteen recommended in- creased toilet facilities, while the Board of Education admitted that there were at least forty-three schools deficient in this respect. (c) The reports were apparently recognized as worth- less by the Board of Education, which paid no attention to them. Out of 131 recommendations submitted in October, 1909, none had received any consideration up to April, 1910. (d) There was nowhere maintained a complete cur- rent record of information necessary for the improve- ment of the hygienic conditions in school buildings, nor was there a record showing improvements obtained through the service of inspectors. The following is a condensed statement of the changes brought about through the revision of the system. 1. Permanent records of the sanitary construction and equipment of school buildings have been made and filed at the central office. 2. Periodic Inspection. (a) Inspection is now made three times a year, in order to note conditions subject to variation : for exam- ple, heating and ventilation. (b) A definite schedule is used to record the inspec- tions which are now governed by facts instead of indi- vidual judgments. (Form 5, pages 187-8.) (c) and (d) The information in these reports is con- sidered in connection with the permanent records relat- ing to th^ respective buildings, transferred to these rec- 172 HEALTH AND THE SCHOOL ords and filed. Records showing improvement obtained as results of reports are filed with reports. It will not be necessary to go into further detail to- night to illustrate the need for scientific regulations in every department of our health supervision system. The same general method of administration as we have out- lined in the two departments discussed is obviously neces- sary for securing real success in the other branches of the service : hygienic regulation of school and home activities, health instruction and physical education. Mr. Martin. — The changes that transformed these poor systems into effective ones all sounded very simple and easy, though apparently it required experts to bring them about. As you were putting the contrasted items before us. Miss Parsons, I tried to analyze the essential elements that distinguished the systems before and after treatment. Would you mind stating what you consider the fundamental differences? Miss Parsons. — In a word, a system of management, 'to be puncture-proof, must provide for each of these things : a good plan, accurate records, and thorough su- pervision. These provisions can be secured only through a rigid application of the principles of scientific manage- ment, i. e., proper distribution of duties, and observance of standards. The system we first considered this even- ing had a good general plan, but it broke down through having inaccurate, ill-kept records, and almost no super- vision. It is absolutely essential for the supervising of- ficer, by means of strict records, to keep in close touch with the work of every inspector ; to control the quantity and quality of service performed by each ; to apportion work in accordance with the requirements of districts, schools, or individual pupils ; and to tell the story of work done and needs still to be met in such a way as to SCIENTIFIC MANAGEMENT 173 command the intelligent interest, confidence, and support of the community. Mr. Ross. — Miss Parsons makes an important point when she bespeaks the cooperation of the community. The citizens are the real proprietors of these proposed health factories. No plan, however perfect, can thrive without their support. As citizens and taxpayers, we must all insist on being currently and accurately informed of what our system is accomplishing; how much health it is manufacturing; what it costs ; what it saves ; how it can be yet further improved. We must aid in the formulation of construc- tive plans when there is need, and we cannot rest till plans for the health of our school children have been actually transmuted into health itself. Suggested Reading Allen and Snedden. School Reports and School Effi- ciency. Minnesota State Board of Health. An Outline for the Health Grading of the School Child. Russell Sage Foundation. TJie Measurement of Edu- cational Processes and Products. Taylor. The Gospel of Efficiency. American Magazine, March-May, 191 1. The Principles of Scientific Management. Terman. Professional Training for Child Hygiene. Popular Science Monthly, March, 1912. 13 X RED TAPE Mr. Young. — At our last meeting Miss Parsons sketched for us the transformation of a nerveless medical and sanitary inspection system into one that was highly efficient. Our limited time prevented us from getting more than a hint of the methods which brought about this transformation, but we did receive the definite im- pression that the secret of the change lay almost entirely in a reorganized system of records and supervision. Mr. Ross. — In other words, the work amounted to almost nothing until it was well watched and accurately recorded. Mr. Martin. — Does this mean that doctors and nurses are shirks or fakirs unless there is some one always at their heels? I can't believe that for a moment. Mrs. Ross. — Nor I. In spite of the evidence in last week's report, I can't quite abandon the idea that the best way to win good service is to put people on their honor and to measure their efficiency by the results they accomplish. Surely this is better than to carry on a system of espionage. Miss Parsons. — The question is not primarily a mat- ter of integrity and good intention, but of intelligent procedure and economy in the use of time. Effective supervision, on the other hand, does not mean a system of espionage; it means rather the intelligent direction 174 RED TAPE 175 and coordination of the service ; the analysis, classifica- tion, and interpretation of results ; and the establishing of standard administrative methods. Mr. Martin. — Isn't there danger of over-standardiz- ing and over-mechanizing in the field of professional service? I can readily see the necessity of standardizing the speed of machines or a method of keeping ac- counts. When it comes to matters requiring expert medi- cal judgment, however, I should fear that laying down hard and fast standards would check individual initia- tive and would degrade professional service to the dead level of routine. Miss Parsons. — That could happen only if a standard were a thing impossible to change, but such is not the case. As was brought out in our last discussion, a standard is not to be regarded as something final and unchangeable, but merely as the most effective method or equipment that scientific inquiry has discovered up to date. In fixing upon a standard of procedure in the medical examination of school children there is nothing that precludes the modification of the standard, provided only the change be based upon the same rigid test that was applied when the standard was originally prescribed. Mr. Martin. — May we not have this point illustrated by a concrete example of standardization in some field of professional service? Dr. Latta. — An excellent example is in the practice of surgery, which, I suppose, would be accepted as the highest type of technical skill in handwork. In teach- ing the technique of an operation upon the eye, for in- stance, the instructor prescribes every step in the process, every movement, and every instrument to be used. Not until the student masters every detail of the operation may he undertake its execution. Having mastered the 176 HEALTH AND THE SCHOOL best standard which surgical practice has already estab- lished, the student is free to use his initiative and in- genuity in raising the standard, but not before. No one would think of criticising surgical practice on the ground that it interfered with professional initiative or placed obstacles in the way of rational progress. Mr. Young. — I should be interested to have Miss Par- sons tell us just how far standardization should be car- ried in the supervision of medical examination and nurses' service. Miss Parsons. — The first requisite of efficient super- vision is that accurate, complete, and prompt informa- tion be available to the supervisor. In other words, the supervisor must know just what the inspectors are do- ing and what they are failing to do ; and he must get this knowledge in time to check up the results and cor- rect mistakes, instead of getting it in an annual report long after the time when he can make most effective use of it. For this purpose, it is absolutely essential that a system of current reports be installed that will produce the necessary information promptly and in a form readily available to the supervisor. Mr. Young. — Do not most systems of medical exami- nation include weekly or monthly reports that serve pre- cisely the purpose you have in mind? Miss Parsons. — Practically all of them provide some form of current report; but none of them, so far as I have discovered, meets adequately the requirements of scientific management. The fundamental basis of all summary reports, of course, is the primary record of individual facts observed. In medical examination these primary facts are contained in the record of conditions found in individual children. Very commonly the char- acter of this record is left almost wholly to the discre- ■ .- ■ I nr ■ 1^" flTin'PT a3NIW»X3 M^^ ^ urifflrmmrj 178 HEALTH AND THE SCHOOL tion of individual examiners. The inevitable result is great variation in the form, order, and definiteness of the records. It has repeatedly been found that, unless there is a prescribed schedule which medical inspectors are required to follow in their work, some of the most obvious physical defects will be slighted or entirely over- looked by certain inspectors. One inspector, for exam- ple, may have an exaggerated interest in children's ade- noids, and pass over defects of vision, as if he himself were blind. Another inspector, with special interest in visual defects, may find that most children need glasses, but fail utterly to note the presence of decaying teeth. We have prepared a chart which brings out this ten- dency to specialization among the inspectors in one of our largest cities. Mrs. Ross. — How can this mental astigmatism of med- ical inspectors be corrected ? Isn't it a natural and inev- itable result of differences in training and native in- terest ? Miss Parsons. — It is natural, but by no means in- evitable. By laying down precise standards of method and procedure to be observed in the routine of medical examination ; by instructing inspectors carefully concern- ing the importance and meaning of these standards ; and by the proper exercise of control on the part of super- visors, the eccentricities of medical inspectors can be almost entirely eliminated. For this purpose it is essen- tial that the blank forms upon which inspectors make their records of individual examinations and their sum- mary reports be so devised as to induce completeness, definiteness, and uniformity in the examination of chil- dren, in the necessary follow-up work, and in the reports of time distribution and results obtained. The four blank forms that we wish to submit as part of our report 2 O 2 O f^ U < u :3 z a: S3 t: K ^ E 5J 2 5 < u ^ i J y < ^ lO U I 2 ^ ^ J w III ul in < < o o 6 J NoiiVNiwvya xxaK do 31.VC!: SKVoao SVIOIC 3AM 3 H Viwa>fKV Q3oavnK3 LN3Wcl0^3^3a, a.S3H-3 omvoao ^vNO!iONru VHHHaOlO ij-a-i IHOia. y.>ia.vLVo saioM3av siisuoi. AavQ^50^■as AHviMi-aci VAliONnPNOJ iH3-l JO 3j.va i8o HEALTH AND THE SCHOOL have been devised to accomplish these purposes. I will ask Mr. Ross, who has helped us greatly in preparing these forms, kindly to explain them to us. RECORD OF INDIVIDUAL EXAMINATION Mr. Ross. — Form i is designed as a record of indi- vidual examinations. In the main the form explains it- self, but it may be well to summarize, very briefly, the advantages which it offers. 1. It provides a working schedule and prescribes the order in which the observations of inspectors shall be made. 2. It provides for economy in clerical labor through the use of check marks and of standard symbols in recording. 3. It brings together on a single slip, four by six inches in size, the complete record of each series of observations on a given child. 4. It makes possible, by the use of carbon sheets, the preparation of several copies of the record at a single writing, so that a duplicate of the inspec- tor's record can be furnished to the principal of the school and through him to the teacher, to the nurse, to the parent if desirable, and to the supervisor of medical inspection for purposes of control. The copy of the record which goes to the su- pervisor's office is filed under the date of the original examination and this becomes a charge against the inspector, to be removed only when the defects noted have been corrected, when the child dies, or moves from the city, or when the 1 ii s 1 1 1 7. 1 Og 1 UJ If) 1 a> 1 0£ 1 s? ^ ax * P' J 10 ^ h V J I Oz y r^S , ^ - o SNnaA'iai. AX3VJ.IMVC KOIOVIHOO aod NOU.D3 1 a, > 1 OS? li) D 5 uin h^ as u xoi So^ °z- d9. " U> i fl s 1 s 1 f 1 < 1 ■» b* ^5 9 i i ° u Ul a. tt 1] iiJ P t ul lO % z u ul p 5 ct«^>JO "C 1MOJC iwoN VtMXVHV cnwv^o J»law^30^^^■3(^ I DlHVDtfO TVWOlXDIjqj * V3HByoiO :)Nm¥3H i Kw^vro COION30V S-llSMOX VU.33J. 1 Ul >- mujMnmoo ■^■aN'HOD NOISI/^ f z £ 111 I, u] p o; n IC D z ;r 1 u ul P 5 atwwonac cmiS a^«N VIW3VN*/ o"a"l?3 .imiocn«Aa<3 5 oiHN/oaO iVNOooNnj < vaHtmcoo 3maV3u P of HHHViSO SQION3QY 5niSNOx HJ.33X WIUWICNDD v=Ma03 NOISIA 0! D S a a J I 3 DtUONBd. IVUDl I o,n«.u.o: Q3WXHTCia rraMiMVia 1 2 ■^^J^ nvjjDi i s % ONIQN2d oaddOAia Qau^mavai 03oa-io]C3 HiUOW j30 AVn Ul "• ■* « -> [- « <^ g ; ?! S ± « :? t - .s s 2 + S » c £ % - i " f o o o 1 84 HEALTH AND THE SCHOOL given date. Provision is made for an exact accounting for all pupils found to have defects. The number of such pupils, decreased by the number regularly dis- charged, gives the number of cases pending at any time. This number must agree with the number of slips (Form i) on file in the supervisor's office; so that an exact balance must be maintained at all times. A similar account is provided for the various kinds of defects discovered and corrected, so that the number of defects, as well as the number of defective children, charged to each medical inspector constantly appears on the record as an index of the efficiency with which in- spectors and nurses are following up their cases and securing the cooperation of pupils, parents, teachers, and family physicians. Department of Public Health and Charities — Philadelphia BUEEAU OP HEALTH DIVISION OF SCHOOL MEDICAL INSPECTION RECORD OF CLASSROOM INSPECTIONS GRADE CLASSROOM SCHOOL MEDICAL INSPECTOR NAME OF PUPIL DISEASE OB DEFECT DATE DISCOVERED DATE OF INSPECTION AND ACTION TAKEN 1 FORM 4. — MEMORANDUM OF CLASS ROOM INSPECTIONS. RED TAPE 185 MEMORANDUM RECORD OF CLASS-ROOM INSPECTIONS Form 4. This record contemplates a periodic inspec- tion (weekly or bi-weekly), in the class-room, of every pupil by a medical inspector or nurse. The object of this inspection is the prompt detection of contagious dis- eases and the discovery of pupils in need of special ex- amination for physical defects. One of these cards for each class-room is maintained by the inspector who, at each successive visit, enters a record of new cases dis- covered and the status of each of the pending cases until the case is finally disposed of. A summary of these class- room inspections is entered in the inspector's daily report (Form 2), and this finds its way into the monthly and annual statement of service rendered and results accom- plished. Mr. Martin. — Isn't there a good deal more red tape about this system of records than is neces- sary; and will not the results be that medical inspec- tors will spend valuable time in compiling records that will never be used, rather than in discovering physical defects of children and in getting them cor- rected ? Mr. Ross. — The clerical work involved in the prepa- ration of the summary reports will not require more than twenty minutes a day of each inspector, so that the amount of "red tape" will not be a serious burden. Even if much more time were required, however, it would be well spent if it enabled supervisors and inspectors to have constantly before them a clearly defined picture of service and results. Miss Parsons. — If it were silver coins, rather than live children, that were being entrusted to the care of i86 HEALTH AND THE SCHOOL inspectors, no system of records and reports necessary to insure carefulness and fidelity on the part of cus- todians would be regarded as useless red tape. Exact accounting and business-like methods are quite as essen- tial to the proper supervision of medical inspection as to the management of financial aiTairs. Mr. Young. — I notice that, while your system makes admirable provision for a record of individual exami- nations and for daily and monthly reports, it apparently does not provide for annual summaries, or for a con- tinuous cumulative history of the physical development of each child. Mr. Ross. — The system contemplates both of these provisions. The annual summaries will be obtained by bringing together the facts for each school, for each medical inspector, and for each supervisory district, and for the city as a whole into compact tabular form. The physical histories of individual children are to be per- manently recorded upon cards similar in most respects to Form i ; the main facts regarding defects found and corrected being entered chronologically opposite the proper dates. Mr. Young. — Are the record forms that you have dis- cussed all that are necessary for carrying on the busi- ness of medical inspection? Mr. Ross. — They constitute the vital part of the rec- ord system, unless we include sanitary inspection in the same system. It seems expedient in our case to have physicians inspect the schools as well as the children, and you will notice that provision was made in the daily service record for an account of time employed in sanitary inspection. We have prepared, in addi- tion, a form for systematizing the records of such in- spection. RED TAPE 187 a g 1 1 1 3 •J i S5 e a > i n 1 1 B « a H a hi a < 1 8 03 n 0^ 1 g 11 iHon E. 2 nvNianlaivas -onI (wrs NOLlVOOl loaaiONi 1 xaaaia 5 noon NOIXVl -IXNaA ONIlVaH 1 ° * ~ IVOO oj^^iJUj. s i _ ? 2 _ 1 5 ■" s < n s 2 S E >* 2 "" < M ^J' i ~ U5 CD 2 a § 8 03 i & a a S i 2 < li 1 1 -3 a 1 kj 0: 1 1 t> Sot 3^S :; aanoHNa t; siuad 9 -= BTMna oi Nouvnaa 3 I ON ll\ ^ai W( )0l [S 3V TC 1 SAi oaN IAS ON III 10 T HEALTH AND THE SCHOOL 1 < 2 O i e. i. 1 + p o 21 1 •d S S P b" 1 1 a 1 o z P i 3 s i It 11 b3 is is e 1 g B a i s 1 i g s 1" i 1 i si g i i >• i 1 i 1 S 3 3 >- S i 1 3 g 1 i 1 i 1 1 §1 i aoijuinninoDv N{ HI 3IJ V [N 00 NC u IQN 30 i'S [YJ .IN V£ irii 31 ja ^ aa XV ns SNO -ffO XVA Hai Has no RED TAPE 189 RECORD OF INSPECTION OF SCHOOL PLANT Form 5 provides for both a current and a permanent record of facts concerning the seating, lighting, tempera- ture, and sanitation of each class room, and the general sanitary condition of coat rooms, toilets, water supply, and the premises generally. The form also calls for a record of recommendations for the correction of sanitary defects, and the action taken by the appropriate authori- ties; thus locating responsibility for any unsanitary con- dition that is permitted to continue. Now, to answer Mr. Young's question whether these forms are all that are necessary for carrying on the busi- ness of medical inspection — they are not all that are re- quired for carrying on the entire business, of course, but are the heart of it. Various supplementary devices are needed to facilitate the work of medical inspectors and economize their time. Printing is far cheaper than writ- ing and more easily standardized. For this reason it is desirable to furnish carefully worded forms for use in notifying parents of the exclusion of children for con- tagious disease ; for giving instructions concerning the treatment of minor affections ; and for urging the regu- lation of children's diet, hours of sleep and personal hygiene. A well-organized medical inspection service will also do well to issue periodical bulletins, as is now being done in several cities and states where parents and pupils are informed, one point at a time, concerning mat- ters of vital and timely interest. By the effective use of appropriate pictures, charts, and other illustrative mat- ter, such bulletins can enlist practically every parent in the community, to some extent, in a program of construc- tive child hygiene. By utilizing the enormous power of 14 igo HEALTH AND THE SCHOOL newspaper publicity, still wider effect can be given to "health-grams" and to a community program of health conservation. Mrs. Ross. — I will frankly confess that this evening's discussion has given me a new sense of the value of forms of recording the observations and service of medi- cal inspectors. It is evident that those who apply the term "red tape" to a well-considered plan for collecting, classifying, and summarizing these facts simply advertise their own ignorance of the basis upon which all efficient management must rest. Mr. Young. — Certainly without the constant applica- tion of fact-tests the best laid plans may come to naught. By the intelligent use of such tests, good intentions may be transformed into substantial results and praiseworthy enthusiasm into scientific certainty. SUGGESTED READING Allen. Efficient Democracy. Chapters V-VH. GuLiCK AND Ayers. Medical Inspection of Schools. Appendix H. (In editions previous to 19 13.) Snedden and Allen. School Reports and School Effi- ciency. XI HEALTH BEGINS AT HOME Mr. Young. — Alert school physicians, perfect school sanitation, the wisest curriculum that can be devised — these agencies seem to herald a day of new vigor and joy to our children. But they are not enough. Our children still spend more than half their time at home. Bad conditions there can counteract to a large degree the best efforts of an enlightened public school system. When we heard the startling figures in the report on the Washington school the fact did not escape us that, if the school was harboring 87 unsound children in every 100, the homes were doing the same thing, and possibly even creating defects just as the school has been doing. Our recent work with parents in securing medical treatment for their children has incidentally convinced us that the homes are indeed responsible for many of the children's defects. Mrs. Ross will report to us on the observations made by the nurses.* Mrs. Ross. — In locating home responsibility for the defective children we had to find out two very essen- tial things — what homes showed most defective children, and how such homes differed from the others. Our nurses accordingly, after they had finished their special work of securing medical treatment for the defective * Based upon an examination of home conditions of New York school children by the New York Committee on Physical Wel- fare of School Children, 1907. igr 192 HEALTH AND THE SCHOOL children, made visits to all the remaining homes of the Washington school children. The children of this school come from a great variety of homes, representing all grades of prosperity and in- telligence, and we supposed that these various grades would be clearly reflected in the various health condi- tions of the children. Our surprise was great, there- fore, when we found but little difference in the physical condition of the children whether they came from homes of opportunity or of neglect. Adenoids and anemia were almost as frequent on the boulevard as in the alley. Even malnutrition was com- mon in the prosperous homes, the ill effect of wrong feeding or overfeeding in these homes equalling in many cases the ill effects of underfeeding in the poor ones. In the better homes, it is true, there was more evidence of money outlay for the children's health. The doctor was constantly being consulted for this and that, but, in spite of this advantage, the proportion of thoroughly healthy children in the better homes was only slightly greater than in the poorer homes. In fact, we found but few children really sound and well in any of the homes of rich or poor, and we were almost led to believe that childhood is a disease and that the normal condition of children is to be forever passing from one ailment to another. One mother, indeed, seemed to regard this as the case when she said placidly, "Yes, the babies have been sick most of the winter, but one can't expect little children to be well much of the time." This woman was bringing her wealth, her college education, her time, and her devotion to bear on the rearing of her children; but she was not keeping them well, and so supposed they couldn't be kept well. On inquiry she admitted that she had never made a study HEALTH BEGINS AT HOME 193 of the hygiene of childhood. This admission furnished the key to her children's ill health, which was not due to any inherent weakness of childhood. In fact, these children had unusually strong constitutions, being en- dowed with a rare physical heritage. What they needed was a hygienic regime which their mother did not know how to provide. This case is not the exception ; it is thoroughly typical of the households that came under our survey. Our inquiry, which we made at every house, as to whether any systematic study of child hygiene beyond the infant stage was being or had been carried on, usually caused bewilderment, and in only one instance met an affirma- tive response. In several homes, it is true, we found that the health of children was recognized as a problem, and some thought was given to it, but this subject of inquiry ranked distinctly lower than the absorbing question of the style of clothes most becoming to their young per- sons. One column of health hints to 20 pages of fashion hints per month seemed a satisfactory arrangement to most of the mothers who showed any interest at all in studying the health of their children. In one exceptional case we found the mother making a thorough study of child hygiene. She declared that bringing up healthy children was a fine art — a compli- cated art which must be faithfully studied to be mas- tered. She was taking a magazine devoted to the sub- ject of health, and reading in addition whatever she could find that bore on the healthful upbringing of her three young sons. The diet, the air, the dress, the sleep, the exercise, the work, and the play for these young boys were provided according to the best stand- ards to be found, with results that any mother would 194 HEALTH AND THE SCHOOL envy. These boys would have carried off the blue rib- bon had their parents been accorded the same opportu- nity for exhibiting- their productions as we delight to give those talented individuals who raise excellent chick- ens and pigs. Mr. Martin. — Your irony cuts home, Mrs. Ross. My own children would carry off few prizes. I have not been so fortunate in finding ready aids for bringing up healthy children as this mother of sons has been. From time to time I have called on the experience of my friends who have succeeded in keeping a fair pro- portion of their children alive, and they have generously told me all they knew ; but what did they know ? One knew that a draft of air in pneumonia was fatal ; another that the patient could only be saved by putting him on the roof. One knew that little children must have plenty of meat to insure good teeth ; another knew that meat, even in small quantities, was a poison. One knew that water at meals ruins children's digestion; another knew that children couldn't drink too much water at any time. One knew that flannels should be worn the year round ; another knew they were never needed. I have tried to avail myself of all these instructions, but, in spite of that, my children aren't very well, and I confess I don't know how to make them so. Mrs. Ross. — Mr. Martin's experience illustrates ex- actly the conclusion that our committee was forced to draw, which was that few parents understand the physi- cal care of children, and that almost none realizes that child hygiene is a scientific art which it is a duty to practice. It is not poverty, overcrowding, or insufficient food that is mainly keeping the mass of children in low health. It is ignorance. I could multiply instances of appalling mistakes we found not only in ignorant homes, HEALTH BEGINS AT HOME 195 but in those of supposedly highest intelligence and cul- ture. We found, for instance, the gifted child of a brilliant statesman suffering from malnutrition. The child was on a double diet which the parents, under doctors' or- ders, were forcing on him in the hope of increasing his scanty number of pounds. The solicitous parents did not observe that the child was scarcely chewing his food but bolting it down in quantities at top speed ; and so it never occurred to them that the excessive food in its unmasticated state was continuing to cause the very condition it aimed to correct. It is probable that the little boy's health would be completely made over if he merely acquired the habit of chewing his food well. Another family we found mourning the death of an only daughter. The little girl, whose adenoids had been neglected, had just died from pneumonia caused by ether irritation during an operation for appendicitis. The doctors were convinced that this rare complication would not have occurred if the respiratory membranes had been kept clear and sound. In another family we found a little boy on the verge of a nervous breakdown. The father was urging him with promised rewards to make further efforts in school. When a friend invited the child to her seashore home to spend a few days of rest and play the father would not consent because the visit would interrupt the all- important school work. Just a little further strain is likely to put a permanent end to this child's school work. In another home we found a baby dying of enteritis because its grandmother thought that this modern talk about the necessity of sterilizing all the bottles and nipples was nonsense. 196 HEALTH AND THE SCHOOL Shall I continue my woeful story, or have I made it clear that, as a rule, our homes are not caring for chil- dren according to established hygienic principles, and that the health of our children would profit infinitely if they were? Mr. Martin. — You have made your point very clear, Mrs. Ross. It is in thorough accord with my own ex- perience. To be sure, my acquaintances all have hy- gienic principles, but they are not established ones ; many of them are mutually exclusive. So far as I know, the raising of children has not been standardized, as the raising of hogs, calves, or chickens has been. The con- ditions necessary for the health of chickens, for instance, are thoroughly understood, and can readily be found in any chicken magazine or special government bul- letin. My fourteen-year-old boy, who is starting a fortune on hens in the back yard, has a great advantage over me, who am trying to raise him. The boy can read enough in one afternoon to. insure his winning all the prizes at the county fair — provided he carries out in- structions. But I, who am raising children, what guide have I to compare with these valuable instructions on chickens? If I could come upon a few principles that didn't contradict one another, that had a scientific foun- dation, and that were warranted to stand wear, I would exchange my whole library for them. Dr. Latta. — The case is not so desperate as that, Mr, Martin, though the government would certainly increase its claim to our respect by elevating the art of child- raising to the level of chicken or corn-raising and put- ting the best method of child culture within the reach of every American parent. Indeed, the country has already begun to advance in this matter. It is going out of fash- HEALTH BEGINS AT HOME 197 ion for a state to appropriate $150,000 for the protection of the health of its people and $750,000 for the protec- tion of its fish, forests, and game, as the Empire State did a few years ago. We have strong reason to believe that the new national Children's Bureau is opening a new era for the health of the nation's children. The Bureau has already attacked the evil which presses most bitterly on the homes of our country, the needless death of hundreds of thousands of babies and little children each year. While, as Mr. Martin says, the government has until recently neglected the matter of children's health, the medical profession has not. Sound standards for bring- ing up healthy children have actually been established, and these have the great virtue of being simple and easily mastered. Mr. Martin. — Then why aren't they known? Why don't the doctors instruct us? Why do they studiously envelop their services in a shroud of mystery? Why is it a breach of etiquette to inquire what drug is about to go into your child's stomach, and another breach, when you see the new doctor entirely reversing the last one's treatment, to ask whether the old doctor was kill- ing your child? Why does the physician say in effect, when he comes into your house, "This is my case. 'That is all ye know on earth and all ye need to know.' " ? Dr. Latta. — That old-fashioned medicine-man trick- ery has nothing to defend it, sir, except that the public encourages it. I am glad to hear a protest made against it. If the people would insist on being treated as in- telligent beings by physicians, and insist as well on a display of intelligence by their physicians, the cause of health would be enormously advanced. If you would help this on, encourage the doctors and the medical 198 HEALTH AND THE SCHOOL schools that do not regard the duty to a family done when a temperature has been taken and a dose pre- scribed. Mr. Martin. — Just how is one to encourage such doc- tors? The advice of a physician is expensive. Most families feel that they cannot afford it unless the case is urgent. Few people can manage to call in a costly private advisor for all the questions that arise in the care of children. Is there no simple way of arriving at the established principles of hygiene for which we are all groping? WHICH OF THESE COWS*) DO YOU GET YOUR MILK FROM ! IF TOU DONT Ask iHE HCAUffl DnrARTMEItT TO GIVE YOU THE RECORD OPTOH? NILKNflN. Tftsteurize your rm\k At borne to be on the 6f^e 6ide. AN APPEAL THAT LEAVES FEW PARENTS UNINSTRUCTED OR INDIF- FERENT. Dr. Latta. — There surely is. Well-selected reading should put the main principles of hygiene within the reach of any fairly intelligent person. It is' important to have such reading directed under competent advice, however, as much of the health literature that appears HEALTH BEGINS AT HOME 199 in newspapers and periodicals has little value, being ill related, unscientific, and even contradictory. Public health officers should give advice in such matters, as well as instruction to the people in simple hygienic prin- ciples. Ex-Health Commissioner Evans of Chicago, when he began to publish his weekly "Health-grams," set a great example to the entire country in practical methods of teaching the people to understand such im- portant matters as the care of young babies, the handling of contagious diseases, the danger of flies, the value of fresh air, clean milk, and pure food. The state Health Almanacs recently published in Virginia and Kansas are also notable examples of forceful and far-reaching pub- lic instruction. The observance of Health-day in a num- ber of states has also proved to be a powerful means of directing tlije attention of entire communities to the study of health. A method which has proved very successful in im- pressing great numbers of people is based on the Mis- souri idea of actual demonstration. The various wel- fare shows held in several cities recently, the Child Wel- fare Exhibits in New York and Chicago in 191 1, the Milk Show in Philadelphia in the same year, and the remarkable Philadelphia Baby-saving Show in 1912, have reached hundreds of thousands of people eager to learn the best standards for rearing their children. Miss Parsons. — Another very effective agency for demonstrating health principles to parents is the hy- gienic school lunch, an institution now successfully es- tablished in over 40 of our cities. The interest which the schools show in the matter of feeding children, and the benefit which the children derive from the lunches, impress parents profoundly with the importance of a 200 HEALTH AND THE SCHOOL properly selected diet. The most progressive schools are taking- advantage of this aroused interest to give parents direct instruction in the subject. We must not lose sight also of the immensely valuable health instruction that can be given to parents by teacher nurses under school direction. The intimate and continuous touch of these nurses with home life in their districts makes their serv- ices among the most important factors in advancing a knowledge of hygiene among parents. Dr. Latta. — In addition to such public work as we have cited, there should be constant instruction carried on by private practitioners. I myself am about to con- duct some classes in hygiene among my patients. I cannot afford the time nor they the money for individual instruction ; but in these classes of twenty-five or thirty members we can cover the necessary ground with one twenty-fifth or one-thirtieth the time and money outlay that individual teaching would require. Mr. Young. — Dr. Latta in his last utterance has rather anticipated a proposal I was about to make. Two things this evening have been made very evident : first, that parents, as a rule, are helplessly ignorant regarding the requirements for their children's physical welfare; second, that it is the duty of physicians to help dissipate this ignorance. I was accordingly about to request Dr. Latta to give us a series of talks in which he should out- line a general health program. Since he is already ar- ranging to hold classes in hygiene among his patients, may I suggest that he include the members of this club in his plan? Dr. Latta. — I welcome Mr. Young's suggestion, as I do every opportunity for extending health instruction, for it is only through the education of the laity in mat- ters of hygiene, and to a certain extent in actual medical BABY SAVING SHOW — PHILADELPHIA, MAY, I912. This exhibit set a new standard for effective instruction in child hygiene. The attendance was more than 100,000. The most important parts of the exhibit were preserved and sent from place to place throughout the city after the main show closed. Such graphic methods will be utilized more and more in public instruction as their value comes to be recognized. The lower photograph is a nearer view of the booth shown in the left fore- ground of the upper picture. HEALTH BEGINS AT HOME 201 matters, that we can hope to make much progress toward our goal of universal health. It is not the doctors but those who have the daily care of the children who really determine their health. The mother who does not know the few fundamental laws of health, or who, knowing them, fails to observe them, has little reason to hope that she will bring up all her children or have those who are spared grow up thoroughly healthy. On the other hand, a mother who does know the simple laws of health and follows them in caring for her children may be reasonably free from the haunting terror of death and disease. Health laws are easy to understand ; as easy as the ten command- ments. Mr. Young. — And fully as hard to keep. Dr. Latta. — Hard sometimes, but not so hard as to suffer the consequences of health laws broken, which are : sickness, sorrow, and loss. Too many parents have gained in grief the knowledge that arrived too late. The day has come, however, for an end to these grievously learned lessons. Parents are demanding to know how to keep their children well, and men of science are telling them how. Miss Parsons. — Are there not many conditions af- fecting the health of children which are out of the direct control of parents, such as smoke and dust in cities, bad school air, and adulterated foods ? Dr. Latta. — There surely are, and such evils can be attacked only by organized public effort, which it is the duty of all parents and public-spirited citizens to assist. Some of these desirable changes can unfortunately come only slowly, but, while parents are struggling with them, they can do much to offset the harmful effect of unsan- itary public conditions by making home conditions as 202 HEALTH AND THE SCHOOL wholesome as possible, thus keeping the resisting powers of their children at a maximum. The health of children who have inherited a fairly sound physique depends upon two main factors: their environment, and their own habits. Parents of naturally healthy children who provide them with the right en- vironment and help them to establish wholesome habits are bestowing upon them a peerless heritage of power and happiness. The necessary elements in the environ- ment are few, but most important : shelter, air, food, clothing, and play space in the physical environment; joy, affection, and hope in the social environment. To provide these vital requirements for children in the right amount and kind is to go far toward securing for them robust health. The necessary habits are simple: to keep the body clean, to eliminate waste regularly and com- pletely, to masticate food thoroughly, to aspire, work, love, play, exercise, and rest in the proper degrees. Such a regime carried on in wholesome surroundings is the guarantee of a healthy, vigorous life. The details to be considered in carrying out this health program will form the basis of our discussions in the talks which Mr, Young has asked me to give. Suggested Reading Bureau of Municipal Research, Philadelphia. Report of the Philadelphia Milk Show. Report of the Philadelphia Baby-saving Show. Child Hygiene Association, Philadelphia. Report of Philadelphia Baby-saving Show. Denison. Helping School Children, Chapters VI-IX. Grice. Home and School. Saleeby. Parenthood and Race Culture. State Health Almanacs of Virginia and Kansas. XII AIR Dr. Latta. — One of the first and most pressing needs of all creatures is shelter, an arrangement which civil- ized man has unfortunately carried to great excess. De- vised in the first place to protect against the destructive elements, storm and burning sun, it has come to be throughout the temperate zone a barrier to the life-giv- ing sunlight and air. The problem of shelter is not how we can be sufficiently protected by it, but rather how we can keep from being destroyed by it. Substan- tial answers to this question have been found in the now popular sleeping porches and window tents, open- air schools, and boys' and girls' camps, all of which are devices for securing the most urgent of all human needs, fresh air. A man can make shift to live a little while without either shelter, clothes, or food. Not so if his air supply is withheld. In that case he promptly dies. Nature has provided liberally for this most pressing and constant of all the vital necessities, making fresh air more abundant than any other life-giving element. This very abundance of air in nature has unfortu- nately led man to think lightly of its value. In the days of Queen Elizabeth, when building fine houses became the rage, Englishmen shut out the wholesome airy drafts from their houses and then began to die of tuberculosis, as they have been doing ever since. To this day 203 204 HEALTH AND THE SCHOOL the matter of proper house ventilation lags far behind the other provisions of sanitation. Bad sewage, for example, in Chicago, a city of 2,250,000, is estimated to be causing less than 400 deaths a year, while the an- nual army of victims from bad ventilation numbers 10,- 000. In the words of ex-Health Commissioner Evans, "Man consumes solid food, liquid food — water, and gaseous food — -air. Ten thousand deaths a year from bad meat, or bad milk, or bad water would produce a world-wide scandal, yet we accept ten thousand deaths a year from bad air with complacency." Mr. Ross. — How are those figures arrived at ? I have never happened to see in a mortality list a death re- ported as caused by bad air. Dr. Latta. — Foul air deaths are never so reported, yet there they stand, bulking about 40 per cent, in every death column. The immediate causes of these deaths are given as tuberculosis, pneumonia, grippe, bronchitis, spinal meningitis, scarlet fever, every one of them air- borne diseases. The numbers that die from these dis- eases are appalling. Do you know that 50 per cent, of all who die in this country between the hopeful ages of 20 and 30 years die of tuberculosis, and that pneumonia now claims almost as many victims annually as tuberculosis, the total roll from each disease being not far from 160,000? Miss Parsons. — I suppose the number of deaths from these diseases, large as it is, indicates but a small pro- portion of the entire number of bad air victims. There must be many more who recover from these diseases and who pay bitterly in suffering and financial loss, as do their friends. Dr. Latta. — Obviously. For every death from tuber- culosis it is estimated that there are not less than five AIR 205 living cases, some of them hopelessly doomed, others destined to make a long, agonizing struggle back to health. The number of people in the United States suf- fering from tuberculosis is probably over 1,000,000. Half of these are able to earn about half their wages, the rest are totally incapacitated. The cost of these cases in loss of wages, cost of treatment, and capitaliza- tion of the earnings cut off by death is annually $1,235,- 000,000. Much of this loss is suffered by the families which are left destitute. Mr. Ross. — I am still puzzled to know why you call the diseases you have mentioned foul air diseases. Are they not all caused by bacteria ? What has bad air to do with them? Dr. Latta. — A great deal, sir. The bacteria that cause the diseases I named, all of which begin in the respiratory organs, can be carried by dust in the air. What we call bad air — indoor air that is not con- stantly changed — is invariably full of harmful bac- teria. Mr. Ross. — What is to prevent these same bacteria from inhabiting the outer air? Dr. Latta. — The sunshine. The sun is the greatest natural germicide. Tuberculosis and a host of other germs cannot survive an application of sunlight. Mr, Ross. — Then do I understand that the single great menace of indoor air is its large number of bac- teria ? Dr. Latta. — That, along with indoor dust which car- ries bacteria, is certainly the most dangerous element in house air, but it is only one of several others, such as undesirable temperature and humidity, organic poisons, poisonous gases, and insufficient oxygen. All these un- favorable elements lower natural human resistance to 15 2o6 HEALTH AND THE SCHOOL disease. Thus, as you see, unchanged indoor air is doubly dangerous because it is not only loaded with germs, but prevents people from resisting them. Children, whose natural power of resisting disease is much lower than that of adults, are never really healthy unless their lives are spent mostly in the open air. Mrs. Ross. — Do you mean that literally. Dr. Latta? Few children can manage to spend most of their time in the open air. Dr. Latta. — And few children, as we have been find- ing out, manage to be really healthy. Parents are begin- ning to suspect the connection between fresh air and healthy children, and they are asking how they can give their children the necessary fresh air while they are providing them with such fruits of civilization as the ordinary school house and the steam-heated flat. They can't do it. Parents who want to see their children red- blooded must either keep them out of the ordinary school house and city flat, or reform the arrangements for ventilating such places. Mr. Martin. — I am struck by your sweeping demand for children's outdoor life. How can we give it to them without making Indians of them? Dr. Latta. — It can be given to them without inter- fering with any of the cultural processes which the civilized parent so strenuously applies to his young. By day the semi-outdoor school, which is the school of the future, will answer the needs of healthy education ; by night the sleeping porch or window tent will pro- vide fresh air without sacrificing any of the refinements of home. Mr. Ross. — Now, before we get the outdoor life com- pletely adopted, let me ask whether it doesn't savor somewhat of a fad. I can't forget the robust men and AIR 207 women who grew up when it was the fashion to shut tightly all the bedroom windows to keep out the dan- gerous night air. What evidence is there that indoor air actually induces disease and lowers resistance, and that outdoor air does the opposite? Can you quote us the figures? Dr. Latta. — Plenty of them, Mr. Ross. As far back as the civil war it was found that the unhoused hos- pital cases showed greater resistance to typhoid, ery- sipelas, and sepsis than cases of the same diseases in well-appointed hospitals, where the percentage of deaths was decidedly higher. The introduction of effective ventilation in children's hospitals has reduced the death rate from 50 to 5 per cent. ; in surgical wards of general hospitals from 44 to 13 per cent. ; in army hospitals from 23 to 6 per cent. The annual death rate among horses in the German military service has been brought down by more roomy quarters and free ventilation from 19 to 1.5 per cent. ; and in Boston, during a certain epidemic, the number of horses lost in badly ventilated stables was 5 to I in those well ventilated. Fresh air renders recovery from disease not only more sure, but more swift. At the S. R. Smith Infirmary on Staten Island a comparison made in two wards of the same nature, containing the same class of patients, showed the average time of recov- ery in the non-ventilated wards to be 16 days, in the ven- tilated wards 10 days. Mr. Martin. — You have left us with no doubt of the desirability of fresh air for our children. How to se- cure it is the next question. Dr. Latta. — It is well to keep two simple rules in mind : I. Keep the children out of doors as much as possible day and night. 208 HEALTH AND THE SCHOOL 2. Make whatever indoor air children must breathe as much like outdoor air as possible. Many people think they are strictly observing the first rule when they are giving their babies and children an outdoor "airing" of an hour or two a day. This is OUT-DOOR SLEEPING SIMPLIFIED. A small tent, hurig like an awning inside the window, leaves the sleeper's head in the open air, at the same time preventing the room from being cooled off. good as far as it goes, but it goes no further toward answering the whole need of fresh air than one glass of good milk a day answers a child's entire requirements for food. The easiest and most effective way to give children outdoor air is to have them sleep in it. This arrangement alone allows them to spend almost half of their time in the open air. Mrs. Ross. — Do you think it safe for children to use sleeping porches the year round? A friend of mine AIR 209 gave up the plan because her children caught so many colds. Dr. Latta. — It is probable that your friend did not realize the importance of protecting her children's heads and feet from exposure. It is perfectly safe for chil- dren to sleep outdoors all the year if they are sufficiently protected. In severe weather, if the extra precaution is taken to cover heads and necks with woolen hoods coming well over the forehead and fastening around the neck, and to keep the feet warm with woolen socks and soapstones, the north wind brings nothing but health and vigor in its blast. "^ r OPEN AIR COMFORT. This bag, designed by Dr. Carrington for use in out-door sleeping or sitting, is inexpensive and easily made at home. The first drawing shows the bag spread out to air; the second shows the blanket folded to 'form the bag; the third (on larger scale) shows the canvas flaps at the bottom and sides drawn into place and buttoned or buckled. Miss Parsons. — I can testify to the wholesomeness and pleasure of the sleeping porch. For a year I have slept on the roof of our settlement house. During that 2IO HEALTH AND THE SCHOOL time r have felt more vigorous than ever before in my life, and have not contracted one cold. The neighbor- hood has taken up the idea, and many of the roofs are now dotted with little shelters where babies are becom- ing rosy and young men strong. Our tenement laws, it would seem, will soon have to provide for some form of sleeping porch or roof, as that is the one easy means of securing an abundance of air for the people in the congested districts. Dr. Latta. — That is an excellent suggestion. No step could be taken that would go further toward se- curing good health for the people. Now, before we leave the subject of open air arrange- ment it will be well to give a warning or two. There Should not be too much direct exposure to the cold air. Sleeping porches should always have fairly warm dress- ing rooms accessible to them, and children's play spaces in winter should be sunny and shielded from the win- ter wind. A cold wind, and especially a damp one, by chilling little children beyond their power of resistance, sets up catarrhal trouble. :; Mr. Martin. — Our children must still spend a fewii hours in the house. How are we to make the house; air as much like outdoor air as possible? Dr. Latta. — Even under present imperfect housing conditions this can be done far more successfully than is usually the case. It is necessary, first of all, to pro- vide for a constant entrance of outdoor air that is free from dust and a constant escape of indoor air by various means, such as open windows, doors, air flues, and open fire places. A house that is heated by a hot-air furnace has always a fair amount of fresh air circulating through it ; so has a house with open fires, which for- tunately cause a stream of fresh air to be forced in AIR 211 through the cracks, even when windows have been faith- fully shut against the cold. An excellent device for securing a well-distributed volume of fresh, warm air in a room having a heat flue opening on the floor is a revolving air deflector set on the register. The deflector is revolved by the stream of warm air which it fans across the floor in every di- rection. The problem of securing a circulation of air becomes pressing in the houses that boast of the popular steam or hot-water heating systems. Such houses rarely have separate ventilating systems, and are at a great disad- vantage compared with those that employ the old-fash- ioned hot-air heating, which ventilates while it heats the house. In these houses and flats housekeepers must double their care to secure outdoor air. Windows should be left constantly open top and bottom with window boards to prevent direct drafts in every occupied room. Rais- ing the window from the bottom is not enough, unless there is a strong cross draft to an opposite window or room. Lowering the window from above is necessary to set up a current of air, the hot vitiated air escaping from the upper opening as the cool fresh air enters below. In very severe weather, when the draft from the open windows seems dangerous to health, occupied rooms should have a thorough blowing out with open windows and doors not less than once an hour. Mr. Ross. — Is not your prescription of so much out- door air in the house likely to run the coal bill up un- comfortably? Dr. Latta. — Oh, yes, the bill is likely to run up a little, though most of our houses would be more com- fortable if we kept them decidedly cooler by means of 212 HEALTH AND THE SCHOOL fresh air. As for the fuel, do you realize that a fair charge for three doctor's visits and a prescription equals the price of a ton of coal? If you really want to reduce your living expense, save on the doctor by spending enough for right living to make his services unnecessary. Mr. Martin. — Is the problem of securing good air in the house solved when we allow for a good circula- tion of air such as you have described? CLEAN CLEANING. The hand-run vacuum cleaner, built like a carpet sweeper, which removes dust without scattering it, is fast supplanting the barbarous broom. Dr. Latta. — Hardly. A circulation of fresh air is the first essential in house ventilation, but not the only one. Outdoor air on entering a house soon acquires the bad characteristics of indoor air, unless great care is taken to prevent this. Those baleful twins, bacteria and dust, are always in waiting to supply some infection, if no worse a one than the common house cold, which is, on the whole, the greatest bane of our winter months. AIR 213 House dust is never free from bacteria, and should be avoided like the plague. The amount of dust in the average house could be greatly reduced by a more sanitary method of furnishing and cleaning than is generally employed. Carpets, up- holstered furniture, and heavy hangings should be shunned. Cushions and rugs should be cleaned out- side, or with a vacuum cleaner. Floors should be smooth enough to clean with cloths instead of brooms. A really sanitary house can be made about as clean every day as the old-fashioned dust-gathering house was twice a year in the back-breaking "house-cleaning" season. A few American housekeepers, remembering that use is beauty, beauty use, have already learned that a dwell- ing is not a museum for the storage of miscellaneous stuff, but a shelter for comfortable living. When all the housekeepers have acquired this idea and firmly cast half their house collections into the ash barrel, the cause of health as well as beauty will be wonderfully advanced. The temperature of indoor air has also an important bearing on its wholesomeness. In addition to the di- rect danger to health from exposure when the indoor heat in winter is excessive, a temperature above 70 de- grees interferes with the rising of the warm expired air, which instead hangs around the head to be breathed again and again. Air issues from the lungs at a tem- perature of about 90 degrees, and when the room tem- perature is 68 degrees or under it rises immediately above the breathing zone. House temperature should be kept between 60 degrees and 68 degrees, according to the activity of the occupants, those most actively em- ployed finding the lowest temperatures most desirable. Moisture, as we have previously learned, is another important element in wholesome indoor air. Care must 214 HEALTH AND THE SCHOOL be taken to keep the relative humidity or moisture from becoming either too high or too low. A house should never be heavily shaded from the sun or set in a hollow, as these conditions foster dampness. The cellar should be kept as dry as possible by a constant circulation of air. When a house has been closed for a time it should be well dried by means of fires or warm sunshine. When the weather is cold enough to require constant fires the danger of dampness gives way to the danger of too little moisture. To avoid this, steam should be added to the heated indoor air by one means or another, except when the outside air happens to be very damp. When a hot-air furnace heats the house, fresh steam should be introduced into the air chamber of the furnace or directly into the air of the house. When stoves are used for heating, pans or kettles of boiling water should always be kept on them. When steam radiators are employed it is often possible to let fresh steam into the air from the pipes. Hot water radiators do not admit of such an ar- rangement and their use makes it necessary to employ some special humidifying device if the relative humidity of the air is to be kept at a proper point. Numerous and satisfactory kinds of humidifying apparatus are now on the market, and it is no longer necessary for any home or school to inflict the deadening effect of "burned-up" air on its members. The need of having an abundant supply of steam con- stantly injected into heated air to keep it at a satisfactory relative humidity was clearly shown by a test made a few years ago by Professor Loveland of the University of Nebraska. Taking two seven-room houses of exactly similar construction and heating equipment, he found that it required a daily amount of 64 gallons of water to raise the relative humidity of one house 10 per cent. AIR 215 above that of the other — i. e., from 20 to 30 per cent. It was also shown that the ordinary furnace water pan exerted no measurable effect on the hygrometer what- ever. This instrument for measuring moisture in the air is simple and fairly inexpensive. It is indispensable for the determination of anything but the vaguest knowl- edge regarding the amount of humidity in the atmos- phere. There remain three things to be guarded against in maintaining pure indoor air : organic and gaseous poi- sons, and deficient oxygen. Ordinarily a free circulation of outdoor air through the house by the use of open windows or hot-air flues is sufficient to give the necessary oxygen, and to keep the air fairly free from organic or gaseous poisons. Any undue source of air contamination must, of course, be strictly avoided, such as plumbing without vents or traps, decaying organic matter in house, cellar, or yard, and neglected garbage pails. Mr. Young. — We are greatly indebted to Dr. Latta for his clear discussion of the meaning of fresh air. His words have doubtless left us all with the following emphatic ideas : That good health in children is absolutely dependent on a constant supply of fresh air. That children should have many hours in the open air every day and night. That indoor air should be made as much like outdoor air as possible by the introduction of a constant stream of outer air into occupied rooms, and further by the keeping of these rooms clean, that is, free from dust, germs, and organic or gaseous poisons. Am I right in emphasizing these three points, Dr. Latta ? Dr. Latta. — They are exactly the points I wished 2i6 HEALTH AND THE SCHOOL to make emphatic. When the children of our land ac- tually come to breathe air provided in accordance with these principles, winter will cease to be the season of sickness, and colds will become as rare as smallpox. Suggested Reading American School Hygiene Association. Proceedings OF THE Sixth Congress. Report of the Committee on Heaping and Ventilating. Ayres. Open-air Schools. Carpenter. Heating and Ventilation of Buildings. Carrington. Fresh Air and How to Use It. Shaw. School Hygiene, Chapter IV. XIII FOOD Dr. Latta, — When a young baby is not thriving- its mother has one consuming purpose in Hfe — to get the right food for it. She knows if she fails the baby will die. Children as they grow older and stronger don't always die when they have the wrong food. They suffer all sorts of ills, however, and fall a prey to many dis- eases whose real cause, improper food, quite escapes the mother's detection, unless she has learned the few fundamental principles which should govern the diet of children. The vital effect that the right or wrong diet has on children has lately received striking demonstrations through experiments carried on in six schools by the Home and School League of Philadelphia.* In one of these schools warm lunches at a cost of 3 cents each were provided to 40 ill-nourished children for 3 months ; each child during that time having on the average 55.3 lunches. The gain in physical strength, mental ability, and conduct of this group was compared with the gain of another similar group of 40 children in the same school; the latter taking no school lunches during the time of the test. The results of testing the two groups at the end of this period were as follows : * Annual Report of the School Lunch Committee Home and School League, Philadelphia, 1911. 217 2i8 HEALTH AND THE SCHOOL AVERAGE GAINS Weight Height Hand strength Lung capacity Children fed 1.78 lbs. .90 in. 4.13 lbs. ii.g6cu. in- Children not fed 80 lbs. . 68 in. 3.19 lbs. s . 40 cu. m. In favor of children fed 98 lbs. .22 in. .94 lbs. 6.56 cu. in. Lesson Averages Conduct Averages Before After Cain Before After Gain The forty fed 64.0 70.1 9.5 69-4 72.0 3.7 The forty not fed 64.5 69.2 7.2 74-2 76.7 3.3 In favor of children fed .... 2.3 0.4 The records, as you see, show that the children who .were fed made greater gains than the other children in every item on which measurements were taken. If such results can be obtained by providing children with some- what less than one substantial meal a day, what may not be expected from three such meals? Mr. Ross. — Is not this little handful of 40 underfed children exceptional ? Dr. Latta. — By no means, sir. Picked up almost at random, they indicate the terrible proportion of under- fed children to be found in all parts of our land of plenty. It has been estimated from careful investiga- tions made in New York City that at least 1,248,000 children in this country are suffering from under-nour- ishment. Mr. Ross. — The children of the poor, I suppose. Dr. Latta. — No, the surprising thing about these shocking figures is that the hungry children are not confined by any means to the homes of the poor. Mr. Ross. — Then why aren't they properly fed? Dr. Latta. — Because parents almost universally choose their children's diet without any special reference to two essential requirements — the nourishing proper- ties and the digestibility of foods. The diet must be regulated in accordance with these H Z W u w w a H < H ►J < W K 5 _S ^ ^ a^ U ^ OS Q ^-O o n-5 OJ FOOD 219 two main requirements : ( i ) food should be nourishing, i. e., it should contain the right amount and proportion of elements; (2) it should be digestible, i. e., it should promote the most perfect assimilation and elimination possible. With these two guides to set the right course in feeding, mothers can weather seas of difficulties. I. NOURISHING FOODS Nourishing food provides completely for two vital processes in children — growth and activity. An abun- dance of all the food elements must be supplied to pro- vide the growing bones, nerves, blood, muscles, and other tissues with their needed materials. The surpris- ing hunger of growing children is normal. They need more food to their weight than grown people do. Not only do they require much tissue-forming food, but, on account of their great natural activity, a large amount of strength-supplying food as well. If a child is lan- guid or is said to have "outgrown his strength," he is either suffering from some physical defect or from an improperly balanced diet. Mr. Martin. — What foods go to forming tissue and what to supplying strength, and in what amounts and proportions should they be provided? Dr. Latta. — The body-building foods fall for the most part under one group — the proteids, or nitrogenous foods; the heat and energy-producing foods under two heads, called the carbohydrates and fats. The following is a classification of our common articles of food ac- cording to their body-building or strength-supplying properties. The table indicates when a food in one class contains elements in another. 220 HEALTH AND THE SCHOOL CLASSIFICATION OF FOODS * I. PROTEIDS — BODY BUILDING MATERIALS Meats (fat) Milk (fat and sugar) Cheese (fat) Eggs (fat) Fish (fat) Nuts (fat) Beans and Peas (starch) NON-NITROGENOUS GROUP- I. Carbohydrates A. Starches -HEAT AND ENERGY MATERIAL (a) Cereals (protein) (b) Bread (protein) (c) Macaroni (protein) (d) Rice (protein) (e) Potatoes (/) Sweet Potatoes (sugar) (g) Fruits (sugar and mineral salts) (h) Green Vegetables (mineral salts) B. Sugars (a) Various Sugars (b) Syrups (c) Honey (d) Sweet Fruits (e) Milk (pro'tein and fat)^ 2. Fats (a) Meat Fat (&) Fish and Vegetable Oils (c) Cream (d) Butter (e) Milk (protein and sugar) NOTE: — Mineral salts, which are also indispensable food ele- ments, have not been put in a separate class in this table. As they are present in small quantities in all foods, it is unnecessary to note the fact in each case. They exist in the largest amount in fruit and green vegetables, which gives these foods a special value. * Based in part upon a classification of foods in The Health In- dex of Children, by E. B. Hoag. FOOD 221 Mrs. Ross. — With the foods thus arranged in classes, in what proportions are we to draw on them to satisfy the needs of a growing child? Dr. Latta. — In every lo parts at least 8 should be selected from the energy-supplying foods, about 7 of these being taken from the carbohydrates (starches and sugars), and a little over i part from the fats. Slightly less than 2 parts of the entire diet should be selected from the proteids for tissue-building. Sugar White bread White potatoes m I Peanuts I Prunes ■ Milk HZ) Salt pork Beef round ED Chicken Cabbage D Bananaa Building materia! Heating and strengthening material FOOD VALUES THAT CAN BE BOUGHT FOR TEN CENTS. The amount of tissue-building material and of heat- and strength- giving material in ten cents worth of certain common food stuffs. 16 222 HEALTH AND THE SCHOOL To make this more concrete, let us see what actual amounts of these various foods should be given to chil- dren between 8 and 12 years old. A child of such age should have in all not less than 4 pounds of food per day, 2 pounds of this being milk. Referring to our classified list of foods, we notice that milk appears 3 times. Its rich supply of the three main food elements gives it a prominent place in each class, and makes it the most nearly perfect single food for children. It pro- vides over a third of the necessary protein and over a quarter of the necessary carbohydrates and fats. In addition to the 2 pounds (quart) of milk, the diet of a child between 8 and 12 should contain about 28 ounces from the carbohydrate group, i or 2 ounces from the fat group, and about 3 ounces from the proteid group. The supply of proteids seems low in our table, but it must be remembered that considerable amounts O'f protein are contained in the carbohydrates which make up the rest of the diet. This simple diet table, to- gether with a simple cost table, are sufficient guides in the choice of food elements for any busy mother who does not care to perplex herself with further intricacies connected with the chemical composition of food. The following bills of fare for children from 2 to 12 years old show a wholesome diet, chosen with reference to the proper proportion of food elements as well as their digestibility. These meals have been planned to feed three children in a family with an $800 income. Wholesome luxuries in the form of fresh fruits and vegetables, cream, olive oil,' ripe olives, etci, can be added at increased expense. FOOD 223 MEALS FOR ONE DAY* FOR THREE CHILDREN IN A FAMILY WITH AN EIGHT HUNDRED DOLLAR INCOME Child 2-4 Years Old Breakfast: 7.30 A.M. Oatmeal Mush Milk Stale Bread Orange Juice Lunch : Milk Stale Bread Butter Dinner: Baked Potato Boiled Onions (Mashed) Bread and Butter Milk to Drink Baked Apple Supper: 5.30 P.M. Boiled Rice i Cup Milk ■34 Cup Bread and Butter i Slice WEIGHT AND COST OF FOOD FOR DAY 0.8 oz. Dry Cereal iVi Cups I Slice 4 Tablespoons II A.M. I Cup I Slice I Teaspoon 1. 00 P.M. Slice Cup Material Rolled Oats. . . Stale Bread . . . Orange Juice . . Butter Potato Onion Apple Sugar Rice Milk Weight oz. Cost 0.8 $0.0030 2.0 0.0080 2.0 0.0150 o.s O.OIIO 2.6 0.0020 i.o 0.0030 2.0 O.OIOO 0.2 O . 0006 1.0 0.0050 34.4 (i qt.) 0.0800 46.7 .1377 Child 4-8 Years Old Breakfast: 7.30 A.M. Oatmeal Mush Top Milk Stewed Prunes Milk to Drink Toast Dinner: Pea Soup Croutons Boiled Onions Baked Potatoes Molasses Cookies I H oz. Dry Cereal J^ Glass 4 or 5 I Scanty Cup I Slice 1. 00 P.M. I Cup 1 Slice Bread 2 Small I Large Supper: 5.30 P.M. Cream'Toast 2 Slices Bread Rice Pudding with Milk and Sugar i Cup Milk to Drink ?4 Glass WEIGHT AND COST OF FOOD FOR DAY Weight oz. Material Rolled Oats. Prunes Milk Bread Peas — Split . Onions Sugar Potato Cookies Rice Butter 1 .0 50 S3-S Cost $0.0045 O.OIOO 0.0800 0.0120 o . 0046 0.0120 o . 0046 0.0039 o . 0040 0.0050 O.OIIO $0 . 1496 SUBSTITUTES OR ADDITIONS For rolled oats or rice: other cereals, such as rolled wheat, wheaten grits, farina, hominy, corn meal, shredded wheat and corn flakes. For orange juice and baked apple: prune pulp or apple sauce. For onions: spinach, strained peas, stewed celery, carrots, or cauliflower tips. An egg may be added every day, and should be included at least two or three times a week. These changes will alter the cost somewhat. ♦Planned by Mary Swartz Rose, Assistant Professor of Nutrition, School of Household Arts, Teachers College. Teachers College Bulletin, Second Series, No. 10. SUBSTITUTES OR ADDITIONS For rolled oats: other cereals as sug- gested in opposite column. For onions and peas: strained dried beans; other vegetables carefully cooked; fresh lettuce. For prunes: fresh ripe apples, baked bananas, other mild fruits well cooked. For rice pudding: junkets, custards, blanc mange, bread puddings and other very simple desserts. For cookies: gingerbread or sponge cake. 224 HEALTH AND THE SCHOOL III. Child 8-12 Years Old Breakfast Oatmeal mush or i J^ oz. dry cereal Top milk M Glass Stewed Prunes 6 or 7 Toast 2 Slices Milk to drink M Glass Luncheon Pea soup I Cup Boiled Onions 2 small Baked Potato I Large Bread and butter 2 Slices Bread Molasses cookies 3 cookies Dinner Baked haddock Small serving Creamed hashed potato H cup Spinach Vi Cup Bread and Butter 2 Slices Rice pudding, milk and sugar I Cup IV. Suggested Dietary for Child Who Will Not Drink Milk. Age 5 Years (i quart of milk concealed in the menu.) Breakfast: 7 A.M. Oatmeal Creamy Egg on Toast Cocoa M Cup Cereal Cooked in i Cup Milk I Egg Yolk with J4 Slice Bread and M Cup Milk I Tsp. Cocoa and H Cup Milk Luncheon: id A.M. Zwiebach and Cream i Piece Zwiebach and I Tbsp. Cream Dinner: 1.30 P.M. Spinach Soup 4 oz. Baked Potato with Cream i Potato and 2 Tbsp. Cream Bread and Butter i Slice Caramel Junket i}^ Cups Supper: Rice and Prunes Zwiebach S.30 P.M. 2 Tbsp. Rice cooked in H Cup Milk and 5 Prunes I Slice WEIGHT AND COST OF FOOD FOR DAY Material Weight oz. Rolled Oats i.S Prunes 2.0 Milk 34-4 Bread 6.0 Butter i.o Peas — Split 1.0 Onions 4.0 Sugar 1.0 Potatoes 8.0 Cookies i .5 Rice I.S Haddock 2.0 Spinach 2.0 65.9 OF Cost $0.0060 0150 0800 0246 0220 0046 0120 0036 0032 0060 0075 oois oois $0 187s WEIGHT AND COST OF FOOD FOR DAY Material Weight Oatmeal 0.9 Egg Yolk o.s Cocoa 0.1 Zwiebach 0.8 Toast 0.7 Spinach Soup 4.2 Potato 4.0 Rice 1.0 Prunes 1.3 Milk 34.2 Sugar 0.4 Butter 0.2 48.3 Cost $0.0030 0.0150 0.0025 0.014s 0.0027 0.0162 0.0032 0.0050 o.oioo 0.0800 0.0013 o . 0036 $0.1570 SUBSTITUTES OR ADDITIONS For rolled oats: other cereals thoroughly cooked. For haddock: rare beefsteak, roast beef or mutton chops; other fish, espe- cially white varieties. For prunes: any mild ripe fruit uncooked or cooked. For onions: string beans, stewed celery, beets, squash. For peas or spinach: turnips or cauliflower. FOOD 225 2. DIGESTIBLE FOODS We have learned what amounts and proportions of food elements go to make a nourishing diet for children. This is only half the problem of diet. To make sure that the diet which contains the right amount of nour- ishment is digestible is fully as important a matter. Children's stomachs are not so strong as those of grown people. That is why digestive upheavals constitute the most numerous afflictions of young children. These are due in almost every case to the ignorance or careless- ness of mothers. If mothers would observe just two fundamental rules for selecting a digestible diet for their children, they would go far toward securing for them steady health and comfort. These rules are simple. A. The diet should be made up of food easy to as- similate. B. The diet should promote elimination of all waste matter by stimulating the bowels to thorough action. A. Foods Easily Assimilated. — Their Selection and Preparation. — Foods that are easy for almost all children to assimilate are milk and small quantities of cream, well-cooked cereals, baked potatoes, fresh eggs, and mild fruits, green vegetables, and well-baked bread with butter. Milk stands first as a food for children of all ages, not only because of its highly nutritious properties, but because of its ready digestibility. Children should not be encouraged to dislike milk. Now and then a rare child feels an actual aversion to raw milk and is unable to digest it, but he can usually be made to assimilate the proper amount (i quart per day) by its use in cooking, as in puddings and soups. 226 HEALTH AND THE SCHOOL Cereals, if properly prepared, are easy of digestion. Those obtained from the whole grain, such as rolled oats and wheat, are preferable to the finer preparations, such as farina and cream of wheat. The dry cereals of known purity, such as shredded wheat, corn flakes, puffed wheat, and granose biscuit, tend to promote bet- ter digestion than the "mushes," because they compel thorough chewing. Eggs to the amount of one a day are easily digested if they are fresh and soft-boiled (they should never be fried). They can be used to good advantage in cus- tards, bread puddings, and simple desserts, as well as in soups. Fruits, which are a daily necessity for all children, must be selected according to the age of the children. For those between i and 4 years old the fruits should be limited to orange juice, baked apples, and prune pulp. The older children can easily digest any mild fresh fruit in perfect condition or stewed, dried fruits, such as dates, prunes, seedless raisins, and figs. The dried fruits should all be cooked without sugar, as they con- tain large amounts of fruit sugar, which is much more digestible than cane sugar. Bananas and apples that are baked are more digestible than raw ones. The in- digestibility of uncooked bananas, however, can be largely overcome by scraping off their soft granular surface, which is composed of raw starch. Fresh vegetables, another necessary item in the daily diet, are easy of digestion when properly selected and prepared. The youngest children should have the mild flavored ones, as carrots, spinach, and string beans, which should be thoroughly cooked and rubbed through a sieve or finely mashed. The older children, who do not need their vegetables mashed, can have celery, FOOD 227 onions, cauliflower, turnips, and squash in addition to the vegetables allowed to younger children. Bread, a constant necessity in a child's diet, is readily digested if thoroughly baked and at least a day old. Corn bread, brown bread, graham and whole wheat breads are desirable variations on the staple white loaf. Zwiebach and toast, if thoroughly dried, are more di- gestible than ordinary white bread, as the second bak- ing converts the starch into dextrose, a form of sugar very easy to digest. Meat is not included in the list of foods easily assim- ilated, as it is a distinct tax to the digestion of children under 8 years old. Even for the older children, who may have meat in small quantities, it is well to provide as many meat substitutes as possible ; for meat, though nourishing, tends to develop putrefactive poison in the intestines, thus inducing fatigue. Among the numerous good meat substitutes are the following: skim milk, cheese (preferably cottage cheese) which is as rich in protein as whole milk, beans, eggs, nuts — ground or thor- oughly chewed — and prepared vegetable proteids. A little caution is necessary in the use of beans, cheese, and nuts, which must be taken in small quantities ac- cording to the digestive capacities of individual children. It should also be remembered, when it is desired to cut down the amount of meat, that oatmeal, macaroni, rice, and gluten flour contain more protein than potatoes or white flour. White fish of various sorts are distinctly more diges- tible than meats. Soup meat also is more wholesome than juicy meat, as it has been deprived of its uric acid- forming elements, and has still all its protein left. Mrs. Ross. — Will you not tell us specifically what foods to avoid giving to children? 228 HEALTH AND THE SCHOOL Dr. Latta. — Assuredly. I have already spoken of meat as being undesirable for children under eight. In the same condemned list stand fried foods, pastry, fresh rolls and bread, syrups and preserves, candy, except in small amounts at meals, and cake, except in small quan- tities in the form of cookies, sponge-cake, and ginger- bread. No tea, coffee, beer, lemonade, or soda water should be given. Children over six may drink weak cocoa made with milk. Mr. Ross. — Why limit the candy so strictly? If sugar supplies strength, why is not candy a good food? Dr. Latta. — Because cane sugar, from which candy is made, can be digested only in small quantities. One more word as to the foods which I have recommended as easily digestible. These cannot, of course, be ex- pected quite to digest themselves. The children must do their part by faithfully chewing their food; the mothers theirs by avoiding monotonous routine in ar- ranging meals. Variety in diet has a marked effect upon its digestibil- ity. The food elements, it is true, should be provided in constant proportion, and but few articles should be supplied at a single meal, but within a week the articles should vary greatly. Surprises and special treats at the table give children wonderful pleasure, thereby stimulat- ing their digestion in marked degree. Indeed, the greatest of all aids to digestion is an at- mosphere of good cheer, for the nerves that govern di- gestion are powerfully affected for good or bad by the state of mind. A scientific diet is powerless to secure a good digestion if children are not happy at their meals. For either parents or children to bring anything but hopefulness and good-will to the table should be re- garded as a family crime, which strikes at the health FOOD 229 of every member. The crowning touch of wholesome- ness which a mother can add to the carefully selected and prepared food she offers her family is an atmo- sphere of good-fellowship and mirth, to which she should require every one at the table to contribute. Foods that are naturally easy to assimilate can be ren- dered indigestible as well as dangerous by careless hand- ling or wrong cooking. To be safe, food must be free from impurities, clean, and fresh. A freshly prepared warm meal is far more digestible than a cold lunch which may contain exactly the same materials. Even a single warm dish, such as a bowl of hot soup, goes far toward transforming a cold lunch. Mothers who habitually pro- vide "pick-up" lunches for the children because the fa- ther is away at noon make a great mistake. Children need as wholesome food as the father does. The value of warm lunches for school children has been well dem- onstrated by the Philadelphia experiment previously cited, and Philadelphia is only one of more than forty Ameri- can cities which are giving successful demonstrations in the proper feeding of school children. The three necessary qualities of digestible food — pu- rity, cleanliness, and freshness, and, we might add, savoriness — can be controlled in large measure, but not entirely, in the kitchen. In the cities children are often at the mercy of the dealers who supply their food. Mothers are not always sure of protecting their children against contaminated milk, stale eggs, embalmed meats, and various adulterations. It is necessary, therefore, for them to be alert as to the sources of the food they buy, and to exercise their influence for the correction of dangerous conditions in its preparation or handling. Dealers are sensitive to the complaints of their cus- tomers. The grocery store, for instance, that swarms 230 HEALTH AND THE SCHOOL with disease-distributing flies, would be cleaned up in two days if the women customers made up their minds to require it. The dirty milkman would overhaul his shop if mothers insisted upon it. Providing the right food for children is evidently not altogether a household matter ; mothers, in order to have the right food in their own homes, must help get it right for the whole community. There is no more vital com- munity problem than this, and no more worthy field of work for women. B. Foods That Assist the Elimination of Waste. — A properly balanced diet must stimulate the bowels to re- move thoroughly all waste. While the diet cannot be held completely responsible for this important function, it plays a very important part in its performance. The daily diet should always contain some materials which assist the action of the liver and bowels. Fruits and green vegetables best serve this purpose and are accordingly indispensable for a healthy diges- tion. Certain fruits and vegetables have a more de- cided effect than others. Spinach and peaches, oranges and grapefruits, thoroughly cooked prunes and figs are all invaluable for preventing constipation. The seedy berries, such as blackberries and raspberries, are excep- tions to the general rule of the action of fruits. A great aid to thorough elimination is an abundance of pure drinking water. If the diet is too dry the processes of assimilation and elimination are greatly in- terfered with. It must be remembered that seven- eighths of the entire body is composed of water, that food to be assimilated must first be reduced to a liquid, that the skin and kidneys can eliminate poisons only when these are in liquid form. Plenty of water must be provided for these important functions. A good rule FOOD 231 is to drink a glass of water (hot or cold, according to taste) the first thing in the morning and the last thing at night. Water at meals is most desirable, in spite of the popular and unfounded notion that it interferes with digestion. One matter, however, should be guarded against in drinking water at meals. It should not be taken to wash down unchewed food, but merely to sat- isfy thirst. A child between 8 and 12 years old needs at least 2 quarts of water a day. In following these general directions as to diet, moth- ers must remember that no rule, however good, works with every child. By careful observation they must find what forms of food seem especially adapted to their own children and what forms, if any, give rise to in- digestion. Normal children, however, may be expected to thrive if their diet is intelligently regulated by the general directions just given. Children who do not so thrive should have the advice of stomach specialists. Suggested Reading Bryant. School Feeding: Its Organization and Prac- tice at Home and Abroad. BuRNHAM. Food and Feeding of Children. The Cyclopedia of Education, Vol. II., pp. 627-630. Denison. Helping School Children, pp. 160-164. HoGAN. Children's Diet in Home and School. Home and School League, Philadelphia. Annual Reports of the School Lunch Committee, 1911 and 1912. Hunt. The Daily Meals of School Children. U. S. Bu- reau of Education, Bulletin, 1909, No. 3. Kittredge. Report of the Nezv York School Lunch Committee, Journal of Home Economics, December, 1912. 232 HEALTH AND THE SCHOOL The Psychological Clinic, April 15, 1912. Sym- posium on School Feeding. WiTMER. The Special Class for Backward Children, Chapter VIL XIV CLOTHING Dr. Latta. — What clothes to wear? This question begins to press even before the baby is born, and con- tinues with unremitting insistence until it receives its final answer in the form of the shroud. Like the other fundamental requirements of civilized man, clothing should be regulated by a few important principles. The two watchwords for clothing children properly are comfort and cleanliness. If clothes are comfortable and reasonably clean they serve all the purposes of health. COMFORT Miss Parsons. — ^Absurd as it seems, I am puzzled to know when clothing is really comfortable. It can- not be that all the surprising demands of children's fashions are comfortable, and yet children endure them without complaint. My neighbor, for instance, who is very faithful in her observance of styles, puts a thick flannel suit on her nine-year-old boy in January, and on his seven-year-old sister a light lawn dress, low in neck and short in sleeve. Neither child appears to be uncomfortable, though it is true each one has catarrh. Dr. Latta. — It is quite possible that the catarrh is due to improper clothing in the case of both these chil- 233 234 HEALTH AND THE SCHOOL dren. The boy may be dressed too heavily and the girl too lightly, and both be suffering injury, though uncon- scious of it. It is not safe to leave the choice of suitable clothing to children, v^ho usually show great indifference in the matter. Mr. Martin. — What other guide is there to follow? Dr. Latta. — There are definite standards of comfort which parents can easily follow in selecting their chil- dren's clothing. Clothes to be comfortable (i) must not press upon the body or obstruct free muscular play ; (2) they must protect against exposure to cold and wet; (3) they must not be oppressive. These are universal rules, the application of which, however, varies greatly in individual cases. I. Clothing must not constrict. — No bands must be allowed to press ; if they leave markings on the body they are too tight. Garters must not exert a percep- tible pull ; no buttons or hooks should be hard to bring together; no shoes should press or twist or rub. Shoes should have broad, low heels and substantial soles, and be straight on the inside line; they should fit the instep and heel snugly and leave the toes free. The growing child must have free circulation and unrestricted activity of muscle. Unless clothing allows fully for this, it does great harm. There are many devices for minimizing the pressure and strain of clothes. Socks in warm weather do away with garter strain; union suits and one-piece dresses lessen the number of waist-bands. Loose trousers for boys and jumper blouses and bloomers for little girls make the desired tree-climbing and fence-jumping easy possibilities. Devices should be studied that are suitable to the climate and that will free children from the bur- den and restraint of clothes. CLOTHING 235 2. Clothes must protect against exposure to cold and wet. Mr. Martin. — That injunction, may I say, is not as simple as it sounds. How is one to know the weight of clothing necessary to protect against exposure to cold? My boy Henry, who dresses in light linen, is al- ways warm from head to foot, while Katherine, swathed in flannels, shivers by the fire. There seem to be no standards for linens and flannels, as there are for bands and garters. Dr. Latta. — There can be no fixed rules for the weight of clothing as long as every child is unique in the rate of his circulation, the number of his red cor- puscles, his amount of fat, the vigor of his exercise, and his natural resistance. Every child must be studied and dressed according to his individual needs, and he must wear enough clothing to prevent his being chilly or damp. If your Katherine seems to need more clothing than most other children do there is probably something wrong with her. Find out what it is, but give her the extra clothes till you correct the condition that has low- ered her resistance. Mr. Martin. — How do you determine whether a child is warmly enough dressed? Dr. Latta. — A very simple but effective test is to find out whether his hands and feet are warm. If these are cold the child either needs more clothes or an im- proved circulation. This point brings up a matter which needs emphasis for all children, however hardy. The extremities must always be kept warm and dry. Sound rubbers, and arctics in severe climates, are no less neces- sary than overcoats ; mittens and warm caps are as im- portant as undershirts. Few children can resist colds and sore throats when their feet and hands are wet or 236 HEALTH AND THE SCHOOL chilled, or escape catarrhal troubles when piercing winds reach unprotected glands in their heads and necks. An indispensable aid in keeping children warmly enough dressed is the thermometer. Indeed, in our climate of marvelous changes the mother who presumes to decide what her children shall wear outdoors with- out consulting an outdoor thermometer puts herself quite at the mercy of the weather man. Living in a sheltered apartment or flat, she often sends the little ones off to school or out for their morning's play quite unconscious that the mercury has dropped 30 degrees in the night. A thermometer outdoors and indoors is necessary for anything but the most haphazard regula- tion of children's clothing. 3. Clothes must not he oppressive. — If a healthy child perspires without exercising rather vigorously he is too warmly dressed. Children who in winter must live in overheated houses and schoolrooms should dress almost as lightly as in summer. Clothes that overheat children cause far more disaster than those that leave them ex- posed. A perspiring child, going into the cold, is robbed of his natural means of resistance. Evaporation is re- ducing his heat at a dangerous rate, and his relaxed skin cannot quickly contract and protect him. On the other hand, a lightly-clad child who is not sweating loses no heat through evaporation and has, moreover, an effective natural protection in the contraction of his skin and outer blood vessels which drives the blood inward, where it does not lose heat, as it does on the exposed surface. The bodily warmth is maintained and the child comes through a brief exposure safely. A valuable rule for saving children from the oppression of clothes is to dress them as lightly as possible without allowing them to be chilly. HITTING THE HEALTH TRAIL. These Eskimo suits enable even frail children to gain the vigor offered by a winter out of doors. A WINTER PRESCRIPTION. Equal parts of out-door work and play are proving highly success- ful with these St. Louis children. CLOTHING 237 Mr. Martin. — Do you approve, then, of my Henry's going so thinly clad ? Dr. Latta. — Decidedly. There is no more active creature alive than a ten-year-old boy. Why should he want flannels in our warm houses? H he attended an outdoor school and his home were kept as cool as English houses, he would need warmer clothes, but un- der present conditions he does not. Now, just a word about flannels. Pure woolen un- derwear is desirable for very young or delicate children or in very cold climates. Hardy children in moderate winter climates, if their outer suits are woolen, are bet- ter off without it ; so are their mothers, to whom the problem of supplying expensive flannel undergarments and keeping them properly washed without shrinking is often a great burden. If moderately warm underwear is desired it can be found in the excellent cotton and linen substitutes for wool now on the market, or in gar- ments containing a small proportion of wool, for it is to be remembered that wool possesses no magic property of its own for "keeping out the cold." The secret of its efficacy is the natural roughness of its texture which contains multitudes of tiny air chambers. Any other fabric spun and woven as wool is, to the extent that it possesses similar air chambers, has the same protective value as wool. As yet, however, no substitute has quite reproduced the springy mesh of wool which continues to serve best when a maximum protection is required. For this reason all cold weather outergarments, which at best are somewhat burdensome, should be of roughly woven pure wool, thus relieving children of every ounce of superfluous weight. It is a good plan also to have a little high-grade woolen underwear in reserve for some unaccustomed exposure, or an occasional cold snap. 17 238 HEALTH AND THE SCHOOL Mrs, Ross. — Many of my friends would be horrified to make any such change in the weight of their chil- dren's underwear during the winter. Two changes a year, one in autumn and one in spring, is their rule. Dr. Latta. — And when their children take cold they lay it to the changing weather and not the unchanging clothes, do they not? Mrs. Ross. — To be sure. I did the same thing until it occurred to me to adapt my children's clothing to the weather. In this matter the thermometer, as you sug- gested, is a great help. One soon learns what weight of clothing best suits a child at a given temperature. The thermometer indicates reliably whether it is a day for the heavy or the light overcoat, the sweater, or the thinnest dress. All these articles are often needed within two days or even one. Miss Parsons. — Striking evidence of your words is given in the Chicago weather record for May, 191 1, which showed a range in temperature from 33 degrees to 94.2 degrees. The whole month was a mad mixture of frost and torturing heat and snow. One can imagine the difficulty the mothers had in keeping their chil- dren sufficiently and not oppressively dressed during these bewildering days, and their sorrow, too, at the toll of sickness and death that the erratic weather exacted. Dr. Latta. — The difficulties would have been under control and the sickness in many cases prevented if mothers had realized the value of following the vagaries of the weather with their thermometers. If a day dawns hot, even after a snowstorm, children should shed their warm clothes. If the next day is ushered in by frost, they should put them on again. There is no other safe way. CLOTHING 239 CLEANLINESS I. Clothes must be reasonably clean. — Only reason- ably. Mud and stains on the outside, unless of long accumulation, do no damage to health. The state of the underclothes is a more important matter, for it is through them that poison may be absorbed back into the blood. Those shrewd Orientals, the progressive Japanese, know the sanitary necessity of clean underclothing. During the war with Russia, whenever a battle was im- minent, the order went forth for every soldier to bathe and put on fresh underclothing. Why? To guard against infections of wounds. Never in history did battle wounds show so small a proportion of infection. Losses from wounds in both armies, compared with losses in most prior wars, showed a reduction of about 60 per cent., the number dying from wounds being but 4.5 per cent, of the entire number wounded. Clothing worn next to the body should be of coarse, soft mesh, as this has the triple advantage of absorbing perspiration, giving plenty of air space, and being easily washed. It should never be worn long enough to ac- quire the odor of the poisons absorbed from the skin and the bodily discharges. Soiled stockings must be particularly guarded against, as leather shoes keep the feet in an almost constant state of perspiration. Miss Parsons. — Many mothers find it too hard and expensive a matter to keep a family of children supplied with the right amount of clean underclothes, and they frankly give up the struggle. Are there not ways of simplifying the problem which will help them? Dr. Latta. — In the tropics all the underclothes of 240 HEALTH AND THE SCHOOL the family are washed every day as a matter of course and necessity. In our temperate land we are unfortu- nately bound by the tradition of "wash day." It is not always possible to get all the necessary washing- done on that dedicated day. A little simple washing on one or two other days of the week, by either the servant or mother or children, would strain no one and might make it much more possible for the anxious mother to square her practice of cleanliness with her ideals. Mrs. Ross. — The difficulty of keeping underclothing clean can be somewhat further simplified by the chil- dren themselves. They should always remove all their day garments at night, shake them out, and hang them to air. This clears the clothing from the particles of dead skin which are constantly rubbing off the body, and freshens them. Frequent baths also serve the double purpose of keeping children's underclothing, as well as themselves, fresh. Dr. Latta. — Those are capital suggestions. Now, just a word concerning the cleanliness of outer gar- ments. While the condition of the outer garments has not such an intimate bearing upon health, it is a great mistake not to have all children's clothes, except perhaps the hats and overcoats, of the kind that can profit by frequent immersions in the tub. When clothes are clean they are free from poisons and germs. Night Coverings. — The principles which govern the selection of day clothing apply with equal force to the night coverings. The same care must be exercised to have them comfortable and clean. As the day clothes must not constrict or press, so the bedding must not burden children. Soggy, heavy, cotton comforters are abominations too often found in otherwise well-ap- pointed nurseries. New cotton comforters covered with CLOTHING 241 a light material serve a useful purpose as extra cover- ings in cold weather; for daily use, however, wool and down comforters and blankets kept carefully washed give the greatest protection with the least weight. Mr. Martin. — It seems a trivial matter to mention, but I have a dreadful time keeping my children covered at all at night, regardless of whether the covering is wool, cotton, or down. They appear to take most of their exercise in their sleep. Mrs. Ross. — I have found it an invaluable practice, until my children were six or seven years old, not only to tuck their coverings well in, but to secure them firmly on both sides with large safety pins. The arrangement is kickproof. Dr. Latta. — That is an excellent plan to substitute for the common custom of mothers, which is to martyr themselves by rising frequently in the night to see that the little ones are covered. This practice is a sad waste of maternal energy, as wide coverings, securely fastened, serve the purpose even better than the visits stolen from the mother's rest. Children require less bedding than grown people, and it is quite as important to see that a child is lightly enough covered as to heap on the bedding if he is cold. Consulting the thermometer to determine the right cov- ering for a given night relieves a mother of much mid- night care. To keep beds fresh and clean is most important. Fre- quent sunning and airing are necessary for mattresses and pillows. An indispensable protection for the mat- tress is an easily washed quilted pad laid under the lower sheet. Unless such a pad is used a mattress in- evitably acquires the stains and odors that lend a hor- ror to second-class hotels and boarding houses, as well 242 HEALTH AND THE SCHOOL as to too many hospitable homes. A mattress pad, washed when necessary, keeps the mattress fresh indefi- nitely. May I repeat now, in closing, the two watchwords for clothing of all kinds — comfort and cleanliness. Suggested Reading. Oppenheim. Care of the Child in Health, Chapter VHL WooLMAN. Hints on Clothing. Teachers' College Bulle- tin, Technical Education, Series A, No. 4. XV PLAYGROUNDS "Happy hearts and happy faces, Happy play in grassy places — This is how, in ancient ages, Children grew to kings and sages." Mr. Young. — An ideal physical environment for our children ! Every son's mother wants it. How many get it? Dr. Latta has been pointing out some of the prac- tical steps necessary for securing the right conditions. He has shown us how to feed and clothe and air our children properly — new accomplishments for most of us. These provisions are all fundamental, but they do not end the program. H we stop with food, clothing, and air, shelter, of course, being assumed, we provide rather less for our children than we do for our valuable horses and dogs. Such creatures must have their daily consti- tutionals on the avenue. What about our children ? Dr. Latta will tell us what the recreational needs of children are. Dr. Latta. — Next to the demand for food, the one conscious crying want of childhood is for play — active, outdoor, happy play. All parents know this. The need is pressed upon them a score of times each day, but seldom does it meet the full response it should. Not that parents are indifferent. They are glad to grant 243 244 HEALTH AND THE SCHOOL their children the luxury of whatever outdoor play is compatible with the ordinary demands of the day, the weather, and the facilities at their disposal. If, instead of a luxury, parents recognized abundant outdoor play as the necessity it actually is, they would abandon their present attitude of mere acquiescence, and move heaven and earth to secure it for their children. They would make it their first consideration in planning their children's days, in selecting the site for their homes, and even in choosing their own professions. Mr. Martin. — While I know in a general way that outdoor exercise is important for children, I should be very glad if Dr. Latta would explain to us why it is so. Just what does active play do for children, and is it really more necessary for them than for grown peo- ple? Dr. Latta. — The cell change in children's growing bodies is very rapid. This not only calls for active as- similation of food, but also results in the formation of much waste which must be promptly eliminated from the tissues and blood and bowels by the excretory organs. The organs, both of assimilation and of elimination, can be held to their proper work only when the whole body is regularly given vigorous and agreeable exercise. Children find this necessary combination in outdoor play. Without it their circulation becomes sluggish and their muscles lose the tone necessary to carry on the vital processes. The results are likely to be anemia, malnutrition, and auto-intoxication. Children need more outdoor play than grown people do because their circu- lation, to be kept up to the higher rate necessary for their healthy growth, requires a greater amount of the stimulus that comes from agreeable muscular activity in fresh air. Don't misunderstand me to say, however, PLAYGROUNDS 245 that children need outdoor play more than grown peo- ple do. They simply need more of it. Mr. Ross. — I notice that you emphasize the need of making exercise for children agreeable. Why so? Aren't we trying to sugar-coat juvenile existence too much? Isn't the wood pile, though less attractive than the baseball diamond, quite as effective an aid to cir- culation? Dr. Latta. — By no means. A boy can chop himself out of breath on the wood pile, to be sure ; he can also develop some stout muscle there. A certain amount of this labor will serve him well enough, but even a year of such work will never give him the rounded physical development that an active baseball season affords. In the stress of playing ball the whole boy is stimulated to keenest activity. Brain and nerves as well as muscles are all brought into powerful action by the joy and ex- citement of the game. It is only under the influence of joyful excitement that children discover their full physi- cal capacities. Joyless exercise won't answer. It is one thing to recognize the demand of children for play. It is another thing to meet it. The need for play space in our cities has become acute. The need for play supervision in both town and country is no less urgent. Individual parents cannot handle these prob- lems alone. They can only be solved by cooperative effort of some kind. In the cities parents meet their children's appeals for outdoor play with a sort of helpless despair. They can- not provide private playgrounds ; neither can they deny the appeals. They are all finally forced to the same ex- pedient — to turn their boys and girls into the common and usually sole repository for children, horses, motors, beggars, thieves, and dirt — the city street. 246 HEALTH AND THE SCHOOL Here the children acquire muscle and lung capacity; also germs and vicious habits. The street exacts a heavy toll for the development it offers. Many children, to be sure, having no other place to play, would perish if they did not have the streets; but just as surely many children perish because they do play there. Mr. Ross. — Now, before Dr. Latta's epigrams have us all converted to some new-fangled theories about children's play, let me ask a question or two. In the first place, is it necessary for the welfare of children to provide them with as much opportunity and space for play as they demand? If my boy, for instance, were free he would never do anything but play — except at meal-time; and, as for roaming, he would stray to the very edge of the world. Secondly, why isn't the city street a pretty good place to play in after all? If it answers for pedestrians, why not for playing children? The children don't object to it. My boy Edward, after a week's visit in a New York flat, came home to find his quiet, ample playground stale and unprofitable in comparison with the city pavements and the adventures they afforded. Thirdly, if parents disapprove of city conditions for their children, why don't they leave the cities? Dr. Latta. — Mr. Ross's protests have opened the en- tire playground question very satisfactorily. As it is one of those rare questions which has only one side, any approach, however hostile, leads to conviction. In answer to Mr. Ross's first question, I will say that it is necessary for the health of children to let them have all the outdoor play they naturally want, just as it is necessary to give them all the food they naturally want. Their health is dependent on these instincts, which in both cases we have seen to be vital ones. PLAYGROUNDS 247 As for your boy, who you believe would do nothing but play if he were left free, may I ask whether you have ever tried the experiment? Normal children are fully as eager to work as to play, if they can find any- thing interesting to work on. When right occupa- tions are provided for children, the number of their play hours can safely be left to their own natural desires. Your boy's roaming propensities, too, are altogether wholesome. His feet are made to cover miles of earth. The best use he can make of a fence is to climb it. Let him roam by all means, but see that he does it in good company. Miss Parsons will give us some sug- gestions in this connection a little later. "Why isn't the street a pretty good place for children after all?" Now and then a city street is. A few care- fully selected, slightly traversed streets may be found in any city where the children can have wholesome, fairly safe fun. There are, in fact, in New York, Baltimore, and a few other cities little organizations called "Guilds of Play" which are devoted to promoting street play under competent leaders. These agencies are doing good pioneer work in demonstrating the desirable possibilities of street play. The experience of Mr. Ross's son on the New York pavements shows the fullness of life that can be reached in these surroundings — dusty, dirty, and dangerous as they are. We certainly do not want to eliminate the children from all the city streets, but we do want to eliminate the dust and dirt and danger, social as well as physical, that at present confronts them there. Even under the best regulations, however, the streets will never fill adequately the children's need for play space. Further provision must be made if the children 248 HEALTH AND THE SCHOOL are to prosper in the cities. This brings us to Mr. Ross's third question — a most interesting" one. "If parents disapprove of city conditions for their children why don't they leave the city?" Most parents who can are doing exactly this. If those who can't could, the cities would be practically emptied. Or, if the people who wanted to live in cities stopped having children, what would the census look like in a genera- tion? Unless our cities desire to lead off in a race suicide crusade, they will not only have to stop making it a punishment to produce and rear children within their precincts, but they will have to offer all sorts of whole- some attractions that will invite the children to come and stay. Our most progressive cities are already alive to this need. We shall ask Miss Parsons to tell us of some of the steps they are taking to meet it. Miss Parsons. — First let me say just a word as to the significance of the playground and recreation move- ment which is now thoroughly launched in this country. Dr. Latta's emphasis on the need of play for children is in line with a great new idea which is stirring our country, and which is destined to have a powerful effect not only on the health but on the character and lives of our whole American people. Within the last six years it has been dawning on the national consciousness that the business of life is threefold — -to work, to love, and to play; that the emphasis on these three great functions should be fairly equal ; and, further, that a scheme of life which doesn't make ample provision for all three necessities — labor, human affection, and recrea- tion- — is bound to turn out warped and unhealthy crea- tures. This is just what has been happening for many years throughout our whole country. PLAYGROUNDS 249 Our laws and ordinances have always recognized the first two requirements of living — the need to labor and the need to love. The law allows no children over six to escape the call to work. Each boy and girl must give eight years to the long school grind. The law also recognizes the human need for love by protecting, as well as its clumsy ways allow, the source of all affection — the family. How do our laws provide for recreation? They al- low for a few holidays and impose a few Sunday re- strictions, some of which greatly lessen the recreational possibilities of that day. With these few perfunctory provisions our cities and states until very lately have dismissed the subject of recreation. Mr. Ross. — Surely that is not quite all they have done. Do not most of our cities, in addition to recog- nizing holidays, provide their citizens with parks and breathing places? Miss Parsons. — To be sure. But, beyond pleasing the citizens' eyes and refreshing their lungs, what pur- pose do these parks serve? Is our one little park in front of the City Hall in any sense a recreation ground? For fifty years it has stood there, a mockery to child- hood, with its careful fences, "Keep Off" signs, and vigi- lant policemen ready to shoo away the children who ven- ture on the smooth walks with their roller skates. Mr. Ross. — Our town is not distinguished from other cities in that respect. Miss Parsons. — It has not been until recently. Our cities have generally been laid out with practically no provision for children's play. This is small wonder, for until very recent years almost no one beyond Froebel and his little stream of disciples has given a serious thought to this central need of childhood. 250 HEALTH AND THE SCHOOL But the revolution has come. When the full mean- ing of the recreation movement once penetrates our town the children will have no difficulty in coming into their own. I predict that within three months our City Hall park will be given over largely to the children, and that before the movement loses headway with us we shall have municipal playgrounds, recreation centers, re- creation streets, gymnasiums, and baths — and these in sufficient numbers to give every child of our town all the wholesome play and recreation that he needs. Mr. Ross. — You will never get taxpayers to carry out so enormously expensive a program. Miss Parsons. — On the contrary, self-protection will compel them to do it, just as soon as they see that it costs less to support this program than the sickness and crime it will prevent. Mr. Ross. — But does it? Miss Parsons. — There is much reason to believe so. It costs $i.oo to keep a child in a playground six weeks. It costs from $18.00 to $40.00 to keep a child in a reform school the same length of time ; and from $40.00 to $60.00 in a hospital. A very few children saved from reformatories and hospitals would mean a sufficient money saving to support a populous playground. The juvenile court records already show an amazing decrease in boyish crime in the neighborhoods where playgrounds have been established. Since playgrounds were opened in the stock yards district in Chicago five years ago, juvenile crime has been reduced on an average of 44 per cent, for the whole district — and what is still more striking — it has been reduced 70 per cent, in the imme- diate vicinity of the playgrounds, while only 28 per cent, in the regions farthest from them. In Cincinnati two years and a half of playground regime, between 1906 and PLAYGROUNDS 251 1909, reduced the number of delinquent children brought before the juvenile court about one-third. Playgrounds have been improving health as well as morals. In Holyoke, Mass., the school medical inspec- tors have found a remarkable falling off in eye and skin diseases among the children v\^ho have had a summer of outdoor play. In Rochester the playgrounds have actu- ally saved a number of lives by providing safe recrea- tion. Before the playgrounds were established, there were annually 15 to 20 deaths from accidental drowning in that city. The year the playgrounds were opened the number fell to 3. Mr. Ross. — I should like to ask Miss Parsons whether any cities have yet launched such a wholesale benevolent scheme for recreation as she proposed for our town? Miss Parsons. — Many cities are to-day working toward such a program. A few are already beginning to carry it out. Chicago leads the world by having the finest system of combined playgrounds and recreation centers to be found. That city is not afraid to spend money for play. Her expenditures in the decade from 1900-1910 amounted to $11,000,000. In Sherman Park alone the recreation buildings cost over $160,000. New York City has appropriated $16,000,000 for promoting recreation. Other cities have been hardly less liberal. Cincinnati in 1910 authorized a $1,000,000 bond issue for parks and playgrounds; Oakland, California, a city of 150.000, appropriated $430,000 for school playgrounds and their improvement; Grand Rapids, a city of 112,000, issued bonds for $200,000 for parks and playgrounds. In 191 1 nineteen cities authorized bond issues for recreation pur- poses to the amount of $4,445,500. Of the 294 cities maintaining supervised playgrounds in 1912, 99 depended 252 HEALTH AND THE SCHOOL entirely upon municipal support. The others received support from a variety of sources, municipal, county, state, and private funds. The drift is strong- and rapid in the, direction of public support. The number of cities establishing municipal playgrounds is increasing every month. It is only the most unenlightened communities that are not falling into line. That keen-scented individual, the ward politician, has. already discovered the popular appeal of the playground, and is now supplementing his time-honored method of bidding for favor with coal and turkeys, by securing recreation grounds for his neighborhood. Mr. Martin. — Our city evidently can not afford to lag behind in a movement that promises health and happiness to our children. We must have playgrounds, too. Mr. Ross. — That is a rather startling proposition tO' be made so lightly. There are many things to consider before we shall be justified in calling on the public treas- ury for the amount necessary to establish playgrounds in our town. Among other things we must ask what department of the town government would best have them in charge; how many, where, and what kind of playgrounds we need. This subject is so new and un- tried for us that I, for one, should hesitate to make any important decision regarding it without at least a year's consideration and study. Miss Parsons. — Your attitude seems to me exactly right, Mr. Ross. We should surely be making a calami- tous mistake to rush into a playground program with- out the most expert advice to guide us. There have been, indeed, in certain cities distressing instances of the misuse of playgrounds, which have been impulsively THE ETERNAL SPIRIT OF PLAY. Even the most cramped quarters of a crowded city playground can- not extinguish the instinct for play in normal children, but they make it difficult for any but the biggest and most boisterous ones to have a chance. THE MOST EFFECTIVE ARGUMENT FOR PLAYGROUNDS. The 1,200 children in the picture had no playground. This picture was effectively used by Detroit Saturday Ni"ht in a campaign which resulted in an appropriation of $65,000 for a playground adjoining this school. PLAYGROUNDS 253 established without any provision being made for their careful supervision. Fortunately we need make no such experimental mistakes, for the methods of promoting, selecting, establishing, and supervising playgrounds have already been standardized. The Playground and Recreation Association of Amer- ica is bringing to a focus the best experience of the whole country in recreation work. More than that, through its conferences and conventions, its publication. The Playground, and its field secretaries, it is making this experience available to any community, urban or rural, that seeks its aid. If we desire to establish playgrounds in our town the association can help us at every step. A field sec- retary can guide us first in a "Recreation Revival," which will probably be necessary to awaken public sen- timent. During such a revival, which may occupy a week, every agency in the town that can possibly help should be pressed into service. Schools and churches, city departments, women's clubs, and private organiza- tions of all kinds should aid in advancing the playground idea. Such concentrated efiforts, though lasting but a week, have already accomplished in various towns far greater results than months and even years of scatter- ing effort have done. After the playground idea has gripped the town and a Recreation Commission been appointed — at present the best form of management for recreational affairs — we shall need expert aid in our next step, a "Recreation Survey" of the town. This survey will disclose exactly what our recreational needs and facilities are. As this highly successful form of calling attention to a public need is rather novel, I think you will be interested to run over a description of a recreation survey recently 18 254 HEALTH AND THE SCHOOL made in Milwaukee. You will see that it calls for a very accurate as well as graphic presentation of the vital facts concerning the question of children's recreation in that community. DESCRIPTION OF RECREATION SURVEY EXHIBIT Prepared by Rowland Haynes, under the Child Welfare Com- mission, for the City Budget Exhibit at Milwaukee, Wisconsin, November, 191 1. 1. Three poster charts showing what 1,421 Milwaukee children seen out-of-doors were doing: 18% working, 32% playing, and 50% doing nothing. 2. Map showing 20 blocks in Milwaukee where 1,058 children between 4 and 15 years of age live, with open spaces free for play, and land built upon or cut up into too small lots for play. These lots and open spaces are shown in colors, and the chil- dren are represented by pins stuck into the streets and open places. 3. Chart showing a second Milwaukee neighborhood with rela- tive amounts of open and occupied space, and traffic conditions of streets. 4. Map showing third Milwaukee neighborhood of 20 city blocks, with schoolyard within its limits and park playground ad- jacent, also several vacant lots. The fact is shown that on a given Saturday morning, when 459 children were out-of-doors in that neighborhood, none were in the schoolyard, none were in the park playground, 38 were on vacant lots, 55 in private yards, and ^66 on the streets. Caption used : "Play Leadership Needed to Use Spaces We Have." 5. Charts showing density per acre in different wards of the city. Percentage of children to total population in the different wards. Every 57 minutes, day and night, winter and summer, a Mil- waukee child reaches the age of 5 and wants a place to play; every 72 minutes a Milwaukee boy or girl reaches the age of 16 and wants a good time. Caption used : "Fight Vice with Wholesome Recreation." 6. Charts showing numbers, distribution, and capacity of mov- PLAYGROUNDS 255 ing picture shows and theaters, numbers of pool tables, billiard tables, and bowling alleys, with estimate given of where young people are on Saturday nights. 7. Chart showing that Milwaukee has giown six times as fast as rural Wisconsin in the decade, 1900 to 1910. An idea of the form and arrangement most effective for such an exhibit as this of the Milwaukee Survey can be gained from the picture of the Philadelphia Baby Saving Show. (Page 198.) When the survey is accomplished we shall need the association's advice in the selection of a permanent rec- reation or playground director, who has been trained for this work. The technical knowledge of such a man is indispensable in determining how best to meet the needs the recreation survey has disclosed. His technical knowledge is fully as necessary for the selection, prep- aration, and equipment of the playgrounds as for the subsequent promotion of playground activities. Mr. Ross. — Miss Parsons has removed most of the difficulties which seemed to be in the way of launching our playgrounds, but I should like to question whether we are not being urged into a great outlay for some- thing that will benefit only a section of our community — the poorer section. We shall not want to send our own children to these rough-and-tumble places, shall we? Miss Parsons. — Your boy Edward's experience with the street crowd in New York would indicate that the public playground is exactly where he would be best pleased to spend his time. Mr. Ross. — Very possibly, but that is not where I should be best pleased to have him. Dr. Latta. — Should not the boy's own advantage settle the matter? What charm has any playground or 256 HEALTH AND THE SCHOOL the most fascinating apparatus in the world if there isn't a crowd of children to use it? Our sheltered, well-to-do children need the expanding influence of the public playground as much as our poor children do. The little starched paraders on the avenues have less fun, on the whole, than the freer children of the poorer streets. The rich children need the democratic sliding- board and the friendly wading pool, too. These necessi- ties of childhood, under proper restrictions, should be set at convenient intervals all over the town. Mrs. Ross. — I should be most happy to have my children enjoying such public privileges if they were under wise and safe supervision. Now, as to Edward's special need, may I ask Miss Parsons what provision has been made for gratifying what Dr. Latta considers the healthy roving instincts of boys? Miss Parsons. — The Boy Scout organization, with its "hikes" and camps, provides very successfully for this instinct, as well as for many other perplexing in- stincts of boys between twelve and eighteen. Cross- country walking clubs are another means of supplying boys with distance to cover. The Chicago Playground Association has lately been carrying on interesting ex- periments with clubs of this sort. Mr. Martin. — What about the girls? They number four to one in my family. Do the playgrounds take them into special account, and has there been any or- ganization devised to serve them as the scout organiza- tion serves the boys? Miss Parsons. — You may well ask about the girls, for until lately their needs have been largely overlooked in favor of their more insistent brothers. In 191 1 a director of the New York Child Welfare Exhibit dis- covered that there was just twenty times as much or- ON THE TOBOGGAN TO HEALTH. These Vermont children find full scope for their love of action on an inexpensive home-made slide. BRINGING THE BEACH TO THE CITY. An inexpensive device which provides the refreshment and exhilar- ation of water play to hundreds of Philadelphia boys through hot weather. PLAYGROUNDS 257 ganized effort being made for the recreation and de- velopment of boys as for girls. This discovery brought about prompt action on the part of recreation leaders. Experts began to study the possibilities of the play- ground for girls as w^ell as for boys, and soon intro- duced special games for girls over twelve. Most of these games are ball games of various kinds, requiring team work, a form of play which girls especially need, and they are proving highly successful. In addition to having playgrounds at their disposal, American girls now have open to them a national or- ganization for play and development which corresponds somewhat to the Boy Scouts. Leaders of the Play- ground and Recreation Association have launched an organization known as the Camp Fire Girls, which is admirably conceived to meet the needs and desires' of young girls of all conditions and climes. The organization is proving immensely popular and only waits for its rapid extension for competent women to take the leadership of the various clubs. In England the girls are being rapidly organized as "Girl Guides" with the assistance of Baden-Powell, the head of the Boy Scouts. These movements indicate clearly that the recreational needs of girls are being studied and met by those best qualified to handle them. Mr. Young. — Our time will not allow us to follow these interesting details any further, but our discussion has already brought out two things of prime importance — the needs of public and organized recreational facili- ties for our children, and a practical program for ob- taining them. 258 HEALTH AND THE SCHOOL Suggested Reading American Academy of Political and Social Science. Public Recreation Facilities. Boy Scouts of America. Official Hand-book. Camp Fire Girls. Manual. Green. Among School Gardens. GuLiCK. The Healthful Art of Dancing. Camp Fire Girls. Manual. Playground and Recreation Association of America. The Playground (a monthly magazine). ScuDDER. Recreation for Rural Communities. Russell Sage Foundation. (Pamphlets.) The Exploitation of Pleasure. Recreation Legislation. The Unused Recreational Resources of the Average Community. United States Bureau of Education. The Reor- ganized School Playground. XVI HEALTH HABITS Mr. Young. — If a child were a plant or a jellyfish, dependent for his welfare merely upon wind, wave, and weather, a right environment would be complete as- surance of his health. Our children are not jellyfish. They are startlingly free agents who react very vigorously to their surround- ings, and if they react in the wrong way, they upset our best endeavors. A wholesome environment is an indis- pensable condition for children's health, but it is only a passive condition, and cannot possibly result in healthy children unless it is reinforced by the active cooperation of the children themselves. Their health still waits upon the final condition — their own habits. Dr. Latta will tell us what these habits should be. Dr. Latta. — A youth's habits are the crowning test of his education. The organization of a child's whole mature life and character depends upon what habits of thought and action have been set in his early years. No higher responsibility and privilege ever come to parents and teachers than to lead children to form their habits right. Mr. Ross. — You are, of course, referring to much more than mere health habits. It would be hard to see the connection, for instance, between the hygienic habit of brushing teeth and a great and good life. 259 26o HEALTH AND THE SCHOOL Dr. Latta. — The connection isn't so remote. More than one great and good life has been wrecked by evil- smelHng teeth and dyspepsia. In emphasizing the over- whelming importance of habit I am, it is true, referring to all the habits of thought and emotion and conduct which make up personality. The health habits are bound up with all these and cannot be completely disentangled from them. A man's habit of cleanliness, a mere physical habit, if you will, has much to do with the spiritual impres- sion he makes; and, again, a man's habitual outlook on life, a mere spiritual phenomenon, you may say, has a powerful effect on the efficiency of his stomach. There is no habit which does not exert a shaping influence upon both mind and body. There are, however, a group of habits whose first ob- ject is the promotion of personal health and strength. These concern the daily routine of the bodily machine, whose efficiency, as in the case of any machine, depends on proper use and care. HEALTHFUL BODILY HABITS The bodily habits have to do with breathing, eating, elimination of waste, exercise, bodily carriage, cleanli- ness, and rest. The rules which should govern these processes are simple and few, and can be both well com- prehended and practiced by fairly young children. BREATHING Respiration is the most urgent of all the bodily proc- esses. As the suspension of this vital process, even for a short time, causes death, nature has arranged for HEALTH HABITS 261 respiration to be automatically carried on by the lower nervous system, without the aid of conscious effort. Through another set of nerve connections respiration can also be converted into a conscious act, which makes it possible to regulate the habits of breathing. These habits are of immense importance. They are indicated in the following brief rules : Breathe through the nose. — The importance of the form of breathing has already been discussed. If a me- chanical obstruction prevents nasal breathing, the con- dition should be corrected. If mouth breathing is a mere habit, it should be broken up. Mr. Martin. — How can it be broken up? Dr. Latta. — By enlisting children's efforts in their waking hours and giving them mechanical help, if nec- essary, during their sleep. If children's noses are un- obstructed it is quite safe to have their mouths held closed at night by means of an elastic support passed under the chin and over the head. Mrs. Ross. — I found an even simpler device which proved highly successful in overcoming the mouth- breathing habit in our boy. His upper jaw was becom- ing much distorted from his habit of leaving his mouth open. Our dentist assured me that it would do little good to straighten his jaw if the boy did not restore nor- mal pressure to his mouth by keeping his lips closed. The dentist suggested that I paste a paper label across Edward's lips after putting him to bed. This I did, tak- ing care that the label should stick only to the skin above and below the lips so as not to irritate the sensitive skin of the lips. While this little device was in no sense a gag, it did act most effectively as a constant reminder to the lips that their business was to stay closed. Edward has now completely overcome the need of the label. 262 HEALTH AND THE SCHOOL Breathe with the diaphragm. — This method of inhal- ing, besides securing full breaths, exerts a tonic influ- ence on all the abdominal organs, their circulation be- ing constantly stimulated by the rhythmical pressure of the contracting diaphragm. Sluggish livers and stomachs are often connected with sluggish breathing, and can be corrected by correcting the breathing habits. Mr. Martin. — How is one to make sure that chil- dren are using their diaphragms when breathing? Dr. Latta. — When the diaphragm is used the abdo- men is visibly forced outward a little at every breath. Otherwise the upper chest alone is visibly extended. A certain amount of chest breathing is desirable, but it should never become habitual as a substitute for deeper breathing. To make diaphragm breathing easy, parents must provide bands and waists loose enough to permit full waist expansion. Take a fezv breaths as full and deep as possible in the fresh air every day. — The best time to do this is on first going outdoors. The lungs at these times seem actually to taste the fresh air, and are stimulated by it to expand their capacity decidedly beyond their stale air limit. This little practice of taking a few deep fresh breaths every day has a remarkable effect in keeping up the vi- tality and the resisting power of children. It is also of distinct service in certain emergencies, such as the beginning of a cold. It is often possible to check a cold in the incipient stages of chills and sneezes by breathing in the way described at the moment the approaching symptoms are felt. In fact, whenever a little extra strength or courage or energy are required, a few deep breaths of fresh air will usually provide the necessary power. HEALTH HABITS 263 Breathe fresh air "whenever possible. — The vital im- portance of fresh air we have already explained. It is equally important that children be trained to enjoy and demand it. A taste for fresh air is easily acquired and is a life-long safeguard against disease. The way to make children love fresh air is to give them plenty of it. EATING Selecting food wisely for children is one thing, and an important thing. Eating it is another thing, and fully as important. In the latter operation the children play the leading parts. In justice to a well-selected diet they must be taught to play their parts well, observing faithfully the following rules : Che-cv food thoroughly. — Everybody knows the im- portance of this rule. How many people practice it? Fletcherism has become a household word, but by no means yet a household practice. Mr. Ross. — And why should it ever become one? The human race enjoyed its meals in its own way scores of centuries before Horace Fletcher learned to chew. What right or reason has one man to try to upset the racial instinct to bolt food? Dr. Latta. — You can't pin your faith to racial in- stincts when science pronounces them wrong, Mr. Ross. Our ancestors had their own reasons for gobbling. We have none. On the contrary, we pay a heavy price for perpetuating the table manners of the troglodites. Mr. Ross. — Why is it so important to chew food? As I remember my physiology, there are quantities of contrivances below the mouth that are designed for nothing but the manipulation of foods. 264 HEALTH AND THE SCHOOL Dr. Latta. — None of them is fitted with teeth, how- ever. Mechanically considered, they are merely a mass of self-contracting elastic tubes. What sort of job can they make of stuff that needs to be chopped and ground ? Not only is the mouth most important as a food mill, but as a food converter. The starches are all digested in the mouth — or ought to be — by being ground up with the saliva. Starch indigestion, a favorite ailment of the day, does not occur among faithful chewers of food. Eat regularly at proper intervals. — Next to thorough mastication this is the most important rule to observe in eating. The stomach becomes accustomed to a regu- lar routine, and is more ready to work at the usual hour than at irregular times. Enough time must always be allowed between meals for the stomach to carry on its work of digestion, which in some cases requires four hours. Having but one compartment, it cannot properly handle a half-digested meal and a freshly eaten lunch at the same time. It should, moreover, have a chance to rest before a new task is placed upon it. Mr. Martin. — Doesn't the mid-morning school lunch interfere with this observance? Dr. Latta. — Not necessarily. H a light lunch fol- lows three hours after a light breakfast, and is in turn followed by a dinner at least two or three hours later, the stomach can handle it very comfortably. One lunch a day, however, in addition to the three regular meals should constitute the limit of indulgence for children. Candy between meals is, of course, taboo. Avoid harmful foods. — Children should be made to understand what constitutes a suitable diet and to ob- serve its restrictions as a matter of course. In addi- tion to the usual articles of food and drink which chil- dren should avoid, such as tea, coffee, fried foods, and HEALTH HABITS 265 pastry, there are certain foods, wholesome enough for some people, but actually poisonous to others. Straw- berries, shellfish, even milk, act as poisons to certain constitutions. Children who happen to show such an idiosyncrasy, known as allergy, should be taught to rec- ognize them and to make a habit of quietly avoiding the troublesome articles of food. Use care in drinking zvater. — Children must be trained to avoid drinking water which comes from doubtful sources, such as attractive roadside brooks and enticing old wells. Danger lurks in any but certified sources of drinking water, and a little temporary thirst is a small price to pay for security from infection. Another precaution very necessary to impress upon children is not to drink cold water when heated with exercise, unless the exercise is to continue for some time after the drink is taken. Everyone who has had any experience with horses knows the importance of this rule. The precaution is not usually so faithfully ob- served in the case of children, but the need for it is exactly the same. In this connection we should mention the paralyzing effect of ice water, which may well be called our national drink. The ice water habit is an acquired one, which children can easily be kept from contracting. Mr. Martin. — Should children be allowed to drink water at all at meal time? Dr. Latta. — They should. Modern experiments have shown that it is highly desirable to drink water in small sips while eating. The water should not, of course, be at a freezing temperature nor excessive in amount. One glass at a meal is a good allowance. The harm in drinking water at meals comes when it is swal- lowed in large amounts to wash down unchewed food. 266 HEALTH AND THE SCHOOL Eat only when hungry. — This does not mean that children should eat whenever they think they are hun- gry. Some profess to be in that condition all the time. When their normal appetites fail, however, it is a mis- take to force them to eat. A diminished appetite in- dicates that the stomach's power of digestion is tem- porarily diminished. Rest may restore the power. Food that must be digested will only weaken it further. There are certain conditions that depress the stomach powerfully, and with it the appetite. Unusual fatigue, pain, and great emotional excitement — notably anger and fear, are ruinous to digestion. The meal should wait till the unwholesome state of mind or body has been improved. Mr. Martin. — Would you allow children's appetites to dictate their choice of foods at all? Dr. Latta. — This is advisable, provided they do not quarrel with the staples of their diet, their milk, ce- reals, and fruit. When they begin to crave abnormal things, like sour pickles, and chalk, and show an aversion to their proper fare, they need the advice of a stomach specialist or possibly some old-fashioned disciplinarian. Drink abundant water. — This habit, if fixed in child- hood, is a powerful defense against those arch enemies of civilized man, constipation, auto-intoxication, and kid- ney disease. The poisons which are constantly forming in the body and which should be eliminated by the kid- neys and the skin can be discharged only if there is an abundance of water to dissolve them. We usually understand by bodily cleanliness the con- dition of the skin. This is highly important, but rather less so than the internal cleanliness of the body. This can be maintained only by drinking plenty of pure water every day. It is an excellent habit to begin the day HEALTH HABITS 267 with a glass of water, hot or cold, according to weather, vitality, and inclination. It is also a good plan to have other regular times for drinking water during the day. The habit soon becomes automatic. Mr, Martin. — What do you call an abundance of water ? Dr. Latta. — From a quart and a half to three quarts a day, according to the climate and the age and activity of the children. Make every meal a feast of mirth. — This obligation rests on every food consumer. Good cheer makes even impossible food digestible. Heated arguments, cares, anxieties, and reproofs are as deadly table companions as flies. The intelligent household does not tolerate them. No item in a child's whole education is more impor- tant than the art of cheerful dining. ELIMINATION OF WASTE The body would be destroyed in a few hours by its own poisons if these were not being constantly elim- inated. The lungs, the skin, and the kidneys are dis- charging poisons from the system all the time. The lower bowels also are constantly gathering the poison- ous waste discarded in the process of digestion. The frequent and regular discharge of this waste is an in- dispensable condition to health. Keep the bowels active. — The necessity of a daily ac- tion of the bowels is generally recognized by mothers of young babies, but is not so often borne in mind after children have become able to care for themselves. Par- ents should not relax their vigilance until the habit is thoroughly fixed, and the children are trained to report 268 HEALTH AND THE SCHOOL any failure of the daily action. If such failure is ex- ceptional it can usually be corrected with a very slight enema. The use of the syringe should never become habitual, however. A chronic tendency to constipation cannot be altered by the use of either enema or drugs. Correct diet and proper exercise will conquer this diffi- culty with most children.* While, in distinction from the bowels, the skin, kid- neys, and lungs discharge their waste without conscious efifort, it should be made plain to children that this process is greatly aided by wholesome bodily habits, such as exercising vigorously, drinking plenty of water, bath- ing, and breathing fresh air. Keep the skin at tvork. One of the organs of elimina- tion, the skin, needs particular attention to offset the enervating effect of civilized life with its deadening clothing and shelter. Frequent bathing to keep the pores clean and open is, of course, necessary, but a more active program than this must be followed to make the skin really vigorous enough to pass off daily the pint or two of effete matter that it should. A very simple but effective tonic is a dash of cold water following a warm bath. This has an almost elec- trical effect on the skin, and in health it should be the invariable practice. A quick, cold sponge bath in the morning is also an excellent means of developing a vigorous skin. This practice is desirable for children, who react promptly from the cold of the water and whose skin is soon glow- ing with warmth. When a sense of chill follows the bath, however, and the bodily temperature is actually lowered, the effect is only damaging. Delicate chil- dren can often be brought up to a state vigorous enough * See suggestions on diet, page 230. HEALTH HABITS 269 to profit by the cold sponge, but the process must be carried on with care and judgment. Another vitaHzing treatment for the skin is a thor- ough perspiration followed by a bath and rubdown. This process removes a quantity of poison from the body and sets all the surface nerves tingling with a new feeling of comfort and energy. This agreeable ex- perience should be granted to children several times a week. Before long our schools will provide the opportunity for it in playgrounds, gymnasiums, and swimming pools. In the meantime it must be made as easy as possible for children to have a cool bath and rubdown at home whenever they have perspired freely. A further means of keeping the skin alive and active is to let it enjoy a change of temperature now and then. Qiildren are not naturally hot-house flowers. Their skins, as were those of their aboriginal ancestors, are made to resist heat and cold. It is actually undesirable that all the rooms in the house be of the same tempera- ture and that children should always bundle up for a brief run in the cold. A short stay in a cooler temper- ature is always refreshing. It is in a long and gradual chilling that danger lies. Mr. Ross. — Will you tell me why you are impressing us with all these directions for exercising the skin ? We have our clothing and we have our furnaces, which our merely skin-protected ancestors did not have. We mod- erns could almost dispense with our skin. Why drag it out into such prominence? Dr. Latta. — Because the state of the skin very large- ly determines one's state of mind, one's comfort, energy, and hope, or one's weariness and despair. This is no exaggeration. By far the greatest number of the nerves 19 270 HEALTH AND THE SCHOOL of sense terminate in the skin. The sum total of their impressions has a tremendous effect on one's conscious- ness. If the skin is clean, healthy, and active, one's sense of existence is brightened by a thousand agreeable sensations. If the condition of the skin is bad the re- verse is true. No theory in health is more easy to demonstrate than this one, and no physical habit is more important to im- press upon children than the habit of keeping the skin at work. EXERCISE While the vital bodily processes, digestion, circulation, respiration, and elimination of waste, are all carried on involuntarily, the vigor with which they are performed depends entirely on the tone of the muscles. This in turn depends on the exercise which is given to the vol- untary muscles. Keep the muscles Urm and elastic. The stomach, the liver, the heart, and the other vital organs do not call for help in handling the details of their work, but they do make a daily demand for power to carry it on — the power that lies in firm, elastic muscles. To the extent that this power fails, the work of the vital organs fails. The only way to keep a good muscular tone is by regu- lar and sufficient exercise. When children are allowed to follow their own instincts, which is seldom, they take all the exercise they need. They rarely need formal exercise in addition to their active play. Mr. Martin. — I wonder whether they don't often take more exercise than is good for them. Dr. Latta. — Not unless they are stimulated to undue endeavor by the admiration or the taunts of their friends. HEALTH HABITS 271 This, however, is one of the serious dangers of unsu- pervised play. It is not an unheard of thing for children to drop dead from trying to make records at jumping rope or to be badly injured by attempting other feats to which they are unequal. Four cautions of utmost importance should be im- pressed upon children in connection with their exercise: (a) never to run or play actively until at least half an hour after a hearty meal; (b) always to stop when they are out of breath or their hearts feel oppressed; (c) never to attempt feats that they really fear; (d) never to cool off suddenly when heated, except by means of a cold bath, which should be followed by vigorous rubbing. With these simple but imperative restrictions children should be encouraged to do all the running and jumping they want to, and to demand as their daily right three or four hours of active outdoor play. The weather, of course, often interferes with this ideal program. In that case the children should be provided with a sheltered space, either at school or at home, where they can be free to romp and roar as much as neces- sary. If children who are housed do not have the chance to play as actively as they would like to, they should be given a few hearty gymnastics every day. Vigorous body bendings, swimming strokes, and dancing steps serve to keep the vital functions active till the skies clear. The habit of exercise is the easiest of all habits for children to form. The only help they need is a good outdoor space and good leaders who can guide them in the most joyful and valuable pursuit of childhood — healthful, friendly play. 272 HEALTH AND THE SCHOOL BODILY CARRIAGE No one disputes the wholesome effect of an erect pos- ture on both mind and body. The acquiring of a fine carriage is a matter on which enormous emphasis is laid in military schools — and in almost no other place. So desirable, however, is a straight and strong carriage con- sidered that parents frequently send their boys to mili- tary schools for no other reason than to have them de- velop a military bearing. This magical bearing could and should have been acquired in the nursery, without the aid of a highly paid, brass-buttoned officer. Mr. Martin. — But how? Apparently the process isn't so easy, for three of my children have passed out of the nursery without gaining a creditable carriage. Dr. Latta. — Either your children weren't well or some one blundered. If children are free from adenoids and eye strain and in reasonable health, straight backs are easy to come by; but the person in charge must un- derstand well the two simple requirements for cultivat- ing such backs. Mr. Martin. — What are these requirements? Dr. Latta. — To hold one's own spine straight, and not to allow the children's spines to slump. Mr. Martin. — That sounds delightfully easy. But what has one's own spine to do with the process? Dr. Latta. — Almost everything. Example is the most powerful force in the early education of children. If you want your children straight be straight yourself. Mr. Martin. — And when example fails, as I've seen it do, how is one to compel children to keep erect? Dr. Latta. — How do they compel the boys in the military school? By making the acquiring of a correct HEALTH HABITS 273 carriage the chief business in hand till the habit of a good position is thoroughly fixed. This process usually takes about six weeks. Most children are not too busy to afford that length of time for acquiring a permanent- ly fine carriage. Could six weeks be spent in any bet- ter way? ERECT CARRIAGE — A HABIT WORTH ACQUIRING. By a little persistent effort, bad posture can be corrected and an erect carriage acquired like any other good habit. Mr. Martin. — I've been ordering my children to stand straight for far longer than six weeks, but you ought to see them when they attempt to straighten up. They fold their shoulder blades across their backs, point their chins toward the sky, and hollow their backs so grotesquely that I am relieved to see them relapse into 274 HEALTH AND THE SCHOOL their natural slouch, which they soon do. Can you tell me how to make them really straight? Dr. Latta. — If they will drop all their efforts with the smalls of their backs and their shoulder blades and chins, and observe the following simple directions, they can easily straighten up. Push the neck hack against the collar. Hold up the chest. Hold in the abdomen. Put the weight on the ball of the foot. Keep this position by day, and as com- pletely as possible by night. Six weeks of this regime will transform your crooked children. CLEANLINESS There are two kinds of cleanliness, aesthetic and hy- gienic. The former concerns itself with appearances and odors, the latter with actual conditions that deter- mine health. Neither of these brands appeals naturally to the young of the human species. Not till the mating instincts appear are parents able to relax their struggles with their spontaneously dirty children. Without stop- ping here to discuss the various hopeful means of coerc- ing children to keep decently clean, I wish to emphasize a few details of hygienic cleanliness which children are always eager to practice when the advantages are un- derstood. Keep the germs washed off. It does not impress little girls and boys much to be told that frequent bathing is a double safeguard to health, aiding both in the elim- ination of bodily poisons and the prevention of infection from outside. These important truths are too general to serve as strong motives. When children find, how- ever, that their little wounds, their cuts and scratches and scrapes, never become sore or fester if well scrubbed. HEALTH HABITS 275 and that burning, itching- surfaces are soothed by cleans- ing, they develop an actual affection for soap and water. When they find that their sore throats and stuffy noses and uncomfortable eyes get well if kept clean, they themselves put in a strong demand for gargles, nasal douches, and eye washes. Mr. Ross. — You surely wouldn't make such clinical processes as these the daily operations of children? Dr. Latta. — Only when an irritated condition of the mucous membranes requires it. This happens often in our barbarously dusty cities. Dust and germs lodge in quantities on the mucous membranes of the eyes, nose, and throat, and should be invariably rinsed out with a mild antiseptic if they cause the least irritation. Ordi- nary inflammation of the nose, throat, and conjunctiva (the mucous membrane of the eye) can easily be checked by a thorough cleansing of the infected surfaces. The mouth and throat should be well rinsed out every day, the eyes whenever they show any irritation, and the nose whenever there has been exposure to infection from another's cold or whenever congestion, either chronic or acute, is present. In catarrh, nasal irrigation should take place twice daily till the condition is relieved. Mr. Martin. — I confess to some fear of nasal irriga- tion. I have heard that it is likely to set up ^ % ^^^ trouble in the Eusta- \^^ *^ '*|^^ C3___ chian tubes. ^\^ r::TT-=i=^=^=s::rT^>^ Dr. Latta. — So it is %^ ^ ■.■■■-'yMi if not done properly; \ .^^>:.y3h'>i-ivt'j3M'i^^^^^^^^^ that is, if liquids are nasal cup. inhaled or injected into^his allows a cleansing wash to flow the nose. This method through the nostrils without the ... , , f strain or pressure caused by in- is very likely to force haling liquids. 276 HEALTH AND THE SCHOOL some of the liquid into the Eustachian tubes and thus inflame them, but if the Hquid is allowed to flow gently into the nasal cavity from a glass cup designed for the purpose, the operation involves neither discomfort nor danger. This means of cleansing and disinfecting the nose has wrought a revolution in the control of nasal afifections, and has put many of the ineffective atomizers into the historic museums, where they belong. Mr. Martin. — What antiseptics should be used in these various washes? Dr. Latta. — For the nose, throat, and mouth a salt solution — one-half teaspoon to a glass of warm water — is effective and safe. Solutions of listerine, glycothymo- line, certain alkaline tablets, and other mild antiseptics are useful, but the brands and the strengths of solutions should have the endorsement of your physician. For a mouth wash alone a solution of 2 teaspoonfuls of cinnamon oil to a pint of water is excellent. For the eyes there is nothing better than a solution of boric acid — 2 tea- EYE WASH CUP. spooufuls to a pint of water. This The only way to solution should be kept ready in a cleanse eyes is to clean, covered bottle and applied with ougVTitW an eye cup or poured into the eye as wash. The shape the head reclines. The easiest way it to^brSiJertrd to rinse the eyes of little children is over the eye, thus to have them lie down, and then to insuring a com- . ,, , , • u 1 j plete rinsing. pour the solution over each closed eye separately. When the eye is opened it immediately becomes filled with the wash without the discomfort that is caused by pouring it into the open eye. Boric acid must not be regarded as a HEALTH HABITS 277 medicine to apply gingerly in the form of drops. It is a cleansing wash that must be used liberally to be ef- fective. Before we dismiss the subject of washes we must con- sider the essential matter of clean teeth. These should be brushed thoroughly up and down — as well as side- ways — with tooth powder or paste at bedtime. They should be lightly brushed also after breakfast, and as many times more in the day — on rising and after other meals — as inclination and convenience dictate. If chil- dren show an unusual tendency to dental decay or to a deposit on the teeth, they should be required to brush their teeth thoroughly two or three times a day. The presence of organic deposits is sometimes only discov- ered by a stain on the teeth which follows the eating of berries or grapes. This deposit should be kept scrubbed off, and the disordered stomach which lies at the root of the trouble brought to a healthy state by a correction of the diet. Mrs. Ross. — Before the general topic of cleanliness is dismissed I should like to ask Dr. Latta just how much bathing children need to keep wholesomely clean. The complete daily bath is, of course, an ideal arrange- ment, but is far from easy to accomplish in large fam- ilies with limited facilities. Dr. Latta. — A partial bath at least should be given every day, either on rising or at bedtime. This should include, besides hand, face, and fingernails, ears, neck, armpits, crotch, and feet. Not less than once a week there should be a complete bath, including hair and scalp if possible, in warm water with plenty of soap, to be followed by a dash of cold water and a vigorous rub. In addition to the thorough weekly cleansing, the whole body should be bathed whenever it has perspired freely. 278 HEALTH AND THE SCHOOL It should also be an invariable rule to cleanse imme- diately any part of the skin that has become abraded or cut, and to protect it from further infection by a simple antiseptic dressing. Boric acid powder scattered over the surface, which is then bound up in aseptic ab- sorbent cotton, is an easy and effective way to dress a simple wound. Do not collect or distribute disease germs. — Clean habits are no less important for the children who prac- tice them than for their associates. Particularly is this true of the habits that concern the spreading of disease germs. In addition to keeping well washed, children should observe strictly the following rules for prevent- ing infection to themselves and others : Never handle the organs of the body, as mucous mem- branes are easily irritated and infected; don't pick the nose, but always carry a handkerchief. Don't rub the eyes or any other organ. Never put anything in the mouth except food and drink or things intended for the mouth. Never exchange or lend candy, gum, whistles, or any- thing that is intended for the mouth. Never kiss upon the lips ; kiss the forehead or cheek. Never face another person when coughing or sneezing. Never spit where it will be possible for the feet or skirts of others to catch up the germs you have left. Never leave anything dirty or offensive exposed where it can be an annoyance or where it can be reached by flies. A clean body in clean surroundings holds disease at arm's length. HEALTH HABITS 279 REST In our discussion of a school child's daily schedule we heard some good suggestions concerning rest, among them being the necessity of long hours of sleep for chil- dren and the need of a partial rest after hearty meals. In addition to arranging for such rest parents must see that the children actually get it. Many children, through poor nervous control or indigestion, have much difficulty in getting to sleep or in really resting when they need to during the day. This is a serious condition which, if continued, is bound to do permanent damage to the nervous system. Restless nights can often be corrected by simplifying children's suppers and avoiding any exciting or straining occupation during the hour before bedtime. Learn to relax. — Often, however, the failure to rest properly is merely a bad nervous habit and must be cor- rected through the cooperation of the child himself. Many of our children even at an early age need instruc- tion in the art of repose, the only defense against our constantly intensifying modern life. They must not be allowed to outgrow the power they had as babies of completely relaxing their brains, nerves, and muscles. Sleep cannot long resist such an invitation. A moment or two of such genuine relaxation during the day is often of great value, averting many stormy tantrums which are merely the automatic results of over- wrought nerves. I know one mother who, when she saw signs of an approaching fit of rage, as her little girl called the unhappy visitations, told the child that if she would sit very still and let herself feel heavy the fit would pass by without touching her. It did, and the 28o HEALTH AND THE SCHOOL little girl was so pleased with her success that she forth- with adopted this method of relaxation for use in mo- ments of emotional temptation. Do not dawdle. — Some children unconsciously try to rest by dawdling half-heartedly over their occupations. This is a pernicious habit, bad both for nerves and char- acter. Children should either be engaged in hearty ac- tivities that interest them and are worth while or should be frankly resting. They should not be reproached for occasionally lying down or sitting in complete idleness. The vacant, contented look- they wear at such times means rest. It is their aimless movements and efforts that must be checked. Dawdling around is neither work, play, nor rest. It opens a sure approach to vicious habits of various kinds, and finds no place in a well- appointed life. Children who are able to direct their energies vigor- ously and effectively and know when and how to rest them have learned a fundamental lesson in self-control. HEALTHFUL HABITS OF MIND Cidtivate cheer, hope, joy, and fun. — Good health re- quires that the state of mind be under control as well as the state of body. Certain habits of thought and feeling should be persistently cultivated, others as per- sistently discouraged. A courageous, energetic habit of action, a cheerful, hopeful outlook, and a readiness to seize upon joy and fun, while not exhausting the list of moral virtues, are those that contribute directly to health and vitality. To help cultivate these tendencies in one's children is as important as providing them with food and baths. HEALTH HABITS 281 Refuse to feci anger, fear, and zuorry. — Like poisons, to be shunned^ are those deadly conditions of mind — anger, fear, and worry. They play havoc with youthful nerves, and should be guarded against with all possible care. No precautions can, of course, keep them entirely away from children, but the troubled moments, when they do come, can be made to have truly educational value. If the anger, fear, or worry can be converted into desirable action, such as punching an offending ruffian, or leaping from before a rushing engine, or running for the doctor, it has served a useful end. It is the help- less bursts of anger and the unreasonable fears that must be firmly checked, and nothing is easier to do when the way is understood. If a child relaxes his muscles completely, or, better still, turns his attention to some- thing worth while, his anger flees from him ; if he takes a few deep full breaths his fear and worry depart. These little physical suggestions outclass, both in sim- plicity and effectiveness, long moral exhortations which have small place in a nursery. It is easier for a small boy to relax his muscles or get busy than to "be good." Mrs. Ross. — Are we, then, to cultivate our children's morals through their muscles? Dr. Latta. — That is certainly a sound method of ap- proach. Young children should be taught to use their muscles and their bodies morally. A healthy, well-occu- pied child is a good child. Mr. Martin. — One question more. In your discus- sion of habits you have said nothing about the vicious habits that we are always being warned to guard our children against. Dr. Latta. — They would hardly come under a dis- cussion of health habits. I may say, though, that, if 282 HEALTH AND THE SCHOOL children master the habits we have outUned this evening, and spend their days in the vigorous manner suggested in our discussion of their daily schedule, they will have little time or inclination to cultivate morbid ways. Mrs. Ross. — I am impressed with the vigilance it will require to see that children form all the good habits you have suggested. Dr. Latta. — Eternal vigilance you may well call it. Children are forming habits of some kind every mo- ment of the day. These habits, acquired in school and out, at work and at play, are the very essence of their education. Shall these habits be good or bad, healthful or harmful? Teachers and parents must give the an- swer. Suggested Reading GuLiCK. The Efficient Life. Health Education League. Habits of Health. XVII CALLING THE DOCTOR Mr. Young. — The chief concern of our club this year has apparently been to learn how to dispense with the doctor. Disease prevention has been our main study and the securing- of conditions favorable for developing the health of children our steady purpose. Mr. Martin. — Is the family doctor, then, to become a relic of the past, and will the new generation be able to regulate that most highly organized of all mechan- isms, the human body, without the aid of experts? Mr. Young. — Hardly. A landsman can run the ship as long- as the wind is fair and the course is set in an open sea ; but, when storms or breakers threaten, the captain is the only man to be in control. The health- iest of us would make sorry work, at times, without the doctor. He must still preside at the supreme mo- ments of birth and death, and on those other critical days when some unpreventable disaster threatens a life in the household. The complete dependence that we often have to place upon him and the serious effects of his decisions upon the lives and happiness of ourselves and children make our selection of the doctor a very vital responsibility. When to send for the doctor and 7vhich one to send for are questions that parents are called upon to answer from the very first, and the wisdom of their decisions 283 284 HEALTH AND THE SCHOOL often determines the very lives of their children. This evening we shall discuss these two questions, on which we are all greatly in need of instruction. Since the choice of a physician should always be made before a sudden demand for his services arises, we shall first consider the question "How to choose a doctor." Dr. Latta, who is far too busy to have any personal interest in the matter, will open the discussion. HOW TO CHOOSE A DOCTOR Dr. Latta. — When a father whose child is suddenly taken sick runs for the doctor, the chances are four to one that he will get an incompetent man. Mr. Ross. — What do you mean? Dr. Latta. — I mean that about four-fifths of our doc- tors have been so inadequately trained that it is dangerT ous to trust them with any serious cases. Mr. Ross. — I can hardly credit your statement, Dr. Latta. Why are such men allowed to practice? Dr. Latta. — Because both the federal and the state governments have given too little heed to the question of medical education. They have failed to realize that a properly fostered and regulated medical service would do more for the welfare and prosperity of the entire country than the best devised tariff or banking system, or even a three hundred and sixty million dollar canal. Without regard to the dignity of the profession or the welfare of the public, they have allowed inferior med- ical schools to spring up wherever private greed saw probable profit in such a venture. The result of this lack of government regulation is that we now have about five times as many medical schools as we need, and almost four-fifths of them are below the best stand- CALLING THE DOCTOR 285 ards. Many of our states annually turn out hundreds of ill-qualified doctors to prey on the public — men who have never become acquainted with the human body by dissecting it, or learned anything of sickness by seeing it. Some of these medical men, to be sure, are gradu- ally starved out of the profession, but during their slow elimination they are a substantial factor in keeping up the death rate. Mr. Young. — Would there be enough doctors left if the unfit were all to be eliminated? Dr. Latta. — Plenty of them. Germany, which main- tains the highest professional efficiency of any European country, has only one-fifth to one-fourth as many doctors as we, and even of this smaller number few are properly supported. In our country most of the doctors are actu- ally failing to make a living, and many who do manage to subsist earn less than skilled laborers do. Mr. Ross. — May I ask Dr. Latta how he has been able to come by all these interesting and remarkably definite figures? Dr. Latta. — In answer let me refer you to two very important reports on medical education made by Abra- ham Flexner for the Carnegie Foundation for the Ad- vancement of Teaching.* These reports should be in the hands of every intelligent person in the country. They are highly instructive and decidedly interesting. Mr. Young. — I have been told that these reports are so arbitrary and prejudiced that their conclusions are to be greatly discounted. Dr. Latta. — Have you read them? Mr. Young. — No. Dr. Latta. — Do so, Mr. Young. The people who * Medical Education in the United States and Canada, 1910; Medical Education in Europe, 1912. 20 286 HEALTH AND THE SCHOOL see prejudice in the dispassionate array of facts, not opinions, which these reports present are those who sup- ply their own. Mr. Martin. — Aren't these reports very technical and intended merely for medical men? Dr. Latta. — By no means. They constitute part of much reliable medical information that is now being prepared especially for the general public. The time- honored policy of medical mystery has been displaced, you know, by a determination on the part of our lead- ing physicians to share with the public whatever knowl- edge will be useful in the common crusade for health. The medical profession can make but little further head- way in the conquest of disease unless the whole public joins in the effort and cooperates intelligently at every step. The wonderful campaign against hookworm in the South, for example, is primarily a campaign of pop- ular medical education. "Making the hookworm inter- esting" through moving picture shows and all sorts of advertising devices is the chief concern of the able doc- tors who are literally transforming the South. Miss Parsons. — This new conception of the physician as a teacher was strikingly voiced by Dr. John B. Murphy in his presidential address delivered at the con- vention of the American Medical Association in 1911. He said : "It is my belief that public instruction in medicine is one of the most important functions which the American Medical Association has to perform. For centuries we have criticized the public for its lack of judgment in its selection of doctors. It has employed the quack, the sectarian, the chiropractor, etc. — and more enthusiastically supported them than it has the regular members of the medical profession. Why? Because these men give the patient some kind of explanation for CALLING THE DOCTOR 287 the results they claim to secure. They educate the peo- ple in their theories. "What has the regular medical profession done to educate the public in the last three centuries ? Nothing ! What have we taught them of the real truths or prin- ciples of scientific medicine? Nothing! What beacon have we set for the layman to assist him in the selection of a skillful practitioner? None! Up to date the 'pat- ent medicine almanac,' quack advertisement, and 'leaves of healing' have been the principal instructors of the public. So long as they continue to be the only sources of public education, just so long the public will be their patrons. When we supply the people with their medical education, based on science, they will be- come affiliated with us and sustain us in our every effort." Dr. Latta. — Dr. Murphy's strong appeal has won a wide response, and his suggestions as to practical ways of educating the public are being already effectively car- ried out by groups of physicians in all parts of the country. Now, before we consider what beacon we can set up to assist the layman in his choice of a physician, let me ask the members of this club what principles they have been following in the choice of their own physicians. Mr. Ross. — I should say that Mrs. Ross and I hadn't followed any principles very consciously. When we moved to this town we selected the doctor who had the most prosperous looking establishment, attended what we considered the "best" families and who seemed to have the most to do. After two years we became dissat- isfied with this man and chose the physician who ranked next in the qualifications I have mentioned. Mr. Martin. — I believe Mr. Ross's method of choos- 288 HEALTH AND THE SCHOOL ing a physician is quite typical. I have taken the same way myself as far as my pocketbook has allowed. Dr. Latta. — Your method of choosing your physician was certainly reasonable, provided you had no more ac- curate standards by which to measure his competency, but, unfortunately, the standards which Mr. Ross has advanced do not give his true measure. It is for the purpose of bringing out really accurate standards that we have been making this apparent digression regarding the number and character of the doctors and medical schools in the country, and the recent changes in pro- fessional standards. Before we can venture to select a doctor it is necessary that we have some notion of what medical training means. We must know that there are a few good medical schools and many poor ones, and we must know how to distinguish between them. We must also realize the emphasis which the leaders of the pro- fession are putting on disease prevention and on public education as the most important means to this end. All these matters weigh heavily in the proper choice of the man who is to take our lives in his hands. We dare select no one who cannot pass creditably through some such examination as the following: I. EDUCATION AND TRAINING 1. What was his general education before he entered a medical school? 2. From what medical school was he graduated? 3. What were its facilities — clinics, laboratories, hos- pitals, etc.? 4. What hospital experience did he have before or af- ter graduation? 5. What professional connection has he had with any CALLING THE DOCTOR 289 other physician or institution of estabHshed rep- utation? What courses of university or cHnical instruction has he attended since his graduation from the medical school ? II. PROFESSIONAL ACTIVITIES AND STANDARDS Treatment of Disease. — Does he diagnose and treat disease according to modern scientific standards, which require : (a) Bacterial and chemical tests for the accurate determination of certain diseases. (b) The use of antitoxins in all cases in which their value has been demonstrated. (c) Attention to the sanitary care and surround- ings of the patient. (d) Open-mindedness with respect to therapeutic agents other than drugs. Prevention of Disease. — Does he strive as energeti- cally to prevent disease as he does to cure it? (a) Does he observe the sacred law of medical cleanliness? For example, does he steril- ize his thermometer and other instruments, wear cap and gown when visiting a con- tagious case, instruct his patients and their attendants in methods of avoiding the con- tracting or carrying of infection ? (&) Does he enforce quarantine regulations or does he connive with his patients in evad- ing them ? (c) What part does he play in the efforts of the community to restrict disease? With 290 HEALTH AND THE SCHOOL what organizations or movements is he afifiliated ? (d) What are his convictions and arguments as to the merits of vaccination, vivisection, "medical freedom," and other disputed health questions? III. SUCCESS 1. What critical cases has he handled and with what results ? 2. What families employ him and in what sort of health does he keep them? 3. What is his present standing with his professional associates and with the general public? Mr. Ross. — Such an examination, if strictly acted upon, would put almost every doctor I know out of business. I fear there wouldn't be enough left to go round. Miss Parsons. — According to the Carnegie report there would be an abundance of them left. There are many really able physicians who, for lack of social con- nections or of suave manners, have failed to win popular confidence. These competent men could be substituted, with great profit to the public, for certain prosperous practitioners whose only claim for fitness are a happy bedside manner and the services of an excellent tailor. Dr. Latta. — Certainly the only way to discourage stupid doctors is to select your men not on the strength of a polished or sympathetic bearing, but on the basis of scientific training and demonstrated efficiency. Study your doctor. Don't leave it to him to tell you how wise he is. He may be following the methods of the dark CALLING THE DOCTOR 291 ages. Remember that the slogan of the modern physi- cian is : "Turn on the Hght." Look out for the man who makes a mystery of all he does, whose conception of duty is the mere prescribing of a few medicines for a few symptoms, and who stubbornly parries all your questions on the assumption that a little knowledge is a dangerous thing — for you. It is, to be sure, but not so dangerous as none. Mr. Martin. — Your words take away my breath, Dr. Latta ! I thought it was the cornerstone of medical ethics to stand by your fellow physicians through every- thing. Dr. Latta. — That has been the basic principle of the medical profession viewed as a mutual protective asso- ciation ; but it is something far grander than that. It should be looked upon as a protective association for all society. One doctor has no right to defend another whose ignorance or avarice is a menace to the public. Do not understand me as speaking in disparagement of the medical profession. Never before this day has it reached such a magnificent conception of its mission to humanity ; never before has it grasped the mysteries and the control of disease and health as it is doing to- day. Just because the medical profession has so much to offer, and because the modern physician can be of such powerful service, I urge you to choose most care- fully the man you call your doctor. WHEN TO CALL A DOCTOR Mr. Young. — We must know not only how to select a doctor, but when to consult him. Most of us have no standards for deciding this critical question. "You should have called me sooner" is the extent of the in- 292 HEALTH AND THE SCHOOL struction which we have received on this point. Dr. Latta will explain to us what is meant by "sooner." Dr. Latta. — There is no matter on which the medical profession so clearly needs to instruct the laity as just this. Speaking- approximately, I should say that one- third of the people who consult physicians are suffering only from slight disorders that hygienic habits would have prevented and would still correct, while, on the other hand, more than half who do seek advice arrive too late to be cured. Mr. Ross. — To be on the safe side, then, is it not better to let the doctor decide whether he is needed or not? Dr. Latta. — If you mean that every one should occa- sionally be looked over by a physician to see that he is sound, I should say most emphatically yes. The an- nual physical examination which our school children now receive is necessary for discovering many defects and morbid conditions which would otherv\?ise either remain undiscovered or be detected too late. The desirability as well as the economy of the periodic medical exam- ination is already recognized by certain shrewd life in- surance companies. Some of them offer their policy holders a free medical examination annually, and others go so far as to grant one whenever it is requested. A periodic examination is a powerful safeguard against the encroachment of serious chronic ailments, and should constitute a part of every one's annual program, just as surely as the summer vacation or the celebration of Christmas. In the handling of acute conditions, however, the doc- tor is not always so important a figure as certain prac- titioners would have you believe. To be sure, if a patient and his friends are so uninstructed that they CALLING THE DOCTOR 293 cannot conjecture whether a pain arises from green apples or cancer, it is well to call some one who can ; but such helpless dependence is not necessary and it is not encouraged by the best men in the profession. A physician with serious work to do teaches his patients to take some responsibility for their own health, to cor- rect their own slight disorders, and to remove the causes of them, too. Mr. Martin. — What do you call slight disorders? Dr. Latta. — I will enumerate them in a moment but before I do, I wish to make it clear that the list of symptoms which I shall offer must not be regarded as an infallible guide. The human frame is the most intri- cate and variable mechanism on earth and even the great- est diagnostician living would never venture to speak with certainty upon its condition unless he could con- firm his opinion by a rigid laboratory test. Mrs. Ross. — If it is so extremely difficult to make an accurate diagnosis, is it not reckless folly for a layman to attempt one under any circumstances? Dr. Lx\tta. — If every case required an expert diagno- sis it certainly would be, but, fortunately for the human race, a rough and ready diagnosis is usually the right one. A certain set of easily recognized symptoms ordi- narily indicates a certain well-known ailment, though, of course, there is always the chance that it does not. Miss Parsons. — I suppose if we allowed ourselves to take no chance at all on our health or personal safety we should be too wholly absorbed to permit ourselves any other occupation. Dr. Latta. — Exactly. It would be idle for me to urge everybody to run to the doctor whenever he feels a little twinge or uneasiness. It is certainly the safest thing to do but it isn't a practical thing to do. I therefore consider 294 HEALTH AND THE SCHOOL it of the highest importance for patients to know as definitely as they may the degree of chance they may be taking under various circumstances in neglecting to see the doctor, so that they need take no serious chance at all. Admitting that they always run some risk in look- ing after their own ailments, I am, nevertheless, going to give you a list of symptoms that ordinarily need cause no serious concern, and that are likely to yield to simple home treatment without the aid of a physician. I do not claim that a single one of these symptoms may not indicate a dangerous condition. I have, in fact, met in my own practice very serious cases of appendi- citis whose presence was manifested to the patients merely by some flitting pains and a slight general feel- ing of sickness. I have known a child with a fractured bone in her arm going about her play with little com- plaint of pain or loss of motion. Such cases, however, are most exceptional. Serious cases are usually indi- cated by definite symptoms, and it is in order that we may run no risk on these that we must distinguish them sharply from conditions that ordinarily need cause but slight concern. For convenience we shall group the less serious symptoms under six heads : 1. Pains without fever, that last but a short time and do not recur. 2. Moderate fevers that begin to subside as soon as the bowels have been thoroughly discharged and which are unaccompanied by eruptions, colds, sore throat, or vomiting. 3. Digestive upsets unattended by fever or exhaustion, or severe, prolonged, or recurrent pain. 4. Colds and coughs of short duration, which are un- attended by fever or marked debility. CALLING THE DOCTOR 295 5. Wounds that can be thoroughly cleansed by home treatment, and are evidently able to unite with- out stitches. 6. Strains and bruises that do not impair freedom of joint or limb, cause no constitutional derange- ments, and in which swelling and pain subside within a day. It is important, of course, to learn from a physician — never a druggist — the best ways of treating these minor ailments, and of preventing such as are preventable. This highly important knowledge, which is easily acquired and is in no way dependent upon previous technical training, should be sought by all responsible persons, and, most of all, by mothers and teachers. The presence or absence of fever, a most important item in every diagnosis, is not a condition which it re- quires the visit of a doctor to determine. A clinical thermometer in the hands of a mother or teacher tells the story just as well. This instrument should be in every home and school. It is indispensable for forming any intelligent judgment as to the condition of an in- disposed child, and its use not only saves doctors' time and patients' money, but on occasion gives the only in- dication of the urgent need of a physician. Mrs. Ross. — Having learned now under what circum- stances we need not call a physician, are we to assume that he will be required for all our other physical ills? Dr. Latta. — He certainly should be consulted about any morbid symptoms that vary from those in the list I have given, as there is a strong likelihood that they indicate a definite disease, more or less serious. Re- member that the most critical matters to observe in de- termining the seriousness of a case are fever, pain, and 296 HEALTH AND THE SCHOOL exhaustion. A fever that does not yield after a clearing out of the bowels calls for medical attention ; so do continuous pain and exhaustion. In fact, any unfavor- able condition that does not soon correct itself should have the attention of a physician. Recurrent headaches and backaches, abdominal pains, swellings, and enlarged glands, persistent lumps, loss in normal weight, and any other mild but lasting symptoms require medical care. They should never be prescribed for by a druggist. Mr. Martin. — You have not mentioned eruptions or sore throats. Are these not often very serious symptoms with children? Dr. Latta. — To be sure, and their seriousness is usu- ally indicated by accompanying fever or exhaustion, for which you are always to be on your guard. Sore throats and eruptions, even when unaccompanied by fever, occa- sionally indicate light forms of contagious disease — measles, chicken pox, whooping cough, diphtheria, or scarlet fever. A child with such symptoms should al- ways be isolated and examined by a doctor. A combina- tion of cold or sore throat or vomiting, together with an eruption, almost invariably indicates a contagious disease, and, while very seldom occurring without fever, calls for immediate medical attention, whether accompanied by fever or not. I will spare you a detailed account of the symptoms of the various diseases. Recent books on the health of children abound in diagnostic tables for the use of teach- ers and patients, and you can easily look up the particu- lar shade of pallor or flush which matches the color of your child. We are interested now not in learning how to pronounce on certain diseases, but in learning how to tell whether we need the doctor for this purpose. As you have seen, the considerations which determine CALLING THE DOCTOR 297 the need of a doctor are simple and few. Let us sum them up now in brief form, easy to remember. A doctor should be consulted at the following times: 1. At regular intervals of not more than a year, in order to guard against obscure defects and ail- ments. 2. Whenever lassitude, pain, swelling, or fever are not promptly relieved by rest, soothing applications, or a cleansing of the intestines. 3. When there is sore throat. 4. When colds and sore throats are accompanied by fever, rash, or vomiting. 5. When any unfavorable symptoms become chronic. 6. When accidents are of such a nature that there is any doubt as to the best treatment to be followed. To follow these simple rules in sending for the doctor, instead of relying merely on one's state of alarm, is to substitute a reasonable degree of assurance for uncer- tainty and to increase very considerably the chances of good health and long life for one's self and one's chil- dren. Suggested Reading Carnegie Foundation for the Advancement of Teaching. (i) Medical Education in the United States and Canada, 1910. (2) Medical Education in Europe, 1912. For aids in diagnosis see references at end of Chapter IL XVIII HEALTH PROBLEMS IN CHILDREN'S INSTITUTIONS Mr. Young. — In outlining a health program for chil- dren Dr. Latta has had much to say about the respon- sibility of parents. What is to be done for children who have no parents or such as cannot care for them? In our town there are about 200 children of this sort. While we are discussing means for improving the con- dition of our more fortunate children, we cannot over- look the orphans. Mrs. Ross, as a trustee of the County Orphanage, has asked that we devote an evening to the special health problems of children's institutions. Dr. Latta will open the discussion. Dr. Latta. — The best institution for children who are not sick or disabled is the one that has closed its doors. Mr. Ross. — May I ask what you mean by that cryptic remark? Should the children be locked in or out? Dr. Latta.i — Out, sir. It is neither desirable nor necessary that normal children be permanently kept in institutions. Mr. Ross. — What other places are there for them? Dr. Latta. — Private families, no end of them. Any genuine orphan without serious defects can actually have his choice of desirable homes. Australia has some- thing to teach us in this matter. The word orphan is not used there, nor are there any orphan asylums. In 298 CHILDREN'S INSTITUTIONS 299 South Australia in 191 1 the Children's Council had 1,479 children under its control, of whom it boarded out 1,220, put 7 in hospitals, and 32 in institutions for defectives and delinquents. The outlay for each child boarded out, including administration expense, was $60 a year, which is $40 less than the minimum expense for a child in our poorest institution, and $140 less than in our most lavish ones. Besides being in a more normal en- vironment at less expense than possible under institu- tional care, the children of Australia, after they are thirteen years old, are given a chance to better their own condition. In 191 1 some of these children, by working part time, earned and deposited $6,500 in the postal savings bank. That the children do not suffer from the economy and simplicity of the boarding out system is strikingly shown by the reduction of mortality among illegiti- mate children, which has shrunk from 27 per cent, to -1.58 per cent, since the Children's Council began its work. Mr. Ross. — Australia is pretty far away. The con- ditions may be so different there that the methods em- ployed in meeting them would fail when applied to our problems. It seems to me far better to have children kept in well-run institutions than trusted to a miscel- laneous assortment of families who, like as not, would want to exploit them under the pretense of giving them home care. Dr. Latta. — Such a criminal way of disposing of chil- dren, while frequently practiced in the past, is hardly possible under the present approved method of selecting homes. This provides for a very careful investigation and continued observation of the families to which chil- dren are sent. Officers who could not be trusted to do 300 HEALTH AND THE SCHOOL such work could certainly not be depended upon to run institutions properly. The placing out system for children is, in fact, no longer an experiment. Australia is not alone in dis- covering that good private homes are far more desir- able places for children to grow up in than even the best institutions. Our progressive states are all finding this out. Massachusetts in the last fifteen years has closed down thirteen institutions for children, though its population has increased greatly in that time. In- diana has similarly closed twelve of its fifty county chil- dren's homes, and is preparing to discontinue others. These changes in each state have been made possible by an extension of the placing out system. Michigan, Minnesota, Wisconsin, and Rhode Island each conduct but one central state school for dependent children; the policy being to retain the children there only so long as is necessary to find suitable free homes for them, and to prepare them for entering these. The results in the four states indicate conclusively that this mode of caring for motherless children is the best as well as the most economical that has so far been devised. Minne- sota and Michigan particularly, having been almost en- tirely free from political interference, have met the needs of their children more adequately than any of our other states, and at a cost that seems incredibly small as compared with amounts elsewhere expended. Miss Parsons. — Just a word at this point. Minne- sota and Michigan undoubtedly lead the other states in the success with which they have carried out their par- ticular method. But, good as it is, it is not the last word in the care of a certain class of children now ranked as dependents. Some of our western states have lately taught us a lesson so obvious that we wonder why CHILDREN'S INSTITUTIONS 301 we have waited so long- to learn it. These states have concluded that the best possible way to arrange for de- pendent children who are not motherless is to board them with their own mothers. This arrangement provides for a large proportion of children who need public aid. The mother can rear her own children both more successfully and more economically than can any other woman who is paid to do it. Mr. Ross. — Do you mean that public money should be given to mothers for bringing up their own children? Miss Parsons. — To be sure, if that is the only con- dition on which worthy mothers can fulfill this most important public task. The arrangement known as "mothers' pensions" has made such a wide appeal that it was considered by fifteen state legislatures in 1913. There are already nine states which have adopted this way of safeguarding their children until the time when a universal compulsory insurance system, such as is in successful operation in Germany, will secure for each in- dustrious family an unbroken circle. Mrs. Ross. — Is the mothers' pension system really working out well where it is in operation ? I have heard rather contradictory reports about it. Miss Parsons. — No one claims that the results have thus far been ideal. They cannot be so until an ideal system of administration has been evolved and that may not be for years. Any pension scheme whose operation is dependent on the discretion of officials is open to abuse ; but present imperfections of method do not in the least impair the soundness of the theory upon which mothers' pensions are based. Dr. Latta. — It is not, of course, the purpose of this evening's discussion to weigh the relative advantages of home and institutional care of children. The question, 21 302 HEALTH AND THE SCHOOL indeed, admits of no discussion. We have a reason, however, for emphasizing incidentally the desirabiHty of avoiding institutional care for children whenever pos- sible. Just now a strong sentiment is springing up in our town in favor of enlarging the capacity of our county orphanage. Such a step is both unnecessary and unde- sirable. It is true that there are children who now need its protection and for whom there is at present no room, but how many children do you suppose there are among the two hundred already there who would not be better off if placed in private homes ? Not more than five. If it is desirable to continue the orphanage at all, let us make it primarily a receiving station, from which the children can either easily return to their own homes when conditions are improved there, or to other homes or special institutions better fitted for them. Mrs. Ross. — Among the advantages of the private home do you include conditions more favorable to health ? Dr. Latta. — Most decidedly. For children less than six years old experience has shown up to the present time that, without a single exception, institutional care is the most deadly kind of care. There is to-day an orphan asylum in Philadelphia in which the mortality of babies under one year old is about loo per cent. Miss Parsons. — I see that the Child Helping Depart- ment of the Russell Sage Foundation has recently made a study of the sanitation of foundling asylums, and has brought out a set of plans for such institutions which call for extraordinary sanitary precautions. Dr. Latta. — This study will doubtless prove highly valuable when the results are widely known and acted upon. In the meantime babies should be kept out of institutions. CHILDREN'S INSTITUTIONS 303 After the first tender years, children resist the strain and limitations of institutional existence rather better, and in the most enlightened institutions survive the ills of childhood as safely as in ordinary family life, possibly more so. It is only one institution in a thousand, how- ever, that can make such a claim. The New York Orphanage at Hastings-on-Hudson and the Seybert In- stitution for Children at Meadowbrook, Pa., are such institutions. They are remarkable examples of what ideal physical conditions, wise direction, and abundant funds can do for the health of institutional children. In referring to the scarcity of contagious disease in his institution, the superintendent of the New York Orphan- age, Mr. Rudolph R. Reeder, said, toward the close of January, 191 3: 'This is our eleventh winter in this Home and the hospital has been closed eight of these win- ters including the present. This means that during the eleven years we have lived here 200 children have passed through eight winters without any of the forms of con- tagious sickness requiring hospital treatment." The Seybert Children's Village, which accommodates 100 children, has also been highly successful in holding off contagious disease. Among the 650 children ad- mitted during the six years of its existence the number of cases of serious contagious disease, with the exception of whooping-cough, stands at the following surprisingly low figures : Measles 24 Chicken Pox 15 Diphtheria i The whooping-cough which invaded the institution during one winter we will refer to later. The very success of the institutions just named is in 304 HEALTH AND THE SCHOOL itself an argument for closing the doors of many others. Without the ample income, the wholesome country loca- tion, and the exceptionally wise management which these two orphanages enjoy, the average institution stands no chance of even approaching their standards of effi- ciency. Listless, undergrown children, with little strength to resist disease, and little energy to make their way, are the products of most children's institutions as now conducted. By having the children for the most part placed in private homes, much of the energy and money which are at present spent in running poorly hundreds of unnecessary institutions could be diverted to the support and conduct of a few necessary and highly efficient ones. Mr. Young. — What do you regard as necessary in- stitutions for children? Dr. Latta. — Hospitals for the sick; asylums for de- fectives, such as the feeble-minded, deaf, blind, and epileptic ; school homes for the delinquent ; and tempo- rary homes for normal children who are destitute and neglected. Such institutions as these society will always have to support, either through charity or taxation. Society not only will have to support such institutions but it will have to supervise them, whether they be public or private. If our school children have need of public health supervision, our parentless institutional children have far greater need. Shall we allow it to be possible for long, do you think, to find, as I did a short time ago in the orphan's home to which I referred, a dormitory in which lOO boys slept and in which there were just 3 windows ? Economical no less than humane considerations make the safeguarding of the health of the children in institutions a matter of the very greatest importance. CHILDREN'S INSTITUTIONS 305 It is, moreover, a matter presenting peculiar difficulties, as the mere bringing- together of many children to live under one roof and one central management complicates highly the problem of securing the best health conditions for each. Let us now^ see just what the complicating factors are and how best to overcome them. We will suppose that the health conditions which we have noted as necessary for children in families are met as they should be in a children's institution; that fresh air, good food, proper clothing, and play space are all provided in abundance. Not that this is often the case, but even when it is there are two further provisions which, though needing little consideration in pri- vate families, cannot be neglected in institutions with- out the gravest danger. These are (i) precautions against contagion; (2) precautions against dezitalidng routine. Mr. Ross. — The need for taking precautions against contagion is, of course, apparent where you have so many children living together. The second need I fail to appreciate. How can you care well for children and train them, too, without making the whole process one of routine? Dr. Latta. — If you will bear with me just a moment while we discuss the subject of contagion, I think I can show you that a too rigid routine for children is as great a menace to their health and vigor as a too general dis- tribution of germs. CONTAGION A children's institution affords an ideal arrangement for the spread of contagion. Day and night, at play, at work, at meals, and at rest, numbers of children are 3o6 HEALTH AND THE SCHOOL close together with every opportunity for passing in- fection from one to another — unless the strictest watch is kept and the most rigid regulations enforced. The ease with which frequent and devastating epidemics can spread in institutions is shown in tragic, chapters from the annals of almost every one whose history covers more than a year or two. And yet institutional condi- tions can be so controlled as actually to provide greater safety from contagious diseases than can possibly be secured in any ordinary well-regulated family. Mr. Ross. — How in the world Dr. Latta. — Nothing easier. Contagious diseases are spread almost entirely by direct or indirect contact with those suffering from them or by contact with people, ani- mals, or even articles that have been infected by them. If everyone who either has a contagious disease or has been exposed to one, and every article which may con- tain infection, is kept away from children, no contagious disease can reach them. To exercise the vigilance necessary to secure such absolute freedom from infection is quite impossible in a normal family, for the members cannot avoid mingling with the general public among whom virulent disease germs are as yet always lurking. A children's institu- tion, on the other hand, can easily meet the conditions necessary for excluding contagious diseases. It is in itself a little world whose entire public can be placed under the strictest scrutiny. In addition to the care that is necessary in any com- munity for securing a safe food and water supply and a sanitary waste disposal system, there are two measures which, if faithfully carried out, make a children's in- stitution practically contagion-proof. These are : ( i ) isolation of all entering inmates until it is demonstrated CHILDREN'S INSTITUTIONS 307 that they arc free from contagious disease or infection of any kind; (2) immediate and complete isolation of any inmate xvho sJiozvs the least deviation from normal health. Institutions where these rules are strictly car- ried out have no epidemics. The contagion is blocked at its first appearance both without and within the fold. 1. Isolation of Entering Inmates. — A thorough medi- cal examination should be promptly given to every child on entering an institution, and until he can show a clean health bill he should be detained in a receiving cot- tage or wing entirely apart from the other children. This simple precaution is a most effective guard to the health of the entire institution. It should be practiced inflexibly, no matter how unnecessary it may appear to be in certain cases. A perfectly well child may be a car- rier of virulent disease germs. This has been demon- strated again and again when the unsuspected source of some mysterious epidemic has finally been traced to a healthy "carrier." No chances should be taken on a possible "carrier" in an institution. Risks that can be lightly taken in families are fraught with almost certain disaster in institutions. The only real safety from con- tagion among large numbers of children lies in the elimi- nation of all risk. 2. Immediate Isolation of Sick Children. — In addition to the strict guard that must be kept against outside infection, it is further necessary that each child within the institution be under trained and watchful eyes every day. Under cottage management (the best system for providing children with personal care) it is easy for the house mother to observe promptly any untoward symptoms that may appear among her children. The child who is affected should be instantly with- 3o8 HEALTH AND THE SCHOOL drawn from the group and placed either in an isolated room in his own cottage or in the institution infirmary until the nature of his sickness is determined. Such prompt care is no less desirable for the child himself than for the others who might be infected by him. Many a serious illness can be checked if promptly recog- nized and correctly treated. Constant scrutiny of the children and immediate isolation and care of the sick are the first duties of the house mother who would avoid trouble. Mrs. Ross. — May I ask whether an ordinary cold should warrant the isolation of a child. Dr. Latta. — A child just coming down with a cold should always be isolated, as he may be exhibiting the first symptoms of a serious contagious disease, particu- larly measles or whooping-cough. A cold itself, as you know, is very contagious and every case should be kept isolated, if possible, until the acute stage has passed. Mothers who find this an irksome requirement, often experience the alternative of having all their children in- stead of one, ill with colds. When children with colds cannot be completely isolated, every reasonable care should be taken to prevent them from passing their germs around. They should always be carefully trained in the use of individual toilet articles, handkerchiefs, towels, tooth brushes, and combs, and in the practice of considerate hygienic habits, such as turning away from people and covering their noses and mouths when sneez- ing or coughing. The most successful way to avoid colds among chil- dren is to develop their own powers of resistance through plenty of good food, fresh air, and exercise. Germs gain little foothold among children who enjoy such a regime. In the Children's Village of the Seybert In- CHILDREN'S INSTITUTIONS 339 stitution no attempt is made to isolate children with colds. The constitutional tone of the children is so good, however, that the rare cases of cold which occur there do not multiply. When a contagious disease does crop out under the guise of a cold, however, it spreads rapidly among chil- dren of even such high resisting power as those in the Children's Village. The one real epidemic that has vis- ited this institution was due to whooping-cough, which attacked about one-third of the whole population in a single winter. It is possible that a general policy of putting a strict quarantine on every child who showed the first symptom of cold or cough would have pre- vented this epidemic. Not having observed the conditions in the Village at the time, however, I offer this sugges- tion not as a criticism but as a query. ROUTINE The deadly effect of institutional routine manifests itself in two distinct ways, on the body and on the mind. Many children cannot endure an unyielding daily sched- ule which includes fixed diet and dress, hours of obliga- tory study and work, and their health suffers accord- ingly. As we have learned in our earlier discussions, a child's daily routine, including what he eats and wears, should be devised especially for him. To make inflex- ible arrangements for a miscellaneous group of children is like providing each with a coat of one size. Some are not covered while others are swallowed up. The requirements of an institution should never become so fixed that the daily program cannot easily be modified to suit the needs of individual children, nor should the supervision be so scanty that children who need special 3IO HEALTH AND THE SCHOOL attention can fail of detection on the part of those in charge. In the so-called congregate form of institution, un- less the number of children is very small, fifty being the maximum, it is impossible to give the necessary at- tention to individual needs that can be given under a well-conducted cottage system ; nor is it even possible to introduce changes which the whole group may greatly need when every detail in the machinery is run accord- ing to directions issued months in advance, as is often the case. Direct Physical Effect. — Not the least of the difficul- ties in adapting institutional conditions to the needs of children lies in the inflexible dietary which has to move in the line of least resistance when large numbers are to be fed. The wholesome exhilaration that children experience, for instance, in securing some specially longed-for table treat is an unknown delight to those who are fed on the congregate plan, and whose meals are often served according to a prescribed weekly sched- ule made out with little respect to changing seasons and markets or the seasonal cravings of children. Miss Parsons. — In citing the greater freedom in diet which is possible under the cottage system, Mr. Reeder tells of a group of boys who begged the cook to make pancakes for breakfast. "When she protested that mak- ing pancakes for twenty-five boys was beyond her capac- ity, they gladly took the responsibility upon themselves, and a great feast of pancakes was spread the next morn- ing. That was but the beginning of innumerable forms of catering to their taste now going on every day in the various cottages." Mr. Ross. — Isn't there danger of tempering the wind too much for those dependent children? The world, CHILDREN'S INSTITUTIONS 311 when they get out into it, won't give them pancakes just because they want them. Dr. Latta. — But they will be the better able to se- cure their own pancakes for having had them in their youth. A growing child derives much of his joy and all of his energy through the satisfaction of his active stomach. Dependent, defective, or delinquent though he be, his need for enjoying food is as great as it is with our own Tom or Harry. The desirability of giving even orphan children meals that they enjoy was suddenly brought home to the New York Orphan Asylum a few years ago, when it was found that more than half of the children were under standard height and weight. The management imme- diately set about making their meals attractive. Sur- prises and relishes that were nourishing were placed on the diet. Muffins and appetizing soups, smoked and salt fish of various kinds, fruit sauces, and alluring des- serts were introduced, to the great delight of the chil- dren. This vigorous diet reform brought about an instant and startling result. Beginning at once, the proportion of children above standard weight and height increased rapidly until in two years, instead of being only half of the number below, it had come fully up to standard. As no change in the environment other than the im- provement in diet was made during this time, the change in the children can very safely be attributed to this factor. I have cited the matter of food as merely one of the items of the physical environment which should be con- stantly adapted to the changing needs and legitimate desires of the children. There are many others. The weight and even style of clothing, the hours of sleep or 312 HEALTH AND THE SCHOOL rest, the violence of play, the amount of work — all these details should be carefully adjusted to the requirements, capacities, and even the tastes of the individual chil- dren. Mrs. Ross. — In our county orphanage we have found that it facilitates individual adjustments to have children of widely different ages in the same cottage. The needs of these children are so various that it is quite necessary to arrange for them individually. Mr. Young. — This arrangement has the additional value of providing a greater variety of interests for the children. Each year of life has interests of its own, and little children, as well as older ones, can share each other's experiences with mutual profit. Dr. Latta. — Mr, Young's point suggests the effect that an overemphasized or monotonous routine has upon the mind and indirectly upon health. Mental Effect. — Through its paralyzing efifect on the spirit and will, a too mechanical regime lowers the whole nervous tone of the children and the energy of all their vital functions. This effect, though brought about through a mental state, shows itself in stunted growth and poor accomplishments, just as palpably as if caused by insufficient food or air. The digestion of children, for instance, in institutions which enjoin complete silence during meals — and there are many of these — cannot be as sound as that of children who are allowed a moderate degree of conversation and merriment while eating. Life means literally nothing either to adults or to chil- dren unless it permits of some independence of action, whether of work or play, some freedom to chase rain- bows, some chance to convert hopes into realities. If the opportunity for such initiative is denied the central dynamo is checked and all the forces of growth with it. CHILDREN'S INSTITUTIONS 313 Mrs. Ross. — In the most progressive institutions, chil- dren are permitted much variation in their dress. The institutional uniform is recognized as destructive both to taste and self-respect. No emblem could mark more emphatically the humiliation and hopelessness of the average orphan's plight than the shapeless, monotonous garments that proclaim their wearers the inmates of certain institutions. Even when economies must be sharply made, it is possible to grant a little latitude in dress. Merely a collar or a ribbon of a small girl's own choosing is a source of joy and inspiration to her. Mr. Ross.— Are there any actual statistics that show the harmful effects of routine or the favorable effects of freedom on the physiques of children? Dr. Latta. — It would seem a rather odd experiment to try to state the effect of hope and joy and independ- ence in terms of pounds and inches. As far as I know, there has been no attempt to make quite so bald a dem- onstration. I have some figures here, however, which are very suggestive. The children in the New York Asylum whose growth we have just seen to have been remarkably advanced by an improvement in their diet showed as much gain again when they were moved into the country and suddenly freed from countless restraints which had been necessary in their city home. During seven years, which included two years of city residence and five years of country life, the children showed the following variations from normal standard in weight and height : 1900 1901 1902 1903 1904 1905 igo6 No. above standard average in both weight and height 39 52 67 66 80 78 ^2 No. below standard average in both weight and height. .87 (^ 67 62 49 54 55 314 HEALTH AND THE SCHOOL The first measurements in 1900 to which we have al- ready referred showed the number of children below standard weight and height to be more than twice as great as the number above. The effect of the vigorous diet reform is plainly indicated in the figures for 1901 and 1902. In 1902 the institution was moved to the country and the congregate form of housing replaced by the cottage system. A much freer life was now pos- sible for the children. Opportunities for play were greatly broadened, and many restraining rules that had been necessary in the confined city quarters were lifted. The improvement in the children following this change was as pronounced as their improvement following the change of diet. This time the number of children above standard, instead of remaining equal to the number be- low, within two years exceeded by over 50 per cent, the number of children below standard. Miss Parsons. — Do you attribute this remarkable im- provement largely to the new freedom from restraint? Dr. Latta. — Very largely. The freer, more home- like atmosphere of cottage life, the wide range of coun- try open for the children's work and play, the opportu- nity to cultivate individual gardens, to build play houses, to swim in the river, to climb trees, and roam in the woods — all these enlarged privileges, while benefiting the children directly by securing for them better care, fresh air, and exercise than they had ever known be- fore, were most dearly prized and, therefore, most stim- ulating to health on account of the coveted freedom which they involved. Mr. Young. — Let us take a moment now in closing to sum up the important principles which have been brought out in this evening's discussion. The problem of rearing children in institutions has r^ P! -^ -gill' ■ ■ a j^ CLi ir, .^-H c -^ s-g ^ •l^s. OS o w .2 te size of 1 en's Villa e growing roups in i of childrci the indi^ .5 >-» M g-d-^ ^a!^ C'l m moc Ch trate smal groi sho and hert illus for The tree "Z 'S b r^r / ;: »' 1 \?~ / ■o j -I 3 •n / > / S. f iio i r A J -0, ? f \ / t , ^ i f '° ° V o '° Jt ^ r. 1 csaj a#{« ^ - w 5 p^ ^a-h. A - » 1° ' 10- \^ SSU*; N:b ^ 9^ JftN FEB MAR APR MAV JUNE JULY AUG &tv\ OCT NOV DEC Vaccination against smallpox we have already re- peatedly discussed. It is so far the only known means of preventing the disease, and its immunizing power for a certain length of time is absolute. The state is justified in the strictest enforcement of this measure. COMPULSORY HEALTH 349 The complete prevention of eye infection at birth by the prompt use of silver nitrate is another matter of scientific certainty. Before the treatment was used, opli- BULLETIN CHICAGO SCHOOL OF SANITARY INSTRUCTION On March 4 the council passed a very important ordinance, one of the most important ordinances passed in a long time. Under it every physician and midwife must report to the Health Department within twenty-four hours the occurence of every case of sore eyes developing within seven days after birth. We hope we may soon be able to take the next step and supply the nitrate of silver drops for use in all cases in which they cannot otherwise be provided. There dxe 60,000 blind persone in the United StaCtes. At le^st ZO.OOO o( these sad causes were Prevents. bLe I IF CHICAGO WILL ENFORCE THE USE OF -THIS- 5f THE MEDICINE DRPPPEfl IT WILL COST -THIS- F'EVEi ce:>jts AND PREVENT -THIS- •THE DROPS' To Lose oKe 6 SIGHT is LiKe LosiKg LIFE iraeir SAVE YOUR. 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Teach- ers usually read persistently about w/ia^ they are to teach, and this is exceedingly in^iportant ; but back of this lies the far more important problem of the person they are to teach. It is this information, that must underlie every operation of a successful teacher, that Professor Hall presents." D. APPLETON AND COMPANY NEW YORK CHICAGO X'^Sl