3609 
 
 >y 2 
 

 Glass, L B 3(0^ 
 Book ^ > ^p 
 
 (lW-w 
 
 2. 
 
 
 ■■.■■■ ■„^; Ki^Ty^A"^ 
 
 mm. 
 
 
 ,'■'^4 
 
 ',-<-.-^;'j,->^ i.,<'>' ■'fr-^.?tL 
 
 
TREASURY DEPARTMENT 
 UNITED STATES PUBLIC HEALTH SERVICE 
 
 HUGH S. GUMMING, Surgeon General 
 
 HEALTH ACTIVITIES IN COLLEGES 
 
 AND UNIVERSITIES 
 
 A DISCUSSION OF THE AIMS, ORGANIZATION, 
 
 ACTIVITIES, AND PROBLEMS OF A STUDENTS' 
 
 HEALTH SERVICE 
 
 JOHN SUNDWALL, M. D., Ph. D, 
 
 Universiiy of Minnesota' 
 
 REPRINT No. 569 
 
 FROM THE 
 
 PUBLIC HEALTH REPORTS 
 
 November 7, 1919 
 (Pages 2489-2518) . 
 
 7^ 
 
 WASHINGTON 
 
 GOVERNMENT PRINTING OFFICEJ 
 
 1920 
 
 o^Uf ^^ 
 
 / / 
 
 Mono^apli 
 
H^ •t B. 
 AUG 10 1920 
 

 HEALTH ACTIVITIES IN COLLEGES AND UNIVERSITIES. 
 
 A DISCUSSION OF THE AIMS, ORGANIZATION, ACTIVITIES, AND 
 PROBLEMS OF A STUDENTS' HEALTH SERVICE/ 
 
 By John Suxdwall, M. D., Ph. D., University of Minnesota. 
 
 INTRODUCTION. 
 
 A very signifiGant trend in education during the past few years 
 is shown in the recognition that health is fundamental to sound 
 intellectual development and that the rigid regulation of all things 
 pertaining to the hygiene of students is indispensable. Generally 
 speaking, there is serious economic and academic loss year after 
 year in our schools, colleges, and universities, due to lassitude, indis- 
 position, illness, and epidemics among students, all more or less 
 preventable. 
 
 For many years universities have inquired into and passed regu- 
 lations respecting the conduct and habits of student's with a view to 
 maintaining and increasing mental efficiency. The university has 
 said to the student : " You must not dissipate. You must not 
 indulge in frequent and late hours of social activities. You must 
 not do this or that which interferes with your studies." No serious 
 or worthy objections have been voiced against the assumption by 
 the university of the authoritj^ to enforce such regulations. 
 
 With a realization of the importance of health and the advance 
 in preventive medicine, the universities see that by special meas- 
 ures for safeguarding the health of their students one of the chief 
 roots of academic loss and inefficiency is reached. Who can justly 
 question, then, the authority of a university to make provisions for 
 service of this kind? 
 
 With a view of providing an agency to deal with the problem of 
 students' health, many colleges and universities have established, or 
 anticipate establishing, a students' health service. In order to sup- 
 port such an activity, the student is required to pay an annual 
 health fee. Naturally there has been much misunderstanding, and 
 some criticism has been directed toAvard the university as a result of 
 this fee. Physicians have asked : " Why should I be burdened with 
 
 ^ Reprint from the Public Health Reports, vol. 34, No. 45, pp. 2489-2518. 
 
 3 
 
4 • HEALTH ACTIVITIES IN" COLLEGES AND UinVERSITIES. 
 
 this fee? Can I not treat my own children?" Again, certain 
 rehgious sects have honestly objected to the inauguration of a stu- 
 dents' heaJth service on the grounds of unbelief in certain medical 
 treatment. 
 
 The contraventions to this new move on the part of the colleges 
 and universities would perhaps be justifiable if the health services 
 established were concerned solely with medical treatment. Let us 
 suspend judgment until the aims of a students' health service have 
 been considered. 
 
 At the outset of this discussion let me impress the reader with 
 this fact: The problem of the university respecting health regula- 
 tions is not one of medical philanthropy but rather one of broad 
 economy. A health service should not be established as a form of 
 contract practice, nor should it be considered a "health insurance" 
 as the term is usually understood. On the other hand, a univer- 
 sity health service should be primarily concerned with the preven- 
 tion of disease and with maintaining a high degree of health among 
 the students. 
 
 AIMS OF A STUDENTS' HEALTH SERVICE. 
 
 1,. A university health service should be as much concerned with 
 the physical welfare of the sound student as it is with that of the 
 iU or the subnormal. In this respect it differs from other health 
 agencies. Instead of concentrating aU its activities on the 1 to 5 
 per cent who are afflicted, it should be actively interested as well in 
 the 95 to 99 per cent who do not feel the necessity of consulting a 
 physician. 
 
 For two fundamental reasons every self-deemed sound student 
 should be given a complete physical examination at least once 
 each year: For the early detection of unrecognized disorders that 
 may prove serious in time if allowed to continue; and to help in 
 impressing every student with the importance of maintaining active, 
 vigorous, positive health . 
 
 Any one who is informed regarding the findings of the examining 
 boards in the physical examinations for entrance into the Army, or 
 with the findings of those who examine entering students at uni- 
 versities where health services have been established, realizes the 
 value of at least one physical examination a year of every student, 
 whether he is apparently physically sound or not. Even when the 
 findings are negative, the assurance that he is physically sound is of 
 value. This is especially true in many cases in which the students 
 concerned have been mistakenly led to think they are not sound 
 physically. And in cases where unrecognized or incipient disorders 
 do exist, by the early detection of those disorders and proper advice 
 or treatment much good can be done. Also there is real need of 
 
HEALTH ACTIVITIES IN COLLEGES AND UNIVERSITIES. 
 
 bringing every student to a realization of the value of keeping up a 
 positive, active normality; and provision must be made whereby 
 this can be done. 
 
 In its interests and activities in behalf of the physical welfare of 
 all students, the university health service is inextricably interwoven 
 with the department of physical education/ Not only should the 
 health service insist on daily exercise on the part of all students in 
 the university, and the faculty, as a direct health measure, but 
 it should emphasize as well the importance of a properly developed 
 active body — the Greek ideal. 
 
 The usual caricature of the average student — a stoop-shouldered, 
 ollow-chested, horn-bespectacled, anthropoid — has altogether too 
 much truth in it. The movements of the average student are 
 lumbering and awkward, the very antithesis of alertness and deter- 
 mination. Further, the academic training of the university tends 
 to make one reflective and inactive; and a more or less permanent 
 habit of reflection and dreaming is often acquired at the expense of 
 "doing.'' 
 
 Faulty posture, slovenly lazy motion, and inactivity are decidedly 
 harmful physical habits. One of the chief concerns of the health 
 service should be to help to stamp indelibly upon all students in the 
 university a determination to possess a sound, properly developed, 
 active body, and a prepossessing personality. The college student 
 should possess all those physical characteristics which stand for har- 
 monious and healthful development, correct and assertive poise, 
 dexterous and efficient motion. ' 'He walks like a soldier, " is 
 decidedly complimentary. Why not develop a university type of 
 physique? Let the highest of praise of physique and carriage be: 
 "He has the bearing of a collegian.'' 
 
 From the foregoing discussion it is readily seen that a university 
 health service is, indeed, very much concerned with the physically 
 sound students — both in the attainment of positive health and in 
 the provision for assuring continuance of this health dm^ing the 
 academic as well as post-academic life. 
 
 Other and related activities of a university health service are : ' 
 
 2. Protection of the sound student from the communicable dis- 
 eases generally brought to the university. 
 
 3. Detection, isolation, and provision for the treatment and care 
 of all students who are victims of communicable diseases. 
 
 4. Advice to, and treatment, and, when necessary, provision for the 
 care of all students who are ill. 
 
 5. Reclamation: Early detection, and correction so far as possible, 
 of beginning bodily disorders such as the degenerative diseases. 
 
 iThe interrelation of the students' health service and physical education is discussed in "School and 
 Society." Vol. VIII, Nos. 201,'202, 203, 1918. 
 
6 HEALTH ACTIVITIES IN COLLEGES AND U]S[IVEESITIES. 
 
 6. Reconstruction: Correction, so far as possible — by advice 
 regarding proper exercise and right living, and by treatment when 
 advisable — of defects in all subnormals. 
 
 (The foregoing objects are to be reached through the personal 
 division of a university health service.) 
 
 7. The students' environment must be made as hygienic as pos- 
 sible. Hence, the division of sanitation must concern itself with the 
 sanitary conditions both on and off the campus. Campus build- 
 ings, rooming houses, and boarding houses must be inspected and 
 regulated so far as possible. 
 
 8. Finally, every student should be made familiar with the ele- 
 ments of personal and public hygiene. In many respects education 
 is a most important branch of the work of a health service. 
 
 ORGANIZATION AND ACTIVITIES. 
 
 The various activities of a health service are closely interrelated. 
 They can, however, be divided into three groups or divisions: 
 I. Personal attention; II. Sanitation; III. Education. 
 
 I. Personal Division. 
 
 Ptiysicdl examinations. — It should be the aim of the students' 
 health service to have on file a complete confidential physical record 
 of every student in the university. It should urge the need of a 
 requirement that every student be given a physical examination at 
 the beginning of each school year. 
 
 The value of these physical examinations may be stated as follows: 
 
 (a) The determination of the physical condition of each student 
 so that proper supervision of his activities will be possible in building 
 up, when necessary, and in maintaining a healthy, harmoniously 
 developed, active physique. 
 
 (&) As already suggested, great good often comes from these physi- 
 cal examinations, in the assurance to a student that he is physically 
 sound. This has been not only our own experience, but also the 
 experience of others. Let me quote from a Harvard report: 
 
 But the greatest value of this examination to my mind, and with this I have been 
 strongly impressed, is not so much the detection of existing disease but the assurance 
 of a larger group of boys who think that they have disease that they are really sound. 
 Curiously enough, there were more boys who thought they had a serious organic 
 defect, usually of the heart, and were found entirely sound, than boys who thought 
 they were well and had disease. In many instances boys were worrying over ail- 
 ments that were purely fanciful; but this worry was having a considerable effect upon 
 their general condition. The importance of the compulsory physical examination 
 seems to be as much the correction of erroneous ideas concerning disease in the healthy 
 as the detection of disease. 
 
 Unfortunately, many people are started out in life on the wrong 
 track. They are led to think that they are weaklings and are physi- 
 cally unable to do many- things essential to happiness and success. 
 
HEALTH ACTIVITIES IN COLLEGES AND UNIVERSITIES. 7 
 
 An amazingly large number of people who are organically sound live 
 a long life of limited usefulness or utter uselessness, and prove to be 
 serious economic burdens to both family and society, simply because 
 of the fatuous sympathy of overindulgent parents and an early 
 attitude of servility on the part of the family and friends. 
 
 Again many students have fallen into the clutches of quacks and 
 mountebanks. The sensational advertising of these charlatans, 
 describing certain normal physiological processes as being abnormal, 
 may have fallen into their hands and morbidly influenced them. As 
 a consequence, many students entering the . university are the vic- 
 tims of either pernicious earty advice and care or of quackery. 
 Naturally there are associated with these conditions various mental 
 disturbances — neuroses and psychoses. The student under such con- 
 ditions has become, as a rule, introspective and melancholy. No 
 greater delight is afforded the service than to assure one of these vic- 
 tims that he is physically sound. This assurance must be followed 
 by frequent periods of advice and mental therapeutics. Thus mental 
 hygiene must play an important r61e in all university health services. 
 
 (c) Another value of physical examination is that the early detec- 
 tion and isolation of those having communicable diseases protects the 
 healthy students from the many grave communicable diseases that 
 annually creep into the university. 
 
 We are beginning to realize more and more that a knowledge of 
 the physical conditions and the regulation of the personal hygiene of 
 the individuals making up a unit or closely associated group are 
 fundamental in all community health activities. It is the custom 
 nowadays for a municipality or State to pass drastic laws regulating 
 garbage disposal, the location of corrals and pig styes, the cleanliness 
 of slaughterhouses, and the distribution of milk and foodstuffs. 
 Commendable as these laws are, they do not strike at one of the chief 
 dangers. While such laws may be rigidly enforced, a typhoid carrier, 
 a victim of tuberculosis, or one who has a mild case of any one of the 
 serious communicable diseases, may sow these diseases broadcast. 
 One tuberculous person or typhoid carrier in a community may do 
 as much harm to the individuals therein as lax enforcement or even 
 nonrecognition of the laws pertaining to sanitation. It is not diffi- 
 cult to see the incongruousness of a regulation which requires the 
 screening of foodstuffs and at the same time makes no provisions 
 whatsoever for determining whether the person who prepares the food 
 or distributes it is a typhoid carrier. 
 
 An example of the value of physical examination for the purpose 
 of isolating and treating getm carriers is seen in the recent Students 
 Army Training Corps examinations at the University of Minnesota. 
 Of the young men who stood in line for physical examination, one 
 was in the eruptive stages of smallpox, two had measles, one had 
 
^8 HEALTH ACTIVITIES IN COLLEGES AND UNIVERSITIES. 
 
 scarlet fever, and several had tuberculosis — one of whom was in such 
 an advanced stage of the disease that he died several days later. 
 Also other communicable diseases were detected. Let us suppose 
 that these examinations had not been made, as is the civiUan custom, 
 and that the infected ones had been allowed to mingle with the other 
 students in their various activities, both in classrooms and barracks. 
 The inevitable result would have been various epidemics with their 
 accompaniments of death, sorrow, and an inestimable academic arid 
 economic loss to the university and country. 
 
 Probably 75 per cent of all illness among students is more or less 
 communicable in nature. Sound students only too frequently con- 
 tract fatal diseases through innocent association with germ carriers 
 and distributors. One student with the so-called "chronic cough" 
 may infect numerous individuals with tuberculosis. Carriers of 
 diphtheria, typhoid, or even meningitis, may sit in classrooms and 
 share rooms with healthy students. 
 
 Venereal diseases must be completely eradicated. 
 
 So important are physical examinations with a view of detecting 
 and isolating carriers of communicable diseases that all students, all 
 members of the faculty, and employees who come in contact with 
 students, should be examined annually at the beginning of the school 
 year. 
 
 It will be readily seen from the foregoing discussion that to provide 
 for the physical welfare and proper development of the sound student 
 and to protect him from infection by others is a most important part 
 of the work of a university health service. Is not this service alone 
 worth the fee ? 
 
 (d) Another important value of frequent thorough physical exami- 
 nation is in the early detection of beginning degenerative diseases, 
 and the determination and correction of physical defects, both of 
 which contribute to subnormaUty. 
 
 It is well known that the so-called degenerative diseases are on 
 the increase in the United States. Various life-saving agencies 
 have found in their investigations that as the mid-period of life is 
 approached a sound, normal physique is a rare finding. 
 
 One-third of two and a half millions of our young men — young 
 men in the very prime of American manhood — failed to pass the 
 physical tests for military fitness under the selective-draft law dur- 
 ing the first draft in 1917-18. 
 
 In the recent Students Army Training Corps examination at the 
 University of Minnesota, of 3,403 young men — ages chiefly 18, 39, 
 and 20 — it was found that about 10 per cent were subnormal and 
 consequently were either accepted for limited service or placed in 
 Group B. Disorders of nutrition, circulatory abnormalities, valve 
 deficiencies, defective vision, bad teeth, infected tonsils, hernias, 
 
HEALTH ACTIVITIES IN COLLEGES AND UNIVERSITIES. 9 
 
 abnormalities of posture, flat feet, were among the common causes of 
 rejection. Many had albumin in urine, some had sugar. 
 
 Many of these defects are correctible. Others, again, can be 
 greatly improved by treatment and advice. The retrogressive 
 changes can usually be arrested. Making provisions for reconstruc- 
 tion and reclamation in such cases should be an important activity 
 of the personal division of a university health service. 
 
 Vaccinations and inoculations. — Prophylactic vaccinations against 
 smallpox and inoculations against typhoid fever, diphtheria, and pneu- 
 monia should be provided for. 
 
 Treatment and care of ill students. — Proper care must be taken of the 
 carrier of, and of those who have contracted, communicable diseases. 
 As soon as they are detected, adequate isolation, medical attention, 
 and care must be provided for them. All students who are ill or in 
 need of medical advice must be given the necessary attention. 
 
 Dispensary cases: Arrangements should be made for physicians 
 and nurses to give advice and treatment to ambulatory cases — 
 dispensary patients. Medical advice, treatment of minor ailments, 
 the necessary vaccinations and inoculations, the preparation of auto- 
 genous vaccines, and the early detection of communicable* diseases 
 are among the invaluable services of the dispensary and associated 
 laboratory. 
 
 Hospital cases : Frequently patients must be put to bed and cared 
 for and in many instances isolated. Hence, the necessity of pro- 
 viding both a general hospital and an isolation hospital. 
 
 Laboratory: A laboratory well equipped with everything neces- 
 sary for making the usual laboratory diagnosis is absolutely essential 
 for an eflicient health service. It is required in all physical exami- 
 nations and in the early detection of many communicable diseases. 
 
 University regulations necessary. — In the efficient administration of 
 a student's health service certain university regulations pertaining to 
 examinations, hygiene, and sanitation are needed. The following 
 regulations pertaining to the personal division of the work should be 
 adopted and enforced in every university: 
 
 1. Students entering the university for the first time shall present themselves to 
 the university health service for physical examination before matriculating. (These 
 examinations should be coordinate with those given by the department of physical 
 education.) Registration will be refused any student whose physical condition ia 
 regarded by the health serArice as dangerous to the health of the other students. 
 
 2. Members of the faculty entering the services of the university must obtain a 
 certificate of health from the uniyersity health service. 
 
 3. All new employees of the university who prepare and serve food to the faculty 
 or students must be approved by the university health service. 
 
 4. At any time during the school year upon request of the university health service 
 any student, instructor, or employee must submit himself for physical examination. 
 
 5. Instructors or officers must report to the university health service any student 
 or employee having or suspected of having any communicable disease (for example, 
 
 182914°— 20 2 
 
10 HEALTH ACTIVITIES IN COLLEGES AND UNIVERSITIES. 
 
 anyone with a chronic cough). Upon examination of such student or employee a 
 report with recommendations will be furnished the dean or officer concerned. 
 
 6. An instructor or officer of the university suspected of having any communicable 
 disease must, upon request of the president, dean, or official concerned, submit 
 himself for examination at the offices of the university health service. 
 
 7. It is the duty of matrons, officers, or those in charge of fraternities, sororities, 
 .clubs, and rooming houses to report to the university health service students suspected 
 of having any communicable disease and to report all illnesses which confine students 
 to their rooms. 
 
 8. Students, instructors, and employees who come in close contact with students, 
 who are absent from classes or from regular duties at the university on account of 
 illness of a communicable nature, must, before renewal of attendance or duties, present 
 to the dean or official concerned a permit from the university health serAdce. 
 
 II. Sanitation. 
 
 Environment plays an important r61e in disease causation and 
 prevention. This is especially true of communicable diseases. It 
 is most important to know and to regulate, so far as possible, the 
 conditions under which students live, the food and water ingested, 
 the air breathed, etc. The division of sanitation is therefore no 
 minor part of a university health service, and ample provisions must 
 be made for this branch of the work. The environment of the stu- 
 dent, both on and off the campus, must be regulated and made as 
 sanitary as possible. 
 
 1. University huildings and campus. — ^A sanitary survey of the 
 campus and its buildings should be made. As a consequence much 
 will be learned to aid in determining just what is needed in sanitation. 
 
 For each building on the campus utilized by students a voluntary 
 health officer — some interested member of the faculty who occupies 
 the particular building for the greater part of his time — may be 
 appointed. It has been the writer's experience that these voluntary 
 health officers for campus buildings are among the most valuable 
 aids of a health service. The voluntary health officer will supervise 
 in general the enforcement of the regulations pertaining to heat, 
 ventilation, light, drinking water, and janitor service. Only too 
 frequently does the janitor need both firm and intelligent super- 
 vision. Convenient boxes may be placed in each building to receive 
 suggestions, complaints, and recommendations relative to the im- 
 provement of conditions. 
 
 For the buildings and campus as a whole, an inspector of sanitation 
 should cooperate with the superintendent of buildings and grounds 
 and the voluntary health officers for each building. 
 
 Meetings of the voluntary health officers should be called from time 
 to time for the purpose of discussing problems of sanitation. The 
 writer takes this opportunity to assure anyone concerned with the 
 direction of a university health service that these meetings will be 
 enthusiastically attended, and much good will be derived therefrom. 
 
HEALTH ACTIVITIES IN COLLEGES AND UNIVERSITIES. 11 
 
 It is difficult to formulate general regulations for campus buildings. 
 What is essential for the sanitary activities of an old building is not 
 at all essential for the new. One building may be the sanitary con- 
 ception (if there was one) of 50 years ago, while another, the latest 
 building erected, may be constructed in accord with the most recent 
 ideas of sanitation. Again, buildings are utilized for different pur- 
 poses; hence different sanitar}^ codes to fit each must be made. 
 
 REGULATIONS. 
 
 The following general regulations may be adopted pertaining to 
 campus sanitation: 
 
 Regulations for Campus Sanitation. 
 
 1. Spitting on the walks of the campus, on the steps of a university building, or on 
 the floors of the halls or rooms of any university building is hereby forbidden. Viola- 
 tion of this rule will render the offender liable to suspension from the university. It 
 shall be the duty of all officers and employees of the university to report violations 
 of this rule to the health service. (Spitting in public buildings violates the law in 
 most States.) 
 
 2. Classrooms shall be swept and dusted after the class periods of the day are over. 
 Sweeping compound or some other material for allaying dust shall be used in sweeping. 
 All blackboards shall be thoroughly cleansed, unless otherwise indicated, at the close 
 of the day. The crayon dust which accumulates on the catch board must be tho- 
 roughly removed at the close of each day's work. 
 
 3. Rooms must be thoroughly ventilated between class periods. (Electric fans may 
 be used to accelerate this ventilation.) 
 
 4. Thermometers shall be provided for all classrooms and the temperature should 
 be held constant at 68-70° F. Provisions should be made for increasing the humid- 
 ity of rooms which are excessively dry. 
 
 5. The voluntary health officer of buildings which contain large assembly rooms 
 must be notified beforehand of proposed meetings. He shall then make provisions for 
 the best possible ventilation of assembly rooms during use. 
 
 6. All lockers used for clothing must be thoroughly cleaned and disinfected at least 
 once each year, and always upon the transference from one student to another. 
 
 7. All clothing kept in lockers in gymnasium dressing rooms, or laboratories, must 
 be kept in sanitary condition. Frequent inspection must be made by the officers of 
 the department concerned. 
 
 8. A bacteriological examination of the water of swimming pools shall be made once 
 each week, or as frequently as is deemed essential. The pools, when found to be un- 
 safe, will not be open to students. 
 
 9. Lavatories and latrines shall be thoroughly cleansed daily and as often as is neces- 
 sary. It shall be the duty of the voluntary health officer of each building to make 
 frequent inspections of the toilet rooms and to insist that the janitor keep them in sani- 
 tary condition. 
 
 10. Specific sanitary regulations to meet the particular demands of certain buildings 
 may be formulated and enforced by the director of the health service, the sanitary 
 inspector, and the voluntary health officer. 
 
 11. The sanitary inspector shall cooperate with the superintendent of the buildings 
 and grounds in keeping the grounds in the very best sanitary condition. 
 
 2, Living conditions. — Nothing can contribute more to the efficient 
 control of the health of students than the provision of properly built, 
 
12 HEALTH ACTIVITIES IN COLLEGES AND UNIVERSITIES. 
 
 properly equipped, and properly managed dormitories, dining rooms, 
 and refectories, sufficient for all students. No doubt for most univer- 
 sities it would be inadvisable — perhaps out of the question — to re- 
 quire all students to live on the campus, especially in the case of stu- 
 dents whose homes are nearby. However, such would be the ideal 
 condition from the standpoint of efficient control of hygiene and 
 sanitation. 
 
 Dormitories, erected with a view to affording the most hygienic 
 living conditions in regard to heat, light, ventilation, furnishings, 
 cleanliness, and drinking water, should be provided by every institu- 
 tion for all students not living at their homes. Where students live 
 in such dormitories, all communicable diseases can be quickly con- 
 trolled, and the closing of the institutions because of these diseases 
 need never occur. 
 
 University owned and controlled dining rooms sufficient to accom- 
 modate all students in the university are most important. Whole- 
 some, nourishing food is, of course, fundamentally essential to the 
 health of the student. Everyone handling food should undergo a 
 physical examination, including laboratory examination, and frequent 
 inspection of the kitchen and dining rooms should be made. We are 
 beginning to appreciate more than ever the value of proper nourish- 
 ment in efficient mental and physical work. 
 
 Besides providing the student with wholesome and nourishing food, 
 it would be well to teach him the amount and kinds of food essential, 
 as measured in calories, vitamines, etc. Unquestionably, the 
 so-called degenerative diseases, which statistics show are on the 
 increase in the United States, are in a large measure due to ignorance 
 of nutrition, and overeating. When a new automobile is purchased, 
 the first chief concern of the owner is to determine the greatest 
 number of miles that can be obtained from a gallon of gasoline. The 
 amount of strength and energy to be derived therefrom should be 
 an important matter in food ingestion. Certainly, if the importance 
 of this matter were universally known and appreciated, high blood 
 pressure, arteriosclerosis, chronic heart disturbances, Bright's disease, 
 apoplexy, and other degenerative diseases would be decidedly 
 diminished. Dining rooms on the campus, if operated under intelli- 
 gent supervision, could do much in supplying this information. Each 
 menu should give the caloric value of the foods served and succinct 
 information relative to the kind and amount essential to proper 
 nutrition. Let the university take the lead in this important matter 
 by supplying the proper nutrition and teaching its relative values 
 and needs. 
 
 We are not unmindful of the great role that dormitories and dining 
 rooms play in the social life of the student. That these buildings 
 solve many perplexing problems relative to the student's life in 
 
HEALTH ACTIVITIES IN COLLEGES AXD UNIVERSITIES. 13 
 
 general is obvious, and that they are of financial value has already 
 been demonstrated in many institutions. 
 
 The establishment, then, of sufficient properh^ constructed dor-, 
 mitories and dining rooms wherein all food? and refreshments are 
 prepared and served with scientific and sanitary care and according 
 to the regulations laid down by the university health service is 
 indispensable to the best living conditions. Under such conditions 
 would not the gain in mental efficiency, physical well-being, and 
 happiness of the students sufficiently compensate the State or other 
 agencies for providing these facilities ? 
 
 When students are compelled to live in rooms promiscuously pro- 
 vided by proprietors whose sole interest is the monthly rental 
 the environment will often be unsatisfactory. The majority of 
 students are compelled to live as cheaply as possible, and usually 
 little attention is paid by the student to the sanitary conditions. 
 Improper heating, insufficient ventilation, overcrowding, poor 
 lighting, and uncleanliness are the lamentable conditions existing 
 in many rooming houses. 
 
 Likewise most dining rooms, lunch counters, and refectories are 
 operated for gain, at the expense of proper service. The average 
 student patronizes the cheaper ones. Too frequently the food is 
 bad — spoiled or adulterated — or has not been prepared with a view 
 to cleanliness. Typhoid and other germ carriers may serve the 
 food and refreshments. Nutrition as a science is ignored. 
 
 With such adverse conditions it is no wonder that so much ill 
 health exists among students and that outbreaks of communicable 
 diseases occur frequently. 
 
 To correct these unfavorable conditions a sanitary survey should 
 be made of the rooming and eating conditions of students, in so far 
 as it is feasible. A sanitary inspector should inquii-e into and 
 regulate, as far as possible, the conditions of heat, ventilation, 
 lighting, cleanliness, equipment, and other things pertaining to the 
 health of the students; and a report in each case should be kept on 
 file at the office of the health service and at the housing bureau. 
 
 Particular conditions demand special regulations; but, in general, 
 regulations similar to those given below^ should be adopted, to 
 be met, as far as possible, by student rooming and boarding houses 
 in order that they may be placed and kept on the approved list, 
 the rating given each to depend upon the degree to which the rec^uire- 
 ments are met. 
 
 Rooming House Regulations. 
 
 1. Heat. — All study rooms should be heated to an even temperature of 68° or 70° 
 when occupied. Pipes must carrj- fumes of gas stove, when used, out of the room. 
 Effort should be made to maintain the necessary humidity. 
 
 2. Ventilation. — Provisions should be made for proper ventilation through suflS- 
 cient windows and transoms. Rooms should have at least one window to outside. 
 
14 HEALTH ACTIVITIES IN COLLEGES AND UNIVERSITIES. 
 
 3. Light. Shaded table lights should be provided. Gas lights must be equipped 
 with mantle and frosted globe. 
 
 4. Cleanliness. — Rooms should be cared for daily, and thoroughly cleaned at least 
 once a week. Mattresses should be well aired at least once each week, and they 
 should be thoroughly cleaned and sunned at least once each year and always upon 
 change of tenants. Bathroom and fixtures should be kept in a neat and clean con- 
 dition. Plumbing should be adequate. 
 
 5. EqidpTnent. — A single bed for each student is recommended, and, if possible, 
 one bed to each room unless sleeping porches are provided. Where two beds are in 
 the same room, there should be at least 6 feet between them. All proprietors of 
 rooming houses should be advised to supply single beds as soon as possible. 
 
 For each study room with two students the following equipment should be provided: 
 One study table, two study and two easy chairs, dresser or chiffonier or both, closet 
 or wardrobe for hanging clothes, mirror, carpet or rugs (preferably the latter), room 
 thermometer, book shelf, and waste-paper basket. Provision should be made for 
 storing trunks. 
 
 6. Bathing facilities. — Hot water should be furnished in lavatory daily, and for baths 
 at least twice each week. 
 
 7. Drinking water. — Drinking water should be furnished from an approved source. 
 
 8. Inspection. — All rooms and houses used by fraternities, sororities, and clubs, 
 and all student rooming and boarding houses should be open to the university health 
 service for inspection and sanitary regulation. 
 
 9. Complaints. — Students should enter complaint to the health service when they 
 feel that these regulations are not obeyed. The health service should immediately 
 investigate with a \dew to enforcing the regulations. 
 
 Information Relative to Rating Rooming Houses. 
 
 In the rating of rooms, a scale of 100 points might be used by the inspector and the 
 following features should be taken into consideration: 
 
 Heat {20 points). — Study rooms should be heated by hot water, steam, or hot air 
 systems. While occupied they should be kept at a temperature of 68° to 70° F. 
 
 Humidity (5 points).— The overdry atmosphere of rooms gives a sense of chilliness, 
 owing to excessive evaporation of the moisture in the air, and favors irritation and 
 infection of the respiratory mucous membrane. If a room at 68° is not warm enough 
 for a healthy person, we may be sure that the air is too dry. Dr. E. P. Lyon found that 
 durinw the heating season the evaporation of at least 15 buckets of water each 24 
 hours is required to supply the needed humidity for the ordinary house of 10,000 
 cubic feet capacity. 
 
 Water vapor can be increased to some extent by evaporating tanks in connection 
 with hot-air systems, or by letting steam escape when a steam-heating system is 
 used. Care must be taken, however, in the latter method, as it might prove harmful 
 or even dangerous to the boiler. In individual rooms, water vapor can be increased 
 to a certain degree by operating an electric fan placed over a vessel containing water, 
 or by other devices, but none of these methods is ideal. Dr. Lyon's tests and results 
 are of great value in this important matter. (See Minnesota Medicine V, December, 
 
 1918.) 
 
 Ventilation {15 points).— At least 1,000 cubic feet per occupant; direct outside air; 
 cross ventilation; transoms; windows; window ventilators. 
 
 Lighting {15 points).— Direct outside light; window area at least 20 per cent of floor 
 area; electric table lights shaded. 
 
 Cleanliness {15 points). — Cleanliness of rooms and halls; condition of bedding and 
 mattress; small rugs; use of vacuum cleaner; washable curtains and draperies; general 
 appearance of house and surroundings. 
 
 Furnishing {15 points). — Single beds; study table or desk; shaded electric table 
 light; study chairs and easy chairs; adequate drawer and closet space. 
 
HEALTH ACTIVITIES IIST COLLEGES AND UiSTIVEESTTIES. 15 
 
 Bathroom (10 points). — One bathroom for each five persons; plumbing; outside 
 ventilation; cleanliness; hot water; same floor with bedrooms. 
 
 Building (5 points). — Upkeep; halls and stairways; fire protection — accessibility 
 to exit, fire escape fourth floor and up — basement; exterior surroundings. 
 
 Rules for Approved Boarding Houses. 
 
 ■1. All rooms where food is stored, prepared, or served to students must be kept 
 thoroughly clean and screened against insects and animals. 
 
 2. No privy vault, open cesspool, hogpen, or chicken pen shall be pennitted within 
 50 feet of any room used for storing, preparing, or serving food. 
 
 3. All garbage must be placed in covered sanitary receptacles and removed from 
 premises at least three times a week. 
 
 4. All water used for cooking, washing dishes, or drinking must come from sources 
 approved by the health service. 
 
 5. Dishes and cooking utensils must be kept in a clean and sanitary condition. 
 
 6. All persons preparing or serving food to students shall keep themselves in a neat 
 and clean condition. Every facility must be maintained to assure the most rigid 
 personal cleanliness. 
 
 7 . All persons preparing or serving food to students shall obtain a certificate of health 
 from the university health service. 
 
 8. The name of the dairy furnishing the milk used and served must be filed with the 
 university health service. 
 
 ENFORCEMENT OF REGULATIONS. 
 
 (1) An inspection of rooming and boarding houses should be made 
 by a representative of the university health service at least once each 
 year or as often as is deemed necessary. These inspections should 
 be made in conjunction with other agencies concerned. 
 
 (2) A list of the rooming and boarding houses approved by the 
 university health service, together with ratings, should be on file 
 at the university health service office and at the housing bureaus. 
 
 (3) All complaints by students respecting rooms and boarding 
 houses should be followed up by immediate inspection on the part 
 of the health service. 
 
 (4) The university health service should cooperate with the State 
 board of health and the city health department in making the inspec- 
 tions and in enforcing the necessary regulations. 
 
 VOLUNTARY HEALTH OFFICERS FOR ROOMING AND BOARDING HOUSES. 
 
 The work of the health service may be very much facilitated by the 
 appointment of voluntary health officers — one for each sorority, 
 fraternity, dormitory, cooperative club, boarding house, and rooming 
 house. This official may be the matron or any one interested, and 
 may be appointed by the particular society concerned. 
 
 These officers should be made familiar with the regulations which 
 concern them, and the closest cooperation should exist between them 
 and the health service. Outbreaks which might lead to serious epi- 
 mics may be readily checked by intelligent and close vigilance on 
 the part of these voluntary health officers. 
 
16 HEALTH ACTIVITIES IN COLLEGES AISTD UNIVERSITIES. 
 
 III. Education. 
 
 Dr. Eugene Lyman Fiske, in his analysis of the Army examinations 
 of the one-third who failed to pass the physical tests, concludes that 
 60 per cent of those rejected owe their physical impairments to either 
 ignorance or neglect. Both go hand in hand, for neglect of bodily 
 organs and functions is the invariable accompaniment of ignorance 
 relative to the causes of morbid processes and their grave results. 
 
 Appreciative and impelling enlightenment in regard to all thmgs 
 pertaining to human physical welfare is the first principle of an 
 efficient university health service. As in every other human-better- 
 ment activity, the most genuine and far-reaching results are to be 
 obtained through education. Education of the masses is a slow 
 process, but it is sure to win. The average student knows little and 
 cares less for the laws of health, and this is but a reflection of the 
 usual American attitude toward hygiene. 
 
 1. COURSES IN HYGIENE 
 
 No greater service can be rendered the college youth than requiring 
 him to devote some time to the conscientious study of both personal 
 and public hygiene. This is so universally accepted by academicians 
 that it would be but useless repetition to present arguments in its 
 behalf. That universities regard hygiene as an essential subject is 
 demonstrated by a perusal of their catalogues. A criticism called forth 
 by the average course in hygiene, however, is the half-heartedness 
 or laxness with which it is conducted. 
 
 As a rule the courses given are in the nature of weekly lectures 
 for perhaps one semester, for freshmen. Attendance is practically 
 the only requirement for credit, and a freshman, as a rule, regards 
 the course as a barricade which he must by some hook or crook sur- 
 mount in order to receive the coveted degree. The class period is 
 usually relegated to some late afternoon hour so that it will in no 
 way interfere with the other courses. The classes are usually large, 
 perhaps all freshmen boys in one section and girls in another, and 
 the course is presented by overburdened and perhaps uninterested 
 lecturers. No wonder then that hygiene has fallen into more or less 
 ill repute and the teaching of it is too often regarded as comparatively 
 unimportant. This is lamentably true notwithstanding that the 
 knowledge which is concerned with laws of self-preservation is after 
 all the first principle of education. 
 
 Hygiene should be placed on the same basis as other academic 
 studies and should be required of all beginning students. At least 
 five or six hours weekly for one semester or two quarters should be 
 devoted to it, and credit toward degrees should be given for it. The 
 course should be conducted as are other classes, by lectures, recitations. 
 
HEALTH ACTIVITIES IN COLLEGES AND UNIVERSITIES. 17 
 
 assignments, demonstrations, experiments, and examinations. Nu- 
 merous opportunities for concrete study of hygiene are afforded in the 
 college or uniA^ersity environment, such as that offered by the sanita- 
 tion of campus buildings and of students' lodging and boarding houses. 
 Then there are various departments in the university which are more 
 or less directly concerned with health matters, such as physiology; 
 bacteriology and pathology; sanitary engineering — water supply and 
 sewage disposal; and architecture — building construction, both pri- 
 vate and public, with special reference to light, heat, humidity, ven- 
 tilation, and plumbing. These departments should be utilized for 
 concrete study whenever it can be done. 
 
 Hygiene, both personal and public, can be made one of the most 
 interesting subjects in the college curriculum. Is it not true that 
 people are fundamentally interested in health? It has been stated 
 that matters relative to health and physical well-being make up the 
 bulk of the laity's conversation. If this is true why not by education 
 substitute facts for the world of harmful misstatements and prevalent 
 superstition ? 
 
 Hygiene should be made actively alive. It might well begin with 
 the consideration of timely and interesting topics. For example, if 
 influenza is rampant, begin with that subject. The vital statistics 
 of the particular locality should guide in the introduction of the 
 course in hygiene. In many localities, typhoid fever and tuberculosis, 
 under normal conditions, are the chief destroyers of early manhood 
 and womanhood — the period of college life. Therefore, in those 
 localities particular consideration should be given to these infections, 
 and the related infectious diseases may be studied in connection 
 with them. Thus, season, latitude, prevailing diseases, epidemics, 
 etc., may determine the introduction to a course in college hygiene. 
 
 The proportion and relative values of the various topics making 
 up hygiene study may be largely determined by the agencies which 
 are most likely to and do most frequently affect the health. For 
 many reasons the course should start out with, and continual em- 
 phasis should be placed on, public health. As President Burton of 
 the University of Minnesota has stated, "The college freshman is 
 more or less fed up on personal hygiene. '^ He has had an over- 
 ingestion of it while at high school and still feels a sense of distention. 
 Again, a student is decidedly socialistic during this period and is more 
 interested in his relations to society than he is in his "innards." 
 
 In general, a course including facts of hygiene and sanitation, which 
 it is vital that all citizens should know, may be outlined as follows: 
 
 Bacteria. — ^Along with a consideration of the prevailing infectious 
 diseases, the subject of bacteria in general may be introduced — their 
 nature, kinds, distribution, growth; pathogenic bacteria and how they 
 gain entrance into the body; toxins and their effects. Interesting 
 
18 HEALTH ACTIVITIES IK" COLLEGES AND UJSTIVEKSITIES. 
 
 concrete examples of pathogenic bacteria may be selected from the 
 various infectious diseases. Naturally these studies lead to public 
 hygiene-sanitation. Contamination of water, milk, and food; sewage 
 disposal, etc., are problems of bacterial distribution. Air and other 
 means of contaminations such as carriers, objects, hands, insects, etc., 
 may likewise be considered. Thus the subject of communicable 
 diseases in a general way may be introduced, reserving the more 
 specific effects of contagious disease until the appropriate place for 
 their study in connection with the physiological system is reached. 
 
 Man's defense against bacteria may be next introduced : bodily re- 
 sistance and how maintained; methods of prevention — cleanliness and 
 asepsis, avoidance of crowds, isolation, quarantine, vaccination, air, 
 sunlight, chemicals, sterilization etc, 
 
 Resjjiratory system. — ^As the vast majority of the communicable 
 diseases enter through the respiratory system, the study of this 
 system may well be introduced here. After the essential consider- 
 ation of the anatomy and functions of the nose, mouth, pharynx, 
 larynx, and lungs, the respiratory infections should be considered. 
 First and foremost, colds; causes and effects, and especially the effect 
 in preparing "soil" for more serious infections; prevention, and here 
 building construction in relation to ventilation, heating, and humidity 
 may be dwelt upon. The subject of colds may be followed by a con- 
 sideration of diseases spread by discharges from mouth and nose; 
 i. e., chronic coughs, tuberculosis, influenza, pneumonia, diphtheria, 
 septic sore throat, tonsilitis, scarlet fever, measles, mumps, whooping 
 cough, cerebrospinal meningitis, etc. The methods of dissemination 
 of these diseases and the means of preventing them should be duly 
 emphasized. 
 
 Focal infections. — Teeth-root abscesses and pyorrhea, diseased ton- 
 sils, adenoids, infected sinuses, and their far-reaching effects in the 
 causation of constitutional disorders such as endocarditis, arthritis — 
 both acute and chronic — chorea, high blood pressure, lassitude and 
 indisposition, and degenerative diseases, should be dealt with. 
 
 A general consideration of the care of the nose, mouth, and throat 
 may now be made. From the above synopsis it will be seen that the 
 subject of the respiratory system and its disorders is indeed lengthy. 
 It is, nevertheless, a most important one. The relative importance 
 of the various diseases should be the guide in presenting them. 
 
 Mental liygiene. — Of great importance is the subject of mental 
 hygiene. The university represents an abrupt transition in the life 
 of the student. New environment and conditions of living, new 
 associations, and perplexing educational methods are more or less 
 disturbing experiences to many students. They have difficulty in 
 ''finding themselves." Again, many students who come to the 
 university have been started ojff early on the wrong track. The 
 
HEALTH ACTIVITIES IN COLLEGES AND UNIVERSITIES. 19 
 
 twig is readily bent in divers ways, and many factors in the earlier 
 life of a student may have brought about a more or less warped 
 condition. 
 
 Many types of psychoses, neuroses, and other slight mental aber- 
 ations — border-land cases — ^have their exacerbations or inceptions 
 during the earlier period of college life. Mental therapeutics — that 
 which endeavors to ''put the student right" with himself, his en- 
 vironments, and his activities — should be an important part of the 
 work of genuine hygiene instruction. 
 
 Instructors in practically all courses offered in the university could 
 do much to prevent these mental disturbances in students. In the 
 introduction of a new subject, the devotion of a class period or two 
 to a brief consideration of what is to be sought and how best to 
 obtain it, is worth while. Our first step, when manual labor of any 
 sort is to be done, is to figure out the maximum accomplishment to 
 be obtained with the least expenditure of energy. This is recognized 
 as efficiency. Why not apply the same method to mental endeavors ? 
 Ear too many students in too many courses "butt their heads against 
 a stone wall" in their compelled efforts to move or remove it. An 
 enormous amount of physical and nervous energy is wasted. Would 
 not a preliminary survey wherein the maximum accomplishment 
 with a minimum expenditure of nervous and physical energy is dis- 
 cussed and demonstrated contribute to mental efficiency ? It would 
 certainly do much, not only toward minimizing psychoses but also 
 toward stimulating interest. But this should not mean a sugar-coated 
 educational process which would seriously affect what is vaguely 
 termed "mental discipline." Making a course "difficult," however, 
 is to be condemned. "Burning the midnight oil" as a routine intel- 
 lectual endeavor for students should be relegated to the past. 
 
 Circulatory system. — This subject should include a survey of the 
 anatomy and physiology of the blood organs — arteries, veins, capil- 
 laries; further emphasis should b^ laid on focal infections, i. e., 
 rheumatic fever, endocarditis, etc., and their relations to the heart. 
 The necessity of exercise and the dangers of overstrain should be 
 duly considered. The etiological factors and the prevention of 
 high blood pressure, arteriosclerosis, and cardio-nephritic degener- 
 ations should receive the proper emphasis. Emergencies, hemor- 
 rhages, and syncope should also be considered. 
 
 Excretory organs. — A study of the skin, the kidneys, etc., should 
 be made. 
 
 PTiysical exercise. — The subject of physical exercise should include 
 a study of the anatomy and physiology of the bones, joints, and 
 muscles, and the physiology of muscular movement. Activity and 
 
20 HEALTH ACTIVITIES IN COLLEGES AND UNIVEKSITIBS. 
 
 muscular exercise in the open air should be emphasized as among the 
 chief measures for maintaining health and as important factors in 
 preventive medicine. There should also be included the reconstruc- 
 tion and prevention of deformities — round shoulders, lateral curva- 
 ture, humpback, knock-knees, weak and fiat feet; the teaching of cor- 
 rect body posture and the development of the various parts and organs 
 of the body; and the cultivation of poise and graceful, coordinate, 
 efficient motion. 
 
 Organs of nutrition. — The essential survey of the gastrointestinal 
 tract from teeth to colon, including the anatomy and physiology of 
 the various gland appendages should be made. In presenting the 
 anatomy and physiology of the organs and systems, care must be 
 taken not to weary the student with too many details. The salient 
 features of this branch of hygiene are: Care of mouth and teeth; 
 mastication; essential food substances; amount of protein, carbo- 
 hydrates, and fats essential as measured in calories; overingestion 
 and its relation to degenerative diseases; regulation of meals and 
 diet; proper cooking of foods; preservation of foods; adulteration of 
 foods; drinking water; gastrointesdnal disorders — dyspepsia, costive- 
 ness, diarrhea, etc. The diseases due to alvine discharges — cholera, 
 dysentery, hookworm, and especially typhoid fever — should be given 
 much attention and the public health phases emphasized. Also, a 
 study should be made of the nutritional diseases — pellagra, scurvy, 
 beriberi, and rickets. 
 
 Sex hygiene. — This important part of the study of hygiene may be 
 presented early in the course, if deemed appropriate. Perhaps no 
 subject pertaining to personal welfare has received more attention 
 in recent years. Perhaps no subject has been more fatuously 
 handled. At times one is almost constrained to feel that as much 
 perversion has been manifested in its usual presentation as that 
 toward which it is directed. The practice of engaging high-priced 
 itinerant lecturers to come aroiftid once a year and present the 
 subject to a large audience is to be condemned. An abnormal 
 curiosity rather than a genuine helpful interest is fostered and this 
 curiosity is the motive for attendance. Again, these meetings are 
 arranged to serve the convenience of the lecturer. Necessarily, an 
 abrupt, more or less sensational introduction to this all-important 
 subject, where both modesty and time forbid a wholesome discussion, 
 is the deplorable result. 
 
 For many reasons sex hygiene should be correlated with general 
 hygiene instruction, and should be presented at the appropriate 
 period by the regular instructor after he has become acquainted 
 with his students and they have become acquainted with his sin- 
 cerity and earnestness. It should include a brief consideration. of 
 genesis; anatomy, physiology, and care of sexual organs; social 
 
HEALTH ACTIVITIES IN COLLEGES AND UNIVERSITIES. 21 
 
 diseases — in relation to the individual, to society, and their economic 
 loss; heredity, and eugenics. 
 
 Clothing. — There should be considered the relation of clothing to 
 health; the kinds of clothing; the need of proper clothing, both under 
 and outer, in winter for conservation of heat and energy; warm- 
 weather clothing, etc. 
 
 Cancer. — Cancer ranks with tuberculosis and pneumonia as a 
 great causative factor in our national mortality. The subject, 
 therefore, is of both profound personal and public interest. Its 
 cause, so far as we know, and its prevention and early treatment 
 should be given due consideration. 
 
 Domestic and public hygiene. — Study should be made of the loca- 
 tion and construction of dwellings; provisions for light, heat, ventila- 
 tion, and humidity; dust in air; water supply; plumbing; drainage; 
 modern bathrooms and toilet rooms; garbage and refuse disposal; 
 nuisances. These subdivisions may be extended to include certain 
 municipal matters; water — sources, contamination, purification, and 
 relation to disease; soil in its relation to disease; sewage and refuse 
 disposal; school and other public buildings; industrial hygiene; 
 communicable diseases not already considered, i. e., smallpox, 
 chicken pox, etc., emphasizing them from the public standpoint 
 with special reference to quarantine, isolation, disinfection, and 
 immunity; patent medicines. 
 
 2. PUBLICATIONS. 
 
 The students' daily paper and other university publications may 
 be utilized for the purpose of disseminating knowledge relative to 
 both personal and public hygiene. The effects of daily succinct dis- 
 cussions on timely hygiene topics are far reaching. 
 
 3. EXHIBITS, 
 
 Every opportunity should be taken to set forth information rela- 
 tive to disease, patent medicines, etc., by means of exhibits, placards, 
 drawings, and moving pictures, so that "he who runs may read." 
 The waiting room at the health service and other convenient rooms 
 should be made use of for placards. 
 
 There are practically no limits to the educational work of the health 
 service, 
 
 PERSONNEL OF A UNIVERSITY HEALTH SERVICE, 
 
 The personnel of a university health service will vary greatly, of 
 course, in different institutions. 
 
22 HEALTH ACTIVITIES IN COLLEGES AND UNIVERSITIES. 
 
 Personal Division. 
 
 Director. — ^At the head of the university health service there should 
 be a director — a man of splendid personality, wide vision, broad 
 sympathies, and unusual training. He must appreciate fully the 
 scope of his work and the relative values of the various activities 
 under his supervision. As his chief • aim is concerned with the 
 maintenance of an active, healthy, vigorous, working student body^ 
 he must be familiar with both preventive and curative medicine. 
 Further, he should understand the theories and practices now in- 
 corporated and taught in the department of physical education, for, 
 and it will stand reiteration, proper daily physical exercise is one 
 of the best preventives of disease in the student's life; and by properly 
 directed exercise many physical defects can be ameliorated and in 
 some cases entirely overcome. 
 
 Assisting the director there should be physicians, nurses, and a 
 laboratory technician familiar with bacteriology and medical labor- 
 atory diagnosis. 
 
 PJiysicians. — The personnel of a university health service should 
 include one or more physicians, depending on the size of the institu- 
 tion. Perhaps 1 physician for each 1,000 students would be a good 
 allotment in general. 'Women physicians are desirable for women 
 students, especially in making the physical examination and for 
 reconstruction work. 
 
 The physicians employed should be especially qualified for their 
 work. In addition to ample training in both preventive and cura- 
 tive medicine, they should be familiar with the theories and prac- 
 tices of physical education. Especially should they be acquainted 
 with the various methods of physical reconstruction and the reclama- 
 tion of subnormal students. The physician should become ac- 
 quainted with the physical status of each student in his group. 
 With such knowledge he can provide the proper measures for main- 
 taining the health of the sound student and group his subnormals 
 into various classes for which suitable exercise and care can be ar- 
 ranged. He should use the "follow up" system, and a complete 
 physical record should be kept of the student throughout his aca- 
 demic career. 
 
 Thus it will be seen that the health service and physical education 
 are interrelated. In fact these physicians may well be employed by 
 both departments where these departments are separated. 
 
 Of course, where no medical school exists in connection with the 
 institution, these- physicians must necessarily keep daily hours at 
 the hospital and dispensary where students may consult them. 
 Where there is a medical school the treatment of ill students may 
 well be taken care of in another way. This matter is discussed in 
 
HEALTH ACTIVITIES IN COLLEGES AND UWIVEESITIES. 23 
 
 Miscellaneous Problems, under the heading, "Relation between 
 medical school and students' health service." 
 
 Nurses.: — The importance of a sufficient number of competent 
 nurses in the health service can not be overemphasized. Nurses' 
 activities are divided as follows: Hospital niirsing; attendance in the 
 dispensary; visiting outside sick students; inspecting rooming 
 houses, etc. The number of nurses required for an effective health 
 service varies with the size of the institution and the particular 
 demands. At least two full-time nurses, one serving as superin- 
 tendent, should be employed. Increase in the nursing staff should 
 be made to meet the demands. In case of epidemics and during 
 certain seasons extra ones are often needed. 
 
 Laboratory technician. — Finally, it is essential that someone well 
 trained and skilled in laboratory technique and diagnosis be em- 
 ployed. The technician's activities are related chiefly to two 
 branches of the service: the personal division, in the various laboratory 
 examinations, and the division of sanitation. In fact the right type 
 of individual with the necessary training may well direct the division 
 
 of sanitation. 
 
 Divisioi> of Sanitation. 
 
 To carry on the activities as outlined, for the division of sanitation, 
 the following should be appointed: A chief of the division of sani- 
 tation ; inspectors of sanitation (one or more as the needs demand) ; 
 voluntary health officers for campus buildings (see p. 2496); and 
 voluntary health officers for sororities, fraternities, clubs, boarding 
 houses and rooming houses (see p. 2501). As has been suggested, 
 the work of the three divisions — personal, sanitation, and educa- 
 tional — overlap, and one properly trained individual may serve in 
 several capacities, especially in the health services of small institu- 
 tions. For example, the chief of the division of sanitation may 
 serve as sanitary inspector and laboratory technician. A number of 
 such combinations can be made with properly trained individuals. 
 
 Division of Education. 
 
 The course in hygiene may be conducted by practically any 
 number of the staff of the health service. Special ones may be 
 delegated for the particular parts of the educational work. 
 
 BUILDING AND EQUIPMENT. 
 
 For the successful administration of a university health service 
 a suitable building, conveniently located, should be provided and 
 used solely for the health service work. The three divisions are so 
 interrelated in their activities that one distinctive building unit 
 should house them all. 
 
 Adequate provision for the personal division requires: 
 (1) A dispensary with a waiting room and examination and 
 treatment rooms; 
 
24 HEALTH ACTIVITIES IN COLLEGES AND UNIVERSITIES. 
 
 (2) A Hospital for noncontagious cases (including nurses' quarters, 
 unless these are otherwise arranged for) ; 
 
 (3) Adequately isolated quarters for contagious diseases (these 
 quarters should be either in a weU-isolated part of the building, or 
 better, in a separate building, or in a wing connected with the main 
 building by inclosed corridor) ; 
 
 (4) A well equipped laboratory which can be utilized in the work 
 of both the personal division and division of sanitation; 
 
 (5) Necessary office space. 
 
 It has been the writer's experience that, for an efficient health 
 service, provisions should be made for hospital facilities of at least 
 5 beds and a daily average of 20 dispensary visits for each 1,000 
 students enrolled. These figures are given as the minimum require- 
 ments. Of course the daily sick call and the number of patients are 
 influenced by the seasons and the presence of epidemics. Conse- 
 quently the hospital and dispensary equipment must be elastic. At 
 times, as during the height of epidemics, every resource wiU be 
 strained in order to care for all those afflicted. 
 
 The laboratory is of great importance. It makes possible the 
 early detection of communicable diseases and provides a place for 
 the routine analyses essential to thorough physical examinations. 
 Preventive vaccinations for typhoid fever, pneumonia, smallpox, 
 diphtheria, etc., may be given and autogenous vaccines prepared. 
 Further, it is essential in the work of the sanitary division for the 
 examination of drinking water, milk, water of swimming pools, etc. 
 
 A hospital, including an isolation hospital for the more serious 
 communicable diseases, a dispensary, and a laboratory are absolutely 
 indispensable to an efficient university health service. 
 
 To initiate a health service, temporary buildings can, of course, 
 be utilized until permanent accommodations are provided. One 
 building could serve as a place for making physical examinations, 
 for the early diagnosing and treating of minor illness among students, 
 and for taking care of bed patients, when noncontagious. It could 
 also serve as the health center of the university in which the admin- 
 istration of the divisions of sanitation and education is carried on. 
 Another building could serve for isolation purposes. 
 
 MISCELLANEOUS PROBLEMS. 
 
 Many problems come up with the initiation, organization, and 
 operation of a students' health service. A brief statement regardmg 
 some of the most important of these problems which have been 
 repeatedly called to our attention may be of interest. For the 
 smaller institutions perhaps the writer's previous discussions on this 
 subject may be of some value.^ 
 
 1 " The university health fee," The Journal of the Kansas Medical Society, October, 19] 5. " Organization 
 and activities of a university health service," School and Society, Sept. 2, 1916. 
 
HEALTH ACTIVITIES IN COLLEGES AND UNIVERSITIES. 
 
 25 
 
 Keference has already been made to the inextricable relationship 
 between the health service and the department of physical education 
 in the university. A close relationship should exist also between 
 the health service and the schools of medicine, and of hygiene and 
 
 09 
 
 
 
 
 
 „ 
 
 
 
 
 
 
 
 
 
 c 
 
 
 
 
 7 
 
 
 
 
 
 
 
 
 jr "S i2 
 
 
 I 
 
 
 g 
 
 1- 
 
 
 c 
 
 
 
 ^ 
 
 
 ,^u) 
 
 3 
 
 
 III 
 
 
 " -r, "^ 
 
 10 
 
 
 
 
 
 
 
 
 
 fe 
 
 
 
 
 
 
 
 
 
 ^ 
 
 
 
 - O UJ 
 
 
 Ol 
 
 -1 
 
 
 
 
 a 
 
 
 
 s 
 
 
 c *-* — 
 
 
 ♦- 
 
 o 
 
 
 
 o 2 a 
 
 -T) 
 
 
 
 5 
 
 
 I 
 
 Q 
 
 i2 
 
 .? 
 
 
 
 
 fcl 
 
 B 
 
 fe 
 
 ■^1 
 
 
 I I 2(2 ° fc - « 
 
 F = <» i ^ ? 
 ,o o a 5i o J » oj 
 .^ uGUJZHlQ 
 
 nyjS.Q 
 
 t-fi 
 
 public health, if these schools are maintained by the institution. 
 The health service must also be in close touch with the housing 
 bureau and with various student organizations. 
 
 1. Relation between the Tiealth service and tJie department of physical 
 education. — To repeat, the university health service is as much 
 
26 HEALTH ACTIVITIES IN COLLEGES AND UNIVERSITIES. 
 
 concerned with the physical welfare of the sound student as it is 
 with the sick. It must be actively interested in the provisions for 
 the maintenance of the health of all students. This makes a close 
 relationship between the service and the department of physical 
 education essential. A specially trained physician, devoting all 
 his time to student health and physical education, should be employed. 
 Not only should he be well trained in medicine but he should have 
 an intimate knowledge of both the theory and practice of kinesiology, 
 calisthenics, outdoor and indoor physical education. He should be 
 familiar with reconstructive and corrective exercises. This physician 
 is a most important member of a students' health service. He must 
 become familiar with the physical records of all the students in his 
 group. It is his concern to keep the sound student well, and to look 
 out for the physical welfare and exercise of the subnormals. He is 
 the teacher of hygiene to incoming students. His work constitutes 
 a continuous ''follow-up system," whereby one of the greatest 
 objectives of students' health service is reached — that of helping the 
 student to possess a better developed and a sounder physique at the 
 conclusion of his college career than he had at the time of his entrance, 
 
 2. Relation ietween medical school and students^ JiealtJi service. — 
 Let me again emphasize the fact that a university health service 
 should not be regarded solely as a sickness insurance agency. The 
 most serious mistake that many institutions have made in establishing 
 health services is to regard them as contract practice procedures and 
 to expend all income from health fees on facilities for medical treat- 
 ment and for the employment of physicians who are concerned only 
 with curative medicine. As a result, in these institutions, only a 
 dispensary and hospital are provided and a practicing physician is 
 engaged. This is not a university health service. Such an activity 
 deals with perhaps not more than 5 per cent of the students. As 
 has been stated before, a real health service should be as much 
 interested in the 95 per cent who do not feel the necessity of consulting 
 a physician as with the 5 per cent who do. It should be primarily 
 interested in preventive medicine, and must be actively associated 
 with all agencies in the university engaged in the physical welfare of 
 students. 
 
 From a study of the aims and functions of a students' health service 
 it can readily be seen that it can not well be made an integral part of a 
 medical school, but should be a separate unit in the university. The 
 larger functions of a health service are entirely independent of those 
 of the medical school. The medical school would not wish to concern 
 itself with these activities, nor could it be expected to do so. It 
 would take up too much time and would interfere with medical in- 
 struction, which is primarily the teaching of diagnosis and treatment. 
 
HEALTH ACTIVITIES IN COLLEGES AND UNIVERSITIES. 27 
 
 However, in the personal division of its activities, especially in 
 the treatment of ill students, the health service should have the close 
 cooperation of the medical school, if a medical school is maintained 
 by the institution concerned. Here the medical school touches the 
 health service in a most vital spot. The curative medical branch of a 
 students' health service, while onl5^a part of its work, is, nevertheless, 
 an important and most costly one. The health service must give 
 its ill students and those in need of treatment the most scientific 
 advice and care; therefore the health service should have a close 
 relationship with the school of medicine, if such a school is main- 
 tained. Certainly the clinical staff of the medical school should be 
 available when expert or special treatment is needed. Likewise the 
 closest afliUation might well exist between the nursing activities of 
 the school and the service. Student nurses might well take a part 
 of their training with the health service. 
 
 Thus for many reasons are the services of the medical staff highly 
 desirable. The greatest value is in the excellence of the service, for 
 the highest grade will thus be available. Again, if the health service 
 is compelled to go elsewhere for its expert service, much of its income 
 would be expended for curative medicine, and consequently its other 
 far-reaching activities would have to be neglected or reduced. 
 
 It has been our experience that the clinical staff of the medical 
 school is willing to cooperate in every way with the health service. 
 The reasons for this willingness and interest are found in the desire 
 to be of the greatest service to the university as a whole, and in 
 that characteristic humanitarianism of the higher types of medical 
 men, manifested by their desire to do all they can in behalf of human 
 welfare. 
 
 In connection with this cooperation the question will come up, 
 *' Should treatment be confined to the dispensary and hospitals of 
 the school of medicine?" There are several serious objections to 
 this arrangement. 
 
 (a) The student does not want to mingle with the average dis- 
 pensary patient. He is not and does not wish to feel that he is a 
 charity patient. He has not the time to wait his turn in the almost 
 endless row of ambulatory patients. He has paid a health fee and 
 consequently feels entitled to service in a different environment from 
 that provided for charity patients. 
 
 (b) Students can not be placed in wards along with the usual type 
 of charity patients. 
 
 (c) When students are sent to the hospital of the medical school, 
 rumors are sometimes started that they are to be used for clinical 
 teaching. While such clinical teaching would in no way diminish the 
 efficacy of treatment, but rather enhance it, nevertheless, rumors of 
 this kind have been found to work materially against both the 
 initiation and the activities of a health service. 
 
28 HEALTH ACTIVITIES IN COLLEGES AND UNIVERSITIES. 
 
 {d) Again, students want all the privacy possible, and this should 
 be given them. They do not want the medical students to treat 
 them, because they are intimately associated with the medical 
 students in so many activities. 
 
 (e) To send students to the medical school's dispensary and 
 hospital would only diminish the teaching facilities, which are, after 
 all, the primary objects of the work carried on in these buildings. 
 
 For the best results the dispensary and hospital facilities of the 
 health service and medical school should be independent. When it 
 comes to exceptional treatment, however, which requires special 
 and costly apparatus for both diagnostic and therapeutic purposes, 
 duplication of such equipment should be avoided. 
 
 The medical school should be compensated for this work. Of the 
 various means of remuneration, the following plan should prove to be 
 mutually beneficial : 
 
 Let the health service establish and maintain three graduate fellow- 
 ships in the school of medicine — one in the department of medicine, 
 one in surgery, and one in the eye, ear, nose, and throat department. 
 These fellowships should be open to graduates of recognized medical 
 schools who have had general internships and are specializing in 
 these departments. The health service would need the services of 
 each fellow not to exceed two hours per day; while the rest of his 
 time could be devoted to his special department. 
 
 The advantage to the health service from such an arrangement 
 would be that the personnel and facilities of these departments would 
 be available for both special and expert treatment. In surgery, for 
 example, the health service could feel assured that any surgical cases 
 among students would receive the most scientific treatment, for the 
 head of the department of surgery, through his graduate fellow, 
 would be responsible for the surgical cases referred to him by the 
 university health service. 
 
 The advantage of such an arrangement to each department would 
 be that the department would have a graduate fellow concerned 
 primarily in research. This always adds to the rank and dignity of a 
 department and school, and, generally, clinical departments are in 
 need of such research workers. 
 
 3. Relation of the health service to the school of hygiene and 'public 
 health. — Where a school of hygiene and public health is maintained by 
 the university, cooperation should exist between it and the health 
 service. Practically the entire division of sanitation could be admin- 
 istered in connection with a school of hygiene and public health. 
 Campus sanitation, including buildings, etc., and off-campus sanita- 
 tion — sanitation in rooming and boarding houses — offer unlimited 
 opportunities for practical public-health teaching. In other words, 
 the division of sanitation may amply serve as a laboratory for 
 instruction in hygiene and sanitation. 
 
HEALTH ACTIVITIES IN COLLEGES AND UNIVERSITIES. 29 
 
 4. Relation of Tiealth service to other university activities. — ^In most 
 universities there are many established agencies concerned with the 
 welfare of the students. There is usually a dean of men and a dean 
 of women who are concerned with the moral and social welfare of 
 students. Then there are the housing bureau and the various organi- 
 zations, such as the Y. M. C. A., Y. W. C. A., etc. The activities of 
 the health service will-in many instances parallel and even duplicate 
 some of the activities of these other agencies. However, a students' 
 health service covers such a large field that there is room for all who 
 are interested in the work. T^Tien there is an apparent duplication 
 or overlapping of interests, cooperation should be arranged. 
 
 5. Relation to the medical profession. — ^Naturally there are many 
 students who, although they have paid the health fee, prefer, when 
 ill, the services of their family physician or a physician of their own 
 choice. The facilities of both the hospital and dispensary should be 
 open to reputable physicians. They should be made to feel that the 
 health service is anxious to cooperate with them in providing the 
 best treatment for the students. When the outside physician learns 
 of the excellent facilities offered by the health service for treatment, 
 he desires the closest cooperation with that service. 
 
 Physicians located in the same city as the university sometimes 
 criticise and offer objections to the establishment of a health service. 
 Especially is this true where the locality is small. On the face of it, 
 these physicians regard a health service as being solely concerned 
 with contract practice and as a consequence feel that they will be 
 deprived of some practice. 
 
 No genuine physician will object when the real purpose of a health 
 service is understood. Again, the fact of the matter is that his prac- 
 tice is not decreased but on the other hand increased. Probably not 
 more than 5 per cent of students ordinarily consult the medical pro- 
 fession. The physician is called as a rule only in case of serious 
 illness. The university health service will deal with 100 per cent of 
 the students and, as a consequence of its many activities, students 
 will be impressed with the importance of preventive measures for 
 maintaining positive health. Naturally, physicians will be consulted 
 more than ever. This statement has been vouched for by the medical 
 profession of at least one locality in which a university health service 
 was established. 
 
 Cooperation and not competition is the desired relationship of the 
 health service to the medical profession. 
 
 6. Sectarian contravention. — The opposition of Christian Science 
 and perhaps other denominations and sects — religious or otherwise — ■ 
 to the tenets and practices of modern scientific medicine must be 
 squarely met. If the health activities are confined solely to dis- 
 pensary and hospital curative treatment, naturally objections will be 
 
30 HEALTH ACTIVITIES IN COLLEGES AND UNIVERSITIES. 
 
 made by these cults to the requirement of health fees and the initiation 
 of health services. However, when the scope and activities of a 
 genuine students' health seivice are explained to objectors of this 
 class, little opposition is encountered. Assuredly no one can object 
 when it is understood that treatment of ill students is only an incident 
 in the activities of a true health service and that the university is 
 primarily concerned with positive health. ' By providing for the 
 physical welfare and proper development of the students, by protect- 
 ing them from the numerous communicable diseases that annually 
 creep into the university, by stimulating them to aspire and labor for 
 healthy, active, and harmoniously developed bodies, all students in 
 the university are served. Treatment of ill or subnormal students in 
 general, and special isolation and treatment of communicable diseases,^ 
 become necessary in order that the vigorous may be protected and 
 the academic efficiency of the university increased, 
 
 7. Required Jiealihfee. — An obligatory health fee is as essential for the 
 maintenance of genuine health service as are taxes for the suppoit of 
 municipal or State health activities. These activities can not exist on 
 voluntary contributions. Under no circumstances should excep- 
 tions be made to the payment of this fee. To make exceptions will 
 undermine the entiie fabric of health conservation and the health 
 service will collapse. Some ground for exception might be held were 
 the university engaged solely in contract practice. When objectors 
 are made aware of the tiue functions of a genuine students' health 
 service, their objections are usually overcome. 
 
 The writer feels that it is the best policy not to overemphasize the 
 term "health fee. " It is preferable to include it with the other essen- 
 tial fees required of students under the term "general fees," then 
 make the proper apportionment. Not that it is best to be in any way 
 clandestine, but, rather, it is best not to emphasize this particular fee 
 which is so essential to the weltare of a university and its students, and 
 which is so much misinterpreted and misunderstood. Similar objec- 
 tions might be raised by many to other required fees, were the fees 
 particulaily pointed out and overemphasized. 
 
 8. Extent of iridividual service. — Just how much service should be 
 given an individual student is a problem difficult to solve. In reading 
 the rules and regulations of health services in different institutions one 
 observes many variations. Some institutions stipulate two weeks of 
 hospital care as the maximum free service. Others require students 
 to pay extra for outside calls. Of course the amount of the health fee 
 required and the availableness of special and expert medical attention 
 are important factors in determining this question. 
 
 In initiating a health service it is not wise to define the limits of 
 individual service. Few chronic cases are to be found among stu- 
 dents and it is rather a rare exception for a student to remain in the 
 
HEALTH ACTIVITIES IN COLLEGES AND UNIVERSITIES. 31 
 
 hospital for more than two weeks. It is well when possible, in my 
 opinion, to proceed on the theory that every service needed by an 
 individual student will be rendered. Where close affiliation exists 
 with a medical school, this service can be readily given. 
 
 The stipulation then of a maximum of individual service must be 
 determined by experience, and it is a problem that must be solved 
 locally. I feel, however, that it is only just to require the payment 
 of hospital fees. A student must pay for his board and laundry out- 
 side of the hospital; so why should he not pay for them when he is in 
 it? Individual exceptions may be made wheie a student is entirely 
 dependent upon his own resources. It is only equitable, as I view 
 it, that the hospital receive this remuneration while the student is 
 "boarding" with the hospital. A hospital fee of $1 a day for occu- 
 pants would certainly be both moderate and just. In the course of a 
 year the items of food, laundry, etc., for hospital patients, become 
 very important ones, and they should be met as nearly as possible 
 by hospital fees. It is only just to that large number of students who 
 never enter the hospital; for the amount saved by charging such a hos- 
 pital fee can be utilized for health activities which concern the sound 
 student as well. 
 
 9. Relation of health service to general academic efficiency. — The 
 health service is of incalculable value in contributing to the general 
 academic efficiency in the university. For example, a vast majority 
 of the daily absences are repoited as due to illness. Sickness is a 
 relative term, and is the most available excuse for our delinquencies. 
 Suppose a system of reporting of absences is devised by which the 
 health service sends one of its representatives to the sick absentee. 
 This would not only aid in prompt attention to all ill students and in 
 the early detection of communicable diseases, but if such an arrange- 
 ment existed, the "sick" absent list would be materially decreased. 
 
 SUMMARY. 
 
 1. Aims. — The university health service endeavors to be a most 
 potent factor in reducing to the very minimum that large annual 
 academic and economic loss which is due to the indisposition and 
 illness of students. Further, its aim is to help each student entering 
 the university to possess a healthy, vigorous, active, and harmoni- 
 ously developed body. The university health service stands for 
 Positive Health. 
 
 2. Activities. — There are three main divisions to its activities: 
 (a) Personal attention, (b) Sanitation, and (c) Education. 
 
 (a) The Personal Division is concerned with the physical examina- 
 tion of all students. Complete physical records should be kept. 
 From each record can be determined, in a large measure, just what 
 procedure is necessary to keep the student in the best physical con- 
 
32 HEALTH ACTIVITIES IN COLLEGES AND UNIVERSITIES. 
 
 djtion during his academic life. The following are some of the 
 branches of the work in the personal division: 
 
 (i) Provisions for maintaining the health of the normal, 
 healthy student by means of proper exercises, etc.; 
 
 (ii) Protection of the physically sound student from communi- 
 cable diseases that are constantly creeping into the university, 
 by the early detection and isolation of all cases of communi- 
 cable disease — tuberculosis, typhoid fever, smallpox, scarlet fever, 
 mumps, measles, etc.; 
 
 (iii) Provisions for the care and treatment of all such cases of 
 communicable diseases ; 
 
 (iv) Reconstruction — Reclamation: Correction of defects, ad- 
 vice and treatment to all subnormals; • 
 
 (v) Advice to and treatment of all ill students. 
 (t>) Division of Sanitation: The students' environment must be 
 made as hygienic as possible; hence this division concerns itself with 
 the sanitary conditions affecting the student both on and off the 
 campus. 
 
 (c) Education: Finally, every student in the university must be 
 made familiar with the elements of personal and public hygiene. 
 Education in these important matters is carried on by means of 
 .^ courses in these subjects, daily bulletins, exhibits, and lectures. 
 
 ADDITIONAL COPIES 
 
 OF THIS PUBLICATION MAY BE PROCURED FEOM 
 
 THE SUPEEINTENDENT OF DOCUMENTS 
 
 GOVERNMENT PRINTING OFFICE 
 
 "WASHINGTON, D. C. 
 
 AT 
 
 5 CENTS PER COPY 
 

 
 ^■^ 
 
 ^ sip-.- -:;■:■- ■'■i':'v -,,..■:,:,. 
 
 sk;«s. 
 
 
 feu*^--:?ya 
 
 
 
 
 ri>T; ; 
 
 >• J- % /"Viif . ^-^ ^ - ^