COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX00061654 RECAP Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/healthessentialsOOjoin Health Essentials for Rural School Children Proposed by The Joint Committee on Health Problems in Education of the National Council of the National Education Association and of the Council on Health and Public Instruction of the American Medical Association Prepared by DR. THOMAS D. WOOD Chairman of the Committee on Health Problems of the National Council of Education 525 W. 120th Street, New York City The Joint Committee on Health Problems in Education of the National Council of the National Education Association and of the American Medical Association Committee of the National Council of the National Education Association on Health Problems in Education Thomas D. Wood, Chairman, Columbia University, 525 West 120th Street, New York City. William H. Burnham, Clark University, Worcester, Mass. P. P. Claxton, U. S. Commissioner of Education, Washington, D, C. F. B. Dresslar, Peabody College, Nashville, Tenn, Clark W. Hetherington, University of Wisconsin, Madison, Wis. David Starr Jordan, Leland Stanford Jr. University, Palo Alto, Cal. John F. Keating, Superintendent Public Schools, Pueblo, Colo. Charles H. Keyes, Skidmore School of Arts, Saratoga Springs, N. Y. Jacob A. Shawan, Superintendent of Schools, Columbus, Ohio Albert E. Winship, New England Journal of Education, Boston, Mass. Committee of the American Medical Association on Health Problems in Education R. W. CoRWiN, Chairman, Minnequa Hospital, Pueblo, Colo. John M. Dodson, . Rush Medical College, Chicago, 111. M. J. ROSENAU, Harvard University, Boston, Mass. Press of American Medical Association Five Hundred and Thirty-Five North Dearborn Street CHICAGO Introduction The first pamphlet report of this joint Committee is entitled "Minimum Health Requirements for Rural Schools." Seven hundred and fifty thousand copies of that eight page report have been printed, through the generosity of the Elizabeth McCormick Memorial Fund of Chicago, and most of these have been distributed throughout the country by the United States Bureau of Education. A moderate number of copies of that report are still available, and these may be obtained from the United States Bureau of Educa- tion in Washington or from the Chairman of the Committee. The first report deals mostly with the health prob- lems of the rural school — the sanitary surroundings of the school child in the country. Minimum sanitary requirements for rural schools are proposed in that report for the purpose of helping to establish a stand- ard of fundamental health essentials in the rural school and its material equipment, so that attainment of this minimum standard may be demanded by public opinion and by educational authorities of every school in the country. Conformity to the minimum sanitary requirements should be absolutely necessary to the pride and self respect of the community ; and to the sanction and approval of county, state, and other supervising and interested official or social agencies. Neglect of anything essential for health, in construc- tion, equipment and care of the rural school plant is at least an educational sin of omission and may rea- sonably be considered a social and civic crime or misdemeanor. The country school should be as sanitary and whole- some in all essential particulars as the best home in the community. Further, it should be pleasing and attractive in appearance, in furnishings and in sur- roundings, so that the community as a whole may be proud of it ; so that the pupils and teacher may take pleasure in attending school and in caring for and improving it. PLAN OF THIS REPORT The purpose of this second pamphlet is: (a) To state the heakh conditions of rural school- children at the present time. (b) To propose and recommend the practical mea- sures which seem necessar}' and possible for the health care of children in country schools. (c) To report praiseworthy efforts which are now being made in a few instances to provide for health care of rural school children, and which may result in giving to rural school children at least as much health care as is provided for children in the cities. Essentials for Health of Rural School Children PRESENT CONDITIONS More than half (about 12,000,000, or three-fifths) of the school children in the United States are attend- ing rural schools. Country children attending rural schools are, on the average, less healthy and are handi- capped by more physical defects than the children of the cities, including all the children of the slums. And this is true, in general, of all parts of the United States. Table I (page 4) is made up from the official sta- tistics of school children gathered from many parts of the country. These statistics lack uniformity; they contain, doubtless, many errors ; but there are probably as many errors in the statistics of the city school children as in those of children in the rural schools. The claim that the health of the people in the coun- try is not so good as the health of those living in cities finds further proof by comparison of the death rate of rural New York and of New York City. Table II (page 5) illustrates this important fact. For the last five years the death rate in rural New York has been higher than the death rate in New York City, the largest city in the world. It is apparent that within the last ten or twenty years the standards of life in cities, in relation to health at least, have risen above those of rural communities. It is just as true, however, and of the greatest sig- nificance, that most of our best human material for leadership in city and country must still come from the farms. For the most part, the raw material to supply the needs of civilization, including the best human sup- ply, must continue to come from the soil. This is in accordance with a great, universal law of life. If rural America is to continue to be a satisfactory nursery of human life for the nation, it must be made healthful and attractive; it must provide conditions favorable for the cultivation of the best. The improvement of human health and welfare in rural America is a problem of the greatest significance in relation to our national welfare. It is a problem affect- ing national safety, national prosperity, national per- petuity. It is a problem dealing with the most essential and most endangered of all of our national resources. No factor is of greater fundamental importance for securing national preparedness either for peace or for possible war. PER CENT 5 20 2.5 30 3S ♦0 4J5 50 I4a8 ^^^^^^^^^%%^^%=$^%^ :^?t.-^ TEETH DEFECTS WMZQM IZ.b 13.4 23.4 TONSILS ADEN0ED5 EYE DEFECTS MALIVUTRITIOM. LgA ENIiARGED Z.7 GLANDS EAR DEFECTS 4 2 BREATHING 2 J DEFECTS 3 5 5PINALI CURVATURE City and Country Children Compared Percentages from All Av^ila"ble Statistics. * 1.65 15 ANEMIA Country ■■■§ 17 17 UNCLEAN city ^//^^^//,\ 1.25 .32 LUNG DEFECTS • .74 .40 HEART DiaEASE .8 .2 .^MENTAL PEFECTS TABLE I Health defects of school children. The most vital phase of this problem of rural health relates to the health and welfare of the children. ~j Country children deserve at least as much health and ' happiness as city children. * This table is based on the reports of over a half million children. Country children are entitled to as careful cultiva- tion as crops and live stock. It is recognized more clearly every day that the pub- lic school is the strategic agency to provide for the children of each community not only the best possible methods of general education but also the best available standards for care of health. In our cities, parents of all grades of prosperity appreciate increasingly the advice and guidance of the schools regarding better care of the children's health. It is evident that the same methods will not apply in country and city, but the fundamental needs of chil- dren in country and city are much the same. With 1900)90/ /902 /905 I904- 1905 1906 1907 1908 I909 1910 1911 9/2 /9/3 1914 ,?( ?n POI iQ ■ * j9.a 1! It \ IP 18.5 II 1/ 1/ \ /_S_3 /sa. I8.Z 17 " 179 I'' /6 /6.2 /'^.9 /T.9 /5 iss- v' y 15.2 /5J y ^ IS.Z ^ I5J__ 155 /-f \ / 14-.$ *♦. ,/^5 /4 /^ 13.9 ^^ ■*.7 TABLE II. Comparative death rates, urban and rural. = = = = New York City. ' — New York State, outside of New York City. reference to the common problems of life and educa- tion the schools of city and country may learn many important lessons from one another. Provisions in schools for health supervision and care of children are still comparatively new both in city and country. About four hundred cities in the United States now have health work of the schools developed to some degree of usefulness and efficiency. The health work in rural schools is still very new, and just enough has been done in a few states and in comparatively few rural schools to demonstrate how important and how practical are these forms of health work. THE CONTROL OF COMMUNICABLE DISEASE DAILY HEALTH INSPECTION Thoughtful care and sympathetic cooperation of J home and school are needed to keep the school from distributing communicable diseases throughout the community. If there is fairly intelligent cooperation of parents, teachers and health officers in school and community, there need be no epidemics in schools. Conscience as well as intelligence on the part of all concerned is requisite for the suppression of con- tagious diseases. No child should ever knowingly be exposed to con- tagious disease. The older the child is before being exposed by accident to contagious disease the less apt he is to catch it. The older a child is before having a contagious disease of childhood, the less severe, on the average, is it likely to be. The early detection of signs of children's diseases and the early exclusion from school of children showing such signs, are the best means of minimizing the communication of disease in schools and of removing the possibility that the school may act as a disease center. INDICATIONS OF HEALTH DISORDERS IN CHILDREN FOR WHICH PARENTS SHOULD KEEP CHILDREN AT HOME AND NOTIFY THE SCHOOL Nausea or vomiting. Chill, convulsions (fits). Dizziness, faintness or unusual pallor (alarming paleness of the face). Eruption (rash) of any kind. Fever. . Running nose. Red or running eyes. Sore or inflamed throat. Acutely swollen glands. Cough. Failure to eat the usual breakfast. Any distinct or disturbing change from usual appear- ance or conduct of child. The foregoing signs should be used also by teachers as a basis for excluding pupils from school for the day, or until signs have disappeared, or until the proper health officer has authorized the return of the pupil to school. Children may be taught — without developing disturbing fears, or attempts to deceive — to notice the above-mentioned signs in themselves or in their com- panions, and thus may help to protect the school from contagious disease. The detection of these first signs of health distur- bance at home, by the parent or the child, before start- ing for school, is of especial importance in the country where the longer trip to school with greater physical exertion, sometimes in bad weather, would be particu- larly injurious to a child at the beginning of an illness. In cases of contagious disease among schoolchildren, the length of time of exclusion from school must be determined by the medical or school authorities. HEALTH EXAMINATIONS TO DETERMINE GENERAL PHYSICAL FITNESS OF THE CHILD AND TO DISCOVER PHYSICAL DEFECTS Every school child should have a health examination once a year. More frequent examinations should be provided for individual pupils who need special atten- tion. All health examinations and attention in rural and in city schools should be under the supervision of regularly appointed school physicians thoroughly trained for their work. Every state should have a state health inspector of schools who should give spe- cial attention to the health work of the rural schools. The routine tests of vision and hearing can best be made by the teachers, as these tests involve to an unusual extent mental and educational as well as health factors, and require the knowledge of pupils, possessed by the teacher, as well as simple methods of examination which all capable teachers can easily learn. The general health examinations in the rural schools can often be done most advantageously by the school nurse with the help of the teacher. There should be for every child a health as well as a scholarship record which accompanies him through his public school career. This should be a part of the recordof the school which the child is attending. The following form or blank has been tested sufficiently in rural as well as city schools to prove its practical value. 8 HEALTH RECORD Name Eorn in on (date) Nationality of Father. . . . Mother. . . . Xo. in family, Adults. . Children. . Number of birth. . . History of Measles. . . Scarlet fever. . . Diphtheria.. Whooping cough Pneumonia Grippe Date of first examination in school 1 yr. 2 yr. 3 yr. 4 j-r. 5 yr. 6 yr. 7 yr. 8 yr. 1. Age and vear 2. Grade . . .' 3. Class 4. Revaccinations 5. Diseases during year... . 6. Date of examinations. . . 7. Height 8. \yeight 9. Nutrition IJ. Anemia 11. Enlarged glands 12. Nervous diseases 13. Cardiac diseases 14. Pulmonary diseases .... 15. Skin diseases 16. Orthopedic defect 17. Defect of vision 18. Defect of hearing 19. Defect of nasal breathing 20. Defect of palate 21. Defect of teeth 22. Hernia 23. Hypertrophied tonsils... 24. Adenoids 25. Mentality 26. Conduct 27. EfIort_ 28. Proficiency 29. Treatment necessary.... FINDING AND REPORTING PHYSICAL DEFECTS DIRECTIONS TO TEACHERS TEST OF EYESIGHT The eyes of children who wear glasses should be tested with the glasses, and if found normal should be so recorded. Hang the Snellen^ test letters in a good clear light (side light preferred) on a level with the head, and so placed that the child does not face a strong light. Place the child 20 feet from the letters. Cover one eye with a card held firmly against the nose, without press- ing on the covered eye, and have him read aloud, from left to right, the smallest letters he can see on the card. Make a record of the result. Children who have not learned their letters, obvi- ously, cannot be given this eyesight test until after they have learned them. Pupils who cannot read may, 1. Snellen test charts may be obtained from the State Education Department, or from educational supplj' houses. however, be tested by charts with pictures of familiar objects designed for this purpose. TO RECORD THE ACUTENESS OF VISION There is a number over each line of the test letters which shows the distance in feet at which these letters should be read by a normal eye. From top to bottom, the lines on the card are numbered respectively 50, 40, 30 and 20. At a distance of 20 feet, the average nor- mal eye should read the letters on the 20-foot line, and if this is done correctly, or with a mistake of one or two letters, the vision may be noted as ^%o or normal. In this fraction the numerator is the distance in feet at which the letters are read, and the denominator is the number over the smallest line of letters read. If the smallest letters which can be read are on the 30-foot line, the vision will be noted as ^%q ; if the letters on the 40-foot line are the smallest that can be read, the record will be ^%o. If the letters on the 50-foot line are the smallest that can be read, the record will be 20/50. If the child cannot see the largest letters (those on the 50-foot line), have him approach slowly until the distance is found from which they can be seen. If 5 is the nearest distance from which the 50-foot letters can be read, the record will be %o (Mo o^ normal). Test the second eye, the first being covered with the card, and note the result as before. With the second eye, have the child read the letters from right to left, to avoid memorizing. To prevent reading from mem- ory, a hole li/o inches square may be cut in a piece of cardboard, which may be held against the test letters so as to show only one letter at a time, and which may be moved about so as to show the letters in irregular order. A mistake of two letters on the 20 or 30-foot line and of one letter on the 40 or 50-foot line may be allowed. Parents should be notified if : (a) Vision in either eye is ^%q or less. (b) Child habitually holds head too near book (less than 12 inches). (c) Child frequently complains of headache, espe- cially in the latter portion of school hours. (d) Either eye deviates even temporarily from normal position. 10 TEST OF HEARING If it is possible, one person should make the exam- ination for an entire school in order to insure an even method. The person selected should be one possessed of normal hearing. The examination should be made with the whispered voice; the child should repeat what he hears, and the distance at which words can be heard distinctly should be noted. The two ears should be tested separately. The test should consist of numbers, 1 to 100, and short sentences. To avoid imitation, it is best that but one pupil at a time be allowed in the room. For very young children a fair idea of the hearing may be obtained by picking out the backward or inattentive pupils and those that seem to watch the teacher's lips, placing them with their backs to the examiner and asking them to perform some unusual movement of the hand or other acts. REPORTING DEFECTS Physical defects should be reported to the homes, and all possible efiforts should be made by teachers, superintendents, school nurses and school doctors to persuade the parents to obtain for the child the care necessary for correction of all defects that it is possible to remedy. Our schools are spending millions in educating, or trying to educate, the children who are kept back by ill health, when the expenditure of thousands in a judi- cious health program would produce an extraordinary saving in economy and efificiency. A dollar spent in a wise, constructive effort to conserve a child's health and general welfare will be more fruitful for the child and for the general good than a thousand times that sum delayed for twenty years. The principle of thrift in education finds its first and most vital application in the conservation and improvement of the health of the children. PHYSICAL DEFECTS Possible injurious effects of the more important physical defects of children may be classified as follows : 11 I. Defective eyes with imperfect vision. (a) Headache, commonly through forehead or back of head or both. (b) Blurring of sight; but in farsightedness with eye strain, vision may be exceptionally good, especially for distant objects. (c) Nausea and dizziness ; sometimes disturbance of digestion, with resulting malnutrition. (d) Nervous exhaustion. (e) Nervous irritation and lack of nervous control, shown in muscular twitching of face, arms and legs. (f) Mental inability to grasp an idea presented through the eyes. (g) Retardation in school. (h) In rare cases, convulsions. Some medical authorities have attributed epileptic and epileptiform seizures to abnormal eyes. II. Defective ears. (a) Catarrh of middle ear — danger of mastoid dis- ease. (b) Deficient hearing — pupil often dull, careless, listless, inattentive, and mentally backward. (c) Retardation in school. (d) Pupils are often considered mentally defective when the only primary defect is imperfect hearing. III. Adenoids. (a) Structural effects : 1. High-arched palate. 2. Narrowing of upper jaw. 3. Deformity of chest, resulting from ob- structed and imperfect breathing, shown by lateral depression of front of chest and prominent sternum (breast bone). 4. Disturbed development of teeth and vocal organs. 5. Large tonsils in one third of cases. 12 (b) Functional disturbances : 1. Mental. a. Disturbance in function of brain re- sulting in aprosechia nasalis, that is, difficulty in forming an idea of any- thing new ; stupidity ; difficulty in retaining ideas ; weakness of mem- ory ; inability to turn thought on a definite subject ; lack of power of attention. b. Irritability, depression and often dis- orderly conduct. 2. Deafness. 3. Defects in sense of smell and taste. 4. Defects in voice (nasal voice). 5. Chronic rhino-pharyngeal catarrh, shown by a persistent nasal discharge. This is often one of the first symptoms. In very young children it is manifested by snuffles. 6. Obstruction of air passages resulting in breathing disturbances, manifested by open mouth and great restlessness at night, the child being forced to assume various attitudes, such as sleeping on face, in order to breathe better. 7. Reflex. a. Catarrhal spasm of larynx, or croup. b. Headache. c. Intractable cough and hoarseness. d. Bronchial asthma. e. Enuresis (incontinence of urine). (c) General effects : 1. Malnutrition and anemia. 2. Underdevelopment, physical and mental. 3. Predisposition to otitis media (middle-ear disease), laryngitis, colds of a remit- tent nature ; increased susceptibility to disease infections, such as tuberculosis, diphtheria, scarlet fever, etc. 13 (d) Description of appearance of a child with marked adenoid enlargement — mouth open ; dull, sleepy, with inquiring look ; upper lip short and thick ; upper jaw narrow ; nasal orifices small and pinched, the face full under the eyes ; listless and indisposed to physical or mental exertion ; stupid and backward ; in school, from one to two years behind the nor- mal pupil of same age ; undersi-zed. IV. Enlarged and diseased tonsils. Enlarged or diseased tonsils produce many of the unfavorable results attributed to adenoids. The two conditions are often associated and it is difficult to dis- tinguish between their effects. Enlarged and dis- eased tonsils mcrease susceptibility to (a) Tonsillitis. (b) Quinsy. (c) Diphtheria. (d) Rheumatism. (e) Tuberculosis. (f) Pneumonia, and other forms of infection. The presence of enlarged tonsils and adenoids in school children should be known and when any distur- bances of health can be attributed to them by a com- petent physician, these structures should be removed. Their absence in such a case is an unqualified advan- tage. V. Defective teeth. "If I were asl«Kd to say whether more physical deterioration was produced by alcohol or by defec- tive teeth, I should unhesitatingly say, defective teeth. In some schools as many as 98 per cent, of pupils have defective teeth. From 50 to 75 per cent, of all school- children in this^country need at this moment dental care." ^ (a) Direct efifects : 1. Pain of excruciating type resulting in great loss of time and rest. 2. Foul breath with unsightly and inflamed mouth. 2. Osier: Lancet. London. Oct. 21. 1902. \ 14 3. Improper mastication of food. 4. Extension or decay in sound teeth. 5. Decay of temporary teeth resulting in unsound and carious permanent teeth. 6. Infection of glands. 7. Infection of maxillary (jaw) bone. 8. Earache with otitis-media (middle-ear disease) and deafness. 9. Headache. 11. Disturbance in function of eye. 11. Frequent digestive disturbance. (b) Indirect effects : 1. Condition of poor nutrition and less resis- tance to disease. 2. Formation by carious teeth of an almost perfect culture bed for growth of patho- genic bacteria. This condition with lowered resistance leads to increased frequency of infection with pneumonia, diphtheria, etc. 3. General infections dangerous to life in some cases. 4. Results which accompany defective hear- ing. 5. Lowering of vitality and temporary or permanent ill health. VI. The condition of the skin is an important indica- tion of the general tone and health condition of the body. Persistent eruptions should be noted and treated. VII. Abnormal condition of the heart, even if tempo- rary, may disturb health, and if neglected may result in permanent weakness of the heart itself or of the body in general. The condition of the heart is always an important index of the health condition, and is often a valuable guide in adjusting the amount of sleep, arrangement of school program, and selection of muscular exercise which is most suitable for the pupil. 15 VIII. The lungs are important as a frequent location of tuberculosis. Lung tuberculosis is more frequent among schoolchildren than has commonly been sup- posed. In pupils who are underweight, anemic, lacking in vitality, even if not coughing, the lungs should be carefully watched. IX. Deviations of spine, roundness of shoulders and stooping postures are common among boys and girls, especially between the ages of 11 and 16. Many children outgrow these conditions without special attention, but these asymmetries should be inspected from time to time to prevent, as far as possible, the more chronic defects in posture, and the occa- sional cases of genuine scoliosis (curvature of the spine) which begin so insidiously. X. Abdominal hernia (rupture) involves serious and often dangerous weakness of the abdominal walls. It is important for the welfare of children, in the occasional cases which exist, that the condition should be detected and given appropriate treatment. CORRECTION OF DEFECTS The problem of securing satisfactory means for the removal of physical defects in rural school children is especially difficult, as hospitals, clinics, nurses, den- tists and surgeons are usually so far distant. The county unit of organization for health,^ as well as other rural interests, has already proved successful and promises the best results. Every county should have one full-time health offi- cer; one or more school or district nurses, and at least one community health center, to provide satis- factory, self-supporting health (including dental, medical, and surgical) service for all the people, including the school children. The fullest possible use should be made of all available means and agencies for providing the health attention needed by the chil- dren. In several cities, clinics for examining eyes and fitting glasses, and dental clinics have been installed and operated successfully in school buildings. The only dental clinic in the United States planned defi- nitely for rural school children is located in a high school building in St. Augustine, St. Johns County, 3. Mason County, Kentucky, has a very efficient county health organ- ization of which the county superintendent of schools is president. 16 Florida. In Alaska, one-room schools are sometimes used for medical and surgical clinics, not only for children but also for adults. CARE OF THE TEETH The examination, dental treatment and daily care of the teeth are matters of the greatest importance for rural as well as city school children. All decayed teeth, whether temporary or permanent, should be filled or otherwise definitely treated. Malocclusion (ineffective meeting) of the teeth should be remedied and can be corrected in early childhood. It has been recently demonstrated that (in addition to daily brushing), the (prophylactic) cleaning of the teeth of children every three to six months by the den- tist or by a properly trained dental hygienist will prevent most of the decay of teeth which takes place. It may be predicted with entire confidence that in the near future adequate dental care will be insured to all school children in the country as well as in the cities. No item in all the wonderful measures for the health care of the soldiers in the trenches of Europe is more significant than the treatment of the teeth provided by the automobile dentist offices used in France and other countries. Shall not our children in the country schools — future citizens and, if necessity requires, defenders of our own republic — receive as good dental care as soldiers in war? The establishment of effective habits of daily brush- ing and cleansing of the teeth is one of the most essen- tial features in health teaching in the schools. Every child should have his own tooth-brush which is kept in a clean place and is used immediately after eating at least once, or better, twice a day. For cleaning the teeth, a good tooth brush with bristles that do not easily break or pull out, should be used. The teeth should be brushed, not only up and down and across, but also by a rotary or cir- cular motion from the gums of one jaw over the teeth to the gums of the other, and so round and round. In addition to the tooth brush, dental floss (waxed silk thread) should be used every day or two to remove the decaying food from between the teeth, where decay most often takes place. The best mouth wash 17 is tin::e water,^ which may be used beneficially once a day to rinse the mouth. THE SCHOOL NURSE The school nurse has already demonstrated the extraordinary value of her services in the health work of the schools. Statistics prove that in one prominent phase of her work the school nurse bridges the gap between failure and success, or at least between inefficiency and efficiency in a vital part of the health program. Without the service of the nurse, only from 15 to 25 per cent, of the pupils have physical defects corrected, following the notice and recommendation sent by the school doctors to the parents. On the other hand, with the aid of the school nurse, from 75 to 90 per cent, of the pupils reported, receive remedial attention. In the cities of the United States there are about 750 nurses giving most or all of their time to the work of the schools. On the other hand, there are today only about fifteen to twenty nurses in rural dis- tricts employed primarily for health work in the schools. The service of the school nurse is, however, even more important in rural communities because of the greater lack, or greater distance, in the country of physicians, hospitals, clinics, and social agencies which are so helpful in advancing health work for the children. The duties of the rural school nurse include promi- nently the following: (a) Assisting in the health examinations of pupils. (b) Explaining to the parents the importance of defects found in children and helping in the arrangements for the medical, surgical or dental treatment required. (c) Giving emergency treatment in health distur- bances and following up treatment, under medical direction, for various conditions. (d) Providing an important part of the health teaching for the pupils and giving in homes visited, suggestions and advice afifecting not only the hea'lth interests of the children, but of the home. 4. To make^ lime water, place one half cup full of finely powdered unslaked lime in a onart bottle. Allow to stand twenty-four hours and pour off the clear liquid into bottle to use for mouth wash. This powder may be used for successive solutions until entirely dissolved. 18 In many a community, not only in city but in coun- try, the tactful, devoted nurse has made for herself a place of the greatest influence in promoting health and human welfare in general. Ever}' community should have the service of a nurse whose first, if not sole, duty is to care for the health of the school children. WARM LUNCHES IN SCHOOLS Every growing child needs a warm, nourishing mid- day lunch. One-quarter, at least, of all school children are insufficiently nourished. Rural school children suffer in as large a percentage of instances from defec- tive nutrition as do the school children in the cities. The practice of providing warm school lunches in city schools is increasing very rapidly and has been so successful that this idea is extending throughout the countr}', and during the present year a great many rural schools in several states have adopted the plan of warm lunches for pupils. A school lunch service should be a part of every rural school. It should be fostered, at least, if not entirely created, owned and managed by the school authorities. It can be most successfully managed cooperatively by Ta) The school authority (district or county). (b) The teacher. (c) Pupils. (d) Parents of the children. Every school building should have a simple kitchen equipment in a small room built for this purpose, or in the school room. A simple equipment, not including the stove, can be purchased for from S4 to SIO. Parents can club together and furnish either a fixed sum of money or supply of food materials. The teacher, with the aid of pupils working in groups periodically, can prepare the lunches. This is now done in man}' of the schools having lunch service. The preparation of the school lunch makes the best possible demonstration for a lesson in domestic science and cooker}'. The children with the warm lunch are better nourished and do their school work, especially in the afternoon, with better results. The instruction in selection and preparation of foods in many cases extends through the pupils to the homes, and this is. 19 in the country particularly, the most effective way of influencing beneficially the standards and methods of the homes. SANITARY AND ATTRACTIVE RURAL SCHOOLS The health of children is affected vitally by their surroundings. The buildings, which house under compulsion three- fifths of the nation's children of school age for eight hundred hours each year, should be beyond all possi- bility of failure, free from unhealthful and unfav- orable features. The rural school is relatively the worst type of building in the country. It should be, in essential fit- ness for its purposes, the very best. EFFICIENT TEACHERS FOR HEALTH WORK The teacher in the rural school has inevitably a larger opportunity and responsibility for all educa- tional functions than does the city teacher. This is especially true in matters relating to the health and welfare of the pupils. She is further .away from the help and services of superintendent, physician, nurse and all health and other social agencies. The wisest conduct and adjustment in ordinary or emergency cir- cumstances requires exceptional understanding and sound judgment, and the rural teacher should, there- fore, be unusually efficient. HEALTH TEACHING Effective health training in the rural schools should aim decisively at the following results : (a) The establishment of health habits and incul- cation of lasting standards of wise and effi- cient living in pupils. (b) The extension of health conduct and care to the school, to the homes, and to the entire community. For this practical and important school task the teacher must have a clear understanding and confident command of the application of facts and principles in the field of health. If this instruction is to be more than occasionally successful — dependent on the individual teacher, who happens to be particularly interested and fortunately situated — there must be helpful and wise supervision in all of the work by a 20 district or county supervisor well qualified to guide the health teaching with the rest of the health program. This supervisor may be the health officer, the regular school supervisor (if trained for this work) or a wise and efficient school nurse. There should be also a state supervisor whose duties should include the sys- tematic direction of the health teaching in the rural schools. All health instruction should lead promptly to the practical training of the pupils in personal health habits and in individual and group efforts for the health work of the school, the home, the community, the state, the nation and the world as a whole. The modern idea of pupil organization and government may be used to good advantage, in pupils' boards of health, health militias and other forms of pupils' organizations. The Boy Scout idea,* which gives such prominence to the health program, may be utilized to as good advantage in rural as in city schools and is being so employed in a number of rural districts. pupils' health organizations In a number of states where "Clean-Up" and "School Improvement" days have been observed, the pupils in many rural school districts have been organized into sanitary squads for the purpose of maintaining improved conditions. The nurses in Kent County, Michigan, and in Grand Forks and La Moure Counties, North Dakota, have '' organized health leagues among the rural school- children for the purpose of maintaining sanitary con- ditions in the schools and for the cultivation of per- sonal health habits. Similar efforts are reported from practically all the other states having county nurses. WHOLESOME PLAY AND RECREATION Rural children have all outdoors to play in and yet, on the whole, they know very little about how and what to play. Many rural schools have not enough space for an adequate playground, which is not a luxury but a necessity for the welfare of the children. A school without a playground is an educational deformity, and presents a gross injustice to childhood, * The Eoy Scout organization is for boys of from 12 to 16 years old. The Eoy Pioneers of A.merica is for boys of from 8 to 12 years of age. 21 Facilities and skilled guidance for play and recrea- tion should be provided at the rural school not only for the pupils in the school, but for the young people in the community. Such provision should include not only athletic games and, sports, school and folk dances, but also dramatic training and expression. Noteworthy pioneer effort in this field is being made very successfully by Mr. A. G. Arvold, founder of the Little Country Theater, in Fargo, N. D. Mr. Arvold attempts to solve through organized dramatics the problem of the desertion of the country for the city l3y young people seeking social diversion.* The national welfare demands that rural life should be made successfully attractive to the best people. This necessitates generous provision for the social, esthetic, emotional and artistic requirements of young people as well as for their intellectual, economic and health needs. COOPERATION IN HEALTH WORK OF THE SCHOOLS If the health program in the rural schools is to be successful, it must enlist the cooperation not only of all individuals logically concerned in this vital aspect of education, but also of all organizations" that may be naturally, or by persuasion, interested in the welfare of the children. The granges, medical societies, w^omen's clubs, and church or other organizations may find abundant work to do if the complete program of health is attempted with any thoroughness. Several phases of the health program may require, in any rural community, the support of, or demonstration by, some volunteer organization before school boards or other governmental agencies are convinced of the necessity and practicability of the new measures. Every com- munity in country as well as in city vitally needs the help of some volunteer organization of unselfish people whose dominant interest is the health and welfare of the children. _*_The Children's Theater, manufactured by the Martin Studios, Willimantic, Mass., is an interesting development in dramatic art. 22 HEALTH WORK IN Activity Medical inspection laws in 23 states. Mandatory laws. Permissive laws. Medical inspection practiced. Dental inspection by dentists. Dental clinics. CITY AND RURAL SCHOOLS OF THE UNITED STATES For City Children For Country Children Mandatory for cities only, in 12 states. Apply to all cities. Enforced in most cities. In over 400 cities. In 69 cities. In SO cities. Clinics for eye, nose, In cities only. throat and other defects. Nurses. Open air classes. 750 in 135 cities. In cities only. Mandatory for rural schools in 7 states. In 7 states. In 6 of the 13 states having such laws. In 13 states, in parts of 130 counties. Permitted in 2 states, but not yet pro- vided. In one rural county, (St. John's County, Florida). None. 12 in 20 rural dis- tricts. Athletics and recrea- tion organized, with appropriate facili- ties and equipment. Warm lunches in schools. Practically all cities and large towns. In over 90 cities in 21 states. Little provision in rural schools. In a few scattered schools in 9 states. 23 REFERENCES ON HEALTH PROBLEMS OF RURAL SCHOOLS Alabama's Country Schools and Their Relation io Country Life. Compiled by N. R. Baker, State Superintendent of Elementary Rural Schools. Department of Education Bulletin No. 33, 1913, Montgomery Ala. Country Life and the Country School. A study of the Agencies of Rural Progress and of the Social Relationship of the School to the Country Community. By Mabel Carney. Row, Paterson & Co., New York, 1912. Educational Hygiene. (Contains chapters on Rural Schools.) Edited by Louis W. Rapeer. Charles Scribner's Sons, New York, 1915. Hygienic Conditions in Iowa Schools. University Extension Bulletin No. 11, State University of Iowa. Important Features in Rural School Improvement, and other topics relating to rural schools, in Bulletins of the United States Bureau of Education, Washington, D. C, 1913, Nos. 3, 8, 23, 30, 42, 43, 44, 49, 52; 1914, Nos. 12, 17, 20, 25, 30, 31, 49; 1915, Nos. 20, 21, 32, 48. Medical Inspection of 469,000 Schoolchildren in Pennsylvania. Health Bulletin No. 71, July, 1915, Harrisburg, Pa., State Department of Health. Minimum Health Requirements for Rural Schools. Report of the Joint Committee on Health Problems in Education of the National Council of the National Education Association and of the Council on Health and Public Instruction of the American Medical Association. Prepared by Thomas D. Wood. Plans for School Improvement in Village and Rural Communities. Issued by State Department of Education, Jefferson City, Mo., 1914. Report of the Ohio State School Survey Commission. A Study of 659 rural village schools. 1914. Rural School Efficiency. Educational Department of State of Maine. Reprinted from Maine School Report, 1907. Sentinel Publishing Com- pany, 1909. Rural School Hygiene, Medical Inspection, Etc. Surveys made by United States Public Health Service in Virginia, Florida, West Vir- ginia, Indiana, Kentucky, North and South Carolina, Tennessee. Public Health Reports, Bulletins: No. 23, Vol. 29; No. 6, Vol. 29; No. 11, Vol. 29; No. 102, Vol. 30. Rural School Nurses. (1) Report of Kent Co. (Mich.) Nurse. (2) The Story of a Red Cross Visiting Nurse on Her- Round of Visits, etc. American Red Cross Town and Country Nursing Service, Washington, Social and Civic Work in Country Communities. Report of a sub- committee of the Committee of Fifteen Appointed by the State Sitper- intendent of Schools to Investigate Conditions in the Rural Schools of Wisconsin. Issued by C. P. Cary, State Superintendent, Bulletin No. 18, Madison, Wis. Social and Economic Surveys in Rural Communities in Minnesota. The LTniversity of Minnesota, 1913-1915. State Legislation Concerning the Examination of Schoolchildren's Eyes, Ears, Noses and Throats. By Dr. Frank Allport, Chicago, 111. TEN GOLDEN RULES OF HEALTH FOR SCHOOL CHILDREN 1. Play hard and fair — be loyal to your team mates and generous to your opponents. 2. Eat slowly. Do not eat between, meals. Chew food thoroughly. Never drink water when there is food in the mouth. Drink water several times during the day. 3. Brush your teeth at least once a day. Rinse your mouth out well with water after each meal. 4. Be sure your bowels move at least once each day. 5. Keep clean — body, clothes and mind. Wash your hands always before eating. Take a warm bath with soap once or twice a week; a cool sponge (or shower) bath each morning before breakfast and rub your body to a glow with a rough towel. 6. Try to keep your companions, especially young children, away from those who have contagious diseases. 7. Use your handkerchief to cover a sneeze or cough and try to avoid coughing, sneezing, or blowing your nose in front of others. 8. Study hard — and in study, work, or play do your best. 9. Sleep: Get as many hours in bed each night as this table indicates for your age. Keep windows iii bedroom well open. Hours of Sleep for Different Ages Age Hours of Sleep 5 to 6 13 6 to 8 12 8 to 10 1154 10 to 12 11 12 to 14 10^/4 14 to 16 10 16 to 18 9J4 10. Be cheerful, and do your best to keep your school and your home clean and attractive, and to make the world a better place to live in. TEN ESSENTIALS FOR HEALTH OP CHILDREN IN UURAL SCHOOLS I. Daily health inspection by parent and teacher with the cooperation of school nurses and doctors for detection of early signs of health disorders, to control and minimize communicable diseases. II. General health examination including dental examination, at least once a year, for discovery of physical defects and estimation of general health and capacity of the child. III. Follow-up health work with provision of medical, sur- gical, and dental care for correction of health defects, with service of school or district nurse, to make effective the health program in the school. IV. Warm school lunches for all rural school children to be paid for, as far as possible, by the homes. V. Sanitary and attractive school houses and surroundings which are essential to health of pupils and teachers. VI. Efficiently trained teachers qualified to do their full share in the care of the health and welfare of the children. VII. Practical health training of all pupils for the establish- ment of health habits and the extension of health conduct and care to the school, to the homes, and to the community in general. VIII. Special classes and schools for the physically and men- tally defective in which children may receive the care and instruction requisite for their exceptional needs. IX. Generous provision for wholesome play and recreation in school and community. X. Organization and cooperation of the home and the school and of interested people and societies to insure to all chil- dren the essentials of health and general well-being. I