Health work in the schools

Front matter

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COPYRIGHT DEPOSIT.

RIVERSIDE TEXTBOOKS IN EDUCATION

CHAPTER I Social Responsibility for the Health of School

Children 1

The spread of school medical work. Physical defects among school children. Parental guardianship of children's health not sufficient. The responsibility of society. The relation of the school medical service to private medical practice. Other functions of school health departments. The reaction of school health work upon the home. Opposition to school medical work. References.

CHAPTER II The Scope and Administration of Health Supervision 15

Stages in the development of school health work. The divisions of educational hygiene. Outline of the scope, procedure, and administration of medical supervision. Method of control. Division of power. Records. Schools and publicity. References.

CHAPTER HI

Plans for Organization for Health Work . . 37

State versus local control. Examples of state departments. City organization of school health supervision. Plan (1): Physician and nurses. The cost of health supervision by Plan (1).

CHAPTER IV The School Nurse: including Suggestions for

Health Supervision by the "Nurse Alone" Plan 48

Spread of school nursing. Nurses necessary for follow-up work. School nurses reduce absence. Other functions of the

CONTENTS

school nurse. Influence of school nurses upon the home. Number needed. Equipment needed by school nurses. A plan for the health supervision of schools by nurses alone. Selected references.

CHAPTER V The Health Grading of School : Children by

Teachers 62

The general importance of the teacher's cooperation. Teachers versus physicians. An outline for the health grading of school children by teachers. Health survey. Suggestions for using the outline for health grading. The significance of the answers to the questions. Some results secured by the outline for the health grading of school children. References.

CHAPTER VI A Demonstration Clinic for Instruction in the

Observation of Defects 90

Verbatim report of a demonstration clinic. A summary of clinics held at sixteen cities.

Chapter VII

Difficulty of getting results from medical inspection. What the school clinic is. Typical school medical clinics of England. Cost, equipment and management. Why free clinics are necessary. The opposition to free school clinics. To protect the health of children is a social obligation. Summary. References.

Chapter VIII

Historical. Dental clinics should be free. Preventing dental decay. References.

CONTENTS xi

CHAPTER EX

The school as a factor in the spread of contagious diseases. The school as a means of controlling contagious diseases. Newer ideas about modes of infection. Danger of the common cup, common towel, etc. Air not a common source of infection. Isolation of "carriers" versus school closing. Ages at which transmissible diseases most often occur.

CHAPTER XIV The Teaching of Hygiene: The First Six Grades 221

Inculcating health habits. Health instruction in the first five grades. Personal hygiene inspection by teacher and pupils. Inculcating food habits. Vital topics of hygiene study for grades three to five. Teaching hygiene in the sixth grade. Hygiene lessons dramatized. Outline of scheme for teaching hygiene in the sixth grade.

CHAPTER XV The Teaching of Hygiene: Seventh and Eighth

Grades 236

Early instruction must deal with the concrete. Focus attention upon health rather than upon disease. Practical instruction in bacteriology for the seventh and eighth grades. Teaching hygiene by means of "sanitary surveys." Helps for the teaching of hygiene in the grades.

CHAPTER XVI The Teaching of Hygiene: Education with Reference to Sex 252

The problem. Need of safeguarding school children. The school's relation to sex-education. Special considerations relating to sex education. Methods and content of instruction by stages. Divided responsibility of the home and school in sex-education. Selected references.

Chapter XVII

Mortality rate and physical morbidity. Premature superannuation. Tuberculosis among teachers. The teacher as neurasthenic. Health suggestions for the teacher. The hygiene of character. How to prevent mental fixation. The responsibility of the normal school. Vocational guidance for teachers. References.

CONTENTS xiii chapter xvrn

What the World is doing for the Health of School Children 285

England. Germany. France. Switzerland. Sweden. Denmark. Norway. Scotland. Ireland. Canada. Australia. Japan. Other countries. The United States. Conclusion. References.

Appendix

School Health Organization in Various Cities of ,the United States 305

Milwaukee. Minneapolis. Philadelphia. Oakland. New York.

Suggestions for a Teacher's Private Library in School Hygiene 315

GLOSSARY 317

INDEX 319

Note: The authorship of the chapters of this book is as follows: Dr. Hoag — Chapters III, V, VI, IX, X, XI, XIV, and XV. Prof. Terman — Chapters I, II, IV, VII, VIII, XII, XIII, XVI, XVII, and XVHI.

p

•N

LIST OF ILLUSTRATIONS

Facing School nurse recording pulse and temperature in an open-air class _, . . 54

^Testing vision 96

Crossed eye and obstructed breathing 99

f Testing hearing . 100 ^'

Teeth examination . . . . . . . . . . . 101 v

Chronological and physiological age 106 /

A school dental clinic in Rochester, New York .... 130 /

Crooked teeth 131 \/

An open-air class in mid-winter, Chicago ...... 206 ■,/

Chicago open-air classes 207 "

The Muroscroll 216 v

LIST OF FIGURES

1. Percentage of recommendations acted on in Philadelphia . 50

2. Teeth diagram 79

3. Weekly average of deaths from measles in London, England 134

4. Curve showing number of cases of diphtheria in Halle, Ger-

many 135

5. Curve indicating average seasonal occurrence of all chil-

dren's diseases in the Berkeley schools 145

6. Showing the average weekly gain or loss in weight of children

attending the Bradford Open-Air School .... 200

7. Haemoglobin tests, Providence Open- Air School . . . 202

8. Curves showing changes in haemoglobin during school year . 203

Chapter I Social Responsibility For The Health Of School Children

The spread of school medical work

The health supervision of schools is not a passing fad. The conservation of the child is a problem which, like that of world peace, is bound to take possession of the minds of all humanitarian people. To the ethical principle of humanitarianism is added the stern counsel of biological laws, which teach us that an elaborate scheme of mental culture which proceeds without regard to the needs of the body is but a house built upon the sands.

It is significant for the future of the movement that with minor exceptions all civilized countries have almost simultaneously taken it up. Its universal development is inevitable. Progress has been remarkably uniform in different countries, though naturally there are some differences in the details of procedure and in the points of emphasis. Germany has forged ahead with her dental clinics and open-air schools; France, with her school lunches and vacation colonies; while England has set the whole world an example in the earnest way in which she has undertaken to ameliorate the evils which medical inspection of schools has revealed. Our own country, on the whole, is behind most of the nations of Europe in the practice of school hygiene, but is making progress rapidly. But the doctor has not been brought into the school without opposition, and it is therefore desirable to inquire further into the justification for this new assumption of responsibility on the part of organized society.

Physical defects among school children

Serious defects of eyes, ears, nose, throat, lungs, teeth, glands, nutrition, heart action, nervous coordination, and mentality have been discovered with surprising frequency wherever they have been looked for. Statistics on these matters have been so indefinitely extended and (when we make allowance for certain differences in procedure) have given such uniform results, that we can safely say that in any school system, no matter where it may be located or to what social classes its patrons belong, from 50 to 75 per cent of its pupils are suffering from one or more physical defects serious enough to require skilled attention.1

While it is not claimed that all this defectiveness is produced by the school, some of it undoubtedly is, and in the case of still other pupils the school is at least a partial cause. At any rate, it is well known that defective pupils are present in the schools in large numbers,

1 Lewis M. Terman, The Hygiene of the School Child, chapter I. Houghton Mifflin Co., 1914.

and that the defects are often unfavorable to a normal physical and mental development. Although many of the defects are curable or preventable, as a rule even intelligent parents and teachers either do not observe them or else they underestimate their seriousness.

Parental guardianship of children's health not sufficient

If all parents were wise in regard to health matters, it would not be so necessary for schools to make a special study of the physical conditions of the children entrusted to their care. All that could then be fairly required would be the guaranty of a healthful school environment, including such things as good ventilation, correct methods of lighting and heating, sanitary plumbing, the control of contagious diseases, frequent recesses, sufficient physical training, and the proper sort of health instruction. But it is a fact and not a theory that not all parents possess the special knowledge which is necessary for the hygienic supervision of physical and mental development. Even intelligent parents may be unable to detect the early symptoms of physical disorder, just as they may be unable to decide upon the best methods or texts for teaching history or geography. They do not see the defects in their own children because they are used to them. Many are so superstitious as to prefer to treat adenoids by suggestion, others so ignorant as to interpret pediculosis capitis as a sign of good health. Plainly, therefore, it becomes the duty of the school department to furnish not only a healthful school environment, but also a health guardianship over its pupils.

The responsibility of society

The children of to-day must be viewed as the raw S material of a new State; the schools as the nursery of the Nation. To conserve this raw material is as logical a function of the State as to conserve the natural resources of coal, iron, and water power. To investigate exhaustively the evils which exist and to remedy all that may be remedied without transgressing unduly upon the jealous precincts of parental responsibility is a plain matter of duty. Theoretically, it matters little how the State performs this duty, whether by a houseto-house census of the children, or in some other way. Practically, however, there is no effective or convenient way except to do the work in connection with the public schools. In many of our best towns and cities the people themselves are demanding such supervision on the principle that it is one of the important functions of the public school system.

The argument that the health supervision of schools invades the rights of the home has exactly the same value as the corresponding argument against compulsory school attendance and prescribed courses of study. The school does not claim anything more than the right to make an examination of the child's physical and mental condition in order that the work of the school may be properly adjusted to his health and growth needs, and, further, to notify and advise parents regarding such defects as are found to exist. This is not an unwarranted assumption of power. The responsibility for remedial action is left entirely with parents. The school has not undertaken forcibly to subject children to surgical operations, nor is there at present any legal method of compelling parents to perform their duty in this respect. We can invoke the law for wanton neglect of a broken bone, but there is no way to punish the neglect of discharging ears, adenoids, or astigmatism, any one of which may prove more serious in the long run than a fractured bone.

It is interesting to conjecture how far present practice in this respect is likely to be modified. Compulsory public education itself is so recent that only a few dec- / ades ago it was considered by a majority of people as a species of meddlesome paternalism. According to the old conception the child was the parents' child; if they questioned the value of an education there was no recourse in the child's behalf. There are a million or more illiterate adults in the United States to-day who are victims of this mistaken social theory. The theory, happily, has been discarded. We now know that the interests of society demand an elaborate scheme of educational processes under social control. Some time we shall understand, just as clearly, that the child's physical growth also stands in need of more expert supervision than the average parent is capable of exercising.

The relation of the school medical service to private medical practice

It is sometimes contended that all medical work should be left in the hands of the family doctor, and that the employment of school physicians is both an ^ impertinence and a needless expense. The practicing physician himself often takes this stand, just as formerly private teachers resented the intrusion into their domain of teachers who were paid at public expense. The two situations are strikingly similar. There were private schools which afforded excellent educational opportunities, but unfortunately they did not reach all the people and they were excessively expensive. Similarly there are families who know enough about health and the causes which are likely to undermine it to seek the frequent advice of high-priced, skillful physicians. On the other hand, a large majority of families can hardly be said to have a family physician, and when they do his function seldom goes beyond the treatment of acute disease or physical injury. Under present conditions the family doctor institution hardly touches the rich field of preventive medicine with which it is the business of the school physician to deal. In the vast majority of cases, if the child's physical needs receive no expert oversight in the school, they will receive no expert attention at all.

It is, therefore, not at all a question of relieving the family physician of any of the functions he has been accustomed to exercise, but of doing the work he has left undone. The practicing physician is not always present when needed. As a rule he docs not appear on the scene until an emergency occurs. He has no commission to go out in quest of disease. He has little opportunity so to order the lives of his clients that they will escape emergencies. We refuse to pay him except to cure our diseases; it is unfair as well as absurd, therefore, to expect that his chief interest will be in the prevention of disease. The wonder is that the disparity between the physician's interest in disease and his interest in health is not greater. It is to the credit of the profession that the better class of practicing physicians almost unanimously indorse the work the schools have undertaken in child hygiene.

Other functions of school health departments

Apart from its contribution to national vitality, the health supervision of schools is entirely justified by its influence upon the efficiency of the school itself. For one thing, it appreciably affects regularity of attendance, which, as Ayres has shown, is one of the important factors in retardation. It does this by eliminating some of the causes of illness, and by treating in the school certain parasitic diseases and other slight ailments which otherwise would require exclusion. Ringworm and pediculosis, especially, have in the past caused a great deal of needless irregularity of attendance. Chronic physical defects, particularly of breathing and of nutrition, have a retarding effect on school progress, even when they are not of such a nature as to cause absence. To the extent that health supervision of schools is successful in securing the medical or surgical treatment of defects, or in ameliorating environmental conditions in the home, it cannot fail to contribute to the solution of the retardation question.

In the prevention of epidemics the school department of health renders invaluable assistance to the local non-educational board of health. The latter is usually given authoritative control in such matters as closing the schools, granting permits to return after illness, etc., but the closer contact of the school health officer with the pupils often enables him to sound the alarm and in many ways to become a necessary ally in preventing the spread of infectious diseases.

Not the least important function of the school health department is that of cooperation with the school architect and sanitary engineers. Of the millions of dollars expended annually in the United States for school buildings, a large part, from the point of view of school hygiene, must be considered as almost wasted. School buildings erected earlier than twenty years ago belong usually to discredited types of architecture, and are being replaced rapidly by new and still more expensive plants. Unless these embody the very best ideas in sanitation and hygiene, they, too, will soon have to be replaced. There is no reason why the better class of school buildings erected to-day should not be well preserved and for the most part hygienic in the year 2000. It would be hard to overestimate the injury that may be wrought in three quarters of a century by a poorly lighted, ill- ventilated, or unsanitary school building of twenty-five rooms. Within that time many thousands of children will have been subjected to its unwholesome influence. The resulting sickness, ill health, and death would appall us, if it were possible to estimate it.

The health department will also give immediate returns in the hygienic supervision of school activities. Competitive athletics, for example, are always dangerous without such control, particularly below the college age. Likewise the hygiene of instruction presents a promising field of research that can best be carried on by official investigation supported by the school itself. There is hardly a limit to the number of hygiene researches which it would be feasible for the school to undertake.

Furthermore, the department of health would give valuable assistance to the teaching corps in hygiene teaching. At present hygiene is one of the least taught, i and probably also the worst taught, of all the branches of the curriculum. This is largely because the teachers themselves have been poorly instructed in the subject., The work of the health department in this respect is twofold: (1) It will give the teachers themselves systematic instruction in the hygiene of physical and mental development, so that they may cooperate intelligently with the work of the department; and (2) it will aid the teachers in the choice of subject-matter and in the methods of presenting hygiene lessons in the schools.

Finally, health supervision in the schools will contribute to the conservation of the teacher's health. This has been fully presented in chapter xvm, and need not be dwelt upon here.

The reaction of school health work upon the home

But, supposing that all defects have been discovered, and that school life goes on without aches and pains, must we go all over the work next year and the next, forever? Is the social mill to go on, indefinitely, grinding out diseased and crippled children by the thousands? The most hopeful approach to this problem lies in the schools themselves. By all means let us remedy defects when they exist, but, in addition, let us endeavor to prevent defects from occurring. The school must investigate the home conditions of defective pupils. It must know more of the child's habits, what time he goes to bed, how long he sleeps, how much he works, how much he studies at home, what he eats, what he drinks, where and under what conditions he sleeps, and what the home environment is in every particular that concerns the child's health. If we read the lesson of the health index aright, it means not only sick school children, but sick school buildings and sick homes as well. The health of the child reflects the health of the community in which he lives.

The surest means of increasing community health are: (1) by increasing the health of the child through improved school conditions, and by attention to his physical defects; (2) by teaching the child sensible, applicable health lessons; (3) by carrying the influences of this health improvement and health instruction into the home.

The public school has not fulfilled its duty when the child alone is educated within its walls. The school must be the educational center, the social center, and the hygienic center of the community in which it is located, — a hub from which will radiate influences for social betterment in many lines.

Opposition to school medical work

Thus far the opposition to health supervision in the schools comes from three chief sources. One of these is the misconception as to the purpose of the work which is likely to be entertained by the more ignorant people of a school community. At first such people are likely to become panic-stricken with the foolish notion that their children may be subjected to some strange kind of violence, forcible surgical attention, hypnotism, etc. As the school health officer becomes a more familiar figure about the school premises, and as his kindly interest in the children becomes known, this fear always disappears.

The two other sources of opposition are harder to eradicate, because founded on prejudice rather than ignorance. These are the Christian Scientists, and the League for Medical Freedom.

The tenets of the former are so well known that they need not be discussed here. It is well to note, however, that the attitude of Christian Scientists toward school health work is not always unfriendly where the purely advisory capacity of the school doctor is understood. On the other hand, where the school authorities, in their communications and notices to parents, are at all insistent in their efforts to bring about the correction of defects, the enmity of this religious sect is likely to be aroused. Notwithstanding certain hygienic principles in Christian Science, its sweeping warfare against medicine must be viewed as the conflict of an absurd superstition with the welfare of the State and its children. Superstition has had to yield to quarantines and to state laws which punish parental neglect in case of acute and immediately dangerous diseases. Here, also, it will have to adjust itself as best it can to the march of science, which, at last, is beginning to question the right of either parental or religious authority to interfere with the health or safety of the child.

The League for Medical Freedom is a less worthy, but a more active and dangerous, opponent of child hygiene measures. This is a recently founded and vigorous organization composed largely of "sectarian" physicians, quacks, and patent-medicine vendors, whose main purpose seems to be to oppose all social restraints on medical practice and to preserve the divine right of all kinds of practitioners, regular and irregular, to prey upon the gullibility of the people. In the short time since it was organized, it has in several cases successfully opposed the extension of school medical inspection, and has defeated progressive legislation on matters relating to hygiene and medical practice generally.

Its methods are always and everywhere the same — to prejudice the minds of those not alive to the real issue by the cry of "medical tyranny," "political doctors," "sacred rights of the family," etc. Teachers will not be deceived by catchwords of this sort, enlisted in the cause of the patent-medicine industry and quack schools of "healing." Teachers are intelligent enough to scent the insincerity in the argument that medical inspection is being fostered for the special benefit of a particular "school" of medicine, — the allopathic versus the hydropathic, homoeopathic, osteopathic, naturopathic, etc. It is well for teachers to understand that real medical science is not torn asunder by separate schools, any more than is the science of chemistry or physics. There is only medical science on the one hand, and quackery and superstition on the other.

All such opposition will gradually be dissipated, or at least silenced. Medical inspection, enlarged to include all phases of school hygiene, will soon be looked upon as a mere matter of course, — the logical and necessary correlate of compulsory education.

(The most important references are indicated by a *)

1. Allen, W. H.: "A Broader Motive for School Hygiene." Atlantic Monthly, June, 1908.

2. Blan, Louis: " Are we taking Proper Care of the Health of our Children?" Ped. Sem., 1912, pp. 220-27.

3. Burnham, W. II.: "Health Inspection in the Schools." Ped. Sem., 1900, pp. 70-94.

*4. Dresslar, F. B. : " The Duty of the State in the Medical Inspection of Schools." Bull. A96, U.S. Bur. of Ed., 1912.

5. Fisher, Irving : " Public Responsibility for the Health of Infants and Children." Fed. Sem., 1909, pp. 395-402.

6. Gorst, Sir John E.: The Children of the Nation. (Chapter iv, pp. 50-66.)

*7. Gulick and Ayres: Medical Inspection of Schools. 1913, pp. 224. (Chapter i.)

8. Gulick, Luther H.: "Constructive Community and Personal Hygiene." Science, 1910, pp. 801-10.

9. Cronin, John J.: "The Doctor in the Public School." Review of Reviews, 1907, pp. 433-40.

10. Forsyth, David: Children in Health and Disease. 1909, pp. 360.

(Chapter vi.) *11. Hall, G. Stanley: "The Medical Profession and Children."

Red. Sem., 1908. *12. Hogarth, A. H.: Medical Inspection of Schools. 1909, pp. 360.

(Chapters in to vin, inclusive.) *13. Moore, Benjamin: The Dawn of the Health Age. Liverpool,

1910, pp. 204. 14. Osier, Dr. William: "Medical and Hygiene Inspection of

Schools." Rept. Inter. Cong. Sch. Hyg., 1907, pp. 465-68. *15. Terman, Lewis M.: The Hygiene of the School Child. 1913.

(Chapter i.) , See Collier s Weekly, June 3, 1911, for an expose of the " League

for Medical Freedom."

See all standard works on school hygiene or medical inspection

of schools.

Chapter II The Scope And Administration Of Health Supervision

Stages in the development of school health work

The health supervision of schools presents three clearly defined stages in its development : —

(1) Its original purpose in almost every case was the detection of contagious disease. The work was merely an extension of that of the local board of health, and was designed to protect the community from epidemics. The value of such inspection immediately became evident.

(2) The second stage is represented by the extension of the scope of the work to include examinations for non-contagious physical defects. The early surveys of the Danish and Swedish commissions had demonstrated an enormous prevalence of defectiveness among supposedly normal children of both sexes and of all ages and classes. It was discovered that many of these defects have a bearing upon the child's school progress, and upon his physical development. It was observed, moreover, that many of them are easily curable or removable. About two hundred cities in the United States, mostly the larger ones, have undertaken to give their school children complete examinations for all kinds of physical defectiveness.

(3) The third stage passes beyond "medical inspection," as such, and becomes a distinct field of preventive medicine. A suitable name for it is "Health and Development Supervision." Its keynote is the cultivation of health and the prevention of defectiveness by the hygienic supervision of all the, school activities.

This phase of child hygiene, the most important of all, is just in its beginning. Health supervision has been too narrowly conceived, but we are coming to realize that almost everything which contributes to the conservation of the child belongs within its scope. The schools, instead of causing sickness and defectiveness, must be made to preserve the child from many kinds of morbidity, repair his already existing defects, and combat his hereditary predisposition to illness and the unfavorable conditions of his social environment.

In order to prosecute the work intelligently hundreds of researches will have to be made; researches to which the public schools must be freely thrown open, and for the support of which public funds should be appropriated. Out of the data from such investigations there will rise, gradually, a new science of educational hygiene which will go as far beyond the usual poverty-stricken courses in "school hygiene" as medical science now transcends the teachings of the eighteenth-century medical school.1

The broad scope of educational hygiene is made clear in the following outline, which is a modifica- 1 See Popular Science Monthly, 1912, pp. 289-97.

tion of the comprehensive suggestions of Louis W. Rapeer.1

The Divisions of Educational Hygiene

I. School sanitation.

A. School sites, hygienic aspects.

B. School arelfftecture, hygienic aspects.

C. Ventilation and humidification.

D. Lighting.

E. Heating.

F. Drinking-water and fountains.

G. School baths.

H. School cleaning.

I. School toilets.

J. Seating.

K. Decoration.

L. The standard schoolroom.

M. Janitor service.

n. Physical education.

A. Playgrounds and play.

B. Athletics and "leagues."

C. Physical training.

D. Correctional exercises.

E. Posture. .F. Recreation.

G. School excursions, "tramps."

H. Physical development examinations.

I. Gymnasiums and gymnastics.

J. Swimming and bathing.

K. Medical gymastics.

L. Social center work for adults.

III. Health teaching.

A. Choice of hygiene texts.

B. Health instruction topics.

1 The authors are indebted to Dr. Louis W. Rapeer for permission to include this valuable outline in the present volume. No one else has made such a thorough study of efficiency in school-health service as Dr. Rapeer.

C. Health habits.

D. Public and personal hygiene.

E. Health education of parents.

F. Feeding and clothing of children.

G. Health education of teachers.

H. Home hygiene, in domestic science.

I. Industrial hygiene, in industrial work.

J. First aid and avoidance of accidents.

K. Talks by doctors, nurses, and specialists.

L. Pupil's cooperation in medical supervision.

M. Health leaflets.

IV. The hygiene of instruction and of mental development.

A. Fatigue.

B. School program.

C. Home study.

D. Examinations.

E. Type of books.

F. Motor aspects of teaching.

G. Cheerfulness and calmness.

H. Part time or whole time.

I. Vacations and their influence.

J. Teaching through play.

K. Attention and inter-recitation recreation.

L. Preventing pathological conditions. M. The hygiene of discipline.

N. The hygiene of classification, promotion, and gradation.

O. The hygiene of mentally exceptional children; the nervous, the feeble-minded, etc.

P. The hygiene of the learning process, habit formation, etc.

V. Medical supervision.

Each of the above divisions should have its special texts, and its special courses in teacher's colleges and normal schools. Space is lacking to show in detail the contents, aim, and procedure for each division, but this will be done for Division V, Medical Supervision. The following outline, based upon Rapeer's conclusions from his valuable comparative study of medical supervision in twenty-five American cities, reveals the scope and procedure for one of the five divisions given above: —