Classrooms and Clinics: Urban Schools and the Protection and Promotion of Child Health, 1870-1930 9780813565408

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Classrooms and Clinics

Critical Issues in Health and Medicine Edited by Rima D. Apple, University of Wisconsin–Madison, and Janet Golden, Rutgers University, Camden Growing criticism of the US health care system is coming from consumers, politicians, the media, activists, and healthcare professionals. Critical Issues in Health and Medicine is a collection of books that explores these contemporary dilemmas from a variety of perspectives, among them political, legal, historical, sociological, and comparative, and with attention to crucial dimensions such as race, gender, ethnicity, sexuality, and culture.

For a list of titles in the series, see the last page of the book.

Classrooms and Clinics Urban Schools and the Protection and Promotion of Child Health, 1870–1930 Richard A. Meckel

Rutgers University Press New Brunswick, New Jersey, and London

Library of Congress Cataloging- in- Publication Data

Meckel, Richard A., 1948– Classrooms and clinics : urban schools and the protection and promotion of child health, 1870–1930 / Richard A. Meckel. pages cm. — (Critical issues in health and medicine) Includes bibliographical references and index. ISBN 978–0–8135–6240–7 (hardcover : alk. paper) — ISBN 978–0–8135–6239–1 (pbk. : alk. paper) — ISBN 978–0–8135–6241–4 (e-book) 1. Child health services—United States. 2. Education, Urban—United States—Health aspects. 3. City children—Medicare care—United States. 4. Children with social disabilities—United States. I. Title. RJ102.M428 2013 362.1083—dc23 2013000434 A British Cataloging-in-Publication record for this book is available from the British Library. Copyright © 2013 by Richard A. Meckel All rights reserved No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, or by any information storage and retrieval system, without written permission from the publisher. Please contact Rutgers University Press, 106 Somerset Street, New Brunswick, NJ 08901. The only exception to this prohibition is “fair use” as defined by U.S. copyright law. Visit our website: http://rutgerspress.rutgers.edu Manufactured in the United States of America

For Mary Paula

Contents

Acknowledgments

Introduction Chapter 1

Chapter 2

Chapter 3

Chapter 4

Chapter 5

Chapter 6

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Going to School, Getting Sick: Mass Education and the Construction of School Diseases

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Incubators of Epidemics: Contagious Disease and the Origins of Medical Inspection

38

Defective Children, Defective Students: Medicalizing Academic Failure

67

Building Up the Malnourished, the Weakly, and the Vulnerable: Penny Lunches and Open-Air Schools

100

From Coercion to Clinics: The Contested Quest to Ensure Treatment

128

The Best of Times, the Worst of Times: Expansion and Reorientation in the Postwar Era

157

Epilogue: Contraction, Renovation, and Revival

195

Notes

207

Index

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vii

Acknowledgments

For historians, the research and writing of a scholarly monograph is often an intensely solitary endeavor. Yet none of us ever works entirely alone, and thus I would like to use this opportunity to thank those who provided me with support and assistance. Very little of the research for this book could have been done without the invaluable help of the staffs of the Rockefeller, Science, and Hay Libraries at Brown University; the Rhode Island Historical Society Library; the Francis A. Countway Library of Medicine at Harvard University; the New York Academy of Medicine; the libraries at Yale University, Columbia University, Rhode Island College, and the University of Michigan; and the Boston, Providence, and New York Public Libraries. Travel to those libraries as well as time away from teaching for research and writing was supported by the Brown University Faculty Research Fund, a National Endowment for the Humanities Fellowship, a National Library of Medicine Publication Grant, and a Spencer Foundation Small Grant Award. I also would be remiss if I did not thank Arthur and the late Carol Taylor, who on my many research trips to New York made their house mine. Chapter 1 is a revised and expanded version of an essay that appeared as “Going to School, Getting Sick: The Social and Medical Construction of ‘School Diseases’ in the Late 19th Century,” in Formative Years: Children’s Health in America, 1880–2000, edited by Alexandra Minna Stern and Howard Markel (Ann Arbor: University of Michigan Press, 2002), 185–207. Chapter 4 contains portions of the following previously published articles: “Open-Air Schools and the Tuberculous Child in Early 20th Century America,” Archives of Pediatrics and Adolescent Medicine 150 (1996): 91–96; and “Combating Tuberculosis in School Children: Providence’s Open-Air Schools,” Rhode Island History 53 (1996): 91–100. I thank the respective publishers for granting me permission to use the material. Over the years, many individuals provided various types of intellectual support that enabled me to produce this book. Invaluable intellectual stimulation was and continues to be provided daily by my wonderful, creative, and so often brilliant undergraduate students at Brown. They have consistently made teaching a pleasure and an equal companion to my scholarship. I owe much to my former and present graduate students, particularly Ashley BowenMurphy, Laura Briggs, Crista DeLuzio, Jessica Foley, Gill Frank, Wen Jin,

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Acknowledgments

Miriam Reumann, James Ross, and Elizabeth Searcy, with all of whom I’ve had the fortune of holding many conversations related to the history of childhood, social welfare, medicine, and public health. I also owe a huge debt to a group of historians, many of whom I met through the American Association for the History of Medicine and the Society for the History of Children and Youth. Publishing with me, sharing conference and symposium panels, reading and providing feedback on my scholarship in progress, or just exchanging ideas with me, they have provided me with an intellectual community that has done much to sustain me as a scholar through the years. In particular I want to thank Rima Apple, Jeffrey Baker, Jeffrey Brosco, John Burnham, Cynthia Connolly, Hughes Evans, Paula Fass, Janet Golden, Gerald Grob, Margaret Humphreys, Kathleen Jones, Alan Kraut, Kriste Lindenmeyer, Howard Markel, Steven Mintz, Heather Munro Prescott, Naomi Rogers, Alexandra Minna Stern, Elizabeth Toon, Arlene Tuchman, and Deborah Weinstein. I also would like to thank Peter Mikulas, at Rutgers University Press, for shepherding this book to publication. I am especially grateful for the enduring patience and professionalism with which he responded to my many questions and requests. Finally, I want to thank my immediate family. I am much indebted to my daughter, Katherine, and my son, Peter, for being who they are and making fatherhood both infinitely challenging and rewarding. Most of all, however, I want to thank my wife, Mary Paula Hunter, to whom this book is dedicated. Without her close reading and critical comments, her constant encouragement and support, and her unflagging faith in me, this book would never have been produced. The depth of my gratitude to her is exceeded only by that of my love for her.

Classrooms and Clinics

Introduction

In the final decades of the twentieth century, American child health advocates and activist child healthcare providers rediscovered the urban public school as a potentially promising site for clinics that could deliver primary healthcare to city schoolchildren and youth. The need for such clinics had been made manifest by years of research, beginning with studies generated by the War on Poverty, demonstrating that economically disadvantaged inner-city children and youth received shockingly little basic medical and dental care or counseling and thus were very likely to have untreated conditions and defects or be at risk for developing them. Moreover, the logic behind siting such clinics in schools seemed both obvious and compelling. Schools were where the children were and thus where healthcare providers could have guaranteed access to them. Parents have to send their children to schools; they do not have to take them to private physicians’ and dentists’ offices or to public clinics. Additionally, since untreated diseases and conditions in schoolchildren were understood to contribute to absenteeism, distraction, dysfunctional behavior, and other causes of poor academic performance, it was arguable that schools had a vested interest in facilitating better healthcare for their students.1 Thus was born the school-based health center (SBHC) movement and the consequent proliferation of primary care clinics in the nation’s schools. In 1981, when SBHCs were made eligible for Maternal and Child Health Block Grant funding, there were less than a few dozen such centers. By 1990 there were 150. Today, there are an estimated 1,900 to 2,000, mostly in urban school districts but also in poor rural ones. Funded by a patchwork of federal, state, municipal, and private foundation money, they provide care for both adolescents

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and younger children and offer an array of primary healthcare services typically including primary medical care, mental health and behavioral counseling, dental screening and treatment, and health education on nutrition, fitness, substance abuse, and sexual health. Although attracting considerable criticism from social and educational conservatives for ostensibly promoting liberal attitudes toward sexual activity and for diverting schools from their basic mission of education, the clinics are widely viewed by contemporary American healthcare reformers as one of the more significant innovations in child and youth healthcare to come out of their much-contested efforts to reorganize and make more equitably available medical, dental, psychological, and related services. Similarly, among contemporary American education reformers, the clinics are viewed as an important component of the full-service school, designed both to improve the physical and psychological well-being of poor city children and youth and to improve their ability to take advantage of the schooling the state is offering them.2 I describe the SBHC movement as originating in a rediscovery of the healthcare-delivery potential of urban schools because the movement does not represent the first time that American child healthcare activists and reformers cast their gaze on city schools and sought to use them to improve both the health and the academic performance of socioeconomically disadvantaged and medically underserved city children. In the early decades of the twentieth century, many of the nation’s large and midsize cities and a significant number of its towns experimented with a variety of methods and means to deliver healthcare services to schoolchildren in the primary grades. Then, as now, a major aim was to improve children’s health and thereby improve their academic performance. In Classrooms and Clinics, I examine that earlier attempt to use schools to provide health services to medically underserved children by situating it within a larger context: sociomedical and educational discourse in the late nineteenth and early twentieth centuries on the relation of schools and schooling, especially in cities and towns, to child health. My intent is to provide a comprehensive history and analysis of that discourse—universally referred to by its participants as school hygiene—and of the programs and policies it inspired. My hope is that in doing so I may provide some historical context for the fundamental issues, questions, and sociomedical arrangements that inform the current attempt to use schools to provide healthcare to the nation’s young. More important, I aim to illumine and explicate how school hygiene served as a critical site for the formative negotiation of the nature and extent of the public school’s—and, by extension, the state’s—responsibility for protecting

Introduction

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and promoting the physical and mental health of the children for whom it was providing a compulsory education. Over the last three decades, historians of public health and medicine, joined by scholars in related fields, have produced a significant body of scholarship detailing and analyzing the relation between late-nineteenth- and early-twentieth-century health reform activism aimed at improving the survival and health of the young and the initial formation of both infant, maternal, and child health policy and what Michael Katz has aptly termed the American semi-welfare state.3 Significantly, however, although acknowledging that this health reform activism had two major foci—reducing infant and subsequently maternal mortality; and protecting and promoting the physical and mental well-being and healthy development of young schoolchildren—the bulk of this scholarship, including my first book, Save the Babies: American Public Health Reform and the Prevention of Infant Mortality, 1850–1929, focuses almost exclusively on infant and maternal welfare.4 This is not altogether surprising. As a prominent child health activist noted at the time, saving the lives of infants and their mothers evoked a much greater response from the public than improving the health of children in school and thus was by far the more visible of the two reform efforts. Reformist agitation designed to get the government involved in improving infant and maternal welfare also produced the Sheppard-Towner Maternity and Infancy Protection Act, which has been widely characterized as the first major piece of federal welfare legislation passed in the United States. In addition, saving infants and mothers was early taken on as a primary mission by the federal Children’s Bureau, the era’s most powerful government advocate for child welfare and the institutional home of a large number of the nation’s most visible proponents of the influential Progressive Era womanist reform ideology that historians refer to as maternalism.5 This is not to say that efforts in the late nineteenth and early twentieth centuries to safeguard and improve the health of schoolchildren have been completely ignored by historians. Quite the contrary. Public health historians have long noted that urban sanitary reformers were involved in school hygiene in the early days of the movement, and that school and schoolchild surveillance were implemented as part of municipal health departments’ efforts to control the spread of epidemic disease and to sanitize and regulate the urban environment. Similarly, historians of education have long cited school hygiene activity as a component in the making and shaping of urban school systems and have pointed to the implementation of school-based health education and physical exams as examples of progressive education’s commitment to educating the whole child and having schools provide social services. Indeed, prompted

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in part by current educational reformers’ embrace of the Progressive Era ideal of the school as dispenser of social and health services, a few historians of education have looked critically at some of the early-twentieth-century school health activity as part of an overall evaluation of the present-day applicability of the Progressive Era model. Additionally, historians of various stripes have chronicled the evolution of certain components of the Progressive Era effort in the use of schools to promote child health, particularly school feeding and physical and health education.6 Nevertheless, there remains no overarching and comprehensive description and analysis of both the origin and evolution of school hygiene and its location within the critically formative national negotiations of the late nineteenth and early twentieth centuries that established the boundaries between public health and private practice and between state and parental responsibility for children’s health. With this book, I hope, at least in part, to fill that gap by examining when, how, why, and by whom the health of schoolchildren was discursively constructed as a sociomedical problem in need of being addressed, and by charting and explaining the changes in that construction and its formative discourse over time. I also attempt to connect the changes in that problem construction and discourse to the design and implementation of various interventions and services and to evaluate how that design and implementation were affected by the response of the various civic, parental, professional, educational, public health, and social welfare groups that considered themselves stakeholders and took part in the discourse. And, most significantly, I examine the answers and evasions called forth by the question at the heart of the negotiations: what services must the state and school provide when they take responsibility for protecting and promoting the health and physical and mental development of schoolchildren? Although a topic of conversation since the establishment of the public school system early in the nineteenth century, the relation of schools and schooling to children’s physical and mental well-being did not generate widespread concern until the last quarter of the century, when it became a major issue in the various public discussions prompted by the dramatic growth of publicly funded, compulsory primary school education and the transformation of childhood that accompanied it. As especially in cities, more and more children attended primary school, and the school day and year expanded significantly, both educators and non-educators began raising concerns about the possible consequences of these changes on the physical and mental condition of the nation’s young. The result was the initiation of an urban school hygiene discourse and reform movement that evolved through four overlapping and

Introduction

5

cumulative stages and had as a major result the progressive, though partial and incomplete, medicalization of American schools and schooling. In the first stage, which began in the 1870s and extended through the 1890s, a collection of primarily urban-based health professionals—deploying the principles of urban sanitary reform, an emerging developmental conception of child health and illness, and a newly constructed collective disease entity called school diseases—raised alarms about the mental and physical perils of schools and schooling, connected those perils to urban life, and called into question the ability of educators to safeguard the health of urban schoolchildren without the assistance and direction of medical experts. In so doing, they provided a medical rationale for state oversight of schools and schooling, gave education reformers a theory and vocabulary for classifying some educational approaches as not only ineffective but also physically and mentally harmful, and helped codify in American educational theory the principle that producing a sound mind in a sound body is an important object of education. In the second stage, which commenced in the 1880s and continued into the 1910s, the focus of attention shifted from the impact that the school plant and regimen could have on schoolchildren to the impact that schoolchildren, as carriers of disease, could have on each other and the general community. With an understanding of contagion increasingly informed by the germ theory, municipal education and public health officials, ultimately aided by court decisions, worked out both the role of the school in controlling the spread of contagious disease and the powers that role gave school officials to enact and enforce policies of surveillance, exclusion and compulsory immunization. In the third stage, stretching roughly from the 1900s into the 1930s, attention shifted again, this time from contagious disease as an epidemic threat to chronic disease and physical defect as causes of academic failure. Faced with evidence that many urban students were not moving beyond the lowest grades, school hygienists promoted and school authorities largely accepted a medical explanation for this lack of progress and then proceeded to negotiate and contest the implications of that explanation among themselves and with a variety of stakeholders—particularly parents, health care professionals and their organizations, and organized charity. The fundamental issues were whether or not schools were responsible for facilitating the correction of the physical defects and conditions believed to be impeding learning; and, if so, what types of facilitation were both effective and legitimate? Could and should they be coercive, promotional, remedial, or some combination? Could and should schools be clinics as well as classrooms, or was the school-based provision of healthcare not only an unjustifiable extension of the school’s historic mission but also a

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dangerous encroachment by the state on the rights and responsibilities of parents and the sanctity of private medical practice? These issues were debated but not definitively resolved, with the result that facilitation, at least in this stage, took the form of a semipublic patchwork of surveillance and remedial services that was limited in extent and type of coverage and always threatening to come apart. The fourth and final stage, which began around World War I and continued into the Depression, witnessed yet another shift in emphasis, from detection and correction to prevention through education and the promotion of healthy living habits. This shift in emphasis was accompanied by a concomitant decentering of the physically defective urban primary schoolchild within the school hygiene gaze, a result of both growing disenchantment with defect detection and correction as the centerpiece of school hygiene activity and an expansion of the focus of school hygiene to include children who were not in the primary grades, did not live in cities, and were not suffering from detectable physical defects. The result was the articulation and adoption of a school health policy formula that drew a sharp line separating the preventive and educational from the remedial and curative and situated the responsibility of the school to the child on the former side and that of parents to the child on the latter. In six roughly chronological chapters and an epilogue, Classrooms and Clinics traces the evolution through these four overlapping stages of the school hygiene discourse and attendant reform movement and looks at their legacy in the following decades. Chapter 1 examines the late-nineteenth-century origins of the American urban school hygiene discourse and illustrates some of the more salient ways that this early stage of the discourse was contoured by urban sanitary reform’s growing interest in the sanitation of places of assemblage, Western medicine’s discovery of the child as both patient and subject, and the increasing location of children at the center of an international discourse on the debilitating effects of modern urban life. In particular, the chapter explores the sociomedical construction of a collective disease entity labeled “school diseases” and its deployment in efforts to transform urban primary schools and schooling and to give to child health experts a central role in the design and operation of both. Chapter 2 examines the causes and consequences of mounting concern at the end of the nineteenth century that the dramatic growth of the urban school population had made urban schools—particularly those in the crowded neighborhoods of the immigrant working poor—incubators of epidemics of deadly diseases like diphtheria and scarlet fever and thus posed a threat to the entire community. Discussing how contagion was understood as the germ

Introduction

7

theory of disease was gaining greater influence, the chapter examines both the logic behind and the legal justification for the surveillance, exclusionary, and compulsory vaccination practices adopted by school systems to inhibit the spread of infection. It also describes the nature and extent of opposition to these practices and relates how court challenges established the principle that the state’s right to control contagious disease supersedes the right of a child to attend school. Chapter 3 details how physician-performed medical inspection of individual students, initiated as a strategy of surveillance and exclusion to prevent the spread of contagious disease, was transformed into a vehicle for the detection of malnutrition and a variety of remediable physical defects and conditions, the correction of which was promoted as a way to both reduce grade retardation and engineer healthier and more productive generations of Americans. Of particular interest is the process by which academic failure was medicalized and the rationale that medicalization provided for schools to take responsibility for facilitating the correction of physical defects. The chapter also situates school hygiene within the emerging child hygiene movement and examines the movement’s organizational maturation and institutionalization within city governments, along with the jurisdictional and directional conflicts between health and school departments that the latter entailed. Chapters 4 and 5 explore the controversial and mostly unsuccessful efforts of school hygiene activists—or school hygienists, as they were known—to promote and facilitate the correction of the discovered physical defects and conditions. Chapter 4 recounts the contested discovery during the first decade of the nineteenth century that a large proportion of urban schoolchildren were seriously underfed and malnourished and describes and analyzes the two programs that were initiated in response: open-air schooling and penny lunches. It also examines how and why it was that, although both programs involved making school a place where children’s health would be significantly improved through the provision of nutritious food, the responses to them from the welfare, educational, and public health communities, as well as from the general public, were quite different. In so doing, the chapter parses the distinction made between controlling disease and relieving hunger or inadequate nourishment, and adumbrates the difficulties faced by school hygienists when they wandered into the no man’s land between relief and education and between parent and state responsibility for the welfare of children. Chapter 5 explores the various proposals put forth for ensuring that the physical defects discovered in medical inspections would be corrected. Ranging from the use of legal coercion to the establishment of publicly funded school clinics and remedial services, these

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proposals and the various attempts to implement them were highly controversial and prompted considerable debate and negotiation on such issues as the boundary between public health and private healthcare, the limits of schools’ legal mandate, parental rights and responsibilities, religious freedom, and the relative value and legitimacy of various existing forms of healthcare. The proposals, and especially their implementation, were also contoured by the theorizing of medical and dental science on the relation between pathological conditions and behavior and on the particular organization and professional needs of the different branches of health care involved. Chapter 6 details the dramatic expansion of school hygiene activity and programs between the end of World War I and the Depression, while demonstrating the irony of that expansion: that it witnessed both a shift in emphasis from detection and correction to prevention through education and a decentering of the physically defective urban schoolchild within the school hygiene gaze that together signaled the end of the urban school hygiene movement, while simultaneously laying the groundwork for what would be the reorientation and contraction of urban school-based health programs and services through the Depression and World War II. The epilogue traces that reorientation and contraction. An overview, its primary purpose is to explore the legacy of the school hygiene movement of the late nineteenth and early twentieth centuries. It is meant and should be read as a postscript rather than as a detailed analysis. A few words are required about the focus of this study and the terminology employed. Although I am well aware that school hygiene reform activity and discussion in this period were not exclusively limited to urban primary schools and schoolchildren, I chose to focus on such schools and schoolchildren because they were the first and dominant concern of school hygienists. Prompted by the initiation of mass compulsory education and contained within a larger discourse on how the city school might be used to ameliorate the impact of urban industrial life on the nation’s young, the school hygiene movement first and foremost focused on city children who were below the initial compulsory attendance age of fourteen and were in the first eight grades. Such children and the schools they attended were variously and at different times designated by the terms “elementary,” “grammar,” “grade,” and “primary,” but I mostly employ the last term, in part for the sake of consistency. I also wish to underline the distinction between the issues raised by a school population whose attendance was compulsory and whose massive numbers contained many children who were socially and physically handicapped and those raised by a secondary-school population whose numbers, at least through the 1920s, were comparatively small and contained few children with social or

Introduction

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physical handicaps, and whose attendance was voluntary. It was urban primary schoolchildren whose forced attendance raised issues of state responsibility, dramatically increased public education expenditures and thus made educational efficiency a concern, and created an opportunity to use the school to counter what reformers of the late nineteenth and early twentieth centuries feared was the damage being done to large numbers of urban children by the poverty and ignorance of their parents. And thus it was urban primary schoolchildren who were the main focus of the school hygiene discourse and movement and are the main focus of this study.

Chapter 1

Going to School, Getting Sick Mass Education and the Construction of School Diseases

In his opening address to the 1884 annual meeting of the American Public Health Association, Albert Gihon, newly elected as president of the association, observed that he was occasionally approached by parents who wanted to know why as each fall progressed into winter at least one of their children would lose his or her appetite, grow pale and fitful, and suffer recurrent headaches and general lassitude. Gihon explained that his response was always the same: he told the parents to visit the child’s school. Once they had done that, he declared, once they had “breathed the vitiated air it breathes, sat on the racking benches, in the blinding glare, [and] sniffed the latrines that even dogs shun,” they would no longer be mystified why the child “does not eat, why its face is wan, its shoulders rounded, its form bent, its gait peevish, and perverse; why it talks and walks in its sleep, sees ghosts, or does not sleep at all.”1 Gihon made his observation to encourage his audience to pay special attention to a report to be delivered later in the meeting by the association’s Committee on School Hygiene, appointed the previous year and charged with investigating sanitary conditions in the public schools of various US towns and cities.2 But his larger purpose was to galvanize support for organized public health activity aimed at improving the hygienic condition of the nation’s urban schools. While noting that school hygiene was only one of several sanitary concerns to be covered at the meeting, he contended that the preservation of the health of city schoolchildren was of such critical importance to the future health and welfare of the republic that it rightly could have been the sole subject of that year’s gathering. Indeed, Gihon warned, conditions within American schools, and especially within city schools, were so bad that a large proportion

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of schoolchildren were having their health irreparably damaged. Although conceding that the typical American school was much better than it had been early in the nineteenth century and acknowledging that since the Civil War many cities had constructed impressive stone or brick school buildings, he charged that too often these “stately schoolhouses are crowded beyond every sanitary propriety with hordes of feeble children” whose health was being destroyed, not only by confinement in airless and filthy schoolrooms but also by lack of exercise and a school-day schedule that stunted their growth and development. “Are not their undeveloped plastic bodies distorted on uncomfortable seats, at uncomfortable desks, their eyesight progressively deteriorated by glaring windows and poor type, their physiological necessities opposed by inflexible rules and protracted hours?” he asked.3 Gihon answered his own question, concluding that for far too many American children, especially urban children, gaining knowledge meant losing health; going to school meant getting sick. Although delivered as if revealing a problem that had as yet received little attention, Gihon’s charge that schools and schooling were destroying the health of American schoolchildren probably came as a surprise to very few members of his audience. For the charge was an old one. Since the creation of public schools in the early part of the nineteenth century, criticism of the sorry condition of American school buildings and their furnishings and concern over their ill effect on the health of schoolchildren had been repeatedly articulated, not only in the writings of such nationally prominent educators as William Alcott, Horace Mann, and Henry Barnard, but also in the annual reports of the local school committees who had direct responsibility for and knowledge of their communities’ schools. Common, too, had been the complaint that rigid and taxing methods of instruction, combined with too little opportunity for exercising the body, were making each successive generation of American children less vigorous and more prone to nervous disorders. Indeed, the allegation that schools and schooling posed potentially serious dangers to the health of children served as one of the major leitmotifs of the nineteenth-century American discourse on public education.4 More immediately, for at least a decade the potential health hazards of schools and schooling had also been the subject of a steadily increasing number of papers, talks, and addresses published in medical and sanitarian journals and delivered before state and local medical societies, civic reform associations, and the American Public Health Association itself. By 1880 the literature on school hygiene had achieved such volume that the Index Medicus, the annual bibliography published by the American Medical Association, felt compelled to create a “school hygiene” category under which to list it. Most

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of those at the 1884 meeting would have also been aware that in recent years their colleagues in Great Britain, Scandinavia, and elsewhere in Europe had begun promoting school hygiene as an integral part of the state’s public health responsibility and were then engaged in studying and debating the extent to which schools and schooling were responsible for a host of maladies that children seemed to develop during the school years.5 Indeed, by the time Gihon delivered his opening address, school hygiene had emerged as the object of a discrete and important discourse within the essentially urban public health movement that significantly reduced morbidity and mortality in American cities during the late nineteenth and early twentieth centuries. Structuring that discourse were two closely related sets of issues. The first of these, often referred to as schoolhouse hygiene, centered on the potential impact on children’s health of school as a physical setting or place and revolved around concerns about the sanitary condition of school buildings and grounds, the causes and effects of atmospheric pollution, the adequacy of lighting in the classrooms, and the design of school furnishings such as desks and blackboards. The second set of issues, which eventually came to be organized under the rubric of hygiene of instruction, focused on school as a process rather than a place and centered on concerns about the health impact of the organization of the school day and the nature and extent of assigned schoolwork in relation to the age and sex of children. As with general concern about the impact of schooling on children’s health, neither of these sets of issues was new. Yet in the final third of the century, both took on new meaning and new social significance as they were caught up in the various public discourses that attended the profound expansion of institutional education in the United States and elsewhere. Along with Great Britain and several other industrialized countries, the United States in the latter part of the nineteenth century dramatically expanded its commitment to educating its young by providing unprecedented amounts of funding for public education and by increasingly compelling parents to send their children to school. Combined with immigration, the decline of employment opportunities for children, and changing parental attitudes toward the value of formal education, this expanded commitment fueled explosive growth in both the school population and the cost of public education. Between 1870 and 1915 enrollment in American schools increased from seven to twenty million, while public-school expenditures burgeoned from $63 million to over $600 million. This growth in school population and cost was particularly dramatic in the nation’s cities, especially the newer ones in the nation’s industrial heartland. Whereas between 1880 and 1910 Boston’s and San Francisco’s school populations increased a heady 54 and 78 percent, respectively, Milwaukee’s

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grew 223 percent, Cleveland’s 250 percent, and Chicago’s 334 percent. Moreover, during the same period, especially in cities and towns, the school day and school year were significantly lengthened, thus making it increasingly common for urban children to spend five or six hours in school each weekday for six to nine months of the year.6 The growth of mass education and the transformation of childhood that accompanied it prompted public discourse on several issues. Not the least of these involved the impact of that growth and transformation on the physical and mental well-being of the nation’s children and future adults. Were town and city schoolhouses fit to be occupied for long periods of time? Did their heating, ventilation, lighting, and general sanitation pose a threat to children’s health? How could school buildings be made healthy, and at what cost? What were the effects on children of compelling them to sit still and use their eyes and brains for long stretches of time? Did those effects vary by age and sex? Could the school day and curriculum be organized so as not to impede the healthy development of children? And did compelling parents to send their children to school place on the state a legal and moral duty to guarantee that schools and schooling would not injure the children? Even more so than in earlier periods of public discourse on education, the late-nineteenth-century discussion of the impact on child health of school and schooling was carried on by noneducators as well as educators. Among the most vocal of the lay participants was a loose coterie of public-minded health professionals who in final third of the century embraced the idea that the social condition of urban populations could be vastly improved if the principles of scientific hygiene could be applied to the urban environment. Directing their attention to city schools and schoolchildren were at least three major developments after the Civil War in public health, medicine, and social reform thought. The first of these developments was the interest that sanitary reform—the environmentalist first phase of the nineteenth- and early-twentieth-century urban public health movement—began to show in inspecting and regulating the sanitary condition of gathering places like factories, meeting halls, and schools. The second was Western medicine’s embrace of a developmental physiology of childhood and the concurrent emergence of medical specialties that were either child centered or used the identification of certain child-specific diseases to help define and legitimize themselves. And the third was the increasing location of the child at the center of a transnational discourse on the degenerative effects of urban industrial life.7 One early consequence of these developments was the accumulation of a body of medical research, mostly European at first, that purportedly identified

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a set of specific diseases and physiologic, ophthalmic, and neuralgic conditions, rooted in contemporary city living but specifically caused by schools and schooling. Relating these diseases and health problems to emerging medical theories on child development, this research and the sociomedical discourse of which it was part constructed a collective disease entity that came to be labeled “school diseases.” Employing this new disease entity and proclaiming allegiance to the principles and goals of sanitary reform, a small but influential group of American medical professionals followed the lead of their European counterparts and engaged in a wide-ranging and sometimes contentious latenineteenth-century public discourse that focused on the mental and physical perils of schools and schooling and called into question the ability of educators to safeguard the health of schoolchildren without the assistance and direction of medical experts who were free from political influence and trained in public sanitation and childhood diseases and development. Commencing in the early 1870s and focusing on city children in what today would be the elementary and middle school grades, this discourse constituted the first stage of a loosely coordinated and often fractious school hygiene movement that over the following six decades contributed to the medicalization of both American education and educational reform and served as a principal site in which the nation initially worked out what would become in the twentieth century the relation of the state, and particularly the school, to child health.8 Sanitarians and the Perils of the City School

In appointing a Committee on School Hygiene in 1883 and charging it with conducting an investigation of sanitary conditions in the nation’s schools, the American Public Health Association cited the disturbing evidence put forth by a number of previously conducted sanitary surveys of city schools. First appearing in the early 1870s, these surveys were largely the product of the institutionalization of urban sanitary reform. In the two decades after the Civil War, as states and municipalities created permanent boards of health and granted them police power to control environmental hazards, professional sanitarians and their allies began lobbying for an extension of that power to include the inspection and regulation of the sanitary condition of schools and other public buildings where large numbers of people assembled. By the mid-1870s, boards of health in New York, Boston, Cincinnati, and a few other cities had begun sending inspectors into schools and regularly though unsuccessfully petitioning their city councils and boards of aldermen for the authority and funding to appoint permanent school sanitary inspectors as Paris, Brussels, and a number of other European cities were doing. State boards of health also turned their attention to city and town schools.

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In 1876 alone, state boards of health sent inspectors into the schools of Madison, Wisconsin; New Orleans, Louisiana; and Baltimore, Maryland. The following year, the Massachusetts State Board of Health conducted a monumental study of the sanitary conditions in the state’s city and town schools, inspecting 159 schools in Boston and 400 urban schools statewide.9 Urban school boards also began conducting sanitary surveys, often in response to parents’ complaints and criticism from local medical societies. For instance, in 1870, citing the concerns of parents, the School Committee of Providence, Rhode Island, created a special subcommittee of two physicians and a local merchant and directed it to report on the health of the city’s schoolchildren and the sanitary condition of their schools. Two years later, New York City’s Board of Public Instruction directed R. J. Sullivan, a physician it had hired the year before to investigate teachers’ absences due to illness, to conduct a sanitary survey of a sample of the city’s schools. Soon after, the Board of Education of Rochester, New York, whose president noted that he had received many complaints from parents that conditions in schools “were so poor as to endanger in many cases the health of their children,” did the same. And in 1875, responding to pressure from the influential Philadelphia County Medical Society, the Philadelphia Board of Education appointed a committee of ten physicians and three chemists and charged them with evaluating complaints that the health of the city’s children was being destroyed by school attendance.10 Whether conducted under the jurisdiction of school hygiene committees, local medical societies, or state and municipal health departments, the initial investigations of urban schools evaluated all parts of the school environment but paid particular attention to the air quality in the schoolrooms and the adequacy of ventilation. In doing so they reflected the conviction of many sanitarians at the time that among the most serious hazards to the health of the public was the poor quality of ventilation in places where people assembled. As the public health historian John Duffy has noted, “Medical and public health journals at this time were preoccupied with the subject of ventilation of public buildings, and article after article cited ‘vitiated air’ as a danger to health and provided technical instructions for installing fresh air systems.” Typical was the wide publicity given to the 1877 planning and installation of a new ventilation system in the US House of Representatives.11 This concern over the ventilation of public buildings was rooted in the fundamental sanitarian conviction that disease was fostered by chemical and organic poisons in the air, and thus that ill health found its most frequent victims where too many people and too little air movement not only prevented the poisons from dispersing but also vitiated or depleted the atmosphere, thereby

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destroying the vitality and resistance of those who breathed the air. Yet the concern was also prompted by changes in the urban built environment. In the nation’s cities in particular, public buildings and gathering places were growing larger and being outfitted with new heating technologies that made adequate ventilation more difficult to achieve. This certainly was true of schools. Prior to the middle of the nineteenth century, most urban schools were built on the district school model, consisting of one or two long common rooms. Although heating and ventilation were often not very good, they did not pose difficult and costly engineering problems. This changed during the 1850s and 1860s, when several American cities embarked on school construction campaigns and began erecting three- to four-story, multiroom school buildings, a number of which were based on the “Quincy School” design set out in Henry Barnard’s School Architecture.12 As cities began constructing such schools and equipping them with newly developed hot-air heating systems, economically maintaining a stable temperature while ensuring an adequate supply of fresh air proved a significant engineering challenge. Since regulating heat and air quality simply by opening windows wasted coal and caused drafts, the plans for most of the urban schools constructed after the Civil War called for some specific ventilating system in which cold air was drawn in, heated by the furnace, and then released into the classroom—where, theoretically, it replaced foul air that was forced out through vents. Until the last decade of the century, most such systems employed passive or natural ventilating technologies: flues in the walls, room vents, and cowlings on the roof. After that, artificial systems—using blowers and fans—became popular.13 In discussing the design and building of new schools, school authorities frequently asserted that installing proper ventilation systems was one of their primary concerns. As the Connecticut State Board of Education declared in its 1874–75 annual report, “in the planning of school houses no subject is so important as ventilation, for none need a plentiful supply of pure air so much as children.”14 However, critics charged that such declarations belied a common reluctance on the part of school boards to spend what it would take to guarantee students such a “plentiful supply of pure air.” Positing that “the difficulties to be overcome in ventilating school-rooms are very great, but not too great to be overcome with money and intelligence,” the Massachusetts Board of Health contended that “the trouble is that every tolerable system of ventilation is expensive and those having the matter in charge cannot bring themselves to lay out the money.”15 Critics also charged that even when cities did lay out the money, it was often wasted because of shoddy construction and maintenance. Indeed, the waste of taxpayer dollars on costly but malfunctioning ventilating

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and heating systems was an issue frequently raised during the 1870s and 1880s by urban school reformers in their battle to trim school expenses and assert control over burgeoning city school systems. One of the earliest skirmishes in that battle occurred in New York City. During the first of many campaigns by civic reformers to restructure the city’s corrupt and politicized school system, the Department of Health sent a staff physician and a chemist on an exploratory inspection of seventeen city schools. Although the inspectors’ report took pains not to disparage the Board of Education, it was unreservedly critical of the sanitary conditions found in the schools. In particular, it noted that although some of the school buildings had recently been erected at great expense to taxpayers, all were decidedly deficient in ventilation and lighting, generally had filthy classrooms and hallways, and had privies and water closets located in such a way that their smells permeated the school atmosphere. As a consequence, the report concluded, the children attending these schools were forced to spend the greater part of their day confined in dark and dirty rooms, breathing noxious fumes and foul or vitiated air, as it was frequently called.16 Although concerned by the report, the city’s Board of Public Instruction chose to give it no official acknowledgment, and there the matter might have ended had it not been taken up in 1873 by Agrippa Bell as he was launching his journal, the Sanitarian. A major figure in the mid-century national quarantine and sanitary conventions and one of the founding members of the American Public Health Association, Bell became a vociferous critic of the sanitary condition of the nation’s schools and devoted considerable space in his new journal to calling attention to what he considered to be the deteriorating health of city schoolchildren. In the first issue of the Sanitarian, Bell published parts of the Department of Health’s report. A few issues later, he indignantly charged in a lead-off editorial that not only had the Board of Education ignored that report, it had also suppressed a report prepared by an outside consultant it had hired because his findings were even more damning than those of the city sanitary inspectors. The latter report, which Bell subsequently published, had been prepared by Lewis Leeds, an expert in ventilation whose designs had earlier that year been awarded a prize at the Vienna Exposition. Leeds confirmed that New York City’s newest school buildings were equipped with costly and up-to-date heating and ventilation systems, but he reported that in no buildings were the systems operating effectively, either because the flues and roof cowlings had never been connected or because school janitors had been negligent in maintaining them.17 Similar conflicts between sanitarians and school officials took place in other major cities. In the mid-1870s, Samuel Durgin, chairman of the Boston

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Board of Health, began sending inspectors into the city’s schools and lobbying for the authority and funding to appoint a corps of school sanitary inspectors. Strongly supporting his efforts was the Boston Medical and Surgical Journal, which during the 1870s and 1880s regularly editorialized on the unsanitary condition of city schools and published several articles detailing the causes and effects of schoolroom atmospheric pollution and calling for the appointment of school sanitary inspectors based in the health department. As in New York, however, those in charge of the school system resisted, unwilling to cede to another municipal agency any of its traditional control over the design, construction, and operation of school buildings. In Chicago, much the same thing occurred, with the Department of Health and Sanitary News on one side and the Board of Education on the other.18 To convince taxpayers, city councils, and school officials of the necessity of installing and maintaining functioning school ventilating systems, advocates of improved school hygiene painted a dire picture of the consequences of inaction. Drawing on the current understanding of the physiology of respiration and the chemical composition of air and employing a still-powerful conception of the body as a unified single organ in which every part was functionally and developmentally connected, they graphically detailed the multiple ways in which atmospheric pollution in schoolrooms could cause and spread disease, stunt mental and physical development, and turn even the most robust children into chronic invalids. Noting that each day some 90,000 Philadelphia children were forced to spend four and a half hours in school rooms where the air was so stale and foul that it made visitors gag, a panel of that city’s physicians suggested that it was frightening to contemplate “the degree of violence done to health, the sum of human suffering engendered, and to what extent life may be shortened by the respiration of the unnecessarily impure atmosphere of the school-rooms.”19 Although such alarms and arguments were put forth primarily to goad officials to action, they were not necessarily exaggerated. In truth, many urban school buildings and schoolrooms were overcrowded and underventilated. Especially in the older cities of the Northeast, it was not unusual for a classroom measuring twenty-five by thirty-five feet to be jammed with sixty to eighty students; to be warmed by an imperfectly controlled heating system; to have its windows nailed shut to save fuel; and to be poorly ventilated by malfunctioning, misplaced, or boarded-up flues. At a time when regular bathing was still something of a novelty, such rooms became offensively close as the day wore on. Visitors described being overwhelmed and nauseated on entering classrooms and of being able to smell a school from some distance away.20

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Conditions were even worse for the thousands of urban schoolchildren who spent their days in rented buildings that were never intended to be schools. Fueled by immigration, the urban school population exploded in the last third of the century, presenting school systems with the seemingly impossible challenge of finding rooms for the ever-increasing numbers of students. Especially in the 1870s and 1880s, when depression and then recession shrank municipal tax revenues, school authorities often met that challenge by temporarily renting unoccupied buildings or rooms within buildings and, with scant remodeling, turning them into schools. Frequently such buildings and rooms were in poor condition, had few windows and little ventilation, and were fitted with temporary privies and outhouses. An 1882 survey of the rented school buildings and rooms in Buffalo, New York, concluded that “they are too small, too cramped, devoid of any sanitary appliances, ill-ventilated or not ventilated at all; their defective arrangements are destructive to the moral sense of decency, while their defects in combination are murderous in effect on the health of the children condemned to study in them.”21 A similar survey of rented classrooms in Knoxville, Tennessee, found them “not only overcrowded but packed to the ceilings,” and singled out one school in particular: an abandoned hotel with eleven rooms, none bigger than eighteen by twenty feet, that housed 594 students and twelve teachers. A Baltimore survey reported 525 white children jammed into a rented building measuring twenty-eight by sixty-three feet and 300 black children occupying a small former church, “so overcrowded and illventilated that inspectors could barely breathe.”22 With such conditions all too prevalent in cities, the round of compulsory attendance laws passed in the decade and a half after the Civil War seemed to many sanitarians to be nothing less than compulsory sickness laws. Writing in the Sanitarian in 1875, Alfred Carrol charged that “in the absence of sanitary supervision of schools, the compulsory education act, enforcing still further overcrowding, must strike every hygienist as an iniquitous assault on the public health.”23 A year later, the New York Medico-Legal Society, founded in 1866 to promote public health work by physicians, released a lengthy report on the sanitary condition of New York City’s schools in which it reasoned: It is obvious that it is the duty of the State or School Boards acting under its authority, when it offers the advantage of a common school education to those within its jurisdiction, to provide school-houses with ample accommodation and sufficient floor and air space, and to conserve in every reasonable way, the health of the pupils. If, on the contrary, the schools are in a condition detrimental to health (as can easily be proved

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to be the case in the schools of this city), school boards are derelict in their duty, and fail to comply with one of the most important requirements of their office. School-houses where young children are herded and forced to sit for hours in a vitiated atmosphere, in constrained positions, do not come up to the standard. It would be cruelty to animals— not to speak of tender little ones—to add to this torture by increase of numbers without increased accommodation. The idea of compulsory attendance under these circumstances is preposterous, and at variance with all wise and beneficent law, and the common rights of humanity.24

In describing the damage done to children who were confined to illventilated and overcrowded schoolrooms, school hygiene advocates drew on the prevailing medical opinion that the pathogenic properties of vitiated air originated in two related but essentially discrete types of atmospheric pollution. The first type was believed to consist of gaseous and organic effluvia exuded from the tissues of sick persons and from putrefying organic matter. Although by the 1870s pioneer bacteriologists were beginning to propound what came to be called the “germ theory of disease,” even the best educated American physicians continued for some time to believe in a miasmatic etiology in which the primary catalysts of disease were atmospheric poisons produced inside and outside of the body. The theory was that when such poisons were breathed in, they caused disease and lessened vitality by introducing toxins into the bloodstream. Accordingly, school hygiene advocates argued that children who spent their day in rooms and schools where a high degree of such pollution existed were not only certain to have their health undermined and their vitality sapped, but they were also much more likely to develop scrofula and consumption as well as measles, whooping cough, scarlet fever, diphtheria, and other so-called childhood epidemic diseases.25 Concern with this type of pollution led to efforts to regulate and improve building sites, situating schools on dry land and away from tanneries, cemeteries, dumps, and other suspected sources of poisonous miasmas. Through much of the nineteenth century, city school boards, usually on relatively tight budgets, characteristically would purchase the cheapest available land as school sites, no matter how badly drained or close to nuisances that land was. By the 1880s, however, this practice was being abandoned, and by 1900 most major cities and several states had adopted ordinances governing the siting of schools. Privies and water closets were also redesigned and relocated so that noxious odors and sewer gas did not escape into the classrooms. And rooms that had contained children with dangerous infectious diseases were increasingly closed off and

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fumigated to destroy whatever poisonous miasma might have been released into the air.26 The second type of pollution implicated as a threat to the health and survival of schoolchildren was that caused by the gaseous and organic byproducts of human respiration and of heating and lighting combustion. Throughout the 1880s the byproduct that elicited most concern was carbon dioxide—or carbonic acid, as it was commonly if inaccurately called. Since late in the eighteenth century, when Antoine Lavoisier had described the role of oxygen in respiration and speculated on the toxic influence of carbon dioxide, scientific discussions of the dangers of vitiated air had been informed by the conviction that breathing and rebreathing the air of closed and ill-ventilated rooms was progressively debilitating and potentially deadly because carbon dioxide displaced oxygen and accumulated in both the atmosphere and the blood. Initially, it was believed that the principal danger of this accumulation was that an excess of carbon dioxide was poisonous and potentially fatal. But by the 1860s, more concern was being shown over the effects of the accompanying oxygen deprivation. Since blood saturated with carbon dioxide could not possibly carry a supply of oxygen sufficient to feed the organs, it followed that prolonged exposure to vitiated air would produce organic damage and malfunction. The deleterious effects of breathing oxygen-depleted air were thus visited on the entire human organism, weakening and causing dysfunction of the heart, the lungs, the kidneys, and especially the brain, which contemporary physiology defined as requiring one-fifth of the oxygen carried in the blood. Indeed, so susceptible was the brain believed to be to oxygen starvation that even slight exposure was said to cause “drowsiness, dizziness, dull headache, an inability to fix the attention, a dislike for application, a weakening of the memory, and a general torpor of the intellectual powers.” Extended and substantial exposure amounted to brain poisoning and involved organic deterioration that could produce both insanity and imbecility.27 Considered deleterious to the physical and mental health of all ages, carbon dioxide pollution was believed to represent a special threat to children because it ostensibly interfered with normal growth and development. Contending that oxygen is the food that a child’s immature organs require to develop fully and operate normally, proponents of better ventilation in schools warned that if American children continued to be subjected to schoolroom atmospheres supercharged with carbon dioxide, the result would be “a generation of dwarfs, a stunted progeny” with organs that were both malformed and malfunctioning.28 School hygienists also warned that schoolchildren were at particular risk because reading, writing, and calculating, even in the healthiest environments,

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placed enormous strains on their still developing organic systems. Performed in a vitiated atmosphere, these activities could cause serious damage to the nervous, visual, and even digestive systems. Of course, such warnings were not new, but in the last quarter of the nineteenth century they increasingly found empirical support in a steadily expanding international body of clinical research that suggested a strong connection existed between school attendance and organic debility, resulting in a variety of pathologic conditions that came to be labeled “school diseases.” Among the earliest and most influential of this research was that aimed at determining the incidence and causes of defective vision among schoolchildren. Going to School, Going Blind

The possibility that schools and schooling might be responsible for vision problems in children had been a subject of discussion among physicians and educators since at least early in the nineteenth century, when Georg Joseph Beer, who founded the first ophthalmologic clinic and school in Europe in 1786 and was one of the most influential figures in the early development of clinical ophthalmology, had complained in a popular text on eye care “how utterly destructive to the eyes of growing young people is the modern system of educational hothouse forcing.” In Beer’s opinion, long hours of close study were producing generations of young people who were not only “pale, feeble and drooping,” but also so “short-sighted and weak-sighted that at last there is nothing for it but calling in doctors for advice.”29 In indicting current methods of education, Beer was clearly responding to the early stirrings of nineteenth-century Romantic educational reform. But he was also articulating what most physicians with training and interest in the physiology of the eye then believed about the relation between visual accommodation and the etiology of errors of refraction. Although early-nineteenth-century medicine embraced several theories of accommodation—that is, explanations of the mechanism by which the eye changes its focus to form clear images of objects at different distances—the dominant theory posited that when a person focused on something nearby, the extraocular muscles squeezed and elongated the globe of the eye, thereby allowing the refracted rays of light to converge on the retina. It was only a small step from there to theorizing that constant focusing on near objects might permanently change the shape of the eye, making it nearsighted at rest. Indeed, such theorizing could draw considerable support from late-eighteenth-century anatomical investigations that had established a fairly strong connection between the axial length of the eye and refractive error, demonstrating that the myopic or nearsighted

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eye was comparatively elongated while the hyperopic or farsighted eye was comparatively shortened.30 The connection between refractive error and eye use also found support in the common observation that those with occupations requiring near work were much more likely to be myopic than those in other occupations. In a 1794 paper read before the Royal Society of London in which he argued that both myopia and hyperopia were due to patterns of use that changed the axial length of the eye, David Hosack offered as proof “the habit of long sight so remarkable in sailors and sportsmen, who are much accustomed to view objects at a great distance, and that of short sight, as of watchmaker and seal-cutters.” A few years later, James Ware made a similar and much-cited argument, noting that university students tended to be more nearsighted than military cadets of the same age. Observing that older students tended to have more vision problems than younger ones, Ware also posited that refractive error increased with years of schooling.31 By the middle of the nineteenth century, the connection between level of schooling and the development of progressively worsening myopia had been the object of enough commentary by eye specialists that many physicians and educational reformers in Europe, Great Britain, and the United States were warning that extensive close work forced children to strain their eyes and thus did damage to their eyesight. Herbert Spencer, for example, lamented in Education the many cases of “eyes spoiled for life by overstudy.”32 But it was not until after the 1851 invention of the ophthalmoscope by Hermann von Helmholtz; the subsequent clarification of the anomalies of refraction and accommodation by Franciscus Cornelis Donders; and the 1862 development of accurate and easily given vision tests by Donders’s assistant, Hermann Snellen, that eye specialists gained the diagnostic technologies to support these warnings with other than vague theorizing on the consequences of overworking the eye muscle or impressionistic surveys of the number of students complaining of difficulty seeing.33 Among the first to examine schoolchildren using the new technologies for determining acuity of vision was Hermann Cohn, a young professor of ophthalmic science at the University of Breslau (now Wroclaw). With the assistance of teachers, Cohn used Snellen-designed acuity charts and an ophthalmoscope to examine the eyesight of 10,060 schoolchildren and secondary-school students in his home city and the Silesian village of Langenbielau. Publishing his findings in 1867, Cohn reported that he had found very few refractive defects among the youngest schoolchildren, but that such defects—particularly myopia— increased dramatically in both severity and incidence with the number of years a child attended school. Indeed, he found that less than 7 percent of elementary

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schoolchildren were myopic, whereas over 26 percent of Gymnasium students were. He also reported that nearsightedness was almost five times more common in city children than in rural children of the same age.34 Cohn interpreted his findings as providing empirical proof that schools and schooling, particularly in cities, were intimately associated with the development of myopia in childhood and adolescence. Dismissing popular notions that the nearsighted eye was a strong eye, he contended that myopia was a symptom of serious fundic pathology. Drawing heavily on the work of Donders, Cohn defined myopia as a progressive disease that, if allowed to advance far enough during childhood and youth, could lead to blindness during adulthood. He also noted that although a predisposition to the condition was often inherited, the disease—which he described as characterized by pathologic changes accompanying a progressive lengthening of the axis of the eye—might develop in any child if he or she were subject to continuous overstraining of the accommodation muscles of the eye. In short, Cohn asserted that children became myopic because, at an age before the eye tissue was mature and firm, long hours of close work in school necessitated the “constant adjustment of the visual apparatus to small and near objects thereby causing a change in the shape and structure of the eye which ultimately becomes permanent.”35 Cohn theorized that myopia was most prevalent among urban schoolchildren because urban living was generally unhealthy and because urban schooling, especially that based on the Prussian model, was highly competitive and demanding. Moreover, noting that the disease was related to asthenopia, or chronically weak eyes—a condition that he believed could be passed on through heredity—Cohn observed that his findings boded ill for the future of the German people and seemed to support Donders’s theory that dysfunctional eyes were “more especially proper to cultivated nations.”36 Indeed, some years later, equating civilization with mass education, Cohn speculated that “it is possible that the Germans have become more than ordinarily predisposed to short-sightedness, by the operation of compulsory education through several generations.”37 Cohn also argued that for most schoolchildren, the impact of schoolwork on the immature tissue of the eye was multiplied by the conditions under which such work was generally done. Poor light, badly designed or ill-fitting desks, and hard-to-read print forced students to bend close to their texts, thereby compelling the eye to work harder to focus. Overheated and poorly ventilated rooms caused blood to congest behind the eyeball, softening the tissue and encouraging axial elongation. Glare from misplaced windows caused children to squint, straining the accommodation muscles even more. Indeed,

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Cohn believed that the environmental causes of myopia were so significant that vision problems among the young could be prevented only if schoolroom conditions were dramatically transformed.38 Cohn’s 1867 report, along with his continuing clinical research, soon inspired numerous other investigations into the eyesight of schoolchildren. By 1883, when an updated compendium of Cohn’s work and recommendations, The Hygiene of the Eye in Schools, came out in both German and English, the international body of published research concerning childhood myopia and schoolchildren had grown to over eighty major studies containing statistics on the eyesight of almost 150,000 schoolchildren.39 Generally confirming Cohn’s finding that myopia and other refractive defects increased in frequency and severity with years of schooling and were more common in cities than in the countryside, these studies lent specificity to the old charge that schools and schooling were responsible for undermining the health of children. In particular, they organized the diverse symptoms that observers had noted in schoolchildren around a central and identifiable pathologic disorder caused or complicated by the physical conditions of schoolrooms and the character of schooling. For instance, the long-supposed connection between extended study in ill-lit and ill-ventilated classrooms and the occurrence of chronic headaches and nervous disorders in schoolchildren could now be conceptualized as part of a unified pathology rooted in the development of vision disorders. After noting that “it is generally known that school-work is often associated with impaired sight and the development of myopia, neuralgia, and disorders of the digestive system,” the author of the school hygiene section in Hugo von Ziemssen’s Cyclopædia of the Practice of Medicine concluded: “It is evident that the entire physical condition of the pupil is connected with the question of nearsight.”40 Indeed, Germany’s great pathologist, Rudolf Virchow, found this new conceptualization so compelling that he used it as the basis for an alarm he produced for the Prussian government in which he identified myopia, nosebleeds, chronic headaches, scoliosis, and other maladies and defects he had observed as common among schoolchildren as constituting a discrete set of diseases for which he coined the term “school diseases.”41 In the United States, Virchow’s concept of school diseases and the findings of Cohn’s study and others that soon followed were initially reported in the medical press. But interest in school-induced diseases was not limited to those with medical training. Educators were also quick to show interest in the European research findings and to disseminate them among themselves. Less than a year after Cohn’s original publication, the Massachusetts Teachers Association invited Henry W. Williams, who would be a professor of ophthalmology at

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Harvard from 1871 to 1891, to lecture at its annual meeting on Cohn, childhood myopia, and school diseases. The following year, when it published Horace Mann’s The Study of Physiology in Schools, the Library of Education attached an excerpt from Cohn explaining the causes and consequences of nearsightedness in schoolchildren. And in 1870, the US Bureau of Education, which used its Circular of Information series to summarize and excerpt from international research on matters pertinent to schools and schooling, provided the first of what would be a long line of contributions to the discourse on school diseases when it published a translation of Virchow’s report and a brief summary of Cohn’s findings. Local school boards also entered the discourse, holding special meetings on school-induced diseases and publishing in their minutes and reports summaries of and excerpts from Cohn and Virchow.42 Also making public the results of European research were various civic improvement organizations like the American Social Science Association, which had been founded in 1865 to promote the scientific analysis of social questions.43 In 1873 the association directed its medical affairs secretary, a young Boston physician named David Lincoln, to prepare a report on the European research being done on childhood myopia and other school diseases and to present it the following year at a conference the association was sponsoring on urban public health. Lincoln—who a few years later would direct a monumental survey of the sanitary condition of public schools in Massachusetts and who subsequently achieved international recognition as an expert on school hygiene—prepared a report for the association that reviewed in detail the findings of the vision testers and discussed in considerable depth the various afflictions that were being identified as school diseases. The report also stressed that what distinguished these latest contributions from earlier alarms on the negative impact of schools and schooling on child health was that they were based on science and empirical research.44 This was a point also made by Virchow, who had noted in his 1869 report that the detrimental influences of schools on the health of children had in past years frequently attracted the attention of physicians and educators, but had not, until quite recently, “been made the subject of a thorough scientific investigation.”45 Indeed, during the 1870s something of a consensus emerged among concerned physicians and educators that although the issues were not new, the way they were being investigated and conceptualized definitely was. That certainly was the opinion of Boston’s nationally influential school superintendent, John Philbrick, who returned from the American Social Science Association conference convinced that a new scientific effort to protect the health of schoolchildren was being “inaugurated by an able body of scientists.” Observing that educational reformers since Horace Mann had been

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making eloquent though largely ineffectual appeals “for hygienic reform in our schools,” Philbrick described the research Lincoln had reviewed as evidence that “a new day has dawned—not a day of eloquent appeals, but a day of serious scientific inquiry.”46 Although much of that inquiry continued to be conducted by European researchers on European schoolchildren, not all of it was. A notable case in point was the significant body of research produced by a small but prolific group of American physicians who, in the two decades following the Civil War, worked to establish ophthalmology in the United States as a clinical specialty distinct from eye surgery. Inspired by the work of Cohn and other European vision testers, well-versed in the latest principles of ophthalmic science, and eager to legitimize their specialty by conducting scientific research that would both publicize their specialized knowledge and skills and demonstrate a social need for them, many of those in the founding generation of American ophthalmologists made substantial contributions to what, in the last quarter of the century, became a flood of international research seeking to demonstrate that childhood myopia involved organic pathology, increased with years of schooling, was more common among city than rural children, and was part of a complex of childhood health problems directly related to city life and school attendance.47 Among the more influential of these early American ophthalmologists was Cornelius R. Agnew, who established an eye clinic at the College of Physicians and Surgeons and ear and eye hospitals in both Manhattan and Brooklyn, and who in 1864 helped organize the New York Ophthalmological Society. Elected president of the Medical Society of the State of New York in 1873, Agnew devoted his inaugural address to arguing that the medical profession should take responsibility for protecting the physical welfare of schoolchildren and, in particular, should take action to stop the rising tide of health problems that modern urban schooling was causing. Reviewing the research of Cohn and other European vision testers, he suggested that all the examinations of schoolchildren pointed toward one conclusion: “Students stooping over badlymade desks, in badly-lighted rooms, and in a vitiated atmosphere, were rapidly impairing their eyes and developing diseases.”48 Agnew also cautioned his audience not to think that the phenomenon was unique to Germany and other European countries. For, as he noted of his American colleagues, “no one who is called upon to treat diseases of the eye has failed to be impressed with the increasing prevalence of asthenopic, refractive, and neurotic difficulties among scholars of both sexes; or to be impressed by the fact that the various maladies just alluded to are growing rapidly more prevalent in cities, schools, colleges, and other centers of civilization.”49 What

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was needed, Agnew concluded, was a concerted effort by the members of the profession to determine the extent of vision problems and related school diseases among American schoolchildren and to change the conditions of school life that were producing them. He thus urged his audience to form school hygiene committees within their state, county, and city medical societies and to conduct examinations of their local schools and the schoolchildren attending them.50 Following his own advice, Agnew oversaw a team of physicians who in the mid-1870s collected and published data on the eyesight and related health problems of nearly fifteen hundred students in New York City, Brooklyn, and Cincinnati. At the same time Edward G. Loring, assisted by other physicians at the New York Ear and Eye Infirmary, examined the eyes of over a thousand New York City public schoolchildren and reported the findings at the 1876 International Medical Congress. Boston’s Hasket Derby, who had studied with Donders in Utrecht and had helped organize the American Ophthalmological Society, embarked on a multiyear research project in which he conducted systematic investigations of refractive defects among students in the Boston public schools as well as at Harvard University and Amherst College. In Cincinnati, D. Booth Williams collected and published data on the eyesight of that city’s schoolchildren. And in Philadelphia, Samuel Risley conducted a study of the eyesight of primary school students.51 At the same time, less prominent American physicians, often commissioned by city and state school departments, and with the encouragement of local and state medical societies, were entering urban schools and using ophthalmoscopes and Snellen-type vision tests to gauge the frequency and severity of vision problems. The result was that by the middle of the 1880s there was widespread agreement among both physicians and educators that “eye diseases and especially near-sightedness are alarmingly frequent among school children and unquestionably originate during school life.”52 American researchers also sought to test Théodule Ribot’s hypothesis that “since constant study creates myopia, and heredity most frequently perpetuates it, the number of short-sighted persons must necessarily increase in a nation devoted to intellectual pursuits.”53 Loring made the French hereditarian’s assertion the centerpiece of an 1877 paper on hereditary myopia and modern education that he delivered before both the American Social Science Association and the New York County Medical Society. Abner W. Calhoun, longtime chair of the Department of Ear, Eye and Throat at Atlanta Medical College and one of the few ophthalmologists at the time in the deep South, conducted several surveys of the eyesight of Atlanta children, seeking to answer a question he posed in the Atlanta Medical and Surgical Journal: “Is modern education exerting an evil

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influence upon the eyesight of your children?”54 In order to test the theses that a predisposition to such diseases could be passed from generation to generation and that childhood myopia was most common among those races with a tradition of formal education, Peter Callan, one of Loring’s and Derby’s associates at the New York Ear and Eye Infirmary, conducted an examination of the eyes and eyesight of African American children in two elementary schools in New York City. Callan noted that he and his assistants found surprisingly few vision disorders and expressed the conviction that “had we examined an equal number of white scholars, we are fully satisfied that our examination would show a much larger percentage of myopia than that found amongst the colored scholars.”55 Virtually all the studies also drew conclusions from the relative incidence of the disease found, usually noting that the percentage of near-sighted American students was considerably lower than that of German students. This statistic, however, provided scant comfort, for the research also showed that American children experienced the greatest rate of increase of myopia from the lower to the higher grades. Citing this statistic, one physician suggested that “the question appears to come to this: is not the difference one of degree rather than of kind, and will not the American youth in a few generations reach or pass the amount of near-sightedness which the Germans display if they adopt the same method of education and exact the same application of the eyes?”56 Following the lead of their European counterparts, American ophthalmologists also researched and delineated the connection between childhood myopia and certain deformities and primary systemic or organic diseases. Charles Lundy of the Michigan College of Medicine drew on the research of Swiss and German orthopedists, the surveys of Agnew, and his own clinical experience to suggest at the 1884 annual meeting of the American Public Health Association that one of the principle causes of adolescent scoliosis was the tortured posture that weak vision, bad lighting, and poorly designed desks forced myopic students to assume. Daniel Bennet St. John Roos, a professor of ophthalmology at the University of New York and one of the founders of the American Ophthalmological Association, investigated whether there was a demonstrable connection between myopia and nervous constipation in children. Risley, Edward Hill, and several others investigated the relation between the causes of myopia in children and chronic headaches and nervous exhaustion. Loring posited a connection between vitiated air, eyestrain, and mental congestion. Albert Rainey proposed that eyestrain was connected to epilepsy. George Stevens suggested a strong relation between chorea and other functional nervous diseases

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and anomalous refraction of the eyes. So, too, did Henry Williams in his 1881 textbook on the diseases of the eye.57 Supporting assertions of a relation between vision problems and other disorders were a set of fundamental assumptions that still informed much medical thought and therapy as the last quarter of the nineteenth century began. Although in both theory and practice, medicine had largely accepted the concept of specific disease entities and was becoming increasingly localistic in organization and approach, many physicians remained committed to the fundamentally systemic view of both health and disease that pictured the body as a unified single organ in which every part was functionally interconnected. The operation of the stomach affected the operation of the mind and vice versa. Thus, local problems always had systemic consequences, and health and disease were always generalized states. Given the pervasiveness of this view within medicine, it is not surprising that in suggesting a causal connection between myopia and diseases of the nervous system, ophthalmologists received considerable support from their colleagues in neurology—another area of medicine that discovered children while defining itself as a specialty in the United States during the last third of the nineteenth century. Adherents of a physiological psychology that maintained the somatic origins of nervous complaints, early American neurologists embraced the notion that chronic headaches and other forms of neuralgia in the young could be linked to structural and functional changes in the eye. S. Weir Mitchell, for instance, regularly opined that one major source of the chronic headaches, nausea, insomnia, and vertigo suffered by many of his young patients were “disorders of the refractive and accommodative apparatus of the eyes.”58 Mitchell and other neurologists also stressed that, as with vision problems, nervous disorders were the inevitable consequence of mental activity in the vitiated atmosphere of the typical schoolroom. Lincoln, who began his career as a neurologist with the Boston Dispensary, asserted in a journal article on the effect of school life on a child’s nervous system that “school work, if performed in a vitiated atmosphere, is particularly productive of nervous fatigue, irritability, and exhaustion.”59 Other neurologists went even further, charging that requiring children to do intellectual work without sufficient fresh air was tantamount to condemning them to chorea, epilepsy, and a host of other serious neurological disorders. Indeed, by the mid-1880s such charges were becoming commonplace; were increasingly making protecting the nervous system a central goal of school hygiene; and were stimulating discussion on what was variously called overstudy, overpressure, and brain forcing.

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Overstudy and the Debilitated Schoolchild

On November 11, 1882, there appeared in Frank Leslie’s nationally circulated Illustrated Newspaper a full-page illustration of Death, with a scythe in one hand and a small coffin in the other, standing over a schoolgirl who had collapsed lifeless on her desk, surrounded by open schoolbooks. The caption underneath read: “Wearied to Death—The Pitiful Fate of Our Overworked Schoolchildren.” Accompanying the illustration was an editorial charging that public schools, abetted by competitive parents, were overworking students, shattering their nerves, destroying their health, and condemning them to invalidism and premature death.60 The editorial was one of many published in the medical and popular press during the last quarter of the nineteenth century as physicians and psychologists mounted a vocal campaign against current educational practice, charging that the hours of study it demanded were inimical to the health of children and were causing an epidemic of mental strain and related disorders among America’s young. “Much of our school system,” claimed a physician in the Boston Medical and Surgical Journal in 1882, “seems almost expressly designed for the manufacture of nervous invalids.” Another physician contended that fatal “mental diseases, such as those induced by over taxation of the brain, are by no means rare in schools” and noted that he personally knew of “three schoolchildren who died of disease of the brain, neither [sic] of whom were over twelve years of age.” And a third asserted that “there is a condition of mind and body not infrequently seen nowadays in child and youth . . . which is characterized by an irritable, easily overwrought, and unsteady nervous system, arrested muscular development, disordered digestion, and enfeebled powers of assimilation, which might be well called cachexia scholastica, since it is largely and sometimes directly brought about by ignorant and foolish parents and teachers, who force and cram and overwork the undeveloped brains of children.”61 To support their claims that excessive schoolwork—or overstudy, as it was frequently called—inflicted great harm on children, many late-nineteenthcentury physicians drew on a long-established body of neurophysiological and developmental theory that conceptualized the healthy, properly developing, and well-functioning body as a balanced federation of tissues fed by common and limited nutritional and energy reserves. The overdevelopment of one organ or muscle system meant the underdevelopment and stunting of another. Explaining why children with overdeveloped brains usually have underdeveloped bodies, one physician noted: “By excessive or premature exercise of the child’s brain, the flow of blood to it is increased and its powers stimulated and perhaps exalted. . . . Meanwhile, by extraordinary exertion, the excess of blood

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to it has been withdrawn from the other organs, and failing of nutrition—waste of substance, muscular weakness and stunted growth of the body follow.”62 Contending that the energy necessary to drive both psychic and physiological processes and development was limited, physicians also warned that excessive mental activity could not only exhaust the brain—thereby leading to pathological fatigue and permanent damage—but it could also deprive other organs and muscle systems of the energy needed to function properly. Excessive study thus could cause indigestion, heart palpitations, and blurry vision. As one writer put it, “abnormally active cerebration results in abnormally weak digestion, flowing thoughts in constipated bowels, lofty aspirations in neuralgic sensations.” Similarly, the channeling of excessive energy and nutritional sources to the brain was believed capable of stunting the development of or causing malfunction within other parts of the nervous system and thus was considered a major cause of functional nervous disorders such as chorea, epilepsy, hysteria, neurasthenia, cephalalgia (chronic and severe headaches), insanity, and torticollis or wryneck (a spasmodic contraction of neck muscles causing the head to tilt to the side, front, or back).63 Admittedly, doctors’ complaints that the health of children was being destroyed by schooling that overtaxed their mental and nervous capacities were hardly new in America.64 From at least the 1830s American physicians, particularly alienists who worked with the insane, had been vociferous critics of educating children too early and too strenuously. During the 1840s they had played a prominent role in the disappearance of the so-called infant schools that had been established in several urban areas in the preceding two decades to provide rudimentary intellectual and disciplinary training to children as young as three years of age. Moreover, the American medical press, like its counterparts on the other side of the Atlantic, had long inveighed against overstudy and its effects on older children’s mental and physical health. In the 1860s, for instance, the Boston Medical and Surgical Journal and the Medical and Surgical Reporter of Philadelphia had lent their strong support to campaigns mounted by coalitions of parents and physicians in their respective cities to have school officials shorten the school day and school session, reduce the amount of homework given, and modify or eliminate the system of competitions and awards that many physician critics claimed drove ambitious students to insanity and invalidism.65 Overstudy had also been a major issue in post–Civil War debates over coeducation in urban high schools, especially after Edward Clarke, a Harvard Medical School professor and specialist in nervous disorders, famously declared in his influential Sex in Education that rigorous intellectual work during puberty

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would stunt the development of girls’ reproductive organs while producing neurologic instability. Admittedly, the belief that intellectual activity and female reproductivity were opposed had a long history in Western medical thought. But Clarke and other late-nineteenth-century opponents of coeducation reinforced it by citing contemporary anthropometric investigations by William Bowditch and others indicating that girls had an intense and accelerated growth spurt during early adolescence, while boys developed more gradually and over a longer period. Noting the different growth schedules, opponents of coeducation argued that not only should girls be educated separately from boys and on a different schedule, but they should also receive little formal education during the critical prepubescent years.66 Yet in the last two decades of the nineteenth century, physicians’ criticism of current educational practice as dangerous to the mental health of children seemed to intensify and to feed into and reinforce similar complaints being leveled by parents, educators, and a variety of social commentators. One probable reason for this was that medical concern with the consequences of overstudy was augmented by fin de siècle anxiety over whether the pace of modern life— particularly modern urban life—was causing widespread mental strain and turning Americans into nervous wrecks. As the neurologist George Beard was popularizing neurasthenia as the “American Disease,” writers claiming expertise in the physical and mental health of children were pointing to the myopic, nervous, and physically enervated schoolchild as embodying the debilitation being affected on young people by the pressures and stimulation of modern urban life. In going to school, the critics claimed, children replicated the transformation that the nation was undergoing: that is, children moved from a relatively unfettered outdoor physical existence to a controlled, indoor, pressured intellectual one. It was all but inevitable that the consequences included myopia, physical enervation, and especially neuralgia. Contending that “the whole nation is suffering nervous degeneration,” Lincoln repeatedly stressed that nowhere was this more true than among the nation’s urban schoolchildren, who were becoming overcivilized and underdeveloped. A. N. Ellis, a Chicago neurologist, made the same point and blamed overwork and overuse of the brain. “What is the effect,” he asked in 1881, “of undue cramming and over stimulation of the youthful mind in the public schools? Is it not to make physical and mental wrecks? Is it not to produce that general condition called nervousness so common among the American people today?”67 American medical criticism of educational practice also grew apace, with the expanding US and international discourses on school diseases. In an 1882 overview article on “The Diseases and Dangers Incident to School-Life” Boston

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physician G. S. Stebbins noted that growing interest in school diseases was fostering ever-greater awareness among physicians of the damage daily being done to the nervous systems of the nation’s schoolchildren. Indeed, Stebbins suggested, some physicians were beginning to suspect that neuralgia from overstudy was as common and serious among schoolchildren as myopia. Such certainly seemed to be the opinion of Abraham Jacobi, the holder of the first American clinical professorship in pediatrics and founder and first president of both the American Pediatric Society and the American Medical Association’s Section on the Diseases of Children. In a talk he gave to the Kings County Medical Society in 1881, Jacobi contended that nervous diseases among the urban young were on the rise and seemed destined to soon pass myopia as the most common ailment afflicting city schoolchildren.68 The heightening of American medical awareness and criticism of overstudy during the last two decades of the century was also fed by the excerpting or publication in complete form in the medical and popular press of a number of important contemporary European investigations of neuralgia and other school diseases. For example, by the mid-1880 Neils Hertel’s Overpressure in the Schools of Denmark was available in English, as were various summaries of Axel Key’s similar study of Swedish schools. American physicians could also read about the investigations of the French National Academy of Medicine into surmenage intellectual and the debates in German-speaking Europe, where overstudy was being blamed for a shocking number of suicides among Gymnasium students. In addition, the American popular and medical press reported fairly regularly on the English Parliamentary investigations that were initiated in 1883 in response to alienists’ claims that overpressure in schools was a prime cause of what recent social statistics were suggesting was a significant rise in insanity and nervous diseases among the British populace. Disputed by education officials, the alienists’ contentions were soon at the center of a heated public debate that was fanned by the press’s hunting out and publishing stories of children driven to nervous exhaustion and even death by the demands of overzealous schoolmasters.69 But perhaps most of all, medical complaints about the consequences of overstudy seemed to intensify in the last decades of the nineteenth century because experts in the physical and mental health of children prominently inserted themselves in the campaign by turn-of-the-century educational reformers to transform urban school systems and change the way that children were taught. Among the most prominent and influential of these experts was G. Stanley Hall, particularly after he assumed the presidency of Clark University and made it a center for graduate training in psychology and education. One of the

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most important psychologists of the late nineteenth and early twentieth centuries, Hall helped birth academic psychology in the United States, pioneered the science of child development, and was the nation’s most influential proponent of bringing scientific psychology to bear on the related practices of child rearing and education. As part of that project, Hall inaugurated and led a child study movement that promised to give a scientific basis to the Romantic naturalism that had been at the center of educational reform from Jean-Jacques Rousseau through Johann Pestalozzi and Friedrich Froebel and continued to animate pedagogic reformers. Compiling the results of empirical observations, child study aimed to map out an anatomy of child physical and mental development that would facilitate Romantic educational reformers’ century-old quest to fit education to the nature of the child.70 Hall, his psychology students and colleagues, and his child study adherents advanced and popularized three propositions that would greatly influence the way that educational hygiene came to be thought about and discussed. The first of these was that all children develop through the same specific, biologically determined mental and physical stages that are characterized by distinct capabilities, talents, and interests. The second was that the timing of this passage was not the same for all children. And the third was that mental and physical development were intimately linked and needed to parallel each other for the child to develop into healthy maturity. Hygienic education, thus, was education that was developmentally appropriate to the individual child and educated the body and mind—or what came to be called the whole child— simultaneously and to the same degree. Designed and conducted correctly, such education would produce healthy children who were well developed both physically and mentally. Indeed, especially after anthropometric studies like William T. Porter’s 1892 survey of St. Louis schoolchildren offered seemingly irrefutable proof that the healthiest children were those who were the most physically and intellectually developed, discussions of overstudy tended to be couched in terms of developmental inappropriateness or overconcentration on the development of the mind at the expense of the body. Hence, both the age of school entry and opportunities for physical exercise became major issues in the 1890s.71 During the decades straddling the turn of the twentieth century, Hall deployed the three developmental propositions as he vigorously promoted the linkage of psychology, pedagogical reform, and school hygiene as a foundation for improving schools and schooling. Creating at Clark a Department of Pedagogy and School Hygiene, he attracted to the university as students or colleagues a generation of psychologists who in the early twentieth century

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would create the field of educational psychology while becoming leading figures in the school hygiene discourse. Hall even brought Sigmund Freud and Carl Jung to Clark to participate in a September 1909 conference on psychology, pedagogy, and school hygiene.72 Largely as a result of Hall’s and his students’ efforts, the prevention of nervous and mental disorders became an increasingly important goal of school hygiene. Indeed, for neurologists and psychologists, nervous system hygiene and school hygiene became virtually synonymous. As William Burnham, a student and then a colleague of Hall, explained in the opening sentence of his influential end-of-the-century summary of the field: “School Hygiene in a broad sense has to do with the conditions that favor the normal functioning of the nervous mechanism.”73 In promoting those conditions that most favored the normal functioning of the nervous mechanism, Hall and those he influenced focused particular attention on the dangers of overstudy—which they defined as developmentally inappropriate methods of instruction that slighted the body in favor of the mind—finding in its consequences a rationale for educational reform. Indeed, for Hall and his adherents, the clinical delineation of the consequences of overstudy offered a powerful critique of those traditional methods of instruction that stressed rote learning, equated education with the accumulation of knowledge, and measured that accumulation by hours devoted to study and success in recitations and exams. Finding the myopic nervous child a potent symbol of the consequences of educational methods that were ill suited to the nature and capabilities of the child, they argued that “present intellectual health and mental ability [are] the only evidence of good education.”74 As Hall asked in a biblical paraphrase that would be much repeated, “What shall it profit the child if he gains the whole world of knowledge and loses his own health?”75 School Diseases and School Physicians

In providing educational reformers with a powerful argument and a graphic vocabulary with which to promote the transformation of American schools and schooling, the late-nineteenth-century construction of school diseases served to medicalize both education and educational reform. In so doing it made the consequence of bad schools and schooling pathological as well as educational. Conversely, it made the measure of good schools and schooling not just the extent to which they managed to achieve educational goals, but also the extent to which they did not damage the bodies and minds of the children who were subjected to them. Moreover, in medicalizing schooling, the construction of school diseases provided both a rationale and an impetus for those claiming expertise in the physical and mental health and development of children to

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become involved in education and educational reform. With their gaze directed toward schoolchildren by urban sanitary reform and by the accumulation of clinical research on various pathological conditions ostensibly associated with attending school, late-nineteenth-century health professionals interjected themselves into the contemporary discourse on education, arguing that their expertise in sanitary matters and in the diseases and development of children made them far more qualified than lay school officials and school board members to guarantee that going to school would not destroy the health of America’s young. Arguing that appropriately trained physicians should oversee everything having to do with schools and schooling, Jacobi spoke for many of his colleagues when he complained during his inaugural address as first president of the American Pediatric Society that “the question of school house building and school-room furniture, the structure of bench and table, the paper and type of books, the number of school hours for the average child and individual pupil, the number and length of recesses, the hours and duration of intervening meals, the alternation of mental and physical education, the age at which the average and individual child should be first sent [to school], have been too long decided by school-boards consisting of coal merchants, carpenters, cheap printers, and under-taught or overaged [sic] school-mistresses, not however, of physicians.”76 Other health experts echoed Jacobi, with some calling for physicians to be appointed by school boards and given responsibility for determining whether the curriculum, educational methods, and school plant posed a threat to the mental and physical well-being of students. In response to such calls, many physicians volunteered to serve on school boards and a young pediatrician, Joseph Rice, provided considerable impetus to progressive education reform with his devastatingly critical The Public School System in the United States.77 Yet the appointments of in-school medical advisors and inspectors did not immediately materialize, in large part because school officials, especially in the newly bureaucratized urban school systems, resisted what they interpreted as an intrusion by noneducators into their domain. Indeed, at the end of the nineteenth century, when health professionals finally gained entry into the schools, it was not so that they could evaluate the sanitary condition of the buildings or advise on the organization and content of the education provided there. Rather, it was as part of an effort to protect both students and the community from epidemics of dangerous contagious diseases.

Chapter 2

Incubators of Epidemics Contagious Disease and the Origins of Medical Inspection

In an 1895 article, Henry Dwight Chapin, a young New York pediatrician and volunteer at a charity clinic, sounded what was becoming a familiar theme in the written and oral comments of American clinicians, nurses, and public health officials concerned with the health and survival of children in the nation’s rapidly expanding urban immigrant ghettos. Noting that each fall and winter epidemics of scarlet fever, diphtheria, measles, mumps, and a host of other contagious diseases flashed through the tenement districts of New York and other large American cities, Chapin suggested that even more than the crowded and often filthy housing in which poor immigrant children lived, the schools in which they spent their days were responsible for these often deadly outbreaks of the so-called infectious childhood diseases. Like those who had begun agitating for school hygiene reform in the 1870s, Chapin expressed outrage at the unsanitary condition of many urban school buildings, noting that the schools where occurrences of these diseases were most frequent were usually those that were most overcrowded, dark, ill ventilated, and filthy. But unlike most of the earlier critics of school hygiene, he did not point to environmental filth or poor ventilation as the chief cause of the epidemics. Rather, he suggested that the outbreaks of disease were specifically caused by germs brought into the schools by students who were infected or who carried infectious material on their clothing, books, and other belongings. Once inside, he warned, these germs multiplied and spread in the near-perfect “incubator of disease germs” afforded by the overheated, overcrowded, and often sunless environment of the tenement district school.1 Chapin’s article was one of several published in the popular and medical press during the last two decades

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of the nineteenth century that called attention to the potential of the urban immigrant and laboring class school to germinate and spread epidemics that could threaten entire cities.2 Taken together, these articles are evidence of the beginning of an expansion and a shift in the focus of the American discourse on school hygiene. As the nineteenth century came to an end, those engaged in that discourse continued to express concern over the impact that schools and schooling could have on students’ eyes, nerves, frames, and general constitutional vigor. But they also began to pay increasing attention to the spread of contagious disease among students, especially those crowded into the bulging schools of the nation’s urban immigrant neighborhoods. Indeed, by the turn of the century, concern over the health hazards that schools and schooling posed to schoolchildren was fast being joined—even arguably eclipsed—by concern over the health hazards that schoolchildren posed to each other and the general community. Several developments contributed to this expansion and shift in the focus of school hygienists’ concern, but three were particularly influential. The first was an increase in epidemic outbreaks of potentially deadly contagious diseases among school-age children, accompanied by a growing conviction that the outbreaks corresponded to the school-year schedule. The second was the expanding influence of the germ theory as an explanation for the origin and transmission of these and other contagious diseases. And the third was the profound transformation in the size and character of the urban school population as a result of mass immigration, the increasingly effective enforcement of compulsory school laws, and the decline of employment opportunities for children. That gathering large numbers of children together in a single room or building could facilitate contagion and thus foster the spread of such childhood diseases as measles, mumps, and chickenpox was not, of course, an idea first entertained by Americans in the late nineteenth century. Since the beginning of public education in the United States, it was fairly obvious to anyone who cared to look that going to school often involved contracting a number of communicable diseases. It was also obvious that mini-epidemics of measles, chickenpox, mumps, and other so-called childhood diseases would periodically course through a school, radiating out into the homes of students and often spreading to their preschool siblings. In such cases, school authorities would often close a school, disinfect and fumigate the room or rooms where sick children had been, and wait until the epidemic ran its course. This was considered bothersome, but not a matter of great concern. Epidemics were rarely severe, school terms were short, and infrequent attendance and interrupted schooling were still more the norm in America than the exception. In

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the years after the Civil War, however, school epidemics caused increasing alarm among parents, educators, and health officials. One reason for this was that newly passed compulsory school laws and accompanying regulations tying funding to attendance and completed curricula made school authorities considerably less willing to close schools for what could be several weeks. Another was the proliferation of two deadly diseases that preyed especially on school-age and younger children. One of these diseases was scarlet fever; the other was diphtheria. An acute infectious disease, scarlet fever is caused by Group A beta hemolytic streptococcus, the bacterium that also causes strep throat. It is characterized by the sudden onset of swollen glands, a sore throat, and a high fever, followed within a few days by the sandpapery reddish rash that gives the disease its name and is a reaction to the erythrogenic toxins the bacteria release. During convalescence the affected skin will often peel, a process known as desquamation. In severe cases, if the patient is not treated with antitoxins and/or antibiotics, the toxins can accumulate and remain circulating in the body, potentially leading to rheumatic fever, kidney disease, and other possibly fatal complications. Less fatal but quite frequent before the development of effective chemotherapy, toxins remaining in the body produced a spasmodic condition of the face and extremities known as St. Vitus’s dance.3 Present in Europe and North America as a relatively mild disease in the seventeenth and eighteenth centuries, scarlet fever seems to have mutated into a much more virulent infection in the middle third of the nineteenth century, becoming the source of a series of deadly epidemics that raged through European and North American cities and small towns from the 1850s through the 1890s.4 Although more deadly to children under six than to school-age children, these epidemics were made visible when they raced through school systems and were most feared and talked about as school epidemics. For instance, in a much publicized example, a scarlet fever epidemic swept through Charleston, South Carolina, in 1881. Health authorities subsequently defined the epidemic as beginning when first one and then several children at a single school presented the telltale symptoms and developed scarlet fever. Within a few weeks the disease had spread to children at almost all the schools in the racially segregated system and ultimately claimed the lives of 117 victims, while leaving scores of others physically impaired.5 Particularly during the 1880s, most American cities and many towns experienced similar epidemics of scarlet fever and typically associated them with schools and schoolchildren. Moreover, although scarlet fever was increasingly better understood as an early childhood disease and declined dramatically in both incidence and virulence after 1890,

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the disease continued to strike fear into the hearts of parents of schoolchildren well into the early twentieth century.6 As fearsome as scarlet fever was, diphtheria was even more terrifying. Also an acute infectious disease, diphtheria is caused by the bacillus Corynebacterium diphtheria, which usually lodges in the throat. It can remain there for weeks, producing little more than minor soreness. In some cases, however, the bacteria multiply and launch an attack on the throat tissue that produces a leathery pseudomembrane that can grow thick enough to block the airway and cause death by strangulation. Also deadly is the virulent toxin that the bacteria produce. Causing high fever, it attacks nerve and muscle tissue, doing damage severe enough to cause death or lifelong incapacitation. Difficult to diagnose because of its various presentations, diphtheria was often confused with septic sore throat and whooping cough or classified as a complication of the measles or scarlet fever even after it was identified as a distinct disease entity in the 1820s.7 As was the case with scarlet fever, a more virulent and deadly strain of diphtheria seems to have emerged in the middle third of the nineteenth century and was responsible for a number of increasingly severe epidemics in Europe and North America from the late 1850s through the beginning of the twentieth century. With an even higher fatality rate than scarlet fever, diphtheria came to be greatly feared for the number of children’s deaths it could cause in a relatively short period. During a few months in 1876, for instance, when it was epidemic in New York City, the disease claimed over a thousand victims, most of whom were children. Indeed, although diphtheria killed people of all ages, by far its most numerous victims were the young. Of the 3,264 people reported as dying from diphtheria in Michigan during the years 1876 through 1879, 3,000, or 92 percent, were under the age of fifteen.8 Diphtheria also provoked considerable fear because its symptomatology and mode of transmission seemingly defied logic. Some cases were mild and presented as little more than a sore throat, while others were deadly and included the full panoply of symptoms. Although increasingly considered a contagious disease, diphtheria did not act like one. It did not confer immunity on those infected, and contracting it seemingly did not require contact with an infected person or object. Yet neither did it act like a disease caused by filth. Though widely believed to be nurtured by poor sanitation and transmitted by sewer gas, it often failed to be kept at bay by hygienic measures, whether personal or domestic. It appeared to afflict both the wealthy and the poor, and it found its way into families devoted to hygiene as often as it did into families where hygiene was a stranger. Indeed, even the most informed and careful parents seemed powerless to protect their children, a point tragically underscored

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in 1883 when diphtheria claimed the life of seven-year-old Ernst Jacobi, whose father, Abraham, was widely considered one of the nation’s leading authorities on the hygienic prevention of the disease.9 The symptomatology and transmission of diphtheria remained in some dispute even after the bacillus causing the disease was identified in 1883 and laboratory and field techniques were developed in the 1890s to collect and analyze cultures taken from the throats of those suspected of being infected. This was because the increasing use of culturing and laboratory analysis to distinguish the infected and contagious from the noninfected and noncontagious revealed the widespread presence of the bacillus in the throats of those who showed no symptoms of the disease. Whether these healthy carriers were sick and contagious and should be treated as such was a contentious issue through the 1920s.10 As outbreaks of scarlet fever and then of diphtheria grew in number and severity, those charged with safeguarding the public health increasingly expressed concern that allowing children to go to school while the diseases were coursing through a city or town was dangerous both to the children and to the larger community. Noting in his 1881 presidential address to the American Public Health Association that although “the part played by schools in the dissemination of contagious disease is only now beginning to be apprehended,” Charles B. White contended that it seemed incontestable that “the assembling of children together in schools during an epidemic constitutes one of the most formidable sources of those local outbreaks of the infectious diseases of children, particularly scarlet fever and diphtheria.”11 Other physicians and public health officials made similar assertions, often referencing an accumulating body of international statistical evidence that seemed to confirm the long-held suspicion that the incidence of contagious childhood diseases increased when the school term began and decreased when it ended. In an early and much-cited example of that body of evidence, the Hungarian demographer Jozsef Korosi demonstrated that in several major cities in Europe the incidence of measles was six times higher when school was in session than when it was not. Also influential was a series of studies published during the 1880s in the British Medical Journal showing that the course and severity of several recent outbreaks of scarlet fever and diphtheria had closely corresponded with the school term. Thus, by 1893 the American sanitarian Jerome Walker could confidently assert that almost no one still doubted that “contagious diseases, especially in cities, largely increase at the fall opening of the schools.” Boston’s health commissioner, Samuel Durgin, agreed, noting that the previous year his department had published a chart that clearly linked yearly increases in the incidence of diphtheria and scarlet fever to the beginning of the school year.12

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Facing what they perceived as a dangerous rise in epidemics of scarlet fever, diphtheria, and other contagious childhood diseases and increasingly convinced that schools were contributing to that rise, urban health officials on both sides of the Atlantic debated what course of action to take. Indeed, according to the British public health historian Anne Hardy, during the 1880s and early 1890s the question of how to control the influence of schools and schooling on epidemics was among the most hotly debated issues in English preventive medicine.13 Particularly at issue was the efficacy and wisdom of closing schools when an epidemic occurred, to limit contact between the infected and the uninfected. This was the traditional method, most trusted by parents and seemingly supported by the research connecting the frequency of epidemics with the schools’ being in session. However, although the practice would continue into the early twentieth century, by the 1880s it was already under attack for being ineffective, especially in crowded urban neighborhoods where the released infected and uninfected children intermingled in the streets as much as they did in their schools. In his 1887 school hygiene manual, Arthur Newsholme, later Chief Medical Officer for England and Wales, noted that although closing schools might work in rural areas, it was all but useless in cities and towns. That was also the opinion of a committee appointed in 1893 by the Massachusetts Association of Boards of Health and charged with assessing the effectiveness of closing schools in cities.14 Another frequently noted drawback to closing schools was that it had become unacceptably disruptive. As school terms were lengthened in the late nineteenth century and curricular goals more clearly established, few school systems had the flexibility to close schools for the four weeks recommended for an epidemic of measles or the six weeks for one of diphtheria. As a consequence, even those who thought school closing was a valuable preventive measure recognized that it had become a problematic option. “Under present imperfect methods,” noted Henry Baker, the highly respected founder and first secretary of the Michigan State Board of Health, “there seems little escape from one of two evils,—either the schools continue to spread scarlet fever, diphtheria, and other communicable diseases throughout cities and throughout the state, as they are now spreading diphtheria; or the schools are closed, and though the public health, which is of the greatest consequence, is furthered thereby, the whole educational work is for the time broken up.”15 As school hygienists debated how to avoid the two evils articulated by Baker, they employed concepts of contagion that were evolving under the influence of the emerging germ theory of disease—that is, the theory that infectious diseases are caused by specific living microorganisms and spread by the

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transmission of those organisms from the infected to the uninfected. Through much of the nineteenth century, common wisdom and medical theory held that although not all infectious diseases were contagious, some—most notably smallpox, plague, scarlet fever, and the measles—certainly seemed to be. People who had such diseases were believed to emit some type of infectious agent that could be harbored in their clothes and possessions, cling to the walls and objects in a sick room, and even infect the atmosphere. Precaution thus demanded the isolation of the sick, destruction or disinfection of contaminated objects, and fumigation and ventilation of sick rooms.16 Although the germ theory did not radically alter these beliefs and practices, it did reorient them and give them greater specificity. Disease was caused and transmitted not by some obscure chemical or organic agent, but by microbes that could be seen under a microscope and identified, even if the specific microbe that caused a specific disease had yet to be isolated. Contamination thus came to be defined by the level of microbial presence and decontamination by the dispersal or destruction of those microbes. Fumigants and disinfectants came to be employed for their germicidal capabilities, and ventilation was promoted as a way of dispersing germs floating in the atmosphere. Most significantly, the growing influence of the germ theory and its central tenet— that specific diseases could be traced to specific and identifiable microorganisms that reproduced in the body—inspired a redirection of the hygienic gaze so that, although keeping the environment in view, it increasingly focused on the bodies of individuals as producers, carriers, and victims of pathogens. In the school hygiene movement, this meant that the hygiene of the individual schoolchild—and eventually of teachers, janitors, and other personnel—joined the hygiene of the school and the hygiene of instruction as a major object of concern and discussion. Battling Germs

As school hygienists embraced the germ theory and its implications and shifted their gaze to the bodies of schoolchildren, they redefined their mission as centering on protecting uninfected bodies from contact with whatever pathogens might be present in the school. One consequence of this redefinition was the initiation during the late 1880s and early 1890s of a new round of school sanitary investigations that differed from those of the 1870s in that they were designed not to discover levels of general filth or carbonic acid pollution, but to determine the prevalence of germs. First in Great Britain, Scandinavia, and elsewhere in Europe, and then in North America, investigators from medical societies, civic organizations, and health departments ranged through

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city schools swabbing surfaces in classrooms, hallways, and privies; collecting dust from between floorboards; and taking samples of schoolroom air. When they examined what they collected under microscopes, they discovered teeming seas of bacteria. In 1891 the US commissioner of education reported that sanitary investigators in Europe had found that dust collected from between schoolroom floorboards was chock-full of microbes. A year later, in his review of school hygiene research, William Burnham noted that several analyses of classroom air had produced similar findings. For example, an examination of air samples taken from Berlin classrooms yielded a count of 15,000 microbes per cubic meter. A test of the air in St. Petersburg schools produced an even higher figure, prompting the Russian investigator to estimate that each of the city’s schoolchildren inhaled over 40,000 microbes per school session.17 The revelation that schools and schoolrooms were swarming with microbes, many of which might prove to cause disease and spark epidemics among schoolchildren and the general populace, provided new impetus and justification for hygienists’ ongoing quest to improve school ventilation. Lobbying for support in getting a school ventilation code adopted, a New York City Health Department official explained to a group of physicians at the New York Academy of Medicine: “Youthful life in our public schools is in constant jeopardy [because] pathogenic germs, invisibly floating in the atmosphere, are ever liable to enter the unprotected system by inhalation and absorption.” Without good ventilation systems and adequate air space per student to disperse the germs, he warned, “epidemics of alarming proportion ensue.”18 Other health officials delivered similar warnings and were often echoed by professional and civic groups like the Milwaukee Women’s Educational Alliance, which in 1891 conducted a bacteriologically informed sanitary survey of the city’s schools and found that in a number of them, per pupil airspace and ventilation were totally inadequate to prevent classrooms from filling with pathogenic bacteria. In one particularly bad school, the alliance reported, “teachers are pale and languid and assert that their classrooms are filled with deadly microbes. The rooms of the younger children are directly over vile [water] closets, and it is the greatest wonder that some epidemic does not break out among them.”19 The discovery that schools were hothouses of germs also reinvigorated ongoing efforts to improve building sanitation, though it increasingly redirected those efforts toward the targeted destruction and removal of germs and the mediums in which they could reside and multiply. Dust was identified as particularly dangerous because of its ability to house germs in cracks and crevices and carry them into the schoolhouse whenever a door or window opened. To keep dust down, school hygiene experts recommended that damp mopping

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replace sweeping and that school chalkboards be washed regularly. They also recommended that school systems cover wooden floors or seal them with one of the many commercial sealants that were coming on the market.20 Most of all, however, they recommended the liberal use of disinfectants and germicides— not just following an epidemic in a school, but on a regular schedule, as was increasingly being done in hospitals.21 Indeed, for many involved in school hygiene, hospitals offered an instructive example, for only by employing rigorous disinfectant regimens were those institutions finally beginning to lessen the incidence among their patients of erysipelas, sepsis, and other streptococcal infections that had long seemed to incubate within their walls. Agrippa Bell, for instance, frequently editorialized in the Sanitarian on the necessity of regular disinfection in schools, noting that diphtheria, scarlet fever, and other infectious childhood diseases were to schools what erysipelas, pus poisoning, and puerperal fever were to hospitals.22 Because little was yet known about how long and in what form pathogens could survive outside the body, care was also taken to minimize students’ contact with clothing and objects that might in turn have come in contact with an infected person or with pathogens floating in the unhygienic atmosphere outside the school. Theories of contagion had long assumed that infectious agents remained in rooms occupied by the sick, on objects they touched, and on clothing they had worn, and the early elaboration of the germ theory did little to challenge that assumption. Indeed, since some of the original work in bacteriology was done with the anthrax bacillus, which produces spores that are incredibly hardy and capable of causing infection long after the original host has died, early germ theory tended to reinforce and even heighten traditional concerns with the contagious power of fomites—the term most commonly used at the time for materials capable of harboring and transmitting agents of infection.23 Rare was the school hygiene discussion of the relation between schools and scarlet fever or diphtheria that did not contain cautionary tales of young children who were stricken after wearing a scarf, hat, or coat of a sibling who had previously died from one of the diseases.24 To inhibit such fomite infection, school hygienists recommended and school boards decreed that storage for coats be moved out of the classroom and into the halls, and that each child be given his or her own peg. At the urging of school hygienists, school systems also eventually discontinued the long-standing practice of having students share books, slates, chalks, pencils, and other educational articles and began providing students with their own books and supplies. Indeed, fomites became a major issue in the turn-of-the-century battle over the state provision of schoolbooks, with opponents of using tax funds to purchase books citing the danger

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of fomite infection to support their case.25 As the conservative editors of the Baltimore American argued in a 1900 editorial that was reprinted in other large city newspapers: One of the most objectionable features of our present socialistic school system is the danger of carrying contagious disease through the exchange of infected state-furnished books from student to student, as they pass from grade to grade. A convalescent diphtheritic child sits up in bed and is given its older brother’s book for amusement. It leafs through the book, wetting its fingers with diphtheric saliva, to turn the leaves. Months or perhaps years after another child thumbs through those same leaves in a similar manner, touching with its moistened thumb the identical spot the diphtheritic child touched, and carrying the latent germs back into its mouth when wetting the thumb for the next leaf. Is there any wonder we have epidemics of diphtheria and other contagious diseases?26

Mounting concern that dangerous germs remained on objects used and touched by the infected also ultimately spawned successful campaigns to rid schools of shared towels and common drinking cups and replace them with roller towels, paper cups, and bubbling drinking fountains, all of which had been developed by 1910. During the first decade of the twentieth century, various bacteriologic investigations implicated shared towels in the spread of conjunctivitis, trachoma, and other eye diseases and the common drinking cup in the transmission of virtually every contagious disease to which children were vulnerable. In a much cited and reprinted 1908 magazine article sensationally titled “Death in School Drinking Cups,” Lafayette College biology professor Alvin Davison reported that his microscopic examination of a common cup in use for nine days in an elementary school revealed that “not less than one hundred thousand bacteria were present on every square inch of the glass.”27 The following year, Kansas became the first of what would soon be many states passing legislation banning common towels and cups from schools and other public places.28 Schoolchildren as Vessels of Germs

School hygienists and school officials recognized, however, that sanitizing the school environment was futile if it was contaminated every day by unclean and infected children. After enumerating a long list of what it called “commendable advances in building sanitation” designed to reduce the concentration of germs in the city’s schools, an 1889 New York City Department of Education report lamented that most of those advances were offset by “contamination from often

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filthy students.”29 Other school hygiene committees and individual hygienists made the same complaint, frequently supporting their concern with what became a few iconic reports of students acting as germ carriers. One of these told of German researchers using a microscope to examine the scrapings from under the fingernails of schoolchildren and discovering the germs that caused fifteen distinct diseases. A second recounted a similar microscopic analysis of “the impurities under the fingernails” of Viennese schoolchildren in which “38 species of spherical bacteria were found in addition to 18 species of fungi and other disease spreading organisms.” And a third described an analysis of the dust and grime brought into school on children’s coats, which revealed a virtual sea of pathogens.30 To late-nineteenth-century American school hygienists, the difficulty of achieving germ-free schools when they were daily filled with germ-laden children seemed particularly great in those urban areas where student populations were made up of the native and immigrant poor—to whom, it was believed, personal hygiene was often a stranger. A physician writing in Education explained that although good ventilation and rigorous disinfection were critical to fighting germs in school, these tactics could hardly be expected to keep the atmosphere germ free when “thirty, forty, fifty, or even sixty children are shut up in a school-room, many of them coming from homes where the bath tub is a luxury, unthought-of, and often the garments are worn day and night, perhaps unwashed for weeks.”31 Another later recalled that most physicians familiar with city schools at the end of the nineteenth century were convinced that the massive influx of immigrant children—whose parents, the physicians believed, were almost uniformly ignorant of germs and their role in contagion—had turned each classroom into a concentrated pool of pathogens.32 Concern with unwashed and potentially contaminated students led to calls for the teaching of personal hygiene as part of the curriculum and to the adoption in some states and cities of ordinances empowering school officials to send home students whom teachers deemed excessively noisome or dirty. California, for instance, passed legislation in 1889 decreeing: “All pupils who go to school without the proper attention having been given to personal cleanliness or neatness of dress shall be sent home to be properly prepared for school or shall be required to prepare themselves for the schoolroom before entering. Every schoolroom shall be prepared with a washbasin, soap and towels.”33 Fear of dirty urban schoolchildren also prompted some educators and school hygienists to propose that shower baths be installed in schools so that unhygienic children could be cleansed and kept in school. Although controversial when first advocated in the mid-1890s, putting shower baths in schools quickly

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gained the support of many big-city school officials. Stating that he considered “the school bath system as important as the school library system,” the president of the New York City Board of Education in 1901 requested $30,000 to construct shower baths in ten elementary schools, thereby initiating a program that over the next few decades would make the provision of bathing facilities a feature of many New York schools. School baths were also established in midsize cities like Providence, Rhode Island, which by 1913 had equipped a third of its primary schools with showers.34 Adopting a Policy of Exclusion

Even more worrisome than dirty students were infected students. Although some physicians continued to believe that infectious disease could originate de novo in filth and be contracted by inhaling miasma, many more were coming to accept the idea that the infectious diseases afflicting schoolchildren were caused by pathogens that reproduced in the bodies of infected children and were somehow transmitted from those bodies to the bodies of the uninfected.35 Preventing that transmission by minimizing contact between the infected and the uninfected was thus increasingly seen as critical in the effort to avoid epidemics in schools. Questioning whether closing schools was either a desirous or an effective method for achieving such minimal contact, those concerned with preventing school epidemics increasingly recommended an alternative: the mandatory exclusion from school of children sick with or recovering from dangerous contagious diseases. As a means of inhibiting the spread of contagious disease, prohibiting sick and recovering children from attending school seems to have been considered for the first time during the 1870s. In an 1875 Sanitarian editorial, Bell called it a novel approach and noted that a medical society in England had begun lobbying school officials to adopt rules preventing the attendance at school of any child sick with, recovering from, or exposed to scarlet fever or measles until a physician certified that the child was no longer contagious.36 The following year, at a meeting of the Boston School Committee, a local physician urged the adoption of similar rules, noting that although parents rarely sent seriously ill children to school, they commonly sent children who were only partially recovered and therefore still contagious. Such children, the physician warned, had to be kept out of the schools, and he recounted how “a single child, sent to school before entire recovery from scarlet fever, in one of the arrondissements of Paris, in 1875, has been clearly shown to have been the direct cause of a hundred and fifty cases, of whom eighteen died.”37 In Michigan, state health department officials also began calling for the exclusion of schoolchildren who

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might be contagious, not only with measles and scarlet fever, but also with diphtheria, the presence and deadliness of which seemed to be increasing at an alarming rate.38 As a means of preventing epidemics of contagious disease, excluding infected children from school was promoted and embraced, in part because it was consistent with the direction that American and European public health was going in the last decades of the nineteenth century. Faced with epidemics of smallpox, scarlet fever, and diphtheria and influenced by a germ-theorybased etiology, public health departments began initiating programs to control contagious disease that were organized around the identification and isolation of the infected and the disinfection and fumigation of their homes. In particular, beginning in the 1870s, municipalities and states began passing legislation or adopting ordinances requiring physicians—and, in some cases, coroners, apothecaries, and teachers—to report to the local health department cases of scarlet fever, diphtheria, typhoid, and other potentially epidemic diseases. Using those reports, sanitary inspectors were soon visiting the homes of the sick, posting warning placards on the outside, and giving instructions on or overseeing the quarantine of the infected and the disinfection and fumigation of the sick room. School exclusion, its promoters argued, was a necessary part of this program and needed to be adopted and enforced if contagious disease were to be controlled.39 Among the first cities to adopt the policy of exclusion was Boston. As part of an 1877 Board of Health order requiring physicians to report cases of diphtheria and scarlet fever, the city mandated that no child from families in which these diseases existed be allowed to attend school until four weeks after the commencement of the last case within the household.40 About the same time, the boards of health of Brooklyn and Manhattan issued similar orders, and by 1892 seventeen major cities and twelve states had followed suit. A few of the state laws, like that enacted in Maine, were simply permissive, authorizing school boards to exclude children infected with or exposed to contagious diseases but giving no other direction. At least one of the laws—that passed by Maryland—placed responsibility for exclusion not on the school authorities but on parents, establishing a $100 fine for anyone who “permits infected children under his or her care to attend any school.”41 Most of the state laws, however, basically directed school authorities to exclude children from households with cases of specified diseases for a specific period of time and required that a child’s recovery or noncontagiousness be certified by an attending physician or health officer. Typical was the Massachusetts law. Passed by the legislature in 1884, it stated:

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The school committees shall not allow any pupil to attend the public schools while any member of the household to which the pupil belongs is sick of smallpox, diphtheria, or scarlet fever, or during a period of two weeks after the death, recovery, or removal of the sick person, and any pupil coming from such a household shall be required to present to the teacher of the school the pupil desires to attend a certificate from the attending physician or board of health of the facts necessary to entitle him to admission in accordance with the above regulation.42

The city ordinances also varied. A few were vaguely worded, open ended, and multipurpose. For example, Jersey City’s ordinance mandated that “no pupil who is not personally clean, or comes from a family afflicted with any contagious disease, or is an imbecile, shall be allowed to remain in school.”43 Others were very specific, like Providence’s 1884 regulation, which excluded from attendance for specified periods children infected with or exposed to smallpox, scarlet fever, diphtheria, measles, whooping cough, mumps, or chickenpox and which applied to parochial as well as public schools. But most of the ordinances were like that adopted by San Francisco in 1893, which decreed: “Those who are affected with, or in whose family there may be any contagious disease shall not be allowed to remain in or to return to school without a certificate from the attending physician.”44 Of course, adopting exclusion regulations was one matter, applying them quite another. One problem was that although the laws empowered or required schools to exclude children sick with contagious diseases, they gave them no help in diagnosing such children. The child who vomited as scarlet fever took hold might be readily identifiable as infected, but not the child who developed a mild sore throat with the onset of diphtheria. Another problem was that the periods of exclusion, although perhaps logical given what was then known about the contagiousness of the diseases, seemed impossibly long to both educators and parents. If the regulations were followed to the letter, the typical excluded student would be out of school for six weeks or more. Teachers and school administrators worried that having several members of each class miss large chunks of the curriculum would vastly complicate teaching and make keeping to a schedule impossible. Parents were concerned that their excluded children would fall too far behind or might lose their place in a class and school. This last was not an unjustified concern, for in the final two decades of the century the urban school population increased so dramatically that the demand for places in school far outstripped the supply. In Boston and New York during the early 1880s, lack of room kept 3,000 to 4,000 children per year

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from attending school. And in Philadelphia, Superintendent James MacAlister estimated that there were 20,000 young children not attending school because of overcrowding.45 In addition, parents often did not see the logic in keeping well children home simply because a member of the family was or had been infected with an excludable disease. Not surprisingly, then, parents subverted the exclusion rules in almost any way they could: by contesting all but the most obvious diagnoses; by failing to report cases of excludable sickness within their households; and, quite commonly, by convincing sympathetic or mercenary physicians to certify their children as fully recovered considerably sooner than was recommended. As a result, even after the exclusion policies were adopted, schools and schoolrooms remained filled with contagious children who infected each other. Indeed, a New York City Health Department report told of one student, certified as recovered though still desquamating from scarlet fever, spending his first day back peeling skin from his hands and fingers and passing it around to his classmates.46 Establishing Medical Inspection

It was not long, then, before those who had promoted exclusion were complaining that the new regulations were having far less effect than hoped because schools lacked the personnel and often the desire to implement the rules and make certain that they were not being flouted or ignored. As the Boston Medical and Surgical Journal editorialized, “To be sure there are rules of the Board of Health which regulate the attendance in school, within certain limits of time, of any child who is suffering from a dangerous contagious disease, or who comes from a house wherein such a disease exists. But who is to watch that these rules are not to be disobeyed—for that they are disobeyed there can be no question?” In answer to their query, the journal’s editors urged that school systems finally comply with the school hygienists’ suggestion that physicians be appointed and allowed to enter schools as sanitary or medical inspectors. In addition to overseeing the sanitary condition of schools and monitoring the hygiene of instruction, these physicians could be called on to examine, diagnose, and certify as contagious or noncontagious children who were suspected of being infected with an excludable disease or who were returning to school after being excluded.47 During the latter part of the 1880s and the early 1890s, arguments that contagious disease control required the appointment of school medical inspectors increasingly became a central part of the school and public hygiene discourses in the United States and abroad. Proponents of medical inspection

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contended that teachers and school administrators did not have the expertise to diagnose infected children or the scientific authority to deal effectively with parents who disputed their diagnoses. Advocates of inspection felt this was especially true with diphtheria, mild cases of which remained incredibly difficult to diagnose. Noting that to the untrained eye, it was impossible to distinguish between the mildly diphtheric throat and the throat irritated by catarrh, a physician speaking before the 1890 annual meeting of the Pediatric Section of the American Medical Association suggested that the only way to prevent schools from propagating diphtheria was to have available a corps of physicians who could examine the throats of all children complaining of soreness.48 Calls for medical inspection to enforce exclusion also frequently echoed the earlier sanitarian argument that compulsory attendance laws made the state morally and legally responsible for ensuring that children going to school faced no harm. Enumerating a series of reasons why cities and towns should embrace school medical inspection, a special committee of the American Public Health defined the first thusly: The State, by statute, requires school attendance at an age when the individual is peculiarly prone to fall a victim of the diseases which prevail in all groups of young persons, and in assuming the control and custody of the child during five hours each day the State becomes morally responsible for the health of the pupil during that period, and it is wholly indefensible that public schools should be conducted in buildings which are insufficiently ventilated, lighted and heated. It is equally indefensible to bring children together, by lawful authority, without using every reasonable endeavor to weed out and exclude infected individuals.49

Proponents of medical inspection also argued that it would improve enforcement of the compulsory vaccination laws that many states and municipalities had on their books. Such laws, prohibiting unvaccinated children from being admitted to school, were a response to the resurgence of epidemic smallpox in the United States during the last third of the century. An ancient, repulsive, and deadly disease that had regularly scourged the colonial American population, smallpox had been brought under relative control during the late eighteenth and early nineteenth centuries by quarantine measures, the widespread use of the vaccination process developed in the 1790s by Edward Jenner, and a probable decline in the virulence of the disease. In the 1870s, however, after years of increasing public and official complacency about vaccination, the disease erupted again, with significant epidemics occurring in each of the last three decades of the century.50

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In elaborating the probable sources of the reappearance of epidemic smallpox, American health officials placed considerable blame on parents, especially immigrants, who neglected or resisted having their children vaccinated in infancy, as was recommended by most regular medical authorities. The presence of such children at school, the officials argued, fanned epidemics as infected children passed the disease to their unvaccinated classmates, who then brought it home to their families. Indeed, by the 1880s many American health officials would have agreed with O. C. DeWolf, commissioner of the Chicago Department of Health, when he argued before the American Public Health Association that the single most important cause of recent epidemic outbreaks of smallpox in his city and elsewhere was the increasing number of unvaccinated children in the public schools.51 In order to compel recalcitrant parents—both immigrant and native-born— to have their children vaccinated and thus diminish the role of the school as a propagator of smallpox, states and municipalities adopted a tactic employed in England and Europe and began empowering or requiring school boards and committees to deny admission to any child who had not been vaccinated.52 As with most other developments in public health policy, the Northeast led the way, with the earliest municipal ordinances being adopted by Boston, New York City, and Brooklyn, and the earliest state laws by Massachusetts and New York. But by the early 1890s most large cities and at least seventeen states had also passed legislation, often incorporating vaccination requirements into compulsory education statutes. Some of the laws, like those passed by Connecticut and Georgia, were simply permissive, empowering but not directing school boards to prohibit the admission of unvaccinated children. Other laws required school boards to do so. And a few, like those passed by New York State and New Jersey, empowered school boards to use funds to hire private physicians to vaccinate unvaccinated prospective students.53 As was true with the exclusion laws, however, enforcement was problematic and uneven. The early laws, especially, were rather vague on how prior vaccination was to be determined and what constituted proof of it. Brooklyn’s law, for instance, stipulated only: “When a child is presented for admission to a public school of this city, the principal shall ascertain at the time that he or she has been satisfactorily vaccinated or has had smallpox, and record the fact with the child’s name.”54 The St. Louis law simply required that a child seeking admission to a school be accompanied by a parent who could certify that he or she had been vaccinated. Moreover, enforcement was left largely to teachers and school administrators who had neither the expertise nor the inclination to examine children for vaccination marks and who, understandably, were

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usually more interested in admitting than excluding children. Public health officials and others who saw the compulsory vaccination of schoolchildren as key to the control of smallpox thus argued that such control would be achieved only if trained physicians were assigned to the schools to make certain that the regulations were followed.55 Despite the increasing agitation from the public health community, in the last decade of the nineteenth century medical inspection remained a muchdiscussed but little realized proposal. One reason for its continuing failure to be adopted was the reluctance of city and town councils to appropriate the funding needed to hire inspectors. In most American towns and small cities, public health activity remained periodic and barely funded and was carried out by part-time health officers and volunteers. In midsize cities, the situation was not much better. And even in large cities, health departments could not embark on an enterprise as large as the examination of sick schoolchildren without being awarded significant extra funding.56 But lack of funding was not the only impediment. Even when such funding was made available, medical inspection was sometimes blocked or delayed by jurisdictional conflicts between school and health authorities and by resistance from some private practitioners. That was certainly the case in Boston, where in the mid-1870s—shortly after returning from the American Social Science Association meeting where he had heard David Lincoln and others discuss the importance of school sanitation—Samuel Durgin, longtime chairman of the Boston Board of Health, began lobbying for funds to pay school sanitary inspectors. Although he was rebuffed each year, he continued through the 1880s to ask for funds, increasingly arguing that the inspectors would play a vital role in the suppression of scarlet fever, diphtheria, and smallpox. His efforts finally paid off in 1890, when the city council granted the Board of Health a special appropriation sufficient to finance the appointment of fifty part-time school medical inspectors. Durgin knew, however, that getting funding from the council was only a first step. Although not legally required to win the approval and support of school officials, he felt he had to do so if medical inspection was to work. Hence, in early spring 1891 he submitted to the School Committee a petition soliciting its formal consent to the Board of Health’s plan to begin medical inspection when the schools reopened the following September. Meeting shortly after receiving the petition, the School Committee proved unreceptive. Although its members acknowledged that some benefit would accrue from having physicians available to examine children suspected of being infected with dangerous contagious diseases, they nevertheless decided to reject Durgin’s request. According to an explanation later provided by a physician who

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attended the meeting, the committee’s decision was motivated by two concerns, both of which in varying forms would critically influence the adoption and evolution of medical inspection throughout the nation. The first was that neither the committee nor individual school administrators would have jurisdiction over the Board of Health inspectors and thus would be powerless to modify their operations if they proved disruptive to the primary mission of each school: educating children. In particular, committee members worried that overzealous or inexperienced physicians might send so many children home for so long a period that some schools would be depopulated and education would come to a standstill.57 The second concern was quite different from the first, had little if anything to do with education, and was expressed by eight of the nine physicians who were members of the School Committee. Although by sitting on the committee they showed themselves committed to the idea that the expertise of physicians was critical to making schools and schooling safe for children, they were uncomfortable with the prospect of physicians actually examining and diagnosing individual students. Specifically, they worried that the inspectors would use their positions to solicit the patronage of the students and their families. As Charles Green later explained in accounting for the opposition to Durgin’s request from his fellow physicians on the committee, “it was apparently believed by some that the medical inspectors would interfere with the family physicians and would seek to displace them.”58 Three years later, however, in October 1894, the School Committee reversed itself, though not because its concerns with jurisdiction and the sanctity of private practice had diminished. The reason was more immediate: an epidemic of diphtheria that had been raging since school opened the previous month. As child after child came down with the deadly disease, parents pressured school officials to make the schools safer or close them down until the epidemic had run its course. Opposed to closing schools, yet aware that they could not enforce the exclusion regulations without assistance, school officials dropped their resistance to having Board of Health physicians in the schools, thus making their school system the first in the United States to allow for the medical inspection of its students.59 Acting quickly to quell the epidemic, the Board of Health hired fifty physicians, and by the first of November it had assigned each of them to a district, containing four schools. Every morning the inspectors made the rounds of their schools, examining any child whom a teacher or principal had identified as having suspicious symptoms. If an inspector judged the child to be infected with diphtheria, he reported the case to the Board of Health and advised the

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school to send the child home and not allow him or her to return until certified as recovered.60 The medical inspector also instructed the school to apply the exclusion rules in regard to any siblings of the infected child. By the end of December the epidemic had receded, and the inspectors turned their attention to routine medical inspections that involved examining selected students for a range of contagious diseases.61 Public alarm over school epidemics played a leading role in prompting school officials in other cities to put aside their resistance to having physicians in the schools and to accept medical inspection. This was especially true in regard to diphtheria, which by the 1890s had become the leading killer of schoolchildren, accounting for over 14 percent of all deaths of those between the ages of five and fifteen.62 In 1895, during a diphtheria epidemic that began with five cases in a single school and then spread throughout the city, Chicago school officials finally agreed to an existing Health Department plan to divide the school system into nine districts and appoint a medical inspector to each. Two years later, prompted by a diphtheria outbreak that began when school opened in the fall, Philadelphia school officials did the same, agreeing not to oppose a Board of Health plan to appoint fifteen volunteer medical inspectors, each of whom would be responsible for visiting two schools daily.63 In New York, medical inspection came not after one school epidemic but after a year in which outbreaks of diphtheria, scarlet fever, and measles plagued the city’s schools. Responding to public concern, the Board of Education agreed to a Health Department investigation aimed at determining whether lax enforcement of the exclusion rules was at fault. A Health Department physician visited all the schools where outbreaks had occurred and questioned and examined the children. He found that a significant number of them had symptoms of excludable contagious diseases. Some of these were children who had continued to come to school even though they had a sibling at home with an excludable contagious disease. Most, however, were children who had mild cases of diphtheria or who had returned to school while still contagious with measles and scarlet fever. When the Health Department reported the inspector’s findings to the Board of Estimate and the School Committee in early 1897, it received an appropriation sufficient to hire a chief school medical inspector and 150 part-time inspectors, who were charged with making daily visits to schools assigned to them and identifying and sending home those children with excludable contagious diseases.64 By 1901, when the American Public Health Association’s newly revived Committee on School Hygiene published a report on what American municipalities were doing to detect and prevent communicable diseases among

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schoolchildren, a number of smaller cities—like New Haven, Connecticut, and Newark, New Jersey—as well as cities outside the Northeast such as Milwaukee, Minneapolis, and Salt Lake City, had also adopted medical inspection of their schoolchildren. And six years later, when the Russell Sage Foundation funded another national survey, it found school medical inspection being conducted in at least 102 cities—including 32 in Massachusetts, where inspection had been made mandatory by a 1906 state law. Not surprisingly, the bulk of these cities were in the Northeast and the Midwest, although most of the major cities of the West and Southwest were also on the list. In the South, however, only New Orleans had established medical inspection.65 To allay the concerns of local physicians, almost all of the ordinances establishing medical inspection had provisions expressly prohibiting medical inspectors from treating the children they examined or even having contact with them outside of school. Moreover, those in charge of medical inspection took pains to assure physicians in their communities that no unfair competition would result. Durgin spoke to a number of medical groups in the years after medical inspection began in Boston and always emphasized, as he did in an 1895 talk to the Boston Society of Medical Improvement, that “the medical inspector never undertakes to give treatment in any case. They merely point out the need of professional treatment where the need exists. The treatment itself must be received from the family physician or in the hospitals or in the dispensaries.”66 The ordinances establishing medical inspection and the rules adopted for the process also made it quite clear that the duties of the medical inspectors were to be circumscribed. Medical inspectors were to limit themselves to examining children and enforcing the exclusion laws by ordering home those who were infected with a contagious disease. Although they were not prohibited from commenting on the sanitary condition of the schools to which they were assigned, they were usually given neither the responsibility nor the right to inspect or monitor it. Nor, initially at least, were they obligated or entitled to oversee the general health of the students in their schools or to evaluate the impact on that health of the school’s environment and instructional methods. Thus, although the adoption of medical inspection finally brought physicians into the schools, it did not do so in the role of the expert advisor long envisioned by proponents of school hygiene reform. In smaller cities and towns, where health departments usually consisted of no more than one or two part-time employees, the responsibility for hiring physicians and conducting medical inspections was often vested with school authorities. But in almost all larger American cities, medical inspection was initially coordinated and carried out by health departments or boards, in part

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because their authority extended into parochial as well as public schools. Thus, for the most part, medical inspectors were the paid employees of health departments and were vested with the police authority those departments enjoyed. In a few cities, however, where city councils initially refused funding or withdrew it after the threat of an epidemic receded, medical inspection was carried out for a time by volunteer physicians, usually under the direction of the health department. One of those cities was Philadelphia, where for the first few years the Health Department relied on the Philadelphia Medical Society to recruit volunteer physicians to inspect children in the schools. Indeed, in what turned out to be a successful effort to win funding by demonstrating the effectiveness of school medical inspection in suppressing contagious disease in the city, the society convinced 200 local physicians in 1899 to pledge to serve for a year as volunteer medical inspectors in the city’s schools.67 During the early years, there were basically two models of medical inspection. The first, adopted by many smaller cities and towns, was developed by Chicago health authorities in response to funding so meager that, two years after they began medical inspection, they could pay for no more than five inspectors to monitor the city’s 236 public and 160 parochial schools. When the Chicago Health Department was notified by a family or dispensary physician of a child having diphtheria, scarlet fever, or another reportable contagious disease, it assigned the case to the inspector in charge of the school district in which the child lived. The inspector would visit the house, explain the exclusion rules to the parents, and make certain the child was isolated. He or she would then visit the school, examine any children who had been exposed to the infected child, and send home those who were either infected or had suspicious symptoms. Before these children or the original infected child would be allowed to return to school, the medical inspector had to certify them as noncontagious. The obvious advantage of this model, which made it attractive to small cities and towns, was that dangerous epidemic diseases among schoolchildren could be monitored by only a few inspectors. In 1897, for instance, Chicago’s five inspectors managed to visit all of the 2,862 homes where cases of diphtheria and scarlet fever had been reported. The disadvantage was that it dealt with contagious children only after they could have infected their classmates and succeeded, if at all, in suppressing only the few reportable diseases to which children were subject. A variation on this model was employed by Charles Chapin in Providence, Rhode Island. With funds sufficient to hire only two school inspectors, Chapin stationed them in city hall and had children whom teachers suspected were infected or sick transported to them. As in Chicago, the school medical inspectors also visited homes with cases of reportable diseases.68

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The other model was that pioneered by Boston and used by New York and most other major American cities. In this model, medical inspectors were assigned a set number of elementary and grammar schools that they would visit each morning and where they would examine pupils whom teachers had identified as being ill or having suspicious symptoms. Any of the examined children determined to be infected with a contagious disease would be sent home with a note to the parents explaining the exclusion rules and recommending that the child be examined by a dispensary or family physician. Inspectors would also frequently examine the other children in the infected child’s classroom to determine whether any of them showed early evidence of being infected. If the detected disease was diphtheria, scarlet fever, or some other legally isolatable disease, the inspectors would immediately notify the health department, which would visit the family and perhaps put a warning placard on the house. If the child had an ailment that was not considered contagious—which at the turn of the twentieth century included most gastrointestinal and respiratory diseases— the medical inspector could recommend but not order that the child be sent home. Children who returned from an absence were also examined and either certified as recovered and noncontagious or sent home again.69 In most cases, medical inspectors recommended that their in-school diagnoses be confirmed by a family or dispensary physician. In the case of diphtheria, this increasingly meant that such confirmation was based on laboratory analysis. The bacillus causing the disease had been isolated in the early 1880s, and by the late 1890s field techniques had been developed that allowed doctors—whether they were in their offices, at a school, or in a clinic—to take cultures from the throats of people suspected of being infected. As a consequence, by the end of the century many health departments had begun to follow the lead of New York City, which in 1894 had established the absence of the bacillus from a throat culture as the main determinant of whether a child could remain in or return to school.70 Medical inspectors were also given responsibility for looking for evidence of vaccination in those incoming students who lacked a physician’s certification. In most cities, however, inspectors were not permitted to vaccinate children, even when health or school authorities were empowered by legislation to vaccinate those children whose parents desired but could not afford it. Some cities, however, made exceptions to this rule during epidemics. For instance, when smallpox swept through Cleveland in 1910, Board of Health physicians, exercising their right of entry into the schools to prevent epidemics, vaccinated 55,000 school children. In nonepidemic times, private practitioners were often called on and paid by the state or city to vaccinate unvaccinated schoolchildren.

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In Chicago, for instance, health authorities had a list of 400 physicians to whom they paid a set fee for vaccinating schoolchildren whose parents had given their approval. And in New Jersey, school districts were empowered by a 1900 law to use school funds to reimburse private practitioners fifty cents for every vaccination provided to a schoolchild whose parents were judged unable to pay for the procedure.71 A Stew of Minor Communicable Diseases

As predicted, early medical inspections revealed that classrooms contained children who were contagious with epidemic childhood diseases. In their first year of operation, Boston’s medical inspectors examined some 14,666 of the city’s 71,495 public schoolchildren and discovered and excluded 70 children with diphtheria, 26 with scarlet fever, 110 with measles, 28 with whooping cough, 43 with mumps, and 34 with chickenpox. Durgin was quick to point to the significance of this, noting “that the number of children who were saved from these diseases by the timely discovery and isolation of the sick ones is, of course, beyond computation.”72 But he also noted that the inspections had revealed a shocking incidence of minor contagious diseases, particularly infectious eye diseases like conjunctivitis and parasitic skin diseases like scabies, ringworm, and especially pediculosis. Indeed, although not particularly looking for them, the inspectors had found more children infested with lice than infected with all of the so-called childhood epidemic diseases combined. Moreover, lice infestation prevailed not just in the overcrowded schools of immigrant neighborhoods. As one medical inspector reported, in a school “within two blocks of the State House,” where “the great majority of these children come from respectable families,” he had found only 24 percent of the 746 students he examined free of nits.73 Similar discoveries were made in other cities, and consequently urban health departments began to broaden their campaigns to prevent contagion in the schools beyond the diseases that had initially inspired exclusion and inspection. This was particularly true of New York City, where Health Department officials—concerned that communicable skin and eye diseases were endemic in the schools—instituted a new system in 1902 in which medical inspectors would visit each of their schools once a week and examine all the students, looking especially for runny eyes and parasitic infestations of the skin and scalp. The examinations were quick and cursory but sufficient enough to show that the schools were less incubators of serious epidemic disease than stew pots of minor communicable afflictions. During November and December 1902, the city’s medical inspectors examined over 100,000 children. They

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found 413 cases of scarlet fever, diphtheria, mumps, measles, and chickenpox, but they also discovered 12,647 cases of contagious eye disease and 9,656 cases of pediculosis and other parasitic skin diseases. With the exception of trachoma—a feared eye disease that landed those infected in an isolation hospital the city established that year—most of the infections discovered were considered minor.74 The discovery of endemic minor communicable diseases among schoolchildren raised an unforeseen challenge. Because city health authorities had originally adopted the policy of excluding all children with contagious diseases, they found that they were soon depopulating the schools. One Health Department official recalled: “When we started sending these children home with orders to stay away until the infections were well, the schoolrooms, in many schools were practically deserted.” Another recounted how fifteen to twenty children in each school were being sent home each day, and that in one school 300 children were out at once. Faced with howls of protest from educators and parents, health authorities concluded that the best option would be to provide in-school treatment but were loath to have medical inspectors provide it, in part because that seemed a waste of their time and in part because it seemed to violate the prohibitions against their doing anything more than examining children.75 A solution was provided by Lillian Wald, the founder of New York’s Henry Street Visiting Nurse Settlement. In 1901 she had traveled to England and had become familiar with the work of the volunteer London School Nurse Society. Established in 1898, the society sent visiting nurses into the elementary schools in the city’s poorest districts to treat children with minor eye and skin infections. On returning home, Wald suggested to the commissioners of both health and education in New York City that nurses could function in a similar way there. They agreed to a one-month experiment, and Lina Rogers, one of Wald’s senior nurses, was hired. Rogers set up shop in four schools and saw students who had been selected by the medical inspector. She washed runny eyes with a boracic acid solution and painted ringworm infestations with collodion after scrubbing them with green soap and a solution of bichloride of mercury. She used a petroleum solution to soak the hair and scalps of children with pediculosis and later combed out the nits. After school, she visited the homes of children who had been sent home and explained each child’s condition to the parents and demonstrated how it should be treated. If the infestation or infection was severe, she put the family in contact with the nearest charitable dispensary or suggested that they see their family doctor, if they had one. After a month, her work was judged such a success that twelve nurses were put

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under her direction, and the following year the Board of Estimate appropriated $30,000 to hire twenty-seven nurses to look after the children in 129 public and 4 parochial elementary schools. The results were immediate and dramatic. In September 1902, 10,567 students had been excluded from school; in September 1903, only 1,101 were.76 Impressed by what New York had accomplished, other cities followed suit. By 1908 students were being treated by twenty-nine nurses in Boston; six in Philadelphia; five each in Baltimore, Grand Rapids, and San Francisco; three in Los Angeles; and two in Seattle. And by 1910 sixtyseven cities were employing one or more school nurses. Initially, most of the nurses were health department employees, but gradually both municipalities and states passed legislation authorizing school systems to expend education funds on nursing services.77 The response of school officials and teachers to the initiation of medical inspection in their systems was mixed. Some expressed gratitude for what they saw as the diminution of hysteria among parents and teachers when diphtheria, scarlet fever, or some other contagious disease broke out among students. At a public meeting to discuss the results of Boston’s new system of medical inspection, the head of one school recounted that “before the establishment of this scheme, by which the Board of Health was brought into such close relation with the schools, there was a great deal of fear of contagion in the school.” But since medical inspection had begun, he continued, there had been “a feeling of security on the part of teachers, principals, children, and parents.” Another principal expressed relief that that he and his teachers could now rely on the assistance of medical authority in dealing with the exclusion of sick children and those exposed to infection.78 Similar sentiments were expressed by a number of school superintendents a few years later, when the National Education Association held its first session on medical inspection. The District of Columbia’s William B. Powell, for instance, observed that medical inspection seemed to be quieting some of the alarm that had long accompanied the possibility of school epidemics, while also making more efficient the enforcement of the exclusion policies.79 At the same time, however, those charged with the education of the young continued to express concern that the rigorous enforcement of the exclusion laws could disrupt that education by banishing too many children from the classroom. Educators seemed particularly rankled by the exclusion of children from families with a case of some serious contagious disease, for such exclusions increased exponentially the number of children who would be out of school at any given time. In Providence, for example, twice as many children on average were excluded for being from households where diphtheria or

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scarlet fever were present as were for actually being infected with the diseases. School officials, principals, and individual teachers were thus often less than rigorous in reporting the presence of a sick child’s sibling, prompting frequent complaints from health officials.80 Some educators also apparently considered the efforts to protect schoolchildren from germs to be excessive to the point of absurdity and complained that teaching was taking a back seat to hygiene. Noting that more than a few of the city’s teachers were less than thrilled with the amount of time and effort they had to devote to protecting their charges from potential infection by germs, the Boston Traveler published what it claimed was one teacher’s imagining of a conversation between a boy of the future and his teacher: “Tommy, have you been vaccinated?” “Yes, ma’am.” “Have you a certificate of inoculation for the croup, chicken-pox, measles, scarlet fever, and diphtheria?” “Yes, ma’am.” “Is your luncheon put up in a patent, antiseptic dinner satchel?” “Yes, ma’am.” “Have you your own sanitary slate-bag and disinfected drinking cup?” “Yes, ma’am.” “Do you wear a camphor bag around your throat, a collapsible life belt, and insulated rubber heels for crossing the electric line?” “Yes, ma’am; all of these.” “Then you may hang your hat on the insulated peg and proceed to study your lesson in the thirty-fourth volume of ‘Hygiene of the Young.’”81

The response of parents to the implementation of medical inspection was also mixed. As was the case with educators, many were relieved that something was being done to reduce the chance of epidemics in schools. Others, though no doubt ashamed to admit their children were infested, were ultimately pleased by the efforts to delouse the schools. Indeed, in several cities and towns, women’s clubs and mothers’ organizations lobbied to get medical inspection started. But many parents continued to resent exclusion and thus to resist it. The published reports and papers of health departments and individual medical inspectors are filled with examples of parents contesting or ignoring an official order that their children be kept home until certified as no longer contagious. Health department officials also frequently complained that parents ignored or deliberately chose not to follow the recommendations

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on how to treat infectious skin and eye diseases, sent home with their infected children. Indeed, as the ranks of school nurses increased, one of their major responsibilities became encouraging families to give their excluded children the treatment they required.82 Despite the opposition of many parents to having their children excluded from school, there were only a few legal challenges to the right of schools to exclude contagious children. And these were invariably decided in favor of the state, usually with the court noting the role of schools in spreading disease and the right of health officials to act as they saw fit to protect the public. “It is a well recognized fact,” declared an Indiana court in explaining its 1900 ruling in one such case, “that our public schools in the past have been the means of spreading contagious disease throughout an entire community. They have been the source from which diphtheria, scarlet fever, and other contagious diseases have carried distress and death in many families. Surely, there can be no substantial argument advanced adverse to the reasonableness of a rule or order of health officials which is intended and calculated to protect, in a time of danger, all school children and the families of which they form part, from smallpox and other infectious diseases.”83 Although parents did not mount much of an organized legal challenge to the exclusion of children with contagious diseases, they did mount a significant one to the exclusion of children who were unvaccinated. In so doing, parents became part of the loosely organized but relatively potent antivaccination movement that took shape late in the nineteenth century, especially in the United States and Great Britain. Many of the most vocal participants in that movement were practitioners of irregular or alternative medicine, medical nihilists, and radical individualists who opposed state medicine or any attempt of the state to limit individual freedom. But there was also a sizable popular and grass-roots segment of the movement consisting in large part of parents who objected to vaccination as a threat to both the purity and the health of their children. At a time when the image of childhood innocence and purity had come to suffuse AngloAmerican culture, more than a few parents were repulsed—as a petition to the Pittsburgh School Board phrased it—by the idea of defiling the blood of their offspring with a serum derived from pus taken from the sores of sick cows. More significantly, parents worried about the very real dangers posed by contaminated serum and unclean vaccination instruments. With little oversight of the way in which the serum was prepared, handled, stored, and administered, the transmission of secondary infections was not uncommon. Tetanus was always a danger. In one incident that caused a near riot, it was responsible for the deaths of three St. Louis schoolchildren who had recently been vaccinated by a physician hired

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with school funds. Syphilis was also a major concern. Although it was probably not really a significant danger, it was widely believed to be so, especially after Herbert Spencer characterized vaccination as the “wholesale syphilization of society.”84 Thus, not alone in his sentiments was the Chicago father who emphatically declared in a letter he wrote the Chicago Public School League opposing school vaccination: “An M.D. who will vaccinate a child is either a stupid ignoramus or a criminal of the deepest type.”85 Parental opposition to compulsory vaccination caused a number of municipalities and states to modify their school vaccination requirements. In Massachusetts, for instance, the legislature responded to parental lobbying by adding a provision that excused children from the requirement if a physician certified them as being physically unfit for vaccination. Other states made exceptions for children whose parents objected on religious grounds. But no state or city rescinded the requirements, despite a spate of lawsuits filed by parents with the aid of organized antivaccination societies. Most of the suits argued that the compulsory vaccination requirements were unconstitutional both because they violated students’ right to due process before being stripped of their right to a public education and because they overstepped state and municipal authority to restrict a citizen’s rights in order to protect the public health. Although the Illinois Supreme Court in 1894 found some merit in these arguments, few other state courts did. Beginning with the 1895 Connecticut Supreme Court’s ruling in Bissel v. Davison, legal challenges to mandatory vaccination were rejected in state after state. And in 1922, drawing on its earlier ruling in Jacobsen v. Massachusetts that a state had the power to compel vaccination, the US Supreme Court ruled in Zucht v. King that states could delegate to municipalities the right to exclude unvaccinated children from school.86 In retrospect, the court decisions upholding the right of schools to exclude unvaccinated or infected children were probably never in doubt, for they were predicated on the often-contested but clearly established police power of the state to limit individual rights to protect the public health. Had medical inspection remained limited to controlling the transmission of contagious disease, it would have remained relatively uncontroversial. However, in the first decade of the twentieth century, school hygienists mounted a successful campaign to expand it to include detecting physical defects and promoting their correction. In so doing, the hygienists not only initiated a new stage in the medicalization of education; they also pushed medical inspection and school hygiene in general into the contested arenas in which early-twentieth-century Americans were negotiating the relative responsibilities for child welfare of families and the state, and the respective provinces of private medical practice and public health.

Chapter 3

Defective Children, Defective Students Medicalizing Academic Failure

The examinations that medical inspectors gave to schoolchildren showing symptoms of disease revealed not only an urban student body plagued with minor contagious skin and eye conditions, but also one in which physical defects were almost universal. Although not charged with detecting such defects, medical inspectors could not help noting them. As they looked for evidence of infection in students’ throats, they were all too often confronted with mouthfuls of carious teeth and swollen gums. As they watched students make their way around their school, inspectors saw some with obvious signs of heart diseases and others with bodies bent or twisted by scoliosis, rickets, or tuberculosis. As they stared into students’ faces, they detected the pallor of the malnourished, the squint of the myopic, the twitch of the chorea inflicted, or the open-mouth breathing of a child with hypertrophied tonsils or adenoidal growths. And as they questioned students and listened to their responses, inspectors discovered some who clearly had hearing and speech defects or seemed cognitively impaired.1 As medical inspectors made their observations known, some urban education and health officials began lobbying for the expansion of medical inspection to include the detection of physical and mental defects and incapacities. One argument offered for such expansion was that it would assist in the identification and segregation of students who were so physically and mentally incapacitated that they were all but uneducable in a regular school. For some time, urban school officials had been complaining that the enforcement of compulsory attendance laws was bringing into their schools children who were not only educationally behind but also physically and mentally unfit for the

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normal classroom.2 It was a complaint with some merit, for the surge of children into city schools after 1880 not only dramatically increased the size of the urban school population but also increased its heterogeneity. Through much of the nineteenth century, children who suffered significant physical and mental disabilities, were disruptive and had behavior problems, or lacked adequate preparation usually soon dropped out or were forced out of school. With the increasing enforcement of compulsory attendance laws, however, that changed. Such children were compelled to remain in school, and the state was compelled to educate them.3 The result, according to many educators, was a dramatic increase in the number of children who were unhealthy, intractable, and uneducable and who, as a consequence, disrupted the classroom and interfered with the education of the majority. While praising the work of his truant officers, the Chicago superintendent of schools ruefully admitted in 1889 that one result of their efforts had been to make his teachers’ jobs more difficult, since “many of those brought from the streets and alleys are not fitted for the ordinary school-room, being physically as well as mentally incapacitated.”4 Most other urban superintendents agreed. The presence of even one or two such children in a class, explained Baltimore’s James Van Sickle, “so absorbs the energies of the teacher and makes so imperative a claim upon her attention that she cannot under these circumstances properly instruct the number commonly enrolled in a class.”5 Indeed, in the opinion of Van Sickle, who earned recognition as an expert on what came to be called “exceptional children,” one of the most serious challenges facing public schools at the beginning of the twentieth century was what to do with “the delinquent and defective children who clog the lower grades of our schools and seriously retard the progress of children of normal mentality.”6 At the very end of the nineteenth century, public school systems had begun to deal with that challenge by removing the most incorrigible, the developmentally backward, and the slowest learners from regular classrooms and placing them in special classes.7 Yet placing children in such classes, particularly classes for the feeble-minded, often proved difficult. Parents resisted the practice and complained that teachers and principals were not qualified to distinguish whether a child was feeble-minded or just slow and uninterested. Many educators agreed. As one school official noted in an 1899 article in Education, deciding whether or not a child was feeble-minded had proved to be “a delicate matter,” which many teachers felt was best left to those with medical training.8 Expanded medical inspection was thus seen as bringing into the schools those with the training and authority to determine whether or not a child was so developmentally handicapped that he or she was not educable in a normal classroom setting.9

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A second and related argument for expanding medical inspection to include the detection of physical and mental defects was that it would allow school systems to identify students who were perfectly educable but who had certain conditions that could be aggravated by the typical classroom environment and the demands of a regular curriculum. Although as convinced as their late-nineteenth-century counterparts had been that schools and schooling placed an unnatural burden on all children’s developing minds and bodies, early-twentieth-century school hygienists had come to believe that, if the environment and instruction were reasonably hygienic, children who were healthy could adjust without serious negative consequences. Hence, they increasingly focused their concern on children whom they considered vulnerable: that is, children who were nervous, suffered from serious eyestrain or severe myopia, were afflicted with chronic constipation or bowel disorders, or were sickly and delicate. Such children, school hygienists came to believe, would get worse if they remained in the regular school environment and were subjected to the regular curriculum. To prevent this, they had to be identified and placed in special classes and classrooms that would not aggravate their conditions.10 A third argument offered for the transformation of medical inspection from the detection of contagious diseases to the provision of more complete physical exams was that it could supply the type of data that would allow for the tracking of each child’s physical and mental welfare and development over time. Achieving the ability to do such tracking—termed physical and mental supervision—had been a much-desired goal of many school hygienists since the child study movement had found in the anthropometric exams of William T. Porter and others the promise that measuring and recording children’s physical development could provide an index of their mental development. Hence, in discussing what the new physical exams might include, some school hygienists pushed hard for the recording of height, weight, and other measures of physical growth and development. Luther Gulick, for instance, in a talk promoting a broader scope for medical inspection, observed that although the typical medical inspector saw the exams as designed to produce records of contagious disease and physical defects, longtime school hygienists saw in them the potential to gather data such as height and weight that would be useful in coordinating mental and physical education.11 It was a fourth argument, however, that ultimately proved most influential in promoting the expansion of medical inspection to include the detection of mental and physical defects. This was that identifying defects and encouraging their correction held great potential for significantly improving the ability of large numbers of the nation’s urban schoolchildren to learn. Many of those

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involved in the discourse on school hygiene suspected that although most of the conditions discovered during contagious disease exams were not serious enough to make a child uneducable, they were serious enough to impede education. A child who was malnourished and anemic or who was experiencing the pain of decayed teeth, swollen tonsils, or infected ears, hygienists noted, was a child who was enervated or distracted, unable to concentrate, and more likely than healthy students to be absent from school. Similarly, a child who had trouble hearing or seeing was more often than not at severe disadvantage in the classroom. As World’s Work asserted in a 1906 editorial promoting the expansion of school medical inspection: “There is many a child classed as dull in the New York schools whose only trouble is that it can’t see the blackboard.”12 Other medical and popular publications editorialized similarly, urging education and health officials to periodically examine schoolchildren, take note of their ailments and afflictions, and notify parents so that treatment might be procured and their child’s ability to learn improved. Indeed, a limited form of such inspection—a biennial examination by teachers of their students’ vision and hearing—had been required in Connecticut since 1899 and had produced some positive results. So, too, had a temporary program established in Providence a few years earlier, in which the director of physical training began giving periodic vision and hearing tests to elementary school students and urging parents of any child with problems to take him or her to either a private physician or the free eye and ear clinic at one of the city’s three hospitals. It seemed reasonable, then, that more expansive exams, conducted by trained medical personnel, held even more promise.13 New York was the first major American municipality to expand the focus of its medical inspection to include the regular examination of children for education-impairing defects and handicaps. In 1903 it enlarged its corps of medical inspectors and required each to visit classrooms on a regular schedule and give all pupils a once-over. Two years later, it instituted a system in which every medical inspector became responsible for providing once during the school year an individual, comprehensive medical exam to every student in the schools to which he or she was assigned. As stipulated in the instructions provided to the medical inspectors, each exam was to include a “consideration of the child’s general health and strength, of the condition of his heart and lungs, of the presence of nervous disease, mental deficiency, deformities of the spine or limbs, as well as afflictions of the teeth, throat, nose, eyes, or ears.”14 To record their findings, the medical inspectors were provided with printed cards on which they could check off whether or not the student appeared malnourished or anemic; had enlarged cervical glands; showed signs of heart,

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pulmonary, or skin diseases; had problems seeing, breathing, or hearing; or had any of several other specific deformities and infirmities. These cards were kept at the school as part of an ongoing record of each student’s health. Another card, on which the medical inspector listed the defects found, was sent to the child’s parents instructing them to take it and the child to their family physician or dentist or to a charitable dispensary or clinic, where the child could receive a more systematic exam and, ideally, get treatment. According to John Cronin, who served as chief medical inspector, it was the hope of health and education authorities that “if the parents of these children were notified as to the existence of these manifold infirmities, and if in each case the necessary medical treatment were applied, a great improvement would result, not only in the health of the school children, but also in their capacity for school work.”15 From what had been gleaned from the earlier, more cursory exams, school and health officials were aware that defects and deformities were not uncommon among the city’s schoolchildren. But they were absolutely shocked by the incidence of health problems that the more comprehensive exams revealed. Of the 55,332 Borough of Manhattan schoolchildren examined from the end of March through the end of December 1905, 33,551, or about 61 percent, had defects or noncontagious diseases that were serious enough to require medical treatment or correction. Thirty percent had defective vision and needed glasses. Thirty-three percent had carious teeth or other oral health problems that needed the attention of a dentist. Thirty-one percent had swollen glands of the throat, and 15 percent had hypertrophied tonsils and adenoidal growths. Two percent of the children were found to be suffering from heart disease or defects, while 4 percent had deformities of the limbs and skeleton.16 When the results of the initial examinations were released by the Health Department, they provoked considerable alarm. The number of children found to have defects seemed so shockingly high that many of the city’s educators and more than a few of its prominent physicians questioned the accuracy of the figures, suggesting that they might have been inflated by the over eagerness and inexperience of the medical inspectors. In response, the Health Department enlisted the services of a group of prominent regular physicians and eye specialists, who agreed to take part in a study wherein they would reexamine a large and representative sample of the city’s elementary school population. When the study was completed, its results showed that, if anything, the regular medical inspectors had been too conservative in identifying defects. Indeed, as more data were collected over the next few years, the percentage of the school population recorded as having visual, dental, and other defects rose considerably.17

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The discovery of such a high incidence of physical defects among the schoolchildren of New York immediately prompted considerable discussion within the city’s education, health, and social welfare communities, particularly in regard to the relative degrees to which the defects could be attributed to the environment and regimen of the schools and to the behaviors and home lives of the children, especially those children who lived in crowded tenement districts. In May 1906 several prominent members of those communities joined together to form the New York Committee on the Physical Welfare of School Children, which after raising funds from a number of charity organizations, launched a study of the home lives and school environments of 1,400 children identified by medical inspectors as having serious physical defects. A year later, based on what a corps of physician investigators were able to glean from home inspections and parental interviews, the committee released the results of that investigation in a lengthy report that was published in the official journal of the American Statistical Association.18 In systematic fashion the report discounted or qualified what it suggested were most of the opinions circulating about the distribution and causes of the defects. Insufficient income, it asserted, was not a major cause, since many of the most common defects recorded—particularly carious teeth, poor vision, and breathing problems due to nasopharyngeal blockages—were found almost equally among children from comfortable homes and those from homes marked by poverty. Nor did race or acculturation seem to play a major role, since the common defects were spread fairly evenly across all nationalities and among the children of native and foreign-born parents. Heredity also did not appear to be an influence, since the investigators could find no clear evidence that parents and children shared the same defects. Likewise, congenital weakness offered little explanation. Almost all the parents interviewed claimed that their children had been healthy at birth, and only in childhood had developed the defects they now possessed. If insufficient income, heredity, level of acculturation, and race could not account for the abundance of detected defects, what could? In answering that question, the report offered an old explanation but qualified it. The primary cause of defects in city schoolchildren, explained the report, was city life, with its overcrowding; poorly lit and ventilated homes and public buildings, including schools; excessive noise; smoky and polluted air; lack of opportunity for children to engage in physical activity; and many temptations.19 Having characterized the physical defectiveness of the city’s schoolchildren as a seemingly inevitable consequence of urban life, the report somewhat surprisingly asserted that this was not a cause for either alarm or despair and offered two reasons for that view. First, it claimed that there was no evidence

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that the incidence of defects was increasing or that the American urban schoolchild was physically deteriorating. “On the contrary,” it asserted, “if a comparison were possible, the children of 1907 would be found to have sounder bodies and fewer defects than their predecessors.”20 Second, and more important, the report maintained that because the vast majority of detected defects were correctable with existing medical, surgical, and dental care, identifying them was a necessary and catalytic first step in their removal. Echoing Chief Medical Inspector Cronin, the report predicted that “parents can and will correct the greater part of the defects discovered by the physical examination of school children, if shown what steps to take.”21 Thus, identifying defects and notifying parents as to their existence and required treatment held the potential for dramatically improving the physical welfare and educational efficiency of the nation’s urban schoolchildren. Both the findings of the New York City medical inspectors and the conclusions of the New York Committee on the Physical Welfare of School Children’s report received considerable attention in the national press and were deployed in support of efforts to get similar systems of defect detection instituted in the schools of other cities.22 In Massachusetts, the playground and recreation advocate Joseph Lee used the New York medical inspection data, along with information being collected in Boston, to convince a number of influential physicians, educators, and child welfare advocates to band together to draft and push through the legislature a bill that would make the inspection of schoolchildren for physical defects as well as contagious diseases mandatory in all cities and towns in the state. Passed in 1906, the legislation included a provision requiring that “the school committee of every city and town shall cause every child in the public schools to be separately and carefully tested and examined at least once in every school year to ascertain whether he is suffering from defective sight or hearing or from any other disability or defect tending to prevent his receiving the full benefit of his school work.”23 Like the initiation of medical inspection for contagious diseases, the initiation of medical exams to detect physical defects called forth a mixed response from parents and the general public. Individuals and groups supportive of efforts to expand school services as part of an effort to improve the quality of both education and those being educated tended to embrace expanded medical inspection enthusiastically. In many midsize and small cities, for instance, mothers’ organizations, women’s clubs, and parent-teacher associations pushed hard for in-school physical examinations, sometimes raising funds to pay the examiners’ salaries. Typical of many newspaper accounts of such activity was a 1910 article in the Atlanta Constitution that described how in the town of

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Athens, Georgia, members of the Mothers and Teachers Club had taken the lead in agitating for school medical inspections and had hired a physician to examine a sample of the town’s schoolchildren.24 Other parents, however, warily greeted the new examination policy, concerned that it might be used to exclude their children from school or would require them to purchase services that they might feel were unnecessary or could not afford. A small minority—including, but in no way limited to, Christian Scientists—vigorously protested that the compulsory exams violated their religious beliefs or infringed on their parental right to control their children. Although disdainfully dismissed by school hygienists as “people [who] insist upon their alleged inalienable right under the constitution of the United States to have diseased or weak-minded children and to allow them to grow up to be defective citizens,” such parents could cause considerable disruption, especially when they were joined by antivaccinationist groups and associations of medical irregulars who feared that state-sponsored school medical inspection represented a major step toward state medicine or an allopathic medical monopoly.25 In 1911, for instance, city school systems around the country had to deal with a public and parental outcry that followed press reports of a speech given by US Senator John Downy Works, a Christian Scientist, at the National League for Medical Freedom’s conference in Chicago that year. Decrying medical inspection both as a violation of parental rights and as state support of medical monopoly, Works also charged that it regularly involved forcing young girls to undress so that they could be inspected by male doctors barely out of medical school. Nor was Works the only politician to oppose medical inspection as a violation of parental rights and an expression of medical monopoly. South Carolina Governor Coleman Livingston Blease condemned it in similar terms when, in 1914, he vetoed legislation passed by the state legislature that would have enabled medical inspections in the schools.26 The response of the regular medical profession to the efforts to expand state-sponsored school medical inspection beyond the detection and control of contagious diseases was also mixed. Although many individual physicians expressed concern that legislation enabling or requiring the expenditure of public funds for medical examinations of schoolchildren represented state intrusion into the realm of private practice, organized medicine and public health tended to be supportive, especially in regard to compulsory vision and hearing exams. At its 1908 annual meeting, the American Medical Association resolved that “it is the sense of the American Medical Association that measures be taken by boards of health, boards of education, and school authorities, and, where possible, legislation be secured, looking to the examination of the

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eyes and ears of all school children, that disease in its incipiency be discovered and corrected.” By February of the following year, similar resolutions had been adopted by the American Public Health Association, the Association of State and Provincial Boards of Health of North America, the Mississippi Valley Medical Association, twenty-one state medical societies, and twenty state boards of health.27 Encouraged by the support of organized medicine and public health and often using the Massachusetts law as a model, several states soon enacted either permissive or mandatory statutes that expanded medical inspection to encompass the detection of physical defects that might impede learning. Typical was the law adopted by Indiana in 1911, which permitted school authorities in towns and cities to institute medical inspection that the law defined as not limited to the detection of contagious diseases but as also involving “the testing of the sight and hearing of school children and the inspection of said children by school physicians for disease, disabilities, decayed teeth or other defects, which may reduce efficiency or tend to prevent their receiving the full benefits of school work.”28 At the same time, in both states that did and did not pass such laws, almost all major cities—especially in the Northeast, industrial Midwest, and West—adopted some form of expanded medical inspection, or medical supervision, as some came to call it. So did many smaller cities and towns. And although some of systems of physical examination existed more in theory than in fact, it was clear by 1913, when the Russell Sage Foundation published an updated revision of its 1908 survey of medical inspection in the United States, that a major shift had taken place. Although still concerned with preventing or suppressing school epidemics, medical inspection was adopting as its major purpose the physical surveillance of the school population and the discovery of those physical defects and frailties that could impede a student’s educational efficiency and development.29 Medical Inspection and Grade Retardation

Lending critical support to this expansion of medical inspection to include the detection of physical and mental defects was a larger early-twentieth-century educational reform effort aimed at countering taxpayer criticism by improving educational efficiency. The dramatic growth of urban school populations between 1880 and 1910 was accompanied by an even more dramatic growth in urban school budgets, in part because cities were not only educating more children, they were also doing so for more days per year. Indeed, the percentage increase in expenditures for urban public education significantly outstripped the percentage increase in numbers of urban schoolchildren. For instance,

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between 1880 and 1910 Chicago’s school budget increased 1,100 percent, while its school population increased only 500 percent.30 As costs increased, so did public criticism—especially from fiscal conservatives, who complained that urban school systems were wasteful, badly run, and seemed more interested in squandering taxpayers’ money on frills such as music and physical education than in efficiently teaching young people academic subjects. Although dismissing some of these criticisms, school authorities did embrace efficiency as an administrative goal and devoted significant efforts toward maximizing education and minimizing waste.31 Central to that effort was ensuring that schoolchildren progressed through the grades on schedule and thus received the fullest education possible. Suspicion that this was not happening was raised at the end of the century by informal surveys in Boston and Philadelphia and confirmed in 1904 by data released by New York City School Superintendent William Maxwell, showing that 39 percent of the city’s schoolchildren were overage for their grade and therefore likely to end their schooling without attaining even a primary school education. Looking at their own records, other large city superintendents found similar percentages of overage students, leading the education authority Edward L. Thorndike to conclude in his influential The Elimination of Pupils from School that barely half of the nation’s schoolchildren made it to the eighth grade.32 Seeking to account for the large numbers of overage children in the early grades, some educators pointed to late entry to school. Most, however, considered the problem a product of failure to progress and sought to discover the reasons why so many students were stuck repeating the elementary grades and thus were retarded in their educational development. Definitely the most ambitious attempt to identify and evaluate the causes of grade retardation was the “Backward Children Investigation” launched in 1907 by the Russell Sage Foundation and headed by Leonard Ayres, an educational statistician, former general superintendent of the schools of Puerto Rico and coauthor of the foundation’s 1908 study of medical inspection. Involving a close examination of the educational progress and mental and physical condition of 20,000 Manhattan schoolchildren and a compilation and analysis of data gleaned from the records of close to sixty American cities, the Ayres investigation resulted in a lengthy and highly influential report published in 1909 titled Laggards in Our Schools: A Study of Retardation and Elimination in City School Systems.33 In the opening chapter of the report, Ayres made clear that the problem he had investigated was one of cost and efficiency, estimating that repeaters were costing American cities $27 million a year. He also rejected as unfounded the argument that a large proportion of the repeaters, which he estimated as

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representing 33 percent of the American public school population, were those who were so mentally incapacitated that they could not be educated in standard classrooms. Although he granted that enforcement of the attendance laws was continuing to pull some “uneducables” into the schools, he contended that the numbers of such children were relatively small and were being steadily reduced by the assignment of these “unfortunates” to special classes and schools. Ayers thus asserted that rather than being composed of students who did not have the mental ability to progress, the laggard population was primarily made up of those who could pass from one grade to the next but did not.34 In exploring why this was so, Ayers considered a number of factors, including irregular attendance, ill-designed curricula, ethnicity, and even gender. But he paid particular attention to the influence of physical defects, noting that “one of the most important objects of the investigation conducted in the New York schools was to determine, if possible, the relation between physical defectiveness and school progress.”35 One probable reason why he paid such close attention to the impact of health on academic progress was that although a causal relationship had long been assumed, it had never been definitively demonstrated. Although, as we have seen, one of the central assumptions to emerge from child study and turn-of-the-century anthropometric exams of schoolchildren was that the healthiest and best developed youngsters were usually the most academically advanced, little empirical evidence existed correlating physical defects and afflictions with retarded school progress. Indeed, the few previous studies that had attempted to show a direct connection between physical defects and school progress had been quite inconclusive. For instance, a study of 10,000 Camden, New Jersey, children had revealed no appreciable differences in the incidence of defects among normal and retarded children. And another study, of Philadelphia children, despite the author’s protestations, had also shown no clear connection. Similarly, the initial aggregation of the data collected by Backward Children investigators did not support a significant causal connection and even suggested a negative one. Of the 20,000 children examined, 80 percent of normal-age children were found to have defects, while only 75 percent of the overage children were.36 Although acknowledging that the figures did not seem to lend support to the hypothesis that physical defects retarded school progress, Ayres theorized that the problem was not in the hypothesis but in the way that the data were being aggregated. Noting that the incidence of defects tended to drop sharply as the age of the child increased, and that the average age of the repeaters in each school was significantly higher than that of “normal” children, Ayres reasoned that the results might be different if the data were standardized by the age of the

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students. Therefore, he and his assistants retabulated the data by age, dividing the children of each age group into bright, normal, and dull categories. A bright child was defined as one who was young for his or her grade, a normal child as one who was on schedule, and a dull child as one who was overage for the grade. As Ayres had suspected, aggregating the data this way greatly changed the results. “In every case, except that of vision,” he reported, “the children rated as ‘dull’ are found to be suffering from physical defects to a greater degree than the ‘normal’ or ‘bright’ children.” Moreover, he noted, dull children were not only more likely to have defects than the other children their age, they were also more likely to have a greater number of them.37 Although in the conclusion of his report, Ayres emphasized that the sources of laggardness were multiple, the primary impact of his study was to focus attention on physical defects as a particularly significant remediable cause of grade retardation and on the tremendous waste of public funds attributable to it. Noting that “here we have for the first time figures which conclusively demonstrate that there is a real relation between physical defectiveness and school progress,” Luther Gulick, head of the Russell Sage Foundation’s newly created Division of Child Hygiene, estimated that defective teeth typically retarded a child by half a year, hypertrophied tonsils by six-tenths of a year, and adenoids by one and one-tenth years. Concluding that “if these figures are substantially significant for all of New York City school children, their educational and economic import is great,” Gulick further observed: The sums of money spent annually in New York City for public education reach high into the millions. It would be a very simple matter to compute how many dollars are wasted each year in a futile attempt to impart instruction to pupils whose mental faculties are dulled through perfectly remedial defects. Roughly speaking, about 60 percent of all children suffer from such defects. If, then, we should show that the instruction given to these children suffers a loss in effectiveness of nearly 10 percent because of remedial physical defects, it is at once evident that the direct financial bearing of the problem is of great significance.38

Aside from “cost,” the most significant word employed by Gulick in his remarks was “remedial.” What situated physical defects at the center of the discussion on grade retardation was less a belief that they were the only or even the primary cause of laggardness and more an appreciation of their potential for correction. Few informed participants in American education, Ayres and Gulick included, doubted that the organization of urban schooling and the social condition of city schoolchildren and their families contributed

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significantly to the vast numbers of overage children clogging the lower grades of urban schools. Nor did they doubt that a complete solution to the problem would require reaching the desirable but daunting goals of effectively reorganizing the way children were educated and improving both the general welfare of poor urban families and the way those families reared their children. Yet if the cause of a significant proportion of grade retardation could be removed by identifying remediable physical defects in children and convincing parents to have them corrected, then the overall problem could be greatly reduced without requiring either major educational or social reform. That certainly seems to be the position taken by L. N. Hine, the progressive and nationally influential superintendent of schools in Crawfordsville, Indiana. Convinced by a study he conducted of his own school system that “physical defects constitute a cause but not the cause of retardation,” Hine was nevertheless an avid supporter of medical inspection, arguing that, unlike poverty, late entry, poor grasp of English, and other seemingly intractable causes of retardation, physical defects were a medical problem that could be medically identified and corrected.39 Other superintendents agreed and promoted medical inspection, not because they had a simplistic view of the causes of educational inefficiency, but because inspection seemed to offer an accomplishable way to reduce the fiscal waste of widespread backwardness among schoolchildren. Noting that few causes of grade retardation seemed as significant or correctable as physical defects, Baltimore’s superintendent concluded in his 1913 annual report that “a system of inspection and treatment is of tremendous economic importance to the city whose school board is spending thousands of dollars annually on backward children.”40 In addition to the Crawfordsville and Baltimore superintendents, education officials throughout the country cited the Ayres study in support of adopting medical inspection as a fiscal and educational efficiency measure. As a consequence, in 1911 when it published a pamphlet titled “What American Cities Are Doing for the Health of School Children,” the Russell Sage Foundation could report that out of the 1,415 cities it had surveyed, 685 had organized systems of school medical inspection that were making some attempt to detect education-impeding defects.41 Of course, not all systems were equally comprehensive. In over half of the systems surveyed, and especially those in smaller locales, defect detection was limited to vision and hearing tests annually given to students by teachers. And even in many municipalities where physicians gave physical examinations, vision and hearing tests were often left to teachers or school nurses. In part, this was a cost-containment measure, but it also reflected the opinion of experts that, with a little training, teachers

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could perform initial vision and hearing testing as well as the average physician and were in a better position to detect students who seemed to have problems. As one school hygiene manual observed, such noted American oculists as Frank Allport and Myles Standish “have long contended that the ordinary routine examinations of the eyes should be undertaken by teachers and school nurses. The teacher can make the test fully as well as can the physician who is not also an oculist, and by virtue of her constant opportunity to observe the symptoms of eye-strain among her pupils she is in even a better position than the school doctor to single out the children who need to be referred to an oculist.”42 Indeed, Allport, who designed a set of eye charts widely used in the schools, thought teachers were capable of doing broad health screening and thus making defect detection far more widely available than it currently was. Warning that “teachers should not attempt to diagnose diseases,” he nonetheless advised that “by means of simple tests, tests which can be given by anyone with intelligence enough to teach, they can detect almost all serious diseases and defects of the eye, ear, nose, and throat.”43 Hence, especially as medical inspection was adopted in small cities and towns, reliance on teachers grew so great that municipal and state health departments issued teacher’s guides, normal schools introduced instruction on detecting defects into their teacher training curricula, and a number of state health departments held demonstration clinics.44 In larger cities, however, the detection of defects was, initially at least, usually the responsibility of salaried medical inspectors who were physicians and who would normally conduct physical exams after they had completed their contagious disease inspections. Devoting three to ten minutes to each child, they paid particular attention to detecting “defects of teeth, throat, eyes, nose, glands, ears, nutrition, lungs, heart, nervous, system, and bodily structure.” The generalized wording was deliberate. Medical inspectors were not supposed to make detailed diagnoses, but rather to simply record the existence of a defect and send a note home urging parents to take their child to a dispensary or private physician or dentist for a more complete examination and appropriate treatment. Indeed, rules prohibiting medical inspectors from asking children to undress, or even placing their ears against the torsos of female students, made detailed and accurate diagnosis—whether of scoliosis and other skeletal deformities or of respiratory and cardiac problems—all but impossible.45 Nevertheless, despite their cursory character, medical exams, especially if given by a skilled and experienced inspector, were neither completely haphazard nor incapable of revealing considerable information about a child’s physical condition. Most school systems had a standardized exam that was designed

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to provide a quick and efficient assay of possible physical ailments. Notable for both its informality and thoroughness was Philadelphia’s standardized exam: As the child enters the room, the inspector notes his gait and standing posture. In a low tone he asks the pupil’s name, age, address, etc., and by the promptness of the reply or the pupil asking to have the question repeated he gets a preliminary idea of the condition of hearing and sometimes mentality. He observes any abnormalities of structure, difference between right and left sides of the body; facial expression, whether a mouth breather etc. He notes color of the skin, presence of anemia, jaundice, desquamation, rash and cleanliness by observing face and neck from front and sides. It is not unusual to find a ringworm back of the ear or on the back of the neck. He observes the hands on both sides for rash, desquamation, cleanliness, also condition of the nails. As these observations are made while the child faces a good light near a window, the same position is used to examine mouth and throat. When the child opens its mouth, the inspector notes the condition of the mucous membrane and teeth; the presence of an odor may indicate uncleanliness of mouth, carious teeth, or nasopharyngeal catarrh. The tonsils are inspected to see if they are hypertrophied or if an exudate is present; then the uvula to see if it is elongated or if signs of nasopharyngeal catarrh exist. Mouth breathing or signs of nasal obstruction are noted. Ears are next observed for impacted cerumen or any discharge. Eyes are inspected for any of the inflammatory diseases of the conjunctiva, cornea, or lachrymal apparatus and the presence of strabismus or ptosis of the eyelids. The child is requested to stand erect with feet together and hands to the sides while the physician notes any deformities or orthopedic defects by viewing the child from all sides. Having obtained all possible data from the inspection, the physician then tests hearing and vision.46

Initially, children who were identified as having defects were directed to private physicians, specialists, and specialized clinics for further diagnosis, but mounting dissatisfaction with the quality of clinic diagnoses and frustration with parents’ tendency to consult cheap but unskilled practitioners led larger cities to hire their own corps of specialists. Thus by 1912 New York, Philadelphia, Chicago, Cleveland, and Boston had on staff or retainer at least one of the following: a neurologist to detect nervous diseases in children, as well as identify and distinguish between the feeble-minded and the slow-witted; a dentist to inspect the mouths of children and record decayed teeth and other oral health problems in need of treatment; an oculist to oversee vision exams and

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prescribe corrective lenses; an otolaryngologist to identify the specific causes of “mouth breathing,” determine whether tonsils or adenoids should be removed, and diagnose the source and severity of ear discharge; and an orthopedist to identify posture and skeletal deformities and recommend corrective devices and exercises. Small and midsize cities also hired or contracted with specialists, although usually they could not afford more than a dentist, an oculist, and sometimes a pediatrician.47 The stated ideal was to examine all children in a system annually, but no system ever managed to do that. A few, however, came close, at least for a few years. By 1912 Oakland was annually examining 95 percent of its students, Boston 73 percent, and Cleveland 68 percent. But confronted with the difficulty of providing annual exams with limited staff, along with a barrage of criticism that such exams of necessity were hurried and inadequate, many school systems gradually settled on the practice of immediately examining students whom teachers suspected as having an education-impairing problem while providing comprehensive exams to all others at entrance and then at two- or three-year intervals. Additionally, quite a few systems, following the lead of Boston and Oakland, increasingly came to rely on nurses to augment the coverage by their corps of physician medical inspectors, both by assisting them and by taking responsibility for much of the initial group screening of students. Thus by 1916 school nurses in San Francisco were performing over 200,000 in-school exams, while physicians did fewer than 10,000.48 Jurisdictional Issues

Whatever form the exams took and whoever did the examining, the expansion of contagious disease detection to include defect identification fanned a long-simmering jurisdictional conflict between school and public health bureaucracies. School authorities had never been happy having within their schools physicians whom they did not employ and control. They had acquiesced to medical inspections conducted by health department physicians begrudgingly and only because state and municipal laws gave health officials the power to control epidemic contagious disease. As soon as that control ceased to be seen as the primary goal of medical inspection, school authorities shifted their position from begrudging acquiescence to outright resistance, demanding that school medical inspections be placed entirely under the jurisdiction of school departments. Following passage of the 1906 Massachusetts state law mandating inspection for education-impairing defects, the superintendent of Boston’s school system began arguing that logic and efficiency demanded shifting authority for medical inspection from the health

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department to his department. Writing at some length on the issue in his 1907 annual report, he declared: In this connection it should be stated that while school physicians were concerned solely with contagious disease, they were properly to be controlled by the board of health. Under the new law, the work of examining into any defect that interferes with the progress of the children in school is not in the main a question of public health. It is rather an educational question and is so directly allied to the work of the department of physical training that the school physicians should be appointed by the school board and become part of this department. The highest efficiency will be impossible until this action is taken.49

That year New York City School Superintendent William Maxwell also began lobbying for school board control of medical inspection, arguing that “efficient service will be obtained only when the Board of Education is made solely responsible for all the work that goes on in the schools.” Maxwell especially criticized the work of the Health Department inspectors as too narrowly focused, contending that “the physicians employed by the Board of Health do not perform any of the functions which it is highly advisable should be performed by a truly educational department of hygiene, such as studying hygienic conditions in the schools and advising teachers regarding the pedagogical treatment of children in cases of fatigue and nervousness.” He also complained, as did other school officials, that Health Department inspectors were often illtrained political appointees who had neither the skill nor the commitment to do the job that was required of them.50 The response of health officials to the demands of superintendents for control was mixed. Some granted the logic of the superintendents’ arguments but expressed concern that controlling contagious disease required the continued involvement of health departments. As a consequence, several city health departments followed the recommendation of the American Medical Association and ceded to school authorities the responsibility for examining students for defects, while retaining for themselves the right and obligation to examine schoolchildren suspected of being infected with contagious disease.51 Other health officials, however, resisted school boards’ incursion into a province they felt was rightly theirs and fought vigorously to retain control of inspections. Indeed, in a number of states and cities the contest for control became acrimonious, with charges of incompetence and venality leveled by each side against the other. Disdainfully dismissing the assertion of the state Board of Education that city health departments sought control of medical inspection to increase

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the number of patronage jobs they had to offer, Pennsylvania Health Commissioner Samuel Dixon explained: “In point of fact, however, the school authorities have up to the present time so persistently neglected this portion of their duties, that the health authorities have been compelled for pure conscience’s sake to assume it. Until the average school director is a man of much more general information and higher culture than is furnished by our elective system, it is probably better that it should be so.”52 To a certain extent, the conflict between health and school officials was one of turf and personality, but it was also one of vision. As Maxwell’s comments above suggest, school officials—at least those who saw real value in having physicians, nurses, and other health professionals involved in the educational process—tended to view medical inspection as part of a larger school hygiene program that would bring medical expertise to bear on improving students’ ability to learn, ensuring that their time in school did not endanger their health, and coordinating the physical and mental education of the schoolchild. These officials envisioned school hygiene departments that would supervise school sanitation, monitor the health of teachers and janitors, examine and sometimes treat schoolchildren while charting their health progress through the grades, and oversee physical training and hygienic education. One of their major concerns was orchestrating the developmental process—that is, both children’s physical and mental growth—and ensuring that neither the school environment nor the educational methods employed subverted that process. Hence, they tended to view medical inspection as part of a larger classification and surveillance system that eventually came to include intelligence testing and behavior monitoring and that had as its goal the accurate charting of mental and physical development. Indeed, those educators promoting school hygiene departments tended to see medical inspection as capable of supplying data on physical development that could provide a better basis than chronological age for determining where children should be situated on the educational ladder. Noting that not all children developed according to the same schedule and convinced that physical and mental development paralleled each other, these educators argued that medical inspection could and should be used to determine and chart each child’s physiological age, which, prior to the deployment of IQ tests, was seen by many educational developmentalists as the best index of mental age.53 Providing crucial expert medical support for the creation of hygiene departments based in school systems were a very influential group of physicians who came to school hygiene not from public health but from physical education, and who tended to regard the National Education Association, rather than the

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American Public Health Association, as their organizational home. Prominent among them were Thomas Dennison Wood and his former Oberlin College roommate, Luther Gulick. Wood, who was a professor of physical education at Columbia University’s Teachers College and the chief designer and promoter of what came to be known as the “new physical education,” consistently used the bully pulpit he occupied as long-serving chair of the American Medical Association and National Education Association’s Joint Committee on Health Problems in Education to support school hygiene programs that were educationally, rather than public health or medically, oriented. Similarly, Gulick—who, prior to joining the Russell Sage Foundation, had been instrumental in establishing the physical education program of the YMCA and had served for a time as director of physical training for the New York City school system—was a consistent and vocal proponent of the position that medical inspection should be controlled by school authorities and be part of an educational hygiene program.54 In opposition to school officials and their physician allies, public health authorities tended to view medical inspection as part of a larger communitybased public health program, the purpose of which was to safeguard and improve the health of all members of the community, twenty-four hours a day. They spoke of medical inspection as a public health activity designed to shield the community from epidemic disease in general, and to protect and improve the health of children in particular. For this reason, resistance to school boards’ taking control of medical inspection was especially strong in those cities that established bureaus of child hygiene within their health departments. Such bureaus, the first of which was created by New York City in 1908, were designed to combine within one administrative unit all public health activities related to infants and children. As a consequence, those who ran and supported them took a broad view of child health work and considered school medical inspection not as a separate activity but as one segment of a comprehensive medical supervision that began with prenatal work and continued through certifying adolescents for work permits. They also—according to Josephine Baker, longtime head of New York’s Child Hygiene Bureau—tended to “regard children of from five to fifteen as children of ‘school age’ rather than ‘school children’” and to assert that since “schools generally have the children under their control only five out of the twenty-four hours each day and for a usual maximum of only 195 out of 365 days of each year, they are not capable of carrying on any well-conceived or extensive program for the health supervision of this group.”55 Public health authorities also noted that not all school-age children attended public schools. In a 1913 talk titled “Why the Control of Medical Inspection of Schools Should Be Vested in Boards of Health,” William Gallivan, chief of

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Boston’s Division of Child Hygiene, argued against a proposed shift of control to school authorities by asserting that “medical inspection of schools under the control of school committees would be confined to the public schools. In Boston, 25 percent of the school population attend private school and are subject to medical inspection under board of health control. Under school committee control this work would have to be abandoned.”56 There was also the matter of funding. Baker, Gallivan, and other health department officials rightly noted that their charters gave them the authority to dedicate part of their budgets to the hiring of physicians and nurses and to the conduct of medical examinations, whereas the charters of school systems generally did not. Hence, in order for school systems to establish departments of medical inspection and hire medical personnel, enabling legislation had to be passed, and even then court challenges were occasionally mounted by disgruntled taxpayers. Indeed, the question of whether or not school funds could be used for health services that were not strictly educational continually hindered the attempts of hygienists based in school systems to implement the comprehensive school health programs they envisioned.57 Nevertheless, despite continued funding difficulties and the best efforts of those public health officials who shared Baker’s and Gallivan’s concerns, each year saw a larger percentage of medical inspection programs come under the control of school authorities. This was especially true as medical inspection expanded into smaller cities and towns whose health departments were less developed and had far fewer personnel than did school departments. Moreover, between 1906 and 1911 alone, twenty states passed enabling legislation. Even to Baker, who fought a bitter, twenty-year battle to retain control of medical inspection, the trend seemed inevitable although regrettable. She acknowledged that “in nearly all of our smaller cities, towns and country districts the school boards and school trustees are better organized, and in many cases are far more efficient, than the local boards of health,” but she also expressed serious concern that the shift toward school board control seemed “more the result of preparedness and expediency than because of the recognition in any large way of the part that the health supervision of children plays in the whole health program.”58 Baker was prescient. As school departments increasingly took control of medical inspection, any hope that it might become a critical part of a comprehensive national child health program began to recede. But this was not yet apparent. And at least for the first two decades of the twentieth century, those involved in school hygiene were very optimistic about the potential of medical inspection to improve both the health of the nation’s urban schoolchildren and the efficiency of cities’ public school systems.

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An International Movement Coalesces

The United States was not alone in expanding the focus of medical inspection from the control of contagious diseases to the detection of physical defects that might impair learning. Nor was it alone in passing laws mandating or allowing expanded medical inspection. In Western Europe and Scandinavia—where the inspection of schools for insanitation and of children for contagious diseases had been in place for some time—several countries were, by the turn of the century, periodically examining their city and town schoolchildren for physical defects. For instance, Germany had been doing so since 1897, when Wiesbaden had instituted Europe’s first system of periodic health exams of schoolchildren. In Great Britain, medical inspection for defects was informally adopted within a few urban areas during the first years of the twentieth century and was authorized for cities and towns nationwide by legislation in England and Wales in 1907 and in Scotland in 1908. Examination for defects was also adopted at this time by Japan, which had made medical inspection mandatory in cities and towns in 1898. So too was it embraced by Mexico, Australia, and Canada, each of which established medical inspection programs in all or some of their cities and towns between 1896 and 1906.59 As systems of medical examination throughout the world were expanding and reorienting their activities toward physical surveillance, the number of health professionals involved in inspecting children steadily increased. For instance, by 1905 in Germany alone there were almost 600 physicians doing medical inspections in over 100 cities. One consequence of this increase was that, especially in those European countries in which medical inspection was most established, involved health professionals began forming associations, organizing conferences, and ultimately establishing journals like La Medicine Scolaire (France) and School Hygiene (England) to exchange the results of clinical research and observation. In 1904 the First International Congress on School Hygiene was held in Nuremberg. Three years later a second convened in London, attracting delegates not only from Europe but also from South and North America, Japan, India, New Zealand, Australia, and South Africa.60 Despite fairly widespread and established interest in school hygiene, US health professionals and educators were relatively slow to get involved in the international exchange of ideas. Indeed, it was to promote American involvement that Sir Lauder Brunton, president of the upcoming Second International Congress on School Hygiene, wrote to Arthur T. Cabot early in 1906, asking his aid in getting together a US delegation to the congress. Cabot, a prominent Boston physician who as chair of the Massachusetts Civic Association was actively

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promoting school hygiene in the state, agreed and encouraged a small group of physicians and educators to make the trip to London.61 Among the group was Helen Putnam, a Providence, Rhode Island, pediatrician who would soon after be elected president of the social reform–oriented American Academy of Medicine and would steer that organization toward promoting the health and survival of infants and children. Over the next decade and a half, she would become a recognized expert on school hygiene, promote school gardens and parent education, serve as editor of the child hygiene section of Child Welfare, and play a prominent role in getting the American Academy of Medicine to host a national conference in 1912 called The Conservation of School Children. Another member of the US delegation was Gulick, who at the time was head of physical training in the New York City public schools. William Burnham, the Clark University psychologist, also agreed to attend but had to cancel and ask Gulick to read his paper, which reviewed two decades of research on mental fatigue. John Cronin, Baker’s head of medical inspection, also read a paper, reportedly causing a stir by suggesting that correcting schoolchildren’s defects would significantly eliminate delinquency among youth.62 Cabot also concluded that the United States needed a national organization like those being formed in Europe, and he convinced several prominent physicians, public health officials, and educators to gather in New York late in 1906 to discuss the feasibility of organizing an American school hygiene association. In addition to Cabot, Gulick, Burnham, and Abraham Jacobi, attending the New York meeting were Herman Biggs, chief medical officer of the New York City Department of Health; Charles Harrington, director of medical inspection in Boston; Edward Stevens, assistant superintendent of New York City’s schools; John Musser, professor of clinical medicine at the University of Pennsylvania; and Henry Walcott, chairman of the Massachusetts State Board of Health. The attendees voted to establish an organizing committee—composed of those present plus G. Stanley Hall and the anthropologist Franz Boas—to schedule a national conference and to explore the possibility of establishing a journal. Three months later, on March 13, 1907, the organizing committee met, drew up a constitution and a set of operating principles, nominated a list of founders, and formerly established the American School Hygiene Association (ASHA).63 ASHA represented a type of voluntary health organization that first appeared in the United States during the opening decade of the twentieth century. Prior to that time, most American voluntary health associations formed at the national level had been like the American Public Health Association and the American Medical Association: professional organizations that focused on a wide range of health matters or primarily concerned themselves with defining

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and standardizing professional ethics and education, providing a forum for the exchange of professional information, and improving the sociocultural authority and economic status of their members. In contrast, ASHA was a voluntary health association formed to combat a specific health problem, and its founding was bracketed by those of similar single-focus associations devoted to combating such problems as tuberculosis, infant mortality, blindness, cancer, heart disease, deafness, paralysis, and venereal disease.64 Like these other associations, ASHA set a number of tasks for itself. One was to provide a national organizational structure and point of intersection for the various groups and individuals interested in school hygiene and the health of schoolchildren. This was not an insignificant undertaking, for by the first decade of the twentieth century, the school hygiene movement had come to include several distinct professional and civic groups. There were the educational psychologists, like William Burnham, Lewis Terman, Henry Goddard, and Fletcher Dressler, most of whom had studied or worked with Hall at Clark. There was a large and vocal group of physicians, like Wood, Gulick, Hugh Rowell, and Ernest Hoag, who either headed physical training or school hygiene departments in urban school systems or were university professors who trained future school hygienists and physical educators. There were the physicians, like Philadelphia’s Walter Cornell, who worked in or ran medical inspection programs for school departments. And there were their health department counterparts, like New York’s John Cronin. There were the chiefs of health department bureaus of child hygiene, like New York’s Baker and Boston’s Gallivan. There were the private practitioners, many of whom were in pediatrics or some other specialized field like otolaryngology, ophthalmology, and dentistry that was beginning to extend its services to children. There were also school and visiting nurses, like Lillian Wald and Lina Rogers. There was a plethora of educators, most notably superintendents, but also principals and even some teachers who had become involved with special schools. And there was a variety of lay reformers, from members of women’s clubs and civic organizations to home economists. In providing a common organizational meeting ground, ASHA helped forge what had been a disparate collection of individuals and groups into a recognized reform community. ASHA also devoted itself to serving as a forum and clearinghouse for scientific investigations into all aspects of school hygiene and to disseminating the results of those investigations not only among its members but also among school officials and the general public. Toward that end it held annual meetings at which scientific papers were given, and in 1913 it brought the Fourth International Congress on School Hygiene to Buffalo, New York. ASHA also

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established a journal, School Hygiene, which editorialized in its 1908 inaugural issue that the association had been formed to encourage scientific investigations of all matters relating to the health of schoolchildren.65 In designing these investigations, those who took part in the conferences and contributed to the journal focused considerable and increasing attention on medical inspection and its implications. However, they did not ignore schoolhouse hygiene, the hygiene of education, and other concerns that had preoccupied their nineteenthcentury predecessors and continued to constitute much of what was understood as school hygiene. Indeed, the collection of articles and papers published in the initial volumes of School Hygiene and in the early transactions of ASHA clearly showed a continuity of concern from when the school hygiene discourse began in the 1870s, while also demonstrating a distinct evolution of attitudes and ideas concerning the nature, severity, and incidence of health risks and problems particular to schoolchildren, as well as what was required to minimize those risks and promote health. School hygienists continued to lament the sanitary condition of many urban schools and call for better siting, plumbing, ventilation, and overall design. After a 1908 fire swept through a Collinwood, Ohio, elementary school, killing 172 children and 2 teachers, the charge that too many schools were firetraps was also frequently heard as ASHA meetings.66 Yet there was also recognition that considerable improvements had taken place and that school design and construction was increasingly informed by hygienic concerns. With the end of the depression of the 1890s and the consequent rise in tax revenues, urban school systems had embarked on school-building sprees in an effort to catch up with their exploding school populations. Between January 1895 and June 1902, for instance, New York City built sixty-nine new public schools in Manhattan and the Bronx. Chicago, Boston, and many other large and midsize cities also were building schools at an accelerated pace. Most of these new schools were constructed according to new school building codes that stipulated window to floor ratios, air and floor space per pupil, minimum ventilation, heating and artificial lighting requirements, plumbing and lavatory specifications, fire egress routes, and a host of other regulations adopted in response to the lobbying of late-nineteenth-century school hygienists.67 Concern with various school-caused diseases also continued to be expressed, though it was tempered by an assumed decline in the incidence and severity of these diseases as well as changing medical opinion as to the nature and seriousness of the various health threats supposedly posed by both the school environment and the rigors of instruction. Fresh air continued to be described as a prescription for health, but by 1910 the argument was

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increasingly being made that although vitiated air caused discomfort because of its heat and humidity, it was not fundamentally dangerous to health. Exposure to such air, it was asserted, could produce headaches, lassitude, and other conditions that might interfere with a student’s ability to learn, but it would not cause organic damage or degeneration. Poor ventilation and unregulated heating thus might impede learning, but they did not fundamentally destroy health.68 Similarly, the nineteenth-century school hygienists’ conviction that sitting at ill-fitting and poorly designed school desks contributed to permanent warping of the spines of countless schoolchildren was being challenged by research suggesting that scoliosis and other skeletal deformities were either genetic or related to disease and poor nutrition. In 1910 the German Orthopedic Association reviewed that research and concluded that although school-related conditions and behaviors could cause discomfort and contribute to poor posture or false scoliosis, real scoliosis usually was the result of congenital anomalies, rickets, infantile paralysis, or some other structural cause. Two years later, Robert Lovett, a Harvard Medical School professor and ASHA founding member, observed at an ASHA meeting that a decreasing number of well-educated physicians believed that schools and schooling were responsible for serious skeletal deformities.69 Concern that schools and schooling were producing a generation of myopes had also diminished by the second decade of the twentieth century. Although there were those who still passionately believed that childhood myopia was a school disease that particularly afflicted the more literate races and nations, they were increasingly in the minority. The hundreds of studies conducted since Hermann Cohn’s pioneering investigation confirmed the Breslau physician’s observation that myopia increased in children with age but eventually called into question his assertion that doing near work in school was the primary cause. Heredity was shown to be a far greater determinant than schooling in predicting myopia in children, as significant rates of myopia were discovered in nonliterate tropical tribes and in German and Danish army recruits with limited schooling. As a consequence, ophthalmologists and other vision specialists began distinguishing between pathological myopia, which they considered degenerative but comparatively rare, and developmental myopia, which they characterized as a fairly common consequence of growth.70 School conditions—especially bad lighting, poorly designed type, and excessive “small work”—could drastically worsen pathological myopia but were believed to have a much less degenerative impact on the developmentally myopic. Indeed, by 1910 school hygienists had begun to regard eyestrain, rather than myopia, as the most serious school-related vision disorder. Believed to be aggravated

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by environmental conditions such as poor type and bad lighting but to result chiefly from the ocular muscles straining to overcome refractive disorders, eyestrain was considered to be as common among the hyperopic (farsighted) and astigmatic as it was among the myopic. And although causing headache, blurred vision, sensitivity to light, and even nausea—and therefore making it difficult for a student to concentrate on schoolwork—eyestrain was regarded as a temporary condition that would soon disappear if corrective lenses were prescribed and used.71 Similarly, although school hygienists continued to view overstudy as harmful and to discuss ways to organize the school day and present the curriculum so as not to cause excessive fatigue, especially among young schoolchildren, they focused as much attention on efficiency as they did on health. Beginning in the late 1890s, American school hygienists, following the lead of their counterparts in Europe, began drawing on the findings and experimental methods of fatigue physiologists like Italy’s Angelo Mosso to construct recommendations on how long and in what order each subject should be studied so as to maximize learning.72 Indeed, by 1910 few if any school hygienists still seemed to believe that overstudy could drive an otherwise healthy child insane or cause his or her death. Similarly, although many school hygienists were still convinced that competitive pressure to achieve, combined with excessive amounts of assigned work, could exacerbate the condition of an already nervous child, few continued to warn that schools were producing hordes of neurasthenics and were responsible for the progressive degeneration of the race. As Thomas Harrington, Boston’s director of medical inspection, asserted at a 1906 New York Academy of Medicine meeting, “any attempt to charge physical deterioration to present-day school life must fail from lack of evidence.”73 Also increasingly rare were those who continued to believe that school and schooling were so taxing on the nerves that delayed entry was necessary for all but the most robust children. At the 1911 ASHA meeting, Luther Gulick recalled that he and his wife had been so concerned about the harm that school could do to their daughter that they had delayed starting her until she was eight. Now, he admitted, he doubted that such a delay was either wise or necessary and feared that by retarding her progress they had done their daughter more harm than good.74 Finally, early-twentieth-century school hygienists occasionally reiterated the late-nineteenth-century nostalgic conviction that urbanization and mass schooling had negatively transformed the carefree, physical, and healthy childhood of an earlier, largely rural America. But they tended to show less concern with the consequences of overcivilization than they did with the physical and

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mental defects that they believed largely resulted from too many city schoolchildren living in overcrowded, poorly lit and ventilated apartments; having little or no space and opportunity for healthy play and exercise; having their lungs and ears assaulted by the smoke and excessive noise of tenement districts; and being stunted in their development by diets that were nutritionally bankrupt because of their parents’ poverty and ignorance. Ascertaining the incidence of those defects, detailing how and why they affected a child’s ability to learn, and exploring how they might be corrected seemed to interest the early-twentieth-century school hygienists a great deal more than writing jeremiads on the destruction of childhood by modern life and schooling. In fact, many school hygienists at the time seemed to be reaching the same conclusion as William Maxwell, who in 1908 had pointedly noted that sport, exercise, and other types of physical training designed to counteract the enervating effects of sedentary and overly intellectual urban life would have little success until the many physical defects afflicting city schoolchildren had been identified and corrected.75 School Hygiene and Child Hygiene

Although committed to disseminating the results of scientific investigations, ASHA did not consider itself solely a scientific or research organization and embraced the additional task of promoting school hygiene, particularly the adoption of medical inspection to detect defects in children. Gulick, who took the minutes at the organizing meeting, reported that it was the consensus of the founders “that the Association should be a distinctly scientific society, but that it should ally itself definitely with local forces, so that the results of the deliberations might become embodied in actual improvement of conditions in the schools.” Hence, an article of purpose adopted by ASHA was “the stimulation of local societies that should conduct an active propaganda, looking to increase the health of school children.”76 To that end, as one of its first official acts, the association passed a resolution urging that every American city and town make adequate preparations for medical inspection and that states pass legislation that would require or at least allow for the detection of physical defects as well as contagious diseases. ASHA also committed itself to lobbying for the establishment of school hygiene offices within municipal and state public health or education departments and was instrumental in convincing the Federal Bureau of Education to establish a Division of School Hygiene in 1912. The association’s members also discussed ways to encourage and coordinate local organizations like women’s clubs, mothers’ congresses, medical societies,

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and civic sanitary groups—all of which, at least in urban areas, were showing increasing interest in promoting school hygiene.77 Lending social import to ASHA’s embrace of activism was the increasingly central place that the promotion of the survival and health of the young was occupying within the broad child welfare movement that had located itself at the center of the swirl of social reform that swept through the United States during the last decade of the nineteenth century and the first two decades of the twentieth. Although child welfare activism—commonly called “child saving”—had been building momentum in the United States since the 1850s, it was not until the end of the nineteenth century and the advent of that period of social ferment that historians call the Progressive Era that it blossomed into a full-fledged reform movement aimed at improving the welfare of children and granting them a special protective relationship with the state. Committed to ameliorating the excesses of industrial capitalism and imbued with a deep faith in a gospel of prevention, American social reformers in the Progressive Era made child welfare both a centerpiece in and a rationale for their various campaigns to improve health, education, and urban life.78 As American welfare historian Michael Katz has observed: “Almost overnight, it seemed, children became the symbol of a resurgent reform spirit, the magnet that pulled a diverse collection of causes and their champions into a new loose, informal—but very effective—coalition.”79 The goals of Progressive Era child welfare activism were many and varied, but virtually all were shaped by at least two central convictions. The first of these was that children, particularly the children of the largely immigrant urban poor, were the chief victims of the familial and social disintegration that seemed to many progressives one of the most salient consequences of a quarter-century of mass immigration, staggering urban growth, and unchecked industrial capitalism. Although generally supportive of economic expansion, progressive social reformers continually expressed concern that the nation was moving ahead at the expense of its young. The second conviction was that childhood was the most malleable and developmentally critical period of life, and thus the harm or good done to children in the present determined the character of the adult population of the future. A nation that exposed large numbers of its children to harmful conditions would invariably become a nation with a sizable population of damaged adults tending toward social dependency and pathology. It followed, then, that both sympathy and self-interest required the protection of children from the consequences of family breakup, sudden impoverishment, harmful environments, neglect, too early entry into the workforce,

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and a host of other dangers that they faced, especially in the nation’s cities and industrial towns. Building on the legacy of nineteenth-century child saving, the earliest Progressive Era attempts to provide such protection were primarily concerned with safeguarding children’s minds and morals. But during the first decade of the twentieth century, they increasingly came to include safeguarding children’s bodies as well. Thus, when a prominent child welfare advocate declared in 1910 that “the ideal we place before us is a protected childhood,” he was conceptualizing such protection as extending to the physical as well as the mental and moral health of children. So too was John Spargo, when he organized his immensely influential 1906 exploration of children in poverty, The Bitter Cry of Children, around the argument that poor children were disadvantaged primarily because with poverty came poor health and inferior physical and mental development. Hence, in 1914, when Columbia University social work professor George Mangold published his classic textbook, Problems of Child Welfare, he could note with approval “a changing social attitude toward the child’s health” and list the promotion of life and health as first among the obligations that progressive societies, out of both humanitarianism and selfinterest, have to their children.80 Providing both theory and rationale for this new reform strategy of preventing future social pathologies by protecting and promoting the health of the young was medicine’s relatively recent reconceptualization of childhood as a special period of life, with specific developmental attributes and needs. In the middle of the nineteenth century Western medicine discovered the child as subject and patient and began to look closely at the child’s body and to chart out a distinct child physiology, which it defined in essentially developmental terms. What made child physiology distinct from that of adults, and what determined a child’s physical response to stimuli, was that the young were developing organisms whose physical processes were constantly evolving. The elaboration and gradual acceptance of this developmental definition of the physical child led turn-of-the century physicians to abandon the longaccepted doctrine that children’s diseases were distinct from adult diseases and to replace it with one that located difference in the developing child’s response to disease. “If the diseases of childhood show such great differences in their number and in the form of their manifestation, as well as in the course of their termination,” the eminent Austrian pediatrician Theodore von Eschereich told an American audience, “this can only be due to the fact that between the growing organism of the child and that of the completely developed adult great differences exist in the reaction called forth by the disease process variations,

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which change constantly in the course of childhood.”81 L. Emmett Holt, whose 1894 The Care and Feeding of Children made him the Dr. Spock of the period, often made the same point, though more succinctly. It was, according to Holt, “not so much that the diseases of early life are peculiar, as that the patients themselves are peculiar.”82 The notion that children’s reactions to stimuli were both different from those of adults and conditioned by their stage of development lent scientific credence to concerns that children suffered greater and irreparable damage from exposure to toxic environments, stress and overwork, and deprivation of sleep or nutrition. Combined with a notion of development that was fundamentally teleological, it also provided support for arguments that damage done early in the developmental process, or arresting the process itself, would have magnified consequences in adulthood. Thus, whereas late-nineteenth-century objections to child labor often focused on its impact on the child’s moral and educational development, early-twentieth-century objections focused on its effect on organic, muscular, and neurological development. “The bad effect upon bodily growth and physical development is one of the most important objections to child labor,” declared Mangold, who went on to describe at length how “premature employment during the day or employment at night paves the way for those physical disabilities which result in an early incapacity for self-support, or in excesses of divers kinds which hasten the breakdown of the individual.”83 Jane Addams, the founder of Hull House, agreed, often arguing that child labor curtailed physical development, called forth harmful physical responses, promoted chronic disease and premature physical incapacity, and was therefore one of the chief causes of adult pauperism.84 Often referred to collectively by contemporaries as “child hygiene,” the early-twentieth-century effort to preserve the lives and health of the young inspired the creation of a wide array of philanthropic and government programs designed to achieve the movement’s two intertwined but distinct goals: reducing the incidence of infant and, subsequently, maternal mortality and safeguarding and improving the health of school-age children. Not surprisingly, most of those programs were located in the nation’s cities, not only because the poor urban child was at the center of the child welfare gaze, but also because cities had sizable and diverse collections of civic, charitable, and voluntary organizations and substantial networks of health professionals, clinics, and dispensaries. As the child hygiene advocate and Rochester, New York, Health Commissioner George Goler often explained, these collections and networks were critical because there was never adequate government funding or oversight to keep the programs running.85 Indeed, in contrast to the situation in

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Europe—where state funding was significant if not complete—in early-twentiethcentury urban America, child hygiene activity was always heavily dependent on the sponsorship of various voluntary and charitable associations and on the work of volunteer health professionals, club women, and others. Nor is it surprising that child hygienists looked to the urban school as a particularly efficient vehicle and site for improving child health. As New York’s Baker explained in her textbook on child hygiene, it was difficult if not impossible for health workers to reach children in their respective families, spread out as they were throughout the city. But in school, where virtually all the city’s young children were gathered for several hours a day, thousands of children could be inspected, instructed, and even treated.86 For child hygienists, then, medical inspection promised to be an effective tool in an overall public health program aimed at improving the physical welfare of the young. In promoting medical inspections and other school health services as a critical piece of a valuable program of child health improvement, school hygienists often described and justified their project as race improvement and employed the language and evolutionary viewpoint of eugenics. It is hardly surprising that eugenics—the pseudoscientific application of genetic and hereditarian theory to the biological improvement of populations—should occupy a significant place in the discourse on school hygiene. During the first third of the twentieth century, genetic and hereditarian theory, especially as it found expression in eugenics, was a critical parameter of the conceptual and linguistic universe that informed virtually all discourse on the application of science to social improvement.87 Although generally strongly opposed to the more radical eugenic propositions—particularly that racial well-being required a high infant and child death rate to weed out the unfit—most school hygienists were sympathetic to eugenicists’ insistence that biology mattered and could be manipulated to improve national and racial populations. Indeed, school hygienists saw the challenge before them as how best to employ biomedical and hygienic science not only to counteract the debilitating effects of the urban environment but also to engineer better children and thus better future populations. As Gulick early explained, “It is now our problem as biological engineers to face the situation, to show what needs to be done and to carry it out [so] that our children shall, under the conditions of city life, not only maintain the average health of the past, but become stronger and finer children than the world has ever seen before.”88 Especially after 1909, when the political economist Irving Fisher published his influential Report on National Vitality, many of those promoting school hygiene as part of child hygiene also often employed a language of conservation

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of human resources that characterized the young as investments in future productivity whose premature death or debilitating sickness represented a significant loss of potential national wealth.89 Prominent among these school hygiene promoters was Lewis Terman, an educational psychologist who had studied with Hall and Burnham at Clark. Best known for developing the Stanford-Binet intelligence test, Terman was also an avid advocate of school hygiene in general and medical inspection in particular, seeing the latter as assisting intelligence testing in identifying and sorting students according to their mental and physical abilities and disabilities.90 While working on his intelligence test, Terman published two influential school hygiene texts, The Hygiene of the School Child, an instructional manual for teachers, and Health Work in the Schools, a guide for administering school health programs coauthored with Ernest Hoag, chief of medical inspection for the Long Beach, California, school system. In both books, Terman generously employed the language of conservation, opening the first chapter of the former by advising: “The rapid development of health work in the schools during the last two decades is not to be regarded merely as an educational reform, but rather as a corollary of a widespread realization of the importance of preventive measures in the conservation of natural and human resources.” And, asserting that “the prevention of waste has become, in fact, the dominant issue of our entire political, industrial, and educational situation,” he declared that “the greatest problem of conservation relates not to forests or mines, but to national vitality, and to conserve the latter we must begin by conserving the school child.”91 But to do that, Terman argued, required “a broader conception of the functions of educational hygiene,” one that went beyond “the usual attention given to heating, lighting, [and] ventilation” and dedicated itself to conserving and improving the health of schoolchildren so as to render them physically and mentally fit to benefit from education and successfully meet the struggles of life. Other school hygienists expressed similar sentiments.92 Yet rendering the nation’s schoolchildren fit to benefit from education and meet life’s challenges required more than simply diagnosing or identifying those with physical and mental defects. It also required eliminating or at least lessening the impact of those defects on children’s ability to learn. Some of this could be accomplished through educational management: moving children who were nearsighted or hard of hearing to the front of the classroom and adjusting the curriculum and schedule of those with heart disease, progressive myopia, or nervous disorders so as not to tax their vulnerabilities. Most, however, required that children with diagnosed defects receive some form of remedial help. Children who were sickly, underdeveloped, and anemic because of malnutrition had to be

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nourished and built up; children with carious teeth, hypertrophied tonsils, adenoidal growths, vision and hearing defects, and other health problems had to receive the appropriate dental, medical, and surgical correction. As medical inspection increasingly centered on detecting education-impairing conditions, the question of how to accomplish these two related remedial goals moved to the center of the school hygiene discourse, generating controversy over what role the public school should play in feeding and building up malnourished and underdeveloped children and in facilitating the corrective treatment of those with remedial defects.

Chapter 4

Building Up the Malnourished, the Weakly, and the Vulnerable Penny Lunches and Open-Air Schools

Early medical inspections’ revelation that a sizable proportion of urban schoolchildren showed signs of malnutrition and underfeeding did not come as a complete surprise to either school hygienists or the general public. That a significant number of city schoolchildren might be going to school hungry or suffering from the consequences of poor and inadequate nutrition had been the object of public discussion since at least 1904, when a muckraking moderate socialist and former Hull House worker named Robert Hunter ventured in Poverty, his influential survey of the extent, nature, causes, and consequences of poverty in the United States, that “there must be thousands—very likely sixty or seventy thousand children—in New York City alone who often arrive at school hungry and unfitted to do well the work required.”1 A structuralist who tied poverty to changes in work and family life wrought by industrialization and urbanization, Hunter considered his estimate relatively cautious and just one of many he used to illustrate the extent of poverty among urban laboring families.2 Yet nothing else he wrote in the book received such an immediate and dramatic response. He later recalled: “Quite incidentally in my book Poverty I made an estimate of the number of underfed children in New York City. If our experts or our general reading public had been at all familiar with the subject, my estimate would probably have passed without comment, and, in any case, it would not have been considered unreasonable. But the public did not seem to realize that this was yet another way of stating the volume of distress, and, consequently, for several days the newspapers throughout the country discussed the statement and some instances severely criticized it.”3 Hunter was not exaggerating in his description of the response. A Bureau of Education

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report noted that “this cautious statement of Mr. Hunter was so garbled by sensational papers that the report was soon in circulation that Robert Hunter had said that there were 60,000 to 70,000 starving children in New York. The result was hysterical excitement.”4 Indeed, especially after New York School Superintendent William Maxwell declared in a 1904 National Education Association meeting at the St. Louis Exposition that there were hundreds of thousands of hungry children in the nation’s urban schools, starving city schoolchildren became something of a cause célèbre, with newspapers and magazines around the nation picking up the story and quoting principals and teachers on the number of children who came to school hungry.5 One reason that Hunter’s and Maxwell’s assertions and the observations of interviewed educators caused such a furor was that neither the American public nor the press had previously considered child hunger a serious national problem. Although the severe depression that began in 1893 had exposed the depth of poverty in American cities, and muckraking journalists like Jacob Riis had given some visibility to poor urban children, most Americans seemed to believe that the overall number of hungry children in the nation was relatively small. After all, the United States was distinguished by its plentiful and comparatively affordable food supply, and American workers were widely believed to be better fed and bigger than their European counterparts.6 Widespread child hunger, evidenced by urban schools filled with the empty-bellied children of the laboring classes, was believed to be a feature of European and especially English cities, not American. In fact, for decades Americans had been reading about the ragged and hungry schoolchildren that compulsory education laws were purportedly pulling into schools in London and Paris. More recently, US newspapers and magazines had widely reported the findings of Great Britain’s Committee on Physical Deterioration, which estimated that 16 percent of London schoolchildren were seriously malnourished and fingered poor nutrition in childhood as a primary reason why so many recruits from the laboring classes had been rejected as unfit for military service during the Boer War.7 Referencing the reports of hungry schoolchildren on the other side of the Atlantic, Edward Devine, of the New York Charity Organization Society, offered the following observation about the furor provoked by Hunter’s estimate: For some years there have come stories from over the sea that compulsory education was revealing an appalling degree of wretchedness in the towns of England and on the continent; that children were coming to school ravenously hungry, weakened by privation, wholly incapacitated by their physical condition from deriving profit from the expensive

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school system maintained for their benefit. . . . And then out of the clear sky there came two or three years ago a startling declaration that as it is in England and France, even so it is in New York; that 70,000 school children habitually go hungry to school. . . . To thoughtful observers at the time it looked like the importation from the literature of foreign revolutionary agitation. It did not seem to fit our facts even on New York’s lower East Side, and certainly not elsewhere in America.8

That Hunter’s estimate did not fit the facts of New York or other American cities was also the opinion initially expressed by many within the charity and education communities, especially after the Salvation Army revealed that few children came to the breakfast kitchens it had set up near a number of schools in poor districts, and a special New York Board of Education investigation reported that it could find no more than a few dozen hungry, breakfastless children in the entire school system. “The origin of the figure 70,000,” opined a New York charity worker, was “three guesses by the author of Poverty, plus a supervisory guess by the Superintendent of Schools for New York City, plus an additional 20,000 by the press for good measure.”9 Others, however, thought Hunter’s estimate fairly accurate. Calling the Salvation Army experiment meaningless and the Board of Education investigation a coverup, the Henry Street Settlement Founder Lillian Wald contended that anyone familiar with schools in the crowded immigrant neighborhoods of New York and other American cities knew that there were significant numbers of city children who came to school each day hungry and underfed. The sociologist and, later, anthropologist Elsie Clews Parson agreed. She had just asserted in her recently published Family Monographs that the nutrition of many children in the poorer sections of New York was no better than in the worst slum areas of London.10 Indeed, over the next few years an expanding number of settlement workers, child and school hygienists, and socialists and progressives mounted a concerted effort to connect poverty, malnutrition, and school failure in a tragic triangle of child waste by demonstrating, in the words of Hunter, that “this curse which poverty lays upon innocent children is an awful one, for it means that they may not grow, that they may not learn, and therefore they may not be strong enough mentally and physically to overcome the cause of it all,—poverty.”11 Among the earliest and most powerful contributions to that effort was The Bitter Cry of Children, published in 1906 and written by another moderate socialist, John Spargo. Convinced that “the evils inflicted upon children by poverty are responsible for many of the worst features of that hideous phantasmagoria of hunger,

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disease, vice, crime, and despair, which we call the Social Problem,” Spargo sought to illustrate and explain how this was so by focusing on what he felt were the three major areas where poverty most impacted the welfare of the young.12 The first of these, he wrote, was poverty’s contribution to excessive infantile disease and mortality; the second, its responsibility for the terrible burdens borne by children who had to labor; and the third, its role in stunting the physical and mental development of the young and robbing them of the opportunity to be effectively educated. In his treatment of the third area, which he characterized as “the tragedy and folly of attempting to educate the hungry, ill fed school child,” Spargo claimed to be influenced by the conclusion of the British Committee on Physical Deterioration that the low vitality and physical defectiveness of English working-class children was not hereditary but rather the result of underfeeding and malnutrition in childhood. In order to establish whether similar underfeeding and consequent malnutrition might be afflicting the children of America’s urban working poor, Spargo sought to test and expand on the estimate by Hunter, whom he asked to write the introduction to his book.13 To that end he secured the cooperation of principals and teachers in sixteen Manhattan schools, who collectively interviewed 28,000 students on what they had for breakfast on a particular day. Their finding was that at least 23 percent of the questioned students had either not had breakfast that day or had had a totally inadequate breakfast, consisting only of bread and coffee or tea. If that percentage applied to the whole urban school population, Spargo postulated, then at least two million schoolchildren in American cities were victims of inadequate nourishment. Echoing Hunter, he warned: Such children, as a result of this privation, are far inferior in physical development to their more fortunate fellows. This inferiority of physique, in turn, is responsible for much mental and moral degeneration. Such children are in very many cases incapable of successful mental effort, and much of our national expenditure for education is in consequence an absolute waste. With their enfeebled bodies and minds we turn these children adrift unfitted for the struggle of life, which tends to become keener with every advance in our industrial development, and because of their lack of physical and mental training they are found to be inefficient industrially and dangerous socially. They become dependent, paupers, and the procreators of a pauper and dependent race.14

Hunter’s and Spargo’s estimates of the extent of underfeeding and malnutrition in American cities were soon augmented both by the release of medical

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inspection data and by specifically targeted studies that sought to gauge the level of malnutrition among schoolchildren in various urban locales. In Chicago, after members of local women’s clubs and parents’ associations charged that many children in the city were coming to school hungry and malnourished, public school authorities initiated a special study involving the examination of the children in eighty-five city schools. When the results were released, they shocked the city. “Hunger Stalking in City Schools: Five Thousand Pupils Don’t Know What a Full Meal Means and 10,000 Others Are Underfed,” blared a frontpage headline in the Chicago Daily Tribune. The following day, Mayor Busse, declaring that he was “shocked by the revelation that there were 15,000 starving or half fed children in Chicago,” promised that his administration would immediately begin exploring ways that these schoolchildren could be fed with public funds and pledged to donate his own money to any philanthropic effort mounted to help relieve the problem.15 Shortly afterward, Boston’s Office of Medical Inspection released records showing that of the 80,000 children who received routine medical exams the previous year, 5,000 showed distinct signs of malnutrition and 6,000 of anemia. In Philadelphia and St. Paul, special examinations of children attending schools in poor districts revealed that over 20 percent were undernourished. Even higher figures were turned up in clinical studies done by dispensary physicians. In a much-cited study, the results of which were published in the Journal of the American Medical Association, a physician who ran a clinic on the Lower East Side of New York reported that over 60 percent of the young children in the families he served were suffering from the effects of serious undernourishment.16 As mounting evidence suggested that a significant proportion of urban schoolchildren were seriously underfed and malnourished, American city schools became the sites of two experiments aimed at building up underfed, anemic, and weakly schoolchildren and by so doing reducing their vulnerability to chronic and epidemic disease and stunted physical, mental, and educational development. The first was largely promoted and funded by antituberculosis societies in conjunction with philanthropies. It involved identifying those schoolchildren who were severely malnourished, anemic, or sickly and who had also been exposed to tuberculosis or were showing the initial signs of infection and then placing them in special open-air schools and classes that employed the fresh-air prophylaxis, invigoration, and feeding therapies that had been developed and refined in tuberculosis sanitariums. The second, far more diffuse and considerably more contested, was promoted by a collection of prominent school hygienists and urban school and health officials, often with the strong support of parents’ associations, civic groups, mothers’ and women’s

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clubs, and other grass-roots organizations. Essentially, it involved making available in elementary schools nutritionally sound lunches and snacks that would make a significant contribution toward meeting the daily nutritional needs of the children who purchased or were given them. Although both experiments involved making school a place where child health would be substantially improved through the provision of nutritious food, the responses that the two called forth from the welfare, educational, and public health communities and the general public were quite different. Although disenchantment with their promise would ultimately develop, for a considerable amount of time open-air classes and schools generated positive reviews and relatively widespread support as both an innovative attempt to provide education to those too sickly to attend regular school and as a logical extension to children of a public health campaign aimed at combating the spread of tuberculosis, the leading killer of the nation’s citizens. Conversely, the school lunch, though also characterized by its supporters as a measure to increase child hygiene and educational efficiency, provoked heated opposition as an unneeded, dangerous, socialist experiment that would turn schools into relief agencies, weaken parental responsibility, and undermine the efforts of the social welfare community to improve social stability through reforming individual families. What the two experiments had in common was that a lack of public funding and commitment, and a consequent overreliance on philanthropy and volunteerism, condemned each to relative ineffectiveness. Open-Air Schooling

The open-air schooling experiment began in the United States during the dead of winter in 1908 when a dozen or so Providence, Rhode Island, elementary and grammar schoolchildren filed into a room on the second floor of an old schoolhouse located on a hill in the city’s east side. Although all the children had at one time or another attended city schools, they were not typical Providence schoolchildren. Ranging in age from six to thirteen, they had been chosen for this ungraded class because they were severely malnourished, anemic, sickly, underperforming in school, and, most important, considered at risk of developing active cases of tuberculosis. Nor was the room into which they filed a typical school classroom. Distinguishing it were several novel features, perhaps the most striking of which was that the brick wall on the southern side of the room had been removed and replaced with a wall of windows, hinged at the top and capable of being raised against the ceiling by means of cords and pulleys. Except in driving snow or rain, these windows were kept wide open. At the other side of the room were two stoves, one for cooking and one

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for heating, though the latter barely kept the temperature of the room above freezing on the coldest winter days. In between and seated at desks bolted to movable platforms were the children, who were outfitted in wool sweaters, mittens, caps, and felt overshoes and were encased in “Eskimo” or sitting-out bags resembling present-day sleeping bags. Although the curriculum was essentially what was taught to other public schoolchildren, the workload was light and instruction was individualized. Periods of rest were frequent and interspersed with such untaxing exercises as arm raising and singing. A hot meal of soup, sometimes supplemented with eggs, milk, and pudding, was served at midmorning and again at noon. Unlike in regular classrooms, the progress of these children was gauged by physical as well as academic standards. Once a week they were examined by a physician and a nurse, who weighed them, checked them for glandular swelling, measured their chest expansion, and drew blood to be tested for hemoglobin content.17 The novel features of both the room and the daily schedule reflected the chief purpose of the school: to build up the strength and vigor of severely malnourished schoolchildren and thereby increase their resistance to developing active tuberculosis. Holding its first day of class on January 27, the Providence open-air school marked the inauguration of American involvement in an international experiment in remedial elementary education and preventive health work that had begun in August 1904, when the Berlin industrial suburb of Charlottenburg conducted a three-month open-air school session in a pine forest just outside the city. Within a few years similar open-air schools in the woods, as they were called, were established elsewhere in Germany and Europe and in Great Britain. Although clearly influenced by the British and continental efforts, open-air schooling in the United States developed along a slightly different path. Rather than being situated in pine woods or in parks at the edge of urban areas, US open-air schools were often located in school buildings and on school grounds in some of the most crowded sections of cities. Moreover, in the United States, the medical supervisory personnel, special equipment and clothing, and some of the food were supplied by tuberculosis societies, often with the assistance of local philanthropies. Although American urban school systems were usually eager participants in open-air experiments—prompted in part by their legal obligation to provide such children with schooling—their participation was almost universally limited to the provision of teachers and classrooms.18 The Providence experiment was soon followed by others. In September 1908, the Boston Association for the Relief and Control of Tuberculosis secured the support of the Boston School Board in establishing the first open-air school

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in that city. The following year Hartford, Connecticut, began an open-air school in a large army tent situated on the grounds of a night school, and Rochester, New York, created an open-window classroom for tubercular and delicate children. In Chicago the Chicago Tuberculosis Institute, financed by a $2,500 grant from the Elizabeth McCormick Memorial Fund, established an open-air school on the roof of the Mary Crane Nursery in the Hull House complex. And in 1910 New York created an open-air school on the roof of an elementary school located in its congested Lower East Side.19 During the second and third decades of the century, the number of open-air schools in the United States increased dramatically, peaking in the early 1920s with the involvement of close to ten thousand American schoolchildren in over 150 of the nation’s cities. In some cities, school authorities and antituberculosis associations followed the Providence example and converted unused classrooms by knocking out walls or by installing casement or double-hung windows that could be swung wide open. These came to be known as openwindow or fresh-air classes. In other cities, based on a simple plan devised by Thomas Carrington, an officer of the National Tuberculosis Association and an expert on hospital construction, shed-like structures were constructed on the roofs of buildings. And a few cities, invariably with private philanthropic funding, constructed specially designed buildings or remodeled existing ones to house substantial open-air schools. Whatever shape they took, open-air schooling sought—not always successfully—to provide what was popularly described by its advocates as “double rations of air, double rations of food, and half rations of work.”20 The development of open-air schooling in the United States linked school hygiene’s effort to improve educational efficiency by improving child health to the international antituberculosis campaign that had been gathering momentum since the end of the nineteenth century.21 At the center of that link was the sickly and malnourished young child and its recent conceptualization as at high risk not only of academic backwardness but also of tubercular infection, which could later result in the clinical development of chronic pulmonary tuberculosis in older adolescents and adults. Prior to 1900 pulmonary tuberculosis—popularly known as phthisis or consumption and the great killer of the industrial world—had been considered primarily an adult disease, largely because childhood tuberculosis usually developed in the cervical glands, in the bones and joints, or as a generalized disease. During the first decade of the century, however, this long-held view was altered dramatically when a series of comprehensive postmortem studies revealed that healed or latent lesions were present in many adults who had shown no

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clinical manifestations of tuberculosis during their lives, and that infection in the bronchial glands and lungs was far more common among children than had previously been suspected.22 At the same time, tests for exposure to the tubercle bacillus, developed in the first decade of the century by Clemens von Pirquet and others, were suggesting that over 50 percent of all schoolchildren might have been exposed and thus could be considered as potentially infected.23 Neither the postmortems nor the tuberculin tests clearly established either the sources and paths of infection or the process by which a childhood infection might much later develop into clinical phthisis in an adult. But that fact did not prevent the idea that consumption had its origins in childhood from quickly establishing itself on both sides of the Atlantic as one of the most commonly held principles of phthisiogenesis. In England Theophilus Kelynack, who edited a highly regarded and often-cited 1908 collection of essays on tuberculosis in infancy and childhood, stated that the postmortem findings had convinced him “that a not inconsiderable proportion of the heavy mortality and extensive crippling occurring in adult life from tuberculosis disease is the outcome of an infection dating back to infancy and childhood.”24 In Germany Emil von Behring, who had just been awarded the first Nobel Prize in medicine for his work on diphtheria antitoxin, declared: “Phthisis is but the last verse of the song, the first verse of which was sung to the infant in its cradle.”25 In the United States Lawrence F. Flick, the first head of the Henry Phipps Institute and a leading figure in the American antituberculosis movement, more prosaically stated that “tuberculous infection takes place in early life; some throw off the disease and become completely sterile, no doubt; but many carry the microorganism throughout life.”26 Admittedly, medical opinions about the etiology and pathology of tuberculosis in children were anything but uniform, and researchers continued to disagree on and debate a host of issues, including the relative importance and relation of the bovine and human forms of the disease, the function of immunity from early exposure, and the symptomatology presented by the various types of tuberculosis in childhood. Nevertheless, the belief that a significant proportion of adult cases of consumption originated in childhood infections continued to gain support and approached being accepted as medical doctrine during the second decade of the century. This was true especially after the Austrian pathologist Anton Ghon clarified the process by carefully and persuasively demonstrating that in children infection of the lung was primary while that of the lymph nodes was secondary, and by arguing that adult consumption developed when healed primary lesions were later inflamed or “lit up” by disease or some other physical trauma.27 Indeed, Ghon not only

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provided convincing support for the argument that adult pulmonary tuberculosis originated in childhood infection, but also furnished that argument with a powerful metaphor. As the American pediatrician L. Emmett Holt explained in the 1914 edition of his The Diseases of Infancy and Childhood, those infected in childhood carried with them “a smoldering ember which at any time may be fanned into flame under the stimulus of an inflammation excited by some other cause.”28 For those involved in the American antituberculosis campaign, the implications of the discovery of childhood infection were clear. Children would have to be targeted if the battle against tuberculosis was to be won. As a Baltimore physician contended in 1908 in the Journal of the Outdoor Life, the official publication of the National Tuberculosis Association: Many eminent authorities upon tuberculosis, especially in France and Germany, are firmly convinced, not only by their reasoning but by their laboratory and clinical experience, that all tuberculosis infections are made in infancy or in childhood, the disease lying latent, until from one cause or another the resistance of the individual is reduced and the disease becomes manifest, . . . it is evident, therefore, that the ultimate solution to the problem of the eradication of tuberculosis rests largely with the coming generation, that is, with the school children of to-day.29

Although most American pediatricians and tuberculosis experts of the time could readily agree that preventing tuberculosis infection among school-age children represented a critical strategy for combating the disease, they could not so readily agree on what that strategy should entail. Some, like S. Adolphus Knopf, argued that efforts should be aimed at reducing the likelihood of exposure to contagious adults by removing nontuberculous children from tuberculous families or by isolating tuberculous parents in sanitariums and hospitals. Others contended that such a course was not only probably illegal but also impractical, given that there were insufficient institutions to care for such children and that the number of tuberculous parents far exceeded the number of available beds in hospitals and sanitariums. A more promising strategy, therefore would be to control the outcome of exposure by improving the health and building up the strength of at-risk children so that they might better resist infection or better resist the development of the disease once they were infected.30 For early-twentieth-century antituberculosis activists, building up the resistance of children meant making an open-air regimen available to them. Developed in the sanitariums and tuberculosis day camps that had proliferated in North America and Europe after 1890, this regimen was based on the

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conviction that a plentiful supply of rest, hearty food, and cold fresh air not only could prevent those infected from developing active cases of the disease but also could help those afflicted effect a spontaneous healing of tubercular lesions, thus conquering the disease or at least rendering it inert.31 Encouraged by the effects such therapy had on children in summer camps, antituberculosis activists argued that even greater results could be achieved if children could continue to receive open-air treatment through the school year, especially since doing so would remove them from the debilitating overheated and noxious environment of the typical classroom and would provide them with sustained exposure to cold air, which was widely believed to promote strength and vigor by increasing the appetite and stimulating respiratory and vascular activity.32 Two major strategies were propounded for providing at-risk urban schoolchildren with an open-air regimen while making certain that they were still given the basic education that was their right. One was establishing “preventoria,” sanitarium-like institutions located in salubrious rural settings.33 But preventoria, the first of which opened its doors in the summer of 1909, were expensive to establish and operate. They also usually limited admission to those who had active cases of the disease or, at least, registered positive on a tuberculin test; and they required that children be separated from their families for months at a time. Even in the 1920s, by which time at least one preventorium could be found in almost every state in the nation, these institutions accommodated only a minuscule fraction of the nation’s children considered infected with tuberculosis. Not surprisingly, then, antituberculosis experts promoted a second strategy, one that would complement the preventoria by casting a much wider net to bring in children in whom the disease was quiescent or whose infection could not be positively determined, but whose weak, sickly, and malnourished constitutions combined with membership in families with tuberculous adults suggested that they would soon be carrying the “smoldering ember.” This strategy was establishing open-air schools and classrooms in the nation’s cities. The children selected for this experiment in tuberculosis prevention would not be those who had open cases or who were sick enough to require treatment at a hospital or sanitarium; state laws increasingly forbid such children from attending public schools. Rather, they would have what were called pretuberculous, or incipient, cases. They might be infected, but the disease in them was quiescent or in the earliest stage of development. If the formulation of medical theory linking childhood infection to the development of adult pulmonary tuberculosis provided a rationale for establishing open-air schools and classes for malnourished and underfed children in the nation’s cities, the accumulation of data purportedly showing malnutrition

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and underfeeding to be shockingly widespread among urban schoolchildren provided a sense of urgency. It was not just a few urban schoolchildren who were in such poor physical condition that they were highly susceptible to contracting and developing the disease; it was a very large proportion of them. Indeed, the widespread prevalence of malnutrition that medical inspections were discovering among schoolchildren was taken by a number of tuberculosis experts as an explanation of why childhood mortality rates from the disease were not declining, as adult rates were.34 In promoting open-air schooling as a way to build up malnourished, sickly, or underdeveloped children and in so doing to combat the spread of tuberculosis, antituberculosis experts and organizations found allies among school hygienists and educators who came to see open-air classes as particularly effective in transforming low-achieving and backward children into progress-making students. Early reports from the initial experiment in Charlottenburg had suggested a positive correlation between time spent in open-air schools, weight gain, and academic progress, as well as improvement in general deportment. This also proved to be the case in the American schools, and proponents of open-air schooling were soon proclaiming that open-air schooling could do wonders for children who were indifferent students. For instance, a publication lauding Boston’s open-air school asserted that after only a few weeks in the class, “the children became more alert mentally and showed considerable increase in attention to work. They improved in appearance, were neater and cleaner, had better manners and were more orderly.” Another, detailing the open-air schooling supported in Chicago by the Elizabeth McCormick Memorial Fund, noted that academic and weight gains were both significant and relatively quick to manifest themselves. Indeed, the growing conviction that an open-air regimen could promote both physical and academic improvement led to the establishment of a number of open-air private schools as well as the remodeling of schools and classrooms in some of the more prosperous of the nation’s suburbs.35 “How Sick Does a Fellow Have to Be?”

With its educational and health benefits being lavishly praised in scores of articles appearing in the popular, medical, and educational press during the years leading up to World War I, open-air school schooling was enthusiastically embraced by many school and child hygiene advocates as an innovation that promised to be effective in building up undernourished and weakly schoolchildren and thus diminishing their susceptibility to both disease and academic retardation. Triumphantly noting that ninety American cities had

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now established open-air classes, a 1917 US Bureau of Education publication promoting open-air schooling called it “one of the most interesting and decided changes undertaken in school management for many centuries” and predicted that it would revolutionize both American schooling and the promotion of schoolchildren’s health.36 Yet if open-air schooling enjoyed a clear medical and educational rationale and was supported by a sense of urgent need, it was saddled with an impossible mission. If open-air schools were to be instrumental in combating tuberculosis by increasing the ability of children either to resist infection or to resist developing the disease after they were infected, then those schoolchildren at greatest risk of infection—as well as those who were infected but were either latent cases or in the early stage of the disease—needed to be identified and helped. But this was no simple task, for in the years before World War I the diagnostic criteria for detecting incipient tuberculosis infection in children as well as identifying those most at risk were anything but precise or commonly agreed on.37 Moreover, although tuberculin testing and particularly the von Pirquet test appeared to hold great promise, such testing was still too distrusted by many physicians and too feared by parents to be employed on any broad scale. Finally, given that even children with active cases of pulmonary tuberculosis generally lack the cough, sputum discharge, hemoptysis, or audibly detectable cavitation characteristic of the adult consumption, and given the general obscurity of symptoms presented by other forms of early-stage tuberculosis in children, diagnosis was more often than not guesswork, based on the presence of suggestive symptoms such as underweight, irritability and inability to concentrate, hypertrophied tonsils, and general sickliness and frailty as well as on a history of environmentally predisposing conditions such as poverty or tuberculosis in the family.38 Such suggestive symptoms and predisposing conditions were also employed to identify children considered at high risk of infection, a class of youngsters increasingly labeled pretubercular. Convinced that whether or not infection would take was dependent on the efficacy of the individual’s natural defenses, physicians therefore pinpointed the frail, underweight, and sickly child of the urban poor as the child most at risk.39 As urban school systems embraced open-air schooling and confronted the task of identifying which of their pupils would benefit most from the “double rations of air, double rations of food, and half rations of work,” they thus had at their disposal only generalized and broadly inclusive diagnostic criteria. Moreover, because they had neither the personnel nor the funds to give children careful physical exams, school systems tended to rely heavily on such easily determined guides as the degree of deviation below established weight norms

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and on the extent to which a child, in his or her teacher’s opinion, seemed too sick or sickly to carry the normal workload. Consequently, school systems cast wide nets that inevitably collected far more students than could be accommodated in open-air schools. For instance, in 1910, when Boston directed its medical inspectors to join with teachers and nurses in identifying elementary schoolchildren in need of open-air treatment, over 4,400 children—or about 5.5 percent of the total primary school population—were singled out. Similar investigations by school physicians in New York, Chicago, and several other cities identified equally large numbers of children in need.40 Yet at no time did any city, with the sole exception of Chicago, make accommodation for much more than a hundred or so open-air pupils—usually those deemed most underweight, most sickly, and most backward—principally because the cost of open-air schooling was three to four times that of normal schooling.41 For unlike in Europe, where public funding was allocated to meet the added expense of feeding and clothing the children, in the United States school systems had to rely on the generosity of philanthropies and antituberculosis associations. Therefore, as an experiment in preventive health work, open-air schooling promised far more than it ever delivered. Indeed, running like an undercurrent beneath the extravagant claims made for open-air schooling was a refrain of regret that only a tiny fraction of the schoolchildren in need would ever benefit from it. As Josephine Baker would later recall with a trace of bitterness, open-air schooling was a greater idea in promise than in reality. Although its chief promoters, like Sherman Kingsley of Chicago’s Elizabeth McCormick Memorial Fund, were disseminating images of formerly frail but now robust children who had had open-air schooling—images that attested to the great work being done for tuberculous and delicate children—the vast majority of such children were being ignored. Recalling that the fund had circulated a poster showing a ragged, undernourished boy standing outside a door marked “Open-Air School,” and asking “how sick does a fellow have to be” to get in there, Baker observed that she and others at the time could not help but see the irony in the question.42 Although rarely made before World War I, observations such as Baker’s became more commonplace in the postwar years and reflected an increasing recognition of the limitations of specialized open-air schooling. Although school systems continued to list open-air classes among their offerings, increasingly what they meant was that they had dedicated for the use of delicate children a number of normally heated classrooms in which windows were left partially open to guarantee an abundant supply of fresh air. In fact, in 1930, when James Rogers—the US Bureau of Education’s expert on school hygiene—reviewed the

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state of open-air schooling, he concluded that it was an experiment in the process of being forsaken.43 Aside from its prohibitive cost and its consequent limitation to but a fraction of the children identified as in need, several other specific developments led to the demise of open-air schooling. One was the growing conviction among tuberculosis specialists that limited, daytime open-air programs had little long-term success in preventing tuberculosis from developing. Follow-up studies of children supposedly cured by open-air classes revealed a disturbing number who redeveloped all their old symptoms once they returned to regular schooling.44 Another critical development was the gradual reversal of opinion on the effects of exposure to cold temperatures. By 1920 complaints from parents and students about the physical discomfort of exposure to cold air, combined with ongoing research into ventilation, had led many of those involved in school hygiene to conclude that unheated classrooms and rooftop structures open to the winter air exhausted rather than invigorated children. In 1923 that conclusion received strong confirmation, when the long-awaited report of the New York State Commission on Ventilation emphatically condemned exposing children to cold winter air. As Rogers later noted, the report delivered a devastating blow to those still proclaiming the benefits of open-air classes. Indeed, in 1924, when he published a revised edition of his 1913 manual on the medical and sanitary inspection of schools, Solomon Newmayer, former head of Philadelphia’s Division of Child Hygiene, recanted his earlier support for exposure to cold air, flatly declaring that “‘Open-Air’ and ‘open-window’ classes are monuments to past mistakes in handling the problem of tuberculosis and its ally, malnutrition, in the schools.”45 Penny Lunches

The second experiment initiated in American cities during the first decade of the twentieth century as a response to reports of widespread malnutrition and underfeeding among schoolchildren was the penny lunch. Referring to food offered for sale—sometimes for a penny, but more often for two to three cents— at both noontime and the morning recess, the penny lunch was intended to combat malnutrition by making available a high-protein, high-calorie supplement to the urban schoolchild’s regular diet. Although since the 1890s various charities had on occasion offered cheap lunches to schoolchildren, the experiment really began in 1908, when the principals of two elementary schools in immigrant neighborhoods in New York City sought the assistance of the New York Home Economics Association leader Mabel Kittredge in establishing a service that would sell low-cost, nutritious lunches in the schools. Kittredge agreed, eventually enlisting the aid of a group of physicians, nurses,

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nutritionists, and social workers who banded together to form the New York School Lunch Committee (NYSLC). By 1914 the committee was providing food for purchase in seventeen elementary schools.46 As the committee was introducing lunches for sale in New York schools, a variety of civic and philanthropic organizations, either on their own or in partnership with municipal boards of education, were doing the same in several other American cities. In Philadelphia the philanthropic Starr Centre Association, which in 1895 had opened a public kitchen to serve low-priced meals in one of the city’s poorest neighborhoods, began selling “penny lunches” at a few nearby schools during the morning recess. The Philadelphia Home and School League began serving a three-cent noontime meal in one school in 1909 and, over the next few years, paid for the equipping of kitchens and for the administration of meal service in several other schools. Also in 1909 the Boston Home and School League voted to provide funding for the initiation of low-cost lunch programs in schools it had already paid to be equipped with kitchens so that cooking classes could be offered. To administer the program, it established a Boston School Lunch Committee and appointed as chair Ellen H. Richards, the pioneering American nutritionist and dietary reformer who had founded the New England Kitchen and had just been elected the first president of the American Home Economics Association.47 In Chicago, after the Board of Education backed away from its initial decision to run a school lunch program, its place was taken by a joint committee of the city’s women’s clubs that, beginning in 1908, hired cooks and managers and soon had a fairly extensive program in place. After 1910 the Board of Education assisted by providing lunchrooms and paying to equip kitchens in the schools. Federations of local women’s clubs were also instrumental in starting and running penny lunch programs in other cities, including Toledo, Milwaukee, Buffalo and Rochester.48 Sometimes the women’s clubs partnered with the school board, and sometimes they took complete financial and administrative responsibility. On rare occasions, local school systems took the initiative, as was the case in Providence. In 1910 the Providence School Committee, declaring its conviction that a lack of nutritious food was impeding learning and causing many children to have to repeat the lower grades, authorized the establishment of penny lunch programs in twenty-three primary schools. Whoever took the initiative, by 1914 lunches were being served in the elementary schools of 100 American cities and, according to Alice Boughton, a leader in the movement, had “become a recognized part of the modern school system.”49 Even more than open-air schooling, the penny lunch experiment was a direct response to the revelations of underfeeding and malnourishment among

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urban schoolchildren. As reports of hungry and poorly nourished city schoolchildren accumulated, a number of school hygienists, a few school superintendents in large cities, and a variety of grass-roots groups—ranging from parents’ and women’s associations to socialist and trade unionist organizations—began proposing that school systems be allowed to use public funds to establish programs in schools that would provide nutritious lunches and snacks at low cost to children whose parents could afford to pay and for free to those whose parents could not.50 Advocates noted that this was what was being done in Great Britain, Scandinavia, and elsewhere in Europe, where organized programs to feed schoolchildren had begun to appear in the late nineteenth century for the stated purpose of meeting the needs of the large numbers of ill-clad and ill-fed children who were being pulled into the classroom by compulsory attendance laws. At first, most of these programs had been philanthropic and located outside the schools, but as the century came to a close, the programs increasingly received public subsidies and more often than not were school-based. Moreover, after the turn of the century, the move toward school-based and statesubsidized lunches picked up momentum. By 1909 Parisian schools had a school lunch service entirely funded by the city and were serving almost eight million meals per year, 68 percent of which were provided free of charge. In Italy forty-four cities had established refezione scolastica, or canteens, in their elementary schools and were making low-cost or free meals available to their schoolchildren. In Germany a 1908 survey revealed 189 cities with school feeding programs, of which over 58 percent were either partially or wholly supported by municipal funds. Similarly, during the first decade of the twentieth century, Sweden, Norway, and Denmark put in place state-subsidized systems, while the Netherlands, Switzerland, and England passed legislation authorizing school authorities to use public funds to feed schoolchildren.51 The American Plan

Although many American cities eventually took responsibility for administering school feeding programs, what became the American school lunch plan fell considerably short of the aspirations of the early advocates of school feeding and was a far cry from the state-subsidized systems that developed on the other side of the Atlantic. Not only were school lunch programs in the United States slow to develop and very limited in scope, but they also tended to restrict their services to those with the means to pay. Not until 1937, during the Depression, were school funds used to provide needy children with free food, and that happened only in four states and for very few children. Indeed, it was not until the 1970s—a quarter-century after a National School Lunch Program

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was established, in 1946—that more than a small percentage of American schoolchildren were reached and a significant number of free meals served.52 Instead of a state-subsidized system to combat malnutrition by providing free meals and snacks to schoolchildren from needy families, what developed in the United States in the early part of the twentieth century were largely selfsupporting programs that aimed to build up underfed and ill-nourished schoolchildren by educating them in proper eating habits and providing cheap and nutritious alternatives to the lunches and snacks sold by vendors around city schools. Especially in the early years, these programs were initiated and funded by charitable, civic, and parent organizations. There are several reasons why American school feeding developed the way it did, but most important is that the proposals for subsidized school feeding programs that would provide meals and snacks at low cost to those who could afford to purchase them and for free to those who could not met with stiff opposition and a host of objections from a wide variety of sources. City councils objected that the cost would be ruinous and provoke taxpayer revolt. City lawyers warned that state and municipal school codes severely restricted what school funds could be used for. For instance, in both Chicago and St. Louis, school boards withdrew their initial backing for low-cost and subsidized school lunch programs paid for with school funds after city lawyers advised them that they were not authorized to use their funds to purchase and provide food.53 Strong objection to any school-based lunch program that would provide free or subsidized meals also came from the charity and welfare communities. In the uproar that followed the initial revelations about hungry and malnourished children in the school systems of New York, Chicago, Baltimore, Boston, and other large American cities, the powerful local Charity Organization Societies and Associated Charities in each of these cities successfully lobbied school officials and city councils not to respond to the agitation of newspapers and to resist allocating any funds for school lunch programs. In Chicago, for instance, even before the city lawyer raised doubts about the legality of using school funds for feeding children, a committee composed of the heads of the city’s major charity organizations had visited the mayor and school superintendent to argue that school-based feeding programs were unneeded.54 Behind the opposition of the established charities was the conviction held by many American charity officials and workers that free or subsidized school feeding was essentially a form of poor relief that, if indiscriminately given, had the potential to undermine families’ self-sufficiency and parents’ responsibility for the care and feeding of their children. Changing views of the causes of impoverishment and the needs of children in poor families had

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somewhat reduced the absolute antipathy toward the provision of material support, or what was called outdoor relief, that had guided organized charity work through much of the nineteenth century. Nonetheless, many charity workers, like many Americans in general, continued to believe that providing material relief to the impoverished and their children, without attempting to deal with the underlying personal and familial causes of the poverty, would almost always exacerbate and perpetuate those causes and encourage pauperism, chronic dependency, and the wholesale abandonment of parental responsibility.55 Warning against following the British example and authorizing the use of public funds for school lunches, one writer in the New York Charity Organization Society’s publication Charities and the Commons noted: “To feed a child is to give relief to its parents, and the effect must be to undermine their independence and self-reliance.”56 Similarly, after Superintendent Maxwell beseeched his school board “in the name of suffering childhood, to establish in each school facilities whereby the pupils may obtain simple wholesome food,” a New York City charity official characterized “Dr. Maxwell’s scheme of feeding hungry school children at public expense in the school buildings” as ill-considered relief that would “breed the pauper spirit” and encourage the “transfer from the family [of] the main responsibility for nurturing, feeding, and clothing their offspring.”57 In fact, some within the charity community even objected to schools providing nutritious lunches that students had to purchase, arguing that if mothers knew that their children had a hearty meal at noon, they would be less concerned with providing one in the evening. Charity officials in England, which shared with the United States both a poor-law tradition and many of the same cultural attitudes toward poverty and relief, also argued that free meals would undermine parental responsibility and increase pauperism. But their arguments seem to have been significantly countered by the conviction, articulated in the physical deterioration investigations, that the children of the laboring classes were degenerating and that poor nutrition due to poverty was the major reason.58 In contrast, American charity officials were effectively able to question whether poverty had the same direct connection to childhood malnutrition in the United States that it seemed to have in Europe. Although gradually convinced by the accumulating medical inspection data that malnutrition was a serious problem among American urban schoolchildren, charity officials contended that there was little evidence that it was exclusive to the poor and thus required material relief. Indeed, as they noted, the evidence seemed to suggest the contrary. The Boston medical inspection data, for instance, showed that 70 percent of the children identified as malnourished were from families judged as self-sufficient to well off. The

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Chicago study showed malnutrition as slightly more common among children of the poor. However, it cautioned that it was difficult to determine how much of the problem “is due to poorly selected and badly cooked dietary and how much to insufficient feeding.”59 Lack of evidence demonstrating that meager family resources were the main contributor to the malnutrition found among American schoolchildren allowed charity officials and other opponents of subsidized school meals to argue with considerable effect that parental ignorance and neglect, rather than poverty, were primarily responsible for the poor nutrition suffered by so many urban schoolchildren. This certainly was the position advanced in 1908 by Edward Devine in the regular column he penned for Charities and the Commons. “Although there are indeed undernourished and badly nourished children, just as there are under educated and badly educated children in the public schools of New York and other American cities,” Devine wrote, “the explanation does not ordinarily lie in the poverty of their parents but rather in their ignorance or neglect.”60 True, Devine admitted, there were “exceptional instances in which there is neither neglect nor ignorance but simply lack of means, as sometimes in the case of a widow, or of a family in which there is a long continued illness.” But in such cases, he contended, “it is essential that the community do something more than give meals to children of school age.” The family’s situation needed to be thoroughly investigated, its needs determined, and an appropriate program of assistance devised. Only the established charities, Divine asserted, with their long experience in and their exclusive devotion to relieving the poor, were competent to deal with the problem. Hence, he advised, “the schools, then, should not be transformed even in part into relief agencies.”61 That schools need not and should not be relief agencies feeding the children of the poor was also a point made by the report on the study of 1,400 children and their families conducted by the New York Committee on the Physical Welfare of School Children. Noting that investigators could find no evidence of the type of long-term physical degradation evident in the children of Europe’s working poor, the report advised that “physical deterioration, when applied to America’s school children, is a misnomer.” Observing that few if any of the families studied seemed to be without the means to purchase adequate amounts of food, the report offered that the vast majority of the underfeeding and malnutrition found among US schoolchildren was likely due to parental ignorance and neglect, combined with poor eating habits among the young. Hence, it concluded, the charitable groups that already existed in most cities were more than capable of dealing with the relatively few cases actually caused by lack of family income.62

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Organized charity’s antipathy toward school lunches was shared by many educators, particularly those who feared that both Progressive Era reformers and poor urban parents were pressuring city schools to move well beyond their traditional function of making students literate and capable of doing basic computations. Like other school-based social service initiatives of the period, school lunch programs were debated within the context of a larger discourse on how the school was to respond to changes in family functioning and parent-child relations that were widely regarded as the consequence of several decades of massive urban growth, industrial expansion, and foreign immigration. Across the ideological spectrum there was considerable agreement that, especially in the nation’s burgeoning cities and among its immigrant and native-born poor, many families were inadequately performing their traditional mission of caring for and rearing a new generation of productive workers and responsible citizens. But there was far less agreement on what needed to be done, particularly on what role, if any, the state—especially the public school—should assume in making sure that the young were sufficiently nurtured and socialized. For many progressives, the public school, which now housed the vast majority of the nation’s urban children for six or seven hours a day, five days a week, was the ideal institution for filling the void created by urban families’ changing abilities and senses of responsibility. Thus, as Lawrence Cremin explains in his magisterial history of American urban education: It was to the school that progressives turned as the institution that would at least complement familial education and in many instances correct and compensate for its shortcomings. The school would help rear the children of ordinary families, it would provide a refuge for children of exploitative families, and it would acculturate the children of immigrant families. Moreover, the school would deliver whatever services children needed to develop into healthy, happy, and well-instructed citizens— it would provide meals for the poorly fed, medical treatment for the unhealthy, and guidance for the emotionally disturbed.63

But where progressive educators saw opportunity, traditionalist educators saw danger, both to urban families and to urban schools. Many echoed the concern of the charity community that providing meals—like providing other services that traditionally had been the responsibility of individual families— would further undermine parental responsibility. In explaining why he listened to charity officials and decided against using public funds to subsidize free or discounted school meals, Chicago’s superintendent of schools expressed the conviction that to do so would weaken parental responsibility by encouraging

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even those parents who could well afford to feed their children to let the school take over the job. He also worried that if schools became relief agencies providing free food to the hungry, they would be expected to provide other forms of material aid. “If free lunches go with free education,” he cautioned, “it could potentially include free shoes and free clothing.”64 In the same vein, a much-quoted New York City principal complained that play centers and other progressive education innovations were not only doing no good but were actually promoting family dissolution. Discrediting parental enthusiasm for these programs, he warned: “Don’t mistake this for love of education. It is parental selfishness that is throwing the burden, and the righteous burden, of the home upon the schools.”65 Unease with school-based lunch programs and their impact on the family and the school was not limited to those directly connected with educating the young or aiding the poor; rather, it was fairly widespread throughout American society. Establishment newspapers like the New York Times railed against the idea, warning: “Anything that enables the family provider to shift his burdens upon the state tends directly to State Socialism.”66 Opposition was also voiced by the Catholic Church, which tended to oppose anything it saw as state intrusion into family matters. Even the generally progressive Massachusetts Civic League released a statement questioning the wisdom of a proposal to initiate school lunches in Boston, warning that they could “lessen the responsibility of the parent and tend to weaken and supersede the home.”67 The league’s misgivings reflected those of its president, Joseph Lee. Although instrumental in making playgrounds, medical inspection, and a host of other social services part of Massachusetts’s schools, Lee worried that providing meals to schoolchildren might cross the line where family assistance began contributing to family dissolution.68 Proponents of subsidized school meals vigorously contested the objections and concerns raised by those who were either adamantly opposed to or wary of establishing subsidized school lunch programs. In answer to the assertions that there was little need in American cities for subsidized school meals because food supplies were relatively abundant and affordable, and that the urban laboring classes were comparatively well fed, school lunch supporters argued that since the turn of the century, and particularly with the economic panic of 1907, food prices had been spiraling upward while family income was stagnating or declining. To support this argument, they cited a number of recent cost-of-living surveys, particularly Robert Coit Chapman’s The Standard of Living among Workingmen’s Families in New York City. Gathering data on the monthly food expenditures of a supposedly representative sample of

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laboring-class families of all incomes and nationalities, and employing the standards of minimum required nutrient intake that were being worked out within the new nutritional science, Chapman reported that over 23 percent of his entire sample of families and over 75 percent of those in the lowest income bracket could not or did not spend enough on food each month to meet the minimum nutritional requirements of both adults and children.69 Although proponents of school meals did not deny that a considerable amount of childhood malnutrition was due to parental ignorance and neglect, they contended that it was both unjust and socially destructive to deprive children and damage future generations in order to punish feckless parents. They also discounted the much-stated concern that school meals would erode parental responsibility and increase pauperism, noting that the parents of many malnourished children already had only feeble commitments to the welfare of their young and that state intervention would encourage, not discourage, such parents to embrace their responsibilities. Moreover, for the woefully ignorant, school feeding would demonstrate what a nutritionally sound meal was. Proponents of school meals also argued that existing charities were not adequately meeting the problem of those children for whom family poverty was the main cause of their malnutrition. “If private charity were sufficient,” Lewis Terman noted, “there would not be so many ill-nourished children.”70 Indeed, in the view of Terman and others, only the state had the means to solve the problem, and it had both the right and the duty to do so. Was this state socialism? Not according to Clark University’s William Burnham, who—in a piece supporting public funding of school meals—argued that it was the right and the responsibility of the public school to establish conditions suitable for learning. Hence, he reasoned, “it is no more socialistic, it may be argued, to provide the proper internal heat by supplying pupils with food than it is to provide suitable external heat by warming the school room.”71 No Free Lunch

Unsupported by widespread anxiety over national physical deterioration or by solid evidence that poverty was the main cause of malnutrition among schoolchildren, the arguments of American proponents of subsidized lunches ultimately proved inadequate. In fact, especially at first, many cities were reluctant to use public funds even to provide equipment for or to administer lunch programs that were self-sustaining. This was particularly true in the larger cities like New York, Philadelphia, and Boston, where the influence of the organized charities was great and where school boards tended to tolerate but not support school feeding. As the executive secretary of the NYSLC explained to a group of home

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economists, “The Board of Education and the Lunch Committee have an understanding that the lunch service may be extended to as many schools as possible so long as no liability accrues to the Board of Education by reason thereof.”72 Lack of or severely limited school board support for school feeding meant that when school lunch programs were established in American urban schools, it was primarily because local voluntary groups took the responsibility for initiating, funding, and administering the programs. In some cases—for example, the NYSLC—these groups were formed in reaction to the refusal of organized charities and public officials to respond to the reports of malnutrition in the school systems. More commonly, the groups that initially organized and funded the school lunch programs were philanthropies, women’s clubs, parents’ associations, and civic organizations—which, either on their own initiative, or at the invitation of principals, established a lunch service in a few schools with the intent of making cheap nutritious meals available for purchase. The central role played by local voluntary organizations in the initiation of school lunch programs had at least two significant consequences. First, it meant that the initial spread of school feeding programs as a school-based social service was slow, uneven, and not very extensive. Although the supporters of school lunch programs liked to boast that by 1914 lunches were being served in the elementary schools of over a 100 American cities, the boast was somewhat misleading. Not only were the 100 cities concentrated in the Northeast, near Midwest, and Far West, but most contained only a few schools each that were serving lunches and snacks. Even in New York, where by 1914 the NYSLC was operating a comparatively broad and well-financed program, only seventeen of the city’s scores of primary schools were offering their students the opportunity to purchase nutritious meals.73 Second, the initiation and operation of school lunch programs by voluntary associations meant that funds were always limited and that, unless they were able to form an alliance with a major charity, the school lunch committees rarely were able to feed children who could not afford to pay. Admittedly, the committees devised ways of feeding a few penniless children—like providing lunch in exchange for work—but the reality was that they could not survive unless they adhered fairly rigidly to the principle that food costs had to be met by receipts from the sale of the meals. In fact, it seems doubtful that many needy, malnourished children benefited from the new school lunch programs unless their situations were made known to one of the local established charities. After investigating the child’s family and determining whether being fed at school was a needed and suitable corrective, such charities might provide tickets that could be exchanged for a school meal.74

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The voluntary associations were well aware of the constraints that their limited finances and reliance on volunteers imposed on their efforts and thus conceived of their programs not as substitutes for school-run feeding, but as demonstration projects designed to convince city officials and school authorities ultimately to take over administrative control. For instance, every year until 1915, when it achieved its goal, the Philadelphia Home and Parents League presented a lengthy petition to the city council and school board in which it described the self-sustainability of its programs and argued that their educational need and value justified their being taken over and vastly expanded by the city. The Chicago Federation of Women’s Clubs similarly petitioned its city council and school board, as did the NYSLC and most of the other volunteer organizations feeding children. In some cities the petitions succeeded without too much delay, as was the case in Chicago, Cleveland, and Cincinnati. In others, it took years to convince city officials to take over administration of the programs. Although the Milwaukee Women’s School Alliance had lunch programs in eleven schools as early as 1908, it was not until 1917 that it could convince the school board to get involved. Similarly, in New York and Boston it was not until after the end of World War I that school boards took responsibility for administering the lunch programs.75 In creating their lunch programs as demonstration projects, the various voluntary organizations sought to avoid the most common criticisms of school feeding by stressing that their goal was to combat malnutrition among urban schoolchildren, not by providing relief to the destitute, but by offering the children of the working poor the opportunity to purchase nutritious food for lunch and snacks. Based on what had been discovered by the breakfast surveys of schoolchildren, many of those involved in establishing school feeding programs were convinced that a large proportion of the malnourished were the children of mothers working either inside or outside the home. Rising after their mothers had begun or left for work, such children were thought to skip breakfast often or to have what was readily available: tea or coffee and bread. Similarly, since there was no lunch to come home to, the children of working mothers would stay at school and use the pennies they received from their parents to purchase sweets, pickles or other unnutritious and often unsanitary offerings of street vendors.76 School lunch supporters argued that months and years of such a daily diet, even if there was a decent evening meal, would necessarily wreak havoc on the physical development of growing children. Providing school meals and snacks for purchase was thus not giving relief to the destitute few but making available to the many a nutritious alternative to what was obtainable on the streets. As a 1909 US Bureau of Education publication

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noted, school lunch programs could and should be justified by “the fact that most children are given pennies to spend, and that there are always people anxious to secure those pennies by starting small shops in the neighborhood of school buildings or bring thither pushcarts at recess. Food obtained from these sources is seldom either wholesome or safe. This presents a constant problem which affects all the children, and from the educator’s point of view is more pertinent than the problem of the relief of a few children.”77 The voluntary associations also promoted school lunches as a vehicle for educating both schoolchildren and their families in scientific nutritional practice, which food reformers, particularly those connected to the emerging home economics movement, were popularizing among the middle classes. Home economists and especially their ideas played a prominent role in shaping the ways in which many voluntary associations designed and promoted their school lunch programs. Using the twin principles of home economics—that malnutrition was more often the result of the consumption of unnutritious food rather than too little food and that nutritious meals could be prepared inexpensively—school lunch committees sought to create lunch and snack menus that were affordable, consistent with scientific nutritional theory, and easily replicable at home. Few of the meals cost more than two or three cents, and most of the snacks were offered for a penny. The meals and snacks were also designed according to dietaries, or guides published by various food scientists and nutritionists who in the early decades of the century sought to determine daily nutritional requirements. Perhaps the most commonly used dietary for children was that published in 1911 by Louise Stevens Bryant, a leading American proponent of school lunches. According to Bryant, a child of ten, weighing sixty pounds, daily required 60 grams of protein, 40 grams of fat, and 250 grams of carbohydrates, yielding a total of 1,600 calories.78 In order to provide as much as possible of a child’s daily requirements while keeping meals inexpensive enough to be purchased with pennies, school lunch programs often relied on a few standard offerings: molasses on bread with a glass of milk, hearty stews, hot cocoa, and macaroni and cheese. But as time passed and programs became more established, more varied menus were adopted. One constant, though, seems to have been the ubiquity of sugar, both because of its high caloric count and comparatively low cost and because school lunch providers had to compete with the sweets and sweetened foods that were for purchase just outside the schoolyard gate. To use sweets as a lure while encouraging children to partake of more hearty fare, many school programs followed the lead of the NYSLC and made the privilege of purchasing cakes and other sweets dependent on first purchasing a soup or stew. Several

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school feeding providers also followed the lead of the NYSLC and catered to children’s ethnic food tastes as a strategy for making the meals more attractive than street food.79 By limiting their goals to the sale of nutritious alternatives to street food and the education of school children and their families in nutritious eating, the organizations and associations that initiated school lunch programs were able deflect concern that school feeding would encourage parental irresponsibility and promote pauperism by dispensing indiscriminate relief. As a consequence, in the years immediately before and after the US entry into World War I, the spread of school lunch programs and the gradual takeover of their administration by school systems progressed steadily. As one postwar survey of school health services noted, the school lunch had become a common feature of most city school systems, and of many suburban ones as well.80 Yet if the narrow focus of the programs allowed school systems to adopt them, it also opened them to criticism that they were less than effective tools for battling schoolchild malnutrition. Especially after the war, critics complained that school lunch programs operated primarily as a service to a population of students defined less by need and nutritional defect than by inclination and ability to purchase the offered food. They also noted that the programs were proving to be poor instruments for education in good eating habits. Food was offered for sale with little or no explanation of what nutrition entailed and what made a nutritious meal.81 School lunch programs were also criticized for privileging poor diet over what were coming to be accepted as equally important causes of malnutrition, such as overfatigue, physical defects, poor health habits, and disorganized and unhygienic homes. Especially prominent in proffering this criticism was William R. P. Emerson, a Boston pediatrician who emerged in the postwar years as perhaps the nation’s best known expert on schoolchild nutrition. As he related in his Nutrition and Growth in Children, over a decade of clinical work with malnourished children had convinced him that the condition was an individual one, had multiple causes, and required a remedial approach not only aimed at improving diet but also at changing eating and health habits, correcting any contributing physical conditions, and reorganizing home life. As a consequence, Emerson became increasingly critical of efforts to combat malnutrition that focused only on diet, and he dismissed school lunch programs in particular as ineffective. Declaring that “school feeding is no panacea for malnutrition,” Emerson explained that the “common fallacy in urging the establishment of school lunches is the belief that the problem of malnutrition is one of diet.”82 Designed not to offer relief to the impoverished hungry and viewed as ineffective in combating malnutrition among the rest of the school population,

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school lunch programs were largely relegated to the margins of the school hygiene discourse until the Depression once again made hungry schoolchildren a national concern.83 Although malnutrition continued to be a major concern of school hygienists during the 1920s, its best antidote was increasingly seen in transforming the health habits and diet of all schoolchildren through education. Indeed, instilling proper eating and general health habits in schoolchildren so as to improve nutrition and overall healthiness became both the rationale and the major goal of the education programs that came to dominate school health activity in postwar years.

Chapter 5

From Coercion to Clinics The Contested Quest to Ensure Treatment

Conflict and controversy similar to that surrounding the efforts of school hygienists to combat malnutrition by establishing school feeding programs attended their efforts to facilitate the corrective treatment of those whom medical inspection had identified as having remedial defects. As was true with school lunches, a central and contentious issue was the relative responsibilities of the school and the family in guaranteeing that children received the treatment they needed. Like those opposing subsidized school lunches, opponents of schools’ playing more than a diagnostic and advisory role in securing treatment for children raised concerns about publicly funded education exceeding its mandate and, in so doing, both departing from its traditional educational mission and encouraging family irresponsibility and the proliferation of state socialism. Additionally, the school facilitation of treatment for correctible physical defects raised the question of at what point the pursuit of public health trespassed on the legitimate province of private practice. In the beginning, however, the major issue for those involved in medical inspection and school hygiene was how to convince the parents of students identified as having physical defects to seek treatment for their children. The Compliance Problem

Implicit in the practice of sending notes home to parents listing a child’s observed defects and suggesting that he or she be taken to a private physician or clinic for further diagnosis and treatment was the assumption that remedial defects were widespread in schoolchildren in large part because parents were often unaware that the defects existed and could be corrected. Hence, it was

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assumed that parental notification would be sufficient to bring about a major improvement in the health and educability of the urban school population.1 It soon became apparent, however, that this was not to be the case. As a medical inspector writing in Popular Science Monthly dryly observed, “one of the principles of medical inspection of school children is to point out the defects, leaving it to those most interested in the welfare of the children to have them attended to and treated—a perfectly reasonable expectation which, however, like many other social theories and assumptions, is, unfortunately, not being borne out by actual facts.”2 Indeed, follow-up exams of children whose families had received notification revealed that in virtually every city where expanded medical inspection had been adopted, no more than 8–9 percent of families notified were actually following the postcard recommendations and taking their children to private physicians and dentists or to public clinics and dispensaries.3 Why such widespread noncompliance existed and what to do about it soon became topics of considerable discussion among school hygienists and others interested in the physical welfare of schoolchildren. Some blamed the notification system, contending that the notes often did not make it home and that, when they did, they were frequently not understood by parents whose English might be limited. Others blamed parental ignorance and superstitious belief in home and folk remedies, especially among poor immigrant families. In a talk delivered at the Fourth International Congress on School Hygiene, Jacob Sorbel, Josephine Baker’s second in command, recalled that parents would frequently respond to the notes that his inspectors sent home by insisting that there was nothing wrong with their children or that they could solve the problem themselves with a poultice or tonic they would concoct. Other school medical inspectors claimed that immigrant parents in particular believed that wearing glasses would destroy a daughter’s marriage chances, that swollen tonsils came from eating spicy foods and required only a change in diet to be cured, and that rows of decaying primary teeth were no problem since they were going to fall out anyway.4 Poverty or meager incomes were also frequently cited as a reason for parental noncompliance. Noting that uncorrected defects tended to be greatest in the neighborhood schools of the laboring poor, many of those involved in medical inspection suggested that lack of means and the consequent inability to afford remedial medical care kept many parents from following the written recommendations.5 As New York’s John Cronin noted, even those parents who came to agree that their child needed glasses were often prevented from providing them by the expense. Good refractive services were costly. Being properly fitted for and provided with corrective lenses by a qualified oculist—either an ophthalmologist or an optometrist—generally cost from five to thirty dollars, which

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was way beyond the means of most urban working families. And although charitable eye dispensaries offered eye exams for free or at a reduced fee to those with meager incomes, either they did not provide or fit lenses and frames or they did so at a cost equal to or greater than that of commercial concerns. Hence, even those parents who were able to secure for their children free eye exams were still faced with what for many was the unbearable expense of purchasing eyeglasses. It is not surprising, then, that many families relied on local spectacle makers to prescribe and fit their children with glasses or simply did nothing.6 To illustrate the extent to which the latter was the case, the socialist and child welfare advocate John Spargo relayed a conversation he had with a priest who served a parish in a neighborhood populated by immigrant Italian laborers and their families. The priest observed that the school principal often complained to him that his parishioners routinely ignored notes sent home indicating that their children had vision problems. “What can they do?” he asked Spargo. “They cannot afford to buy glasses. Of the 300 families belonging to my church, I am in a position to say that there are not more than 10 in which the father earns more than $9 a week. Many of them only earn six or seven. They have all they can do to get food: glasses are impossible.”7 Yet if poverty was recognized as an impediment to parents’ securing for their children the treatments recommended by medical inspectors, it was rarely seen as the only or even the major impediment. Many of those involved in the discourse on compliance tended to agree with Philadelphia’s Director of Medical Inspection Walter Cornell, who suggested that although the meager resources of the families of many schoolchildren was a problem, it was not the most difficult one. “Far worse than poverty to combat,” he insisted, “is indifference or active hostility. The fact remains that a large number of our recommendations are ignored. . . . I have notified parents that their child has but one third of its normal vision and have been told to mind my own business.”8 That was also the assessment of a Bureau of Education analysis, which noted: “Much time is necessarily lost on cases among the foreign born populations as well as among some uninformed natives who view the authorities’ interest in their children with fear and suspicion, and have strong prejudices and superstitions regarding medical, surgical, and dental treatment.”9 That parental apathy and recalcitrance were all too common responses to the notifications sent home was a theme articulated repeatedly by those involved in medical inspection. Although Baker was well aware of the many obstacles that some New York families faced in getting treatment for their children, she recalled that “parents as a class were far from cooperative” and admitted that her early hope that parental notification would result in the correction

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of identified defects was dashed on the rocks of indifference and resistance.10 Charles Chapin, complaining that parents routinely ignored the notices his medical inspectors sent out, observed that “our experience in Providence has convinced us that mere advice by written notice to parents amounts to little.” And in their text on medical inspection and supervision, Ernest Hoag and Lewis Terman advised that “experience proves that frequently parents will not, even when urgently advised by the school doctor or nurse, secure for the child so afflicted the proper medical care.”11 Although frequently tinged with prejudicial assumptions about the urban working poor’s intelligence, knowledge, and concern for their children, medical inspectors’ complaints of parental noncompliance were probably only slightly exaggerated. Taking one’s child to a physician for a condition that was neither life-threatening nor potentially crippling remained a relatively rare practice among all but the middle and upper classes. And taking one’s child to a dentist was virtually unheard of. Although most cities had dispensaries— either privately endowed or attached to hospitals—where those with limited means could receive treatment, the working poor tended to use them only if the health threat was deemed serious enough to lose a day’s pay. For most health problems, they tended to treat themselves and their children with home and folk remedies or seek the assistance of auxiliary health care providers like toothpullers, bonesetters, and midwives. Moreover, in the turn-of-the-century American city, these traditional remedies and healers were augmented by an array of cheap patent medicines and a small army of spectacle peddlers, street surgeons, and so-called snip doctors, who would quickly and cheaply—if sometimes with disastrous results—perform tonsillectomies, adenoidectomies, and other minor operations. As Michael Davis, director of the Boston Dispensary, noted in his 1921 study of urban immigrant health practices, the home remedy, midwife, and drugstore were usually the first treatment options and the local quack doctor often the second. It is hardly surprising, then, that the vast majority of parents who received a note from a medical inspector either ignored it or pursued a course of action that health and school authorities considered equivalent to ignoring it.12 The near consensus that parental apathy or recalcitrance was a major reason why identified defects were not being corrected prompted a number of school hygienists to call for prosecuting parents as a goad to improving overall compliance. At an ASHA meeting, William Maxwell predicted that “if half a dozen parents in as many parts of the city were fined or imprisoned for failure, after repeated warnings, to provide their children with necessary eyeglasses or to have adenoid growths removed, the example thus set would

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do more good than any amount of preaching on the subjects.”13 Other school hygienists concurred, declaring that if parents knew they could be prosecuted for failing to act, they would be far less likely to ignore their children’s remedial defects. Yet prosecuting parents proved difficult since the legal basis for doing so was unclear. With the exception of laws passed by Colorado and New Jersey in 1909 and by Indiana in 1911, none of the legislation enabling or mandating medical inspection contained penal provisions for the fining or prosecution of parents who did not have their children’s identified defects corrected. And the Colorado law, the most punitive of the three, had so many exceptions written into it that by 1911 only one parent—a father whose child’s throat was almost completely blocked by enlarged tonsils—had been prosecuted under it.14 Moreover, although some municipalities and states experimented with prosecuting recalcitrant parents for neglect or excluding from school children with uncorrected defects and then prosecuting their parents under the truancy laws, neither approach proved easily defensible in court. The laws allowing for exclusion of children for disease usually stipulated that the disease be communicable, which adenoids and poor vision certainly were not. And although the courts had extended “wanton neglect” to include failure to treat certain serious conditions like broken bones, they seemed disinclined, as Hoag and Terman noted, to extend it to include “discharging ears, adenoids, or astigmatism.”15 In fact, the relatively few times when health and school authorities were able to use the child protection laws to compel parents to have defects corrected, it was almost always in cases where the families were destitute and other more clearly defined forms of neglect were present. As Cornell observed in 1912: “So far as I know, no action against an obstinate but well-to-do parent has ever been taken.”16 Ironically, the one strategy that proved somewhat successful in compelling parents to have their children’s enumerated defects diagnosed and corrected had a negligible effect on the health of children who remained in school. This involved taking advantage of the provision common to many state child labor laws stipulating that children applying for work permits had to be certified by the local department of health as fit to work. Beginning with New York, several cities took to denying the permits until all the defects enumerated in the child’s most recent school medical inspection had been corrected. Faced with the loss of their child’s potential income, most parents, it appears, acquiesced and secured the recommended treatment for their children. Yet as school hygienists ruefully acknowledged, although such acquiescence might improve the health of the workforce, it did little to better the physical condition of schoolchildren or to increase educational efficiency.17

Diagram of ventilation flow, three-story school building source: John Shaw Billings, Ventilation and Heating (New York: Engineering Record, 1893), 420.

Contagious disease exclusion notice source: Luther Halsey Gulick and Leonard P. Ayres, Medical Inspection of Schools (New York: Charities Publication Committee, 1908), 35.

Checking for vaccination marks, New York source: Luther Halsey Gulick and Leonard P. Ayres, Medical Inspection of Schools, rev. ed. (New York: Charities Publication Committee, 1913), facing 21.

Physician and nurse doing medical inspection, Toledo source: Luther Halsey Gulick and Leonard P. Ayres, Medical Inspection of Schools rev. ed. (New York: Charities Publication Committee, 1913), facing 76.

Testing hearing source: Ernest Bryant Hoag and Lewis M. Terman, Health Work in the Schools (Boston: Houghton Mifflin, 1914), facing 100.

Open-air school, Chicago source: Goldsberry Collection, Library of Congress Prints and Photographs Division, Washington, D.C., http://www.loc.gov/pictures/item/98504819.

Postcard notifying parents of their child’s need for dental treatment source: Luther Halsey Gulick and Leonard P. Ayres, Medical Inspection of Schools, rev. ed. (New York: Charities Publication Committee, 1913), facing 137.

Reaching through school fence to buy food from a street vendor, Philadelphia source: Emma Smedley, The School Lunch (Media, PA: Emma Smedley, 1920), facing 112.

Before and after adenoid removal source: Lewis M. Terman, The Hygiene of the School Child (Boston: Houghton Mifflin, 1914), facing 213.

Parent authorization form for clinic treatment source: Luther Halsey Gulick and Leonard P. Ayres, Medical Inspection of Schools, rev. ed. (New York: Charities Publication Committee, 1913), 75.

School dental clinic, Philadelphia source: S. W. Newmayer, Medical and Sanitary Inspection of Schools (Philadelphia: Lea and Febiger, 1913), facing 86.

Dentist’s agreement to volunteer at school dental clinic source: Luther Halsey Gulick and Leonard P. Ayres, Medical Inspection of Schools, rev. ed. (New York: Charities Publication Committee, 1913), 123.

Nurse doing preliminary screening, Orange, New Jersey source: May Ayres, Jesse F. Williams, and Thomas D. Wood, Healthful Schools (Boston: Houghton Mifflin, 1918), facing 210.

Nurse irrigating students’ ears, Cleveland source: Leonard P. Ayres and May Ayres, Health Work in the Public Schools (Cleveland: Survey Committee of the Cleveland Foundation, 1915), facing 20.

The “Rules of the Game” source: Anne Whitney, Who’s Who in Health Land (Washington: Government Printing Office, 1923), frontispiece.

The child health alphabet source: Mrs. Frederick (Antoinette R.) Peterson, The Child Health Alphabet (New York: Child Health Organization, 1918), 9.

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The Critical Importance of School Nurses

Recognizing the difficulty of compelling parents to act, school and health officials increasingly embraced suasion, turning to school nurses to follow up on the work of the medical inspector, visit the homes of children with defects, and through explanation and persuasion convince parents to secure treatment for their children. Nurses had already proven themselves effective in follow-up work with children who had been excluded from school for minor infectious diseases like ringworm and pediculosis. It seemed logical that they might be just as effective in follow-up work with children who had been identified by medical inspectors as having one or more defects. Again New York City led the way, expanding its nursing corps in 1908 and charging the nurses with following up on the notices enumerating defects that the Division of Medical Inspection had been sending home to parents since 1903. In the afternoons and on Saturday mornings, the nurses visited the households of notified families, explained what the notification meant, detailed the dangers of inaction, and urged parents to take their child to a private physician or public dispensary to have its condition diagnosed specifically and treated appropriately. In cases where the parents could not or would not take the child to a clinic, the nurse would volunteer to do so herself, although she could only do so if she first secured the parents’ permission. As Baker advised nurses: “Neglect to observe this simple precaution may result in civil suits for negligence or malpractice being brought against the individual nurse or the school or health board. It is illegal in practically every community for any operation, inoculation, vaccination or any other type of medical treatment to be given to a minor without the consent of the parents.”18 Within six months, New York City’s Bureau of Child Hygiene was claiming great success, estimating that compliance had risen from less than 10 percent to over 70 percent—a figure it would later revise significantly downward.19 Taking note of New York’s claims, health and education officials in other cities were quick to embrace home visitation by school nurses as one way to improve parental compliance with the recommendations that medical inspectors sent home. In seeking funding for the hiring of nurses, the president of Philadelphia’s Board of Public Education explained: “It is the follow-up work of the school nurse that renders the recommendations of the medical inspector effective.”20 Geoge Goler, the health commissioner of Rochester, New York, agreed, patiently explaining that the hiring of school nurses to visit the homes of children with defects would immeasurably improve compliance. That was also the message delivered by St. Louis’s chief medical inspector, James Stewart, when

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he told an audience at the 1910 National Conference on Charities and Corrections that prior to sending nurses into the homes of schoolchildren, his department had found “comparatively little attention given by parents to the physical condition of their children.”21 Thus, by 1912 Charles Chapin could observe that throughout the nation, those overseeing school medical inspection were reaching the conclusion that “owing to apathy, poverty, or ignorance of the parents, nothing will be done to improve the condition of the child unless the case is followed by the visiting nurse.”22 School nurses were effective because, like the other types of visiting nurses who became such fixtures in early-twentieth-century tenement districts, they were innovative and resourceful, and they operated as social workers and family advocates. The best were skilled negotiators of the myriad charitable agencies that operated in the urban sphere, able to find a free splint or direct a family to a charitable agency providing free coal or food. By all accounts, they were also relatively successful—albeit often only after several visits—in gaining the trust of parents and in explaining why this or that treatment was necessary and how it could be acquired.23 Indeed, usually with several schoolchildren in tow, they became familiar sights in the waiting rooms of the general and specialized charitable dispensaries and clinics that dotted the urban landscape in the early decades of the twentieth century. As the director of the Boston Dispensary noted in his 1910 annual report, always among the myriad immigrant poor seeking treatment, “youngsters come shepherded by school nurses and wait in curious dread for the Eye Doctor and Dentist.”24 The amount of health work that nurses were responsible for and could accomplish in a single day can be glimpsed from the following schedule copied from the logbook of a school nurse in St Louis, a city that relied on nurses to screen children for contagious diseases along with doing follow-up work: 8:45–10

AMES SCHOOL Absentees inspected 12 Vaccination scars inspected, 16 Edna Bowenschulte, F susp mumps. Form 11a. Sent child home. Mother of Rosalyn consulted me in regard to clinic hour

10:10–11:30

WEBSTER SCHOOL Absentees inspected, 16 Contact inspections (measles), 11 Beula, skin. Form 11a. Sent child home. Mother of Alma consulted me in regard to medical clinic.

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Mother of Loretta consulted me in regard to artificial eye. 11:35–12

DOUGLAS SCHOOL Absentees inspected, 6 Contact inspections (measles), 3 Contact inspections (chickenpox), 1

12:12–12:15

Copied 11-J Health Department

12:15–12:45

Lunch at Douglas School

1:15–3:30

JEWISH HOSPITAL CLINIC Henry M. foreign body, eyes, new case Oliver M. vision, new case Melba F. new case, adenoids and tonsils removed. Bennie M. new case, adenoids and tonsils removed. Rosalyn F. old case, adenoids and tonsils removed.

Left Jewish Clinic at 3:30 with Loretta to go to optical company. Arrived 3:50. Had frames for glasses fitted, also an artificial eye for this child. Left there at 4:20. Then made visit to Ellis home, 4:40. Advised mother to have child’s adenoids and tonsils removed, which she agreed to do and signed a consent blank for same. Left at 4:55.25

Yet school nurses were not miracle workers. Although school and health officials repeatedly sung their praises as the most important components in the school health plan, they also recognized that deploying a corps of nurses would not alone solve the noncompliance problem. For one thing, as Baltimore’s health commissioner noted in 1913, no city had enough nurses to visit the homes of all the children with defects and convince the parents that correction from a trained physician or dentist was necessary, especially since studies in his city and elsewhere were showing that it took three to four visits to do so. For another, even if a city could hire enough nurses, the diagnostic and treatment options available to the children of parents who could not afford private care were limited and, in the opinions of some school hygienists, ill suited to provide the type of correction children needed.26 Although charitable dispensaries and clinics had grown significantly in number since the turn of the century and, in addition to dispensing medicine, were increasingly offering medical, surgical, and sometimes dental care, they remained far too few in number to accommodate more than a fraction of the tens of thousands of city schoolchildren who required defect correction. According to school hygienists like Los Angeles’s Jesse Burks, this was especially

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a problem when the defect was chronic or, as was often the case with runny ears, inflamed eyes, ulcerated teeth, and certain skin diseases, required daily treatments. Since it was rare that parents, nurses, or even the children themselves had the time each day to make what was often a cross-town trek and idle away hours in a crowded dispensary waiting room, these defects often did not receive the treatment they required.27 Those involved in school medical inspection also complained that although some dispensaries and clinics had staff trained in dealing with children and their diseases, many did not and, indeed, viewed children as less than desirable patients. Noting that most oculists considered refracting children tedious and bothersome, Baker observed that in the typical eye clinic, children were passed off to the youngest and least experienced physician and sometimes to the optician who was responsible for making the lenses. The result, she charged, was that far too often the prescriptions children received were incorrect and ended up doing more harm than good.28 Similar complaints were made about the available charitable dental care. Responding to a questionnaire on the availability of treatment for schoolchildren in Philadelphia, Cornell lamented “the almost absolute lack of dental dispensary facilities in the city” and complained that although Philadelphia’s three dental colleges operated charitable clinics, the dental students were neither experienced nor competent in treating children.29 Some school hygienists also worried about the consequences of exposing schoolchildren to some of the people who used charitable clinics. Although thankful that his city’s charitable dispensary offered surgical correction to schoolchildren who needed it, Seattle’s chief medical examiner cautioned that too often “little girls after the operation are put to bed next to a prostitute or unfortunate woman and on the men’s side the boys are placed next to a drunken individual or a dime-novel hero.”30 Dispensaries and hospital clinics also sought to limit their services to those families and individuals who could not afford private care and, after the turn of the century, increasingly employed social workers or relied on school nurses to investigate and certify a family’s financial neediness.31 This left near-poor families and those with moderate incomes to negotiate the medical marketplace as best they could—which often was not good enough for those who oversaw medical inspection. In explaining the difficulty his department faced in securing proper eye exams for children identified as having vision problems, Providence’s Chapin complained that “the parents of the children would not consult a specialist for advice. The children of the really poor could be sent to a hospital, but wage earners of moderate means, not realizing the importance of attending to their children’s eyes, would refuse to pay for suitable advice, and,

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of course, would be refused treatment at the hospital on the ground that they were not really needy.”32 Those involved in medical inspection considered the lack of appropriate diagnostic and treatment options for children whose parents could not afford skilled private care particularly critical in regard to oral diseases and to visual, ear, nose, and throat problems. In part this was because these ailments constituted the vast majority of the physical defects that medical inspection was discovering in urban schoolchildren. During the 1910–11 school year, for instance, inspectors in Chicago, Cleveland, New York City, Oakland, Rochester, St. Louis, and Newark, New Jersey collectively examined 473,603 schoolchildren and found 304,746 physically defective, with a total of 496,037 defects. Of these defects, 435,816, or 88 percent, were defects of the teeth, nose, throat, ears, or eyes.33 But it was more than just awareness that visual, aural, nasopharyngeal, and dental problems represented the preponderance of the physical ailments suffered by schoolchildren that prompted concern with the lack of treatment available to them. It was also a growing conviction among child health experts and educators that failure to correct these defects condemned tragically large numbers of American schoolchildren not only to academic failure, but also to stunted physical and mental development and incapacitating—even life-threatening— disease and degeneracy.34 The belief that many students classified as mentally dull and backward were really children of normal intelligence who could not see the blackboard and had difficulty discerning the words on the schoolbook page had become close to dogma among school hygienists and educators by the first decades of the twentieth century. So too had the conclusion that the debilitating headaches long associated with overstudy were primarily the product of eyestrain among children with myopic, hyperopic, and astigmatic refractive disorders and thus could be all but eliminated if such children were provided corrective lenses. It seemed obvious, then, that if those schoolchildren who needed corrective lenses could have them prescribed and furnished, a major improvement in child health and academic performance would follow.35 Equally significant, in the decades straddling the turn of the twentieth century, medical research and theorizing focused attention on nasopharyngeal blockages and inflammations and dental and gum disease as related complexes in the introduction and production of serious disease, impaired mental and physical development, and overall systemic degeneracy. Toward the end of the nineteenth century, tonsillitis, which had long been recognized as a childhood ailment, was transformed from a painful condition to a dangerous one when etiologists, speculating on the portals through which microbes could enter the

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lymph and blood systems, focused on the tonsils as a major entry point for germs. Inflamed and hypertrophied tonsils meant the presence of potentially pathological microbes that were fast multiplying. Failure to treat the condition, either medically or surgically, thus put the child at severe risk.36 Similarly, adenoids, normally a soft mound of lymphoid tissue located just behind and above the uvula, were given pathological properties by turnof-the-century research and theory connecting their enlargement to the blockage of airflow through the nasal passages. Such blockages, researchers theorized, forced the afflicted to breathe through their mouths and suffer the attendant consequences, especially those related to oxygen starvation.37 During the last two decades of the nineteenth century and first two decades of the twentieth, medical researchers connected hypertrophied adenoids to a host of maladies, including feeblemindedness in some and “a vacant, stupid look” in all; underdeveloped lung capacity and sunken chests; stunted physical growth and skeletal deformity; impaired hearing and sometimes deafness due to the spread of infections from the nasal to the aural passages; chronic catarrh of the head; various contagious diseases from germs breathed in with no filtering; and all-around poor health and impeded physical and mental development.38 Indeed, William Osler, arguably North America’s most eminent pathologist and medical educator at the time, instructed his students that adenoids were not only among the most common afflictions of childhood but also among the most serious, because they could have significant adverse affects on mental and bodily growth. Surgically removing adenoids from schoolchildren in which they were hypertrophied thus represented far more than relieving such children of a painful and bothersome condition; it involved protecting them from serious disease and the development of adverse physical and mental conditions. Some researchers even claimed that an adenoidectomy could transform a dimwitted, incorrigible, chronically truant problem child into a tractable student capable of performing well enough to pass through the grades on schedule.39 As with tonsils and adenoids, decayed teeth and infected gums were increasingly seen in the first decades of the twentieth century as major portals for the entry of bacteria into the blood and lymph streams. By the second decade of the century, many health professionals had embraced the view that the teeth and gums, combined with the tonsils and adenoids, formed an interconnected focal point of infection that made the mouth the main entry for bacterial infection throughout the body. Tooth decay was thus connected to children’s contracting diphtheria, scarlet fever, and other childhood diseases as well as developing infections and consequent inflammations of the heart, glands, and joints. The Encyclopedia Americana reported: “The best medical

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authorities of our time say that many diseases such as rheumatism and infections of various organs including the heart, kidneys, appendix, etc., come from foci of infection. A great proportion of the foci are abscesses at the apices of the roots of teeth or pyorrhea pockets about the teeth.”40 Moreover, especially as tooth decay was increasingly understood as bacterial in origin, some dentists and physicians suggested that a mouth full of carious teeth was not only an effective entry portal for pathogenic bacteria but also an ideal medium for their multiplication. The foul breath of a child with decayed teeth could be both noxious and dangerous, and thus the treatment and prevention of caries would improve the health of the afflicted child while protecting that of his or her classmates.41 Tooth decay and gum disease were also associated with nutritional disorders and thus identified as significantly contributing to the large numbers of sickly, anemic, underweight, and underdeveloped schoolchildren whom medical inspectors were discovering in urban school systems. The association rested on the accepted connection between good digestion and good nutrition. Carious teeth and infected gums, it was theorized, inhibited good digestion by making it painfully difficult for a child to chew his or her food completely and by releasing toxins that, when swallowed, upset the stomach. Children with decayed teeth and infected gums were thus children who were more likely to contract disease and less able to resist its ravages, and who therefore potentially faced lives of invalidism and degeneracy. “If I were asked to say whether more physical deterioration was produced by alcohol or defective teeth,” Osler was reputed to have declared, “I should say unhesitatingly, defective teeth.”42 School Clinics Proposed

Concern over the consequences of leaving uncorrected the massive numbers of ear, eye, nose, throat, and oral defects discovered in urban schoolchildren— combined with frustration over the limits of what could be accomplished through follow-up work if there were no improvement in the diagnostic and treatment services available to urban families of meager or limited means—led some of those involved in medical inspection and the promotion of school hygiene to call for the establishment of clinics exclusively dedicated to examining and treating schoolchildren. Dissatisfaction with the quality of clinic diagnoses and frustration with parents’ tendency to frequent cheap but unskilled practitioners had already led several large cities and a few midsize ones to hire specialists and establish diagnostic clinics where children who had been identified by medical inspectors as having any of a variety of defects could receive a more thorough examination and have those defects specifically diagnosed.43

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Now calls came for school and health authorities to go one step further. As early as 1909 Chapin, surveying the limited treatment options available in most cities, suggested that if the great mass of urban schoolchildren were to have their defects corrected, one of two things would have to happen: either existing clinics and dispensaries would have to be subsidized, so that they could greatly expand their treatment capacities, or separate clinics for schoolchildren would have to be established. Noting that the British, in making treatment part of their school medical service, had rejected the first in favor of the second, Chapin recommended that US cities do the same.44 Terman echoed Chapin, arguing in the Psychological Clinic that publicly funded school treatment clinics were as necessary and justified a requisite of public education as publicly funded textbooks.45 Goler also called for the establishment of school clinics to increase the treatment options available to urban schoolchildren. Complaining that local dispensaries were being used to their utmost capacities, yet only a fraction of students with defects were being treated, Goler advised a gathering of school hygienists that “we must have dispensaries of our own connected to the schools in which to do the work. We should have a dispensary for eye, ear, nose, throat, and teeth, as well as for general child work for each group of schools, and the sooner we get them the better.”46 Although united in agreement that the greatest challenge they faced was improving the rate of appropriate treatment for the defects their medical inspectors identified, municipal education and health officials were divided over the advisability of extending their publicly funded medical inspection programs to include the opening of clinics where specific diagnoses and treatment would be provided at taxpayer expense. A few, like William Gallivan, chief of Boston’s Division of Child Hygiene, were steadfastly opposed to the establishment of special school clinics in connection with medical inspection. Speaking at the Fourth International Congress on School Hygiene, Gallivan contended: The necessity for such invasion of school buildings does not seem to me to be warranted by any conditions now existing among school children. True, statistics show that a large percentage of school children present physical defects. True, these defects should be corrected, so that the child might grow to a sturdy manhood. But until it can be shown that parents have lost all sense of parental love and responsibility, the present custom practiced in Boston of having all defects corrected either by the family physician or dentist or at some medical charity seems best.47

Others—like George Holmes, supervisor of medical inspection in Newark, New Jersey—felt just the opposite. In a 1911 medical journal article, Holmes

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urged that “free public school clinics be established to care for the diseases and defects common to school children. No pupil to be admitted unless attending a public school, presenting a printed slip showing that he or she has been referred for treatment by a medical inspector, and that his or her home has been visited by a school nurse, finding such poverty that free treatment is necessary and right.”48 Most of those involved in school medical inspection stood somewhere in the middle of these two positions. Although convinced of the need to improve rates of defect correction and sympathetic to the argument that existing treatment options were inadequate, they responded warily to the proposals for school clinics, conscious that attempting to establish publicly funded treatment facilities would be both difficult and controversial. For one thing, there was the issue of legality. English local education boards could use school funds to pay for treatment because the 1907 Education Act gave them authority to do so. American municipal education officials had no such legislative permission. Indeed, even when a few states began passing enabling legislation during World War I, it was narrowly focused, allowing the use of school funds for dental or eye treatments but not for the correction of other types of defects.49 If US municipalities were to provide treatment to their schoolchildren, they would have to either liberally interpret the school codes or sidestep the issue by providing that treatment through their health departments. But both these options were problematic. The former invited taxpayer challenges and even lawsuits, as occurred in Los Angeles and Seattle; the latter, at least when medical and surgical clinics were at issue, provoked opposition from organized medicine and raised the contentious issue of where the boundaries were between public health and private practice. Although the American Medical Association came out in 1911 in favor of school clinics, it made clear that its support was limited to clinics that were charitable and staffed with volunteer physicians.50 Most state and local medical societies took a similar stance. Although they encouraged their members to volunteer for charitable clinic work, they were quick to oppose the establishment of tax-supported clinics staffed by physicians employed by school or health departments. Even the New York Academy of Medicine, traditionally a staunch supporter of school hygiene initiatives, formally registered its opposition to health department physicians’ performing tonsillectomies and adenoidectomies on schoolchildren, advising that “the functions of the Department of Health should be restricted to the prevention of disease and no therapeutic activities should be undertaken.”51 Of equal concern was the inevitable opposition of local physicians, who, although uneasy with medical inspection, had reluctantly acquiesced to its

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implementation because of assurances that nothing would be done that would lure fee-paying patients away from them. Proponents of publicly funded school clinics never failed to emphasize that clinic treatment would be available only to those children whose families’ inability to pay for private care had been carefully investigated and determined by school nurses. But many local physicians, and especially those who served the native-born and immigrant laboring classes, feared that school nurses had neither the time to make such determinations nor the inclination to deny treatment to children who might otherwise not receive it. Envisioning widespread “clinic abuse” by families who could afford private care, these physicians protested strenuously to city school and health officials. ‘This thing is all right if it is done rightly,” a local physician wrote to the head of medical inspection in St. Louis, “but it is neither right nor proper for a corps of doctors living at the public expense to treat our patients and work into our families after we have spent years working up a practice.”52 Moreover, on at least one occasion, local physicians may have done considerably more than simply verbally protest the clinics. In an incident reported nationally, “snip doctors” who served Manhattan’s Lower East Side immigrant community purportedly caused a riot among immigrant parents by spreading rumors that an adenoid and tonsillectomy clinic sponsored by the Health Department at an elementary school was part of a larger plan by city officials to perform the surgical procedure on all children in the neighborhood without first consulting parents or obtaining their permission.53 School clinic proponents tended to dismiss the objections of physicians in immigrant neighborhoods as the mercenary concerns of quacks and those of more established family doctors as misguided, arguing that the clinics were certain to help more than hurt their practices. Chapin, for instance, repeatedly expressed his frustration that the physicians who complained to him could not see that the clinics would increase their practices by demonstrating to parents who could afford to pay their fees the benefits of a whole range of procedures and services.54 Nevertheless, he, like other public health and school health officials, was careful to navigate a course that would neither blatantly ignore the concerns of local physicians nor clearly violate the promises made to them when medical inspection was initiated. Likewise, Baker, although overseeing a school medical inspection program that provided more treatment than any other in the country, regularly warned against antagonizing local family physicians and advised that the good achieved by school-based clinics was often counterbalanced by the attacks on the entire school hygiene program they provoked from local physicians.55 Also contributing to the wariness of school and health department medical inspection officials were the objections that school clinic proposals soon began

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to elicit from those who saw the state provision of child health services as leading to an increase in pauperism and parental neglect. Responding to an early Health Department request for funding to run school clinics, the New York Times editorialized: “It will not do to hire physicians, oculists, dentists to give free treatment of children’s ailments,” for “that is pauperizing and it relieves parents of responsibility precisely at points where they should be held rigidly responsible.”56 Similarly, a proposal by the Elementary School Committee of the New York City Board of Education to use school funds to provide glasses for visually impaired children whose parents did not have the means to pay for them ignited a firestorm of protest from the city’s organized charity community. When the recommendation came up for consideration by the Board of Education, opposition was voiced by representatives of the United Hebrew Charities, the New York Association for Improving the Condition of the Poor, and the New York Charity Organization Society. The society also published a statement of opposition in Charities and the Commons, contending that supplying eyeglasses to children at the expense of the taxpayer was unneeded, paternalistic, and “the first long step toward turning over the whole responsibility for the support and care of children to the state.”57 The school board apparently agreed with the opposition. As the New York Times reported the following day, it summarily rejected the committee’s recommendation on “the ground, first that there were plenty of organizations which would perform this service in the case of real need, and second, that any general action by the School Board, if not absolutely unlawful, would be false charity and tend to defeat the ends for which it was intended.”58 Finally, school and health department officials were undoubtedly aware that school clinic proposals would elicit the same objections concerning parental rights and medical monopoly that continued to be leveled against medical inspection. When, in 1916, the Chicago Public School League asked parents to write in concerning any unsatisfactory conditions in the public schools, they were surprised by how many letters had to do with medical inspection and recent proposals for treatment clinics. One parent worried that her children could be excluded from school if they refused treatment with which she might not agree. A second wrote that this seemed to be yet another attempt by health department doctors to interfere in the rights of both the school and the parent to shape the child as they saw fit. And a third, sounding like a spokesperson for the League of Medical Freedom, characterized the proposed treatment clinics as “a subtle move by the dominant school of medicine to establish a medical oligarchy over the people, thereby depriving them of their rights to self government and to choose the medical practitioner of their choice in time of sickness.”59

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A Patchwork of Diagnostic and Treatment Services

Concerned about the legality of creating municipally funded school clinics and facing an array of vocal opponents, American municipal officials in charge of school medical inspection moved cautiously. Rather than follow the lead of their British counterparts, they joined with civic and parents’ groups, organized charities and philanthropies, professional societies, and existing hospitals and dispensaries in fashioning a semipublic medical welfare patchwork of diagnostic and treatment services that, although ultimately providing needed corrective treatment to tens of thousands of urban schoolchildren, was extremely uneven in coverage, always inadequate, and consistently threatening to come apart. As an initial contribution to this patchwork, a number of urban school systems and health departments in larger cities began offering minor forms of treatment at their diagnostic clinics. At the same time, many smaller and midsize American cities established partnerships with medical and dental societies, charitable organizations, and parents’ and civic associations to create similar diagnostic and minor treatment clinics. The municipalities would provide rooms and the assistance of school nurses, and the private organizations would cover the equipment and operating costs and supply the other personnel, often volunteer doctors and dentists. As a consequence, by 1916, as a survey done by ASHA revealed, 77 of the nation’s 100 largest cities had such clinics. In 22 cities, public funds supported all or some of the clinics; in the remainder, private money did.60 The treatment that was offered varied in extent and kind according to the type of clinic and, most important, the type and extent of funding. Many cities hired dentists and dental hygienists and funded dental clinics, but New York was virtually alone in establishing publicly funded, full-service, inpatient ear, nose, and throat (ENT) clinics where children could receive adenoidectomies, tonsillectomies, and other surgical procedures to correct pharyngeal and aural blockages and problems. And even it was able to support such clinics for only a few years. In Seattle the school system established and operated for seven years a polyclinic that offered a wide array of medical and surgical procedures. But it was able to do so only by relying on the services of volunteer physicians. In other cities that had diagnostic ENT clinics for schoolchildren, the treatment offered was usually limited to nurses’ irrigating runny ears and cleaning impacted ones.61 More extensive treatment had to be secured from private practitioners or from privately funded clinics and dispensaries. In a few cases, these clinics were created especially for schoolchildren by a charity, philanthropy, or

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parents’ association. In Los Angeles, for instance, an amalgam of parents’ organizations funded a polyclinic that occupied its own building and had a staff of paid and volunteer physicians who, among other services, performed tonsillectomies, adenoidectomies, and incisions of the tympanic membrane to release pressure and fluid caused by inner ear infections.62 More commonly, the clinics providing such treatment to schoolchildren were hospital outpatient ENT clinics with which school systems formed relationships. Beneficial to the school systems and to the children whose parents could not afford private care, these relationships were also beneficial to the hospitals to which the clinics were attached. By demonstrating that adenoidectomies and tonsillectomies could be done safely and effectively and that they brought about almost immediate improvement in the child’s condition, the operations performed on schoolchildren helped convince both the profession and the public that the removal of adenoids and tonsils was not only desirable but also necessary. Indeed, hospital clinics sometimes went to what might be considered extreme lengths to demonstrate that desirability and need. During the 1920–21 school winter break, volunteer and staff physicians connected to the four hospital ENT clinics in Rochester, New York, joined with specialists from the philanthropically funded Eastman Clinic to mount a massive adenoidectomy and tonsillectomy demonstration clinic. In a little more than two weeks’ time, the Rochester physicians, using school gymnasiums as operating theaters, removed the tonsils or adenoids of more than 8,500 of the city’s schoolchildren. Such demonstrations apparently worked. According to the medical historian Rosemary Stevens, during the 1920s tonsillectomies and adenoidectomies, more than any other medical or surgical procedure save childbirth, were what brought middle-class paying patients into hospitals.63 Municipally funded school diagnostic eye clinics also offered limited treatment, which they supplemented by establishing relationships with charities, parents’ and civic organizations, and existing eye clinics. In addition to refracting children identified as having vision problems, the clinics often treated minor eye infections. Children with more serious eye infections or organic problems were taken to eye clinics that had agreed to accept them. What the school clinics rarely did was use public funds to provide the corrective lenses they prescribed. A 1919 US Bureau of Education survey of school health services revealed that only three of the fifty-six cities that maintained school eye clinics used tax dollars to pay for the glasses provided to schoolchildren. In the others, glasses were paid for either by a charitable organization that had a relationship with the clinic or through a special fund created by a parents’ association or civic club. The latter, for example, was the arrangement

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in Cleveland. After hiring two oculists, the city established an eye clinic in one of its elementary schools, where schoolchildren whose families had been certified by a school nurse as unable to pay for glasses were refracted and prescribed corrective lenses. The clinic then ordered the lenses at a discounted cost from a local manufacturer and paid for them with a fund maintained by donations from the parents’ associations of various schools. When the glasses were ready, the child returned to the clinic and had the lenses and frames fitted. The school nurse would then periodically follow up to make certain that the child was wearing the glasses and that the frames remained straight.64 Although vision correction and ear, nose, and throat care constituted a significant portion of the semipublic patchwork of diagnostic and treatment services offered to urban schoolchildren, dental services constituted the largest. In fact, dental clinics accounted for the majority of school clinics established in US cities, both before and after World War I. A survey done on the eve of the American entry into the war discovered that there were school dental clinics in 59 of the 100 largest American cities, while there were school eye clinics in just 21 and ENT clinics in only 8. Another survey, done in the mid-1920s revealed that in midsize cities, dental clinics were the first and often the only school clinics to be established.65 As Leonard and May Ayres pointed out in their 1915 survey of Cleveland School Health Services, one major reason why dental clinics proliferated so much more rapidly and extensively than did other types of school clinics was “that the commonest of all physical defects among school children is decayed teeth. Cases of dental defectiveness are frequently greater in number than all other sorts of physical defects combined.”66 Indeed, especially after schools began hiring dentists to do more thorough exams, estimates of the percentage of urban schoolchildren with at least one seriously decayed tooth ranged as high as 96 percent. Moreover, as a medical inspector writing in Dental Cosmos noted in 1914, securing free or low-priced dental treatment was more difficult than securing similarly priced medical treatment. Dental services remained the least common of dispensary and clinic services, and although families of limited means could usually find a physician who would treat them for a reduced fee, they could rarely find a dentist who would do so.67 Equally or perhaps more significant was the strong support that school dental inspection and clinics received from organized dentistry and from the upper levels of the dental profession. As early as 1906, municipal dental societies had begun responding to medical inspection’s revelation of mass dental caries among the young by establishing free dental clinics for schoolchildren. They also began lobbying for the appointment of dentists to medical inspection corps and, along with the National Dental Association, began promoting both

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prophylactic and reparative care of children’s teeth as critical to improving the general health and educational efficiency of the nation’s schoolchildren. In 1910 the National Dental Association joined with the Cleveland Dental Society to launch a short-term program with Cleveland elementary school students to demonstrate that dental clinics offering instruction, prophylaxis, and treatment could improve not only oral health but also students’ behavior and academic performance. The centerpiece of the program was an experiment conducted at the Marion School, located in a crowded immigrant ghetto and attended by children from some of the poorest families in the city. After dentists inspected the teeth of the entire student body, forty children, determined to have the least healthy mouths, were asked to participate in a fourteen-month experiment in which they would be required to follow a set of oral hygiene behaviors, including toothbrushing three times a day, and submit to extensive prophylactic, reparative, and restorative dental work as well as to an array of psychological, medical, and educational exams. Those who completed the experiment would be given a five-dollar gold piece, a rather significant incentive given the economic circumstances of their families.68 Ultimately twenty-eight children stayed in the experiment the full fourteen months, collected their gold pieces, and provided what was deemed remarkable evidence of the transformative potential of school dental work. As reported by those conducting the experiment, many of the children seemed to undergo a dramatic physical and behavioral transformation: the unkempt became well groomed, the fragile became sturdy, and the wild and intractable became well behaved and compliant. Educational improvement also appeared dramatic, with psychological testing on the children—half of whom were at least two years behind other children their age—revealing an average improvement of 54 percent in intellectual efficiency. The fact that the experiment was methodologically primitive, making the statistical results suspect, was largely ignored at the time. Indeed, the experiment was regarded as a demonstration of truth bordering on revelation. Dental, educational, and medical journals reported the results with barely a question concerning the experiment’s methodology. School hygienists, dentists, and educators visited the school to talk to and observe the children. The children themselves became celebrities and were interviewed by newspapers and magazines.69 Along with other promotional efforts mounted by the National Dental Association and state organizations, the Marion School experiment catalyzed urban dental societies to step up their efforts to convince municipal authorities of the benefits of making diagnostic and corrective dental services available to schoolchildren. As the results from the experiment were becoming apparent,

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the Cleveland Dental Society, with funding from dental manufacturers and with a commitment from eighty-five of its members to give a week of their time, opened six clinics around the city. Soon after, the Rochester Dental Society, in New York, opened the first of two dental clinics it would sponsor, and the Philadelphia Dental Society, drawing on the volunteer efforts of 210 of its members, established a clinic for city schoolchildren and began performing extractions, fillings, and other operations. In 1911 the Denver Dental Association equipped and began operating a clinic, and the Cincinnati Dental Society expanded one it had opened in 1909. Dental societies in other large cities soon followed suit or encouraged their members to volunteer their services to clinics being set up by charity and social service organizations.70 The enthusiasm that dentists and especially their professional associations showed for establishing clinics to improve the oral health and educational efficiency of school-age children was to a significant extent fueled by the desire of the leaders of the profession to achieve some parity with medicine and to have dentistry considered a form of health care based on modern science, concerned with preventing diseases and doing good, and necessary not only for adults but also for children. Like medicine, dentistry in the early twentieth century was attempting to reform itself by standardizing practice and training, limiting access to the profession through licensure, and promoting periodic checkups and preventive prophylaxis for the whole family. Unlike medicine, it was having only limited success. Despite the late-nineteenth-century formulation of theories linking dental caries to bacteria and plaque buildup and oral infection to systemic disease—thereby grounding dental science in modern bacteriology and providing a rationale for oral prophylaxis—American dentistry at the beginning of the twentieth century was largely mechanical. Although leaders of the profession echoed the pioneer dental histologist and plaque discoverer J. Leon Williams’s dictum that “a clean tooth never decays,” the rank and file largely ignored oral hygiene and concentrated on extracting teeth and supplying restorative and reparative appliances to adults. Indeed, dentists rarely saw children because their services weren’t geared toward them and because most parents, other than those who were well-to-do, still considered losing teeth— even permanent teeth—a normal part of growing up. And statistically, at least, they were correct. During World War I, the dental standard for acceptance into the army was rather low: six serviceable bicuspid or molar teeth, with at least two sets of opposing teeth on one side of the mouth and one on the other. Yet almost 10 percent of all recruits failed to meet the standard.71 In supporting clinics that would identify and treat dental defects in children and therefore combat backwardness and grade retardation, organized dentistry was thus

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seizing an opportunity both to convince parents of the benefits of purchasing prophylactic and other dental services for their children and to demonstrate that dentistry was a form of health care that was grounded in science and committed to the public good. As most of its promoters envisioned it, the school dental clinic would provide those children whose families could not afford private dental care with four related services. The first would be a thorough cleaning in which built-up plaque and calculus were scaled from the teeth surfaces and the mouth was put in order. The second was a careful oral exam for the purposes of detecting and recording on a dental chart all cavities and gum problems. The third involved instructing the child in brushing, flossing, and other oral hygiene procedures. And the fourth was providing the child with emergency relief and dental repair and restoration.72 Not surprisingly, it was the fourth function that provoked the most concern among rank-and-file dentists. Although nowhere near as opposed as physicians were to school clinics providing treatment, rank-and-file dentists did express some objection to the provision of more elaborate restorative and reparative procedures. Although generally supportive of the clinics’ potential for introducing American families to the necessity and benefits of child dental care and for spreading the message that teeth could be kept for a lifetime if they were cared for, dentists were concerned that the clinics could also take from them future consumers of their most lucrative services. To address the concerns of dentists—and to keep costs down—many clinics, at least initially, limited themselves to doing emergency extractions and basic or temporary reparative work. Not atypical was the Milwaukee school dental clinic of which a 1916 description said: “To this clinic are referred the children who are in need of dental attention which cannot be secured for them through the service of private dentists. Individual appointments are made for these children and only temporary work is done, that is to say, no fillings of gold, no croons [crowns], bridges or work of this nature is done, the principal work being extractions, treatments and temporary fillings.”73 Also at issue was how to ensure that children who attended the clinics received a thorough teeth cleaning. The crush of potential patients and the distaste of many dentists for a task that was tedious and time-consuming meant that school dental clinic cleanings were often cursory at best. This caused some concern until a solution was offered by a Bridgeport, Connecticut, dentist and oral hygienist, Alfred Fones. For some years Fones had been promoting the idea that female assistants could be specially trained to do the scraping and scaling involved in teeth cleaning and thus allow dentists to devote their time to more skilled and remunerative dental work. In 1913 he opened the nation’s first school to train what he termed dental

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hygienists, and a year later he convinced the Bridgeport Board of Education to fund a demonstration project that would show not only that dental hygienists could do the required cleaning but also that a program of prophylaxis and education could greatly reduce the incidence of dental decay among the young. Ten recent graduates of Fones’s school were hired to clean the teeth once a year of all Bridgeport first and second grade public school students and to instruct them in the value and procedures of oral hygiene. After five years, Fones reported spectacular results. The incidence of dental decay among Bridgeport’s elementary schoolchildren had dropped over 30 percent, ample proof of the value of both dental hygienists and prophylaxis combined with education. As a result, other schools for dental hygienists were established, and a number of urban school systems began hiring their graduates and making oral hygiene a focus of their dental service.74 Dental Clinics in the Postwar Era

The predominance of school dental clinics not only continued but increased after World War I, especially as school clinics were established in smaller cities and towns. A 1923 survey of child health work in eighty-six mid-size American cities revealed that dental clinics were by far the most numerous and often the only school clinics operating. A major reason for this growing imbalance between school medical and surgical clinics and school dental clinics was stiffening opposition from organized medicine and the medical profession in general to both philanthropic and tax-funded treatment services for schoolchildren. As we have seen, the mainstream or allopathic medical profession and its various organizations had long been ambivalent about the provision of medical and surgical services to schoolchildren. They had supported the creation of school clinics, but only those that mirrored the organization and eligibility policies of existing charitable independent and hospital-based dispensaries. Some of this support and encouragement was rooted in the altruism and social consciousness of Progressive Era medicine. But an equal or greater amount came from the critical role the dispensaries and medical inspection played in meeting the institutional needs of the profession and particularly that of its urban elites and emerging specialists. Through World War I, the clinics and dispensaries treating schoolchildren had the support of influential elements of the profession because they provided what charitable clinics and dispensaries had long provided: an opportunity for young urban medical elites to gain postgraduate clinical training. The physicians who volunteered for or worked as staff in the ENT or eye clinics received valuable experience in offering specialized services to children, experience that was available few other places.

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Hence, whatever misgivings they might have about the potential competition to private practice that such clinics and dispensaries posed, urban medical elites and the organizations they controlled tended to support their continued existence and even expansion.75 In the 1920s, however, when postgraduate clinical training moved into hospitals, support for the clinics and dispensaries evaporated and was replaced by hostile opposition. Local medical societies increasingly railed against what they termed clinic abuse and, in a few cases, joined with conservative taxpayer groups to file lawsuits challenging the legality of school and other types of clinics providing treatment. Although several of those suits were dismissed, at least two led to state supreme court rulings that severely restricted school-based corrective services in those states. In 1920, deciding a suit brought against the Denver school system, the Colorado Supreme Court ruled that school-based clinics could provide diagnostic services and special exercises to overcome orthopedic disabilities but should not provide “medical or surgical treatment for disease. That would be to make infirmaries or hospitals of the schools.” Two years later, the Washington Supreme Court, in a suit brought against the Seattle school system, ruled that a school board could not maintain clinics and purchase equipment in excess of that necessary for preventive and educational health work.76 At the same time, the American Medical Association sponsored a number of investigations of dispensary and clinic use, promoted the creation of fee schedules, and, in 1922, passed a resolution declaring its opposition to “all forms of ‘state medicine.’”77 Bereft of their traditional professional support, public dispensaries and clinics declined significantly in number during the 1920s and, as a consequence, so too declined opportunities for defect correction available to children whose parents could not afford private care. Indeed, even those clinics that continued to exist often offered a level of service that discouraged their use. As Thomas Wood and Hugh Rowell explained in a 1927 discussion of the increasingly problematic relationship between school health supervision and charitable hospital clinics, “to avoid competition with private practitioners, hospital staffs are kept as small as possible, with resultant delay in cases, especially operations. . . . Often children’s appointments for tonsillectomy and similar operations must be made several months ahead of time. During the interval between diagnosis and operation, interest lags, conditions change, and the child fails to appear.”78 Quite a different relationship persisted through the 1920s between school dental clinics and the dental profession and its organizations, in large part because philanthropic and publicly funded dental clinics remained the primary site of postgraduate dental training and a major source of employment

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for young dentists. Hence, dentists and dental societies resisted attempts to remove funding from existing school dental clinics and promoted the opening of new ones. When the New York City Board of Education resolved in February 1924 to stop supporting and indeed prohibit dental clinics in the schools, a collection of city and county dental associations led a successful effort to get the resolution rescinded. Significantly, the resolution to abolish dental work in the schools had been sponsored by a board member who was the mayor’s private physician and who charged that because they provided treatment to children whose parents could well afford to pay for it, the clinics were an egregious example of clinic abuse and an “improper encroachment upon private practice.”79 For over a decade after World War I, then, the number of school dental clinics continued to grow. Indeed, based on contemporary surveys, it seems likely that by 1925 there were somewhere between 400 and 600 publicly funded clinics in the United States providing oral health services to school-age and, in some cases, even younger children.80 The most numerous of such clinics were those staffed and run by municipal school or health departments. Many of these were expanded diagnostic clinics, but a significant number were clinics that had been initiated by a philanthropy, dental society, or parents’ or civic organization and bequeathed to the city. Among the nine full-time and four parttime clinics the City of Chicago was supporting by 1917 were at least three that had been started by charitable organizations with volunteer dentists. Similarly, Cincinnati, Cleveland, Denver, Providence, Washington, and a host of other cities ultimately took over the operation of clinics that had been begun and run by local dental associations and societies.81 If operated by school departments, clinics would often be housed in centrally located schools, usually in a room that had been furnished with one or more chairs and the equipment necessary for dentists and hygienists to work on students. In fact, quite a few city schools built after the war contained rooms specifically designed and equipped as clinics. If operated by health departments, dental clinics might be at city hall, the department’s offices, or storefront neighborhood clinics. In Philadelphia, where responsibility for medical inspection was shared by the school and health departments, four of its eight free dental clinics were in schools and four were in health department centers.82 Most, if not all, of these municipally run clinics sought to limit service to elementary schoolchildren whose families could not afford private dental care. In Chicago, for instance, the rule was that children were accepted for clinic care only after a school nurse certified that they came from families with a weekly income of three dollars or less per person. It is doubtful, however, that such

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rules were stringently enforced. As one study of the clinics has noted, scattered commentary from those involved suggests that thorough investigations of family income were the exception rather than the rule, and children in pain or with some other critical dental condition were rarely turned away. A few cities also followed the lead of Bridgeport and sought to provide prophylactic treatment to all schoolchildren, regardless of family income. Detroit was one of these. By 1919, with a staff of three dentists and twenty-six dental hygienists, it was providing at least one cleaning per year to over 99 percent of the 21,000 elementary students attending public and parochial schools in the city. Moreover, during the summer it held dental clinics at which older children could have their teeth cleaned and repaired for a minimal fee.83 During and after World War I, dental schools also opened school dental clinics as they began, for the first time, offering their students clinical training in pediatric dentistry. Probably the first to do so was the New York College of Dentistry, which in 1917 began holding a Saturday afternoon clinic where neighborhood children between the ages of seven and fourteen were treated for free. Newspaper accounts reported that up to ninety children at a time were being worked on by the dental students. Not long after, Northwestern University opened a fifteen-chair clinic in central Chicago to treat children in the city school system, and Western Dental College began a similar clinic in Kansas City. Like the municipal clinics, dental school clinics offered free treatment to children from families with meager incomes. In addition, however, they also offered service at reduced fees for those families who were not indigent but found the high price of private dental care difficult to manage. Indeed, a well-respected 1922 survey of community dental services suggested that dental school clinics, which often charged no more than the cost of materials, were becoming the chief source of children’s dental care for urban families of moderate means.84 Dotted throughout many cities were also one- or two-chair clinics funded by individual philanthropists and small philanthropies, dental societies, charities, parent-teachers’ and mothers’ clubs, health organizations like Tuberculosis Societies and the Red Cross, civic and fraternal associations, and neighborhood settlement houses. For instance, by the mid-1920s Providence, Rhode Island, boasted seven small public dental clinics. Of these, three were funded by the Department of Health and one each by the parent-teachers’ association, the Providence Dental Society, a settlement house, and the Rotarians. In Chicago, clinics were funded by the United Charities, settlement houses, and the philanthropist Julius Rosenwald, who supported eight clinics for a decade. In Washington, D.C., the local chapters of the National Mothers’ Congress, the Red

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Cross and the Tuberculosis Society each established a clinic. Indeed, in the immediate postwar years, sponsoring a dental clinic for poor urban children became a popular form of social giving, with various clubs and organizations and even socialites raising funds for the clinics.85 Among the more notable features of the proliferation of dental clinics for schoolchildren—and certainly one that generated considerable popular, civic, and professional interest—was the actual and attempted establishment of grand, showcase clinics in a few cities. The first of these was in Boston and was founded with a bequest from James Bennett Forsyth, a wealthy industrialist whom the New York Times reported endowed the clinic because “he thinks (and his opinion is substantiated by dentists) that much of the poor scholarship and delinquency among children—to say nothing of their physical welfare—is the result of imperfectly cared for teeth.”86 Committed to research, training, and service in the “hitherto neglected field of children’s dental problems,” the Forsyth Dental Infirmary for Children, as it was originally called, opened for full operation in 1915. Providing clinical training to Harvard Dental School students and its own interns, the Forsyth Infirmary also joined with Tufts University in 1916 in opening a training school for dental hygienists. Since Boston, virtually alone among major American cities, steadfastly refused to use public funds to correct any physical defects of its schoolchildren, the Forsyth Infirmary met a critical need. To get children into the clinic, an informal relationship with the Boston school system was established and a schedule worked out, whereby each day school nurses would bring groups of schoolchildren to the clinic for examination and treatment. Initially, many of the children brought in were older elementary schoolchildren who were suffering acute pain and in need of emergency treatment. But as time progressed, the patients got younger, and the infirmary increasingly focused on preserving newly erupted teeth, especially the six-year molars.87 As was the case with almost all school dental clinics, eligibility for treatment at the Forsyth Infirmary was limited to children from families whose income was below a certain level. However, the infirmary’s trustees set that level high enough so that a large proportion of Boston schoolchildren qualified. Moreover, to attract families who were loath to accept outright charity, the infirmary charged a small nominal fee for each service: five cents for an exam and cleaning and ten to twenty-five cents for other operations. During the first five years, an average of over 20,000 children a year were seen and treated at the infirmary; during the next five, the yearly average climbed to over 35,000 children. Indeed, during the early 1920s the Forsyth Infirmary was treating over half of all children whom Boston medical inspectors identified as having decayed teeth or other oral health problems.88

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Dedicated to research and training as well as the provision of oral health care and housed in a magnificent neoclassical marble building containing a spacious children’s waiting room; a main operating room with space for 104 fully equipped dental chairs; facilities for performing nose, throat, and ear operations; a research laboratory; and an amphitheater that could seat 250 people, the Forsyth Infirmary excited both admiration and envy among the nation’s urban health officials, dental societies, and dental schools. Soon after it opened its doors, New York City dentists, with the encouragement of municipal officials, embarked on a campaign to raise $5 million to establish at Columbia University a children’s dental infirmary similar to the Forsyth. The stated goal was for the infirmary to train dentists and dental hygienists and provide free dental care for all of the city’s 900,000 schoolchildren. Although the project generated considerable excitement, the desired funding could not be secured. Sixteen years would pass before a $4 million gift from the Guggenheim family would enable the construction of a Forsyth-like dental clinic in Manhattan.89 Chicago also embarked on an effort to construct a grand municipal clinic that would train dental care givers and serve city schoolchildren. In 1922 the administration of Mayor William Hale Thompson announced that $200,000 from the profits taken in by that and the previous year’s Pageant of Progress fairs would be used to construct a dental clinic capable of treating up to 50,000 Chicago schoolchildren per year. According to the former Chicago Health Commissioner John Dill Robertson, who spearheaded the project and chaired its board of trustees, the clinic—which would also include a home nursing and oral hygienist school—would be “as big as the famous Forsyth Infirmary and render as much service.” Backed enthusiastically by the Chicago Dental Society, various child welfare organizations, the city health and school departments, the Chicago Tribune, and the mayor’s office, the clinic project rushed ahead. Ground was broken in early 1923, and within a few months the shell of a twostory, half-block-long building had been erected on the city’s near West Side. That, however, is as far as the project progressed. A scandal involving irregularities in accounting for pageant funds plus revelation that Robertson would profit from the proposed nursing and hygienist schools halted construction and put the proposed clinic in what turned out to be permanent suspension. Five years after construction began, the building, then an abandoned hulk, was sold for a fraction of what it had cost.90 A more successful attempt to create a Forsyth-like clinic occurred in Rochester, New York, due in large part to the commitment and funding of George Eastman, the founder of Kodak. In 1916 Eastman donated $1.4 million to transform the Rochester Dispensary, established in 1910, into a dental clinic for

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the city’s schoolchildren. Following the construction of a large and impressive building containing sixty-three dental operating units, x-ray equipment, and hospital facilities for the surgical removal of adenoids and tonsils, the clinic opened its doors in October 1917. By 1919 its licensed dentists were yearly performing 46,000 tooth treatments, 15,000 fillings, 20,000 root canals, 12,000 extractions, and a variety of other dental services. Like the Forsyth Infirmary, the Rochester Dispensary was liberal in its definition of the level of family income that qualified children for treatment and sought to attract those reluctant to take charity by charging a five-cent fee per visit. Unlike the infirmary, however, the dispensary developed a formal relationship with the school system and sent squads of dentists and dental hygienists into the schools, where, using portable chairs, they provided some 70,000 exams and cleanings per year. For this service the school system paid the clinic $20,000 yearly.91 The schoolchildren of Rochester, of course, were both lucky and exceptional. The dental care they received was, on average, better than that received by the schoolchildren of any other significantly sized American city and far superior to that received by most children in small towns and rural areas. In making dental care available to virtually all primary schoolchildren in the Rochester’s public schools and in offering comprehensive services—from the prophylactic to the restorative and even surgical—the partnership between the dispensary and the school system demonstrated what a semipublic system of school clinics and services could provide. But in its exceptionalism, in the fact that only a few cities came even remotely near to replicating its achievements, Rochester’s semipublic school dental service also testified to what was not being done elsewhere. Although it was often held out as an example of school hygiene’s success in fostering the correction of education-impairing physical defects, it highlighted how irregular, inequitable, and ultimately ineffective the semipublic patchwork of remedial services actually was. By the third decade of the twentieth century, school hygienists’ awareness of and frustration with that ineffectiveness inspired many of them to deemphasize detection and correction and embrace prevention through education. Although they did not forsake medical inspection and school clinics, school hygienists increasingly expressed the hope that teaching children how to live healthily might reduce the need for both diagnostic and remedial services.

Chapter 6

The Best of Times, the Worst of Times Expansion and Reorientation in the Postwar Era

For urban primary school health programs—the main focus of school hygiene discourse and activity since the 1870s—the period between the end of World War I and the Depression was one of contradiction. In many respects, it was a time of unprecedented expansion. It was during these years that school-based detection and correction services reached the apex of their development as they grew in number and type in most of the cities that had begun them in the first two decades of the twentieth century and were initiated in many other cities, including some in the South, which had not. Similarly, during this period, urban primary schools became the laboratories for testing the effectiveness of immunization programs, special classes for handicapped children, and a wide variety of other health promotion initiatives. Little wonder, then, that in a postwar review of city schools’ activities, the US Bureau of Education could confidently declare: “The detection of physical defects in school children and the adoption of preventive as well as curative measures are now generally accepted as an essential part of a well-ordered city school system.”1 Yet if the 1920s were a period of expansion for urban primary school–based detection and correction services, they were also a period in which changes in medicine, public health, and school hygiene itself laid the groundwork for what would be the decline of such services, leading to their virtual extinction some three decades later. The War as Catalyst for Expansion

Those involved in school hygiene during the postwar years were well aware that urban school health programs were expanding and tended to identify as the primary catalyst for that expansion the war itself and particularly the

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importance it had lent to healthy children as human capital and national assets. As US Commissioner of Education Philander Claxton observed: “The great war now ended has shown to every nation the priceless value of the health of its citizens. The beginnings of health supervision of schools and school children before the war, are now seen as movements of the greatest significance for national conservation.”2 Ellwood Cubberly, dean of the School of Education at Stanford University and one of the nation’s most prominent interwar educational authorities, was even more emphatic, contending that “it was not until the World War shook us out of our complacency on the subject of national health, and largely silenced opposition to attempts to improve the physical stamina of our people by health service in the schools, that we have really undertaken in earnest to do for our children what they so much need to have done for them.”3 Along with giving school hygiene a nationalist rationale, the war also provided it with seemingly irrefutable proof that much work still had to be done. That proof was in the results of the physical exams given to draftees. Although the army’s physical standards for admission were relatively low—and were reduced even more as the war progressed—almost 30 percent of all draftees could not meet them. When the provost general released the first draft rejection figures in 1918, they provoked considerable comment. A few health experts, like the popular health advisor Woods Hutchinson, expressed little surprise, noting that the US rejection rates were actually lower than those of France and England.4 Most health experts, however, expressed concern, finding in the rejection rates a disturbing revelation of the physical unfitness and defectiveness of the nation’s youth. School hygienists, in particular, latched onto the figures as alarming evidence that for too many American children the passage through childhood and school still involved the accumulation of uncured diseases and uncorrected defects. A postwar study surveying and promoting city school health services noted: “The Great War forced upon us with unescapable logic the fact that the end products of our educational system, our young men and our young women, had in large proportion marked deficiencies. It was a shock to read of the enormous number of rejections from army service of boys in their teens and young men in their twenties.”5 Convinced that most of the rejected draftees would have passed the physical exams had needed medical care been available to them earlier in life, school hygienists used the draft results to stimulate greater effort on the part of municipalities to detect and promote the correction of the physical defects of their schoolchildren. Rare was the postwar school hygienist publication or school or health department report that did not couple a plea for more school-based

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health services with a reference to the draft rejection figures.6 Apparently such coupling was effective, for in the first five years after the war, the number of cities with systematic medical supervision and inspection programs increased significantly. Of the 324 city school systems that responded to a joint 1922 survey of school health programs by the National Education Association and the American Medical Association, 94.9 percent reported regularly giving health exams to their primary school students, and 61 percent reported giving such exams at least once a year. Additionally, in 46 percent of the cities with school health programs, school funds were used to support some type of corrective or remedial treatment; in most of the rest, support was provided by health departments or philanthropic and civic groups.7 Much of the expansion prompted by the war involved increases in the type of clinical and diagnostic services established before the war. This, as we have seen, was especially true for dental services. The large numbers of young draftees discovered to have already lost a majority of their teeth to dental decay provided graphic and convincing testimony of the critical need for improving the availability of dental care to the nation’s children.8 But the expansion also included new types of services, designed to discover and promote the correction of defects that the war helped make apparent. One such defect was impeded speech. It had certainly been clear before the war that some children lisped, stuttered, or had other speech impediments. But it was only after the incidence of such speech impediments was illustrated by their causing the rejection of 10 percent of all officer candidates that school hygienists really took notice. Especially after the 1919 publication of Margaret and Smiley Blanton’s pioneering Speech Training for Children: The Hygiene of Speech, a work aimed at parents and teachers, school systems increasingly offered both speech testing and speech therapy.9 Another set of defects among schoolchildren publicized by the war were orthopedic problems, especially spinal curvature, poor posture, and flat feet. Over 12,000 young men were rejected by the draft board examiners for having spinal curvatures so severe as to make them, in the eyes of the armed forces, incapable of performing any military duty. Another 3,000 were deemed unfit for combat but capable of limited service. Flat feet also disqualified thousands for service, accounting for some 4 percent of all rejections. Since both conditions were believed to originate in childhood—spinal curvature from rickets, tuberculosis of the bones, developmental problems, and poor posture habits; flat feet from poorly fitting shoes and early foot trauma—and were thought to be at least partially remedial if caught early, their detection and correction became a major concern of postwar school health services. School systems hired orthopedists

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to provide more careful exams for skeletal deformities, created departments of corrective physical education, and established posture classes and clinics where students identified by their teachers as habitual slouchers were sent. The systems also made the examination of feet a regular part of medical inspection and, in general, paid a great deal more attention to the carriage of the young as both a contributor to and a sign of health.10 The war also helped revive interest in the nervous and neurotic child, as well as in children who were considered mentally subnormal. Almost 9 percent of those rejected for army service were disqualified because of neuroses or mental deficiency. Considerably higher than what had previously been assumed to be the proportion of such disorders among the young, that rejection rate increased long-simmering fears of mental degeneracy and lent impetus to a push by child psychiatrists and psychologists to make the prevention and correction of mental defects as important a part of school health services as the prevention, detection, and correction of physical defects.11 Noting that during the past two decades the physical inspection of schoolchildren had rapidly developed into a major movement in public education—justifying itself as both a public health measure and a means of improving educational efficiency—one psychologist who spoke at the 1921 ASHA conference opined: “I think it no foolish prediction to state that we are now on the verge of another such movement, or what might be called a logical extension of this movement, in the field of mental inspection. The scientific studies in psychiatry and psychology of the past decade are unanimous in their conclusion that mental abnormalities are nearly as prevalent as physical abnormalities among schoolchildren, and are in many instances of much graver import.”12 His prediction was not far off. In the postwar years, psychologists and psychiatrists were hired by urban school systems to distinguish mentally subnormal students from those deemed hopelessly feeble-minded; establish ranges of normal mental ability and classify students accordingly; diagnose nervous, personality, and behavioral disorders; and advise on curriculum reform and other methods to promote good mental hygiene.13 Some historians of education have characterized this entrance of psychologists and psychiatrists into the schools as initiating the medicalization of American education. It seems more accurate, however, to characterize it as an extension and redirection of a medicalizing process that, as we have seen, had been going on since at least the late nineteenth century. In addition, as demonstrated in chapter 3, the causes, natures, and remedies of such educational problems as grade retardation had for some time been conceptualized and discussed in medical terms. Thus, doing so was not new. What was new

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and what signaled a new direction in this medicalization was the increasingly psychological orientation of the discussion. As the interwar years progressed, the fractious behavior or educational difficulties of a schoolchild were less frequently attributed to adenoids and other physical defects and more frequently to maladjustment and mental defects.14 The war also helped make visible certain groups of children who, although perfectly educable, were considered to have special needs that prevented their inclusion in regular classrooms and thus required special classes and schools. Perhaps most prominent among these “exceptional” children were those who because of congenital deformity, accident, or disease were severely handicapped in the use of their limbs. The plight of such “crippled children,” as they were known, and particularly the lack of both educational opportunities and clinical care for them, had attracted some interest before the war.15 But it was only after the war—when the needs of maimed veterans jump-started rehabilitative orthopedics and the first victims of the 1916 infantile paralysis epidemic came of school age—that significant attempts were made to deal with both the care and the education of the physically disabled.16 As was the case with other school health services, the initial push to improve the care and education available to “crippled children” came from private organizations working as both philanthropies and advocacy groups. In 1919 almost fifty Ohio Rotary clubs organized the first state society for crippled children and pushed through the state legislature a bill allocating funds for their local care and education. Two years later the Shriners initiated their campaign to build hospitals for the most severely crippled children, and Rotary Clubs in New York and a number of other states began lobbying their legislatures to follow Ohio’s example. By the mid-1920s this activity had led several American cities and towns to become aware of their crippled schoolage children and make special provision for them in the public schools. Such provision included not only special classes with specially designed seats and school-based orthopedic clinics where crippled children stretched their distorted skeletons and “exercised” their atrophied limbs, but also transportation to and from school.17 At the same time, city schools began establishing classes for other students whose physical defects were irremediable but not so severe as to make them uneducable or require their assignment to special institutions.18 Among these were children whose hearts were congenitally impaired or had been damaged by scarlet fever, diphtheria, or another disease and who were judged unable to endure the strain of climbing stairs or other activities normally required of students. The draft exams had revealed that significant numbers of young

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men came out of childhood with damaged and diseased hearts and had fueled mounting interest within medicine and public health in the early detection and management of so-called cardiac cases. As a consequence, working with the public schools was one of the initial goals set by many of the local and state societies for the prevention of heart disease that were organized in the years immediately after World War I.19 The draft exams also revealed that there were fairly large numbers of young adults who were not blind but whose eyesight had been severely damaged by childhood accident or infection. Pushed by newly founded societies for the prevention of blindness, urban school systems established sight conservation classes in rooms with strong but nonglaring lights, walls painted a dull gray, and heavy window shades to block out the direct rays of the sun. Students were either taught without books or used texts that had bold, large-size print and unglazed paper. Written work, when it was assigned, was primarily done on the blackboard. The stated purpose of these arrangements was to provide the rudiments of an education while doing no more damage to the students’ eyes.20 Along with witnessing the expansion of services to detect and correct defects and the initiation of classes for the handicapped, the postwar era also saw a dramatic renewal of interest in city elementary schools as both incubators of and guardians against epidemic disease. After years of being largely ignored as settled, the question of whether schools should close or remain open during an epidemic was resurrected by the 1916 polio outbreak. In New York City, where the disease peaked during the summer of that year and killed some 2,400 children while crippling thousands more, fearful parents pressured school officials to delay the scheduled fall opening of schools. In other cities, where the epidemic came later in the year, parents kept their children out of school and urged the suspension of classes until the danger of infection had passed.21 Taking note of the extent to which the public still feared that schools spread epidemics, the US Bureau of Education asked the American Public Health Association to review past and present literature on the subject and formulate a definitive policy recommendation. The association did so, reporting in mid-1917 that the weight of expert opinion was that, in general, schools should be kept open during epidemics and closed only as a last resort. The wisdom and viability of that recommendation was dramatically tested the following year as the influenza pandemic spread through the nation, ultimately killing 600,000 people, almost 30 percent of whom were children. Again panicked parents pressed for closing the schools, and most cities complied. The fact that the three cities that did not—New York, Chicago, and New Haven—had among the lowest rates of school-age child

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mortality from the disease was subsequently taken as dramatic evidence of the wisdom of keeping schools open.22 In the decade after the war, urban primary schools also expanded their roles as agents of immunization beyond their long-time promotion of smallpox vaccination through requiring it for admission. The targeted disease was diphtheria. Since the end of the previous century, when it was discovered that temporary immunity was conferred by the antitoxin serum developed to treat diphtheria’s symptoms, immunologists had been tantalized by the possibility that a method of providing more lasting immunity might be developed. Early in the second decade of the twentieth century, that possibility was brought close to realization when Emil Behring, the discoverer of the antitoxin, developed a toxin-antitoxin mixture that appeared to provide long-term immunity and the Austrian physician Bela Schick developed a skin test for determining who was susceptible to diphtheria and thus could profit from immunization. Almost immediately, the New York City Health Department—led by its laboratory director, William Park—initiated a study, using children in orphanages and hospitals to test the effectiveness of a program in which toxin-antitoxin was given to those whom the Schick test revealed were not already immune to the disease. In 1921, with funding from the Red Cross, the Health Department switched its efforts to public schoolchildren. Although realizing that immunization would be most effective if done in the preschool years, Park and his colleagues felt that schoolchildren would be easier to reach. To counteract what they knew would be widespread concern and resistance from parents, they mounted a massive public education campaign in which the techniques of the newly emerging advertising industry were employed to spread the message that agreeing to immunization represented intelligent and concerned parenting.23 Other large and mid-size cities soon followed New York’s example. Providence, Rhode Island, began immunizing schoolchildren in the fall of 1921. Boston began the following spring and over the next three years convinced the parents of close to 40,000 schoolchildren to allow immunization. In 1922 Chicago also began a major diphtheria immunization campaign, a significant part of which involved convincing parents to allow school and health authorities to test and immunize their school-age children. According to its own estimate, during 1923 and 1924 alone, the Chicago Health Department distributed to city parents approximately one million bulletins explaining the dangers of diphtheria and the necessity and safety of immunization.24 The results of all these campaigns were significant. Parents’ initial resistance gradually faded, and in the second half of the decade hundreds of thousands of city schoolchildren

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across the country were tested for immunity and immunized if they lacked it. A 1927 survey of Massachusetts and Michigan, for instance, reported that in the former state 52,881 children in 116 cities had been immunized that year, while in the latter enough toxin-antitoxin serum had been distributed to municipal health departments during the three previous years to immunize over 600,000 children.25 School Hygiene Broadens Its Focus

An apex designates both the highest point reached and the beginning of decline. So it was with the urban school hygiene movement. The postwar period also witnessed a reorientation of school hygiene that resulted in the urban primary schoolchild and the detection, correction, and mitigation of his or her defects migrating out from the center of the school hygiene gaze, where they had been for so long. Part of this decentering migration was the consequence of postwar school hygiene’s expanding its focus to include children who were not in the primary grades, did not live in cities, and were not suffering from detectable physical defects. It was, for instance, during the 1920s that the health needs of high-school students were for the first time seriously taken up by school and health officials. Several school systems initiated high-school entrance physical exams, started keeping defect and development records of their high-school pupils, and made available to them some of the clinical services to which younger students had long had access. Many more systems, responding to the importance given to health and physical education in the National Education Association’s 1918 reformist document Cardinal Principles of Secondary Education, beefed up their high-school physical training programs and introduced instruction on healthy living into the curriculum.26 In the postwar years, school hygiene, as well as child hygiene in general, also began to pay serious attention to preschool children. Although child health experts had long acknowledged the importance of the preschool years—especially regarding vulnerability to deadly childhood diseases— organized child hygiene activity had tended to focus almost exclusively on infants and schoolchildren. This changed after World War I, as a generation of child development scientists spotlighted the preschool years as a critically important stage of childhood in determining later physical and mental health. Contending that many of the major childhood diseases as well as the defects found to be so prominent in schoolchildren were most likely to be contracted or initiated between the end of infancy and the beginning of school entry, Arnold Gesell—one of the most influential of these early childhood

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development experts—described it as tragic in his 1923 The Preschool Child from the Standpoint of Public Hygiene and Education that “child welfare provisions, public health activities and social legislation have hitherto shown a tendency to slight the pre-school years.”27 Responding to the urgings of Gesell and others in child development, both tracks of child hygiene broadened their vision in the postwar years to include the preschool child. In 1919 the major infant welfare advocacy group—the American Association for the Study and Prevention of Infant Mortality—changed its name to the American Child Hygiene Association and declared itself devoted not only to infants but also to young children. Simultaneously, discussions of medical inspection at the annual meetings of both ASHA and the National Education Association began to explore how parents might be encouraged to identify and correct whatever defects their young children might have before they entered school. By 1925 those discussions had led to the National Congress of Parents and Teachers’ initiation and promotion of Summer Roundup Programs designed to encourage parents to ensure that their children were free from defect on school entrance.28 The postwar school hygiene gaze also broadened to include children who did not live and go to school in cities. Although the healthiness of schools and schooling and the health of schoolchildren outside urban areas had never been entirely ignored in the school hygiene discourse, they had largely been peripheral to the main discussion. Rooted as it was initially in an anti-urban romanticism and developing in a child hygiene movement primarily concerned with improving the health and survival rates of the offspring of an urban working class that was both largely immigrant and economically vulnerable, school hygiene had focused predominantly on city schoolchildren for the four decades following its emergence as a health reform movement in the 1870s. If nonurban schools and schoolchildren were mentioned, it was often to provide a contrast to the unsanitary environment and physical defectiveness of their city counterparts. This changed after World War I. As suburbs and exurbs grew in number, school hygienists began discussing the particular problems and possibilities presented by school systems that were often well funded and had populations of students whose relation to health and health care was often decidedly different than those of children in urban schools. More significantly, during the years immediately before and after the war, school hygienists concluded that rural schoolchildren were not as healthy as had previously been suspected and as a consequence began directing an increasingly large proportion of their attention to determining and meeting their health needs. Suspicion that rural children might not be as healthy as

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had long been popularly assumed began to develop in the second decade of the century, when the Rockefeller Sanitary Commission publicized its findings that large numbers of children in the rural South were malnourished and sickly as a result of hookworm infection.29 It furthered developed after a few states began mandating school medical inspection in rural areas as well as in cities and towns. In 1913, at the Fourth International Congress on School Hygiene, a researcher from the Department of Health of Pennsylvania, the first state to systematically collect and aggregate medical inspection records from rural areas, used that data to suggest pointedly that the image of robust country child might be inaccurate. The following year, as part of an investigation of the healthiness of rural schools and schoolchildren, Thomas Wood and his Joint Committee compared the incidence of defects found among the rural Pennsylvania children with that found by medical inspectors among the schoolchildren of New York and other large cities. The results were eye-opening. As Wood explained in in the Journal of Education, the investigation determined that without a doubt “the children in the country are less healthy and more handicapped than the city children.”30 Taken up by large city newspapers like the New York Times, which devoted a Sunday Magazine feature story to what it termed the surprising news that “pupils of the ‘Little Red Schoolhouse’ are far behind youngsters of the crowded streets in physical well-being,” the Joint Committee’s findings became both a reference point and an inspiration for expert and popular discovery during the 1920s of a variety of pathologies in rural children. So too did the committee’s explanation of why country schoolchildren apparently had 10–20 percent more defects than did their city counterparts. It was not because city children were immune to the overcrowded and unsanitary conditions in which many of them lived; nor was it that country children had less access to open air and exercise than previously supposed. Rather, in the opinion of the committee, the major reason was that city children attended more sanitary and hygienically designed schools, were exposed to a more hygienic daily regimen, and had available to them comparatively superior health supervision and treatment. In short, in spite of their general environmental disadvantage, city schoolchildren were healthier than country schoolchildren because they were the beneficiaries of changes to school buildings and schedules and the implementation of diagnostic and treatment services that were the products of decades of urban school hygiene activity.31 The contention that rural schoolchildren were less healthy than city schoolchildren received powerful support from the draft rejection figures, which showed that rural recruits were more likely to have multiple defects and be disqualified

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for service than their urban counterparts. And the interpretation of this greater defectiveness as resulting from a lack of sanitary schools and school-based health services was reinforced by subsequent surveys of rural schoolchildren’s health by the US Public Health Service and the Federal Children’s Bureau. Hence, by 1920 a consensus was emerging within the American school hygiene movement: if rural schoolchildren were to have their health improved, then school hygiene reform would have to refocus its efforts on improving rural schools and providing to rural children the type of diagnostic and corrective services that were already available to their urban counterparts.32 School hygienists, however, knew that this would be no easy task. The implementation of school hygiene measures in urban areas had been possible because cities had both well-funded and bureaucratically diversified school systems and public health departments and had sizable and diverse collections of civic, charitable, and voluntary organizations and substantial networks of health professionals, clinics, and dispensaries. Rural areas had none of these assets and thus could not construct the public-private coalitions that were supporting school hygiene work in cities. Recognizing this, school hygienists used their various forums and partnered with the US Bureau of Education to produce and disseminate a collection of manuals, bulletins, and broadsheets with advice about how to improve the sanitation of the one-room schoolhouse, how to offer medical inspection and health surveillance when physicians and nurses were few and far between, and how to develop a health education curriculum for the ungraded classroom. They also lobbied state legislatures to pass laws making medical inspection and physical and health education mandatory in all public schools. And, like their counterparts in infant welfare, they looked to the federal government for funding to assist the states in extending to rural areas health services available to the young in towns and cities.33 In 1920 school hygiene supporters convinced Arthur Capper, a Republican US Senator from Kansas, and Simeon Fess, a Republican Congressman from Ohio who chaired the House Education Committee, to jointly sponsor a bill that called for an annual allocation of $10,000,000 in matching funds to be available to the states to support a wide variety school health activities, particularly in rural schools, along with the hiring of physical education teachers and directors, school nurses, and physician medical inspectors. To qualify for the grants, states would have to appropriate funds equal to the amount they received and pass legislation that both accepted the terms of the federal act and made both physical education and medical inspection universally available. The bill also provided for a $300,000 annual appropriation

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to the US Bureau of Education so that it could establish and administer a Division of Physical Education and a $200,000 annual appropriation to the US Public Health Service to create and operate a Division of Child Hygiene. Initially, the bill’s chances of passing seemed favorable. Both presidential candidates and their parties were on record as supporting enhanced school health activity as a means of countering the physical degeneracy revealed by the draft exams. Moreover, concerned as it was with improving the health of schoolchildren, the bill—popularly known as Fess-Capper—seemed a logical companion piece to the Sheppard-Towner Maternity and Infancy Bill, which was simultaneously and successfully working its way through Congress. Yet when Fess-Capper came up for hearings early in 1921, it was met with a withering barrage of opposition from organized medicine, medical freedom advocates, state’s rightists, fiscal conservatives, and antistatist and parents’ rights groups, as well as from a variety of religious organizations, including the Church of Christ Scientist and the Catholic Church. The bill also received little support from the broad coalition of women’s groups who were so critical in getting Sheppard-Towner passed. Their lack of enthusiasm for Fess-Capper seems motivated in large part by fear that a Division of Child Hygiene in the US Public Health Service would work to wrest control of maternal and infant health from the Children’s Bureau. Consequently Fess-Capper was tabled and, although reintroduced in the next two sessions of Congress, never came up for a vote. As a consequence, rural school health programs grew slowly and never approached even the limited successes of their urban counterparts.34 The expansion of school hygiene to include rural children did, however, have a number of significant positive consequences. Among these was making visible the health conditions and problems of Native American children in reservation and boarding schools and of African American children in country schools. Postwar school hygienists discovered an issue that had long been registered by physicians and nurses attached to the Bureau of Indian Affairs’ medical service: namely, the unusually high rates of tuberculosis and trachoma infection suffered by Native American schoolchildren. And in 1924 the Red Cross joined with the bureau to design courses of health instruction for Indian schools.35 School hygiene also discovered, or at least finally began paying attention to, the condition of African American children, particularly those in rural schools. This was especially true after 1920, when the Julius Rosenwald Fund—the Chicago-based philanthropy that between 1917 and 1932 built almost 5,000 schools for African American children in fifteen states across the South—contracted with Fletcher

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Dressler, former chief of the US Bureau of Education’s Division of School Hygiene, to evaluate the schools already built and suggest a design for a basic rural school that would be relatively inexpensive to construct but that would also be consistent with the highest standards of healthy ventilation, lighting, furnishing, and room design.36 Finally, along with schoolchildren who were not in the primary grades and who did not live and go to school in cities, children without obvious physical defects or special needs also increasingly became of the object of school hygienists’ attention in the postwar years. Although such normal children, as they were often labeled, had never been entirely absent from the school hygiene discourse, they had rarely if ever prompted much discussion, especially during the first two decades of the twentieth century, when detecting and correcting physical defects were the major foci of concern. This changed in the years between World War I and the Depression, however, as school hygiene—as well as child hygiene, educational reform, and child welfare in general—focused an increasing amount of attention on defining, supporting, and improving normal children.37 Evidence of this shift can be seen in the evolving concerns of the decennial White House Conferences on Children. When the first conference was held, in 1909, it was dedicated to the welfare of the dependent and defective child. But when the third opened, in 1930, the welfare of the normal child had been added. Lest there be any confusion about what was meant by normal, the conference’s Committee on Child Development provided a definition: “The term normal does not mean simply the usual or the average. Neither does it mean the best, although ordinarily it carries a connotation of all these ideas. The most important meaning which we wish to attach to it is the absence of ill health or incapacity.”38 Referring to this definition when he opened the conference, President Herbert Hoover reminded the conferees that the majority of American schoolchildren were “reasonably normal” and asserted that it was the responsibility of the nation not only to provide “aid to the physically defective and handicapped child,” but also to provide “protection and stimulation to the normal child.”39 There were several reasons for the postwar shift of attention to the normal child. Not the least of these was an increasingly conservative era’s reactionary response to what it saw as prewar reformers’ almost exclusive concern with those who were socially and physically handicapped. Not uncommon within the 1920s school hygiene discourse was the complaint that in privileging the needs of the defective child, school health programs and services had thus far largely ignored the needs and welfare of the normal child. “Wail of the Well,”

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a satirical poem reproduced in several education and hygiene journals, articulated this complaint by having its schoolchild narrator grouse: Johnny Jones has lost a leg Fanny’s deaf and dumb, Marie has epileptic fits, Tom’s eyes are on the bum, Sadie stutters when she talks, Mabel has T.B. Morris is a splendid case of Imbecility. Billy Brown’s a truant, And Harold is a thief; Teddy’s parents gave him dope, And so he came to grief. ... So everyone of these darn kids Goes to a special school. They’ve especially nice teachers, And special things to wear, And special time to play in, And special kinds of air; They’ve special lunches right in school, While I—it makes me wild! I haven’t any specialties— I’m just a normal child.40

The complaint that school health services privileged defective children both justified and masked a fundamental irony of the 1920s expansion of school health services: as they became increasing institutionalized and widespread, services originally designed to improve the health and academic performance of urban poor children with physical defects ended up going disproportionately to relatively healthy and well-to-do children. As David Tyack and other historians of education have noted, the health and other social services that American public schools increasingly offered in the years after World War I were not evenly distributed across the educational landscape. Although spending little to promote the health of their young schoolchildren before the war, affluent communities more than made up for that in the 1920s. They built schools that were well lit and airy, had well-appointed

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lunchrooms and gyms, and often contained well-equipped medical and dental examining rooms along with special rooms for delicate and impaired children. Affluent communities also put in place extensive physical and health education programs and had on staff nutritionists and an array of medical, dental, and psychological professionals. Indeed, a comparison of the survey data collected for the 1930 White House Conference with that published in 1922 by the Joint Committee on Health Problems in Education shows that the greatest growth and diversification of school health services during the 1920s was in cities with populations of 10,000 to 30,000. It also shows that these cities were spending more per pupil on health services than larger cities, in some cases five or six times more.41 Disenchantment with Defect Correction

A second reason for the movement of the urban primary schoolchild with defects from the center of the school hygiene gaze was the growing dissatisfaction with defect detection and correction as the centerpiece activities of school health programs. Although those involved in school hygiene had never viewed such detection and correction as constituting more than a part of what they considered a complete school health program, they had made an implicit decision to prioritize the activities, at least initially. One important rationale behind this decision was, as we have seen, the conclusion that defect correction was an accomplishable means of combating grade retardation and achieving much-desired educational efficiency. Another was the assumption that defect correction had to occur before a child could benefit from other accepted components of a school health program, such as physical training and recreation. As William Maxwell explained as early as 1908, although physical training and recreation were “admirable and necessary” parts of any school health program, “what a farce it is to urge the boy . . . who cannot breathe properly because of adenoid growths in his throat, to go in for relay racing or cross-country running! The conclusion is inevitable; the urban school can do little for the child suffering from physical defects . . . until those defects are removed.”42 Postwar school hygienists did not abandon this conclusion and assumption, but they did begin to reevaluate how accomplishable defect correction was through school-based services, whether it was indeed a solution for poor student behavior and academic performance, and whether it might be better accomplished through parts of a school health program that stressed prevention. Even before the end of World War I, some of those involved in school hygiene had begun to raise questions about the actual effectiveness of defect

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identification and correction in promoting academic efficiency. It was apparent that some city schoolchildren had been relieved of painful or bothersome conditions that were impeding their learning and that others, especially those with formerly undetected problems with their vision and hearing, had been made better able to take advantage of the education being offered them. However, it was also becoming apparent that medical inspection and defect correction were not proving to be the panacea for urban grade retardation and academic inefficiency that school hygienists had presumed they would be. Accumulating data on grade retardation, although somewhat imprecise, indicated that the percentage of overage children was not dropping as significantly as had been hoped. Some educators and hygienists interpreted this relative stasis as evidence that defect detection and correction efforts needed to be doubled, but others interpreted it as a challenge to the assumption that physical defects and other remedial conditions were the primary causes of retardation and thus that their correction or removal would allow the grade-retarded child to progress.43 Particularly influential in advancing this latter interpretation were those educational psychologists, like Lewis Terman, who were involved in developing intelligence testing and promoting its use in the classification of students by mental ability. Noting in his Intelligence of School Children that “the number of school laggards has decreased but little, and their needs are almost as little provided as before the campaign on their behalf began,” Terman advanced that he, Leonard Ayres, Luther Gulick, and most other school hygienists had misdiagnosed the problem as primarily attributable to remedial conditions such as physical defects. Current research, he asserted, was disproving that diagnosis and suggesting that many children who failed to progress did not have the mental ability to do so and most likely never would, no matter how their conditions were changed. As he succinctly if somewhat callously put it, “the over-age child is usually a dull child.”44 Not everyone agreed with Terman and the intelligence testers. More than a few school hygienists and educators found their assessment undemocratic and overly deterministic.45 Nevertheless, most recognized that approaches to dealing with the laggard problem were increasingly shifting away from trying to make all students capable of mastering a standard curriculum and toward identifying each student’s mental abilities through testing and providing an appropriate level and method of instruction. As Philadelphia’s Solomon Newmayer noted in his 1924 school hygiene manual: “Considerable interest has been shown in the last five years in grading children in the public schools according to their mental status. The child who was found to be below the normal average has been singled out and studied for the purpose of adopting

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some method of educating him.” Indeed, by the mid-1920s, even those school hygienists who had spent much of the previous decade promoting medical inspection and school clinics as ways to improve educational efficiency were acknowledging that the transformative potential of defect correction was probably less than they had assumed. New York’s Josephine Baker, for instance, conceded in 1925 that many of the claims for defect correction were probably overblown and observed that “it is improbable, if not actually impossible, that any amount of treatment of physical defects, whether it be the fitting of glasses, dental hygiene and treatment, or medical or surgical practice, will transform the truly dull child into a brilliant scholar.”46 Also prompting a reevaluation of the importance lent to defect detection and correction was an increasingly unavoidable mountain of evidence suggesting that along with not appreciably lessening grade retardation, the medical inspection and correction programs established by most urban school systems had largely failed to accomplish their stated purpose: improving the overall health of the urban school population by reducing the incidence and severity of physical and mental defects. Postwar aggregations of medical inspection results indicated that the percentages of both defects and defective children had dropped but little since the first decade of the twentieth century. In particular, an aggregation produced by Thomas Wood and his Joint Committee—which showed less than 10 percent of all schoolchildren to be free of defects—prompted a swelling chorus of questions and doubts concerning the overall worth of the whole medical inspection program. As one prominent school health official observed, “in several communities, these examinations have been carried on for a generation. During all this time there has been little improvement in the number, kind, or severity of the defect found. . . . Considering the large amounts of money being spent for this work, the results seem discouraging.” Baker agreed, noting: “It is somewhat of an indictment of the way in which school health supervision or medical inspection has been carried on to note that physical defects are almost as prevalent to-day as they were fifteen years ago.”47 In discussing why medical inspection had failed to reduce the incidence and severity of physical and mental problems among schoolchildren, many postwar school hygienists, as well as child health specialists, cited the continuing difficulty of getting diagnosed defects corrected. With the exception of dental treatment, the school clinic movement had largely failed to significantly increase treatment options for the urban poor. And many poor parents remained reluctant to pay a private physician to correct a defect that seemed neither prominent nor crippling. As a consequence, in few if any cities were

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more than a fraction of the identified defects ever corrected. Baker’s estimate for New York was one-third, and she guessed that the rate for most cities was no better and probably worse.48 School hygienists and child specialists also pointed to the continuing inadequacy of in-school examinations. The understaffing that had long plagued most urban medical inspection corps grew worse in the postwar years, as several cities either cut back their medical inspection staffs or failed to increase them to match the growth of school populations. As a consequence, although the number of school systems offering medical inspection expanded after the war, as did the number of children being inspected, the ratio of inspectors to students shrank, especially in the larger cities that had pioneered medical inspection. New York in 1921, for instance, had the same number of medical inspectors it had had in 1905, although its school population had doubled. Chicago, which underwent a major postwar fiscal retrenchment, had fewer inspectors in 1921 than in 1905. With not enough staff, medical inspection bureaus had to examine children as infrequently as every three to four years and to rely increasingly on auxiliaries like teachers or nurses to do more frequent screening. Those involved in medical inspection feared that the intervals between the exams were too long, and thus defects often developed undetected. They also expressed misgivings about the increasing use of auxiliaries to do initial screening and lamented the lack of exam thoroughness and standardization and the generally low quality of the physicians hired—all of which, they contended, led to diagnostic data that could not be compared and were often incorrect anyway.49 To offset the problems caused by understaffing, cities experimented with a number of alternatives to providing physicians’ inspection for all students. Some, like Milwaukee, shifted responsibility for basic medical inspection from physicians to nurses. Others, like Detroit, used teachers for screening and a squad of three specialists to examine those children identified as sickly. Yet other cities began allowing the use of private physicians for some of the required exams. As early as 1915 New York, in an effort to relieve its increasingly overburdened medical inspection staff, began giving families the option of having the entrance exam done by their family doctor or pediatrician. In the postwar years, Boston, Chicago, and a number of other large and medium-size cities followed suit. The hope was that this would free up medical inspectors to give more frequent exams to children in the upper grades. However, it did not quite work out that way, at least not initially. Except in the most prosperous school districts, the option was rarely exercised. Whether this showed, as school health officials asserted, that most urban residents had come to trust school medical services or, as local medical societies charged, that most

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families, even if they could afford to, were unwilling to pay for what they could get for free, is difficult to determine. But it did eventually force a number of cities, whose medical inspection corps continued to shrink though the 1920s, to end up requiring those families who could not demonstrate real neediness to use a private physician for the entrance exam. Moreover, urban medical societies, motivated by both altruism and self-interest, further promoted this privatization of medical inspection by encouraging their members to provide for free or at a reduced rate in-office exams to schoolchildren whose parents could not afford full fees.50 The Turn toward Prevention

For many in school hygiene, however, the problem seemed rooted less in the inadequacy of the available inspection services and more in the inadequacy of an approach that focused too much attention and effort on identifying and correcting individual defects and not enough on preventing the development of those defects by monitoring and promoting the overall health of the child. As one school hygienist observed after reviewing a number of proposals put forth to improve medical inspection as a means of combating the persistence of defects among schoolchildren, “the difficulty has been, however, that the emphasis has been in the wrong place. Those engaged in this phase of school health have been more interested in finding and correcting defects than in preventing them. The program has been too much occupied with disease and too little with building health.”51 Such assessments with what was wrong with existing school health programs were heard with increasing frequency in the postwar years, as school hygienists embraced prevention and health promotion and, although not abandoning detecting and correcting defects, made those activities secondary to using education and habit training, as well as play and various physical activities, to promote healthy patterns of living and thus the development of healthy, defectless bodies and minds. Hence, by 1925, Baker could report in Child Hygiene that a consensus had emerged in school hygiene that “too much stress has been laid upon the relative importance of the presence of individual defects and not enough upon consideration of the child’s health as a whole. Within recent years, our tendency has been toward health education rather than the correction of already existing defects.”52 Health Education and the Promotion of Healthy Living

When postwar school hygienists spoke of employing health education to improve the child’s heath as a whole, they usually had in mind a very

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expansive definition of what health education involved. The term itself was new and was meant to convey a wider range of goals, techniques, and activities than traditional hygiene instruction. Thomas Wood and Hugh Rowell explained in their 1927 school hygiene textbook: “Health education is the sum of experience in school and elsewhere, which favorably influences habits, attitudes, and knowledge relating to individual, community, and racial health.”53 Included in that sum of experiences was physical activity: exercise, free play, and organized games and sports. The goal of making physical education part of young children’s health educations was not new, of course, but achieving it would be. As we have seen, at least since the 1890s school hygienists had been arguing that primary schoolchildren required such activity to balance their physical and mental development and to offset the strain of intellectual work. But prior to the second decade of the twentieth century, the hygienists’ arguments had had little effect. Although physical education was achieving some legitimacy as a necessary part of schooling, it was doing so primarily in colleges and high schools and was centered around calisthenics, drill, and competitive sports, all of which were viewed as inappropriate for young children. In the primary grades, recess remained more of a goal than a reality, and the playgrounds that cities had begun to build were designed more to encourage safe and moral play after school than to allow for physical activity during it. Even in Gary, Indiana, where the progressive education innovator William Wirt had instituted a nationally famous “work-study-play” program making physical activity a major part of each day, few children in the primary grades took part.54 This began to change somewhat during the war years, as rising alarm over the poor physical condition of American conscripts gave added force to the arguments of Wood and other physical education advocates that free play, games, dance, and other forms of noncalisthenic and noncompetitive physical activities were not only appropriate for primary schoolchildren but were also critical to their development. As early as 1918, the curriculum manual for the Horace Mann Elementary School, the progressive primary education institution connected to Teachers College at Columbia University, emphasized that physical activity was a required part of each school day and identified the physical dramatization of stories, simple folk dancing, marching and skipping to music, and a variety of games as appropriate means of making it so. A few years later public school curriculum manuals were beginning to follow suit, especially in those states that, responding to a national lobbying campaign by physical educators, began passing legislation making some form of physical education or activity mandatory in all public schools. This led the head of the

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National Physical Education Service, which directed the campaign, to predict that by the end of the decade every elementary school would have a physical education program that occupied a major part of the school day and centered on free play and other natural childhood activities. The prediction was somewhat optimistic, for although physical activity did become an accepted and valued component of elementary school education, it never became more than a relatively minor one. Indeed, even in health education, educating the body tended to take a back seat to educating the mind. Although not ignoring physical activity, the health education around which postwar health programs increasingly came to be organized was primarily centered on teaching lessons about healthy living.55 Both exemplifying and immensely influencing the postwar school hygiene shift toward health education was the work of the Child Health Organization (CHO), founded in the summer of 1918 when a group of prominent New York pediatricians, including L. Emmett Holt and Dwight Chapin, joined forces with the school hygienist Thomas Wood; the community health educator Sally Lucas Jean; and several publicly minded physicians, nurses, educators, and social workers. Their purpose was to create an advocacy organization dedicated to improving the health status of the nation’s school-age children by making interactive instruction in healthy living universal in American schools. Holt was made chairman of the organization, and Jean was hired as its director. Adopting the slogan “health in education—education in health,” the organization soon formed a partnership with the US Bureau of Education, which agreed to publish and distribute materials that CHO produced. That partnership continued and even expanded after CHO merged in 1923 with the American Child Hygiene Association to become the American Child Health Association, with Herbert Hoover as its first president.56 The organization immediately dedicated itself to two overarching goals. The first was promoting normal growth and development—as indicated by height and weight gains—as a better index of overall child health than the absence or presence of specific defects. The second was developing and popularizing a method of health education, along with appropriate materials and guides, that exploited children’s interests and was appropriate to the way they learned. Such a method, it was believed, would be more effective than the memorization of lists of temperance precepts and physiological and anatomical facts that had constituted much of the health education offered in American schools to that point. As we saw in an earlier chapter, a significant segment of the school hygiene community had from the beginning of comprehensive medical inspection

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favored the systematic surveillance of schoolchildren’s growth and development, typically through the frequent recording of weight and height. Such growth and development data, these hygienists believed, could provide a better basis than chronological age for determining where children should be situated on the educational ladder. Noting that not all children developed on the same schedule and convinced that physical and mental development paralleled each other, they argued that individual weight and height records could be used to determine and chart a child’s physiological age, which, prior to the deployment of IQ tests, was seen by many educational developmentalists as the best index of mental age.57 Yet before World War I, little in-school growth recording was actually done. The privileging of defect detection and the relative infrequency of school-based exams generally discouraged the practice. So too did the lack of interest of most of those who oversaw medical inspection. Philadelphia’s Walter Cornell spoke for many of his fellow municipal directors of medical inspection when he declared that “medical inspection is not anthropometry,” and thus that “records of height and weight have no practical value.”58 In the immediate postwar years, however, keeping track of the height and weight changes of schoolchildren became a major focus of health surveillance of the children, though less as a means of gauging intellectual development and more as a way of tracking overall health. CHO was highly instrumental in bringing this about. As one of its first actions, the organization initiated a campaign to convince American school officials to make the regular weighing and measuring of their students a central part of their health surveillance programs. Proclaiming as its goal getting a scale in every school, CHO developed promotional materials, charts for the recording of weights and heights, and report cards to be kept by the children and sent home to parents. The US Bureau of Education, which had secured a special appropriation to do so, printed the materials and distributed them to school systems throughout the country. At the end of two years, the monthly weighing and measuring of children had become a regular part of the health surveillance of schoolchildren in much of urban America.59 Behind CHO’s decision to push weighing and measuring, rather than some other diagnostic method, as a primary health surveillance tool was the growing conviction of Holt, Wood, and most other child health experts that, especially during the years of growth, there is a strong correlation between nutrition, health, and development. Indeed, for Holt, who probably did more than any other American physician to popularize the weighing of infants as a diagnostic tool, the processes of growth and development made good nutrition the most important requisite for infant and child health. “Health and

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normal nutrition are not quite synonymous terms;” he explained to Stanford medical students in a series of lectures that CHO subsequently published, “yet as applied to children during the period of growth, they are so closely allied that one may be taken as an index of the other. While there may be normal nutrition without health, there cannot be health without normal nutrition.” Hence, he concluded, “the health, growth and physical development of children and to a considerable degree their mental development and progress depend upon their nutrition.”60 Wood shared Holt’s views on the relation of nutrition to health and development in the young and considered regular weighing and measuring to be a particularly effective way of using that relationship to monitor the health of schoolchildren, especially in between the increasingly infrequent comprehensive exams given by medical inspectors. Regular weighing, he and Rowell noted in their textbook, “reveals sudden changes in weight, which may be the early indication of health disturbance or actual disease process.” Combined with measuring, they advised, it also reveals whether a child is underdeveloped, a sign of malnutrition that many child health experts believed was a primary cause of both disease and defect.61 Terman agreed and explained in the postwar edition of his school hygiene manual: “There is hardly a defect found among schoolchildren which is not in greater or less degree produced by malnutrition. In this category we may include eye-strain, dental defects, spinal curvature, and nervousness, as well as the infectious diseases.”62 CHO was instrumental in defining and distributing a set of developmental norms against which schoolchildren’s weight and weight gains could be assessed. Such norms and their display in tabular form as weight charts had first been produced in the 1870s as a product of anthropometric research. By the turn of the century, they were being developed and employed by Holt and other pediatricians to monitor the progress of infants and particularly to detect and treat acute gastroenteritis. By the late 1910s, weight norms were being adopted by William Emerson and other nutrition specialists as an aid to diagnosing malnutrition and measuring recovery. If a child’s weight was 7 percent below the norm, Emerson advised, he or she was probably malnourished and a prime candidate for a nutrition clinic. Originally, the norms were defined in terms of the relationship of weight to age, but by the 1920s it was increasingly accepted that the weight to height relationship was more sensitive to variations in both development schedule and body type. It was just such a weight-height table that Wood, in collaboration with the child development scientist Bird Baldwin, developed in 1921. Distributed by the US Bureau of Education, it became the standard guide in most schools.63

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CHO’s second goal was integrally related to the first. If good nutrition was the basis for health, then encouraging good nutrition and all that contributed to it was the basis of health promotion and disease and defect prevention. Hence, simultaneous with its efforts to put a scale in every school, CHO initiated a campaign to make the promotion of good nutrition and related behaviors a regular part of every school health program. Guiding that campaign were two principles. The first was that good nutrition consisted of far more than consuming a sufficient amount of nutritious food. Consistent with the ideas being propagated by Emerson and other postwar child nutrition experts, CHO promoted a nutrition and health improvement regimen that required adequate rest at night; a sanitary, well-ventilated, and orderly home environment; personal and mouth hygiene; regular bowel movements; exercise through games and play; and the correction of physical defects—along with a well-regulated and nutritional diet that included plenty of leafy vegetables, fruit, and milk. In other words, it was a regimen of good health habits. How best to interest children in developing those habits was a challenge that led to the development of the campaign’s second guiding principle: in order to be effective, a campaign to promote children’s health had to be aimed at developing habits rather than simply imparting precepts and had to employ education techniques and practices that caught the interest of children, were appropriate to the way they learned, and got them actively involved in the process.64 Jean was primarily responsible for developing CHO’s program of health education, and what she put together was definitely different from what had long passed for school-based instruction in hygiene. Like most postwar health educators, Jean was rather dismissive of past efforts to impart health principles to schoolchildren—and with good reason, for such efforts had proven far from successful. This was not, however, for lack of past conviction on the part of health reformers that schools offered an ideal opportunity to transform the health knowledge and practices of children and thus improve the health of the nation. Indeed, a move to make the teaching of hygiene and the rules of health a regular part of the curriculum accompanied the nineteenth-century creation of common schools and produced a number of texts aimed at both children and adults. Most of these texts, like William Andrus Alcott’s widely circulated The House I Live In, or the Human Body: For Use in Families and Schools (1834) were primers and used anatomy and physiology to teach hygiene. Believing that the body was part of a God-created world that was governed by natural law, Alcott and other health reformers before the Civil War assumed that the more children knew about how the body was constructed and operated, the more skilled and invested they would be in caring for it. Although perhaps a

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logical assumption, it was, however, translated in the antebellum classroom into the memorization and rote recitation of body parts and functions. In the rare instances when teachers were willing to set aside the regular curriculum to teach hygiene, they did so as they taught all subjects, using memorization and drill.65 In the postbellum years, health education in primary schools continued to be centered on the memorization of physiological and anatomical facts, but it gained a larger presence in the curriculum after the Women’s Christian Temperance Union (WCTU) embarked on a campaign to make the schools a primary field of battle in its war against alcohol and other stimulants. The WCTU created and disseminated to school systems a trove of teaching materials designed to convince students that the consumption of stimulants was physically harmful. It also mounted a highly successful lobbying effort to convince state legislatures to require that school health instruction include explanations of and warnings on the evils of alcohol and narcotics. By 1890 thirty-eight states had complied and were requiring temperance teaching in the schools and mandating that physiology textbooks devote a certain amount of space to evils of alcohol, tobacco, and narcotics. The WCTU’s victories, however, may have been pyrrhic. Although they gained health education a slightly bigger place in the curriculum, they generated considerable opposition from the medical and education communities, both of whose members complained that temperance physiology was not just unscientific but also presented in a manner that made it deadly dull, completely ineffective, and age inappropriate.66 During the decade and a half before World War I, these complaints were heard with increasing frequency, especially from those in school hygiene who were focusing on improving as well as protecting the health of schoolchildren. In the Ninth Yearbook of the National Society for the Study of Education, Wood described the mounting frustration of school hygienists with the character of school-based health education and opined that “no phase of instruction seems more important than to teach the child how to live in a healthful manner. No subject is taught, on the whole, so unsuccessfully.” The reasons, Wood went on, were not hard to fathom. Teachers were ill prepared and uninterested, and the curriculum was either all “dry fact and dense theory” or enumerations of the ill effects of stimulants on the body. Of these later, Wood observed that “nothing can be more readily shown than that in the case of most individuals the knowledge of the ill effects of unhygienic activities does not in itself result in the formation of hygienic habits . . . boys who do not stand aghast at the abasement and the menace of the drunkard, will not be

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prevented from drinking solely through knowledge of the various ill effects of alcohol on the heart and nervous system.”67 Ernest Hoag and Lewis Terman were even more contemptuous, writing: “The rather common practice of attempting to instruct very young pupils in such subjects as the effects of narcotics and stimulants, the physiological uses of food, the structure of the body, the functions of organs, the chemistry of the air, the nature of the blood, the growth of bacteria, and the methods by which they are spread, and the like, is so absurd as to seem past belief. Yet these are some of the many topics to be found mentioned in most courses of study for children in the lower grades, and in part required by laws of the state.”68 Jean fully agreed with these sentiments and was determined to have CHO lead a revolution in the teaching of hygiene to grade schoolchildren. As a Baltimore school nurse, she had participated in an experimental program aimed at demonstrating the effectiveness of health teaching designed to change behaviors rather than impart facts. She drew on that experience to devise a plan for CHO wherein the organization would define a set of easily understood and remembered good health behaviors and present them in a way that would be interesting to young children and encourage them to make those behaviors habitual. To that end, CHO identified eight basic health behaviors—“rules of the health game,” as it labeled them—and made them the centerpiece of its health education promotional program.69 Printed on virtually every piece of literature that CHO distributed, the rules were: A full bath more than once a week Brushing the teeth at least once every day Sleeping long hours with the windows open Drinking as much milk as possible, but no coffee or tea Eating some vegetables or fruit every day Drinking at least four glasses of water a day Playing part of every day out of doors A bowel movement every morning70 To make learning the rules interesting, CHO recruited writers to create stories and plays with vivid and fantastical characters and fairy-tale and parablelike narratives that demonstrated the benefits of healthy habits and the costs of poor ones. It also distributed through the US Bureau of Education materials describing and encouraging the creation of a wide variety of health activities, games, plays, and pageants in which children could fantasize what CHO

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called a healthland, populated with health elves and health fairies who by word and deed taught lessons on healthy living. Perhaps most notably, CHO hired and trained young performers to visit schools and health fairs and, as child-friendly characters, to teach their audiences good health habits while entertaining them. Best known among these was a clown character named Cho Cho, who delighted children with his magic and buffoonery while demonstrating how to brush teeth properly, what foods were good to eat, and other good health behaviors.71 To encourage children not only to learn the rules, but also to make them part of the daily behavior, CHO made the process a game with stages and rewards. It was a strategy pioneered over the previous few years by the National Tuberculosis Association as part of its program to involve children in the selling of its Christmas seals. To interest children in participating as well as to employ them in promoting the seals, in 1915 the association created a League of Child Health Crusaders who, dressed like medieval knights and maidens, would participate in civic parades and pageants. By 1917, however, the children were increasingly focusing on themselves as the association expanded the purpose of its program to improving the health of the young and thus their resistance to tuberculosis. Children were recruited to enroll in a fifteen-week Modern Health Crusade that challenged them to complete every day a number of specified health tasks—such as washing their hands, sleeping so many hours, and playing outdoors—and to keep a record on a provided score card. An overall completion rate of 75 percent was necessary for the child to ascend, rank by rank, from page to knight banneret. Those who made it to the highest rank received a gold-plated pin. CHO reduced the Modern Health Crusade’s eleven health chores to the eight rules of the game and dropped the medieval symbolism, but it adopted the chore record and fully embraced the principle of forming good health habits as interactive learning that earned rewards. Through the US Bureau of Education, it sent to thousands of schools materials that would allow teachers to encourage and reward their students for learning and following the rules of the game.72 CHO also deliberately and quite self-consciously employed both competition and its handmaiden, shame. Through the Bureau of Education, it distributed weight-gain charts that could be prominently displayed in classrooms and would show each child’s weekly gain. It also encouraged the giving of awards to the individual children and to the classes who came closest to the healthy norm. And it designed and distributed large yellow tags, which on one side had the rules of the health game and on the other blanks in which to write a child’s name and how much underweight he or she was that week. Attached to the

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child’s clothing and worn home, the tag’s intent was hard to miss. Envisioning what would take place once nine-year old “Buddie Lathrop” arrived home with his tag attached, one contemporary writer observed: “If Buddie’s mother is worthy of motherhood, it is fair to say that she will finger the yellow tag thoughtfully enough to cause her to read what is printed on the reverse side of the tag. She should, for there she will find printed the eight rules of the new game.”73 To interest teachers in making the teaching of hygiene part of their instructional repertoire, CHO joined with the National Education Association, the Russell Sage Foundation, and the Bureau of Education to sponsor training events and health education conferences. It sent a public health nurse with Cho Cho so that while the clown was entertaining their students, teachers could be instructed on how to incorporate health lessons into the daily schedules. It provided templates for teachers to conduct daily inspections of children in their classes, quizzing them as to how long they had slept the night before and whether they had brushed their teeth, bathed, and eaten any fruit. And it helped design and produce a Health Education Series of over a dozen pamphlets that the Bureau of Education printed and distributed nationally. Among these were pamphlets titled Wanted! Teachers to Enlist for Health Service, Teaching Health, and Suggestions for a Program in Health Teaching in the Elementary Schools.74 Although leading the way, CHO was hardly alone in promoting the adoption of a new school-based health education. A number of other health organizations, including the Red Cross, the National Child Labor Committee, the National Tuberculosis Association, and the American Child Hygiene Association, also produced and disseminated child health education materials and lobbied for more health education in schools. In 1920, in an effort to coordinate their efforts, these and a few other health organizations joined with CHO to create a National Child Health Council. As one of its first tasks, the council launched a study of health teaching in the schools and produced a report that was published and distributed by the US Bureau of Education. At the heart of the report were six recommendations: health teaching should be positive rather than negative; it should be tailored to the developmental stage of the children at which it is aimed; its purpose should be to develop healthy habits as well as impart knowledge; it should be made interesting and stimulating and get children involved; it should be aimed at and designed to meet the needs of the well or normal child; and its impact should spread out from the school into the family and community.75 Commercial enterprises and trade associations also joined CHO in promoting the new school health education. Especially prominent among these was

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the Metropolitan Life Insurance Company, which had embraced health education after concluding that improving the health habits of its subscribers and their families was good business. Through its welfare bureau, the company produced and circulated a variety of child health education materials, including The Metropolitan Mother Goose and a series of “Health Heroes” pamphlets recounting the lives of Louis Pasteur and other major contributors to medicine and public health. By 1924 the company’s involvement in health education for schoolchildren had become so extensive that it established a separate Bureau of School Health. The National Cleanliness Institute, the education arm of the National Soap Manufacturers Association, also focused its attention on schoolchildren. In the postwar era it lobbied states and municipalities to require that every classroom have a sink and provided funding and assistance to CHO and the US Bureau of Education to promote frequent hand washing and bathing by schoolchildren.76 A similar though larger effort was mounted by the National Dairy Council, organized in 1915 by the dairy industry to research and promote milk as an all-around healthy and nutritious food that was particularly good for growing children. When milk prices plummeted after World War I as surplus supplies were dumped on the market, the council initiated a major national campaign to increase consumption by focusing on schoolchildren. Following CHO’s example, it produced and distributed—through the Bureau of Education, the Department of Agriculture, and local committees it organized—stories, plays, and films featuring milk fairies and driving home the message that the copious consumption of milk was absolutely necessary for healthy childhood development. It also produced and distributed instructional materials for teachers, like Health Habits: Suggestions for Developing Them in School Children, a work that went through three editions and identified drinking two to three glasses of milk every day as one of the most valuable health habits a child could form. Perhaps most significantly, the National Dairy Council convinced local dealers to provide schools with milk at reduced cost if the schools established programs in which parents contracted to pay for their child to be provided so many times per week with milk at lunch or the morning recess. The council’s efforts were not in vain. By the mid-1920s milk consumption among school-age children had risen dramatically, and the daily drinking of milk was fast becoming accepted as a basic requirement for healthy child growth and development.77 The New Public Health, the New Curriculum, and the New Parenting

Although successful, the CHO-led campaign to position health education at the center of school health programs, along with the messages preached and

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the methods employed, provoked some resistance. Many parents, particularly among the laboring and immigrant poor, understood and resented that their children were being taught that their home life was essentially unhealthy and needed to be improved. Such parents also objected to the not very subtle assertion that they were not knowledgeable enough nor concerned enough to do what was best for their children. Diet in particular was a point of contention, especially for immigrant families. The health plays and stories as well as the direct nutrition advice stressed the consumption of foodstuffs that could complicate adherence to dietary laws or were peripheral to the cuisines that immigrant groups were fashioning as part of their ethnic identities.78 Moreover, the health materials often explicitly targeted ethnic eating habits and foods or described immigrant parents as both ignorant of and resistant to good nutrition. For instance, in the “Revolt of the Skinnies,” an article about health teaching in the Oakland schools, an Italian immigrant mother is unflatteringly depicted as complaining to a teacher who has been using CHO materials in her class: “‘Whazza da matta wid you?’ she asks the teacher. ‘My Emilio, he come home wanta the string beans, wanta me cooka da carrot, da spinach. Emilio, he no wanta eat da spaggett!’”79 Various parents’ and parent rights’ groups also objected to what they saw as the schools’ propagandizing specific health behaviors and views of health and usurping parents’ role in the socializing of children. Primary school health education did not inspire the degree of opposition that high-school programs often did, largely because programs for younger children included little if any sex education. But it did have opponents, especially among those parents who felt that teaching habits and behaviors was the right and responsibility of the parent or, like Christian Scientists, believed that the definition of health being propagated by the school health education programs conflicted with their religious views. Closely allied with these parents were the defenders of socalled medical freedom, who objected to health education as a state-sponsored advertisement for allopathic medicine. Indeed, both groups were instrumental in derailing the 1921 effort by school hygienists to secure federal funding to assist school systems, especially those in rural areas, establish school health programs that would include health education, physical activity, and medical inspection.80 More than a few educators also had problems with the new health education, considering both the methods and materials fluff and poor replacements for the fact-based lessons in anatomy, physiology, and bacteriology that constituted the older hygiene instruction. Similarly, medical professionals, in both private practice and public health, expressed concern about the qualifications

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of teachers in primary schools to teach hygiene and seemed less than pleased that clowns and fairies were assuming the position of experts on child health and nutrition. Indeed, following CHO’s merger with the American Child Hygiene Association, an organization in which public health physicians were prominent, Cho Cho and the fairies were sent packing and Jean was demoted, ultimately causing her to quit.81 Moreover, although the new organization continued to produce and disseminate health plays and stories and was quick to assert that health education was central to any school health program, it also made a point of emphasizing that instruction was not alone sufficient. In one of its first major publications—a study of child health services in eighty-six cities—the organization advised: “Defective eyesight, troublesome tonsils, adenoids, weak hearts, bad teeth, mental and social adjustments and numerous other deficiencies do occur in the school child and they cannot be taught ‘out.’ Their correction requires the attention of the physician, the dentist, and the psychologist.”82 That also seems to be one of the messages sent in 1927, when 325 physicians attending the American Public Health Association’s annual meeting came together to form the School Physicians Association both to replace the American School Hygiene Association—which had disbanded earlier that year—and to stress the guiding role of medical professionals in school health. Indeed, the School Physicians Association, which ultimately became the stillexisting American School Health Association, initially restricted membership to physicians.83 Despite the criticism, however, the overall response to the new health education seems to have been generally positive. Although immigrant parents may have resented the implications of the teaching, they were not entirely resistant to the lessons taught. As Elizabeth Ewen and others have shown, urban immigrant mothers often modified their parenting in at least partial accordance with what their children were learning in school and with the advice they were receiving from public health nurses, social workers, and others who sought to improve the lives of immigrant children by reorganizing the immigrant family. Hence, although largely alien to immigrant parents’ own childhoods, the consumption of milk, especially after it was made safer in the 1920s, became a regular part of the nutrition of their offspring. And to the extent that it was possible in tenement apartments, more frequent bathing of children was also adopted, as was sleeping with windows open.84 Middle-class parents were even more receptive, in large part because what was being taught in school replicated and reinforced much of the advice they were getting from the small army of family health counselors who in the 1910s began appearing in newspapers and women’s and family magazines as both

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regular columnists and feature writers. Indeed, by the 1920s child-rearing advice was so pervasive in publications aimed at the middle class that organizing children’s home lives around good nutrition, fresh air and exercise, and personal hygiene and cleanliness had become for many middle-class mothers and fathers a marker of their commitment to their offspring and their general worthiness as parents.85 Middle-class parents also found attractive the new health education’s focus on the so-called normal child and its delineation of the paths to both good and ill health as essentially behavioral ones. The main focus of the new health education was not the defective child whose parents, through ignorance, obduracy, or lack of means had failed to provide him or her with needed medical or dental treatment. Rather, it was the child who was well cared for and relatively healthy and who required not correction but instruction on how to remain so. Moreover, implicit in the message of the new health education was the belief that strict adherence to that instruction—by both parents and children—could improve a child from the normal to the exceptional. In fact, by the end of the decade—especially after the 1927 publication of Hugh Chaplin and Edward Strecker’s Signs of Health in Childhood: A Picture of the Optimal Child with Some Suggestion as to How This Ideal May Be Attained— the object of health education was increasingly being defined as assisting the child to achieve his or her full health potential.86 Although expressing some reservations, the physicians, nurses, and dentists who provided the bulk of the school-based diagnostic and treatment services and who oversaw medical inspection were also generally receptive to the postwar shift in school health programs toward education. Although continuing to examine children for contagious diseases and physical defects, medical inspectors increasingly saw themselves and were seen by others as health education resources, willing and able to advise teachers and oversee health instruction. School nurses also increasingly took on the role of health educators and, by the 1920s, descriptions of their duties tended to stress education over the detection and treatment of minor diseases.87 To some degree this shift may have been in response to a campaign by organized medicine to sharply limit the medical procedures that school nurses were allowed to perform. But to a greater extent, it and the parallel shift by school physicians reflected the increasing importance that the encouragement of healthy living was being given by both public health and private care. During the decade following World War I, public health completed a reorientation begun earlier in the century, moving away from an exclusive focus on the environment and toward one that encompassed the individual and his or her behavior. The result was what was commonly referred to as a “new public

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health,” which was based on the premise that sanitary engineering and disease control had accomplished much of what they could and that further improvements in the health of the public would depend on convincing individuals to modify their behaviors in accordance with the principles of personal hygiene and preventive medicine. Such behavior modification was often characterized as the development of preventive health habits moored by a hygienic way of thinking, or a “hygienic conscience,” as the new public health proponent, Charles-Edward Amory Winslow, termed it.88 Although the ultimate goal was to change adult habits and ways of thinking, it was usually acknowledged that adults were often set in their ways and difficult to modify. Hence, postwar preventive public health focused a good deal of attention on children, who were seen as more malleable. As Josephine Baker explained, “it is evident that the preventive part of public-health work, to be effective, must begin at the time of life when habits of health are most easily established. The child is plastic material. Prevention of disease and assurance of good health in childhood are simply and readily secured. With adults, preventive work is difficult.”89 Public health’s embrace of education also reflected a growing conviction within its ranks that the patchwork of philanthropic and publicly funded healthcare services for children that had developed over the previous two decades would never be capable of providing more than a tiny fraction of what was needed. In a talk he delivered at the first annual conference of the American Child Health Association, Haven Emerson, formerly New York City’s commissioner of health and at the time a professor of public health at Columbia University, forcefully articulated this point. Contending that the child who was adequately served by the nation’s semipublic patchwork of child health services was “about as rare today as the clinical thermometer was fifty years ago,” Emerson argued that the only solution was for public health to embrace suasion and use health education to persuade children to demand good healthcare and parents to spend the money to provide it.90 During the 1920s medicine and dentistry also embraced health education, particularly that which was aimed at children. Although their spokespersons and publications grumbled about the errors and simplifications in some of the new health teaching, both organized medicine and organized dentistry began using its methods and messages. In the decade after World War I, the American Dental Association produced and made available to schools posters, slides, and films demonstrating the importance of mouth hygiene and the necessity of regular trips to the dentist. It also produced, printed, and circulated a number of health plays appropriate for children, perhaps the most popular of which was The Bad Baby Molar. Although more leery of school health programs, the

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American Medical Association took similar steps. Among these was its 1923 launch of a popular health magazine called Hygea. Although aimed at an adult readership, the magazine devoted considerable space to discussing and promoting child health education and reproduced and made available to schools stories and plays that appeared in its pages. With titles like “The Good Health Elves,” the stories and plays often followed the models developed by CHO, although they tended to place more emphasis on the authority of physicians or nurses. That health education for children was critically important but needed the guidance of medical professionals was also one of the core themes of Health Education, the detailed report that the Joint Committee on Health Problems in Education published in 1924.91 Not surprisingly, organized medicine and dentistry were particularly supportive of one of the core teachings of the new health education: good health required regular supervision in the form of periodic checkups by health professionals. Medical inspection had introduced American children and their parents to the practice of regular physical and oral exams; health education would convince them to look to private practitioners as a supplemental or substitute source of those exams. It was not lost on private practitioners how valuable an ally health education could be if it could do what Emerson suggested it should do: convince children to demand regular health care and parents to pay for it. Finally, the positioning of health education as the major function of school health work found considerable support among educators and school authorities. Particularly receptive were those who had embraced progressive education and the curricular and other reforms inspired by John Dewey. The new health education was based on many of the principles that Dewey had laid out in The School and Society (1900), The Child and the Curriculum (1902), and Democracy and Education (1916). It assumed that the purpose of education is not only to gain knowledge but also to learn how to live, and that such learning is most effective when it engages the child’s interests and results in the formation of habits. It was interactive and sought to involve students in their own learning. And it accepted the premise that school and schooling could transform society by shaping children’s values and behaviors. Not the least of the many attractions that the new health education held for progressive educators and urban social reformers was the potential they saw in it for Americanizing the vast number of immigrant families who filled the nation’s cities. As Maxwell noted at a meeting of the American School Hygiene Association, among the most important reasons for making health education part of the regular primary school curriculum was “to give to our enormous alien population new

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ideals and new habits in the rearing of children and in establishing among them American standards of living.”92 One did not have to be a progressive educator, however, to find the shift of school health activity toward education appealing. School administrators and teachers of all stripes were basically receptive to the change because a health program organized around education was more closely related to the normal daily operation of schools and to their traditional mission of imparting knowledge and developing skills than one that was organized around the detection and correction of physical defects. Despite the best efforts of progressive reformers to turn schools into multifunctional social agencies, schools and schooling remained primarily dedicated to and organized around students’ learning in an orderly manner lessons that teachers presented. Feeding the hungry and malnourished and detecting and correcting minor diseases and physical defects, though valued and educationally justified in theory, were in fact disruptive of that organization. An education-oriented health program was also far easier to run if a school had to rely on auxiliaries such as classroom teachers. In a 1921 Elementary School Journal article, the supervisor of hygiene for Kansas City described how her school system, inspired by the war and the draft results to mount a major campaign to improve the health of its primary school students, was able to do so even though the city government refused to appropriate the funding to hire an adequate number of school physicians and nurses. The challenge, she noted, was how “to devise a health service for grade children which is simple enough to be carried on by the teacher without the help of physician or nurse and which does not consume a prohibitive amount of the teacher’s time and strength.” Her system’s solution, she explained, was to adopt the program outlined by CHO in which weighing and measuring were combined with individual and group teaching and the development of good health habits were encouraged and reinforced by children’s participation in plays and pageants and by competition between health teams. The equipment required was a pair of scales for every school building, measuring rods, weight charts and individual weight records and tags, a small library of some of the collection of health lessons, plays, and activities available from the US Bureau of Education and other sources, and a reproducible folder of materials to be sent to parents instructing them on how to improve the healthiness of their child’s home and home life.93 Kansas City was one of many American cities that opted to accomplish a postwar expansion of its school health program by adopting one that relied on teachers and was centered on the classroom and education. Not the least significant reason for this approach was that in adopting such programs, city

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school and health officials were able, at least partially, to navigate a fundamental contradiction at the heart of postwar school hygiene in the United States: the rhetorical and emotional commitment to expanding school health work so that a real improvement in American child health might be accomplished was largely unaccompanied by any significant fiscal or structural commitment to support that expansion. Indeed, although during the 1920s many states passed legislation requiring school systems to establish health programs that included physical education, health education, special accommodation for the handicapped, and mandatory medical inspection, that legislation was consistently undermined, according to a US Bureau of Education analysis, by “the failure to provide adequate financial support for administration and supervision, and the failure to provide administrative means for making the laws locally effective.”94 Schools Educate

Perhaps nowhere was the refocus of the school hygiene discourse on promoting health and preventing disease and defects in all schoolchildren through educating them in healthful habits and healthy modes of living more clearly illustrated or forcefully affirmed than in the report on school health programs that came out of the 1930 White House Conference on Child Health and Protection. Convened by President Hoover to demonstrate both his and the nation’s commitment to safeguarding and improving the health and well-being of America’s young, the conference was a massive affair, attracting over 3,000 attendees and producing over 300,000 pages of research results and recommendations, representing the work of 1,200 experts arranged in seventeen committees overseen by four sections. School health programs were discussed in the Section on Education and Training, chaired by Frank J. Kelly, a division chief in the US Bureau of Education. A 400-page report summarizing those discussions and enumerating a set of recommendations was produced by a Committee on the School Child headed by Wood.95 Unlike earlier reports and surveys published by the US Bureau of Education or the American Child Health Association, the report produced by Wood and his committee did not focus exclusively or even chiefly on urban public primary schools and schoolchildren. Equal attention was given to rural, suburban, private, parochial, “negro,” and Indian schools, as well as to high-school, preschool, and kindergarten students. Nor did the report focus solely on defective children and their health needs. Rather, taking its cue from Hoover’s charge to the conferees that they concern themselves not only with “aid to the physically defective and handicapped child,” but also with “protection and stimulation to the normal child,” the report dedicated much of its discussion and

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many of its recommendations to measures that would protect and promote the healthy development of the majority of American schoolchildren who, in the words of the president were “reasonably normal.”96 In many respects, the report represented the final triumph of the educators’ vision of school hygiene over that of the child hygienists. Not only did Wood and his committee forcefully reiterate the educators’ position that school hygiene should be under the sole control of school authorities, but they also emphatically asserted that the fundamental mission of the school health program was of one piece with the fundamental mission of the school: to educate. This meant that the primary concern of the school health program should be “providing through school health channels educational guidance which will help the child develop behavior essential to daily healthful living in the home, school, and community and assist him to become intelligently self-directive in matters of healthful living.”97 And it also meant, as the report explained, that “all phases of the program have important and indispensable contributions to make to the education of the school child.”98 Hence, while acknowledging both the legitimacy and desirability of schools’ providing periodic physical, mental, and dental exams; doing follow-up work; and making cheap nutritious meals available for purchase, the committee insisted that the character of these services “should be determined in accordance with the criterion that all health work in the school should be educational in character.”99 Indeed, the report defined the role of school doctors and nurses as primarily educational, declaring that “the function of the school medical service is not to make diagnosis or to give treatment, but to assist the school in its work of education.”100 In emphasizing the fundamentally educational character of all school health services, Wood and his committee drew a distinct line separating the preventive from the remedial and situated the responsibility of the school to the child on one side and that of parents on the other. In crossing that line, the committee asserted, the school health program not only exceeded the educational mandate of the school system of which it was part, but it also violated the right and responsibility of parents to provide for the welfare and well-being of their children. In a statement that would be quoted verbatim by school hygienists over the next several decades, the committee concluded: “The school health service should do nothing for the child that can be done effectively by the family, unless it is something done primarily to educate the child or his parents. Remedial or curative work should be left largely to the family, for, while the promotion of health is one of the cardinal objectives of the school health program, no service should be performed that takes away the fundamental privilege and

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responsibility of the home in relation to its children.”101 The message could not have been clearer. The role and responsibility of the school was to point out the road to child health and to instruct both children and their parents on how that road might be accessed and traveled. But it was not the school’s responsibility, nor even its place, to supply the material assistance and corrective services that were essential for many schoolchildren to journey to the road’s end.

Epilogue Contraction, Reorientation, and Revival

Although those involved in school health continued to discuss urban primary schools and schoolchildren, and to offer various proposals for improving the organization and operation of city school health programs, the shift in emphasis during the 1920s from detection and correction to prevention through education—along with the concomitant decentering of the physically defective urban schoolchild within the school hygiene gaze—effectively brought to an end the intense discursive negotiation, begun some six decades earlier, of the urban school’s relationship to the health of its pupils. At least a half-century would pass before child and adolescent health advocates would again look intently at the urban school’s daily capturing of a diverse and often medically underserved and unhealthy or at-risk population of young people as a prime opportunity to deliver needed health services—and, in so doing, initiate a renegotiation of the relationship of the public school to American child and youth health and healthcare delivery. The earlier negotiation left a legacy that was both significant and unsettled. It initiated a way of thinking about and analyzing education from a medical perspective and codified within American educational thought and practice the proposition that good health is both a product and a gauge of good education. Equally or perhaps more significant, it served as a site for the negotiated formulation of three foundational principles that defined the state’s responsibility for the health of the children for whom it was providing a compulsory education and framed discussion of the role of the urban school in protecting and promoting the health of its students. The first of these principles was that in creating a system of mass compulsory education, the state assumed a moral

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and legal responsibility for ensuring that school as both a place and a process did no physical or mental harm. Those involved in urban school health, like those in school health in general, would continue to study and debate how best to make the environment of the school healthy and safe. Indeed, they would eventually expand their conception of health to include the emotional and their conception of the environment to include the social. But they would not seriously question the value of achieving a healthy and safe environment or the state’s right and responsibility to pursue it. Similarly, those involved in school health would continue to study and debate how pedagogy and the school-day regimen could be formulated so as not to be inconsistent with or detrimental to the physical and mental development of schoolchildren. But, again, they would not question the soundness of doing so or express doubt that the state was responsible for ensuring that schooling did no damage to the health of those compelled to experience it. The second principle framing discussion of the urban school’s relation to child health was that a pedagogical commitment to educating the whole child, an assumed correlation between health and the ability to learn, and an equation of national health and well-being with the health and well-being of the nation’s children justified the state’s use of the public school to improve the health of the young. Little consensus, however, was achieved concerning what should be the nature of that use, and the debates over this question led to the negotiation and articulation of a third principle. This was that in using the school to improve health of the young, the state was necessarily constrained by the functions of the school accorded by law and tradition, by the rights and responsibilities of parents, and by the separate domains granted in the United States to public health and private healthcare. In essence, the school could and should take responsibility for educating both children and their parents in healthful behaviors, including the consumption of corrective medical and dental services. But it could not and should not be a major provider of those services or a primary site for their provision. To do so would be to make the school a clinic or hospital, would violate the sanctity of private practice, and would abrogate the principle that the primary responsibility for providing healthcare to children lay with their parents. These three principles served as the basis for a governing formula that significantly shaped and directed school health policy and activity during much of the mid and late twentieth century, a period when the delivery of organized health services in urban schools underwent contraction and reorientation and the health of city schoolchildren gradually disappeared as a sociomedical issue from public consciousness. However, this contraction and reorientation did

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not happen immediately, uniformly, or at an even pace. Rather, it proceeded slowly, unevenly, in fits and starts, and with periods of reversal. Contraction was far less pronounced in well-to-do small cities and exurbs like Evanston, Illinois, or Newton, Massachusetts, than it was in large cities and industrial towns. Moreover, not all health services contracted at the same rate or to the same degree. Required by law, medical inspection—particularly vision and hearing screening—persisted, though increasingly underfunded and considered even by its supporters as so cursory that it was close to useless and an inexcusable waste of money. Dental services—especially in those cities like Boston, Rochester, and New York, where the school systems had established formal relationships with large privately funded clinics—also survived to one degree or another well into the 1960s. Additionally, those services, like physical and health education and psychological screening and counseling, that could be most successfully incorporated into the core educational mission of the school actually experienced growth. Perhaps most significant, the policy of urban schools’ eschewing responsibility for the provision of remedial services was neither absolute nor unfailingly adhered to. Where educational screening ended and treatment began remained somewhat murky, especially in dental exams. Although in-school dental clinics were consistently characterized by school health officials as primarily preventive and educational, they continued to offer emergency remedial care and even some restorative procedures.1 Moreover, before the policy began to be renegotiated at the end of the century, it faced at least two serious, if ultimately unsuccessful, challenges. The Depression and School Health Programs

One of these challenges came during the Depression, when widespread impoverishment in urban areas and industrial towns pushed schools toward becoming relief agencies and healthcare providers. Schools initially responded to rising need among their students by working with voluntary, professional, and charitable organizations to revive and expand the semipublic patchwork of services that had been stitched together in the second decade of the century. In Chicago, the city dental society announced in the winter of 1930 that it would establish a number of roving dental clinics, staffed by society volunteers, to serve the school-age children of the unemployed and impoverished. In Milwaukee the county dental society did the same, as did dental societies in other cities. In New York, the Guggenheims opened their long-awaited clinic in 1931 and began offering free and reduced-cost dental care to children in the public primary schools on the Upper East Side.2 At the same time, the Red Cross, which since 1929 had been supplying free school lunches in drought-stricken

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agricultural areas, began doing so in a number of cities as well. Women’s clubs also got back into the business of providing lunches, either by doing so directly or by raising funds that they donated to the school lunch departments of municipal school systems. Newspapers established hungry children funds and channeled the donations they solicited to their local school systems. Parent-teacher associations, often with assistance from community chest funds, established clinics and purchased milk to be distributed in schools. Municipal governments also occasionally provided assistance, usually from mayoral discretionary funds or from relief funds. So too did a number of state governments.3 Major assistance also came from the school relief funds, established by both small and large cities and funded with ostensibly voluntary contributions—usually 1 to 3 percent of salary—from teachers and other school system employees. Created to ensure that a lack of adequate food or clothing would not discourage regular school attendance, the funds provided tens of thousands of city schoolchildren with lunches and with necessary clothing, most often shoes. In New York, for instance, the system’s 45,000 teachers had by the end of 1931 contributed over $1 million, which was used to provide daily rations of milk and crackers for thousands of students and to purchase and distribute 15,000 pairs of shoes. Six months later the amount contributed had risen to $2 million, and the fund was feeding 46,000 schoolchildren in over 450 schools.4 As the Depression deepened, however, the patchwork began to fray and come apart. With their incomes plummeting, dentists became decidedly less willing to volunteer their services and considerably more hostile to charity clinics that offered free dental care. Enthusiastically supporting the establishment of school dental clinics early in the Depression, members of the Chicago Dental Society later resoundingly rejected a Rosenwald Fund proposal to partner with them in increasing the number of clinics operating. The Chicago Daily Tribune reported at the time that the dentists feared that the clinics would further erode their already drastically shrunk patient rolls. Teachers too grew more hesitant to give, especially in those cities where their pay had been cut. Chicago’s school relief fund was all but depleted by 1933, and the New York City superintendent of schools took to pleading for donations by reminding teachers of their relative prosperity and job security. The hungry children’s funds also reported donations falling off, as did other civic and philanthropic organizations that had supported school feeding and health services.5 Increasing the impact of shrinking supplementary funding and services was a simultaneous reduction of school health services as the continued free fall of urban tax revenues forced cities to slash the budgets of their school and health departments. A National Municipal League survey revealed that by early

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1932, every one of the nation’s twenty-five largest municipalities was facing deficits and had or was about to cut all parts of its budget. Detroit, confronted with a $20 million decline in tax revenues, was considering slashing $5 million from school funding. Newark was looking at $2 million in cuts and New York at $6.5 million, a figure it raised to close to $7.8 million when it set its 1933 school budget. Hardest hit of all was Chicago, where budgetary mismanagement and declining tax revenues forced city officials to cut the school budget by nearly a third.6 For the most part, urban school systems responded to reduced funding by protecting the core academic subjects and the integrity of the school term, while slashing away at ancillary services and subjects. Particularly targeted were the social and health services that had become embedded in the schools, especially since World War I. Guidance counselors and school psychologists and social workers were let go, and their programs and clinics terminated. The ranks of physical education and recreation teachers were thinned out significantly, as were those of speech and orthopedic therapists. Medical inspection, dental, and nursing corps were further reduced or switched to part-time status. Since municipal health department budgets were being slashed as well, school medical and dental inspection staffs were also cut in those cities where the salaries of school doctors, dentists, nurses, and dental hygienists were paid with public health funds. In New York City, per capita municipal spending on public health decreased 27 percent between 1932 and 1934, having as one result a significant decline in the number of Health Department school medical and dental inspection staff. Indeed, by 1933 the city was down to just 53 school physicians, 15 school dentists, and 29 dental hygienists to deal with 765,000 elementary schoolchildren distributed over 635 school buildings.7 In the hope of offsetting some of the impact of the municipal budget cuts, school hygienists, like many others involved in the provision of urban social services, looked to the federal government. The plight of hungry schoolchildren had already been invoked by congressional progressives in their fight during the winter of 1931–32 to enact legislation that would allocate federal funding to assist localities in meeting their relief needs. Vigorously opposed by the Hoover administration, the legislation failed to pass, and no assistance was forthcoming. But with the election of Franklin Delano Roosevelt, school hygienists grew more optimistic. One of the Roosevelt administration’s first actions was to convene a Child Health Recovery Conference to determine what impact the Depression was having on the health of the nation’s young. Summarizing its findings, Secretary of Labor Frances Perkins admitted that the evidence was somewhat contradictory but suggested that it was reasonable to conclude that “somewhere in the neighborhood of one-fifth of all preschool and

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schoolchildren are showing the signs of poor nutrition, inadequate housing, and lack of medical care.”8 To help ameliorate the first, the Reconstruction Finance Corporation, which became a major New Deal agency, began loaning municipal school systems funds to furnish and equip cafeterias and lunchrooms. And to staff these new facilities, the Works Progress Administration supplied funding for the hiring of close to five thousand female lunch workers. Most important, after being authorized to do so by Congress in 1935, Roosevelt’s Department of Agriculture began purchasing surplus food commodities and distributing them to school systems throughout the nation, to be used in making inexpensive school lunches available. Although the commodities were sometimes difficult to transform into lunches that children would actually eat, school systems in all parts of the country quickly signed up for the service. By 1936 the Department of Agriculture claimed to be feeding some 350,000 children in 60,000 schools ranging across twenty states. And by 1942, when the program ended, an estimated five million children had received subsidized lunches for which they paid five to ten cents.9 Though it was not their primary intention, New Deal legislation and programs also served to offset somewhat the reductions of school nursing and medical and dental staffs carried out by most urban school systems as the Depression took hold. Title V of the Social Security Act, which was signed into law in August 1935, authorized funding to assist states and municipalities support general child health programs. Although little if any of this funding seems to have gone directly to schools, some of it did go to community health centers, which often used the money to hire additional physicians, dentists, and nurses and to offer such school-related health services as free school entrance medical exams and dental care for schoolchildren who had been identified as having oral defects in need of repair.10 Help also came from the Works Progress Administration, which, by granting exemptions to its eligibility requirements for relief, made it possible for municipal health departments to hire physicians and especially dentists, who were then loaned to school departments. Combined with the rise in school tax revenues that came with the limited economic recovery of the second half of the 1930s, this led to a partial restoration of medical and dental staffs and the reestablishment of school dental clinics throughout urban America. Indeed, a 1939 survey of dental services in the nation’s most heavily urbanized counties suggests that by the end of the Depression there were as many or more in-school dental clinics than there had been at the beginning. The survey, however, does not report how many children were being served or describe what sorts of services were being offered, though it

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does note that those clinics run by school departments offered far fewer remedial services than did those operated by health departments.11 Federally subsidized school lunches, though not free ones, outlived the Depression, finding continued life in the 1946 National School Lunch Act.12 Federally subsidized medical and dental services did not. Because they were intended as temporary emergency measures meant to counteract the effects of mass unemployment and economic deprivation, the New Deal programs that contributed to the maintenance and in some cases expansion of school health services came to an end when war-inspired economic activity pulled the nation out of the Depression. As a consequence, by 1942 those connected to urban school health programs were again emphasizing that the school’s role in improving child health lay primarily in teaching children healthy habits and in persuading their parents to assume their responsibility to provide not only needed medical and dental treatment but also periodic checkups. The need for such persuasion seemed especially urgent at the time because war preparations were pulling large numbers of young doctors and dentists into the armed services, thus drastically reducing the pool from which school health departments had historically drawn their medical and dental examiners.13 This forced school health departments to hire on a part-time or retainer basis physicians and dentists in private practice and to experiment with various methods for shifting the site of the screening exam from the school to the doctor or dentist’s office. One such method, adopted by a number of cities, was to work with the local dental and medical societies to build a rotating pool of practitioners who could be called on to examine a child referred by a teacher or nurse. Another, pioneered by New York City, was to forge agreements with dentists in private practice to provide free exams in their office with the understanding that they would be contracted to provide any necessary treatment. The result of both methods was to further the ongoing shift of schoolchildren’s health screening and care to the offices of private dental and medical practitioners.14 Chronic Failure

A second serious challenge to the policy of schools not offering remedial services and instead emphasizing prevention and the education of children and their parents in good health practices came from that policy’s chronic failure to achieve its goal: producing a population of students who were healthy and free from physical and mental defects. As always, the evidence of this failure lay in the accumulated medical and dental inspection records, which with depressing regularity continued to show the same discovered defects and the same low rates of correction. The initial response of those in school health to this

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continued evidence of failure was not to doubt the wisdom of an approach that combined screening with prevention and education, but to tweak it so that it might be more effective. Between 1932 and 1942, two major studies of urban school health practices were conducted in an attempt to produce recommendations for such tweaking. The first of these was carried out by the Research Division of the American Child Health Association, assisted by a grant from the Metropolitan Life Insurance Company. Conducted during the worst years of the Depression, the study aimed in part show how such programs could continue to promote and improve the health of schoolchildren despite shrinking budgets and declining personnel. But its stated main purpose was to discover why defects were not being corrected and to recommend how they might be. The problem, according to the study, was that in examining all children, health programs were trying to do too much with too little and, thus, were not doing anything effectively. To improve effectiveness, the study suggested that schools adopt a system of triage, employing teachers and nurses as initial screeners. Only those children observed as having the most serious and obvious health problems would be examined by physicians and dentists. This would afford the medical and dental examiners more time for each exam, provide nurses with more time to visit with and instruct the child and its parents, and limit the population of students recommended for treatment to a number that actually might be accommodated by existing clinics and private practitioners.15 A few years later, the second study, the influential Astoria Demonstration Study, offered similar recommendations while also offering a strong defense of existing school health policy and theory. The problem was not, the Astoria Study argued, that the preventive and educational approach was faulty, but rather that it had not really been fully implemented. Practice had not caught up to theory. What was needed was closer coordination between all components of the school health program, together with classroom teachers and private practitioners, to help the schoolchild and his or her parents appreciate the necessity of good health practices, including getting regular checkups and needed remedial dental and medical care.16 Nevertheless, criticism of the ineffectiveness of school health programs continued to grow, and during the latter years of World War II, it served to revive the Progressive Era idea of in-school remedial clinics and make that idea part of the postwar national discussion of what the government’s role should be in making healthcare more affordable and accessible. Concern over the cost and availability of healthcare had emerged in the 1920s and, by the 1930s, had led to several proposals for government assistance in establishing cooperative, nonprofit community health centers; increasing the supply and equalizing the geographic distribution of healthcare facilities and

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providers; and introducing health insurance as a means of financing healthcare. All these proposals were brought together in the discussions of a national health program that occupied a major place on the American political agenda from the mid-1930s through the early 1950s.17 Initially, schools and schoolchildren were not a significant part of these discussions. As David Tyack has noted, New Deal health and social service reformers seem to have had little faith that schools would deliver services to those children who needed them most. Hence, although the Social Security Act authorized funding for communities to improve their child health services, the funding was channeled to health departments and county and community health centers. Similarly, neither schools nor schoolchildren received much attention in The Need for a National Health Program, the report on national health care presented to Roosevelt in 1938 by his Interdepartmental Committee to Coordinate Health and Welfare Activities. Nor were they targeted by the National Health Bill, introduced the next year in Congress by Senator Robert F. Wagner, a New York Democrat.18 The absence of schools and schoolchildren from the national discussion on healthcare ended during World War II, as once again the release of data based on the medical exams of draftees cast a spotlight on the continuing prevalence of poor health and physical defects among the nation’s youth and thus the continuing failure of the schools to produce graduates who had sound minds in sound bodies. Particularly influential was a study of Hagerstown, Maryland, draftees, in which researchers compared the defects discovered for each inductee in the draft exams with those recorded a decade earlier in his school medical exam. In almost 70 percent of the cases, the defects were the same, indicating the failure of the screening and educational approach to convince parents of the necessity of purchasing the corrective medical services needed by their children.19 The Hagerstown study became a lightning rod for continuing frustration over the perceived ineffectiveness of school health programs and served to connect that ineffectiveness to problems in the larger healthcare system. Surgeon General Thomas Parran remarked: “This small pilot study crystallizes the record of school health inspections in every part of the country. Year after year, time and money are spent to ‘discover’ the same defects in the same appalling volume, [then] the discoveries are embalmed in the reports of health departments and school systems the country over. More significantly, the Hagerstown experience points to the fact that our medical care system is not meeting basic needs.”20 Among the initiatives mounted to involve school health programs in meeting those basic needs were several that sought to write and get Congress to consider legislation that would authorize federal funding to enable school health

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programs to offer treatment as well as screening and education. The result was that between 1946 and 1950, over a half-dozen versions of a bill seeking to authorize such funding were introduced into Congress. Although the versions varied in minor specifics and in the amount of funding sought, they were remarkably similar in describing their purpose as “providing for the general welfare by enabling the several states to make more adequate provision for the health of schoolchildren through the development of school health programs for the prevention, diagnosis, and treatment of physical and mental defects and conditions.”21 They also were remarkably similar in stressing that special attention would be directed at the detection and correction of defects that impeded physical and mental development and hindered a child’s ability to learn. Although ultimately passed by the Senate, the legislation failed in the House, victim of the postwar lobbying juggernaut that organized medicine launched against all proposed legislation that would establish government-supported medical service for any but the indigent and the military. In lobbying senators and testifying at hearings, representative of the American Medical Association objected strenuously to school health programs providing treatment, especially since such treatment was to be provided to all regardless of ability to pay. They also, quite successfully, characterized the proposals as representing a radical departure from existing school health policy, citing the many previously published assertions by school hygienists and their associations that the provision of remedial service is the responsibility of the family and should not be usurped by the school.22 The fate of the bills may have also have been determined by the qualified support they received from even those long committed to state involvement in improving the health of schoolchildren. State and national public health leaders testified in favor of federal funding for school clinics that offered treatment but argued that such funding should be channeled through state and municipal health departments and that the clinics should be located not in schools but in county and community health centers. Representatives of the National Education Association and the American Association for Health, Physical Education, and Recreation also testified in favor of the funding, while seeking to rechannel it by offering amendments that would direct a significant portion of the matching funds to expanding health and physical education programs in the schools. The associate director of the US Children’s Bureau offered detailed and graphic testimony of the sorry state of American schoolchildren’s health and the inability of many parents to purchase recommended medical and dental care but stopped short of supporting the placing of that care in schools. So too did Oscar Ewing, the Federal Security Administration director who was leading the Truman

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administration’s effort to design a national health program. Although he did not specifically oppose having treatment clinics in schools, Ewing believed a better alternative was providing health insurance to families so that parents could exercise their responsibility for the healthcare of their children by purchasing such care from private practitioners.23 Not coincidentally, that was also the position taken by the Special Committee on School Health that the US Federal Security Agency created and charged with defining guiding principles and priorities for school health programs. Composed of representatives of the Children’s Bureau, the Public Health Service, and the Office of Education, the committee produced a report identifying as the most basic of those principles that “parents have primary responsibility for the health of their children. Health service programs should be designed to assist parents in discharging this responsibility but not to assume it for them.” The report also recommended that the “fullest possible use should be made of the family physician and dentist,” and that “clinical facilities should not be set up in school buildings.”24 By the early 1950s, discussion of using schools as sites for the provision of remedial medical and dental services for children had all but ceased. Ensuring that it would remain so was a dramatic increase in the consumption of private medical and dental care for children. In part, this increase resulted from the postwar spread of private health insurance. But it was also and arguably to a greater extent the result of a significant change in the attitude of American parents regarding the necessity and desirability of providing their children with regular medical and dental care. Many of the men and at least some of the women who became parents in the 1950s had experienced the benefits of regular medical and dental care when they were in the armed forces during and after World War II. They thus came to parenthood more likely than any previous generation to purchase such care for their children. And purchase they did, significantly increasing the percentage of school-age children who regularly visited private practitioners. The increase was especially dramatic for dental care, with the proportion of American schoolchildren seen by a dentist at least once a year rising from a tiny fraction at the beginning of the 1950s to close to half by the end of the decade. At the same time the proportion of dental care for children provided by urban school clinics shrank significantly from the 6 percent that the American Academy of Pediatrics pegged it at in 1949. Hence, even though a majority of urban school systems continued to claim, when surveyed, that they offered some remedial dental services, the number of children at midcentury actually receiving those in-school services appears to have been both minimal and declining.25 Combined with improvements in corrective and preventive medicine and dentistry, including the introduction of fluoridation, the postwar boom in the

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consumption of private healthcare services had at least two major impacts on school health program practice and theory. First, it significantly decreased the number of children that school medical and dental screening identified as having untreated defects and conditions and thus reduced the concern that those in school health had historically shown about encouraging correction. Culminating a trend begun in the 1920s, the defective schoolchild slipped into invisibility, as promoting physical fitness and psychological and emotional health became dominant concerns of school health programs.26 Second, the increase in income for physicians and especially dentists that resulted from the boom further reduced whatever attraction school health service continued to hold for members of those two professions and hardened the general opinion that school-based services were both second rate and an infringement on private practice. In the postwar years school health officials complained that the low salaries they could offer made it increasingly difficult for them to hire school physicians and dentists. Indeed, no longer needing the employment opportunities that school health work offered, dentists joined their physician colleagues in opposing government-assisted healthcare and adopted a similar condescending attitude toward clinic dental care.27 During the 1960s, the years of decline and reorientation culminated in the virtual disappearance from urban schools of any corrective services. Urban school systems continued to screen for health problems and proper development, but this mostly involved record keeping, since the vast majority of examinations were done by private practitioners who then filled out forms that the school provided. Children who needed treatment and whose families could not afford to pay for it were channeled into a system of welfare medicine of which schools were definitely not a part. Indeed, there was seemingly wide agreement—even among people advocating government-assisted healthcare for medically underserved urban schoolchildren—that schools were inappropriate sites for the delivery of healthcare services. Hence, when health reformers in the War on Poverty era rediscovered economically disadvantaged urban schoolchildren and sought to increase their access to healthcare, they did so with two approaches that did not use schools in any significant way. One of these approaches was to make available private medical and dental care through needs-based Medicaid. The other was to bring healthcare close to where the children lived, by subsidizing neighborhood health centers. Only when these two approaches proved less successful than hoped would the urban school migrate back into the child health reformer gaze, and only then would Americans once again begin debating what role the urban school should play in improving the health of its students.

Notes

Introduction

1. E. M Gustafson, “History and Overview of School-Based Health Centers in the U.S.,” Nursing Clinics of North America 40 (2005): 595–606; Paul Brodeur, “School-Based Health Clinics,” in To Improve Health and Health Care 2000: The Robert Woods Johnson Anthology, ed. Stephen L. Isaacs and James R. Knickman (San Francisco: Jossey-Bass, 1999), 3–22. 2. Brodeur, “School-Based Health Clinics,” 4–9; Callie Shanafelt, “Putting Health Where Kids Trip Over It,” accessed May 14, 2012, http://www.healthycal.org/archives/8105; Health Resources and Services Administration, “School-Based Health Centers,” accessed May 18, 2012, http://www.hrsa.gov/ourstories/schoolhealthcenters; James Marone, Elizabeth Kilbreth, and Katherine Langwell, “Back to School: A Health Strategy for Youth,” Health Affairs 20 (2001): 122–27; Joy G. Dreyfus, “School-Based Health Centers in the Context of Educational Reform,” Journal of School Health 68 (1998): 404–8, and “Schools as Places for Health, Mental Health, and Social Services,” Teachers College Record 94 (1993): 540–67. 3. Michael Katz, In the Shadow of the Poor House: A Social History of Welfare in America, rev. ed. (New York: Basic, 1996), x. 4. See, for instance: Alisa Klaus, Every Child a Lyon: The Origins of Maternal and Infant Health Policy in the United States and France, 1890–1920 (Ithaca: Cornell University Press, 1993); Kimberly Johnson, Governing the American State: Congress and the New Federalism, 1877–1929 (Princeton: Princeton University Press, 2007), 136–55; Kriste Lendenmeyer, A Right to Childhood: The U.S. Children’s Bureau and Child Welfare, 1912–46 (Urbana: University of Illinois Press, 1997); Richard A. Meckel, Save the Babies: American Public Health Reform and the Prevention of Infant Mortality, 1850–1929 (Baltimore: Johns Hopkins University Press, 1990); Molly Ladd Taylor, Motherwork: Women, Child Welfare, and the State, 1890–1930 (Urbana: University of Illinois Press, 1994); Theda Skocpol, Protecting Soldiers and Mothers: The Political Origins of Social Policy in the United States (Cambridge: Belknap Press of Harvard University Press, 1992), 480–554. 5. S. Josephine Baker, Fighting for Life (New York: Macmillan, 1939), 149. On Sheppard-Towner, see Meckel, Save the Babies, 200–219; Johnson, Governing the American State, 136–55. On the maternalist politics of the Children’s Bureau, see Skocpol, Protecting Soldiers and Mothers, 480–554. For overviews of maternalism and the scholarship on it, see Seth Koven and Sonya Michel, eds., Mothers of the New World: Maternalist Politics and the Origins of the Welfare State (New York: Routledge, 1993); Patrick Wilkinson, “The Selfless and the Helpless: Maternalist Origins of the Welfare State,” Feminist Studies 25 (1999): 571–98. 6. John Duffy, “School Buildings and the Health of American School Children in the Nineteenth Century,” in Healing and History: Essays for George Rosen, ed. Charles Rosenberg (New York: Science History, 1979), 161–78; Lawrence Cremin, American Education: The Metropolitan Experience, 1876–1980 (New York: Harper and Row, 1988), 295; William J. Reese, Power and Promise of School Reform: Grassroots Movement during the Progressive Era (New York: Teacher’s College Press, 2002), 186–212;

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Michael W. Sedlak and Stephen Schlossman, “The Public School and Social Services: Reassessing the Progressive Legacy,” Educational Theory 35 (1985): 371–83; David Tyack, “Health and Social Services in Public Schools: Historical Perspectives,” Future of Children 2 (Spring, 1992): 19–31; William J. Reese, “After Bread, Education: Nutrition and Urban School Children, 1890–1920,” Teachers College Record 81 (1980): 496–525; Andrew R. Ruis, “School Meals and Nutrition Policy in the United States, 1900–1946” (PhD diss., University of Wisconsin, 2011); Martha Verbrugge, Active Bodies: A History of Women’s Physical Education in the Twentieth Century (New York: Oxford University Press, 2012). 1. Going to School, Getting Sick

1. Albert L. Gihon, “The Sanitary Responsibilities of the Citizen: An Address Delivered at the Opening of the Twelfth Annual Session of the American Public Health Association,” Public Health Papers and Reports 10 (1884): 7. 2. American Public Health Association, Committee on School Hygiene, “Report,” Public Health Papers and Reports 10 (1884): 503–6. 3. Gihon, “The Sanitary Responsibilities,” 15. 4. See William A. Alcott, Essay on the Construction of School-Houses to Which Was Awarded the Prize Offered by the American Institute of Instruction, August, 1831 (Boston: Hilliard, Gray, Little, and Wilkins, 1832); Horace Mann, Report of the Secretary of the Board of Education, on the Subject of School Houses Supplementary to His First Annual Report (Boston: Dutton and Wentworth, 1838); Henry Barnard, School Architecture; or, Contributions to the Improvement of School-Houses in the United States (New York: A. S. Barnes, 1848); Catherine E. Beecher, “The Health of Teachers and Pupils,” American Journal of Education 2 (1856): 399–408; John Duffy, “School Buildings and the Health of American School Children in the Nineteenth Century,” in Healing and History: Essays for George Rosen, ed. Charles Rosenberg (New York: Science History, 1979), 161–78. 5. For a comprehensive overview of European school hygiene activity and research during the 1860s, 1870s, and 1880s, see William H. Burnham, “Outline of School Hygiene,” Pedagogical Seminary 2 (1892): 9–71. Also instructive are Ludwig Kotelmann, School Hygiene, trans. John Bergstrom (Syracuse, NY: C. W. Bardeen, 1899); and Arthur Newsholme, School Hygiene: or the Laws of Life in Relation to School Life (Boston: D. C. Health, 1894). 6. US Department of Education, Office of Educational Research and Improvement, National Center for Education Statistics, 120 Years of American Education: A Statistical Portrait (Washington: Government Printing Office, 1993), 36, 59; US Bureau of Education, Report of the Commissioner of Education for the Year Ended June 30, 1880 (Washington: Government Printing Office, 1882), table 2; and Report of the Commissioner of Education for the Year Ended June 30, 1910 (Washington: Government Printing Office, 1911), vol. 2, table 24. On school expansion and the transformation of childhood, see Steven Mintz, Huck’s Raft: A History of American Childhood (Cambridge: Harvard University Press, 2006), 174; and David I. Macleod, The Age of the Child: Children in America, 1890–1920 (New York: Twayne, 1998), 75–77. 7. On American urban sanitary reform, see John Duffy, The Sanitarians: A History of American Public Health (Urbana: University of Illinois Press, 1990), 66–109. On Western medicine’s discovery of the child, see Richard A. Meckel, “Health and Science,” in A Cultural History of Childhood and Family in the Age of Empire, ed. Colin Haywood (Oxford: Berg, 2010), 178–85.

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8. By “medicalization,” I mean the process by which human behaviors and social activities and conditions are defined as medical conditions subject to the authority of health professionals and appropriate for a medical model of treatment. Articulated and elaborated by social scientists in the 1970s, the concept was first applied to American educational developments by Sol Cohen when he described the mental hygiene movement of the 1930s as initiating the medicalization of American schooling. See Renee Fox, “The Medicalization and Demedicalizatioon of American Society,” Daedalus 106, no. 1 (1977): 9–22; Sol Cohen, “The Mental Hygiene Movement, The Development of Personality and the School: The Medicalization of American Education,” History of Education Quarterly 23 (1983): 123–49; Peter Conrad, The Medicalization of Society: On the Transformation of Human Conditions into Medical Disorders (Baltimore: Johns Hopkins University Press, 2007). 9. Duffy, The Sanitarians, 139–45; Duffy, A History of Public Health in New York City, 1866–1966 (New York: Russell Sage Foundation, 1974), 213–15; Judith Walzer Leavitt, The Healthiest City: Milwaukee and the Politics of Health Reform (Princeton: Princeton University Press, 1982), 72; US Bureau of Education, “Hygiene in the Public Schools,” Report of the Commissioner of Education for the Year Ended June 30, 1877 (Washington: Government Printing Office, 1879), lix–lxv; David F. Lincoln, “Sanitation of Public Schools in Massachusetts,” Eighth Annual Report of the State Board of Health of Massachusetts, 1877 (Boston: Albert J. Wright,1878), 229–51. 10. Rochester Public Schools, Thirty-Second Annual Report of the Board of Education, 1874–1875 (Rochester, NY: Post, 1875), 59. See also US Bureau of Education, “Hygiene in the Public Schools,” lxii–lxiii; School Committee of the City of Providence, Special Committee on Health, Health and Education (Providence, RI: R. A. Reid, 1870); R. J. Sullivan, “Sanitary Superintendence of Public Schools of New York,” Sanitarian 1 (1873): 362–64; Philadelphia School District, Board of Public Education, Report of the Committee Appointed to Inquire into the Sanitary Condition of the Schools (Philadelphia: Markeley, 1875). 11. John Duffy, “Early Days of the School Health Movement,” Conspectus of History 1 (1981): 48. For a contemporary discussion of ventilating the House of Representatives’ chamber, see John L. Smithmeyer, An Essay on the Heating and Ventilation of Public Buildings: With Special Reference to the Senate and House of Representatives of the United States (Washington: R. O. Polkinhorn and Sons, 1886). 12. John D. Philbrick, City School Systems in the United States (Washington: Government Printing Office, 1885), 156–64; Forrest Noffsinger, “A Century of Progress in Schoolhouse Construction,” American School Board Journal 89 (December 1933): 39–40; William W. Cutler, “Cathedral of Culture: The Schoolhouse in American Educational Thought and Practice since 1820,” History of Education Quarterly 29 (1989): 5–7. 13. Forrest Noffsinger, “A Century of Progress in School Heating and Ventilation,” American School Board Journal 90 (July, September, and November 1935), 38–39, 37–38, 36. 14. Connecticut State Board of Education, Annual Report, 1874–75 (New Haven, CT: Tuttle, Morehouse, and Taylor, 1875), 54. 15. Quoted in US Bureau of Education, Report of the Commissioner of Education for the Year Ended June 30, 1873 (Washington: Government Printing Office, 1874), cxxx. 16. City of New York, Board of Health, Third Annual Report, 1872–1873 (New York: D. Appleton, 1873), 320–22; “School Poisoning in New York—A Suppressed Report,” Sanitarian 1 (1873): 193–95; Duffy, A History of Public Health in New York City, 215–16.

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17. “School Poisoning in New York,” 193–98; “Quack Ventilation for Public Schools,” Sanitarian 2 (1874): 37–40; Lewis Leeds, “New York City School Houses: A Further Examination into Their Unsanitary Condition,” Sanitarian 1 (1873): 371–77. 18. “Medical Inspection in the Schools of Boston,” Boston Medical and Surgical Journal 106 (1882): 330–32; “A Bill to Provide for the Sanitary Inspection of Schools,” ibid., 141; E. M. Wright, “School Hygiene,” Sanitary News 1 (1881): 260–65; A. L. Reed, “Dangers of the School-Room,” ibid., 169–74. 19. Philadelphia Board of Public Education, Sanitary Condition of the Schools, 19. 20. A. N. Bell, “Perils of the School Room,” Public Health Papers and Reports 2 (1874– 75): 283–91; US Bureau of Education, Report of the Commissioner of Education for the Year Ended June 30, 1873, cxxv; Leeds, “New York City School Houses,” 373– 74; Marvin Lazerson, Origins of the Urban School, 1870–1915 (Cambridge: Harvard University Press, 1971), 11–12. 21. City of Buffalo, Department of Public Instruction, Annual Report of the Superintendent of Education, 1881-1882 (Buffalo, NY: Haas and Kelly, 1883), 18. 22. D. F. Wright, “Report of the Committee on School Hygiene in Tennessee,” in Tennessee State Board of Health, Second Report, 1880–1884 (Nashville, TN: Albert B. Tavel,1885), 237; Baltimore Board of Commissioners of Public Schools, Forty-eighth Annual Report, 1875–1876 (Baltimore, MD: King Brothers, 1876), xxviii. 23. Alfred Carrol, “Preventable Sickness,” Sanitarian 3 (1875): 403–4. 24. New York Medico-Legal Society, Report of Special Committee on School Hygiene (New York: Terwilliger and Peck, 1876), 8–9. 25. Bell, “Perils of the Schoolroom,” 284; Richard A. Meckel, Save the Babies: American Public Health Reform and the Prevention of Infant Mortality, 1850–1929 (Baltimore: Johns Hopkins University Press, 1990), 15–16. For a detailed and representative contemporary explanation of the physiology of respiration, see Andrew Combe, The Principles of Physiology Applied to the Preservation of Health and the Improvement of Physical and Mental Education, 7th ed. (New York: Fowler and Wells, 1855), chapters 10–11. For a good overview of changing popular and medical attitudes toward fresh air, see Peter C. Baldwin, “How Night Air Became Good Air, 1776– 1930,” Environmental History 8 (2003): 412–29. 26. Noffsinger, “A Century of Progress in School Heating and Ventilation,” 38–39, 37– 38, 36; Noffsinger, “A Century of Progress in Schoolhouse Construction,” 39–40. 27. P. J. Higgins, “School Room Ventilation,” Popular Science Monthly 19 (1881): 534. See also Combe, The Principles of Physiology, 156–78; George T. Palmer, “What Fifty Years Have Done for Ventilation,” in A Half Century of Public Health, ed. Mazyck P. Ravenal (New York: American Public Health Association, 1921), 337–38; New York Commission on Ventilation, School Ventilation: Principles and Practices (New York: Teachers College Press, 1931), 1–2. 28. Bell, “Perils of the Schoolroom,” 289. 29. Quoted in Hermann Cohn, The Hygiene of the Eye in Schools, trans. W. P. Turnbull (London: Simpkin, Marshall, 1883), 29. 30. Diane D. Edwards, “Physiology of the Eye,” in The History of Ophthalmology, ed. Daniel M. Albert and Diane D. Edwards (Cambridge, MA: Blackwell Science, 1996), 126–32. 31. David Hosack and George Pearson, “Observations on Vision,” Philosophical Transactions of the Royal Society 84 (1794): 196–216; James Ware, “Observations Relative to the Near and Distant Sight of Different Persons,” ibid. 91 (1801): 31–50. Ware is still cited in ophthalmology texts today.

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32. Herbert Spencer, Education: Intellectual, Moral, and Physical (New York: D. Appleton, 1861), 23. See also Kotelmann, School Hygiene, 32; Mann, Report of the Secretary of the Board of Education, 71; Barnard, School Architecture, 47. 33. Cohn, The Hygiene of the Eye in Schools, 54–55. 34. Ibid., 53–54. 35. Ibid., 64–65. See also Hermann Cohn, “Eyes and School-Books,” Popular Science Monthly 19 (1881): 54–58. 36. Quoted in David F. Lincoln, “School Hygiene,” in Cyclopædia of the Practice of Medicine, ed. Hugo von Ziemssen (New York: William Wood, 1879), 19:606. See also Cohn, The Hygiene of the Eye in Schools, 71–77. 37. Cohn, “Eyes and School-Books,” 56. 38. Cohn devotes the second half of The Hygiene of the Eye in Schools to considering the impact on students’ eyes of school furnishings, lighting, sanitation, books, and print. 39. For lists of this research, see Cohn, The Hygiene of the Eye in Schools, 64–66; C. J. Randall, “Myopia in School Children,” American Journal of the Medical Sciences 90 (1885): 84–85. 40. Lincoln, “School Hygiene,” in Cyclopædia of the Practice of Medicine, 19:607. 41. For a translation of the report, see Rudolf Virchow, The Injurious Influences of the Schools: A Report, trans. John P. Jackson (New York: Miller, Haynes, 1871). 42. Henry W. Williams, Optical Defects in School Children: An Address before the Massachusetts Teachers’ Association at its Annual Meeting, October 17, 1868 (Boston: A. Mudge, 1869); Williams, “Optical Defects in School Children,” Boston Medical and Surgical Journal 79 (1868): 255–59; Hermann Cohn, “Nearsightedness in Children,” in Horace Mann, The Study of Physiology in Schools (New York: Schermerhorn, 1869), 145–52; Virchow, The Injurous Influences of the Schools; Foster J. Flint, “An Historical Study of Health Education in Massachusetts” (PhD diss., Boston University, 1954), 52–53. 43. Gary Dorrien, Social Ethics in the Making: Interpreting the American Tradition (Oxford: Wiley-Blackwell, 2009), 18. 44. Lincoln’s report, originally titled “The Health of Pupils in Public Schools,” was first delivered at the 1874 meeting of the American Social Science Association and again, after revisions, at the 1875 meeting. See David F. Lincoln, “Report on School Hygiene,” Journal of Social Science 8 (1875): 261–65, and “School Hygiene,” Sanitarian 3 (1875): 193–202. 45. Virchow, The Injurious Influences of the Schools, 1. 46. Boston School Committee, Annual Report, 1876 (Boston: Rockwell and Churchill, 1877), 102. Kotelmann made the same observation a few years later (School Hygiene, 32). 47. On the emergence of ophthalmology as a specialty, see especially George Rosen, The Specialization of Medicine with Particular Reference to Ophthalmology (New York: Froeben, 1944). See also Alvin A. Hubbell, The Development of Ophthalmology in America, 1800 to 1870 (Chicago: American Medical Association, 1908); Rosemary Stevens, American Medicine and the Public Interest (New Haven: Yale University Press, 1971), 98–114. 48. Cornelius R. Agnew, “The Importance of Science, and of Some of the Relations of the Medical Profession to Education,” Sanitarian 1 (1873): 8. On Agnew, see Julius Hirschberg, The History of Ophthalmology, trans. Frederick C. Blodi (Bonn: Weyenborgh, 1990), 9:109. 49. Ibid., 7.

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Notes to Pages 28–30

50. Ibid., 9. 51. Cornelius R. Agnew, “Near-Sightedness in the Public Schools,” Medical Record 12 (1877): 34; Edward G. Loring, “Are Progressive Myopia and Conus Due to Hereditary Predisposition, or Can They Be Induced by Defect of Refraction Acting through the Influence of the Ciliary Muscle?,” in Transactions of the International Medical Congress of Philadelphia, 1876, ed. John Ashhurst Jr. (Philadelphia: International Medical Congress, 1877), 33–38; Hasket Derby, “On the Prevention of Near-Sight in the Young,” Boston Medical and Surgical Journal 102 (1880): 533–35; Derby, “Influence, on the Refraction, of Four Years of College Life,” Transactions of the American Ophthalmological Society 2 (1879): 530–536; Derby, “A Report on the Percentage of Near-Sight Found to Exist in the Class of 1880 at Harvard College,” Boston Medical and Surgical Journal 96 (1877): 337–43; Samuel D. Risley, “Weak Eyes in the Public Schools of Philadelphia,” Transactions of the Medical Society of the State of Pennsylvania 13 (1881): 62–66. 52. Superintendent of the Buffalo Department of Education, “Report on Schools and School Hygiene,” in City of Buffalo, Department of Public Education, Annual Report of the Superintendant of Education, 1883–1884 (Buffalo, NY: Haas and Kelly, 1885), 75. See also, for instance, Birdsey G. Northrup, “Near-Sightedness in Schools: Its Causes, Prevalence, and Prevention,” in Connecticut State Board of Education, Annual Report, 1878 (Hartford, CT: Tuttle, Morehouse, and Taylor, 1879), 48–53; William J. Conklin, The Influence of School-Life on Eyesight, with a Special Reference to the Schools in Dayton (Dayton, OH: Board of Education, 1880). 53. Théodule Ribot, Heredity: A Psychological Study of Its Phenomena, Laws, Causes, and Consequences, 1st American ed. (New York: D. Appleton, 1875), 40. 54. Abner W. Calhoun, “Is Modern Education Exerting an Evil Influence upon the Eyesight of Your Children?” Atlantic Medical and Surgical Journal 15 (1878): 641–58. See also Edward G. Loring, “Is the Human Eye Changing Form and Becoming Nearsighted under the Influence of Modern Education?” Medical Record 12 (1877): 732–34. 55. Peter Callan, Examination of Coloured Schoolchildren’s Eyes (New York: Wood and Reilly, 1875), 5. 56. Lincoln, “School Hygiene,” in Cyclopædia of the Practice of Medicine, 19: 608. Lincoln was summarizing points made by Loring in “Is the Human Eye Changing Form and Becoming Nearsighted under the Influence of Modern Education?” 57. Daniel Bennet St. John Roos, “The Cure of Constipational Diseases in Children by Use of Glasses,” Medical Record 18 (1880): 393–98; Samuel D. Risley, “Relation of Headache to Affections of the Eye,” Journal of the American Medical Association 11 (1888): 757–59; Edward H. Hill, “Headache, Eyestrain, and Nervous Exhaustion,” New York Medical Journal 32 (1881): 55–61; Edward G. Loring, “The Influence of Vitiated Air and the Direction of Light on the Eyes,” Public Health 6 (1877): 359–62; Albert L. Rainey, “Eye Strain as a Cause of Epilepsy,” New York Medical Journal 64 (1897): 45–49; George T. Stevens, “Some Remarks on the Relations between Anomalous Refraction of the Eyes and Certain Functional Nervous Diseases,” Medical Record 11 (1876): 567–71; Henry W. Williams, The Diagnosis and Treatment of the Diseases of the Eye (Boston: Houghton, Mifflin, 1881), 72. 58. S. Weir Mitchell, “Headaches from Eyestrain,” American Journal of the Medical Sciences 71 (1876): 363–67. On the late-nineteenth-century discovery of childhood mental disorders, see Kathleen Jones, “‘A Sound Mind for a Child’ Body: The Mental Health of Children and Youth,” in Children and Youth in Sickness and Health, ed. Janet Golden, Richard A. Meckel, and Heather Munro Prescott (Westport, CT:

1-50 1-51 1-52 1-53 1-54 1-55 1-56 1-57 1-58

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Notes to Pages 30–34

30 31 31 32 32 32 32 33 33 34

59. 60. 61.

62.

63.

64.

65.

66.

67. 68.

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Greenwood, 2004), 43–59. On the origins of neurology as a specialty and its embrace of a somatic concept of nervous disease, see Francis G. Gosling, Before Freud: Neurasthenia and the American Medical Community, 1870–1910 (Urbana: University of Illinois Press, 1987), 15–20. David F. Lincoln, “The Nervous System as Affected by School Life,” Sanitarian 3 (1875): 197. “Our Overworked School Children,” Frank Leslie’s Illustrated Newspaper, November 11, 1882, 185–87. R. F. Edes, “High Pressure Education: Its Effects,” Boston Medical and Surgical Journal 106 (1882): 221; G. S. Stebbins, “The Diseases and Dangers Incident to SchoolLife,” ibid., 555; quoted in William Blaikie, “Is American Stamina Declining?” Harper’s Magazine 79 (1889): 242–43. A. N. Bell, “The Physiological Condition and Sanitary Requirements of School-Life and School Houses,” Sanitarian 23 (1889): 347. This idea had been part of the AngloAmerican discourse on education at least since the 1860s, when Herbert Spencer had warned against overworking the brain by reminding readers that “Nature is a strict accountant; and if you demand of her in one direction more than she is prepared to lay out, she balances the account by making the deduction elsewhere” (Education, 268). W. J. Conklin, “The Influence of Public Schools on Brain Building,” Journal of the American Medical Association 2 (1884): 258. See also Philip Coombs Knapp, “The Influence of Overwork in School in the Production of Nervous Diseases in Childhood,” Boston Medical and Surgical Journal 85 (1896): 37–39. On the discourse on overwork and overstudy in the nineteenth and early twentieth centuries, see John Duffy, “Mental Strain and ‘Overpressure’ in the Schools: A Nineteenth-Century Perspective,” Journal of the History of Medicine and Allied Sciences 23 (1968): 63–79; Gail Gaisin Glicksman, “Overstress among American School Children, 1840–1920” (PhD diss., University of Pennsylvania, 1997); Joseph Kett, “Curing the Disease of Precocity,” in Turning Points: Historical and Sociological Essays on the Family, ed. John Demos and Sarane Spence Bookcock (Chicago: University of Chicago Press, 1978), 183–211; A. Brian Gill and Steven Schlossman, “‘A Sin against Childhood’: Progressive Education and the Crusade to Abolish Homework, 1897–1941,” American Journal of Education 105 (November 1996): 27–66. Carl F. Kaestle and Maris A. Vinovskis, Education and Social Change in NineteenthCentury Massachusetts (New York: Cambridge University Press, 1980), 56–61; Howard P. Chudacoff, How Old Are You? Age Consciousness in American Culture (Princeton: Princeton University Press, 1989), 33–34; Kett, “Curing the Disease of Precocity,” 187–90; Jones, “‘A Sound Mind for a Child’ Body,” 44; Duffy, “Mental Strain and ‘Overpressure’ in the Schools,” 65–66; Glicksman, “Overstress among American School Children,” 111–14. Edward H. Clarke, Sex in Education; or, A Fair Chance for Girls (Boston: J. R. Osgood, 1873). On overstudy and the coeducation debate, see David Tyack and Elisabeth Hansot, Learning Together: A History of Coeducation in American Public Schools (New York: Russell Sage Foundation, 1992), 146–55; Crista DeLuzio, Female Adolescence in American Scientific Thought, 1830–1930 (Baltimore: Johns Hopkins University Press, 2007), 50–89. Lincoln, “The Nervous System as Affected by School Life,” 196; A. N. Ellis, “Relations of Insanity to Modern Civilization,” Sanitary News 1 (1881): 137. G. S. Stebbins, “The Diseases and Dangers Incident to School-Life,” Boston Medical and Surgical Journal 106 (1882): 553–55; “Headache and Neuralgia in School

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70.

71.

72.

73. 74. 75. 76. 77.

Notes to Pages 34–39

Children,” Sanitary News 1 (1881): 95. On Jacobi and the origins of American pediatrics, see Sydney Halpern, American Pediatrics: The Social Dynamics of Professionalism, 1880–1930 (Berkeley: University of California Press, 1988), 35–56; Russell Viner, “Abraham Jacobi and the Origins of Scientific Pediatrics in America,” in Formative Years: Children’s Health in the United States, 1880–2000, ed. Alexandra Minna Stern and Howard Markel (Ann Arbor: University of Michigan Press, 2002), 23–46. Dr. [Neils Theodor Axel] Hertel, Overpressure in High Schools in Denmark, trans. C. Godfrey Sorenson (London: Macmillan, 1885); Burnham, “Outline of School Hygiene,” 65–66; Anson Rabinbach, The Human Motor: Energy, Fatigue, and the Origins of Modernity (New York: Basic, 1990), 147; J. Middleton, “The Overpressure Epidemic of 1884 and the Culture of Nineteenth-Century Schooling,” History of Education 33 (2004): 419–35; “Overpressure in Schools,” Science 4 (1884): 497–98. The best comprehensive biography of Hall remains Dorothy Ross, G. Stanley Hall: The Psychologist as Prophet (Chicago: University of Chicago Press, 1972). On Hall and child study, see ibid., 279–308; Leila Zenderland, “Education, Evangelism, and the Origins of Clinical Psychology: The Child Study Legacy,” Journal of the History of Behavioral Sciences 24 (1988): 152–65. Ross, G. Stanley Hall, 279–308; Carita Constable Huang, “Making Children Normal: Standardizing Children in the United States, 1885–1930” (PhD diss., University of Pennsylvania, 2004), 109, 195–96; J. M Tanner, Galtonian Eugenics and the Study of Growth: The Relation of Body Size, Intelligence Test Score, and Social Circumstances in Children and Adults,” Eugenics Review 58 (1966): 122–25; William T. Porter, “The Physical Basis of Precocity and Dullness,” Transactions of the Academy of Science of St. Louis 6 (1893): 161–81. While Freud addressed his five lectures on psychoanalysis exclusively to the members of the Psychology Department and attending psychologists, Jung delivered three lectures to the educators on the role of mental hygiene in school hygiene. For his efforts, Clark awarded him a Doctor of Letters in Education and School Hygiene. See Clark University, “Freud Centennial History: Psychology, Pedagogy and School Hygiene, September 6–11, 1909,” accessed November 10, 2010, http://www.clarku .edu/micro/freudcentennial/history/1909psych.cfm; Twentieth Anniversary (Worcester, MA: Clark University, 1909); Lectures and Addresses before the Departments of Psychology and Pedagogy in Celebration of the Twentieth Anniversary of the Opening of Clark University, September 1909 (Worcester, MA: Clark University, 1909), vii. Burnham, “Outline of School Hygiene,” 9. Ibid., 65. G. Stanley Hall, “School Hygiene,” Pedagogical Seminary 1 (1892): 8. Burnham received his PhD at Johns Hopkins under Hall before following him to Clark. Abraham Jacobi, “The Relations of Pediatrics to General Medicine,” Transactions of the American Pediatric Society 1 (1889): 15. Joseph M. Rice, The Public School System in the United States (New York: Century, 1893). See also Lawrence Cremin, American Education: The Metropolitan Experience, 1876–1980 (New York: Harper and Row, 1988), 228.

2. Incubators of Epidemics

1. Henry Dwight Chapin, “Crowded Schools as a Promoter of Disease,” Forum, May, 1895, 299. 2. See, for instance, H. B. Baker, “The Relations of Schools to Diphtheria and to Similar Diseases,” Sanitarian 9 (1881): 68–82; J. A. Larrabee, “The Schoolroom: A Factor in

1-69 34 1-70 35 1-71 35 1-72 36 1-73 36 1-74 36 1-75 36 1-76 37 1-77 37 2-1 38 2-2 39

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Notes to Pages 40–44

3.

4.

5.

6.

7.

8.

9.

10. 11. 12.

13. 14.

15. 16.

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the Production of Disease,” Journal of the American Medical Association 11 (1888): 613–14; Morris Moreau, “Infectious Diseases in Public Schools,” Sanitarian 34 (1895): 497–507; Gardner Swarts, “The Control of Epidemic Diseases,” Journal of the American Medical Association 14 (1890): 496–99. Harry F. Dowling, Fighting Infection (Cambridge: Harvard University Press, 1977), 58– 59; Anne Hardy, The Epidemic Streets: Infectious Disease and the Rise of Preventive Medicine, 1856–1900 (Oxford: Clarendon Press of Oxford University Press, 1993), 16, 57–59; Hardy, “Scarlet Fever,” in The Cambridge Historical Dictionary of Disease, ed. Kenneth F. Kiple (New York: Cambridge University Press, 2003), 990–92. Anthony S. Wohl, Endangered Lives: Public Health in Victorian England (Cambridge: Harvard University Press, 1983), 128–29; Hardy, The Epidemic Streets, 56–59. H. B. Horlbeck, “Scarlet Fever as It Affected the White and Colored Race, Comparatively in Charlestown, S.C. during the Summer and Spring, 1881,” American Public Health Association, Reports and Papers 7 (1881): 291–92. In his memoir, Britain’s Arthur Newsholme noted that he found the continued fear surprising: “Scarlet fever has undoubtedly become a much milder disease. Such terrible cases as I saw in the period of 1881–90 now seldom occur” (Fifty Years in Public Health [London: G Allen and Unwin, 1935], 180). Dowling, Fighting Infection, 18–21; Ann G. Carmichael, “Diphtheria,” in The Cambridge World History of Human Disease, ed. Kenneth F. Kiple (New York: Cambridge University Press, 1993), 680–83. Carmichael, “Diphtheria,” 681; Henry B. Baker, “The Relations of Schools to Diphtheria and to Similar Diseases,” American Public Health Association, Reports and Papers 6 (1880): 111. Evelyn Hammonds, Childhood’s Deadly Scourge: The Campaign to Control Diphtheria in New York City, 1880–1930 (Baltimore: Johns Hopkins University Press, 1999), 21, 29. Abraham Jacobi was the author of a widely respected text on the prevention and management of diphtheria, A Treatise on Diphtheria (New York: William Wood, 1880). On the issue of carriers, see Hammonds, Childhood’s Deadly Scourge, 139–65. Charles B. White, “Presidential Address,” American Public Health Association, Papers and Reports 7 (1881): 241. Jerome Walker, “The Need for Sanitary Supervision of Schools,” Sanitarian 30 (1893): 194. See also Jozsef Korosi, Statistique Internationale Grande Ville (Paris: Congres Internationale de Statistique, 1876); Ludwig Kotelmann, School Hygiene, trans. John A. Bergstrom (Syracuse, NY: C. W. Bardeen, 1899), 320–30; Bernard Harris, The Health of the Schoolchild: A History of the School Medical Service in England and Wales (Buckingham, UK: Open University Press, 1995), 37–38; Samuel H. Durgin, “One Year’s Experience in the Medical Inspection of Schools and the Supervision over the Isolation and Release of Infected Persons,” Boston Medical and Surgical Journal 134 (1896): 360–61. Hardy, The Epidemic Streets, 50. Arthur Newsholme, School Hygiene, or the Laws of Health in Relation to School Life (Boston: D. C. Heath, 1887), 124–25; Massachusetts Association of Boards of Health, Report of the Quarterly Meeting 3 (1893): 4. Baker, “The Relations of Schools to Diphtheria,” 133. On the propagation and growing professional and public acceptance of the germ theory in America in the late nineteenth and early twentieth centuries, see Nancy

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18. 19. 20.

21.

22.

23. 24.

25. 26.

27. 28.

29. 30.

31. 32. 33.

Notes to Pages 45–48

Tomes, The Gospel of Germs: Men, Women, and the Microbe in American Life (Cambridge: Harvard University Press, 1998). “The Health of School Children,” in US Bureau of Education, Report of the Commissioner of Education for the Year 1890–’91 (Washington: Government Printing Office, 1894), 2:1043; William H. Burnham, “Outline of School Hygiene,” Pedagogical Seminary 2 (1892): 36–37. Moreau Morris, “Infectious Diseases in Public Schools,” Sanitarian 34 (1895): 497. Quoted in William J. Reese, Power and the Promise of School Reform: Grassroots Movements during the Progressive Era (New York: Teachers College Press, 2002), 49. Morris, “Infectious Diseases in Public Schools,” 498–501; Alice Upton Pearmain, “The Boston Schools: A Sanitary Investigation,” Municipal Affairs 2 (September 1898): 500; Burnham, “Outline of School Hygiene,” 33; Tomes, The Gospel of Germs, 96–98; “The Danger of Dust in School Rooms: How It Can Be Reduced Nearly One Hundred Percent,” School Hygiene 1 (1908): 37. As Stuart Galishoff and a number of other public health historians have noted, the discovery that germs could not survive in a toxic environment led to something of a mania for disinfectants. See Galishoff, Safeguarding the Public Health (Westport, CT: Greenwood, 1975), 33–34. See also Tomes, The Gospel of Germs, 76–77. A. N. Bell, “Sanitary Inspection,” Sanitarian 8 (1882): 34. For a discussion of the adoption of disinfection in hospitals, see Charles E. Rosenberg, In the Care of Strangers: The Rise of America’s Hospital System (New York: Basic, 1987), 143–47. Tomes, The Gospel of Germs, 36–37, 60–61. The editors of the Boston Medical and Surgical Journal reprised a number of the most popular stories in “The Contagiousness of Scarlet Fever, Diphtheria, and Some Other Common Diseases,” Boston Medical and Surgical Journal 124 (1891): 243–44. Andrew McClary, “Beware of the Deadly Books: A Forgotten Episode in Library History,” Journal of Library History 20 (1985): 427–33. Quoted in “One Dangerous Phase of State Socialism,” Atlantic Constitution, January 17, 1900. For a contemporary discussion of books as transmitters of disease, see “Disease in Second Hand Books,” in US Bureau of Education, Report of the Commissioner of Education for the Year Ended June 30, 1900 (Washington: Government Printing Office, 1900), 2:2548–86. Alvin Davison, “Death in School Drinking Cups,” Technical World Magazine 9 (1908): 625. Fletcher B. Dressler, School Hygiene (New York: Macmillan, 1913), 113–16. For a contemporary discussion, see J. W Kerr and A. A. Moll, Common Drinking Cups and Rolling Towels (Washington: Government Printing Office, 1912). Quoted in “Sanitary Defects in the Public School Buildings and the Public School System of New York,” Sanitarian 24 (1890): 230. Henry Sabin, “The Doctor and the School,” Education 17 (1896): 133. See also “Foreign Miscellanies,” Pedagogical Seminary 1 (1891): 303; W. L. Schenk, “Personal Hygiene in the Schools,” Journal of the American Medical Association 17 (1891): 864–65. Sabin, “The Doctor and the School,” 132. S. Josephine Baker, Fighting for Life (New York: Macmillan, 1939), 77–79. Quoted in Hannah Clark, “Sanitary Legislation Affecting Schools in the United States,” in US Bureau of Education, Report of the United States Commissioner of Education for the Year 1893–’94 (Washington: Government Printing Office, 1896), 2:1302–3. Cities that adopted similar legislation included Baltimore, Chicago, Des Moines, Detroit, and Jersey City.

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49 49 49 49 50 50 50 50 51 51 51 52 52 52 53 53 53 54

217

34. Marilyn T. Williams, Washing the Great Unwashed: Public Baths in Urban America, 1840–1920 (Columbus: Ohio State University Press, 1991), 54–55; School Committee of the City of Providence, Annual Report of the School Committee of the City of Providence, 1912/1913 (Providence, RI: Providence Press, 1913), 58. 35. A short but informative contemporary discussion of de novo versus direct infection can be found in Robert Farquharson, School Hygiene and Diseases Incidental to School Life (London: Smith, Elder, 1885), 241–42. 36. “Protection of School Children,” Sanitarian 3 (1875): 45. 37. “Medical Inspection of the Public Schools of Boston,” Boston Medical and Surgical Journal 106 (1882): 330. 38. “Restriction and Prevention of Diphtheria,” in Michigan State Board of Health, Sixth Annual Report of the Secretary of the State Board of Health (Lansing, MI: W. S. George, 1878), 86–89. 39. Charles V. Chapin, “History of State and Municipal Control of Disease,” in A Half Century of Public Health, ed. Mazyck P. Ravenal (New York: American Public Health Association, 1921), 143–44; “Quarantining School-Children after Having Contagious Diseases,” Medical and Surgical Reporter 58 (1888): 306–7; Galishoff, Safeguarding the Public Health, 29–32. 40. Massachusetts Emergency Hygiene Association, Six Lectures on School Hygiene (Boston: Ginn, 1886), 100. 41. Quoted in Clark, “Sanitary Legislation Affecting Schools,” 1312. 42. Quoted in ibid., 1311. 43. Quoted in ibid., 1315. 44. Quoted in ibid., 1343. See also City of Providence, Annual Report of the Superintendant of Health, 1885 (Providence, RI: Snow and Farnham, 1885), 15. 45. “Report of the Committee on School Hygiene,” Public Health Papers and Reports 27 (1901): 261–79; Marvin Lazerson, Origins of the Urban School: Public Health in Massachusetts, 1870–1915 (Cambridge: Harvard University Press, 1971), 11–12; Diane Ravitch, The Great School Wars, New York City, 1805–1973 (New York: Basic, 1974), 115; John D. Philbrick, City School Systems in the United States (Washington: Government Printing Office, 1885), 155. 46. “Recent Investigations Relating to the Prevention of Diphtheria and Scarlet Fever,” Boston Medical and Surgical Journal 126 (1892): 368; Massachusetts Association of Boards of Health, Report of the Quarterly Meeting 4 (1895): 13–14; Lillian D. Wald, “Medical Inspection of Public Schools,” Annals of the American Academy of Political Science 25 (1905): 290. 47. “Medical Inspection of the Public Schools of Boston,” 330–31. See also C. O Probst, “How May School Children Be Protected against Contagious Disease,” Monthly Sanitary Record 3 (1890): 301–4; Swarts, “The Control of Epidemic Diseases,” 497; K. C. Hurd, “The Necessity of Having Medical Directors for Our Public Schools,” Medical Journal of Baltimore 28 (1892–93): 441–50. 48. “Recent Investigations,” 369; J. Lewis Smith, “Prevention of Diphtheria,” Journal of the American Medical Association 21 (1893): 850. 49. “Report of the Committee on School Hygiene,” 262–63. 50. G.H.M. Rowe, “On the Necessity of More Stringent Laws and Stricter Enforcement of Existing Ones for Public Health,” Boston Medical and Surgical Journal 122 (1890): 169–74; Dowling, Fighting Infection, 23–24. 51. O. C. DeWolf, “The Results of Attempting to Check the Spread of Smallpox in Chicago,” American Public Health Association, Papers and Reports 6 (1880): 81–87. On

218

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53.

54. 55.

56. 57.

58.

59.

60.

61.

62.

63.

Notes to Pages 54–57

resistance to vaccination among immigrant communities, see Judith Walzer Leavitt, The Healthiest City: Milwaukee and the Politics of Health Reform (Princeton: Princeton University Press, 1982), 81–85; Stuart Galishoff, Newark, the Nation’s Unhealthiest City, 1832–1895 (New Brunswick, NJ: Rutgers University Press, 1975), 154–55. John Duffy, “School Vaccination: The Precursor to School Medical Inspection,” Journal of the History of Medical and Allied Sciences 33 (1978): 344–48. On European policy, see E. P. Hennock, “Vaccination Policy against Smallpox, 1835–1914: A Comparison of England with Prussia and Imperial Germany,” Social History of Medicine 11 (1998): 49–71. “Requirements by School Boards of Certain Cities as to the Vaccination of School Children,” in US Bureau of Education, Report of the Commissioner of Education for 1894–95 (Washington: Government Printing Office, 1897), 1:207; Clark, “Sanitary Legislation Affecting Schools,” 1301–49. Quoted in Clark, “Sanitary Legislation Affecting Schools,” 1329. Ibid., 1340; Duffy, “School Vaccination,” 347. Indeed, when Elmira, New York, became the first American city to hire a full-time school physician, in 1872, it did so with the intent of having him enforce the municipal statute excluding unvaccinated children from schools. See James Frederick Rogers, “Health Services in City Schools,” in Biennial Survey of Education in the United States, 1938–40 (Washington: Government Printing Office, 1942), 1:1. John Duffy, The Sanitarians: A History of American Public Health (Urbana: University of Illinois Press, 1990), 140–45. Durgin, “One Year’s Experience,” 360; Boston School Committee, Annual Report, 1891 (Boston, 1891), 27–30; “Boston Society for Medical Improvement,” Boston Medical and Surgical Journal 134 (1896): 366–68. Quoted in “Boston Society for Medical Improvement,” 366. The concerns of the physicians on the committee were not unjustified, since treating a child’s disease or disorder often introduced a physician to a family who would become patients. Durgin, “One Year’s Experience,” 361; “Boston Society for Medical Improvement,” 366–67; “Report of the Committee on School Hygiene,” 265; Edith Lindsay, “Origins and Development of the School Health Movement in the United States” (PhD diss., Stanford University, 1943), 346. It appears that all the physicians appointed as medical inspectors by Boston in 1894 were men. However, as medical inspection spread to other cities, women physicians soon entered the ranks as inspectors, in part because the jobs were initially filled by physicians at the margin of the profession who needed to supplement their incomes. For instance, S. Josephine Baker began her public health career as a school medical inspector (Fighting for Life, 56–57). Durgin, “One Year’s Experience,” 362; George H. Martin, “Medical Inspection in the Public Schools of Massachusetts,” in Seventy-Fourth Annual Report of the Board of Education of Massachusetts, 1911 (Boston: Wright and Potter, 1912), 165–70. The best discussion of turn-of-the-century child death rates in the United States by cause is in Samuel H. Preston and Michael R. Haines, Fatal Years: Child Mortality in Late Nineteenth-Century America (Princeton: Princeton University Press, 1991), 3–48. See especially table 1.1. W. S. Christopher, “Medical Inspection in the Public Schools,” in Proceedings and Addresses of the Annual Meeting of the National Education Association, 1901 (Chicago: National Education Association, 1901), 236–37; “Medical Inspection,” in Report and Handbook of the Department of Health of the City of Chicago for the

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Notes to Pages 57–63

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57 58 58 59 59 60 60 61 61 61 62 62 63 63

64.

65. 66.

67. 68.

69.

70.

71.

72. 73. 74.

75.

76.

77.

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Years 1911–1918 Inclusive (Chicago: Severinghaus, 1919), 491–92; Luther Halsey Gulick and Leonard P. Ayres, Medical Inspection of Schools (New York: Charities Publication Committee, 1908), 24; Allson Hepler, “Public Health, Professionalism, and Public Education: School Nursing in Philadelphia,” unpublished paper, 7–9; Edward T. Morman, “Scientific Medicine Comes to Philadelphia: Public Health Transformed, 1854–1899” (PhD diss., University of Pennsylvania, 1986), 219. John Duffy, A History of Public Health in New York City, 1866–1966 (New York: Russell Sage Foundation, 1974), 218–19; Wald, “Medical Inspection of Public Schools,” 291–92. Gulick and Ayres, Medical Inspection of Schools, 25–27. Durgin, “One Year’s Experience,” 360. See also “Report of the Committee on School Hygiene,” 262; Severance Burrage, “Medical Inspection of School Children,” in Proceedings and Addresses of the Annual Meeting of the National Education Association, 1898 (Chicago: National Education Association, 1898), 541. Hepler, “Public Health,” 11–12; Gulick and Ayres, Medical Inspection of Schools, 26–27; Leavitt, The Healthiest City, 73. Chicago Department of Health, Biennial Report of the Department of Health of the City of Chicago for 1897 and 1898 (Chicago: Cameron and Amberg, 1899), 12–13, 15–16; Christopher, “Medical Inspection in the Public Schools,” 236–37; Charles V. Chapin, Medical Inspection of the Schools of Providence (Ansonia, CT” Emerson, 1909), 3–6. Gulick and Ayres, Medical Inspection of Schools, 29; Durgin, “One Year’s Experience,” 360–61; Baker, Fighting for Life, 56–57; “Report of the Committee on School Hygiene,” 260–64; “Medical Inspection of Schools,” in US Bureau of Education, Report of the Commissioner of Education for the Year 1897–98 (Washington: Government Printing Office, 1899), 2:1489–511. On the development of throat culturing and its promise for identifying schoolchildren and others infected with diphtheria, see Hammonds, Childhood’s Deadly Scourge, 46–87. Leonard P. Ayres and May Ayres, Health Work in the Public Schools (Cleveland: Survey Committee of the Cleveland Foundation, 1915), 41; Chicago Department of Health, Biennial Report for 1897 and 1898, 19. Durgin, “One Year’s Experience,” 360. Edward M. Greene, “Pediculosis in Boston’s Public Schools,” Boston Medical and Surgical Journal 138 (1898): 70. Lydia Gardner Chace, “What Medical Inspection Means in New York Schools,” Charities 10 (1903): 409; New York City Health Department, Annual Report of the Board of Health of the Department of Health of the City of New York, 1903 (New York: D. Appleton, 1905), 10–11. Baker, Fighting for Life, 79; Lina L. Rogers, “The Physician and the Nurse in the Public School,” in Proceedings of the National Conference of Charities and Corrections, 1905, ed. Alexander Johnson (Columbus: Fred J. Heer, 1905), 275. Wald, “Medical Inspection of Public Schools,” 291–93; Honor Morton, “School Nurses in England,” Charities and the Commons 16 (April 7, 1906): 62–65; Lina L. Rogers, “A Year’s Work for the Children in the New York Schools,” American Journal of Nursing 4 (1903–4): 181–84. Lindsay, “Origins and Development,” 413–14; Patricia Ann Regan, “A Historical Study of the Nurse’s Role in School Health Programs, 1902–1973” (EdD diss., Boston University, 1974), 32–37.

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Notes to Pages 63–68

78. For a description of the meeting, including quotes and paraphrases of the comments of those attending, see “Boston Society for Medical Improvement,” 367. 79. W. B. Powell, “Medical Inspection of Schools,” in Proceedings and Addresses of the Annual Meeting of the National Education Association, 1898 (Chicago: National Education Association, 1898), 459–61. 80. Providence Board of Health, Annual Report of the Superintendant of Health of the City of Providence, 1898 (Providence, RI: Farnham and Snow, 1898), 29. 81. Quoted in “In Sanitary Boston: Entrance Exam Proposed for Admittance to Public School,” Journal of the Medical Society of New Jersey 2 (1905–6): 293. 82. “Report of the Committee on School Hygiene,” 263–64; Reese, Power and the Promise, 201–8. 83. Quoted in James A. Tobey, Public Health Law (Baltimore: Williams and Wilkins, 1926), 86–87. 84. Quoted in Martin Kaufman, “The American Anti-Vaccinationists and the Arguments,” Bulletin of the History of Medicine 41 (1967): 471. For good overviews of the American vaccination controversy during the Progressive Era, see Michael Willrich, ‘“The Least Vaccinated of Any Civilized Country’: Personal Liberty and Public Health in the Progressive Era,” Journal of Policy History 20 (2008): 76– 93; James Colgrove, State of Immunity: The Politics of Vaccination in TwentiethCentury America (Berkeley: University of California Press, 2006), 17–44. For a complementary overview of English antivaccination agitation in the late nineteenth and early twentieth centuries, see Nadja Durbach, Bodily Matters: The Anti-Vaccination Movement in England, 1853–1907 (Durham, NC: Duke University Press, 2005). 85. Quoted in “Complaints on Schools Told: Parents’ Letters to League Protest Chiefly on Medical Inspection,” Chicago Daily Tribune, December 30, 1916. 86. “Vaccination,” in Cyclopedia of Education, ed. Paul Monroe (New York: Macmillan, 1911–13), 5:193; “Vaccination of School Children,” Journal of the American Medical Association 25 (1895): 505; Tobey, Public Health Law, 25; Colgrove, State of Immunity, 72. 3. Defective Children, Defective Students

1. John J. Cronin, “The Doctor in the Public School,” Review of Reviews 35 (1907): 434. 2. “The Grading of Defective Public School Children,” Boston Medical and Surgical Journal 148 (1903): 349–50; Maximillian Groszmann, “To What Extent May Atypical Children Be Successfully Educated in Our Public Schools?,” in Proceedings and Addresses of the National Education Association, 1904 (Chicago: National Education Association, 1904), 754–56; C. G. Pearse, “Separation of Physically and Mentally Defective Children from the Regular School,” in Proceedings and Addresses of the National Education Association, 1907 (Chicago: National Education Association, 1907), 321–22; “Backward Children in Public Schools,” in US Bureau of Education, Report of Commissioner of Education for the Year 1899–1900 (Washington: Government Printing Office, 1901), 2:1341–43. 3. Lawrence Cremin, The Transformation of the School: Progressivism in American Education, 1876–1957 (New York: Knopf, 1961), 127–28. On the nature and extent of the changing urban school population and the challenges it presented to educators, see Paul D. Chapman, Schools as Sorters: Lewis M. Terman, Applied Psychology, and the Intelligence Testing Movement, 1890–1930 (New York: New York University Press, 1988), 39–45.

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Notes to Pages 68–69

3-4 68 3-5 68 3-6 68 3-7 68 3-8 68 3-9 68 3-10 69 3-11 69

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4. Quoted in Chicago Department of Public Instruction, Thirty Sixth Annual Report of the Board of Education for the Year Ending June 30, 1890 (Chicago: Hack and Anderson, 1891), 39. Contemporary estimates of the percentage of feeble-minded schoolchildren who were truly uneducable placed the figure around 2 percent. See Will S. Monroe, “Feeble-Minded Children in the Public Schools,” in Proceedings of the National Conference of Charities and Corrections, 1894, ed. Isabel C. Barrows (Boston: Geo. C. Ellis, 1895), 430–33. 5. James H. Van Sickle, “Provision for Exceptional Children in the Public Schools,” in Proceedings of the First, Second, and Third Congresses of the American School Hygiene Association, 1907–1909 (Springfield, MA: American Physical Education Review, 1910), 82. 6. Quoted in Baltimore Board of School Commissioners, Eighty-First Annual Report, 1909 (Baltimore: J. C. Dulany, 1910), 51. For a detailed account of what was being done to solve that problem by 1911, see James H. Van Sickle, Lightner Witmer, and Leonard P. Ayres, Provision for Exceptional Children in Public Schools (Washington: Government Printing Office, 1911), 1–92. 7. Providence, Rhode Island, led the way in these innovations. In 1894 the city established a special education class for backward children, and was soon followed by Springfield, Illinois; Chicago; New York; Philadelphia; and Los Angeles. In 1908 Providence began an open-air class for malnourished, sickly, and delicate children. See Leo Kanner, History of the Care and Study of the Mentally Retarded (Springfield, IL: C. C. Thomas, 1964), 50; Richard A. Meckel, “Combating Tuberculosis in School Children: Providence’s Open-Air Schools,” Rhode Island History 53 (1996): 91–100; James Frederick Rogers, Schools and Classes for Delicate Children (Washington: Government Printing Office, 1930), 4–8. 8. Henry Lincoln Clapp, “Special Schools for Feeble-Minded Children,” Education 18 (1898–99): 203. See also Walter S. Cornell, Health and Medical Inspection of School Children (Philadelphia: F. A. Davis, 1912), 72. 9. With the development of IQ testing in the second decade of the century and its deployment in schools after World War I, the responsibility for identifying and classifying the feeble-minded and other children labeled mentally retarded gradually shifted from physicians who were medical inspectors to psychologists. On this process, see Chapman, Schools as Sorters, chapters 2–4. 10. “The Grading of Defective Public School Children,” 350; Groszmann, “To What Extent,” 757–58; C. G. Pearse, “Schools for Defectives in Connection with Public Schools,” in Proceedings and Addresses of the National Education Association, 1907, 111–13; S. L. Heeter, “Separate Schools with Separate Courses of Training for the Separate Needs of Our Children,” In Proceedings and Addresses of the National Education Association, 1911 (Chicago: National Education Association, 1911), 1035–37. 11. W. S. Christopher, “Medical Inspection in the Public Schools,” in Proceedings and Addresses of the National Education Association, 1901 (Chicago: National Education Association, 1901), 236–39; R. O. Beard, “The Physiology of Childhood as Applied to Education,” in Proceedings and Addresses of the National Education Association, 1902 (Chicago: National Education Association, 1902), 725–27; D. P. MacMillan, “The Diagnosis of the Capabilities of School Children,” in Proceedings and Addresses of the National Education Association, 1904 (Chicago: National Education Association, 1904), 738–44; William Burnham, “The Ideal Schoolhouse,” Revue of Education 7 (1901): 17; Carita Constable Huang, “Making Children Normal: Standardizing Children in the United States, 1885–1930” (PhD diss., University of

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12.

13.

14.

15. 16. 17. 18.

19. 20. 21. 22. 23.

24.

25. 26. 27.

Notes to Pages 70–75

Pennsylvania, 2004), 128–29, 198–199; Luther H. Gulick, “Constructive Medicine: How It Has Grappled with a Single Problem in School Hygiene,” American Physical Education Review 14 (1909): 261–71. “Preventing Sickness, A City Investment,” World’s Work 12 (1906): 7914. See also George H. Martin, “Medical Inspection in the Schools of Massachusetts,” in Proceedings of the First, Second, and Third Congresses of the American School Hygiene Association, 19. “Physical Examination of School Children,” Boston Medical and Surgical Journal 152 (1905): 587; “Children Wrongly Blamed: Physical Defects Often Responsible for Stupidity,” Washington Post, April 23, 1905; Edith Lindsay, “Origins and Development of the School Health Movement in the United States” (PhD diss., Stanford University, 1943), 352; School Committee of the City of Providence, Annual Report of the School Committee, 1899–1900 (Providence, RI: Farnam and Snow, 1900), 243. Quoted in Cronin, “The Doctor in the Public School,” 435. See also Luther Halsey Gulick and Leonard P. Ayres, Medical Inspection of Schools (New York: Charities Publication Committee, 1908), 85. Cronin, “The Doctor in the Public School,” 435. John J. Cronin, “School Children and Their Medical Supervision,” Charities 16 (1906): 59. Cronin, “The Doctor in the Public School,” 436. John Duffy, A History of Public Health in New York City, 1866–1966 (New York: Russell Sage Foundation, 1974), 479; New York Committee on the Physical Welfare of School Children, “The Physical Welfare of Children: An Examination of the Home Conditions of 1,400 New York School Children Found by School Physicians to Have Physical Defects,” Publications of the American Statistical Association 10 (1907): 271–316. New York Committee on the Physical Welfare of School Children, “The Physical Welfare of Children,” 296–300. Ibid., 300. Ibid., 302. Gulick and Ayres, Medical Inspection of Schools, 86–87; “School Board Widens Scope of Examinations,” Los Angeles Times, July 23, 1906. Quoted in Martin, “Medical Inspection in the Schools of Massachusetts,” 112. See also Lindsay, “Origins and Development,” 352; “An Act Relative to the Appointment of School Physicians, section 5,” in Massachusetts Board of Education, Annual Report of the Massachusetts State Board of Education, 1906–1907 (Boston: Wright and Potter, 1907), 11. “Child Hygiene for School Examination: Mother’s Congress and Teacher’s Association Agitate an Important Subject,” Atlanta Constitution, March 6, 1910; “Medical Inspection for School Children,” ibid. Cronin, “The Doctor in the Public School,” 435. See also Huang, “Making Children Normal,” 125–126. “Works Describes Details of Medical Inspection,” Los Angeles Times, November 25, 1911; “Blease Vetoes School Bill,” Chicago Daily Tribune, February 2, 1914. Quoted in Frank Allport, “The Eyes and Ears of Children,” in Proceedings of the First, Second, and Third Congress of the American School Hygiene Association, 229. See also John J. Cronin, “The Status of Medical Inspection in America,” in Proceedings of the Fourth Congress of the American School Hygiene Association, 1910 (Springfield, MA: American Association of School Hygiene, 1910), 176–83.

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70 70 70 71 71 71 72 72 73 73 73 73 74 74 74 75

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75 75 76 76 76 76 77 77 77 78 78 79 79 79 80 80 80

223

28. Quoted in Indiana State Board of Health and Indiana State Board of Education, Manual of Instructions for School Authorities and School Physicians (Indianapolis: William B. Burford, 1912), 19. 29. “Medical Supervision of School Children,” Charities 16 (1906): 3–5; Edward L. Stevens, “The Next Move in School Supervision—Hygiene,” World’s Work 16 (1908): 1040–32; Luther Halsey Gulick and Leonard P. Ayres, Medical Inspection of Schools, rev. ed. (New York: Charities Publication Committee, 1913), 13–20. 30. US Bureau of Education, Report of the Commissioner of Education for the Year 1880 (Washington: Government Printing Office, 1882), lxvii–lxx, and Report of the Commissioner of Education for the Year 1910 (Washington: Government Printing Office, 1911), 744–45. 31. David B. Tyack, The One Best System: A History of American Urban Education (Cambridge: Harvard University Press, 1974), 201. On the embrace of efficiency by what Tyack labels “Administrative Progressives,” see ibid., 177–216; Raymond Callahan, Education and the Cult of Efficiency (New York: Wiley, 1963). 32. Marvin Lazerson, Origins of the Urban School: Public Education in Massachusetts, 1870–1915 (Cambridge: Harvard University Press, 1971), 139; New York City Department of Education, Sixth Annual Report of the City Superintendent of Schools (New York: Department of Education, 1904), 47; Philadelphia School District, Board of Public Education, Ninety-First Annual Report, 1909 (Philadelphia: Walther, 1910), 58; “City’s Children Dull, School Statistics Say,” New York Times, January 17, 1905; Edward L. Thorndike, The Elimination of Pupils from School (Washington: Government Printing Office, 1907). 33. Leonard P. Ayres, Laggards in Our Schools: A Study of Retardation and Elimination in City School Systems (New York: Charities Publication Committee, 1909). 34. Ibid., 3–5. 35. Ibid., 117. 36. Ibid., 119–21; Walter S. Cornell, Health and Medical Inspection of School Children (Philadelphia: F. A. Davis, 1912), 187–88. 37. Ayers, Laggards in Our Schools, 125–26. 38. Quoted in Leonard P. Ayres, “Relation between Physical Defects and School Progress,” in Proceedings of the Fourth Congress of the American School Hygiene Association, 104. 39. L. N. Hine, “A Study of Retardation,” in Proceedings of the Sixth Congress of the American School Hygiene Association, 1912 (Springfield, MA: American School Hygiene Association, 1912), 55. 40. Baltimore, Department of Public Safety, Annual Report of the Sub-Department of Health, 1913 (Baltimore: J. C. Dulaney, 1914), 23. 41. Calculated from data contained in Luther Halsey Gulick and Leonard P. Ayres, Medical Inspection of Schools, rev. ed., 20, table 6. 42. Lewis M. Terman, The Hygiene of the School Child (Boston: Houghton Mifflin, 1914), 270. See also Myles Standish, “Should the Examination of the Eyes of School Children Be Conducted by the Teacher or the School Physician?” in Proceedings of the Fifth Congress of the American School Hygiene Association, 1911 (Springfield, MA: American School Hygiene Association, 1911), 98–101. 43. Quoted in Terman, The Hygiene of the School Child, 270. 44. S. B. Walsh, “The School Teacher as a Factor in Public Health,” School Hygiene 5 (1912): 208–13; Ernest Bryant Hoag and Lewis M. Terman, Health Work in the Schools (Boston: Houghton Mifflin, 1914), 90–109.

224

Notes to Pages 80–86

45. Gulick and Ayres, Medical Inspection of Schools, rev. ed., 37. See also Cornell, Health and Medical Inspection, 37–45; “Medical Inspection of School Children,” in US Bureau of Education, Report of the Commissioner for the Year Ended June 30, 1907 (Washington: Government Printing Office, 1908), 433. In an attempt to make the exams more accurate, New York City instituted an entrance exam in 1913 that had to be done with the child’s clothing removed. To meet parental concerns, the city allowed private physicians to perform the exams. See “New School Entry Exam,” New York Times, August 24, 1913. 46. S. W. Newmayer, Medical and Sanitary Inspection of Schools (Philadelphia: Lea and Febiger, 1913), 168–69. 47. Cornell, Health and Medical Inspection, 89–98; Hoag and Terman, Health Work in the Schools, 305; School Committee of the City of Providence, Annual Report of the School Committee, 1909 (Providence, RI: Providence Press, 1909), 9; Providence Board of Health, Annual Report of the Superintendant of Health, 1907 (Providence, RI: Providence Press, 1907), 12. 48. Cornell, Health and Medical Inspection, 21; Gulick and Ayres, Medical Inspection of Schools, rev. ed., 41; “City to Safeguard Health in Schools,” New York Times, August 24, 1915; Hoag and Terman, Health Work in the Schools, 58–61; San Francisco Department of Health, Report of the Department of Health, San Francisco for the Fiscal Year July 1, 1915–June 30, 1916 (San Francisco: Neal, 1916), 43. 49. Quoted in Gulick and Ayres, Medical Inspection of Schools, 153. 50. William Maxwell, “The Necessity for Departments of Health within Boards of Education,” in Proceedings of the First, Second, and Third Congresses of the American School Hygiene Association, 207–12. See also New York City Department of Education, Ninth Annual Report of the City Superintendent of Schools for the Year Ending July 31, 1907 (New York, 1907), 142–43. 51. “Report on School Inspection,” Journal of the American Medical Association 57 (1911): 1741–57. 52. Samuel G. Dixon, “The Medical and Sanitary Inspection of Schools,” in Proceedings of the First, Second, and Third Congresses of the American School Hygiene Association, 36. 53. For the most substantive treatment of this branch of school hygiene, see Huang, “Making Children Normal,” especially chapters 3 and 4. For a contemporary explanation of the concept of physiological age and its uses, see Terman, The Hygiene of the School Child, 61–71. 54. On Wood and his role in school hygiene, see Huang, “Making Children Normal,” 139–48; William Cromartie Burgess, “The Life of Thomas Denison Wood, M.D., and His Contributions to Health Education and Physical Education” (PhD diss., Teachers College, Columbia University, 1959). On Gullick, see Stephanie Wallach, “Luther Halsey Gulick and the Salvation of the American Adolescent” (PhD diss., Columbia University, 1989); Thomas Winter, “Luther Halsey Gulick,” The Encyclopedia of Informal Education, 2004, www.infed.org/thinkers/gulick.htm. 55. S. Josephine Baker, Child Hygiene (New York: Harper and Brothers, 1925), 282. 56. “Medical Inspection in the Public Schools: Abstracts of Three Papers Read at the Fourth International Congress on School Hygiene,” American City 9 (1913): 316. 57. Court cases decided between 1910 and 1925 gradually expanded the right of schools to do health work without specific enabling legislation. However, they also restricted those rights, generally limiting health work to that which was preventive

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80 81 82 82 83 83 83 84 84 85 85 86 86

Notes to Pages 86–90

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86 87 87 88 88 88 89 90 90 90

58. 59.

60.

61. 62.

63.

64.

65. 66.

67.

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and educational. See James A. Tobey, Public Health Law (New York: Commonwealth Fund, 1939), 248–49. Baker, Child Hygiene, 281. See also Gulick and Ayres, Medical Inspection of Schools, rev. ed., 167–71. Lindsay, “Origins and Development,” 340–41; Gulick and Ayres, Medical Inspection of Schools, rev. ed., 7–12; Hoag and Terman, Health Work in the Schools, 285–303. On the establishment and growth of medical inspection and a national medical service in Great Britain, see Bernard Harris, The Health of the Schoolchild: A History of the School Medical Service in England and Wales (Buckingham, UK: Open University Press, 1995); John Welshman, “The School Medical Service in England and Wales, 1907–1939” (PhD diss., Oxford University, 1990). On Canada, see Mona Gleason, “Race, Class, and Health: School Medical Inspection and ‘Healthy’ Children in British Columbia, 1890 to 1930,” Canadian Bulletin of Medical History 19 (2002): 95–112. Thomas D. Wood and Hugh Grant Rowell, Health Supervision and Medical Inspection of Schools (Philadelphia: W. B. Saunders, 1927), 17–25; Hoag and Terman, Health Work in the Schools, 285–99; Gulick and Ayres, Medical Inspection of Schools, rev. ed., 7–12. “The American School Hygiene Association,” School Hygiene 1 (1908): 2–3. Richard Meckel, Save the Babies: American Public Health Reform and the Prevention of Infant Mortality, 1850–1929 (Baltimore: Johns Hopkins University Press, 1990), 108–9; “Putnam, Helen Cordelia (1857–1951),” in The Biographical Dictionary of Women in Science, ed. Marilyn Olgilvie and Joy Harvey (New York: Routledge, 2000), 1059–60; “Free Clinics to Stop Crime,” Chicago Daily Tribune, August 11, 1907. “The American School Hygiene Association,” 2; “Minutes of the Meeting for the Organization of the School Hygiene Association of America Held at the University Club, New York City, on December 3, 1906,” in Proceedings of the First, Second, and Third Congresses of the American School Hygiene Association, 5–6; “Minutes of the Meeting of the Committee on the Organization of the School Hygiene Association, Held at the New York Academy of Medicine, West 43d Street, New York City, on March 13, 1907,” in ibid., 9. Meckel, Save the Babies, 110; Richard H. Shryock, National Tuberculosis Association, 1904–1954: A Study of the Voluntary Health Movement in the United States (New York: National Tuberculosis Association, 1957), 182. “The American School Hygiene Association,” 2. R. Clifton Sturgis, “Schoolhouse Construction as Affecting the Health and Safety of Children,” in Proceedings of the First, Second, and Third Congresses of the American School Hygiene Association, 107–8; William Estabrook, “Ten Commandments of School Construction,” in ibid., 189–91; “Collinwood School Fire,” The Encyclopedia of Cleveland History, accessed January 11, 2013, http://ech.case.edu/ech-cgi/ article.pl?id=CSF. For an overview of school fire protection theory and policy a few years after the Collinwood fire, see Russell Sage Foundation, Division of Education, Fire Protection in Public Schools (New York: Russell Sage Foundation, 1913). Although by 1910 only thirteen of the forty-six states had adopted school building codes, almost all major cities had. For a survey of the state codes, see Wilbur Thoburn Mills, American School Building Standards (Columbus, OH: Franklin Educational, 1910), 114–63. For Boston’s code for elementary school buildings, see ibid., 164–79. See also Joseph Tomlinson, “School Inspection,” Journal of the Medical

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68.

69.

70.

71. 72.

73.

74. 75. 76. 77.

78.

Notes to Pages 91–94

Society of New Jersey 1 (1904–5): 183; Sturgis, “Schoolhouse Construction as Affecting the Health and Safety of Children,” 104–6; Frank J. Cooper, “Schoolhouses and the Law, “ in Proceedings of the Fifth Congress of the American School Hygiene Association, 165–67; Lazerson, Origins of the Urban School, 12–14; Jacob Riis, The Battle with the Slum (New York: Macmillan, 1902), 353–54. W. E. Watt, “Humidity and Scholarship in School,” in Proceedings of the Fourth Congress of the American School Hygiene Association, 119–23; George T. Palmer, “What Fifty Years Have Done for Ventilation,” in A Half Century of Public Health, ed. Mazyck P. Ravenal (New York: American Public Health Association, 1921), 344– 45; Fletcher Dressler, School Hygiene (New York: Macmillan, 1913), 137–38. William A. Stetcher, “An Inquiry into the Problem of Desks of School Children,” in Proceedings of the Fifth Congress of the American School Hygiene Association, 33– 39; Terman, The Hygiene of the School Child, 73–80; Robert W. Lovett, “The Relation of School Life to Lateral Curvature of the Spine,” in Proceedings of the Sixth Congress of the American School Hygiene Association, 174–79. For a comprehensive overview of the evolution of medical thinking on the relation of school and schoolwork to eye health, see Terman, The Hygiene of the School Child, 245–81. Also good is Miles Standish, “The Hygiene of the Eye,” in Proceedings of the Sixth Congress of the American School Hygiene Association, 111–14. Terman, The Hygiene of the School Child, 264–69; Dressler, School Hygiene, 231– 38; Cornell, Health and Medical Inspection, 237–40. Ludwig Kotelmann, School Hygiene, trans. John Bergstrom (Syracuse, NY: C. W. Bardeen, 1899), 188–200; Marion E. Holmes, “The Fatigue of the School Hour,” The Pedagogical Seminary 3 (1895): 213–34; William Burnham, “Recent Studies of Fatigue,” in Proceedings of the Fifth Congress of the American School Hygiene Association, 81–87; L. A. Robinson, Mental Fatigue and School Efficiency (Columbia, SC, 1912). Thomas Harrington, “Medical Inspection in Public Schools as Contributing to Health and Efficiency,” in Proceedings and Addresses of the National Education Association, 1908 (Chicago: National Education Association, 1908): 205. See also Tom A. Williams, “Nervousness and Education,” in Proceedings of the Fourth Congress of the American School Hygiene Association, 105–12; Cornell, Health and Medical Inspection, 333–34; Terman, The Hygiene of the School Child, 392. On early-twentieth-century popular and medical attitudes toward homework, see Brian Gill and Steven Schlossman, “A Sin against Childhood: Progressive Education and the Crusade to Abolish Homework, 1897–1941,” American Journal of Education 105 (1996): 27–66. Luther H. Gulick, “Introductory Remarks by the President,” in Proceedings of the Fifth Congress of the American School Hygiene Association, 20. “Maxwell Pleads for School Hygiene,” New York Times, January 19, 1908. “Minutes of the Meeting,” 6. Ibid. Fletcher Dressler, a prominent member of ASHA, was appointed first head of the Education Bureau’s Division of School Hygiene. On the establishment and early work of the division, see “The Division of School Hygiene of the United States Bureau of Education,” School and Society 15 (1922): 322–26. On Progressive Era reformers’ commitment to a gospel of prevention, see James T. Patterson, America’s Struggle against Poverty, rev. ed. (Cambridge: Harvard University Press, 1994), 20–34. On the early child welfare movement, see Richard A. Meckel, “Protecting the Innocents: Age Segregation and the Early Child Welfare Movement,” Social Service Review 59 (1985): 455–75. On Progressive Era child welfare, see Leroy

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91 91 91 92 92 92 92 93 93 94 94

Notes to Pages 94–10 0

3-79 94 3-80 95 3-81 96 3-82 96 3-83 96 3-84 96 3-85 96 3-86 97 3-87 97 3-88 97 3-89 98 3-90 98 3-91 98 3-92 98 4-1 100 4-2 100

79. 80.

81. 82. 83. 84.

85.

86. 87.

88. 89.

90. 91. 92.

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Ashby, Endangered Children: Dependency, Neglect, and Abuse in American History (New York: Twayne, 1997), 79–100; Kriste Lindenmeyer, A Right to Childhood: The U.S. Children’s Bureau and Child Welfare, 1912–46 (Urbana: University of Illinois Press, 1997); James Martin, Childhood and Child Welfare in the Progressive Era: A Brief History (New York: St. Martin’s, 2004); Susan Tifflin, In Whose Best Interest? Child Welfare Reform in the Progressive Era (Westport, CT: Greenwood, 1982). Michael B. Katz, In the Shadow of the Poorhouse: A Social History of Welfare in America, rev. ed. (New York: Basic, 1996), 117. George B. Mangold, Problems of Child Welfare (New York: Macmillan, 1914), 10–11. See also Edward T. Devine, Misery and Its Causes (New York: Macmillan, 1910), 244; John Spargo, The Bitter Cry of Children (New York: Macmillan, 1906). Theodore von Eschereich, “The Foundation and Aims of Modern Pediatrics,” American Medicine 9 (1905): 58. L. Emmett Holt, The Diseases of Infancy and Childhood: For Use of Students and Practitioners of Medicine (New York: Appleton, 1897), 31. Mangold, Problems of Child Welfare, 310, 318. Jane Addams, “Evils of Child Labor,” in Children and Youth in America: A Documentary History, ed. Robert H. Bremner with associate editors John Barnard, Tamara K. Hareven, and Robert M. Mennel (Cambridge: Harvard University Press, 1971), 2:655. George Goler, “But a Thousand a Year,” Charities 14 (1905): 970; Goler, “Medical Inspection—A Way to Child Welfare,” in Proceedings of the Thirty-Eighth National Conference of Charities and Corrections, 1911, ed. Alexander Johnson (Fort Wayne, IN: Fort Wayne Printing 1911), 98. Baker, Child Hygiene, 281. Mark H. Haller, Eugenics: Hereditarian Attitudes in American Thought (New Brunswick, NJ: Rutgers University Press, 1963), 173. The scholarly literature on eugenics in the twentieth century is considerable and growing, but the classic study remains David L. Kevles, In the Name of Eugenics: Genetics and the Uses of Human Heredity (New York: Knopf, 1985). On the United States, two useful newer studies are Wendy Kline, Building a Better Race: Gender, Sexuality, and Eugenics from the Turn of the Century to the Baby Boom (Berkeley: University of California Press, 2001); and Alexandra Minna Stern, Eugenic Nation: Faults and Frontiers of Better Breeding in Modern America (Berkeley: University of California Press, 2005). Luther Gulick, “Physical Training in New York Schools,” American Physical Education Review 8 (1903): 32. Irving Fisher, Bulletin 30 of the Committee of 100 on National Health, being a Report on National Vitality: Its Wastes and Conservation (Washington: Government Printing Office, 1909). On Terman’s early work and its relation to the challenges facing turn-of-the-century urban schools, see Chapman, Schools as Sorters, 17–38. Terman, The Hygiene of the School Child, 10. Ibid. See also William Burnham, “The Problems of Child Hygiene,” Pedagogical Seminary 19 (1912): 395–402.

4. Building Up the Malnourished, the Weakly, and the Vulnerable

1. Robert Hunter, Poverty (New York: Macmillan, 1904), 216. 2. On Hunter and other Progressive Era analysts of poverty in the United States, see James T. Patterson, America’s Struggle against Poverty in the Twentieth Century, 4th ed. (Cambridge: Harvard University Press, 2000), 3–18.

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Notes to Pages 10 0–106

3. Robert Hunter, introduction to John Spargo, The Bitter Cry of Children (New York: Macmillan, 1906), vii. 4. Caroline L. Hunt, The Daily Meals of School Children (Washington: Government Printing Office, 1909), 45. 5. Spargo, The Bitter Cry of Children, 64; Louise Stevens Bryant, School Feeding: Its History and Practice at Home and Abroad (Philadelphia: J. B. Lippincott, 1913), 196; “The Hunger Problem in the Public Schools: What a Canvas of Six Big Cities Reveals,” Philadelphia North American, May 31, 1905. 6. Jacob Riis, The Children of the Poor (New York: Charles Scribner’s Sons, 1892); Riis, Children of the Tenements (New York: Macmillan 1903); Hasia Diner, Hungering for America: Italian, Irish, and Jewish Foodways in the Age of Migration (Cambridge: Harvard University Press, 2003), 51–54. 7. William J. Reese, “After Bread, Education: Nutrition and Urban School Children, 1890–1920,” Teachers College Record 81 (1980): 499. On schoolchild malnutrition as an issue in the English national deterioration hearings, see Deborah Dwork, War Is Good for Babies: A History of the Infant and Child Welfare Movement (London: Tavistock, 1987), 167–81; Bernard Harris, The Health of the Schoolchild: A History of the School Medical Service in England and Wales (Buckingham, UK: Open University Press, 1995), 140–52. 8. Edward T. Devine, “The Underfed Child in the Schools,” Charities and the Commons 20 (1908): 413. 9. New York Committee on the Physical Welfare of School Children, “Physical Welfare of School Children: An Examination of the Home Conditions of 1,400 New York School Children Found by School Physicians to Have Physical Defects,” Publications of the American Statistical Association 78 (1907): 272. 10. Lillian Wald, “Under-Nourished School Children,” Charities 13 (1904–5): 600–601; Elsie Clew Parsons, “The School Child, the School Nurse, and the Local School Board,” Charities 14 (1905): 1098–99. 11. Hunter, Poverty, 216. 12. Spargo, The Bitter Cry of Children, xiii. 13. Ibid. 14. Ibid., 117–18. 15. “Hunger Stalking in City Schools,” Chicago Daily Tribune, October 2, 1908; “Steps to Relieve Hungry School Children,” ibid., October 3, 1908. 16. Bryant, School Feeding, 202–3; E. Mather Still, “A Study of Malnutrition in the School Child,” Journal of the American Medical Association 52 (1909): 1982; Still, “Dietary Studies of Undernourished School Children in New York City,” Journal of the American Medical Association 53 (1910): 1890. 17. For contemporary descriptions of the Providence open-air school, see Ellen A. Stone, “A Fresh Air School,” Journal of the Outdoor Life 5 (1908): 134–46; “First Open-Air American School,” Journal of Education 67 (1908): 126; Walter H. Small, “The Providence Association,” Journal of the Outdoor Life 6 (1909): 82–86; Walter E. Kruesi, “The Providence Fresh Air School,” Charities and the Commons 20 (1908): 97–99. 18. Leonard P. Ayres, Open-Air Schools (New York: Thompson, Brown, 1915), 13–29; Elnora W. Curtis, “Outdoor Schools,” American City 1 (1909): 115–18; Sherman C. Kingsley and Fletcher B. Dressler, Open-Air Schools (Washington: Government Printing Office, 1917), 152. For a description and evaluation of the open-air school movement in Great Britain, see Linda Bryder, “Wonderlands of Buttercup, Clover, and Daisies: Tuberculosis and the Open-Air School Movement in Britain,

4-3 100 4-4 101 4-5 101 4-6 101 4-7 101 4-8 102 4-9 102 4-10 102 4-11 102 4-12 103 4-13 103 4-14 103 4-15 104 4-16 104 4-17 106 4-18 106

Notes to Pages 107–109

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19.

20.

21.

22.

23.

24.

25. 26.

27.

28. 29.

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1907–1939,” in In the Name of the Child: Health and Welfare, 1880–1940, ed. Roger Cooter (London: Routledge, 1992), 72–95. Isabel F. Hymas and James J. Minot, “Boston’s Outdoor School,” Journal of the Outdoor Life 6 (1909): 187–92; Walter E. Kruesi, “The School of Outdoor Life for Tuberculous Children,” Charities and the Commons 21 (1908): 446–49; Joseph Lee, “Open Air Rooms in the Boston Schools,” in Proceedings of the Child Conference for Research and Welfare, 1910 (New York: G. S. Stechert, 1911): 187–91; Betty Godfrey, “An Inexpensive Outdoor School,” Good Housekeeping 50 (1910): 670; Ayres, Open-Air Schools, 63, 70; Sherman C. Kingsley, “Tuberculous Children on a City Roof,” Survey 23 (1910): 863; Louise E. Dew, “Open-Air Schools for Abnormal Children,” World To-Day 20 (1911): 557–64. Leonard Ayres, “Open-Air Schools,” in Proceedings and Addresses of the National Education Association, 1910 (Chicago: National Education Association, 1911), 902. See also Thomas S. Carrington, “How to Build and Equip and Open-Air School,” Survey 24 (1910): 144–51; Kingsley and Dressler, Open-Air Schools, 24–31, 175. On the international antituberculosis crusade, see Mark Caldwell, The Last Crusade: The War on Consumption 1862–1954 (New York: Atheneum, 1988); on the US campaign, see Richard Shryock, National Tuberculosis Association, 1904–1954 (New York: National Tuberculosis Association, 1957). For a detailed account of this transformation in medical thinking on the etiology and pathology of tuberculosis as related to childhood infection, see Richard A. Meckel, “Open-Air Schools and the Tuberculous Child in Early 20th Century America,” Archives of Pediatrics and Adolescent Medicine 150 (1996): 91–96. C. von Pirquet, “The Frequency of Tuberculosis in Childhood,” in Transactions of the Sixth International Congress on Tuberculosis, 1908 (Philadelphia: W. F. Fell, 1908), 2:559–68; L. Emmett Holt, “A Report on One Thousand Tuberculin Tests in Young Children,” in ibid., 551–58; Bryder, “Wonderlands of Buttercup, Clover, and Daisies,” 73. T. N. Kelynack, introduction to Tuberculosis in Infancy and Childhood: Its Pathology, Prevention, and Treatment, ed. T. N. Kelynack (London: Bailliere, Tindal, and Cox, 1908), 1. Quoted in Maurice Fishberg, Pulmonary Tuberculosis (Philadelphia: Lea and Febiger, 1919), 118. Quoted in Francis Harbitz, “Concerning Latent Tuberculosis,” in Transactions of the Sixth International Congress on Tuberculosis, 1:112. On Flick’s life and work, see Barbara Bates, Bargaining for Life: A Social History of Tuberculosis, 1876–1938 (Philadelphia: University of Pennsylvania Press, 1992). Quoted in May Michael, “Resumé of Literature on Tuberculosis in Children during 1918 and 1919,” American Journal of the Diseases of Children 19 (1920): 287. According to Michael, who between 1912 and 1922 wrote an annual review of American and foreign research on tuberculosis in children for the American Journal of the Diseases of Children, Ghon’s theory of the determinacy of childhood primary infection in the lung reigned relatively unchallenged for almost a decade, until it was modified by the research of Eugene L. Opie concerning secondary infection as a cause of adult apical tuberculosis. See ibid., 287–88. L. Emmett Holt, The Diseases of Infancy and Childhood: For Use of Students and Practitioners of Medicine, 6th ed. (New York: Appleton, 1914), 1022. Henry Barton Jacobs, “The Prevention of Tuberculosis among School Children,” Journal of the Outdoor Life 5 (1908): 85–86. See also John. H. Lowman, “Tuberculosis

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30. 31.

32.

33.

34. 35. 36. 37.

38.

39.

40. 41.

42. 43. 44. 45.

Notes to Pages 109–114

and the Schools,” Charities and the Commons 18 (1907): 657; Luther H. Gulick, “Tuberculosis and the Public Schools,” Charities and the Commons 21 (1908): 253. For a summary of the two positions, see “Progress in Pediatrics,” American Journal of the Diseases of Children 1 (1911): 457. For a discussion of the origin and development of sanitariums and the principles of open-air therapy, see Caldwell, The Last Crusade, 67–97; F. B. Smith, The Retreat of Tuberculosis, 1850–1950 (London: Croom Helm, 1988), 97–135. Sherman Kingsley, Open-Air Crusaders (Chicago: Elizabeth McCormick Memorial Fund, 1913), 48; Jay Perkins, “Fresh Air Schools: How They Accomplish Their Results,” Providence Medical Journal 13 (1913): 35–39; Lewis M.Terman, The Hygiene of the School Child (Boston: Houghton Mifflin, 1914), 155–57. On the establishment and operation of preventoria for children in the United States, see Cynthia A. Connolly, Saving Sickly Children: The Tuberculosis Preventorium in American Life, 1909–1970 (New Brunswick, NJ: Rutgers University Press, 2008). James Kerr, “The Elementary School and Tuberculosis,” School Hygiene 1 (1910): 15. Ayres, Open-Air Schools, 92. See also Kingsley and Dressler, Open-Air Schools, 234–35. Kingsley and Dressler, Open-Air Schools, 7. Indeed, debate continued even after the National Tuberculosis Association issued standardized diagnostic criteria in 1917. For those criteria, see “Standards of Diagnosis of Pulmonary Tuberculosis in Children,” American Review of Tuberculosis 1 (1917–18): 183–86. For a critique of those standards by one of the leading experts of the time on pulmonary tuberculosis, see Maurice Fishberg, “A Criticism of the Standards of Diagnosis of Pulmonary Tuberculosis in Children issued by the National Association for the Study and Prevention of Tuberculosis,” New York Medical Journal 106 (1917): 967. May Michael, “Resumé of the Work on Tuberculosis in Children for 1912,” American Journal of the Diseases of Children 5 (1913): 176–78; Holt, The Diseases of Infancy and Childhood (1914), 840–46, 854–59, 1031–49. Holt, for instance, defined predisposing causes as “all the conditions which bring about diminished resistance to tuberculous infection,” and prominently listed the conditions attending urban poverty (Diseases of Infancy and Childhood [1914]), 1018–19. For a contemporary assessment of how the notion of predisposition was evolving, see “Predisposition,” American Review of Tuberculosis 2 (1918–19): 43–48. Lee, “Open Air Rooms in the Boston Schools,” 187; Kingsley and Dressler, Open-Air Schools, 171. Chicago represented the sole exception because the Elizabeth McCormick Memorial Fund made a major commitment to open-air schooling and poured thousands of dollars into erecting and maintaining open-air facilities. S. Josephine Baker, Fighting for Life (New York: Macmillan, 1939), 162. James Frederick Rogers, Schools and Classes for Delicate Children (Washington: Government Printing Office, 1930), 4–8. Ibid., 21–22. S. W. Newmayer, Medical and Sanitary Inspection of Schools, 2nd ed. (Philadelphia: Lea and Febiger, 1924), 178. See also Rogers, Schools and Classes for Delicate Children, 4–6; New York State Commission on Ventilation, Ventilation: Report of the New York State Commission on Ventilation (New York: E. P. Dutton, 1923), 527–28.

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Notes to Pages 115–118

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46. Mabel Hyde Kittredge, “Report of the New York School Lunch Committee,” Journal of Home Economics 4 (1912): 482; Alice Boughton, “Report of the Penny Lunches Served by the Starr Centre Association, Philadelphia,” Journal of Home Economics 2 (1910): 178–81; Emma Smedley, The School Lunch: Its Organization and Development in Philadelphia (Media, PA: Emma Smedley, 1920), 1–14; Bryant, School Feeding, 147–49. 47. Alice Boughton, “School Lunches,” Journal of Home Economics 3 (1911): 80–81; Boughton, “The Administration of School Lunches in Cities,” ibid. 6 (1914): 214; Bryant, School Feeding, 164–65; Mary H. Moran, “Boston High School Lunches,” Journal of Home Economics 2 (1910): 182–84; Sarah Stage, “Ellen State and the Social Significance of the Home Economics Movement,” in Rethinking Home Economics: Women and the History of a Profession, ed. Sarah Stage and Virginia Vincenti (Ithaca: Cornell University Press, 1997), 17–33. 48. John C. Gebhart, Malnutrition and School Feeding (Washington: Government Printing Office, 1922), 21; Mary E. L. Small, “Elementary School Lunches under School Department Direction, Buffalo, N.Y,” Journal of Home Economics 4 (1912): 490; William J. Reese, Power and the Promise of School Reform: Grassroots Movements during the Progressive Era (New York: Teachers College Press, 2002), 195–97. 49. Boughton, “The Administration of School Lunches in Cities,” 214. See also Bryant, School Feeding, 164; School Committee of the City of Providence, Annual Report 1910/1911 (Providence, RI: Providence Press, 1911), 84. 50. “Maxwell Advocates City Lunch Kitchens,” New York Times, June 10, 1908; “Favors School Lunch: The Supt of Schools Favors Feeding Starving Children at Public Expense,” Washington Post, May 13, 1909; Lillian D. Wald, “The Feeding of School Children,” Charities and the Commons 20 (1908): 371–74; James Hamilton, “School Children’s Lunch Room,” Charities and the Commons 20 (1908): 400–402; John Spargo, Underfed School Children: The Problem and the Remedy (Chicago: Charles H. Kerr, 1906); Spargo, “The Physical Condition of Our School Children,” Independent 64 (1908): 1387–90. On socialist, civic clubs and other grass-roots advocacy for school feeding, see Reese, Power and the Promise, 189–200. 51. For histories of school feeding in Europe written by early-twentieth-century American advocates of school feeding, see Bryant, School Feeding, 143-46; Spargo, The Bitter Cry of Children, 271–90; Gebhart, Malnutrition and School Feeding, 5–11. For a recent historical analysis of the development of school feeding in Great Britain, see John Welshman, “School Meals and Milk in England and Wales, 1906–1945,” Medical History 41 (1997): 6–29. 52. Gordon W. Gunderson, The National School Lunch Program: Background and Development (Washington: Government Printing Office, 1971), 14; Susan Levine, School Lunch Politics: The Surprising History of America’s Favorite Welfare Program (Princeton: Princeton University Press, 2008), 2. 53. “Hungry School Children in Chicago,” Charities and the Commons 21 (1908–9): 94. In 1913 Massachusetts passed a bill authorizing school funds to be used to purchase food and provide other support for school lunches except support for free lunches. Illinois soon followed suit, but few other states did. See Gebhart, Malnutrition and School Feeding, 7–8. 54. “Hungry School Children in Chicago,” 93; Reese, “After Bread, Education,” 499–500. 55. On scientific charity and the concern with outdoor relief, see Michael Katz, In the Shadow of the Poorhouse: A Social History of Welfare in America, 2nd ed. (New York: Basic, 1996), 60–87.

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Notes to Pages 118–126

56. Arthur Clay, “The School Feeding Question in England,” Charities and the Commons 17 (1906–7): 706. 57. Edward T. Devine, “The Underfed Child in the Schools,” Charities and the Commons 20 (1908): 414–15. 58. Dwork, War Is Good for Babies, 170–72; Welshman, “School Meals and Milk,” 8–9. 59. “Hungry School Children in Chicago,” 93. See also Bryant, School Feeding, 202–3. 60. Devine, “The Underfed Child,” 414. 61. Ibid., 415. 62. New York Committee on the Physical Welfare of School Children, “Physical Welfare of School Children,” 30. 63. Lawrence Cremin, American Education: The Metropolitan Experience, 1876–1980 (New York: Harper and Row, 1988), 295. 64. Quoted in “Hungry School Children in Chicago,” 96. 65. Quoted in Hunter, Poverty, 210. 66. Quoted in Reese, Power and the Promise, 194. 67. Massachusetts Civic League, Medical Inspection in the Schools (Boston: Massachusetts Civic League, 1906), 4. 68. Joseph Lee, “The Integrity of the Family as a Vital Issue,” Survey 23 (1909): 305–13; Lee, letter to the editor, Survey 32 (1914): 103. 69. Robert Coit Chapman, The Standard of Living among Workingmen’s Families in New York City (New York: Russell Sage Foundation, 1909), 123–61. 70. Terman, The Hygiene of the School Child, 115. See also Mary E. L. Small, “The Educational and Social Possibilities of School Lunches,” Journal of Home Economics 6 (1914): 437–39. 71. William Burnham, “Food and Feeding,” in Cyclopedia of Education, ed. Paul Monroe (New York: Macmillan, 1919), 2:629. 72. Edward Brown, “Feeding School Children in New York City,” Journal of Home Economics 7 (1915): 119. 73. Ibid., 120; Ira S. Wile, “School Lunch Progress in New York,” Journal of Home Economics 6 (1914): 442. 74. Bryant, School Feeding, 148–49; John C. Gebhart, “Municipal School Feeding,” National Municipal Review 8 (1919): 160–62. 75. “Educational Need and Value of Lunches in Elementary Schools,” Journal of Home Economics 5 (1913): 55–57; Brown, “Feeding School Children,” 120; Leonard P. Ayres, The Cleveland School Survey: Summary Volume (Cleveland: Cleveland Foundation, 1917), 231–34; Treva Kaufman, “School Lunch Work in Ohio,” Journal of Home Economics 10 (1918): 490–94; Reese, Power and the Promise, 197–98. 76. Spargo, The Bitter Cry of Children, 87–90; Terman, The Hygiene of the School Child, 104–5. 77. Hunt, The Daily Meals of School Children, 13. 78. “Educational News and Editorial Comment,” The Elementary School Journal 15 (1914–1915): 504–505; Bryant, School Feeding, 243. 79. Boughton, “The Administration of School Lunches in Cities,” 216; Kittredge, “Report of the New York School Lunch Committee,” 486. 80. Gebhart, Malnutrition and School Feeding, 12. 81. D. C. Bliss, “Malnutrition, A School Problem,” Elementary School Journal 21 (1921): 517; Lydia Roberts, “Malnutrition, the School’s Problem,” Elementary School Journal 22 (1922): 460–61.

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Notes to Pages 126–132

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82. William R. P. Emerson, Nutrition and Growth in Children (New York: D. Appleton, 1922), 241. 83. For a description and analysis of the public discourse on whether the Depression was seriously affecting the nutrition of American children, see Richard A. Meckel, “Politics, Policy, and the Measuring of Child Health: Child Malnutrition and the Depression,” in Healing the World’s Children: Interdisciplinary Perspectives on Health in the Twentieth Century, ed. Cynthia Comacchio and Janet Golden (Montreal: McGill-Queens University Press, 2008), 235–52. 5. From Coercion to Clinics

1. The director of New York City’s school medical inspection program explained soon after his city had begun examining children for physical defects: “If the parents of these children were notified as to the existence of these manifold infirmities, and if in each case the necessary medical treatment were applied, a great improvement would result, not only in the health of the school children, but also in their capacity for school work” (John Cronin, “The Doctor in the Public School,” Review of Reviews 35 [1907]: 435). 2. E. H. Lewinski-Corwin, “The Practical Necessity of School Clinics,” Popular Science Monthly 84 (1914): 500. 3. Ernest Bryant Hoag and Lewis M. Terman, Health Work in the Schools (Boston: Houghton Mifflin, 1914), 50–51; S. Josephine Baker, “School Medical Inspection in New York City,” in Transactions of the Fourth International Congress on School Hygiene, ed. Thomas A. Storey (Buffalo: Courier, 1914), 4:335; Lewinski-Corwin, “The Practical Necessity of School Clinics,” 501. 4. “Preventing Sickness, A City Investment,” World’s Work 12 (1906): 7914; Jacob Sobel, “Prejudices and Superstitions Met with in the Medical Inspection of School Children,” in Transactions of the Fourth International Congress on School Hygiene, 4:82–83. 5. Albert Moxley et al., “Studies in School Medical Inspection,” in Proceedings of the Ninth Congress of the American School Hygiene Association (Springfield, MA: American School Hygiene Associatiation, 1917), 236–37. 6. Charles Chapin, “Municipal Sanitation,” American Journal of Public Health 19 (1909): 671; Cronin, ““The Doctor in the Public School,” 436; J. H. Berkowitz, The Eyesight of School Children (Washington: Government Printing Office, 1920), 49–50. 7. Quoted in John Spargo, The Bitter Cry of Children (New York: Macmillan, 1906), 252–53. 8. Walter S. Cornell, Health and Medical Inspection of School Children (Philadelphia: F. A. Davis, 1912), 72. 9. Berkowitz, The Eyesight of School Children, 42. 10. S. Josephine Baker, Fighting for Life (New York: Macmillan, 1939), 149. 11. Charles Chapin, “The Municipalization of Medical Treatment for School Children,” Medical Officer (London), March 30, 1912; Hoag and Terman, Health Work in the Schools, 275. 12. Michael M. Davis, Immigrant Health and the Community (New York: Harper Brothers, 1921), 129–33. On self-treating, see Charles E. Rosenberg, “Health in the Home,” in Right Living: An Anglo-American Tradition of Self-Help Medicine and Hygiene, ed. Charles E. Rosenberg (Baltimore: Johns Hopkins University Press, 2003), 1–20. 13. William Maxwell, “The Necessity for Departments of Health within Boards of Education,” in Proceedings of the First, Second and Third Congresses of the American

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14.

15.

16. 17.

18. 19.

20. 21.

22. 23.

24. 25. 26. 27.

28.

29.

Notes to Pages 132–136

School Hygiene Association, 1907–1909 (Springfield, MA: American School Hygiene Association, 1910), 210. Almuth C. Vandiver, “Statutory Enactments Relating to the Medical and Sanitary Inspection of Schools,” in Proceedings of the First, Second and Third Congresses of the American School Hygiene Association, 51; Luther Halsey Gulick and Leonard P. Ayres, Medical Inspection of Schools, rev. ed. (New York: Russell Sage Associates, 1913), 167–68; S. W. Newmayer, Medical and Sanitary Inspection of Schools, 2nd ed. (Philadelphia: Lea and Febiger, 1924), 66. Hoag and Terman, Health Work in the Schools, 5. See also “Medical Inspection of School Children,” in US Bureau of Education, Report of the Commissioner for the Year Ended June 30, 1907 (Washington: Government Printing Office, 1908), 432. Cornell, Health and Medical Inspection, 60. Newmayer, Medical and Sanitary Inspection of Schools, 2nd ed., 89; Daniel McClure, “Examination of School Children for Labor Certificates,” in Transactions of the Fourth International Congress on School Hygiene, 4:303–7. S. Josephine Baker, Child Hygiene (New York: Harper and Brothers, 1925), 300. Hoag and Terman, Health Work in the Schools, 50. Josephine Baker would later assert that the compliance rate in New York never exceeded 35 percent (Fighting for Life, 151). Philadelphia School District, Board of Public Education, Ninety-Second Annual Report, 1910 (Philadelphia, 1911), 66. James Stewart, “Medical Inspection of School Children,” in Proceedings of the 37th National Conference of Charities and Corrections, 1910 (Fort Wayne, IN: Fort Wayne Printing 1910), 196. See also George Goler, “Medical Inspection—A Way to Child Welfare,” Proceedings of the 38th National Conference of Charities and Corrections, 1911 (Fort Wayne, IN: Fort Wayne Printing, 1911), 102. Chapin, “The Municipalization of Medical Treatment for School Children.” On activities of visiting nurses in Progressive Era American cities, see Lillian Wald, House on Henry Street (New York: Henry Holt, 1915); Mary Gardner, Public Health Nursing (New York: Macmillan, 1915); and Barbara Melosh, The Physician’s Hand: Work, Culture, and Conflict in American Nursing (Philadelphia: Temple University Press, 1982), 113–58. On the activities and responsibilities of school nurses during the same period, see Lina Rogers Struthers, The School Nurse: A Survey of the Duties and Responsibilities of the Nurse in Maintenance of Health and Physical Perfection and the Prevention of Disease among School Children (New York: G. P Putnam, 1917). Boston Dispensary, Annual Report, 1910 (Boston: Geo. H. Ellis, 1911), 7. Reproduced in Charles H. Judd, Survey of the St Louis Public Schools (Yonkers, NY: World Book, 1918), 1:258–59. City of Baltimore, Department of Public Safety, Annual Report of the Sub-Department of Health, 1913 (Baltimore: Meyer and Thalheimer, 1914), 14. Jesse D. Burks and Francis W. Burks, “Public School Clinics,” in Educational Hygiene from the Pre-School Period to the University, ed. Louis W. Rapeer (New York: Charles Scribner’s Sons, 1915), 315. S. Josephine Baker, “Sight Conservation,” in City of New York, Board of Education, Twenty-Third Annual Report of the Superintendent of Schools, 1921 (New York: Board of Education 1922), 119–20. Quoted in George Heitmuller, “School Clinics,” Washington Medical Annals 16 (1915): 4.

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Notes to Pages 136–141

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30. Quoted in Bryce E. Nelson, Good Schools: The Seattle Public School System, 1901– 1930 (Seattle: University of Washington Press, 1988), 100. 31. Paul Starr, The Social Transformation of Medicine (New York: Basic, 1982), 182–83. 32. Charles V. Chapin, Medical Inspection of the Schools of Providence (Ansonia, CT: Emerson, 1909), 9–10. 33. Computed from data presented in Gulick and Ayres, Medical Inspection, rev. ed., 38. 34. See, for instance, Walter S. Cornell, “The Influence of Nasal Obstruction on the Mental Development of Children,” School Hygiene 1 (1908–9): 117–19; Thaddeus P. Hyatt, “The Importance of Teeth in the Mental, Moral, and Physical Development of the Child,” in Proceedings of the Ninth Congress of the American School Hygiene Association, 271–73. 35. For a good overview of the evolution of thinking on myopia and eyestrain, see Lewis M. Terman, The Hygiene of the School Child (Boston: Houghton Mifflin, 1914), 245–81. 36. Ernest Bryant Hoag, Health Studies (Boston: D. C. Heath, 1909), 216–17; L. Emmett Holt, The Diseases of Infancy and Childhood: For Use of Students and Practitioners of Medicine 6th ed. (New York: Appleton, 1914), 294–303; Abraham Jacobi, “Contagious Diseases, Their Relative Communicability, Dissemination, and Prevention,” in Proceedings of the Fifth Congress of the American School Hygiene Association (Springfield, MA: American School Hygiene Association, 1911), 53. On the operation’s rise and then decline in popularity, see Gerald Grob, “The Rise and Decline of Tonsillectomy in Twentieth-Century America,” Journal of the History of Medicine and Allied Sciences 62 (2007): 383–412. 37. Perceval Macleod Yearsley, Adenoids (London: Medical Times, 1901), 7–13. 38. For a review of evolving medical thinking on adenoids and their relation to school performance, see William Burnham, “The Hygiene of the Nose,” Pedagogical Seminary (1908): 155–69; Terman, The Hygiene of the School Child, 197–219. 39. William Osler, The Principles and Practice of Medicine, 8th ed. (New York: D. Appleton, 1919), 468–71; “Neglect Imperils Pupils,” New York Times, November 17, 1908; “Operation Cures Bad Boy,” ibid., August 9, 1915. 40. “Health Education,” in Encyclopedia Americana (New York: Encyclopedia Americana, 1919), 14:30. For an overview of contemporary theory on how the teeth, gums, tonsils, and adenoids formed an interconnected focal point of infection see Terman, The Hygiene of the School Child, 165–95. 41. “Infectious Diseases, Oral Hygiene, and Dental Inspection,” Dental Digest 16 (1910): 273–74; W. A. Evans, “The Relation of Conditions of the Oral Cavity to the Health and Morals of School Children,” Dental Digest 16 (1910): 290–94. 42. Quoted in Leonard P. Ayres and May Ayres, Health Work in the Public Schools (Cleveland: Survey Committee of the Cleveland Foundation, 1915), 29. It should be noted that there is some question as to whether Osler actually said this. 43. Hoag and Terman, Health Work in the Schools, 110–11. 44. Chapin, “Municipal Sanitation,” 670–72. 45. Lewis Terman, “School Clinics for Free Medical and Dental Treatment,” Psychological Clinic 5 (1912): 276. 46. George Goler, “Medical Inspection in Rochester,” in Transactions of the Fourth International Congress on School Hygiene, 4:160. 47. William Gallivan, “School Clinics,” in Transactions of the Fourth International Congress on School Hygiene, 4:467. 48. Quoted in Gulick and Ayres, Medical Inspection, rev. ed., 87.

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Notes to Pages 141–146

49. In 1917 Rhode Island authorized school committees to use school funds for dental treatment, and Pennsylvania did the same for dental and eye treatments. See Edith Lindsay, “Origins and Development of the School Health Movement in the United States” (PhD diss., Stanford University, 1943), 400. 50. “Report of the Committee on Medical Inspection in the Schools,” Journal of the American Medical Association 57 (1911): 1750–851; “McGilvra et al. v. Seattle School Dist. No. 1, 113 Wash., January 1921,” Pacific Reporter 194 (1921): 817–20. See also Nelson, Good Schools, 146–64. 51. Quoted in Julia Graham Lear, “School-Based Services and Adolescent Health: Past, Present and Future,” accessed March 2, 2011, http://www.healthinschools.org/ static/papers/past-future.aspx. See also “Dental Clinic Saved for Los Angeles,” Dental Digest 28 (1922): 23. 52. Quoted in Stewart, “Medical Inspection of School Children,” 198. 53. The New York Times reported: ‘“Jackleg’ doctors, who practice among the poverty stricken tenement dwellers, are blamed for inciting the panic.” (“East Side Parents Storm the Schools,” June 28, 1906). For an in-depth analysis of the riot, see Alan M. Kraut, Silent Travelers: Germs, Genes, and the Immigrant Menace (New York: Basic, 1994), 226–54. 54. Terman, “School Clinics,” 277; Chapin, “Municipal Sanitation,” 670. 55. Baker, Child Hygiene, 295. See also Morris Ogan, “How Can Better Results Be Obtained in Securing Correction of Defects,” in Proceedings of the Tenth Congress of the American School Hygiene Association (Springfield, MA: American School Hygiene Association 1917), 142–49. 56. “School Children’s Defects,” New York Times, September 2, 1913. 57. “Free Eye-Glasses for School Children,” Charities and the Commons 18 (1907): 130–31. 58. “Free Glasses Plan Meets Opposition,” New York Times, April 20, 1907. 59. “Medical Inspection,” Chicago Daily Tribune, December 30, 1916. 60. Lawrence Augustus Averill, “The School Clinic,” American Journal of School Hygiene 1 (1917): 96. 61. For a description of the establishment and operation of the New York clinics, see Baker, “School Medical Inspection in New York City,” 4:338; J. H. Berkowitz, Free Municipal Clinics for School Children: A Review of the Work of the School Children’s Nose and Throat Clinics in New York City and Conditions which Necessitate Such Institutions (New York: Department of Health of the City of New York, 1916); Nelson, Good Schools, 100. 62. Burks and Burks, “Public School Clinics,” 244; “School Clinic Requires Aid,” Los Angeles Times December 17, 1914; “Practical Aid for Many Thousands of Children,” ibid., December 12, 1915. 63. Edwin S. Ingersoll, “Report of the Tonsil and Adenoid Clinics in Rochester during 1920 and 1921,” in Proceedings of the Thirteenth Congress of the American School Hygiene Association, 1921 (Springfield, MA: American School Hygiene Association, 1922), 173–76; Rosemary Stevens, In Sickness and Wealth: American Hospitals in the Twentieth Century (New York: Basic, 1989), 106. On American medicine’s embrace of and then disenchantment with tonsillectomies, see Grob, “The Rise and Decline of Tonsillectomy,” 383–412. 64. Berkowitz, The Eyesight of School Children, 49–50; Ayres and Ayres, Health Work in the Public Schools, 30–31.

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Notes to Pages 146–151

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65. Averill, The School Clinic, 96. See also his “The Present Status of School Health Work in the 100 Largest Cities in the United States,” American Journal of School Hygiene 1 (1917): 30–38, 53–62; American Child Health Association, A Health Survey of 86 Cities (New York: American Child Health Association, 1925), 181. 66. Ayres and Ayres, Health Work in the Public Schools, 29. 67. Harvey J. Burkhardt, “The General Plan of the Proposed Work at the Eastman Dispensary,” in Proceedings of the Ninth Congress of the American School Hygiene Association, 279–80; E. L. Pettibone, “The School Dental Clinic as an Economic Factor,” in ibid., 288; J. J. Cronin, “Municipal Control of Dental Clinics,” Dental Cosmos 56 (1914): 153. 68. Pettibone, “The School Dental Clinic,” 287–89; Alyssa Picard, Making the American Mouth: Dentists and Public Health in the Twentieth Century (New Brunswick, NJ: Rutgers University Press, 2009), 14–17; Stephen L. Schlossman, JoAnne Brown, and Michael Sedlak, The Public School in American Dentistry (Santa Monica, CA: Rand, 1986), 8–9. For an account by the principal of the school, see Cordelia O’Neil, “Mouth Hygiene: What It Has Done for Us—What It Can Do for You,” in Transactions of the Fourth International Congress on School Hygiene, 4:206–13. 69. Picard, Making the American Mouth, 17–19; Schlossman, Brown, and Sedlak, The Public School in American Dentistry, 8–10. 70. Herbert L Wheeler, “The Field of Independent Dental Infirmaries,” in Proceedings of the Ninth Congress of the American School Hygiene Association, 274–77; A. Downing, “Oral Hygiene—Where It Begins and Where It Leaves Off,” in ibid., 266; “Dental Clinics,” Journal of the American Medical Association 64 (1915): 1782; “School Board Takes over Dental Clinic from Dental Association,” City of Denver 2 (October 11, 1913): 9–10; Heitmuller, “School Clinics,” 3–5; Newmayer, Medical and Sanitary Inspection of Schools, 2nd ed., 286–87. 71. Quoted in Schlossman, Brown, and Sedlak, The Public School in American Dentistry, 5-6. On the oral hygiene condition of the initial batch of World War I recruits, see “Dental and Oral Conditions of Recruits,” Dental Cosmos (1916): 1071–75. 72. I. H. Goldberger, “A Plea for Oral Hygiene for School Children,” American Journal of School Hygiene 1 (1917): 186. 73. “Ideals of the Heads of the Two School Hygiene Departments Concerning This Work,” January 1, 1916, Box 3, Folder “Public Health Sickness Survey 1916–17,” City Club of Milwaukee: Records, 1909–1975, Milwaukee Manuscript Collection AS, State Historical Society of Wisconsin, Milwaukee Area Research Center, Golda Meir Library, University of Wisconsin–Milwaukee, accessed March 4, 2011, http:// www.mu.edu/cgi-bin/cuap/db.cgi?uid=default&ID=3652&view=Search&mh=1. 74. Picard, Making the American Mouth, 30–34; Schlossman, Brown, and Sedlak, The Public School in American Dentistry, 12–14; Albert Fones, “Report of Five Years of Mouth Hygiene in the Public Schools of Bridgeport,’’ Dental Cosmos 16 (1919): 607–18. 75. Charles Rosenberg, “Social Class and Medical Care in Nineteenth-Century America: The Rise and Fall of the Dispensary,” Journal of the History of Medicine and Allied Sciences 29 (1974): 50; Starr, The Social Transformation of American Medicine, 180–84. 76. Quoted in Robert H. Bremner, Children and Youth in America (Cambridge: Harvard University Press, 1971), 2:917–18. See also James A. Tobey, Public Health Law (New York: Commonwealth Fund, 1939), 249.

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Notes to Pages 151–155

77. “Minutes of the Seventy-third Annual Meeting of the American Medical Association Held in St. Louis, May 22–26, 1922,” Journal of the American Medical Association 78 (1922): 1715. 78. Thomas D. Wood and Hugh Grant Rowell, Health Supervision and Medical Inspection of Schools (Philadelphia: W. B. Saunders, 1927), 51. 79. “Drop Dental Work in Public Schools,” New York Times, February 14, 1924. See also “Says Dentists Ask Clinics in Schools,” ibid., February 25, 1924; “Schools to Retain Dental Clinics,” ibid., February 28, 1924. 80. American Child Health Association, Health Survey of 86 Cities, 181; Miriam S. Leuck, A Further Study of Dental Clinics in the United States (Chicago: University of Chicago Press, 1932), 106. 81. Michael M. Davis, Community Dental Service (Chicago: American Hospital Association, 1922), 86; “School Board Takes over Dental Clinic,” 10; Report and Handbook of the Department of Health of the City of Chicago for the Years 1911–1918 Inclusive (Chicago: Severinghaus, 1919), 561; US Bureau of Education, Biennial Survey of Education, 1916–1918 (Washington: Government Printing Office, 1921), 1417. 82. “Dental Clinics to be in New City Schools,” Chicago Daily Tribune, December 21, 1927; US Bureau of Education, Biennial Survey of Education, 1916–1918, 1417. 83. US Bureau of Education, Biennial Survey of Education, 1916–1918, 1417; Schlossman, Brown, and Sedlak, The Public School in American Dentistry, 20; Davis, Community Dental Service, 73–74. 84. “Free Dental Clinic for Children,” New York Times, January 2, 1917; William J. Gies, Dental Education in the United States and Canada (New York: Carnegie Foundation for the Advancement of Teaching, 1926), 265, 273, 324–26, 411–12; Davis, Community Dental Service, 26–27, 44. 85. Leuck, A Further Study of Dental Clinics in the United States, 107; Newmayer, Medical and Sanitary Inspection of Schools, 2nd ed., 286–87; Davis, Community Dental Service, 86; “Teeth of Pupils Bad,” Washington Post, April 29, 1917; “Clinics for Teeth of School Children,” ibid., September 27, 1917; “Children’s Teeth Will Be Cared For,” ibid., September 8, 1918; “Free Dental Clinics: They Offer the Rich an Almost Untouched Charity,” New York Times, August 8, 1915; “Mrs. V. Astor Gives Benefit at Her Home: 800 at Entertainment in Aid of Free Dental Clinic,” ibid., January 18, 1922. 86. “Boston’s Dental Infirmary,” New York Times, November 14, 1912. See also “Dedication of Forsyth Dental Infirmary for Children,” Items of Interest: A Magazine of Dental Art, Science and Literature 37 (1915): 1–14. For a detailed history of the founding and growth of the Forsyth Clinic, see Rollo Walter Brown, Dr. Howe and the Forsyth Infirmary (Cambridge: Harvard University Press, 1952). 87. Harold D. Cross, “The Work of the Forsyth Clinic among School Children,” in Proceedings of the Thirteenth Congress of the American School Hygiene Association, 52–56. See also Herbert Wheeler, “The Field of Independent Dental Infirmaries,” in Proceedings of the Ninth Congress of the American School Hygiene Association (Springfield, MA, 1917), 280–83; Gies, Dental Education in the United States and Canada, 265, 273, 324–26. 88. Cross, “The Work of the Forsyth Clinic among School Children,” 54–56; Davis, Community Dental Service, 50–57. 89. “Urges Dental Work for 900,000 Pupils: Dr. L. W. Loxtater Favors a $5,000,000 Dispensary and Institute for Research,” New York Times, May 28, 1916; Irwin Unger, The Guggenheims: A Family History (New York: HarperCollins, 2005), 197–98.

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90. Quoted in “City to Get Huge Dental Clinic: Announced as Unequaled Anywhere in the World,” Chicago Tribune, January 19, 1923. See also “Fixing Teeth Free for Poor Kiddies, Plan,” ibid., January 22, 1922; “Where Dental Woes of Poor Children Will Be Looked After,” ibid., December 24, 1922; “200,000 Relic of City Pageant Put on Block: Council Seeks to Dispose of Dental Clinic,” ibid., October 27, 1928. 91. Harvey J. Burkhardt, “Dentistry and Health Conservation,” Modern Medicine 1 (1919): 79–82; Burkhardt, “The General Plan of the Proposed Work at the Eastman Dispensary,” 279–80. 6. The Best of Times, the Worst of Times

1. J. H. Berkowitz, Standardization of Medical Inspection Facilities (Washington: Government Printing Office, 1919). 2. Philander Claxton, “Letter of Transmittal,” in ibid., 4. 3. Ellwood Cubberly, introduction to Charles Keene, The Physical Welfare of the School Child (Boston: Houghton-Mifflin, 1929), v. 4. Report of the Provost General to the Secretary of War on the First Draft under the Selective Service Act, 1917 (Washington: Government Printing Office, 1918), 44–48; Woods Hutchinson, “Weighed in the Balance of War: How Our National Physique Stood the Acid Test of the Draft,” Red Cross Magazine, April 1919, 38–42. 5. American Child Health Association, A Health Survey of 86 Cities (New York: American Child Health Association, 1925), 147. 6. See, for example, “A Billion Dollars a Year Wasted,” Journal of the National Education Association 11 (1922): 422–23. 7. Thomas D. Wood, Health Service in City Schools of the United States: Report of the Joint Committee on Health Problems in Education of the National Education Association and the American Medical Association (New York, 1922); Thomas D. Wood and Hugh Grant Rowell, Health Supervision and Medical Inspection of Schools (Philadelphia: W. B. Saunders, 1927), 167. Not surprisingly, the joint committee found that most of the diagnostic and treatment services were dental. 8. Alyssa Picard, Making the American Mouth: Dentists and Public Health in the Twentieth Century (New Brunswick, NJ: Rutgers University Press, 2009), 2. 9. Margaret Gray Blanton and Smiley Blanton, Speech Training for Children: The Hygiene of Speech (New York: Century, 1919); Frederick Martin, “The Prevention and Correction of Speech Defects,” in Proceedings of the Twelfth Congress of the American School Hygiene Association, 1920 (Springfield, MA: American School Hygiene Association, 1921), 153–58. 10. Lewis Terman and John C. Almack, The Hygiene of the School Child (Boston: Houghton Mifflin, 1929), 71–89; S. Josephine Baker, Child Hygiene (New York: Harper and Brothers, 1925), 404; Wood and Rowell, Health Supervision, 409–43. For overviews, see David Yosifon and Peter N. Sterns, “The Rise and Fall of American Posture,” American Historical Review 103 (1998): 1057–95; and Beth Linker, “A Dangerous Curve: The Role of History in Scoliosis Screening,” American Journal of Public Health 102 (2012): 606–16. 11. When Henry Goddard estimated in 1911 that 2 percent of New York City schoolchildren were severely feebleminded, many objected that his figure was much too high. By 1920, however, the consensus, based on subsequent studies and the draft exams, was that it was substantially too low. See William H. Burnham, “The Significance of a Mental Examination of Children at School Entrance,” in Proceedings of the Twelfth Congress of the American School Hygiene Association, 164–67; Edgar A. Doll, “Psychiatry and

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12. 13.

14.

15.

16.

17.

18.

19.

20. 21.

Notes to Pages 160–162

Psychology in School Hygiene,” in Proceedings of the Thirteenth Congress of the American School Hygiene Association, 1921 (Springfield, MA: American School Hygiene Association, 1922), 177–80. Doll, “Psychiatry and Psychology in School Hygiene,” 177. On the entrance of psychologists into the schools as mental health examiners and IQ testers, see T. K. Fagen, “Compulsory Schooling, Child Study, Clinical Psychology, and Special Education: Origins of School Psychology,” American Psychologist 47 (1992): 236–43; Sol Cohen, “The Mental Hygiene Movement, the Development of Personality, and the School: The Medicalization of American Education,” History of Education Quarterly 23 (1983): 123–50; Paul D. Chapman, Schools as Sorters: Lewis M. Terman, Applied Psychology, and the Intelligence Testing Movement, 1890–1930 (New York: New York University Press, 1988). See in particular Cohen, “The Mental Hygiene Movement.” For a contrary opinion, more in line with the one expressed here, see Stephen Petrina, “The Medicalization of Education: A Historiographic Synthesis,” History of Education Quarterly 46 (2006): 503–31. On the increasing tendency to define troublesome and failing students as emotionally and psychologically maladjusted rather than as physically defective, see Michael Sedlak, “The Uneasy Alliance of Mental Health Services and the Schools,” American Journal of Orthopsychiatry 67 (1997): 356–57. For a contemporary description of such work, see “How Our Schools Save Children from Handicaps: Maladjusted Children Are Studied by the Psychological Clinic,” New York Times, August 4, 1929. Evelyn M. Goldsmith, “The Place of the Crippled Child in the Public School System,” School Hygiene 1 (1908): 114–17; Terman and Almack, The Hygiene of the School Child, 90–91. The 1916 infantile paralysis epidemic, the first of a number of major polio outbreaks to sweep the country, affected an estimated 15,000 to 27,000 Americans, 80 percent of whom were under five. See Henry Edward Abt, The Care, Cure, and Education of the Crippled Child, reprint ed. (New York: Arno, 1974), 3. On the war and the expansion of rehabilitative services, see Beth Linker, War’s Waste: Rehabilitation in World War I America (Chicago: University of Chicago Press, 2011). “State Care for Crippled Children,” in Children and Youth in America, ed. Robert Bremner with associate editors John Barnard, Tamara K. Hareven, and Robert M. Mennel (Cambridge: Harvard University Press, 1971), 2:1032–40; Abt, The Care, Cure, and Education, 23–25, 53–59; Terman and Almack, The Hygiene of the School Child, 90–93. On the creation of such classes, see Margaret A Winzer, “From Isolation to Segregation: The Emergence of Special Classes,” in The History of Special Education: From Isolation to Integration (Washington: Gallaudet University Press, 1993), 312–36. Robert Hurtin Halsey, “Heart Disease among School Children,” in Proceedings of the Thirteenth Congress of the American School Hygiene Association, 96–99; A. K. Aldinger, “Recent Tendencies in Physical Education,” in ibid., 165. R. B. Irwin, “Sight Saving Classes for the Partially Blind,” in Proceedings of the Twelfth Congress of the American School Hygiene Association, 103–4. Naomi Rogers, Dirt and Disease: Polio before FDR (New Brunswick, NJ: Rutgers University Press, 1992), 11; “Poliomyelitis and the Schools,” American Medicine 22 (1916): 599–600; “Parents Plan Fight on School Date,” New York Times, September 19, 1916; “Appeal to Mitchel in Paralysis Fight: Parents of 18th School District Urge Him to Delay School Opening,” ibid., September 21, 1916; “Mayor to Confer on School Opening,” ibid., September 22, 1916.

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22. “Closing Schools as a Means of Controlling Epidemics,” in US Bureau of Education, Biennial Survey of Education, 1916–1918 (Washington: Government Printing Office, 1918), 409; US Office of Education, Annual Report of the Commissioner of Education, 1919 (Washington: Government Printing Office, 1920), 60; Wood and Rowell, Health Supervision, 124; Baker, Child Hygiene, 330–31. For a recent reevaluation of the comparative benefits of closing schools or keeping them open during the epidemic, see Alexandra Stern, Martin Cetron, and Howard Markel, “Closing the Schools: Lessons from the 1918–19 Influenza Pandemic,” in Health Affairs 28 (2009): 1066–78. 23. For detailed historical analyses of New York’s initiation of Schick testing and immunization in the schools, see Evelynn Maxine Hammonds, Childhood’s Deadly Scourge: The Campaign to Control Diphtheria in New York City, 1880–1930 (Baltimore: Johns Hopkins University Press, 1999), 176–90; James Colgrove, State of Immunity: The Politics of Vaccination in Twentieth-Century America (Berkeley: University of California Press, 2006), 81–112. For a contemporary account, see Abraham Zingher, “Diphtheria Preventive Work in the Public Schools of New York City,” Archives of Pediatrics 38 (1921): 336–59. For the use of orphans in vaccine trials and other medical experimentation, see Susan E. Lederer, “Orphans as Guinea Pigs: American Children and Medical Experimenters, 1890–1930,” in In the Name of the Child: Health and Welfare, 1880–1940, ed. Roger Cooter (London: Routledge, 1992), 96–123. 24. Clarence L. Seaman, “Diphtheria Immunization in Providence, A Progress Report,” Rhode Island Medical Journal 8 (1925): 146–47; Report of the Department of Health of the City of Chicago for the Years 1923, 1924, and 1925 (Chicago, 1926), 208. 25. James Wallace, The State Health Departments of Massachusetts, Michigan, and Ohio with a Summary of Their Activities and Accomplishments, 1927–1928 (New York: Commonwealth Fund, 1930), 55, 61. 26. Ethel Wakeman, “Bringing Medical Help to High School Pupils,” Hygea 7 (1929): 275–78; “High School Health Programs,” in Proceedings of the High School Conference of November 21, 22, 23, 1918 (Urbana: University of Illinois Press, 1919), 55–56, 61; American Child Health Association, Health Trends in Secondary Education (New York: American Child Health Association, 1927), 1–5; National Education Association of the United States, Cardinal Principles of Secondary Education: A Report of the Commission on the Reorganization of Secondary Education (Washington: Government Printing Office, 1918), 11. 27. Arnold Gesell, The Preschool Child from the Standpoint of Public Hygiene and Education (Boston: Houghton-Mifflin, 1923), ix. On the discovery of the preschool child by child hygiene, see Robert Tank, “Young Children, Families, and Society in America during the 1920s: The Evolution of Health, Education, and Childcare Programs for Preschool Children” (PhD diss., University of Michigan, 1980), 164– 82. For a good brief look at Gesell, who was the director of the Yale Clinic of Child Development for many years, see Alice Boardman Smuts, Science in the Service of Child, 1893–1935 (New Haven: Yale University Press, 2006), 173–90. On the emergence of the science of child development, the best overview remains Hamilton Cravens, Before Head Start: The Iowa Station and America’s Children (Chapel Hill: University of North Carolina Press, 1993). 28. Philip Van Ingen, The Story of the American Child Health Association (New York: American Child Health Association, 1936), 10; Ellen S. Stewart, “The New World and the Demand It Will Make upon Public Education and American Homes,” in Proceedings and Addresses of the National Education Association, 1919 (Washington:

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29.

30.

31.

32.

33.

34.

Notes to Pages 166–168

National Education Association, 1919), 56; Thomas D. Wood, “Report of the Committee on Health Problems in Schools,” in ibid., 159; Charles B. Lewis, “The Scope and Value of Health Inspection in the Public Schools,” in Proceedings of the Twelfth Congress of the American School Hygiene Association, 85; Ellen C. Lombard, Parent Education (Washington: Government Printing Office, 1929): 13–14. On the Rockefeller Sanitary Commission’s campaign to eradicate hookworm in the South, see John Ettling, The Germ of Laziness: Rockefeller Philanthropy and Public Health in the New South (Cambridge: Harvard University Press, 1981). On the effect of that campaign on efforts to promote medical inspection and other programs to improve southern schoolchildren’s health, see William A. Link, “Privies, Progressivism, and Public Schools: Health Reform and Education in the Rural South, 1909– 1920,” Journal of Southern History 54 (1988): 623–42. Thomas D. Wood, “Report of the Joint Committee on Health Problems in Education,” Journal of Education 81 (1915): 327. The investigation ultimately yielded three reports: Joint Committee on Health Problems in Education, Minimum Sanitary Requirements for Rural Schools (Chicago: Press of the American Medical Association, 1914), Rural School Houses and Grounds (Chicago: Press of the American Medical Association, 1914), and Health Essential of Rural School Children (Chicago: Press of the American Medical Association, 1916). See also William A. Howe, “The System of School Medical Inspection in New York State,” in Proceedings of the Tenth Congress of the American School Hygiene Association, 1917 (Springfield, MA: American School Hygiene Association, 1918), 178–79; James Wingate, “How Can Better Results Be Obtained in Securing Correction of Defects of Children in Rural Communities,” in ibid., 154. Philip Sumner Spence, “School Children in City Healthier than in Country,” New York Times, March 8, 1914; Wood, “Report of the Joint Committee,” 327. In Chicago, Health Commissioner W. A. Evans broadcast the report’s findings in his Chicago Daily Tribune column, “How to Keep Well,” and over the next few years he regularly reported on surveys in both Illinois and other states that revealed the unhealthiness of rural school children. See, for example, W. A. Evans, Chicago Daily Tribune, July 3, 1914; January 27, 1915; and April 16, 1916. Baker, Child Hygiene, 308; Tallaferro Clark, “The Physical Care of Rural School Children,” Public Health Reports 31 (1916): 2759–64; Keene, The Physical Welfare of the School Child, 409–36; Mildred B. Curtis, “Health Problems of Our Rural School Children,” in Proceedings of the Tenth Congress of the American School Hygiene Association, 24–26. See, for instance, “Rural-School Health,” in Keene, The Physical Welfare of the School Child, 409–36; Joint Committee on Health Problems in Education of the National Education Association and the American Medical Association, Health Essentials for Rural School Children (Chicago: Press of the American Medical Association, 1921); Noah Showalter, Handbook for Rural School Officers (Boston: Houghton Mifflin, 1923). A proposal for federal funding of school health services had first been put forth in 1919 as part of a more comprehensive education funding bill that was the initial salvo in an unsuccessful fourteen-year struggle to create a federal department of education. Correctly judging that the comprehensive legislation was doomed, supporters of the proposal drafted legislation dealing only with it. On the battles over the more comprehensive legislations, see Douglas J. Slawson, The Department of Education Battle, 1918–1932: Public Schools, Catholic Schools, and the Social Order

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36.

37.

38.

39. 40. 41.

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(Notre Dame, IN: University of Notre Dame Press, 2005); “The Towner-Sterling Bill,” Capital Eye 1, no. 3 (1921): 3–9. On the battle over the exclusive physical education legislation, see “Fess-Capper Physical Education Bill,” in Report of the Commissioner of Education for the Year Ending June 30, 1920 (Washington: Government Printing Office, 1920): 66–67; James Harlean, “Of, For, and By the People: Humanitarian Measures Before Congress,” American Review of Reviews 63 (1921): 192–96; “The Fess-Capper Bill,” Capital Eye 1, no. 3 (1921): 10–14; Federal Aid for Physical Education: Hearing before the Committee on Education, House of Representative, Sixty-Sixth Congress on H.R. 12652 (Washington: Government Printing Office, 1921); M. G. Braumbaugh, “Amended Fess-Capper Physical Education Bill,” American Physical Education Review 27 (1922): 29–30; “Educational Bills before the 68th Congress,” High School Journal 7 (1924): 93–97. William Shonick, Government Health Services: Government’s Role in the Creation of Health Services 1930–1980 (New York: Oxford University Press, 1995), 169–70. For an overview of federal policy toward the health of Indian schoolchildren, see David H. DeJong, “Unless They Are Kept Alive: Federal Indian Schools and Student Health,” American Indian Quarterly 31 (2007): 256–82. For an early assessment of Indian schoolchildren’s health status, see J. W. Schereschewsky, “Infectious and Contagious Diseases among Indian School Children,” in Transactions of the Fourth International Congress on School Hygiene, ed. Thomas A. Storey (Buffalo, NY: Courier, 1914), 4:502–11. For the campaign against trachoma, see Robert Trennert, “Indian Sore Eyes: The Federal Campaign to Control Trachoma in the Southwest, 1910–1940,” Journal of the Southwest 32 (1990): 121–49; Todd Benson, “Blinded with Science: American Indians, the Office of Indian Affairs, and the Federal Campaign against Trachoma, 1924–1927,” American Indian Culture and Research Journal 23 (1999): 119–42. Signaling the discovery of the health of African American children as a health issue, in 1926 the Weekly Report of the US Public Health Service carried for the first time a series of reports on the health of those children. On the discovery of the health of African Americans as a public health issue, see David McBride, From TB to AIDS: Epidemics among Urban Blacks since 1900 (Albany: State University of New York Press, 1991), 69–82. On Dressler and the Rosenwald schools, see Peter M. Ascoli, Julius Rosenwald: The Man Who Built Sears, Roebuck and Advanced the Cause of Black Education in the American South (Bloomington: Indiana University Press, 2006), 233–36. For an excellent treatment of this phenomenon, see Carita Constable Huang, “Making Children Normal: Standardizing Children in the United States, 1885–1930” (PhD diss., University of Pennsylvania, 2004): 268–449. Kenneth D. Blackfan, “Abstract of the Report of the Committee on Growth and Development,” in White House Conference on Child Health and Protection, White House Conference 1930: Addresses and Abstracts of Committee Reports (New York: Century, 1931), 54. Herbert Hoover, “Opening Address,” in ibid., 7–8. Quoted in James W. Trent Jr., Inventing the Feeble Mind: A History of Mental Retardation in the United States (Berkeley: University of California Press, 1994), 148. David B. Tyack, “Health and Social Services in Public Schools: Historical Perspectives,” Future of Children 2 (1992): 5–7, 15; Joint Committee on Health Problems in Education, Health Service in City Schools of the United States, 4–11; James Frederick Rogers, comp., School Health Activities in 1930: Summary of Information Collected for the White House Conference on Child Health and Protection (Washington: Government Printing Office, 1931), 3, 19.

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Notes to Pages 171–177

42. Quoted in “Maxwell Pleads for School Hygiene,” New York Times, January 19, 1908. 43. As early as 1917 Boston’s superintendent of schools remarked on the growing conviction that that the “mental and scholastic shortcomings of certain pupils were unremediable [sic], or practically so” (Annual Report of the Superintendent of Schools, City of Boston, 1917 [Boston: Boston Printing Department, 1918], 102–3). 44. Lewis M. Terman, The Intelligence of School Children (Boston: Houghton Mifflin, 1919), 111, 115–17. 45. See, for instance, William C. Bagley, “Professor Terman’s Determinism,” Journal of Educational Research 6 (1922): 376–85. For a thought-provoking and slightly different interpretation than mine of this transition, see Stephen Woolworth, “When Physicians and Psychologists Parted Ways: Professional Turf Wars in Child Study and Special Education,” in Science Encounters the Child: Education, Parenting, and Child Welfare in 20th-Century America, ed. Barbara Beatty, Emily Cahan, and Julia Grant (New York: Teachers College Press, 2006), 96–115. 46. S. W. Newmayer, Medical and Sanitary Inspection of Schools, 2nd ed. (Philadelphia: Lea and Febinger, 1924), 346; Baker, Child Hygiene, 379. See also Chapman, Schools as Sorters, 85–92. 47. Baker, Child Hygiene, 354. See also Wood and Rowell, Health Supervision, 260; Keene, The Physical Welfare of the School Child, 9. 48. “After Examination—What?,” Survey 64 (1930): 354; S. Josephine Baker, Fighting for Life (New York: Macmillan, 1939), 115–16. 49. W. A. Howe, “Efficiency in School Health Service,” Educational Review 64 (1922): 58–59; Frederick Green, “Cooperation of Physicians in Health Work in Schools,” in Proceedings and Addresses of the National Education Association, 1919, 167; William A. Howe, “The System of School Medical Inspection in New York State,” in Proceedings of the Tenth Congress of the American School Hygiene Association, 178–79; “127 Nurses Out, Dr Robertson Fears Epidemic,” Chicago Daily Tribune, November 22, 1919. 50. “Ruhland Expands Duties of School Nurses,” Milwaukee Sentinel, August 11, 1920; John Duffy, A History of Public Health in New York City, 1866–1966 (New York: Russell Sage Foundation, 1974), 321; “Medical Examination of New York City School Children,” School and Society 33 (1929): 196–97; Baker, Child Hygiene, 269. 51. Keene, The Physical Welfare of the School Child, 9. 52. Baker, Child Hygiene, 352. 53. Wood and Rowell, Health Supervision, 36. 54. Huang, “Making Children Normal,” 51–59; Roberta J. Park, “Physiologists, Physicians, and Physical Educators: Nineteenth-Century Biology and Exercise, Hygienic and Educative,” International Journal of the History of Sport 24 (2007): 1637–73; Lee F. Hamner, The Gary Schools: Physical Education and Play (New York: General Education Board, 1918), 5–7. The classic study of the Gary plan remains Ronald Cohen and Raymond A. Mohl, The Paradox of Progressive Education: The Gary Plan and Urban Schooling (Port Washington, NY: Kennikat, 1979). 55. The Curriculum of the Horace Mann Elementary School (New York: Teachers College, Columbia University, 1918), 136–38; “Brief Retrospect of the Three Years’ Work of the National Physical Education Association in Promoting State Legislation (1919–1920–1921),” American Physical Education Review 27 (1922): 388. 56. On the formation of the Child Health Organization, see Huang, “Making Children Normal,” 271; “Child Health Organization of America,” in The Greenwood Encyclopedia of American Institutions: Social Service Organizations, ed. Peter Romanofsky

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171 172 172 172 173 173 173 174 175 175 175 176 176 177 177

Notes to Pages 178–183

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178 178 178 178 179 179 179 180 180 181 181 181 182 182 183

57. 58. 59.

60.

61. 62. 63.

64.

65.

66.

67.

68. 69. 70. 71.

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(Westport, CT: Greenwood, 1978), 1:220–22; Philip Van Ingen, “The History of Child Welfare Work in the United States,” in A Half Century of Public Health, ed. Mayzyck P. Ravenel (New York: American Public Health Association, 1921), 302– 4; Richard K. Means, A History of Health Education in the United States (Philadelphia: Lea and Febiger, 1962), 123–30. See chapter 3. See also Huang, “Making Children Normal,” especially chapters 3 and 4; and Terman, The Hygiene of the School Child, 61–71. Walter S. Cornell, Health and Medical Inspection of School Children (Philadelphia: F. A. Davis, 1912), 51. Marguerite Vollmer, Sally Lucas Jean: Health Education Pioneer (Geneva: International Journal of Health Education, 1973), 48–49; Edith Lindsay, “Origins and Development of the School Health Movement in the United States” (PhD diss., Stanford University, 1943), 247–48; Huang, “Making Children Normal,” 293–94; Van Ingen, “The History of Child Welfare Work in the United States,” 303. L. Emmett Holt, Food, Health and Growth: A Discussion of the Nutrition of Children (New York: Macmillan, 1922), 3–4. See also his Weighing and Measuring: A Guide to Progress in Health (New York: American Child Hygiene Association, 1924). Wood and Rowell, Health Supervision, 80. Terman and Almack, The Hygiene of the School Child, 46–47. Jeffrey P. Brosco, “Weight Charts and Well Child Care: When the Pediatrician Became the Expert in Child Health,” in Formative Years: Children’s Health in the United States, 1880–2000, ed. Alexandra Minna Stern and Howard Markel (Ann Arbor: University of Michigan Press, 2002), 93–94; Huang, “Making Children Normal,” 304–10. For a good contemporary discussion of the development of weight charts and their application as a child health surveillance tool, see Baker, Child Hygiene, 418–23. Sally Lucas Jean, “Interesting School Children in Health Habits,” in Proceedings of the Twelfth Congress of the American School Hygiene Association, 167–71; Vollmer, Sally Lucas Jean, 45–50. Alcott published a revised and enlarged edition in 1837, and that was the edition that was most widely circulated. On antebellum health education in the schools, see Elizabeth Toon, “Teaching Children about Health,” in Children in Youth in Sickness and Health, ed. Janet Golden, Richard A. Meckel, and Heather Munro Prescott (Westport, CT: Greenwood, 2004), 85–89; Charles Rosenberg, “Catechisms of Health: The Body in the Prebellum Classroom,” Bulletin of the History of Medicine 69 (1995): 175–97. For an in-depth historical analysis of temperance education in American schools, see Jonathan Zimmerman, Distilling Democracy: Alcohol Education in America’s Public Schools, 1880–1925 (Lawrence: University of Kansas Press, 1999). Thomas D. Wood, “Health and Education,” in Ninth Yearbook of the National Society for the Study of Education, ed. Thomas D. Wood (Chicago: University of Chicago Press, 1910), 62–65. Ernest Bryant Hoag and Lewis M. Terman, Health Work in the Schools (Boston: Houghton Mifflin, 1914), 233. Means, A History of Health Education, 128 (see also 136). See also Vollmer, Sally Lucas Jean, 24–38. Anne Whitney, Who’s Who in Health Land (Washington: Government Printing Office, 1923), frontispiece. Vollmer, Sally Lucas Jean, 46–47; Means, A History of Health Education, 128–30; Frank Ward O’Malley, “Cho Cho’s Sugar Coated Lessons,” Red Cross Magazine 14 (November 1919): 26–30, 68–69.

246

Notes to Pages 183–189

72. Endorsed by the National Education Association, the Crusade for Health came to involve tens of thousands of schoolchildren. See Terman and Almack, The Hygiene of the School Child, 484; Naomi Rogers, “Vegetables on Parade: American Medicine and the Child Health Movement in the Jazz Age,” in Children’s Health Issues in Historical Perspective, ed. Cheryl Krasnick Warsh and Veronica Strong-Boag (Waterloo, ON: Wilfred Laurier University Press, 2005), 31–32; Van Ingen, “The History of Child Welfare Work in the United States,” 304–5. 73. O’Malley, “Cho Cho’s Sugar Coated Lessons,” 29. 74. Means, A History of Health Education, 187–88; “Child Health Organization of America,” 1:222. 75. US Bureau of Education, Health for School Children: Report of the Advisory Committee on Health Education of the National Child Health Council (Washington: Government Printing Office, 1923), 15–16. 76. Richard K. Means, “A Leader in Health Education: The Metropolitan Insurance Company,” Health Education 16 (1985): 44–46l; Means, A History of Health Education, 87–88; Rogers, “Vegetables on Parade,” 37; Toon, “Teaching Children About Health,” 97. 77. Aubyn Chinn, Health Habits: Suggestions for Developing Them in School Children (Chicago: National Dairy Association, 1924). On the industry’s effort to increase consumption by promoting milk as the perfect food for growing children, see E. Melanie DuPuis, Nature’s Perfect Food: How Milk Became America’s Drink (New York: New York University Press, 2002), 90–123. For a reproduction of a milk contract, see Wood and Rowell, Health Supervision, 406. 78. Complicating the conflict between school nutritionists and immigrant parents was the complex role that food played in turn-of-the-century immigrant groups’ acculturation and construction of ethnic identities. For a description and analysis of that role, see Hasia Diner, Hungering for America: Italian, Irish, and Jewish Foodways in the Age of Migration (Cambridge: Harvard University Press, 2003). 79. Quoted in Huang, “Making Children Normal,” 286. 80. See note 34 above. 81. Rogers, “Vegetables on Parade,” 39. 82. American Child Health Association, A Health Survey of 86 Cities (New York: American Child Health Association, 1925), 148–49. 83. American School Health Association, “About ASHA,” accessed February 2, 2013, http://www.ashaweb.org/i4a/pages/index.cfm?pageid=3279. 84. Elizabeth Ewen, Immigrant Women in the Land of Dollars: Life and Culture on the Lower East Side (New York: Monthly Review, 1985), 139. See also Daniel Burstein, Next to Godliness: Confronting Dirt and Despair in Progressive Era New York (Urbana: University of Illinois Press, 2006) 85. On child-rearing advice during the 1920s, see especially Julia Grant, Raising Baby by the Book: The Education of American Mothers (New Haven: Yale University Press, 1998). 86. Hugh Chaplin and Edward Strecker, Signs of Health in Childhood: A Picture of the Optimal Child with Some Suggestions as to How This Ideal May Be Attained (New York: American Child Health Association, 1927). 87. Patricia Ann Regan, “A Historical Review of the School Nurse’s Role in School Health Programs, 1902–1973” (EdD diss., Boston University, 1974), 45–47. 88. Charles-Edward Amory Winslow and Pauline Brooks Williamson, The Laws of Health and How to Teach Them (New York: Charles E. Merrill, 1925), 169. On the

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183 183 184 184 185 185 185 186 186 186 187 187 187 187 188 188 189

Notes to Pages 189–197

6-89 189 6-90 189 6-91 189 6-92 190 6-93 191 6-94 191 6-95 192 6-96 192 6-97 193 6-98 193 6-99 193 6-100 193 6-101 193 7-1 197

89. 90.

91. 92.

93. 94. 95. 96. 97. 98. 99.

100. 101.

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new public health, see George Rosen, A History of Public Health (New York: MD Publications, 1958), 393–404; James H. Cassedy, Charles V. Chapin and the Public Health Movement (Cambridge: Harvard University Press, 1962), 126–42; Barbara Gutman Rosenkrantz, Public Health and the State: Changing Views in Massachusetts, 1842–1936 (Cambridge: Harvard University Press, 1972), 128–76; John Duffy: The Sanitarians: A History of American Public Health (Urbana: University of Illinois Press, 1990), 205–20. Baker, Child Hygiene, 38. Haven Emerson, “The Part of the General Public in Bringing about a Complete Program of Child Health Services,” in Transactions of the First Annual Conference of American Child Health Association, 1923 (New York: American Child Health Association, 1923): 65; see also 71. Rogers, “Vegetables on Parade,” 42–43; Bertha Morris Parker, The Good Health Elves: A Health Play for Children (Chicago: American Medical Association, 1925). William Maxwell, “The Necessity for Departments of Health within Boards of Education,” in Proceedings of the First, Second, and Third Congresses of the American School Hygiene Association, 1907–1909 (Springfield, MA: American School Hygiene Association, 1910), 210. On Dewey’s educational and curricular philosophy and influence on progressive educators, see Lawrence A. Cremin, American Education: The Metropolitan Experience, 1876–1980 (New York: Harper and Row, 1988), 164–74. On urban progressive education and the Americanization of immigrants, see David Tyack, The One Best System: A History of American Urban Education (Cambridge: Harvard University Press, 1974), 229–55. Maud A. Brown, “Health Program in the Kansas City Schools, 1919–21,” Elementary School Journal 22 (1921–22): 132–38. US Bureau of Education, “State Legislation for Physical Education,” in Biennial Survey of Education, 1916–1918 (Washington: Government Printing Office, 1921), 1:418. White House Conference on Child Health and Protection, The School Health Program: Report of the Committee on the School Child (New York: Century, 1932). Hoover, “Opening Address,” 7-8. White House Conference on Child Health and Protection, The School Health Program, 140. Ibid., 249. Although this is asserted throughout the 400-page report, it is most clearly and forcefully articulated in the abstract of the report that had been published the year before. In the abstract, the various services of the school health program are listed one after another and accompanied by a brief explanation emphasizing their educational function. See Thomas D. Wood, “Abstract of the Report of the Committee on the School Child,” in White House Conference 1930, 171–74. White House Conference on Child Health and Protection, The School Health Program, 85. Ibid., 171.

Epilogue

1. Michael Sedlak, “Attitudes, Choices, and Behavior: School Delivery of Health and Social Services,” in Learning from the Past: What History Teaches Us about School Reform, ed. Diane Ravitch and Maris A. Vinovskis (Baltimore: Johns Hopkins University Press, 1995), 73–79; Stephen L. Schlossman, JoAnne Brown, and Michael Sedlak, The Public School in American Dentistry (Santa Monica, CA: Rand, 1986).

248

Notes to Pages 197–201

2. “Chicago Dental Society to Open Free Clinics for Needy,” Chicago Daily Tribune, December 4, 1940; “Dental Society to Treat Poor Pupils for Free,” Milwaukee Sentinel, December 3 1931; “Guggenheim Gives Plan for Unit,” New York Times, January 5, 1930; “Dental Care for 58,467,” ibid., February 17, 1933. 3. “Advises Red Cross to Widen Lunches,” New York Times, April 14 1931; “Obtains $6,000 Lunch Fund for School Children,” Chicago Daily Tribune, December 4, 1930; “Chicago Women’s Clubs Help Feed Children,” ibid., June 25, 1931; “Hungry Pupil’s Fund Held Great Aid to Health,” ibid., January 9, 1933; “Poor Children Assured Food,” Los Angeles Times, October 6, 1931. 4. “$100,000 for Relief Spent in Schools,” New York Times, January 30 1931; “Teachers Vigilant to Aid Distressed,” ibid., November 1, 1931; “Fate of Children in the Depression,” ibid., May 29, 1932; $80,000,000 Spent for Relief in 1932,” ibid., February 8, 1933. For a description of a teachers’ relief fund in a small city, see Robert Greet, “The Plainfield Schools in the Depression, 1930–37,” New Jersey History 90 (1972): 69–82. 5. “Dentists Reject Rosenwald Fund Clinic Project,” Chicago Daily Tribune, May 27, 1932; “5,000 Teachers at the End of Rope: Tell Privations,” ibid., March 20, 1932; “Dr. O’Shea Pleads for School Relief,” New York Times, March 8, 1933; “Drop in Gifts to Hungry Children Causes Concern,” Chicago Daily Tribune, February 19, 1933. 6. “Survey Finds Cities Cutting Expenses,” New York Times, April 14, 1932; “Newark Discusses School Budget Cuts,” ibid., January 29, 1931; “School Cuts Held Menace to Pupils,” ibid., May 23 1932; “School Budget Cut $7,825,000,” ibid., July 18, 1932; “Chicago Schools Face Lean Period,” ibid., March 6, 1932; “Slash for Schools in Chicago Stands,” ibid., July 19, 1933. On the impact that the cuts had on Chicago school services, see Sedlak, “Attitudes, Choices, and Behavior,” 70–72. 7. David Tyack, Robert Lowe, and Elizabeth Hansot, Public Schools in Hard Times: The Great Depression and Recent Years (Cambridge: Harvard University Press, 1984), 39–41; Michael Sedlak, “Attitudes, Choices, and Behavior,” 71–72; Sedlak, “The Uneasy Alliance of Mental Health Services and the Schools,” American Journal of Orthopsychiatry 67 (1997): 355; Schlossman, Brown, and Sedlak, The Public School in American Dentistry, 28; American Child Health Association, Physical Defects: The Pathway to Correction (New York: American Child Health Association, 1934), 120–21. 8. Quoted in “The Proposed National Conference on Child Recovery,” School and Society 38 (1933): 401. See also Richard A. Meckel, “Politics, Policy, and the Measuring of Child Health: Child Malnutrition in the Great Depression,” in Healing the World’s Children: Interdisciplinary Perspectives on Child Health in the Twentieth Century, ed. Cynthia Comacchio, Janet Golden, and George Weisz (Montreal: McGill-Queens University Press), 242–44. 9. Susan Levine, School Lunch Politics: The Surprising History of America’s Favorite Welfare Program (Princeton: Princeton University Press, 2008), 44–47. 10. US Children’s Bureau, Grants to the States for Maternal and Child Welfare under the Social Security Act of 1935 and the Social Security Act Amendments of 1939 (Washington: Government Printing Office, 1940), 1–5; John Duffy, A History of Public Health in New York City, 1866–1966 (New York: Russell Sage Foundation, 1974), 348. 11. In 1937 the New York City Bureau of School Hygiene—using dentists on loan from the Health Department, which had hired them with Works Progress Administration

7-2 197 7-3 197 7-4 197 7-5 197 7-6 198 7-7 198 7-8 199 7-9 199 7-10 199 7-11 201

Notes to Pages 201–205

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201 200 200 201 201 202 202 202 202 203 203 204 205

12.

13.

14. 15. 16. 17.

18.

19.

20. 21.

22. 23. 24.

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funds—opened twenty new dental clinics in schools, reversing a six-year decline in its ability to provide dental exams. There was some controversy, however, because the dentists did not qualify as unemployed or on relief. See “To Add 20 Dental Clinics,” New York Times, December 15, 1936; “WPA Dismisses 35 in Dental Clinic,” ibid., November 2, 1937; Joseph Mountin and Evelyn Flook, “Dental Programs Sponsored by Health Agencies in 94 Selected Counties,” Public Health Reports 54 (1939): 1625–36; Schlossman, Brown, and Sedlak, The Public School in American Dentistry, 32–33. The act required school systems taking part in the program to provide lunches free to those children who could not pay for subsidized ones, but it did not provide either fiscal or administrative support for the schools to do so. By 1943 close to 50 percent of American dentists under thirty-five years of age were in the armed forces. See Alyssa Picard, Making the American Mouth: Dentists and Public Health in the Twentieth Century (New Brunswick, NJ: Rutgers University Press, 2009), 112. Dorothy B. Nyswander, Solving School Health Problems: The Astoria Demonstration Study (New York: Commonwealth Fund, 1942), 300. American Child Health Association, Physical Defects, 114–22. Nyswander, Solving School Health Problems, 2, 20–27. For a comprehensive description and analysis of those discussions, see Jonathan Engel, Doctors and Reformers: Discussion and Debate over Health Policy, 1925–1950 (Columbia: University of South Carolina Press, 2002). David Tyack, “Health and Social Services in Public Schools: Historical Perspectives,” Future of Children 2 (1992): 19–31; “Recommendation I: Expansion of the Public Health and Child Welfare Services Submitted to the Conference by the Technical Committee on Medical Care,” in Proceedings of the National Health Conference, July 18, 19, 20, 1938, Washington, D.C. (Washington: Government Printing Office, 1938): 41–42. Antonio Ciocco, Henry Klein, and Carroll E. Palmer, “Child Health and Selective Service Physical Standards,” Public Health Reports 56 (1941): 2365–75. A 1946 review of government health services said of the study: “The dramatic import of these finding has stimulated a basic reorientation of the present system of school medical services” (Bernard J. Stern, Medical Services by Government: Local, State, and Federal [New York: Commonwealth Fund, 1946], 38). Quoted in US Public Health Service, Annual Report for the Fiscal Year, 1944 (Washington: Government Printing Office, 1944), vi. The phrase appears in, for example, “A Bill to Provide for the General Welfare by Enabling the Several States to Make More Adequate Provision for the Health of School Children Through the Development of School Health Programs for the Prevention, Diagnosis, and Treatment of Physical and Mental Defects and Conditions” (S. 1290, 80th Cong. 1947). See also School Health Service (National Health Plan), Hearings on H.R. 4312, H.R. 4313, H.R. 4918, S. 1411, H.R. 4660, H.R. 392, Before the House Subcommittee on Public Health, Science, and Commerce, 81st Cong. (1949). School Health Services, Hearings on S. 1290, Before the Senate Subcommittee of the Committee on Labor and Public Welfare, 80th Cong. (1948), 41–64. Ibid., 26–29, 30–34, 16–25, 10–15. US Federal Security Agency, Priorities in Health Services for Children of School Age (Washington: Government Printing Office, 1950), 2, 10.

250

Notes to Pages 205–206

25. Schlossman, Brown, and Sedlak, The Public School in American Dentistry, 43; Maryland Y. Pennell, Katherine Bain, and John P. Hubbard, “Child Health Services in Twelve Metropolitan Districts,” Public Health Reports 65 (1950): 912. 26. Sedlak, “Attitudes, Choices, and Behavior,” 76–77; Sedlak, “The Uneasy Alliance of Mental Health Services and the Schools,” American Journal of Orthopsychiatry 67 (1997): 356–57. 27. Schlossman, Brown, and Sedlak, The Public School in American Dentistry, 45.

7-25 205 7-26 205 7-27 206

Index

Addams, Jane, 96 adenoids, hypertrophied, 82, 99, 131–32, 135, 142; as cause of backwardness and behavioral problems, 138, 161; as portal for bacteria, 138. See also adenoidectomies adenoidectomies, 138, 141, 144–45, 156 African American schoolchildren, rural, 168–69 Agnew, Cornelius, 27–29 Alcott, William Andrus, 11; The House I Live In, 180 Allport, Frank, 80 American Academy of Medicine, 88 American Association for Health, Physical Education, and Recreation, 204 American Association for the Study and Prevention of Infant Mortality, 165 American Child Health Association, 177, 189, 192; research division, 202 American Child Hygiene Association, 165, 177, 184, 187 American Dental Association, 189 American Home Economics Association, 115 American Medical Association, 11, 83, 88, 159; opposition to federal funding for school health, 168, 204; opposition to treatment in schools, 141, 188, 204; promotion of health education, 189–90; section on childhood diseases, 34, 53; support for medical inspection, 74–75, 141. See also Joint Committee on Health Problems in Education American Ophthalmological Association, 129 American Pediatric Society, 34, 37 American Public Health Association, 10–12, 17, 29, 42, 54, 57, 88, 187; Committee on School Hygiene 10, 14; report on closing schools during epidemics, 162; and school hygienists, 85, 187; support for medical inspection, 75

American School Hygiene Association (ASHA), 131, 160, 165, 187, 190; organization and activities, 88–94; surveys sponsored, 144 American Social Science Association, 26, 28, 55 American Statistical Association, 72 anthropometric studies, 33, 35, 69, 77, 178, 179. See also Bowditch, William; Porter, William T.; weighing and measuring astigmatism, 92, 132, 137 Astoria Demonstration Study, 202 Atlanta, GA: schoolchildren’s eyesight surveyed, 28 Atlanta Constitution, 93 atmospheric pollution: gaseous, 12, 18, 20– 22; microbial, 44–45, 48. See also school diseases; ventilation Ayres, Leonard, 146, 172; directs Backward Children Investigation, 76; Laggards in Our Schools, 76–79 Backward Children Investigation, 76–79. See also grade retardation Baker, Henry B., 43 Baker, S. Josephine, 85–86, 88, 97, 113, 129–30, 133, 136, 142, 173–75, 189; Child Hygiene, 175 Baldwin, Bird, weight chart, 179 Baltimore, MD, 68, 79, 109; charity organization opposition to school feeding 47; sanitary surveys of schools, 15, 19; school nurses, 63, 145 Baltimore American, 47 Barnard, Henry, 11; School Architecture, 16 Beard, George, 33 Beer, Georg Joseph, 22 Behring, Emil von, 108, 163 Bell, Agrippa N., 17, 46, 49. See also Sanitarian Berlin, Germany, 45, 106 Bissel v. Davison, 66

251

252

Index

Boas, Franz, 88 Boston, 12, 26, 28, 34, 42, 49, 73, 87, 88, 90, 92, 106 122, 126, 154, 197; adopts exclusion, 49–50; clinics, 134, 140; diphtheria immunization, 163; malnutrition, 104, 113, 118; medical inspection for contagious disease, 52, 55–57, 60–61, 63–64; medical inspection for defects, 81–82, 174; nurses, 63, 82; open-air schools, 106–7, 111, 113; school feeding, 115–18, 121–22, 124, 126; school sanitary inspection, 14–15, 17; vaccination required, 54. See also Boston Dispensary; Durgin, Samuel; Forsyth Dental Infirmary for Children; Gallivan, William; Harrington, Charles Boston Dispensary, 30, 131, 134 Boston Medical and Surgical Journal, 18, 31–32, 52 Boughton, Alice, 115 Bowditch, William, 33 Breslau (Wroclaw), Poland, 23, 91 Bridgeport, CT, 153; dental hygienist experiment, 149–50 Brooklyn, NY, 27, 50; eyesight of schoolchildren surveyed, 28; vaccination required, 54 Brussels, Belgium, 14 Bryant, Louis Stevens, 125 Buffalo, NY, 89; school feeding, 115; school sanitary survey, 19 Burks, Jesse, 135 Burnham, William, 36, 45, 88, 98, 122 Cabot, Arthur T., 87–88 California: cleanliness legislation, 48 Canada: medical inspection, 87 Capper, Arthur, 167–68 Carrington, Thomas, 107 Catholic Church: and Fess-Capper bill, 168; and school feeding, 121 Chapin, Charles V., 59, 131; on need for school clinics, 136, 140; on need for school nurses, 134; on physicians’ resistance to school clinics, 142 Chapin, Henry Dwight, 38, 177 Chapman, Robert Coit, 121–22 Charities and the Commons, 118–19, 143

Charleston, SC: scarlet fever epidemic, 40 Charlottenberg, Germany: open-air school, 106, 111 Chicago IL, 13, 18, 66, 74, 168; board of education, 115; dental clinics, 152–55, 198; department of health, 54, 57, 59, 61, 163; diphtheria immunization program, 163; malnutrition, 104, 113, 119; medical inspection, 59, 81, 134, 143, 174; openair schools, 107, 111, 113, organized charities, 117; school feeding, 115, 117, 120–21, 124; schools, 57, 68, 76, 90, 173, 198–99; vaccination, 61–62. See also Elizabeth McCormick Memorial Fund Chicago Daily Tribune, 104, 155, 198 Chicago Dental Society, 155, 198 Chicago Federation of Women’s Clubs, 124 Chicago Public School League, 66, 143 chickenpox, 9, 51, 61–2, 64, 135 Child Health Organization (CHO), 177–80, 182–87, 190. See also Cho Cho; Holt, L. Emmett; Lucas, Sally Jean child hygiene: municipal health department bureaus of, 85–86, 89; as Progressive era child welfare movement, 7, 95–97; and school hygiene, 85–86, 97 child study, 35–36. See also Hall, G. Stanley; hygiene of instruction child welfare, Progressive era, 94–95 children, developmental physiology of, 13; as rationale and theory for child hygiene, 95–96 Cho Cho, 183–84, 187 Christian Scientists, 74, 186 Cincinnati, OH: dental clinics, 152; dental society, 148; school sanitary surveys, 14; schoolchildren’s eyesight surveyed, 28 Clark University, 34–36, 88–89, 98, 122, 214n72 Clarke, Edward, Sex in Education, 32–33 Claxton, Philander, 158 Cleveland, OH: Marion school dental experiment, 147; medical inspection, 81–82, 132; school dental clinics, 146–47, 152; school expansion, 13; school eye clinics, 146; school feeding, 124; vaccination, 60, 66 Cleveland Dental Society, 147–48

Index

Cohn, Hermann, 23–27, 91; The Hygiene of the Eye in Schools, 25 Collinwood, OH, 90 Colorado: medical inspection legislation, 132; supreme court ruling on school treatment, 151 Columbia University, 95, 155, 189; Teachers College, 85, 186 Connecticut: medical inspection, 58, 70; state board of education, 16; vaccination laws, 54, 66. See also Bissel v. Davison conservationism, 97–98 contagious diseases: concern that schools were incubators of epidemics, 38–43. See also exclusion from school; school closing Cornel, William, 89, 130, 132, 136, 178 Cremin, Lawrence, 120 crippled children, 161 Cronin, John, 71, 73, 88–89, 129 Cubberly, Elwood, 158 Davis, Michael, 190 defect correction, school facilitation of, 98–99; critical role of school nurses, 133–39; disenchantment with, 171–75; eschewed by school hygienists, 193–94; and parental compliance, 129–33; school clinics proposed and debated, 139–43; uneven patchwork of diagnostic and treatment services, 144–54; after World War I, 157–64 defects, mental. See mental deficiency; nervous disorders defects, physical. See errors of refraction; eye diseases; eyestrain; hearing defects; heart disease; malnutrition; nasopharyngeal defects; oral defects; skeletal deformities; speech impediments Denmark, 116; Overpressure in the Schools of Denmark, 34 dental clinics, 144, 146–156; in Depression, 198, 200. See also Forsyth Dental Infirmary for Children; Guggenheim Dental Clinic; Rochester Dental Dispensary dental hygienists, 144, 149–50, 153–56, 173, 199 dentistry, organized, 89; and health education, 189–90; support for school dental

253

inspection and clinics, 146–49, 151–52; support terminated after World War II, 206 Denver, CO: dental clinics, 152; Denver Dental Association, 148; lawsuit challenging treatment in school clinics, 151; school system, 66 Depression, impact on school health services, 197–201 Detroit, MI: dental clinics, 153; medical inspection, 174; schools and the Depression, 199 Dewey, John, 190 diphtheria, 6, 63–65, 161; antitoxin for, 108; definition, virulence, signs and symptoms, 41–42; and establishment of medical inspection, 52–59; exclusion for, 43, 50, 65; incidence, 59, 61–62; and fomites, 46–47; and poor ventilation, 20; school immunization campaign, 163; schools as incubators, 38, 42–43; and tooth decay, 138 disease causation and transmission, theories of: germ theory, 20, 43–46, 50, 215n16; miasmatic theory, 20–21, 49 disinfectants, 39, 44–46, 48, 50 Donders, Franciscus, 22, 24, 28 Dressler, Fletcher, 89, 169 Duffy, John, 15 Durgin, Samuel, 17, 42, 55–58, 61 Elizabeth McCormick Memorial Fund, 107, 111, 113 Emerson, Haven, 189–90 Emerson, William R. P., 179–80; Nutrition and Growth in Children, 126 England, 87, 108, 116, 118, 158; parliamentary investigations of overstudy, 34; ragged and hungry schoolchildren, 101– 2. See also Great Britain ENT clinics, 144–46 epidemics: linked to school term, 42; schools as incubators of, 38–43 errors of refraction, 22–23, 25, 27–28, 30, 92, 137. See also astigmatism; hyperopia (farsightedness); myopia Eschereich, Theodore von, 95 eugenics, 97

254

Index

Ewing, Oscar, 204–205 exclusion from school, for communicable disease, 5, 7; enforcement, 51; laws and ordinances, 50–51, 132; rationale for, 49– 50; response of educators, 62; response of parents, 51–52, 62, 64–65; school nurses and treatment, 62–64 eye clinics, 27, 146, 145–46, 150 eye defects. See errors of refraction; eye diseases; eyestrain eye diseases, 28, 65; conjunctivitis, 47, 61; trachoma, 47, 62, 168 eyestrain, 29, 69, 91–92, 137 feeble-mindedness. See mental deficiency Fess, Simeon, 167 Fess-Capper bill, 167–68 Fisher, Irving, 97 Flick, Lawrence, 108 fomites, 46–47 Fones, Alfred, 149–50 Forsyth, James Bennett, 154 Forsyth Dental Infirmary for Children, 154–56 France, 87, 103, 109, 158 Freud, Sigmund, 36, 214n72 Gallivan, William, 85–86, 89, 140 Gary, IN, 176 Germany, 25, 27, 106, 108–9, 116 Gesell, Arnold, 164–65; The Preschool Child from the Standpoint of Public Hygiene and Education, 165 Ghon, Anton, 108 Gihon, Albert, 10–12 Goddard, Henry, 89, 239n11 Goler, George, 96, 133, 140 grade retardation, 7, 68, 115, 138, 148, 171– 72, 174; and medical inspection, 75–79; as a medical problem, 79, 160 Great Britain, 12, 44; Committee on Physical Deterioration, 101–3; medical inspection, 87; open-air schooling, 106; school feeding, 116; vaccination, 65. See also England; Scotland Guggenheim Dental Clinic, 155, 197 Gulick, Luther H., 69, 78, 85, 88–89, 92–93, 97, 172

Hagerstown, MD: study of defective recruits, 203 Hall, G. Stanley, 34–36, 88–89, 98. See also child study; Clark University Harrington, Charles, 88, 92 Hartford, CT: open-air schools, 107 health education, 2, 167, 171; new, 182–85; old, 180–82; and physical education, 176–77. See also Child Health Organization; Jean, Sally Lucas hearing defects, 67, 70–71, 73, 75, 81, 98– 99, 138; ear infections, 70, 145 heart disease, 67, 71, 89, 98, 162 Henry Street Visiting Nurse Settlement, 62, 102 high school students, 32, 164, 176, 186, 192 Hine, L. N., 79 Hoag, Earnest, 89, 98, 131–32, 182 Holt, L. Emmett, 96, 109, 177–79. See also Child Health Organization; nutrition; weighing and measuring Hoover, Herbert, 169, 177, 192, 199 Hull House, 96, 100; open-air school, 107 hungry schoolchildren, discovered and debated, 100–104 Hunter, Robert, 100–103; Poverty, 100 hygiene of instruction, defined, 12 hyperopia (farsightedness), 23, 92 Illinois Supreme Court, ruling on school vaccination requirement, 166 immigrants, children of: communicable diseases among, 61; as focus of Progressive era child welfare, 94; health education as acculturation for, 120, 190; hunger and malnutrition among, 102; Marion School experiment, 147; and school feeding, 114; schools feared as incubators of epidemics, 38–39 immigrants, as parents: compliance with medical inspector recommendations, 130; health practices, 131; seen as ignorant and superstitious in regard to hygiene, health care, and nutrition, 48, 129, 186 Indiana: medical inspection legislation, 65, 75, 132 influenza pandemic, and school closing, 162–63

Index

intelligence testing, 67, 81, 160, 172. See also Terman, Lewis International Congress on School Hygiene: first, 87; second, 87–88; fourth, 89, 129, 140, 166 Italy, 92; refezione scolastica, 116 Jacobi, Abraham, 34, 37, 42, 88 Jacobsen v. Massachusetts, 66. See also vaccination Japan: medical inspection, 87 Jean, Sally Lucas, 177, 180, 182, 187. See also Child Health Organization Joint Committee on Health Problems in Education, 85, 116, 166, 171, 173, 190. See also American Medical Association; National Education Association; Wood, Thomas Dennison Julius Rosenwald Fund, 153, 168, 198 Jung, Carl, 36, 214n72 jurisdiction, issues of, between public health and education departments, 7, 55–56, 82–86 Kansas City, MO, 154, 191 Katz, Michael, 3, 94 Kelynack, Theophilus, 108 Key, Axel, 34 Kingsley, Sherman, 113 Kittredge, Mabel, 114 Knopf, S. Adolphus, 109 Knoxville, TN, 20 Lee, Joseph, 73, 121 Lincoln, David, 26–27, 30, 33, 55 London, England, 23, 88; hungry schoolchildren, 101–102; school nurses, 62 Los Angeles, CA: clinics, 145; school nurses, 63 malnutrition, in schoolchildren: discovered and debated, 100–104; hookworm as cause, 166; and open-air schools, 104–7, 110–11, 114; and penny lunches, 114–15, 117–19, 122–27; weighing and measuring to detect, 178–80 Mangold, George, 95–96; Problems of Child Welfare, 95

255

Manhattan. See New York City Mann, Horace, 11, 26 Marion School experiment, 147 mass compulsory education, 3, 4; as catalyst for school hygiene discourse, 8, 13; and growth of urban school population and cost, 12–13; and responsibility of the state to protect health of schoolchildren, 19–20, 53, 195–96; and transformation of urban school populations, 24, 39, 67–68, 101, 116 Massachusetts: diphtheria immunization, 164; exclusion rules, 50–51, 58; medical inspection legislation, 73, 75, 83; sanitary survey of urban schools, 15, 26; state board of health, 15, 16, 88; vaccination requirements, 54, 66. See also Jacobsen v. Massachusetts Maxwell, William, 76, 83–84, 93, 101, 118, 131, 171, 190. See also New York City measles, 20, 38–9, 41–44, 49–51, 57, 61–62, 134–35 medical inspection, for detection of contagious disease: adopted, 56–58; implemented, 58–63; jurisdiction, 66, 73; and local physicians, 58; models of, 59–60; proposed and debated, 52–56; response of parents, 64–65; and school nurses, 62 medical inspection, for the detection of defects and disabilities: adopted and implemented, 71–73, 79–80; arguments for, 67–70; and child hygiene, 97; and debate over schoolchild hunger and malnutrition, 100, 104, 111, 118, 128; during Depression and after, 197, 199; exams, 70, 80–81; jurisdictional issues raised by, 82–87; legislation enabling or requiring, 75; outside US, 87; parental compliance problem, 129–33; privatization, 174; as a remedy for grade retardation, 73–79; response of organized medicine, 74–75; response of parents, 73–74; role of nurses, 133–35; role of physicians, 80–82; role of teachers, 79–80; in rural areas, 166–67. See also Astoria Demonstration Study; defect correction; World War I: as a catalyst for the expansion of school health services

256

Index

medicalization, of American education, 5, 7, 14, 66, 195; defined, 209n8; and school diseases, summary, 36–37; after World War I, 160–61 mental deficiency, 67, 81, 160; and intelligence testing, 172 Metropolitan Life Insurance Company, 185, 202 Mexico: medical inspection, 87 Michigan, 29; adoption of exclusion from school, 49; diphtheria deaths, 41; diphtheria immunization, 164 Milwaukee, WI, 12; dental clinics, 149, 197; medical inspection, 58, 174; school feeding, 115, 124 Milwaukee Women’s School Alliance, 124 Minneapolis, MN: medical inspection, 58 Mosso, Angelo, 92 myopia: associated with other diseases, 30–31; attributed to overstudy, overcivilization, and urban life, 29, 33; causal theories, 22–23; clinical studies connect to school attendance (European), 23–27, (US), 27–30 nasopharyngeal defects, 72, 81, 137, 144. See also adenoids; tonsils National Child Health Council, 184 National Cleanliness Institute, 185 National Conference on Charities and Corrections, 134 National Dairy Council, 185 National Dental Association, 146–47. See also dentistry, organized National Education Association, 84–85, 159; and CHO, 184; and federal funding for school health programs, 204; and medical inspection, 63, 165; and physical education, 164. See also Joint Committee on Health Problems in Education National League for Medical Freedom, 74, 143 National Mothers Congress, 153 National Tuberculosis Association, 107, 109, 184; Modern Health Crusade, 183. See also open-air schools Native American schoolchildren, 168 nervous disorders: medical inspection detection of, 70, 80–81, 83; as a school

disease, 22, 25, 29–36; World War I and, 160 Netherlands: school feeding, 116 New England Kitchen, 115 New Haven, CT: medical inspection, 58; response to influenza pandemic, 162 New Jersey: medical inspection, 77, 132, 137; vaccination, 54, 61 New Orleans, LA, 15; medical inspection, 58 New York Academy of Medicine, 45, 92, 141 New York Association for Improving the Condition of the Poor, 134 New York Charity Organization Society, 101, 118, 143 New York City, NY, 89, 92, 97, 141, 166, 173, 189, 201; and Depression, 198–99; diphtheria immunization, 163; exclusion rules, 50, 52; medical inspection for contagious disease, 57, 60, 62–63; medical inspection for defects, 70–73, 80, 129–30, 132–33, 174; myopia of schoolchildren, 28–29; open-air schools, 107; organized charities, 117–22; school baths, 49; school clinics, 143–44, 152–53, 155, 197; school feeding, 114–26; school nurses, 62–63, 133; school sanitary investigations, 14–15; schools, 17, 19, 47, 49, 51, 77, 88, 90, 115; vaccination required, 54; ventilation, 17, 51. See also Baker, S. Josephine; Bell, Agrippa N.; Cronin, John; Guggenheim Dental Clinic New York Committee on the Physical Welfare of School Children, 72–72, 119 New York School Lunch Committee (NYSLC), 115, 122–26 New York State: vaccination, 54 New York Times, 154, 166; opposition to health department physicians treating schoolchildren, 143; opposition to school feeding, 121 Newark, NJ: and Depression, 199; medical inspection, 58, 137 Newmayer, Solomon, 114, 172 Newsholme, Arthur, 43 normal child: defined, 169; school hygiene embraces, 169–70 Norway: school feeding, 116

Index

nurses. See school nurses nutrition: as basis of child health, 178–79; focus of health education, 180, 186–88; nutrition clinics, 179 Oakland, CA, 186; medical inspection, 82, 137 Oberlin College, 85 open-air schools, 5, 104, 105–14. See also tuberculosis, childhood; tuberculosis, pulmonary oral defects, as portal for bacteria: decayed teeth, 70, 75, 81, 138–39, 154; infected gums, 67, 138–39 organized charity: opposition to public funding for provision of eyeglasses, 143; opposition to public funding for school feeding, 117–20, 122–23; and school clinics, 145, 148, 152 Osler, William, 138–39 overstudy, overpressure, brain-forcing, 23, 30, 31–36, 92, 137 Paris, France: hungry and ragged schoolchildren, 101; scarlet fever, 49; school sanitary inspection, 14; school feeding, 116 Park, William, 163 Parran, Thomas, 203 Parson, Elsie Clews, 102 Pennsylvania, 84, 88, 166 penny lunches. See school feeding Perkins, Frances, 199 Philadelphia, PA, 15, 18, 28, 32, 54, 59, 89, 130, 133, 136, 172, 178; dental clinics, 136, 148, 152; Division of Child Hygiene, 114, malnourished schoolchildren, 104; medical inspection, 57, 59, 63; medical inspection exam, 81; organized charities, 122; overaged schoolchildren, 76–77; school feeding, 115, 124 Philadelphia Home and School League, 115, 124 Philbrick, John, 26–27 physical education, 37, 69, 76; corrective, 160; and Depression, 199; federal funding for proposed, 167–68, 204; new, 85; as part of health education, 176; state laws requiring, 176–77, 192. See also

257

American Association for Health, Physical Education, and Recreation; Gulick, Luther H.; Wood, Thomas Dennison Pirquet, Clemons von, 108; skin test, 112 Pittsburgh, PA, 65 poliomyelitis, 91; 1916 epidemic, 161–62 Popular Science, 127 Porter, William T., 35, 69 preschool children, 164–65; summer roundup programs, 165 preventoriums, 110 Progressive era reform: and public schools, 120–21. See also child hygiene; child welfare Providence, RI, 88; diphtheria immunization, 163; exclusion rules, 51, 63; medical inspection, 59, 63, 70, 131; open-air schools, 105–7; school clinics, 136, 152–53; school committee, 115; school feeding, 115; school nurses, 131. See also Chapin, Charles V. psychological services, 187; and medicalization of education, 160; post–World War I expansion of, 160–61, 171–72; post– World War II expansion of, 197, 199, 206 Putnam, Helen, 88 Red Cross, 153, 163, 168, 197 Rice, Joseph, 37 Richards, Ellen H., 115 Robertson, John Dill, 155 Rochester, NY, 15; defects of schoolchildren, 137; open-air schools, 107; school clinics, 145, 155–57, 197; school feeding, 115, school nurses, 133. See also Goler, George Rochester Dental Dispensary, 145, 155–57, 197 Rockefeller Sanitary Commission, 166 Rogers, James, 113–14 Rogers, Lina, 62, 89 Roosevelt, Franklin Delano, 199–200, 203 Rosenwald, Julius, 153, 168, 198 Rowell, Hugh, 89, 151, 176, 179 rural schoolchildren, 24, 27, 92, 167, 192; discovery of poor health, 165–67 rural schools, 1, 43; design, 169; health programs, 168, 186

258

Index

Russell Sage Foundation, 58, 75, 79, 85, 184; Backward Children Investigation, 76; Division of Child Hygiene, 78 Salt Lake City, UT: medical inspection, 58 Salvation Army, 102 San Francisco, CA, 12; exclusion rules, 51; school nurses, 63, 82 Sanitarian, 17, 19, 46 Sanitary News, 18 sanitary reform, 5, 6, 13; and perils of the city school, 14–22 scarlet fever, 6, 63, 161; definition, virulence, signs and symptoms, 40–41; and establishment of medical inspection, 52, 55–59; exclusion for, 43, 49–52, 65; and fomites, 46–47; incidence, 59, 61–62; schools as incubators of, 38, 42–43; and tooth decay, 138 Schick, Bela, skin test, 163 school-based health centers (SBHCs), 1–2 school clinics: in 1920s, 160–61, 167, 173; in Depression, 197–199; in 1940s and 1950s, 197, 200, 202; debated, 139–43; patchwork of services and funding, 144–50; role of school nurses, 133–39. See also dental clinics; ENT clinics; eye clinics school closing, as a response to epidemics: and 1916 polio epidemic, 162; and 1918 influenza pandemic, 162–63; debate over, 43, 49, 56 school diseases, 5, 6, 14, 22–26; and the medicalization of education, 36–37; term coined by Rudolf Virchow, 26 school feeding: during the Depression, 197–98, 200; milk snack programs, 185; National School Lunch Act (1946), 201; in open-air schools, 106; penny lunch experiment, 104–5, 114–27 school health services, attempts to get federal funding for: Fess-Capper bill, 167–68; after World War II, 202–5 school hygiene: emerges as a discourse on the hygiene of urban schools and schooling, 1–37; expands to include the hygiene of the schoolchild and medical inspection for contagious disease,

38–66; focus on defects and academic failure, 67–156; growth and reorientation after World War I, 157–94; legacy of, 195–97 School Hygiene (England), 87 School Hygiene (US), 90 school lunches. See school feeding school nurses, 65, 79, 84, 86, 89, 154, 168; certify families as needy, 146, 152; critical importance of, 133–39; as health educators, 177, 188, 193; perform medical inspections, 79–80, 82, 152, 202; treat minor diseases and conditions, 62–63, 144, 146. See also Rogers, Lina; Wald, Lillian schoolhouse hygiene, 90; defined, 12 schools. See rural schools; urban schools scoliosis, 25, 29, 67, 80; false, 91 Scotland: medical inspection, 87 Seattle, WA: lawsuits, 141, 151; school clinics, 136, 144; school nurses, 63 sex: developmental differences and concerns about schooling, 32–33 shower baths, 48–49 Shriners, 161 skeletal deformities, 70, 82, 91, 138. See also scoliosis skin diseases, parasitic (pediculosis, scabies, ringworm), 61, 133; in-school treatment, 62 Snellen, Hermann, 23, 28 Sorbel, Jacob, 129 Spargo, John, 130; The Bitter Cry of Children, 95, 102–3 speech impediments, 159, 199 Spencer, Herbert, 23, 66 St. Louis, MO: medical inspection, 133; physical defects, 137; schoolchild growth study, 35; vaccination, 54, 65 Starre Center Association, 115 Stevens, Rosemary, 145 Sweden, 116 Terman, Lewis M., 89, 98, 122, 131–32; Hygiene of the School Child, 98, 140, 172, 179, 182; Intelligence of School Children, 182 Thorndike, Edward, 76

Index

tonsils, hypertrophied, 67, 70–71, 81–82, 99, 112, 129, 132, 137, 187; as portal for bacteria, 138 tonsillectomies, 131, 135, 141–45, 151, 156, 235n36 treatment, by nurses of minor diseases and conditions, 62–63, 144, 146. See also defect correction Truman, Harry, 204 tuberculosis, childhood (bones, glands), 107. See also preventoriums tuberculosis, pulmonary (phthisis), theory of childhood origin, 107–8. See also National Tuberculosis Association; openair schools Tyack, David, 170, 203 urban schools: adopt exclusion policies, 49–51; and Depression, 197–201; establish medical inspection for contagious diseases, 52–63; establish medical inspection for detection of defects, 67–73; expansion of, 12–13; judged healthier than rural schools, 166; as potential incubators of epidemics, 38–40, 43–44, 49–52; sanitarian concern with, 14–22; and school diseases, 22–37; as site of school clinics, 1–2, 139–50 US Bureau of Education, 100, 157, 162, 191–92; establishes Division of School Hygiene, 93; eye clinics, 145; and FessCapper bill, 167–68; and immigrants, 130; open-air schools, 112–13; partnership with CHO, 177–79, 182–85; and rural schoolchildren, 167; school closing, 162; school lunches, 124 US Bureau of Indian Affairs, 168 US Children’s Bureau: federal funding for school health services, 168, 204–5; infant welfare, 3; rural schoolchildren, 167 US Department of Agriculture, 185 US Federal Security Agency, 204; Special Committee on School Health, 205 US Public Health Service: division of child hygiene proposed, 168; proposal for federal funding for school health services, 205; and rural schoolchildren, 167

259

vaccination, required for school attendance, 74, 133, 163; adoption, 53–54; court rulings on, 66; and medical inspection, 60, 134; parental opposition, 65–66; problems with enforcement, 54 Van Sickle, James, 68 ventilation: and microbes, 38, 44–45, 48: new views, 91, 114, 169; and origins of school hygiene, 13, 15–22. See also atmospheric pollution Virchow, Rudolf, 25; and school diseases, 26 Wagner, Robert F., 203 Wald, Lillian, 62, 89, 102 Ware, James, 23 Washington, DC: dental clinics, 152–53 Washington State: supreme court rules against treatment, 151 weighing and measuring, 69, 178–79, 191 White House Conference on Child Health and Protection (1930), 169, 171; report of the Committee on School Hygiene, 192–94 whooping cough, 20, 41, 51, 61 Wiesbaden, Germany, 87 Williams, J. Leon, 148 Winslow, Charles-Edward Amory, 189 Wirt, William, 176 women’s organizations: and Fess-Capper bill, 168; and medical inspection, 64, 73; as participants in school hygiene movement, 89, 93, 97; and sanitary surveys, 45; and school feeding, 104, 115–16, 123–24, 198 Wood, Thomas Dennison, 85, 89, 151, 166, 173, 176–79, 181, 192–93 Works, Senator John Downy, 74 Works Progress Administration, 200 World War I, 6, 8, 111, 113, 124, 126, 141, 146, 148, 150, 152; as a catalyst for the expansion of school health services, 157–64 World’s Work, 70 Zucht v. King, 66

About the Author

Richard A. Meckel is a professor in the American Studies Department at Brown University. His previous books are Save the Babies: American Public Health Reform and the Prevention of Infant Mortality, 1850–1929 and Children and Youth in Sickness and Health, edited with Janet Golden and Heather Munroe Prescott.

Available titles in the Critical Issues in Health and Medicine series: Emily K. Abel, Suffering in the Land of Sunshine: A Los Angeles Illness Narrative Emily K. Abel, Tuberculosis and the Politics of Exclusion: A History of Public Health and Migration to Los Angeles Marilyn Aguirre-Molina, Luisa N. Borrell, and William Vega, eds. Health Issues in Latino Males: A Social and Structural Approach Susan M. Chambré, Fighting for Our Lives: New York’s AIDS Community and the Politics of Disease James Colgrove, Gerald Markowitz, and David Rosner, eds., The Contested Boundaries of American Public Health Cynthia A. Connolly, Saving Sickly Children: The Tuberculosis Preventorium in American Life, 1909–1970 Tasha N. Dubriwny, The Vulnerable Empowered Woman: Feminism, Postfeminism, and Women’s Health Edward J. Eckenfels, Doctors Serving People: Restoring Humanism to Medicine through Student Community Service Julie Fairman, Making Room in the Clinic: Nurse Practitioners and the Evolution of Modern Health Care Jill A. Fisher, Medical Research for Hire: The Political Economy of Pharmaceutical Clinical Trials Alyshia Gálvez, Patient Citizens, Immigrant Mothers: Mexican Women, Public Prenatal Care and the Birth Weight Paradox Gerald N. Grob and Howard H. Goldman, The Dilemma of Federal Mental Health Policy: Radical Reform or Incremental Change? Gerald N. Grob and Allan V. Horwitz, Diagnosis, Therapy, and Evidence: Conundrums in Modern American Medicine Rachel Grob, Testing Baby: The Transformation of Newborn Screening, Parenting, and Policymaking Mark A. Hall and Sara Rosenbaum, eds., The Health Care “Safety Net” in a Post-Reform World Laura D. Hirshbein, American Melancholy: Constructions of Depression in the Twentieth Century Timothy Hoff, Practice under Pressure: Primary Care Physicians and Their Medicine in the Twenty-first Century Beatrix Hoffman, Nancy Tomes, Rachel N. Grob, and Mark Schlesinger, eds., Patients as Policy Actors Ruth Horowitz, Deciding the Public Interest: Medical Licensing and Discipline Rebecca M. Kluchin, Fit to Be Tied: Sterilization and Reproductive Rights in America, 1950–1980 Jennifer Lisa Koslow, Cultivating Health: Los Angeles Women and Public Health Reform Bonnie Lefkowitz, Community Health Centers: A Movement and the People Who Made It Happen Ellen Leopold, Under the Radar: Cancer and the Cold War Barbara L. Ley, From Pink to Green: Disease Prevention and the Environmental Breast Cancer Movement Sonja Mackenzie, Structural Intimacies: Sexual Stories in the Black AIDS Epidemic David Mechanic, The Truth about Health Care: Why Reform Is Not Working in America

Alyssa Picard, Making the American Mouth: Dentists and Public Health in the Twentieth Century Heather Munro Prescott, The Morning After: A History of Emergency Contraception in the United States David G. Schuster, Neurasthenic Nation: America’s Search for Health, Happiness, and Comfort, 1869–1920 Karen Seccombe and Kim A. Hoffman, Just Don’t Get Sick: Access to Health Care in the Aftermath of Welfare Reform Leo B. Slater, War and Disease: Biomedical Research on Malaria in the Twentieth Century Paige Hall Smith, Bernice L. Hausman, and Miriam Labbok, Beyond Health, Beyond Choice: Breastfeeding Constraints and Realities Matthew Smith, An Alternative History of Hyperactivity: Food Additives and the Feingold Diet Rosemary A. Stevens, Charles E. Rosenberg, and Lawton R. Burns, eds., History and Health Policy in the United States: Putting the Past Back In Barbra Mann Wall, American Catholic Hospitals: A Century of Changing Markets and Missions Frances Ward, The Door of Last Resort: Memoirs of a Nurse Practitioner