RECOGNITION OF HEALTH AS AN OBJECTIVE REPORT OF CONFERENCE AT BOSTON OCTOBER, 1923 By Harriet Wedgwood FORMERLY JUNIOR SPECIALIST IN SCHOOL HYGIENE BUREAU OF EDUCATION School Health Studies No. 7 DEPARTMENT OF THE INTERIOR BUREAU OF EDUCATION 1924 WASHINGTON t GOVERNMENT PRINTING OFFICE : I*t4 ADDITIONAL COPIES OF THIS PUBLICATION MAY BE PROCURED FROM THE SUPERINTENDENT OF DOCUMENTS GOVERNMENT PRINTING OFFICE WASHINGTON, D. C. AT 5 CENTS PER COPY CONTENTS Page Introduction 1 Program 1 Physical education and school health-Dr. John Sundwall 3 1. Early history: Physical education eras 3 2. The rise of the school health movement 4 3. Rise of the play movement and decline of physical education- fourth era <5 4. Physical education comes to the front again-fifth era 6 5. Interrelationship between the school's health service and physical education 8 6. Training a new type of supervisor of health and physical educa- tion 9 Certain adolescents in industry-Dr. Hugh Grant Rowell 13 Discussion_______________________________________________________ 24 III RECOGNITION OF HEALTH AS AN OBJECTIVE REPORT OP CONFERENCE AT BOSTON, OCTOBER, 1923 INTRODUCTION Need for discussion of the variation in definition, standards, and practice in school health supervision throughout the country has long been recognized by specialists dealing with the various phases of this work. Since school health supervision is many-sided, it is obvious that standardization will be of slow growth; this growth must necessarily start with consideration of only a few of the most impor- tant aspects of health supervision. As a beginning, therefore, two conferences were called by the United States Commissioner of Education for October, 1923. One was held in Boston in connection with the American Public Health Associa- tion's annual meeting; the other was held in Detroit, in connection with the annual meeting of the American Child Health Association. At the first of these two conferences, held in Boston on October 9, the principal topics considered were as follows: The unification of the school health program; the relation of physical education to that program; the future training of the school health supervisor; and the report of a study made by Dr. Hugh Grant Rowell of the health of a group of working children in New Bedford, Mass., as compared with the health of children remaining in school. The need for further research in respect to everything that concerns, or throws light upon, the school child's health, made this study most welcome for presenta- tion at this conference. Representatives from 14 States, the District of Columbia, and two foreign countries were present, as follows: Arkansas, 1; Connecticut, 2; Illinois 2; Louisiana, 1; Maine, 3; Massachusetts, 34; Michigan, 1; New Hampshire, 8; New York, 10; North Carolina, 2; North Dakota, 2; Rhode Island, 2; Wisconsin, 2; District of Columbia, 2; Austria, 1; Canada 1; total, 76. PROGRAM Chairman, Harriet Wedgwood, United States Bureau of Education. General Topic: School Health Supervision. Physical Education and School Health.-Dr. John Sundwall, Director, Division of Hygiene, Public Health and Physical Education, University of Michigan, Ann Arbor, Mich. 1 2 RECOGNITION OF HEALTH AS AN OBJECTIVE Certain Adolescents in Industry.-Dr. Hugh Grant Rowell, Lecturer in Physical Education, Teachers College, Columbia University, New York City; formerly Director of Health and Hygiene, New Bedford (Mass.) School Department. (Doctor Rowell's study was made under a grant from the committee on scien- tific research of the American Medical Association.) Opening of discussion. Prof. C. E. Turner, Associate Professor in Biology and Public Health, Massachusetts Institute of Technology, Cambridge, Mass. Open discussion from the floor. Summary of discussion. Dr. Merrill Champion, Director of the Division of Hygiene, Massachusetts State Department of Health, Boston, Mass. PHYSICAL EDUCATION AND SCHOOL HEALTH By Du. John Sundwall /. Early History: Physical Education Eras Leonard in his History of Physical Education says:1 The different systems or sorts of physical training which were brought forward for trial, and the agencies which prompted its spread in the tJnited States during the nineteenth century, fall into three groups, centered about 1830, 1860, and the decade from 1880 to 1890. During the first era, centering around 1830, four systems of physical training sprang forth. These were (1) military drill and discipline as introduced by Capt. Allen Partridge into the military academies; (2) the introduction of the German or Jahn system by university-trained German refugees-Beck, Follen, and Lieber-and the building of the first school, college, and public gymnasia in the United States-all of them outdoor gymnasia and of the early Jahn type; (3) the attempt to provide manual labor as a system of exercise in educational institu- tions; (4) the introduction of "calisthenics" for girls and women by Miss Beecher in her schools at Hartford and Cincinnati. None of these systems at this early date met with more than temporary and local interest or success. The second era, centering around 1860, saw the introduction and promotion of "new gymnastics" for men and women and children by Dio Lewis, an unusually able and enthusiastic personality, who estab- lished his Normal Institute for Physical Education in Boston in 1861. His contagious enthusiasm created a wave of popular interest that spread to all parts of the country. But, as is so often the case, interest in the system began to wane with the death of its originator. The third era, including the years 1880-1890, saw the introduction of the Swedish or Ling systems into the United States by Nissen, Baron Posse, Enebuske, Bolin, and others. Time will not permit a discussion here of the rise and fall of the various systems. So far as the public schools and colleges were con- cerned, the greatest rivalry centered on the comparative values of the Gorman-Jahn, or heavy gymnastics, and the Swedish-Ling, or light gymnastics. Naturally, the Jahn system flourished in the schools of German American cities such as Cincinnati, Milwaukee, and St Louis. The Turnverein contributed much to its popularity. The Swedish- 'Leonard, F. E., History of Physical Education,p. 227, 1923. 3 4 RECOGNITION OF HEALTH AS AN OBJECTIVE Ling system became more widely used in the New England States and, through its w Jl-established physical education training schools, gained much influence in the West. So far as we can discover, the various systems of physical training had their origin as health measures. In fact the two national sys- tems-German and Swedish-were nourished in the atmosphere of war and preparation for war. When gymnasia were built at our educational institutions-the first at Yale, Harvard, and Amherst, 1860-they were dedicated to the health of the students. It was assumed at that time that physical training was practically the only known approach to health and strength. It was regarded by its enthusiasts as the universal means of disease prevention and cure. They claimed that, if one would but indulge daily in prescribed gymnastics and calisthenics, the perfection of health and strength would be realized and maintained. Even to-day some of our much advertised physical culturists, through the media of their colorful magazines, would have us believe that physical exercise is the one approach to health. We must bear in mind, however, that the early systems of physical education were devised before the sciences now making up modern hygiene and public health had been developed. With the intro- duction and growth of physiology, biochemistry, bacteriology, pathology, and closely allied medical subjects, we began to realize more and more that there is no single approach to health and physical perfection. Indeed, we have learned that there are many factors which are of even greater importance in the maintenance of health than daily exercise. Malnutrition, focal and other infections, im- paired elimination of the body's waste matter, insufficient rest and sleep, faulty habits of living, nervous instability-any of these may contribute far more to a "break down" than does neglect of exercise. Again, we have learned that there is little in the usual physical edu- cation that will greatly help subnormals, although some physical educators place great emphasis on this particular objective. 2. The Rise of the School Health Movement Physical education failed to keep up with and to utilize the impor- tant contributions to health promotion and disease prevention made by the rapidly developing medical sciences. The school health movement was the next step in logical development. With a view to controlling communicable diseases, Boston in 1894, Philadelphia in 1896, and New York in 1897 began inspection of school children when epidemics threatened. Physicians came to the schools in these three cities to inspect pupils suspected of having contagious diseases. Pupils found to be infected wore taken out of the schools PHYSICAL EDUCATION AND SCHOOL HEALTH 5 and isolated or quarantined. These beginning adventures in school medical inspection proved to be of inestimable value. Not only did they show the futility of closing schools to prevent or block epidemics, but they disclosed the necessity of enlarging the school health activities to include concern for other approaches to health, normal growth, and physical development of school children. Interest in school health began to spread. School inspections brought to light an alarming number of physical defects, such as malnutrition, caries of teeth, enlarged and infected tonsils and adenoids, defective hearing and vision, and cardiac and pulmonary disorders. In fact, physical examinations of school children indicate that 70 per cent have actual or potential physical defects. It is interesting to note that the interest in personnel and the organization and administration of the school health activities developed largely outside of physical education. To state it more forcibly, nine-tenths, or even more, of these interests and activities concerned with the health, normal growth, and the sound develop- ment of school children were included in the school hygiene move- ment, which was quite apart from physical education. 3. Rise of the Play Movement and Decline of Physical Education- Fourth Era It is a rather sad commentary on physical education that, although created as a health measure, it failed to keep up with and apply the important contributions of the medical sciences, and thus failed to serve adequately the health needs of our schools. It got off on the wrong track. It became largely concerned with the methods and technique of exercise. The disciples of Jahn had endless controver- sies with the followers of Ling as to the relative merits of the two systems. Again new method and technique cults sprouted forth, each proclaiming the superiority of its particular method. Time and effort devoted to the technique controversy were largely wasted, for, after all, systems of exercise are not the important thing. The old systems of physical training suffered a severe blow in this country with the rise of the play movement, which centers about the year 1900 and has had a rapid and widespread growth. The new psychology, with its recognition of the tremendous role that the instincts and emotions play in the activities, growth, and education of the child; the development of biology and the appli- cation of the theory of evolution to educational processes; and the new social order-all contributed to the widespread interest in the play movement. "Let us utilize and direct the play instincts of children for our physical education and abandon all formal gymnastic and calisthenic drills" was the challenge of the new "play" enthusiast. 9872°-24t 2 6 RECOGNITION OF HEALTH AS AN OBJECTIVE Naturally, as play is healthful, instructive, and popular, it began to dominate physical education. One serious difficulty, however, with the play movement is that it has become largely emotional, and when emotions dominate any movement there are dangers ahead. Mankind is born with certain fundamental instincts which run to physical competition, emulation, rivalry, and desire for mastery. Furthermore, one can indulge and gratify these fundamental and impelling interests not only by actual participation in competitive sports and games but by looking on. Hence the rapid rise and domi- nation of athletics-professional, intercollegiate, and interscho- lastic-and the building of bleachers and stadia for seating many thousands of spectators. In our colleges and even in our high schools play became specialized. By specialized play I mean that the main emphasis is placed on the special training of a comparatively small number of students for competitive performances. This in itself has contributed little that is worth while to the physical welfare of the schools. The play movement may be regarded as the fourth era in the history of physical education in the country. 4. Physical Education Comes to the Front Again-Fifth Era The appalling revelations of the "draft" examinations, wherein it was found that more than one-third of the Nation's youth were unable to pass the ordinary tests for normal physical fitness, and the findings of physical examinations in our schools have been directly responsible for a renewal of interest in physical education. The term "physical education" is regarded by people in general as funda- mentally a health measure. Somehow or other our citizens have come to accept the term "physical training or education" as an activity wholly concerned with health. Because of this conception, 25 or more States since 1915 have enacted laws whereby physical education and health teaching and supervision are made compulsory in their public schools. Thus physical education has come to the front again-established firmly in the schools of many States by statute. The prime object of this legislation was to improve the physical condition of school children-to achieve positive health and physical efficiency. With the establishment of physical education by State legislation, we note the fifth era in its development and progress in the United States. Whether it will stand the test of the times will depend upon an intelligent interpretation and application of its genuine objectives and functions. Physical educators in recent years have been doing all in their power to meet the new demands, but they find that in many quarters the school health movement has taken over and incorporated in its PHYSICAL EDUCATION AND SCHOOL HEALTH 7 interests and activities most of the " approaches" to health promo- tion-positive health and physical efficiency. Furthermore, the school health agencies now control the means of communicable dis- ease prevention and control. In other words, the school health service, including its staff of physicians, dentists, and nurses, is best prepared to handle most of the positive health and physical efficiency program of the school. While physical education was concerning itself chiefly with technique, methods, and devices for gymnastics, calisthenics, games, plays, and athletics, important approaches to health and physical efficiency brought forward by rapidly developing biological, hygienic, and medical sciences had been appreciated and applied by other school health agencies. In its attempt to assert itself and to convince itself and the public of its value-finding its traditional field fairly well covered by the school health movement and wishing more or less independence of the school health agency-physical education began to cast about for other objectives, outside of those concerned with the body. It found them in a large measure in certain mental, moral, and social values which physical education claims are the invariable products of games, sports, and athletics. As a result, in at least one State there is a State director of physical education and a State director of school health. The objectives found are named as follows:2 Obedience, subordination, self-sacrifice, cooperation, friendliness, loyalty, capacity for leadership, fair play, sportsmanship, self-confidence, self-control, mental and moral poise, good spirits, alertness, resourcefulness, decision, perseverance, courage, aggressiveness, and initiative. Leading educators who have given serious thought to these mental, moral, and social objectives claimed for physical education by physi- cal educators do not feel that physical education can stand on these pretensions. Professor Snedden, among others, has said, "It will serve no useful purpose for the supporters of physical education to urge as primary, or even as important secondary, objectives of their proposed program, objectives of social, civic, or moral education." Again, these schoolmen feel that the numerous virtues enumerated above are to be reached far more effectively through other channels than those offered by physical education. In fact, these attributes are among the "sought-after" objectives in all education. There- fore schoolmen want to see a "back to the body movement" on the part of physical education. This is certain, that no system of physical education in our public-school system will survive and flour- ish unless it has the closest cooperation of schoolmen and unless its objectives meet with the full approval of the general educator. Physical education must be a part of the school system. 1 See report of Society of Directors of Physical Educators in Colleges: Am. Phys. Educ. Rev., June, 1920 8 RECOGNITION OF HEALTH AS AN OBJECTIVE Physical education in order to survive must have an important and particular "job" to do; and this job must be one that is not covered by some other interest and activity in the school. According to schoolmen, seeing to it that every child is not only given an oppor- tunity but is required to develop and maintain a sound, vigorous, and harmoniously developed body is the "big job" of physical edu- cation. But, as has already been stated, there are many approaches to health and physical efficiency-some of these are already in charge of and can be handled best by health agencies other than that which has been known as "physical education." Hence proper relation- ships between physical education and these agencies must be estab- lished. 5. Interrelationship Between the School's Health Service and Physical Education In meetings of public health workers and school hygienists, it is frequently up to me to defend physical education as being something more than a health problem; to show that it is interested in the pro- motion of health and normal growth through proper exercise, but that it includes other objectives as well. At meetings of physical educators, it is frequently my duty to emphasize the health side of the physical education program. Let us assume that both the school health service and physical education are designed fundamentally for positive health and physical efficiency of school children. If this is true, there is no reason why separate administration should be maintained. Independent super- vision leads to duplication, friction, misunderstanding, economic waste, and worst of all to poor results. Some phases of the work may be overemphasized, others slighted. To combine them under one general supervision is the logical thing to do. But before doing so a new type of supervisor of school health and physical education must be trained. Although physical education may have important objectives which are only remotely related to health-such as harmonious develop- ment, neuromuscular control and precision, recreation, guidance of fundamental instincts in play, and development of certain desirable social and moral qualities-it also controls one of the important approaches to positive health and physical efficiency, that is, proper physical exercise. On the other hand, the traditional training in physical education does not prepare one, in any way, to supervise other phases of the school's health service. And yet, to repeat, the interest and activities of the health service and of physical education center on the human body in attaining and maintaining health and physical efficiency. Both are concerned with physical examinations, PHYSICAL EDUCATION AND SCHOOL HEALTH 9 in follow-up procedures, and in physical efficiency tests. In many phases of the work there is an overlapping of interests and activities. Now the public is not willing to support, in our school system, two separate agencies which are concerned primarily with the sound, vigorous, and harmonious development of the body. Nor do our school administrators want this arrangement. To reiterate, too much misunderstanding, lack of sympathy, friction, duplication, and academic and economic loss are the invariable results of a dual administration of the school's physical welfare activities. 6. Training a New Type of Super visor of Health and Physical Education A new type of physical welfare director for our school system is in- dispensible. One whose training has been such that he is well quali- fied (1) to teach health and develop health habits in the schools; (2) to organize and supervise the school's health service with fits personal, environmental, and educational phases; and (3) to super- vise physical education and athletics, being familiar with the various objectives of these activities. The University of Michigan offers a new program of study for the training of this type of supervisor of school health and physical edu- cation-physical welfare activities of school children. The course of study, covering four years, leads to the degree of bachelor of science in education. The hope is to train genuine school men and women for future supervisors of school health and physical education; these should be influential teachers and administrators in schools. Health supervision in its broadest sense must be an integral part of the machinery of our public schools, not set apart as something auxil- iary or adventitious. Four groups of courses make up the program of study at the Uni- versity of Michigan for the training of supervisors of school health and physical education. Group I. This group consists, first, of subjects which may be re- garded as cultural in character and at the same time of professional value: Rhetoric, chemistry, psychology, sociology, public speaking; and, second, of subjects that acquaint the student with scientific methods of teaching and with educational administration-educa- tional measurements, educational psychology, educational admin- istration, vocational guidance, secondary education. A liberal allowance is made for electives, which may be taken in the college of literature, science, and the arts, or in the school of education. Group II. This group consists of subjects which will acquaint the student with the structure and functions of the body and its organs and with the normal vital processes. The following sciences 10 RECOGNITION OF HEALTH AS AN OBJECTIVE are included: Zoology; anatomy; general physiology; and applied physiology, with particular reference to such topics as nutrition, metabolism, growth, neuromuscular physiology, exercise, fatigue, and rest. Group HI. The subjects in this group will familiarize the student with the fundamentals of right living-health promotion and disease prevention. Further, the student will be trained in the recognition of various abnormal body processes which frequently appear during school age-such as various types of physical defects, retrogressive changes, and communicable diseases; in measures for their prevention; and in proper attention to them, such as reference to doctor, or other specialist, or outside health agency. It must be emphasized here that it is not the intention that this group of studies will prepare the student "to handle" personally all the physical abnormal processes which occur in school children. He should be able, however, to detect early disease processes and retrogressive changes, appreciate the significance of these abnormal conditions, and to arrange for proper treatment by reference to physicians and specialists. Further, he will be instructed in the methods of disease control through cooperation with nurses, the city's health department, and the homes. Mental hygiene will be given due consideration. Bacteri- ology, introductory hygiene, physical reconstruction, and school health problems make up this group of studies. School health problems will include consideration of the following: (1) Physical examinations, physical records, follow-up system, anthropometry; (2) promotion of health-food, nutrition and growth, air, activity, fatigue, rest, bodily poisons, mental hygiene, sex hygiene, prevention and correction of defects; (3) first aid and emergency treatment; (4) prevention and control of communicable diseases; (5) environment and sanitation. Group IV. This group of studies will prepare the student to organize and supervise the various interests and activities that come in physical education and athletics. The following courses will be given to both men and women in combined classes: Kinesiology, community play movements, history and principles of physical edu- cation, and the theory and administration of physical education. The various courses in athletic coaching and in the technique and practice of physical education will be given to men and women sepa- rately, as listed in the curriculum under "Education VIII." Upon the completion of this group of subjects students should be able to teach the various plays and games and coach with effectiveness the different athletic sports. Those desiring to prepare themselves especially for the coaching of football, baseball, track, or basketball, however, should register for the summer courses in which more advanced instruction is offered. PHYSICAL EDUCATION AND SCHOOL HEALTH 11 In conclusion permit me to state that in presenting this discussion, I am not unmindful of the places where physical education and school health have been efficiently correlated. 7. Aims and Activities of the School's Health Service A. Personal Phase: 1. Promotion of Health (Physiological Hygiene). a. Physical examinations. b. Bureau of records (follow-up system). c. Provisions for maintaining positive health, such as the body's rela- tion to food, air, activity, rest, fatigue, poisons, injury, and exercise. d. Prevention and correction of defects-defects due to disease; defects of special senses, teeth, and tonsils; postural defects. e. Mental hygiene-prevention and correction of emotional instability, . potential neuropaths. 2. Prevention of Communicable Diseases (Community Hygiene). a. Early detection of communicable diseases in the school, symptoms, etc. b. Isolation and treatment of those exposed or inflicted. Here cooper- ation with the city's health department, with the homes, with social agencies, with visiting nurses, and with physicians is essential. c. Blocking the routes taken by communicable diseases-contact infec- tion, water, milk, food, flies, and personal prophylactic measures- vaccination, inoculation. B. Environmental Phase (Sanitation): a. Location, construction, ventilation, heating and lighting of school building. b. Adequate floor space, seats, and desks adaptable to pupils. c. Sewage disposal; water, milk, food supply. d. Playground facilities-space, equipment, etc. e. Sanitation of school building and playground. f. Sanitation of homes through cooperation with outside health agencies. C. Educational Phase (Teaching of Hygiene): School children must be taught the principles of health promotion and disease prevention. They must be made to appreciate that positive health and physical efficiency are moral obligations to society. Hence, the proper teaching of hygiene becomes a most important phase of a school's health service. a. Graded instruction with auxiliary lectures, placards, posters, moving pictures, etc., for each year, in health promotion and disease pre- vention. b. Inculcation of keen and impelling appreciati i on the part of the school children that they owe it to society and country to maintain at all times perfect health and physical efficiency. c. Lasting health habits must be instilled in pupils. Objectives and Activities of Physical Education and Athletics a. The promotion of health and normal growth by means of proper exercise- gymnastics, games, etc. b. The correction and prevention of abnormalities due to bad posture; a symmet- ricax development, etc. 12 RECOGNITION OF HEALTH AS AN OBJECTIVE c. Harmonious development of the body (Greek ideal). Personality, securing an erect and self-respecting carriage of the body and neuromuscular con- trol required for prompt and accurate response and graceful, agile, coordi- nate, and effective movements. Of greater importance in secondary schools and colleges. d. Activity. The development of a lasting desire to be active-to do many things with a fair degree of strength and endurance. Of greater importance in secondary schools and colleges. e. Recreation. The profitable utilization of the pupil's time during the inter- vals between mental application-games, sports, gymnastics, etc. f. The proper guidance of the fundamental interests and instincts of play, rivalry, pugnacity, and mastery, through competitive games, sports, and athletics. g. Utilizing every opportunity to develop those important social, mental, and moral qualities afforded in physical education and athletics: Obedience, subordination, cooperation, reliability, self-sacrifice, friendliness, loyalty, capacity for leadership, sportsmanship, self-confidence, self-control, mental and moral poise, good spirits, alertness, resourcefulness, decision, perse- verance, courage, aggressiveness, initiative. CERTAIN ADOLESCENTS IN INDUSTRY Presentation of a Nutrition Study in Neu) Bedford, Mass. By Dr. Hugh Grant Rowell Public interest is thoroughly aroused by the problem of children leaving school and securing permits to go to work. The public wants to know what children shall be permitted to work, and in what positions; at what age they may begin work and what shall be the required physical standards and educational requirements. Because of this widespread interest in the child-labor problem it is desirable to present any facts which may aid in a solution.1 The present methods of handling children of school age who enter, or seek to enter, industry are not standardized either among nations or States. The action of England in 1920,2 declaring 14 years as the minimum age for industrial employment, is significant, because 12 years had been the minimum age standard since 1901 3 in that country.4 The English act is pertinent to this paper because it is applicable to the textile industry, which is prominent in New Bed- ford, Mass., as well as in England. I have seen only two English children who had worked under the older law. In these, general physical development seemed to have been injured, although there was no such apathy or dullness of eyes as are popularly believed to result from employment in the textile industry. No one method of certification for adolescent employment is used uniformly throughout the United States; the need for such a method exists and will probably be supplied when more field study under all conditions can be made. At present the minimum employment age is somewhere from 14 to 16 years, but there are exceptions to this. Some States, as Massachusetts, have a definite code of permissible positions; in other places the local dominating industry and its needs largely determine the rules and practice. * The proposed Foster child-labor amendment to the Constitution, passed by both Houses during the last session of Congress and submitted to the States for ratification, reads as follows: "Section 1. The Congress shall have power to limit, regulate, and prohibit the labor of persons under 18 years of age. "Sec. 2. The power of the several States is unimpaired by this article except that the operation of State laws shall be suspended to the extent necessary to give effect to legislation enacted by the Congress. ' Employment of women, young persons, and children act. England, Chit. Stat., 1920. • Factory and workshop act. England, Chit. Stat., 1901. 4 The employment of children under 14 years of age was greatly restricted, however, by the educational act of 1918, commonly known as the Fisher Act. 13 14 RECOGNITION OF HEALTH AS AN OBJECTIVE Medical control of child-labor conditions varies. Originally certain officials could require physical examination for the apparently unfit. The permissive and mandatory laws came later. Certain States and the Children's Bureau have suggested or even furnished examina- tion forms 5 for use, but so far local standards seem to be the chief criteria of physical fitness, depending on local interpretation of whatever law may exist. The extent of the physical investigation of the child labor applicant depends on public opinion. The adolescent girl objects to examination beyond a certain minimum, and in most cities she is examined with all outer clothing upon her. A more thorough study can be and should be made of the boys. The public will not permit features with objectionable possibilities; nor should such features be carried out on the unwilling. Regarding reexamination, Virginia requires a new testing after a year if the certificate is to continue in force. Other States, of which I believe Massachusetts is one, desire repetition of examination on change of position or employer. At least such is my interpretation. Certain States demand a preliminary examination only. Completion of the sixth grade represents the minimum scholar- ship standard. Further education to a specified age, at night school or continuation school, is usually required. Where day con- tinuation school is required, it places the employer under a slight competitive handicap as compared with employers in States where this is not demanded. For example, Massachusetts requires it and Rhode Island does not. Nevertheless, the continuation school offers the best possible means of watching the physical welfare of the adolescent. In the textile industry, an important employer of child labor, a difficult situation exists. The artificial humidifier has removed the climatic advantage formerly held by certain New England cities. The South now offers strong competition because its own cotton fields are near its mills, and because its laws are more lenient toward child labor than those of the North. The textile industry itself, at least in many northern cities, has greatly improved working conditions, partly on its own initiative and partly because of suggestions from bureaus and other sources. State inspection is excellent in Massachusetts. Children 14 years of age and over are permitted in Massachusetts to work only at certain jobs that are considered safe and harmless for suitable persons. The employers do not care particularly to employ adolescents, but do so in some cases as a means of meeting competition and of offering work to other members of the families of desirable employees. The employees themselves seem fairly well satisfied with conditions. * Physical standards for working children: U. S. Children's Bureau, Publication 79( 2d ed.), 1923. CERTAIN ADOLESCENTS IN INDUSTRY 15 The Children's Bureau has assembled, under the advice of a group of physicians, a suggestive code of physical standards for working children.8 Some general recommendations of this code are: (1) That 16 years be made the minimum age for granting of em- ployment certificates, and that the certificates be granted then only to children of normal development; (2) that physical examination precede certification and be made for a given position only; (3) that at least one yearly physical examination be given each employed child under the age of 18 and a reexamination on change of employer or general type of job; and (4) that centralized control of methods of examination be adopted. The adolescent applicant for employment should come up to cer- tain minimum standards of height and weight for specified age. These standards, as determined by the Children's Bureau, are given in the following table: Minimum physical standards Age Weight (in clothing) Height 14 years 15 years 16 years Pounds 80 85 90 Inches 58 58 59 When a child falls below these specifications, examination by two physicians to determine whether racial or family characteristics are responsible for the underdevelopment is urged. Further minimum standards of physical fitness for children seeking to enter industry are given. Important among these is that unmis- takable signs of puberty should be present. Sound health should be attested by the absence of serious physical defect. In case of serious remediable defects, issuance of working papers should be postponed until these are corrected. In certain cases which are in process of treatment-such as malnutrition, partial blindness, partial deafness, and orthopedic defects-provisional certificates limited to three months may be issued; at the expiration of this time another exami- nation should be given and the child excluded from any occupation dangerous to him. When the applicant first presents himself for physical examination a complete personal history should be obtained, and results of the examination should be recorded by means of a cumulative system. The usual reasons for child labor are either economic or a dislike for school. Large families, supportable at times with difficulty on wages which industry can pay and survive, are often in better condi- ' Physical standards for working children: U. S. Children's Bureau, Publication 79 (2d ed.), 1923. 16 RECOGNITION OE HEALTH AS AN OBJECTIVE tion with the addition to the budget. Some nationalities are notably thrifty and use the added earning in part to accumulate property. Some parents consider their children a commercial asset. Dislike for school may be due to lack of interest or dislike for something in the school. It may be due to inability to handle the school type of work. The junior high school is held up as one prob- able remedy. Assuredly vocational guidance is needed. Neverthe- less, not all can benefit by education of a certain type beyond a given point. Woolley in 1915 examined 50 unselected children who had gone to work at 14 years of age and found about one-half border-line cases, or worse, in mentality.7 I wonder if nature is not actually doing a little vocational guidance work for us. One thing is sure- the mentally inferior groups are large in industrial cities. Unless we permit these groups to work we must provide suitable educational facilities in addition to our present ones-often a 10 per cent addition, and this frequently of a highly specialized sort of education. Before doing so wo would do well to assure ourselves that the benefit to the child not now in school would warrant it. Educators are having no easy time finding adequate funds as it is. With this resume of the general background, we can turn to a consideration of nutrition. The Children's Bureau has for some time advocated various investigations, two fields of which are these: (a) The rate of growth and development of children employed in different occupations and industries as compared with children not in industry; (&) the effect of employment in specific occupations, at different stages of physiological development, upon the growth and health of normal children. Harmon in 1909 noted that there was little available statistical material showing the effect of excessive child labor under healthful conditions.8 The work of a few, such as Woodbury,® Woolley,10 and a handful of others, is about all on which we can base opinions regarding nutri- tion as related to child labor. The reason is that the work is still being organized, public approval in municipalities is yet to be won, and the value of supervision must be proved before research work can be successfully emphasized. And yet, it is only through research that we can meet our problem. The writer was fortunate in securing an appropriation for nutrition studies from the committee on scientific research of the American Medical Association. The added help thus made possible permitted, after a preliminary survey had suggested 1 Woolley, Helen Thompson. A New Scale of Mental and Physical Measurements for Adolescents, and Some of Its Uses. Jour, of Ed. Psych., November, 1915. • Harmon, William W. Handicaps in Later Years from Child Labor. Annals of Am. Acad. Pol. and Soc. Sc. Supp., March, 1909, p. 122. •Woodbury, Helen Sumner. Working Children of Boston. U. 8. Dept, of Labor. Children's Bureau. Publication No. 89. 1922. '• Wooley, Helen Thompson, and Fischer, Charlotte Rust. Mental and Physical Measurements of Working Children. Psychological Monographs, vol. 18, 1914, No. L PP- 1-247. CERTAIN ADOLESCENTS IN INDUSTRY 17 that conditions were apparently unusual, the study of which this paper is a report. This study, here presented in tabular form, was simply the assem- bling of facts-under what I felt to be a conscientious interpretation of the Massachusetts labor laws-from the routine physical examina- tions of adolescents belonging to the industrial population of New Bedford, Mass. The study involved comparison of a group of chil- dren 14 and 15 years of age who applied for working cards, and who returned for further examination on change of position, with a group of grammar school children of the same ages. The Massachusetts laws are based on standards for working chil- dren similar to those suggested by the Children's Bureau, except that 14 years is the minimum age, and reexamination is made only on change of position. To offset this, I was able to introduce careful health work, such as coordination of school and industrial health records; monthly weighing (in continuation school); careful home follow-up work through the teachers and the nurse, whom we also used for the teaching of home hygiene; and medical advice as needed. All this was made possible through the interest and cooperation of the continuation school director, Mr. Saddler. The New Bedford plan has been reported in several magazines.11 Reaction was good locally, both among employers and employees, and a few of the former were inclined to place some value on our opinions as to suitability and refused to accept a child who evaded us in a technical manner. Parents were usually interested and co- operated. Every effort was made to place the child suitably and to assist him if possible. The examinations were made by one physician, except for certain tests which were made by nurses thoroughly familiar with a very definite set of standards and whose work was constantly checked. Uniformity of statistics can therefore reasonably be expected. Three groups of children were considered, designated as- 1. The single card group.-Children who had only one examination. From this we can secure a fair index of the average child employed, since it is the largest of the subgroups. 2. The repeaters.-Those who had more than one physical examination, because of change of positions. Here we can determine the effect of industry on physical progress, both through the group and through analysis of various jobs. 3. The grammar school group.-Children who actually met the same require- ments in age and education as the industrial adolescents and might be expected at any time to apply for working cards. As many records as possible were secured, but this group is one for comparative purposes only. n Rowell, Hugh Grant: Nation's Health. May, 1923; The Question of Physical Injury to the Work- ing Child, Boston Med. and Surg. Jour. May, 31, 1923; Medical Clinics of North America, Boston Number, Nov., 1923. 18 RECOGNITION OF HEALTH AS AN OBJECTIVE Table \ .-Comparison of adolescent groups according to weight Nutrition groups Boys and girls Single card- ers Repeat- ers, 450 indi- viduals; 1,184 exam- inations Both indus- trial groups Grammar groups Seventh grade Eighth grade Both grades 14 years of age 15 years of age 14 years of age 15 years of age Seven per cent under- /Boys / 63 } 178 / 6 2 0 0 weight (Girls ( 18 ( 2 3 0 0 Ten per cent underweight.. /Boys (Girls } 287 / 144 ( 86 } 517 / 10 ( 14 7 9 10 12 4 1 } 67 Normal weight /Boys (Girls.... | 619 / 481 ( 188 | 1,288 / 21 11 23 10 } 118 I 10 23 6 Ten per cent overweight /Boys (Girls.... । ns / 66 ( 48 | 232 f 1 1 7 2 4 5 3 1 2 } 25 Twenty per cent over- /Boys / 33 | 169 / 2 2 1 0 weight... (Girls.... / 7y ( 57 ( 0 0 1 2 Total /Boys.... 787 40 24 39 15 118 113 (Girls 397 Grand total 1,200 1,184 2,384 77 50 78 26 231 Table 2.-Number and per cents in various groups NUMBER Nutrition groups Single carders Repeaters Total Grammar group Seven per cent underweight 97 81 178 13 Ten per cent underweight 2S7 230 517 67 Normal .. 619 669 1,288 232 118 Ten per cent overweight 118 114 25 Twenty per cent overweight 79 90 169 8 Total 1,200 1,184 2,384 231 PER CENT Seven per cent underweight 8. 08 6.84 7. 47 5.63 Ten per cent underweight 23.92 19.43 21.68 29.00 Normal 51. 58 56.50 54.03 51. 08 Ten per cent overweight 9.83 9.63 9.73 10.83 Twenty per cent overweight 6.58 7.60 7.09 3.46 Total 100.00 100.00 100.00 100.00 Total underweight 32.00 26.27 29.15 34. 63 Normal 51. 58 56.50 54.03 51.08 Ten per cent overweight 9.83 9.63 9.73 10.83 Twenty per cent overweight 6. 58 7.60 7.09 3.46 Comparison of adolescent groups according to weight {Tables 1 and 2).-From these tables we find that the percentage of underweight children in the grammar school group is considerably greater than the percentage of underweight children in the industrial groups. The actual figures compare closely with the general average obtained in the entire school system in Fall River, Mass., in a nutrition study made this year, where 28 per cent were underweight (using the 7 per cent borderline). In the New Bedford group it is evident that the adolescents who remained in school had a higher percentage of under- weight than those who went to work or continued in work. The CERTAIN ADOLESCENTS IN INDUSTRY 19 causes are probably that the most fit physically are a little more inclined to go to work; that the extra funds in the family budget permit better living; and in certain cases the child who goes to work is allowed somewhat different food. The percentage of underweight in all classes suggests that we may have blamed industry too much at times. Table 3.-Average monthly gain, in pounds, of the repeaters BOYS Nutrition groups Num- ber of cases Length of time (months) observed Weight at begin- ning of period Weight at end of period Gain Aver- age gain per month Actual Nor- mal 1 Actual Nor- mal 1 Ten per cent underweight 67 3.17 93.96 105.31 98.88 109.37 4.92 1. 55 Seven per cent underweight 28 3.14 99.78 107.0 103.3 108.7 3.42 1. 09 Normal weight 166 3. 51 107.3 107.3 110. 91 109.1 1.8 .51 Ten per cent overweight 33 3.57 123.1 92.09 125.39 113.12 2.29 . 64 Twenty per cent overweight 12 4.31 141.7 110.8 140.3 114.5 '1.4 '.32 GIRLS Ten per cent underweight 241 3. 21 80.96 104.1 94.3 105.3 13.34 4.15 Seven per cent underweight 14 1.86 104.6 111.6 105.6 112. 5 1.0 .50 Normal weight 76 3.33 107.3 106.6 110.0 117.7 2.7 .81 Ten per cent overweight 18 3.19 114.34 101.83 115.4 104.9 1.06 .33 Twenty per cent overweight 23 3.69 139.3 107.3 142.3 108.9 3.0 .81 Average monthly gain of the repeaters (Table 5).-This table reveals the general tendency of repeaters in the various nutrition groups to gain in weight. Duration of employment varied from one week to nine months. 1 Based on age and height of the cases considered. J Loss. Table 4.-Repeaters' progress in weight GIRLS [Standard, one-half pound per month] Nutrition groups Less than normal Normal Better than normal Number Per cent Number Per cent Number Per cent 10 per cent underweight 9 21.95 2 4.88 30 73.17 7 per cent underweight 3 23.07 4 30.77 6 46.16 Normal weight 23 32. 86 22 31.43 25 35.71 10 per cent overweight 7 35.00 4 20.00 9 45.00 20 per cent overweight 5 22.73 6 27.27 11 50.00 Total .. 47 28.31 38 22.89 81 48.80 BOYS [Standard, 1 pound per month] 10 per cent underweight 17 28. 33 9 15.00 34 56.67 7 per cent underweight 5 19.23 6 23.08 15 57.69 Normal weight - - 59 32.96 38 31.23 82 45.81 10 per cent overweight 8 30.77 5 19.23 13 50.00 20 per cent overweight 6 35.29 4 23. 53 7 41.18 Total... -. 95 30.84 62 20.13 151 49.03 20 RECOGNITION OF HEALTH AS AN OBJECTIVE Repeaters' progress in weight (Table -This table shows in each nutrition group the percentage maintaining less-than-standard prog- ress, normal progress, or better-than-standard progress for the age. The remarkable tendency of the underweights to gain is shown. Table 5.-Gains in different types of work 1 BOYS Textile Non tex- tile Outdoor Clerical Errands Domestic Number of cases Average gain pounds.. Average weight do.... Per cent of gain... 258 2. 365 108. 92 2.17 41 2.28 111. 98 2.4 34 2.75 108.96 2.52 61 2.339 113.18 2.06 37 2.337 107.06 2.18 51 o S4 105^ 22 2.41 GIRLS.' Number of cases Average gain .pounds.. Average weight. ...do Per cent gain. 156 1.825 104.64 1.74 36 2.58 107. 38 2.402 - 23 .7282 115. 73 3.22 22 3.647 113.06 .6205 > The Baldwin-Wood tables mean average at 14 and 15 years would be 0.894 per cent per month on a mean average of 112 pounds. 1 The Baldwin-Wood tables mean average at 14 and 15 years would be 0.43 per cent per month on a mean average of 115 pounds. Gains in different types of work (Table 5).-Table 5 shows compara- tive percentage gains in different types of work. For boys the difference in any sort of work is slight. The outdoor group are generally a very strong type and perhaps represent the best physical standards; this is necessary for the type of labor. The gain in all groups should be noted. For girls we find a less percentage gain in the textile column, but gain requirements at this stage are considered to be only half as much as with boys. Therefore, the girls actually made a better record, except in domestic work. The time element is not considered in this table. Table 6.-Job analysis-Average progress per month in certain classes of work Gains are indicated by plus sign (4-), losses by minus (-) BOYS GIRLS Weavers: Lbs, Oz. Lbs. Oz. Ten per cent underweight - +2 3^ +0 7« Seven per cent underweight +3 7^ +1 Normal. -- +1 9 +1 15^ Ten per cent overweight +1 14 +2 4^ Twenty per cent overweight.. -0 +1 14 Cleaners: Ten per cent underweight - +1 13M +1 4 Seven per cent underweight. +2 13 +0 9 Normal - +1 3 +0 15 Ten per cent overweight +1 13J* -0 10 Twenty per cent overweight -0 10 - - Sweepers: Ten per cent underweight - +2 7 - Seven per cent underweight. - +0 13^ - - Normal - +0 6 - Ten per cent overweight -0 14 - Twenty per cent overweight -0 9 - - CERTAIN ADOLESCENTS IN INDUSTRY 21 BOYS GIRLS Wire boys and girls: Lbs. Oz. Lbs. Oz. Ten per cent underweight .... +0 12 -0 4 Seven per cent underweight +1 4 - - Normal +1 9^ +0 10 Ten per cent overweight... - - +0 3 Twenty per cent overweight... - - +1 8 - - Bobbin boys: Ten per cent underweight - - - - Seven per cent underweight - +2 5 - - Normal +1 5 - - Ten per cent overweight - -0 4 - - Twenty per cent overweight - +2 0 - - Yarn boys: Seven per cent underweight - -0 8 - Normal ............ - - - -1 0 ---■ III-- - Ball wrappers: Normal. +4 4 - - Ten per cent overweight +4 4 - Loom fixers: Seven per cent underweight +1 0 - - Normal +1 0 - Harness boys and girls: Ten per cent underweight- - -- +0 1 Seven per cent underweight +0 1 - - Normal +1 1 +0 3 D oilers: Ten per cent underweight - - -2 7 Seven per cent underweight - -0 15^ Normal.............. - +0 12 Ten per cent overweight - +1 12 -0 12 Twenty per cent overweight - - -0 14^ Spoolers: Normal -0 4 II1- 1 Ten per cent underweight- - - +2 lOVs Seven per cent underweight - ...... - -0 4 ■ - 1. +0 7 Ten per cent overweight - - - -2 1 Twenty per cent overweight - - +2 5 Battery boys and girls: Normal _ +2 3 +3 Ten per cent overweight - -0 7 Cloth inspectors: Ten per cent underweight.. - ... - +1 Seven per cent underweight ...- - +0 11 -- - - +0 6^ Ten per cent overweight... - - +1 2 Twenty per cent overweight - - +4 4 Spinners: Ten per cent underweight - +9 0 ■1 -» ... . +0 9 Ten per cent overweight.... - - +0 13>/> Twenty per cent overweight - -0 8 Harness girls: Ten per cent underweight ; - +0 1 1-• - +0 3 Trimmers: Twenty per cent overweight. - -1 13 Pickers: Ten per cent underweight - +0 8 Operators: Ten per cent overweight - - +0 7 22 RECOGNITION OF HEALTH AS AN OBJECTIVE Job analysis (Table 6).-Various types of work were studied for the effect on boy and girl members of the various standard nutrition groups, and the gain was determined in pounds per month. Dura- tion of employment on a given job varied from a few weeks to eight months. Customarily the most satisfactory gain was made in the children whose weight indicated the poorest nutrition. The groups which showed least gain were the 10 per cent underweight wire girls and the subnormal doffers. The two apparently unsatisfactory types of work are known to be rather active, though light types of work, and it is possible that we might do well to require normal weight for these positions. Using the standard of 1 pound per month for boys and half a pound per month for girls, we find that the tendency was to exceed normal requirements. Many will probably be surprised to note that real gain has taken place at all. Americanization workers and attendance officers, as well as inspectors, possess a most satisfac- tory knowledge of industrial conditions and recognize thoroughly the difference in types of tasks as well as the finer differences between mills. My New Bedford associates in these positions have offered opinions which check rather well with the statistics in this paper. In a study in untilled ground, such as this is, one is never quite sure what factors may prove important. Personal change of loca- tion necessitated its conclusion at the end of a year. It is recog- nized in presenting it that certain other statistics would be desirable but these presented are the ones which circumstances permitted. Taken as such they bring out certain definite facts which are at least valuable as suggestions for work in other cities and as indicating what occurs in a city known as an important employer of child labor. We have seen, using weight as our standard, that the adolescents in industry proved after a brief period of work to be in better condi- tion than a similar group in grammar school. In the industrial group we have seen that with boys the per cent gain has differed little, no matter what work was done; with girls the per cent gain or loss showed greater variation. The job analysis and other analyses show that the gains were best in the underweight groups, somewhat in proportion to the amount of underweight. The gains were usually greater than the mean average gain obtained from the com- bined mean averages at these ages in the Wood-Baldwin tables. The girls who were doffers and the wire girls did not do well, and are really alone in this.12 The correctness of certain figures regarding under- weights is attested by their close comparison with the general average in Fall River, Mass., a city within a few miles with almost the same conditions and problems. 11 Harmon, Wm. W., Handicaps in later years from child labor. Annals of American Academy of Political and Social Science, Supp., March, 1009, p. 122. CERTAIN ADOLESCENTS IN INDUSTRY 23 New Bedford13 has long had an excellent board of health and good school hygiene. An adequate system of easily reached parks per- mits fresh air for most children. The tenement problem has its solution in education of immigrants rather than in building changes. A great variety of nationalities are intermingled in New Bedford, including the Yankee, French-Canadian, English, Portuguese, and Azorean as the chief elements of the population. The racial factor in development is not indicated in the statistics here given, but has been studied and will be used in a later paper. The average mill has made some effort toward good conditions, and many of the fac- tories are excellent in every way. Thorough inspection is conducted through the Massachusetts Bureau of Labor and Industries. The result must be admittedly good working conditions. The local medi- cal control of the adolescent laborer is too recent to have shown an effect on statistics. The main intention of regulation of child labor is to permit nor- mal growth physically and mentally. Education is desirable as far as it can be assimilated or be a source of benefit to individual or group. It must be recognized that wages depend on the ability of an indus- try to pay. Textile wages are usually considered high. In large families it must be expected that youth assist by earning at a feasible age. Broadly applied, the suggestion is that the Massachusetts stand- ards and laws are satisfactory when actually carried out. The elim- ination of the unfit is the important thing, and the conditions for working and the degree of control of the adolescent are determining factors as to the permissible age. Certain tasks must be selected, as they are, and only these permitted. When all examining phys- icians perform their duties adequately, and have a definite basis on which they can perform them, the adolescent in industry will cease to be a problem. The coordination of school-health systems with industrial examinations offers the only real method of truly knowing a child's physical condition and physical possibilities through the combined record. To my mind the solution of the adolescent labor problem through- out the country is to be found in the enactment of reasonable, stand- ard legislation, constructed upon accurate knowledge of conditions and much field study, and the enforcement of such legislation. The scientific and popular literature on the subject must be increased and the assistance of the press continued, revealing to the public why we need its cooperation in a matter affecting many of the rising generation. 13 Rowell, Hugh Grant. The Question of Physical Injury to the Working Child. Boston Med. and Surg. Jour., May 31, 1923. 24 RECOGNITION OF HEALTH AS AN OBJECTIVE DISCUSSION Professor Turner in opening the discussion commented upon Doctor Sundwall's plan, pointing out that the important thing is to secure a clear vision of the task in hand, to know as exactly as possible what a sound, complete school health program should be, and then to develop the personnel for its execution in the best possible manner. He said,11 We must be careful to avoid professional jealous- ies which may rise if the various groups of specially trained people begin to worry about the prerogatives of their profession instead of thinking about the task at hand." Professor Turner also described briefly the program of study in health education at the Massachusetts Institute of Technology. Dr. Taliaferro Clark, of the United States Public Health Service, called attention to the difficulty of drawing accurate conclusions from a comparatively small amount of data, and the liability of reaching conclusions agreeing -with our preconceived beliefs on the subject. He complimented Doctor Rowell for having steered clear of these two pitfalls set for the feet of the investigator, and felt that he had made a definite contribution to one phase of the subject of the school child's health. Dr. Harold H. Mitchell, of the American Child Health Association, discussed both papers, as follows: I might say, in general, regarding the child-labor problem that it seems to me very questionable whether prohibitory legislation should be extended to include children 16 years of age or older, and when laws are rigid I have considerable doubt as to the advisability of including 16 or even 15 year old children. Such legislation must presuppose that it is better for the child to continue full-time schooling than for him to be employed at a suitable occupation. We are too prone in this country to pass a law concerning an evil and then sit back self- satisfiedly with the expression "Well, that's taken care of." There is no doubt that vocational education is still at such an early stage of development that many youngsters fail to profit by schooling continued during the adolescent period when they dislike school and have an earnest desire to find some profitable occupation. Only a few communities as yet have even any form of vocational education. Fewer still have any that is worthy the name. High schools that are designed to meet the demands of colleges are obviously unsuitable to the great mass who never attend college. If we face the situation as it is and not as we would like to have it, we must admit that it will be some time before we can make it profitable for a youngster to continue schooling when there are a great number of powerful forces pulling him away from the school routine. Although vocational guidance is also in its infancy, honest attempts to advise boys and girls during their early wage-earning experience, to keep them away from blind-alley jobs, and to help them to adjust themselves to profitable occu- pations, should result in as much benefit both from the educational and health aspect as the restraint of unsatisfactory school life. Such an approach to the problem would mean educational and health supervision of the adolescent while at work, rather than prohibition of employment. RECOGNITION OF HEALTH AS AN OBJECTIVE 25 We have considered we could pass upon a child's physical fitness to leave school for wage earning, but in no place have these laws for physical examination to determine physical fitness resulted in adequate health supervision or protection. The study I made a few years ago in Newark of 1,200 boys and girls who had been at work for six months or longer showed quite definitely that this examination for physical fitness was inadequate for either health protection or health supervision. Physicians are usually asked to decide whether the child is physically fit to be employed. Very few physicians are willing to make a decision that a child has physical defects that are likely to be of serious danger to his health if he leaves school for employment. Examining physicians have told me that if they were asked merely to pass upon the physical condition of the child, and if they could make such recommendations or statements to the officer issuing work permits that would make it possible for the issuing officer to prevent children leaving school for wage earning without correction of physical defects that are actual handicaps-in other words, if the responsibility for keeping the child in school were placed upon the issuing officer rather than on the physician-a larger number of physical handicaps might be corrected before the child leaves school for work. The physician is not able to say that the employment is likely to result in danger to the health of the child, but he would be willing to say that certain physical defects should be corrected. In regard to the direction or the coordination of health service and physical education discussed by Doctor Sundwall, I might mention my own experience in West Virginia, where I was a physical director in the high school. I found that the boys I examined for physical defects responded to my suggestions that their defects should be corrected, and they were much more interested in what I had to say about their physical condition than boys of similar age whom I had examined as a physician in both New York and Newark. I attribute the response I had from the boys in West Virginia to their association of me with their physical activities-basket ball, track athletics, and other sports-which were vital to them. They were interested in being physically fit, so that they might succeed in their sports. The boys I had examined as a physician were not interested in health because they could not feel any connection between health and the vital activities of their lives. I feel that this experience suggests that there should be a close correlation between the health examination, the develop- ment of health habits, and a "natural" physical education program. We have made too little use of physical activities as a means of interesting youngsters in caring for their health. I have recently seen a school where such usual measurements as chest expansion and girth of arms have been dispensed with by the physical education teacher, and a physical examination by a physician has been substituted. The physical education teacher was present at the time of the medical examination, assisted the physician, and did the follow-up work by persuading pupils that they could become physically fit through the correction of their physical defects and through the practice of health habits, and that this physical fitness had a direct relationship to proficiency in their sports. Mr. F. G. Marshall, superintendent of schools of Malden, Mass., regarded the health instruction of children as an important part of school health work and said such teaching had been introduced into the Malden schools. Miss Georgie B. Collins, special health teacher in the Malden (Mass.) public schools, said she believed that school health super- vision-or the school health service-should include classroom in- 26 RECOGNITION OF HEALTH AS AN OBJECTIVE struction in matters of health, and that a special teacher is needed for the work because the regular teacher is already overburdened. Dr. William J. French, director of the child health demonstration at Fargo, N. Dak., agreed with Miss Collins in respect to the need for health instruction, but disagreed with the statement that the regular teacher is already overburdened. Health teaching, if cor- related with the other subjects of the curriculum, makes all teaching easier and more vital and interesting. Dr. Florence M. Ross, of the Rhode Island College of Education, Providence, R. I., asked for definite suggestions in working out the health program for normal schools, but there was not time for a discussion of this. Dr. Charles H. Keene, however, of the Pennsylvania Department of Public Instruction, Harrisburg, Pa., outlined what, in his opinion, school health supervision should include. The seven points which he stressed as component parts of school health supervision are as follows: 1. Sanitation of the school plant. 2. Physical education. This should include formal gymnastics (both with heavy apparatus and with hand apparatus); plays and games; sports and ath- letics; mass activities; folk dancing and the latest developments; story plays. 3. Health supervision, including medical inspection, and including also special classes and the work of the physician and school nurse. 4. The hygienic arrangement of the school program. 5. The training of teachers. This should include the general training of all teachers and special training of special health teachers. 6. The health of teachers. 7. Health training and instruction of pupils, including physiology and hygiene. Doctor Champion, in summing up the discussion, commented favorably on the proven possibility of groups with widely different vocations, yet each having a distinct relation to the school child's health, getting together and talking matters over pro and con. He called attention to the generally harmonious relations between physicians, physical educators, nurses, and school people in his own State. He said he believes that harmony is possible, to the benefit of all concerned, if each group is willing to learn the viewpoint of other groups in the working out of a program of school health work which will be of greatest good to the child. HEALTH EDUCATION PUBLICATIONS MAY BE PROCURED FROM THE Superintendent of Documents, Government Printing Office, Washington, D. C. Remittance must accompany order. Stamps are not accepted. Na Title Num- ber of pages Price Single copy or first copy of an order Each addi- tional copy *1 HEALTH EDUCATION SERIES Wanted! Teachers to Enlist for Health Service! 8 Cents 5 Cents 1 *2 Diet for the School Child __ - 14 5 2 3 Summer Health and Play School 12 5 2 *4 Teaching Health 16 5 2 *5 Child Health Program for Parent-Teacher Associations and Women's Clubs _ 16 5 3 6 Further Steps in Teaching Health. __ - 20 5 3 7 The Lunch Hour at School 62 5 4 8 Health Training for Teachers 15 5 2 9 Your Opportunity in the Schools 16 5 2 10 11 Suggestions for a Program for Health Teaching in the Elementary Schools. Milk and Our School Children 107 31 10 5 6 2 *12 Sleep. The need of more sleep for school children. Suggestions for in- teresting children. - 22 5 2 13 Dramatics for Health Teaching 16 5 2 *14 The Kindergarten and Health ___________ 38 5 3 15 Suggestions for a Program for Health Teaching in the High School .. 40 5 3 16-J The Continuing Need for Teachers of Child Health 18 5 CU 2 17 Helps for the Rural School Nurse _ 52 18 What Every Teacher Should Know About the Physical Condition of Her Pupils ----- 18 SCHOOL HEALTH STUDIES *1 Health for School Children. A report of the Committee of the National Child Health Council 75 10 7 *2 The Child Health School Conducted in the University of Chicago During the Summer of 1920. By Lydia J. Roberts_____________________________ 60 10 7 *3 Who's Who in Health Land? "A study of methods and devices used in the schools of Newton, Mass., for health teaching . 32 10 5 4 Growing Healthv Children, Trenton, N. J.. Public Schools 35 5 3 5 Health Promotion in a Continuation School 28 5 3 6 Municipal and School Plavgrounds and their Management... 22 (*) 5 (*) (*) 5 (*) (*) 2 7 Recognition of Health as an Objective, Report of Conference at Boston, October, 1923 27 8 School Health Supervision, Report of Conference at Detroit, October, 1923. 18 (*) 3 PHYSICAL EDUCATION ♦1 Preparation of School Grounds for Play Fields and Athletic Events 17 5 3 *2 3 Athletic Badge Tests 17 5 3 Suggestions for a Physical Education Program for Small Secondary Schools - - 79 10 5 4 4 5 (*) WALL CHARTS Classroom Weight Record. Printed on heavy paper. Space for 48 pupils. Poster No. 4. Weight-Height-Age Tables for Boys and Girls. (Revised). Poster No. 5. Sleep. Picture and table of hours needed at different ages. MISCELLANEOUS 5 1 5 2 5 2 36 5 3 Folder. Interest-Arousing Devices for Health Teaching. Single copies free on application to Bureau of Education. Educational Hygiene. Bureau of Education Bulletin, 1923, No. 33. By Willard 8 Small Obtainable from Government Printing Office HEALTH CARDS Card No 1 What is Health? Card No 2 Rules of the Health Game - Free copies will be sent by the Bureau of Education, on request, one copy to a person, so long as free copies are available. The publications which are starred (*) can be obtained only from the Government Printing Office, Washington, D. C. A set of Health Education Bulletins Nos. 1-14 will be sent by the Superintendent of Documents, Government Printing Office, for 75 cents. 27