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

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Classrooms and Clinics is the first book-length assessment of the development of public school health policies from the late nineteenth century through the early years of the Great Depression. Richard A. Meckel examines the efforts of early twentieth-century child health care advocates and reformers to utilize urban schools to deliver health care services to socioeconomically disadvantaged and medically underserved children in the primary grades. Their goal, Meckel shows, was to improve the children’s health and thereby improve their academic performance.

Meckel situates these efforts within a larger late nineteenth- and early twentieth-century public discourse relating schools and schooling, especially in cities and towns, to child health. He describes and explains how that discourse and the school hygiene movement it inspired served as critical sites for the constructive negotiation of the nature and extent of the public school’s—and by extension the state’s—responsibility for protecting and promoting the physical and mental health of the children for whom it was providing a compulsory education.

Tracing the evolution of that negotiation through four overlapping stages, Meckel shows how, why, and by whom the health of schoolchildren was discursively constructed as a sociomedical problem and charts and explains the changes that construction underwent over time.  He also connects the changes in problem construction to the design and implementation of various interventions and services and evaluates how that design and implementation were affected by the response of the civic, parental, professional, educational, public health, and social welfare groups that considered themselves stakeholders and took part in the discourse. And, most significantly, he examines the responses called forth by the question at the heart of the negotiations: what services are necessitated by the state’s and school’s taking responsibility for protecting and promoting the health and physical and mental development of schoolchildren.  He concludes that the negotiations resulted both in the partial medicalization of American primary education and in the articulation and adoption of a school health policy that accepted the school’s responsibility for protecting and promoting the health of its students while largely limiting the services called for to the preventive and educational.

LanguageEnglish
Release dateNov 7, 2013
ISBN9780813570419
Classrooms and Clinics: Urban Schools and the Protection and Promotion of Child Health, 1870-1930

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    Classrooms and Clinics - Richard A. Meckel

    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.

    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—dc232013000434

    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

    For Mary Paula

    Contents

    Acknowledgments

    Introduction

    Chapter 1. Going to School, Getting Sick: Mass Education and the Construction of School Diseases

    Sanitarians and the Perils of the City School

    Going to School, Going Blind

    Overstudy and the Debilitated Schoolchild

    School Diseases and School Physicians

    Chapter 2. Incubators of Epidemics: Contagious Disease and the Origins of Medical Inspection

    Battling Germs

    Schoolchildren as Vessels of Germs

    Adopting a Policy of Exclusion

    Establishing Medical Inspection

    A Stew of Minor Communicable Diseases

    Chapter 3. Defective Children, Defective Students: Medicalizing Academic Failure

    Medical Inspection and Grade Retardation

    Jurisdictional Issues

    An International Movement Coalesces

    School Hygiene and Child Hygiene

    Chapter 4. Building Up the Malnourished, the Weakly, and the Vulnerable: Penny Lunches and Open-Air Schools

    Open-Air Schooling

    How Sick Does a Fellow Have to Be?

    Penny Lunches

    The American Plan

    No Free Lunch

    Chapter 5. From Coercion to Clinics: The Contested Quest to Ensure Treatment

    The Compliance Problem

    The Critical Importance of School Nurses

    School Clinics Proposed

    A Patchwork of Diagnostic and Treatment Services

    Dental Clinics in the Postwar Era

    Figure Insert

    Chapter 6. The Best of Times, the Worst of Times: Expansion and Reorientation in the Postwar Era

    The War as Catalyst for Expansion

    School Hygiene Broadens Its Focus

    Disenchantment with Defect Correction

    The Turn toward Prevention

    Health Education and the Promotion of Healthy Living

    The New Public Health, the New Curriculum, and the New Parenting

    Schools Educate

    Epilogue: Contraction, Reorientation, and Revival

    The Depression and School Health Programs

    Chronic Failure

    Notes

    Introduction

    1. Going to School, Getting Sick

    2. Incubators of Epidemics

    3. Defective Children, Defective Students

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

    5. From Coercion to Clinics

    6. The Best of Times, the Worst of Times

    Epilogue

    About the Author

    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 Bowen-Murphy, Laura Briggs, Crista DeLuzio, Jessica Foley, Gill Frank, Wen Jin, 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.

    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 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 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 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.

    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 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 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 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 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 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 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.

    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 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,

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