Body Politics

With the publication of The Birth of the Clinic (1963), Michel Foucault inaugurated a new wave of social medicine scholarship concerned with the ways in which states have sought to monitor and discipline individual minds and bodies.Footnote ⁸ In particular, this scholarship—like Foucault himself—has been primarily concerned with the ways in which power has changed guise from the outright abuse of absolutist monarchies to the more covert coercion of liberal states. As a result, much has been written about colonial and racial medicine, eugenics, the medicalization of prostitution, and the classification and stigmatization of individuals considered to be physically and mentally deviant from the norms established by nineteenth-century medicine and psychiatry.Footnote ⁹ Scholarship on the politicization of bodies and on the coercive potential of medical science has thus usefully blurred the lines between autocracy and democracy, nation and empire, individual and society.Footnote ¹⁰ In so doing, this literature has proven invaluable to our understanding of state control of human bodies, particularly of its more subtle and surreptitious manifestations within nascent liberal states.

Yet Foucault's pendulum has swung so far in the direction of absolute (if not absolutist) coercion as to obscure the convergence of interests, and thus the opportunities for cooperation, between individuals and the state. By exaggerating the stature of the state, such scholarship has, wittingly or not, minimized the state's reliance on the support of its individual components—or subjects—for the preservation of its body politic. Within Russian historiography, valuable work on the agency of imperial subjects, on the ideological implications of autocratic subjecthood, and on the practical manifestations of civic action has cleared the path for more explorations of the ambiguous nature of centralized power in tsarist autocracy.Footnote ¹¹ Similarly, literature exploring the traces of civil society in tsarist Russia has pointed toward possibilities for individual initiative and civic action within the confines of the autocratic state. The ongoing debate as to whether tsarist Russia could be said to have had a civil society has hinged largely, as Christopher Eley has pointed out, “on the way one defines the term.”Footnote ¹² Although this has elicited much debate within the field of Russian history, a rich body of scholarship now exists that has adopted a more nuanced understanding of the term than that held by historians of western Europe—that is, civil society as a fairly coherent form of autonomous bourgeois social action—to show the myriad opportunities for individual initiative within the tsarist state. Historians like Joseph Bradley, for instance, have focused on the rich activity of voluntary associations, while scholars like Ben Eklof have long shown the many ways in which peasants, provincial instructors, school inspectors, and doctors took the initiative to address the shortcomings of their educational institutions.Footnote ¹³ Within this body of scholarship, literature on the development of public hygiene in imperial Russia has demonstrated the extent to which imperial subjects, be they medical professionals or newly emancipated peasants, took it upon themselves to make up for the state's shortcomings.Footnote ¹⁴

A comparative assessment of school hygiene policies in imperial Russia, western Europe, and the United States has the potential to reveal further instances of individual initiative, as well as of collaboration between subjects and the state. Building on scholarship addressing the nature of civil society in the tsarist state, as well as on public hygiene scholarship that has noted a correlation between a state's ideology and its approach to public health measures, this article will reveal an instance in which the autocratic state and civil society were able to cooperate in pursuit of shared goals.Footnote ¹⁵ Although medical professionals in late imperial Russia often disagreed with and were frustrated by the tsarist state's approach to public health and its attitude toward the medical profession, they—as well as other imperial subjects—were able to find a convergence of interests within the field of school hygiene.Footnote ¹⁶ This was made possible, in part, by the vocabulary of school hygiene, which reconciled well with that of the autocratic, organic state.Footnote ¹⁷ Just as proponents of school hygiene measures compared the social body with that of the individual, so autocratic ideology envisioned the state as a “great social organism,” whose vitality depended on the well-being and collaboration of its individual parts.

As this article will show, this organic conception of the state, which squared poorly with liberal state ideologies, provided tsarist Russia and its subjects with a useful vocabulary that would serve to justify and encourage the institutionalization and expansion of medical supervision of student bodies. Looking beyond the borders of individual states and through the open windows of school buildings and international hygiene councils, this article will therefore compare the state of school hygiene in the autocratic tsarist empire with that in the more liberal nations of France, Germany, the United Kingdom, and the United States—then considered trailblazers in social hygiene theory—in order to relegate tsarist Russia to its rightful place in public health scholarship.Footnote ¹⁸ By assessing the ways in which school hygiene legislation and implementation in imperial Russia measured up to the medicalization of education undertaken by its Western neighbors, this article will demonstrate that the ideology and institutions of Russian autocracy gave greater leeway to physicians and individual subjects within the tsarist state to influence the body politic than had their counterparts in the more liberal states in which school hygiene theories first arose. It will therefore flip Foucault's thesis on its head, considering the ways in which individual initiative could, within the field of school hygiene, coexist and cooperate with autocracy.

De-exoticizing Imperial Russia

For physicians in imperial Russia, as for the Russian intelligentsia more broadly, actively borrowing ideas from western Europe was both desired and practical—generally viewing western Europe as more culturally advanced than their own state, and lacking sufficient resources and institutions of their own, Russian physicians considered western European medical knowledge a useful tool in their medical bag. Early efforts to stem the tide of epidemic diseases such as cholera within the Russian Empire were modeled on quarantine measures adopted by mercantilist states, and sanitationist notions that proposed filth as a generator of disease were slowly usurped by Robert Koch's and Louis Pasteur's theories of bacteriology.Footnote ¹⁹ By the latter part of the nineteenth century, Russian physicians, pedagogues, and statesmen would come to focus on more specific and targeted measures of social hygiene, drawing inspiration from new notions of child development put forth by their neighbors to the west.Footnote ²⁰

This increased concern with children and with childhood development was part of a broader pan-European trend, spurred on by fears of national degeneration. By the latter half of the nineteenth century, low birth rates, demographic losses due to war, and concerns about the potentially detrimental effects of a sedentary and overly-indulgent bourgeois lifetyle on one's physical and moral development led European polities to think concertedly about the vitality of their body politics. France's defeat in the Franco-Prussian War of 1870–1871, the United Kingdom's poor performance in the Boer Wars of 1899–1902, Germany's frustrations in its efforts to become a colonial power, and the United States’ increased immigration levels prompted those states to think more seriously about public health measures at the conclusion of the nineteenth century.Footnote ²¹ Nevertheless, imperial Russia's devastating losses in the Crimean War of 1853–1856 and subsequent shrinking on the international stage alerted the tsarist autocracy earlier and more urgently of the need to conceptualize public health as a holistic, multifaceted project that required the individual and the state to work together symbiotically.Footnote ²²

Since the pace of the institutionalization and professionalization of public hygiene within the tsarist state failed to match physicians’ enthusiasm for such measures, medical professionals found ways to develop and elaborate upon their knowledge by joining pan-European and transatlantic networks of social hygiene specialists. Many physicians from within the Russian Empire received their training in European institutions and attended international public health and school hygiene conferences in which they took part in multi-day lectures and discussions with physicians from all over Europe and the world.Footnote ²³ Even those physicians who remained within the empire's borders were plugged into this broader transnational network; they eagerly devoured the theoretical expertise of their Western counterparts through specialized periodicals and attended academic lectures in medical universities such as that in Dorpat (modern-day Tartu, Estonia), where the empire's physicians were privy to a German education right at home.Footnote ²⁴ By the end of the nineteenth century, periodicals published within the empire frequently featured articles on school hygiene and child development littered with the names of French and German men of science, citing these specialists but without including their first names—a sure indication of their audiences’ familiarity with the personages referenced therein.Footnote ²⁵

If this admiration for their Western counterparts’ work had remained at the level of the abstract, Russian physicians and administrators would have been guilty of what nineteenth-century Romanian statesman and pedagogue Titu Maiorescu termed “forms without substance”—straightforward adoptions of foreign notions that lacked meaningful real-life application. But this was not the case. In fact, the tsarist state built upon the theoretical knowledge of Western physicians and made efforts to implement school hygiene measures more quickly and comprehensively than did the states in which those theories were first developed. Drawing on the institutions and ideology of autocracy, imperial Russia became an unacknowledged leader in the implementation of medical inspections in schools, tending to both buildings and bodies, minds and souls, as part of a holistic and multidimensional social project that aimed to nurture the “great social organism” that was the tsarist state. By no means a universally successful project, school hygiene in the final decades of the Russian Empire nevertheless demonstrated the adaptive resiliency of tsarist autocracy.Footnote ²⁶

Forms with Substance

Although Germany boasted renowned hygiene experts, France claimed for itself the mantle of “the great initiator of hygiene,” and the United Kingdom prided itself on the professional independence of its physicians, the actual implementation of school hygiene measures in these states proved to be rather slow.Footnote ²⁷ The same may be said for the United States, which, by the turn of the twentieth century, spurred on by concerns with racial purity in the wake of increasing immigration, began to take greater interest in social hygiene, primarily as it applied to areas with high concentrations of (undesirable) immigrant populations.Footnote ²⁸ While all of these states tended to agree on the significance of individual health for the vitality of the body politic as a whole, various impediments—to be discussed below—caused these states to fall short of their very own medical experts’ expectations. Although hoping that schools would be “a means to an end—the rearing of healthy citizens,” many of the tsarist state's Western neighbors had, on the eve of the First World War, failed to successfully reconcile school hygiene theories with the practical and ideological features of their liberal state ideologies and individualistic economic philosophies.Footnote ²⁹

As such, while France appointed doctors to Parisian elementary schools in the 1830s and 1840s and Germany hired its first school doctor in 1883, none of these initiatives was quick to take root.Footnote ³⁰ The School Medical Board of Paris was only completed in 1883 and had few sister institutions outside the capital, with medical school services being extended to the suburbs of Paris only after 1885.Footnote ³¹ Even though laws passed in 1886 and 1887 made medical and sanitary inspections obligatory for all French elementary schools, public as well as private, by 1910 the duties of the French school doctor had become centered less on “attention to the school as a whole than to the care of individual scholars.”Footnote ³² Meanwhile, Germany had only a handful of school doctors, in Frankfurt (1883), Breslau (1888), Dresden (1893), Nuremberg (1897), and Konigsberg (1897), until a successful school inspection scheme in Wiesbaden in 1897 initiated a more consistent wave of school physician appointments, and this only in urban schools.Footnote ³³ By 1910, German country schools were “still, to a very large extent, outside the scope of school medical inspection,” and upper and private schools were altogether exempt from this requirement.Footnote ³⁴

On the other side of the Channel, although the London School Board appointed a medical officer in 1891, the United Kingdom made no concerted attempts to implement medical inspections of schools until its Education (Administrative Provisions) Act of 1907, which, upon going into effect on January 1, 1908, finally put into place “a compulsory system of medical examination of children in public elementary schools.”Footnote ³⁵ Across the pond, Massachusetts remained, by the turn of the twentieth century, the only state in the US to have a compulsory medical inspection law for its schools.Footnote ³⁶ Other states had only partial provisions—if at all—for the medical examination of children, with Vermont requiring that schoolchildren's hearing and vision be tested annually, and Connecticut requiring the same inspections only triennially.Footnote ³⁷ This general lack of consistent and compulsory medical oversight of schools in the United States prompted one 1908 school hygiene report to state that, although “there seem[ed] to be a general impression in America that medical inspection [was] still experimental and on trial, and that [Americans were] leading in this important work,” “the reverse of both of these impressions [was] true.”Footnote ³⁸

Meanwhile, to the east, the tsarist state was taking resolute steps toward the erection of a rationalized and comprehensive program for the medical oversight of its schools. Although the Russian Empire only established a medico-sanitary office under its Ministry of Public Instruction in 1904, it had, as early as 1872, already required permanent doctors in secondary schools, pedagogical colleges, and municipal schools, in addition to medical oversight in zemstvo schools and, by 1889, had initiated concerted efforts to implement consistent medical supervision of all its urban public schooling institutions.Footnote ³⁹ By 1896, “all educational institutions [were] subject to sanitary and medical supervision—state, public, and private [institutions], male as well as female.”Footnote ⁴⁰

With the creation in 1904 of the medico-sanitary department of the Ministry of Public Instruction under the leadership of professor of hygiene G. G. Khlopine, medical supervision of schools was formally institutionalized throughout the Russian Empire, with clear forms, guidelines, and expectations for aspiring school physicians.Footnote ⁴¹ Unlike its French, German, British, and American counterparts, the tsarist state was at the forefront of efforts to institutionalize uniform school hygiene measures, making school medical inspections mandatory across the Russian Empire, in both urban and rural areas, in public as well as private schools at all levels of learning. Despite numerous shortcomings, which Russian physicians were quick to point out and lament, school hygiene measures within the Russian Empire nevertheless had taken a more comprehensive form than did those in Western nations. Even when these measures remained at the level of the abstract or were unsatisfactorily implemented due to a lack of personnel and resources, the intentions of the tsarist state on this front surpassed those of other polities by the turn of the twentieth century.

Thus, by the time Dr. A. Nikitin wrote a report on the general state of medical oversight of the empire's schools for the Journal of the Ministry of Public Instruction in September of 1907, the tsarist state had approximately 1,559 registered school physicians, of which 86 were women.Footnote ⁴² Among these were also a small number of dentists, paramedics, and eye specialists who stepped in when called upon. Overall, these physicians supervised 1,702 educational institutions, composed of 706 elementary schools, 885 secondary schools, and 111 professional schools.Footnote ⁴³ The majority of school physicians were responsible for the inspection of only one educational institution, while smaller numbers simultaneously supervised two, three, and even four schools, and a minority oversaw both urban and zemstvo schools. Nearly half of the empire's school doctors registered at the time of the report had been employed in their posts for fewer than five years, with fewer than one hundred school doctors occupying their posts for twenty-five years or more.Footnote ⁴⁴ Far from sufficient for the practical medical supervision of all the empire's pupils, the efforts to narrow the gap between legislation and reality were nevertheless concerted and consistent.

Eager to make school hygiene a comprehensive social project with deep roots across the empire's vast expanses, the tsarist state employed a diverse body of physicians. According to Nikitin's report, late imperial Russia's medical community was made up of a wide age range, different religious confessions [or affiliations], and diverse social, educational, and professional backgrounds. The majority of the empire's school doctors were between the ages of thirty and fifty.Footnote ⁴⁵ Many adhered to the Orthodox confession, but significant numbers also identified with the Jewish, Catholic, Lutheran, Gregorian, Muslim, Protestant, and Anglican faiths, among others.Footnote ⁴⁶ Although predominantly originating from bourgeois, noble, and clerical backgrounds, some school physicians were also the sons (and daughters) of peasants, officers, clerks, doctors, and pharmacists, to name a few.Footnote ⁴⁷

At the time of Nikitin's survey, the majority of appointed school doctors had studied at Moscow University and at the Military-Medicine Academy, with smaller contingents of graduates from universities in Kiev, Warsaw, Kazan, and others.Footnote ⁴⁸ Some had received their medical training abroad, with a handful of school doctors holding diplomas from universities in Paris, Bern, Geneva, Lausanne, Würzburg, Berlin, Zurich, Vienna, Krakow, and Bucharest.Footnote ⁴⁹ To Nikitin's disappointment, few of these had actually specialized in hygiene and sanitation, the majority holding one or more other specialties.Footnote ⁵⁰ This cadre of school physicians therefore had “a quite random composition,” with specialists in one or more of the following fields: childhood illness, surgery, obstetrics, orthodontics, dermatology, pathology, epidemic diseases, and psychiatry, to name a few.Footnote ⁵¹

Serving the Individual and the Community

Whatever its shortcomings, medical oversight of schools in imperial Russia was qualitatively more comprehensive than that in France, Germany, the United Kingdom, and the United States both in terms of scope and of implementation. State-driven efforts to bring schools under medical supervision targeted all types of institutions of learning, attempting to spread as wide a net as possible over the empire's schools. Unlike school hygiene measures to the west, which tended to focus on large urban areas and to privilege public elementary schools, those in the tsarist state sought early on to reach both public and private schools, at all levels of learning, in cities and countryside alike. The tsarist state also took more concerted measures toward the actual implementation of medical supervision of schools, advocating for the specialized training of its school physicians, engaging the help of local and provincial administrations, and positioning school doctors as employees of the state rather than of private interests. Although many of its plans regarding medical inspection of schools remained unfulfilled, the late imperial Russian state was much more willing than its Western counterparts to envision and lay the groundwork for greater medical oversight of its youngest subjects—and this long before the 1905 Revolution compelled the tsar to turn his previously unquestioned autocracy into a de jure constitutional monarchy.

The explanation for these divergencies seems to lie within the very nature of the autocratic land empire. To begin with, there was the size and scope of the tsarist state. Vast, demographically diverse, and geographically consolidated within one contiguous landmass, imperial Russia was not naturally conducive to civic homogeneity. The wide distances between its various regions, its insufficiently developed infrastructure, and its unevenly distributed population obscured the links between autocratic subjects and widened the gap between society and the state. Although the zemstva were intended to help overcome these challenges, the under-governance of the countryside nevertheless continued to be a real problem, posing serious roadblocks to top-down, uniform implementation of public hygiene measures.

By the turn of the twentieth century, imperial Russia had fewer than four state officials for every 1,000 of its 130 million subjects—less than a third of Germany's numbers.Footnote ⁵² As Stephen Kotkin notes, this made the tsarist state “top heavy and spread thin,” with most of the provincial empire “left to be governed by local society, whose scope of governance, however, was restricted by imperial laws and whose degree of organization varied widely.”Footnote ⁵³ This might perhaps explain the diversity of the empire's physician corpus—just as schooling has been identified as a tool by which modern states sought to unify its populations, so too school hygiene more specifically, with its comprehensive reach in public and private schools, in urban as well as rural areas, had the potential to promote a unity of practice and of purpose to the empire's heterogeneous population.Footnote ⁵⁴ Unable to permeate into the daily lives of its vast, heterogeneous population, the tsarist state had to allow its subjects to carry out such measures on their own.

That tsarist administrators and physicians understood the need to foster uniform practices across the empire is apparent in their approach toward the empire's non-ethnically Russian, non-Orthodox subjects, known as inorodtsy.Footnote ⁵⁵ Pedagogical publications emphasized the importance of educating inorodtsy in order to bring them into closer communion with the “Russian spirit,” while reports on public health and school hygiene routinely decried the unsanitary conditions of Jewish and Islamic schools. Russian physicians described the former as covered in dirt and insufficiently lit, and the latter as improperly ventilated, cold, and lacking in furniture.Footnote ⁵⁶ Although some of these complaints were also directed at the empire's other schools, Jewish and Islamic educational institutions were specifically singled out for their hygiene infractions, indicating that they were perhaps more closely scrutinized than were other public schooling institutions. Much as the French, British, and German states more closely policed public health in their colonies, and the United States generally directed its meager school hygiene efforts to areas with high immigrant populations, so the Russian Empire, forced to face the issue of demographic diversity more directly than its Western counterparts, likely looked to school hygiene as a means of more effectively controlling its heterogeneous social body.Footnote ⁵⁷

These efforts sought to extend throughout the tsarist state and had, at least in theory, vast institutional backing. Among the most important institutions for social hygiene in imperial Russia were the zemstva, which, after their creation in the 1860s, rationalized provincial administration and extended public health to the empire's cultural and political peripheries. As part of the Great Reforms of the 1860s, the tsarist state created the provincial zemstva to see to tasks that the central government was unequipped to undertake on its own.Footnote ⁵⁸ Aware of the need to reform or perish, as well as of the practical difficulties of administering such an expansive land empire, the autocratic state began to delegate authority for local administration, education, infrastructure, and public health to these provincial administrations. Neither fully autonomous nor entirely controlled by the center, the zemstva embodied the intersections between autocracy and civil society and zemstvo medicine, drawing upon public health discourse that reconciled well with the organic theory of the state, and managed to carve out for themselves a sphere of influence unique within the system of autocratic—and even zemstvo—governance. As a result, although the central administration was consistently in conflict with these institutions, zemstvo medicine continued to flourish even as the tsarist state began curtailing other zemstvo activities in the 1870s and 1880s.Footnote ⁵⁹

As cholera ravaged the empire in the 1890s and the state realized its inability to provide relief, zemstvo medicine expanded and functioned with less central oversight than programs for popular education or food supply.Footnote ⁶⁰ This delegation of public health services to zemstvo administrations gave physicians greater opportunities to practice their craft, contributing to the professionalization of the empire's physician corpus. As the zemstva became responsible for “community welfare,” which included the administration of orphanages, asylums, vaccinations, and hygiene education, physicians in the empire's provinces acquired new powers and prestige, slowly replacing the folk medicine and midwifery that had previously constituted the bulk of medical knowledge and practice in the Russian countryside.Footnote ⁶¹ This delegation of authority to provincial medical professionals squared uncomfortably with the notion of an all-powerful central government, but reconciled with the ideology of the state as organic organism, made up of interdependent parts that worked together for the well-being of the whole. Within the field of school hygiene, the interests of civil society and autocracy converged within the zemstva—the connecting tissue between society and the state.

School doctors were particularly important ligaments within this system, serving as intermediaries between center and periphery, school child and public health. After the enactment of the Great Reforms, school doctors everywhere, although subordinate to district physicians, served on local pedagogical councils, economic committees, and boards of trustees, on which they had voting power.Footnote ⁶² They often received their education in state-sponsored institutions, became state employees and, at least in theory, received state salaries. Although at the turn of the twentieth century remuneration for school doctors had been either nonexistent or largely symbolic—with only 1.5 percent of school doctors receiving a yearly salary of more than 1,000 rubles—the new 1904 law formalizing universal medical oversight of the empire's schools set the annual salary for school doctors, male as well as female, at 1,200 rubles, with the possibility of earning additional income for performing supplementary inspections, providing lessons on hygiene, and working in boarding schools.Footnote ⁶³ Even when remuneration was uncertain or insufficient, school physicians in imperial Russia were, as employees of the state, also incentivized through the possibility of acquiring a prestigious rank, gaining rewards for service, receiving free education for their children, and acquiring a state pension.Footnote ⁶⁴ Therefore, although largely left to their own devices (and resources) while in the field, school doctors in imperial Russia typically had more to gain from their posts than did their Western counterparts.

Given all of these incentives, as well as the emphasis the tsarist state placed on school hygiene training and practice by the first decade of the twentieth century, school physicians in imperial Russia did “not have the right to be at the same time [employed] in any other medical service” while holding a position within schools.Footnote ⁶⁵ Although this constraint initially made the position of school doctor less attractive, physicians quickly petitioned for higher salaries to offset the potential disadvantages of this restriction. When, in an effort to lure women into lower-paid positions, Dr. Arkhangel'skii portrayed school medical inspection as a woman's job—stating that women had a greater insight into and understanding of childhood illnesses and only they could properly communicate with children—members of the education commission to which he spoke were quick to condemn his “mercantilist calculations” and to state that the importance of the position required that it be properly remunerated regardless of who occupied it.Footnote ⁶⁶

This differed significantly from the form and function of school hygiene in the more liberal nation-states of France, Germany, the United Kingdom, and the United States, where physicians had no uniform and widespread system in place to support their work, routinely complained about their lack of authority and remuneration, and had no incentives to view their appointments within schools as worthy of their time and effort. As mentioned above, by 1907, the UK had made medical inspection mandatory only for its public elementary schools, less than a handful of states in America required medical inspection of young schoolchildren, and rural German schools remained largely outside the scope of medical oversight, while upper and private schools in Germany were entirely exempt from inspection.Footnote ⁶⁷ Although in France school hygiene measures extended to both public and private institutions, French physicians nevertheless decried the largely advisory roles played by French hygiene councils, resented doctors’ precarious position at the mercy of politicians’ whims, and wished for greater regulatory powers.Footnote ⁶⁸ They also bemoaned France's attempts to “bind . . . the interests of public health to those of commerce”Footnote ⁶⁹ by assigning the responsibility of public hygiene services to the Ministry of Commerce, and criticized the organization of public hygiene services for not “find[ing] space for the [coordinated] action of the state, the department, and the commune.”Footnote ⁷⁰

Finally, physicians in all these states were neither properly incentivized nor sufficiently encouraged to work in schools. They routinely complained of abysmal or nonexistent remuneration, which they believed gave “the whole movement an appearance of triviality and fail[ed] to attract competent and experienced men of the medical profession.”Footnote ⁷¹ School doctors in France, Germany, the United Kingdom, and the United States were largely expected to work on a voluntary basis, were seldom considered full-time state officials, and often lacked state pensions, making it practically impossible for them to devote their time and attention fully to their nations’ schools.Footnote ⁷² In the United States in particular, physicians were actively discouraged from devoting themselves entirely to school hygiene, as this work was said to be “exceedingly monotonous” and, “if the doctor [was to be] prohibited from having an outside practice, opportunities for increasing his skill and experience [would be] to a great extent cut off.”Footnote ⁷³

The position of school doctor within these states was, therefore, much more limited and disincentivized than within imperial Russia, where school physicians were full state employees, received numerous monetary and professional benefits, and held a more prestigious place within the mechanism of tsarist autocracy. By recognizing them—at least in theory—as empowered servants of the state, tsarist Russia also encouraged them to conceive of themselves as servants of community interests. This allowed them to understand their role as a professional estate with responsibility to the public at large rather than solely to their corporate interests—in other words, it compelled them to serve both the individual and the community.

Tending to Buildings and Bodies

Once appointed, school physicians in imperial Russia were expected to tend to individual hygiene for the benefit of public hygiene as whole. Public hygiene, whose object was understood to be “the state of health of the social individual—of the people,” and whose study and practice was considered to be closely connected to that of other sciences, could not be developed without a focus on individual hygiene.Footnote ⁷⁴ This latter focus was “the first step in social hygiene,” and constituted “the science of the conservation and improvement of the bodily and mental health of a person.”Footnote ⁷⁵ It consisted of “1) the knowledge and study of the normal composition and function of the human body, 2) the knowledge and study of all that which surrounds the individual, [and] 3) the knowledge and study of the relationship between the individual and his surroundings.”Footnote ⁷⁶ Knowing how “to preserve and improve the health of a person, [and] to indicate the causes of ill health and the means of their destruction” were central to the undertaking of individual hygiene.Footnote ⁷⁷ Like Foucault's clinic, school hygiene in the tsarist state bound the individual to society and made the former's health the business of the latter. As a result, the medical supervision and inspection of the empire's schools became a manifold mission, integrating the physical inspection of buildings and of bodies with that of the world outside school walls, and uniting prevention, diagnosis, and treatment under the same umbrella.

School physicians thus began by tending to the foundation of school hygiene—the salubriousness of school buildings. Among the basic duties of the school doctor was the inspection of the air, soil, and water quality in the empire's schools. Some even discouraged the use of wood in school construction because of its predilection for cracks and rodent burrow holes, which made ideal homes for pathogenic microbes, suggesting that smooth brick or cement be used instead, as those materials were more hygienic.Footnote ⁷⁸ They tried to ensure that school buildings provided purified water, that lavatory facilities were regularly cleaned, and that proper heating and ventilation were maintained, as improper quantities of either could make children susceptible to colds and allergies, or lead to a reduction in their blood oxygen levels.Footnote ⁷⁹ Physicians further agonized over the square footage of classrooms and the length of desks, trying to ensure that pupils had sufficient space and that the size of their desks corresponded to their age and height.Footnote ⁸⁰ Heeding German physician Hermann Cohn's warnings about the proliferation of myopia among schoolchildren, school doctors in the tsarist state also tried to provide for better lighting, encouraged good posture to mitigate eye strain, and prompted teachers to give their pupils frequent breaks from study, preferably to be spent in physical exercise outdoors.Footnote ⁸¹

In addition to their roles in inspecting and providing recommendations for the salubriousness of school buildings, school doctors were also tasked with ensuring that schoolchildren themselves were free of contagious diseases and of non-contagious ailments. Aside from encouraging outdoor games, promenades, and lessons in the open air to stave off the dangers of overwork, promote blood oxygenation, and strengthen children's overall physical constitution, school doctors were also expected to tend directly to the physical health of each child by conducting periodical inspections of school buildings, student bodies, instructor corpus, and personnel.Footnote ⁸² Physicians attached to boarding schools had the additional charge of tending to the health and physical development of pupils by overseeing their food, sleep, clothing, bed linen, exercise, and time spent between lessons.Footnote ⁸³ As a result, medical supervision of schools in imperial Russia aimed toward a holistic supervision that took into consideration the physical conditions both of school buildings and of school bodies, targeting both the outer and inner worlds of the empire's young pupils.

Yet physicians’ responsibilities did not end there. To properly oversee the health of schoolchildren, school doctors in imperial Russia were also expected to document and treat illnesses among the student body. They were charged with keeping records of all medical examinations, registering the sick and the deceased, and reporting on the activities they conducted in and around schools.Footnote ⁸⁴ Besides filling out forms related to the physical conditions of each school building, physicians were also tasked with filling out detailed questionnaires concerning the health of the schoolchildren themselves, answering questions about each student's food intake, weight, height, chest circumference, dental health, prior and current illnesses, physical disabilities, place of living, guardians, performance in school, and ability to engage in physical exercise.Footnote ⁸⁵ Separate lists, filled out by dentists and optometrists, provided for more specific observations about children's eyesight and dental health.Footnote ⁸⁶ Finally, physicians were also expected to cure ailing children, providing them with both a diagnosis and a treatment. They were “required to vaccinate and revaccinate, to treat poor sick pupils free of charge, and to manage affairs in case of epidemics.”Footnote ⁸⁷ In this way, the responsibilities assigned to school physicians in imperial Russia made the medical inspection of the empire's schools a closed circuit in which school doctors not only supervised and inspected the physical conditions of buildings and of bodies, but also often had the first and final word on what jeopardized the health of schoolchildren and what prescription would provide the best cure.

This situation differed considerably from that in western and central Europe. By 1910, German school hygienists had still “as yet confined [their] efforts to medical inspection and [had] gone only a little way toward medical supervision . . . towards which medical inspection is only the preliminary step” [emphasis in original].Footnote ⁸⁸ While they complained of their curtailed authority in regard to school bodies and lamented the complete lack of hygienic supervision of school buildings, their French counterparts felt that they were expected to give too much attention to “the school as a whole than to the care of the individual scholars.”Footnote ⁸⁹ In the United Kingdom, although British education policy had, by 1907, begun to operate under the premise that “it is a great deal cheaper to spend pence on children than pounds on paupers,” the “medical examination of school children [was] still in the experimental stage.”Footnote ⁹⁰ No comprehensive examination of schoolchildren's physical health was at that point undertaken in the United States.

Furthermore, and perhaps most significantly, school doctors in these states were not only curtailed in their efforts to inspect schoolchildren but were also explicitly prevented from offering treatment. Among the factors contributing to this was the protective stance of individual physicians in France, Germany, the United Kingdom, and the United States, who, encouraged in their private practice by their states’ economic imperatives, were quick to guard their incomes against the encroachment of school doctors whose foray into medical treatment threatened to draw patients, and therefore income, away from their colleagues in private practice. This was certainly the case in Germany, where physicians in private practice explicitly framed their opposition to medical treatment in schools around their belief that this would entail a “curtailment of their own practice.”Footnote ⁹¹ On the other hand, the tsarist state's overwhelmingly large population and comparatively small cadre of physicians meant that the professional struggle there was more acute between school instructors and school doctors than between physicians in private practice and those employed in schools. Although this particular contention between school instructors and physicians within imperial Russia (as elsewhere) was often cited as an impediment to the proper implementation of school hygiene measures, it at times had the opposite effect of expanding medical oversight in schools by prompting instructors to educate themselves about and monitor their pupils’ hygiene.Footnote ⁹²

To the west, even the mere suggestion of school medical oversight and treatment elicited struggles not just between physicians in private practice and those in schools, and between instructors and school doctors, but also between individuals and the state. This is apparent in France, where the ethics of the medical profession demanded that medical inspectors “respect the rights of each and to not encroach upon any one person.”Footnote ⁹³ As late as 1910, the French school doctor was expected to look after and inspect the individual and collective health of schoolchildren, but “he [could] not and ought not [have] given treatment.”Footnote ⁹⁴ His task was to “officially inform the family of the state of health of the student, but his right end[ed] there”—it was up to the father to “freely choose his doctor and to treat his child as he [saw] fit.”Footnote ⁹⁵ It was for these same reasons that French schools, unlike those in the Russian Empire, did not employ medical specialists such as dentists and optometrists, believing that these would make it more difficult to prevent the school from becoming a dispensary or polyclinic.Footnote ⁹⁶

This ambivalence toward medical treatment within schools was perhaps most starkly expressed in the United States, where the public was more likely to consider the compulsory inspection and medication of school children as a threat that extended beyond parents’ freedom of choice in determining how and from whom their child received treatment. As a spokesperson for the National League for Medical Freedom stated in 1912, mandatory medical oversight and treatment of schoolchildren was “fraught with the greatest evils at once to the young, to the citizen, to the nation, and to the cause of scientific advancement.”Footnote ⁹⁷ These opponents of medical inspection and treatment went so far as to denounce these measures as illustrative of an “autocratic spirit”—for them, the ultimate insult.Footnote ⁹⁸

Laying Strong Foundations

Yet this “autocratic spirit” did not simply entail a curtailment of individual liberties—at least not in this instance. In tsarist Russia, the archetypal autocracy, the ideology (or “spirit”) of autocracy animated a “great social organism” whose individual members were crucial to the strength and vitality of the whole. In its efforts to use school as a means by which “to reach perfection in the physical, moral, and mental condition of its pupils with the goal of making of them more or less perfect people, citizens, fathers, and mothers,” the tsarist state enlisted the help of all of its subjects.Footnote ⁹⁹ Thus, while medical oversight of schools was intended as yet another means by which the autocratic state could mold its young into ideal subjects, this new field of activity could not have been undertaken by the state alone. It required the help of doctors, pedagogues, parents, and students in a communal and holistic project whose boundaries extended from buildings to bodies, outside the confines of school walls, and into the home. In this way, it combined a greater control over young minds and bodies with a more significant endowment of individual responsibility for the well-being of society as a whole, thereby demonstrating that autocracy not only could coexist with individual and collective action, but in fact thrived on it.

Parents had “the most difficult role” in this communal affair, with mothers expected “to lay a solid foundation for their children's future upbringing, to give [them] the[ir] initial physical, mental and moral development.”Footnote ¹⁰⁰ In fact, pedagogues and physicians alike believed that “upbringing begins long before the birth of the child,” mothers’ spiritual and physical development enveloping “the upbringing of all mankind.”Footnote ¹⁰¹ Once children exchanged the confines of the home for those of the schoolhouse, the school would then “erect on the foundation laid by the mother the whole finished building, giving society and the state healthy, intelligent and moral members, capable of serving and of bringing benefit” to the community that nurtured them.Footnote ¹⁰² Society and the state were tasked with ensuring the success of this project by embellishing the erected “building,” “guard[ing] it from destruction and, consequently, attending to the preservation of health, to the feeding of the mind, and to the maintenance of morality among its members.”Footnote ¹⁰³ The upbringing of children was thus, “from the very beginning the business of the state, which [was], more than any individual, interested in the development of man as a social being.”Footnote ¹⁰⁴

The individual, having been thus holistically and communally nurtured from birth, would become “his own teacher,” “brought up under the influence of society and of the state.”Footnote ¹⁰⁵ While pedagogical philosophy actively discouraged instructors and physicians from “crushing a child's will” by means of fear and punishment, “full freedom of the student [did] not and ought not [have] exist[ed]”—the student was expected “to obey school orders and rules and [. . .] to comply with them, [. . .] get accustomed to work and order and acquire the habit of stifling personal impulses and motivations in the interests of a common cause.”Footnote ¹⁰⁶ Without learning to curb his/her egotistical tendencies and develop self-control, a child would grow up to be a drag on society rather than “a useful link.”Footnote ¹⁰⁷ Working together, therefore, the physician and the pedagogue were expected not only “to impart knowledge that would save an individual from those misfortunes and evils that he may encounter due to his ignorance,” but also “to direct his spirit, to clarify the rational purpose of life and release him into life with animated willpower so that at the foundation of his life would be a love for humanity and for his native land.”Footnote ¹⁰⁸

This idea of a symbiosis between man and society translated quite seamlessly into the notion that “life in society, love and compassion for one's own kind, and mutual labor and assistance” constituted “the levers of human success, development, and self-improvement.”Footnote ¹⁰⁹ Since social consciousness was thought to occupy “first place” in human life, school was considered to be “society in miniature,” and tsarist society “an organism [made up of] of living forces;” a well-functioning school was thought to be crucial for preparing children to live a life of public service.Footnote ¹¹⁰ School hygiene was to play an important role in this mission, teaching children that the vitality of their society was dependent on their own physical, moral, and mental well-being. By so intimately linking public health to the health of individual subjects, tsarist autocracy was able to reconcile the individual initiative of non-state actors with community-oriented public service, avoiding the contradictions that plagued liberal, individualistic state ideologies.

Unlike in France, Germany, the United Kingdom, and the United States, where central administrations saw an ideological contradiction between their self-proclaimed liberalism—which divorced individualism from selflessness, making the two mutually incompatible—and the medical supervision of their schoolchildren, in imperial Russia the tsarist state, by virtue (rather than in spite) of its autocratic nature, more successfully integrated individual and collective action into its top-down yet bottom-heavy school hygiene measures. As Laura Engelstein has pointed out, in imperial Russia, “precept and practice were more consistent” and “reformers were spared the ironies of imperfect liberation that so focus Michel Foucault's iconoclastic ire.”Footnote ¹¹¹ Understanding individuals to be constitutive elements of society and society to be constitutive of the state, tsarist Russia did not suffer from the same existential crises when seeking to impose uniform and compulsory medical inspection, supervision, and treatment in its schools. As a result of its organic state ideology, which blurred the lines between society and the state, tsarist Russia was able to lay the foundations for a school hygiene system that had the potential to give the state strong, healthy, and loyal workers and soldiers, and the individual, as “a social animal,” the chance to feel himself “a member of a great social organism.”Footnote ¹¹²