LOUIS AGASSIZ
“A natural law is as sacred as a moral principle”

CIVICS AND HEALTH

BY

WILLIAM H. ALLEN

Secretary, Bureau of Municipal Research

Former Secretary of the New York Committee on Physical Welfare of
School Children, Author of “Efficient Democracy” and “Rural
Sanitary Administration in Pennsylvania,” Joint Author
of “School Reports and School Efficiency”

WITH AN INTRODUCTION

BY

WILLIAM T. SEDGWICK

Professor of Biology in the Massachusetts Institute of Technology

GINN AND COMPANY
BOSTON ·  NEW YORK ·  CHICAGO ·  LONDON

Entered at Stationers’ Hall

Copyright, 1909
By WILLIAM H. ALLEN

ALL RIGHTS RESERVED

910.4

The Athenæum Press
GINN AND COMPANY ·  PROPRIETORS ·  BOSTON ·  U.S.A.

INTRODUCTION

It is a common weakness of mankind to be caught by an idea and
captivated by a phrase. To rest therewith content and to neglect the
carrying of the idea into practice is a weakness still more common. It
is this frequent failure of reformers to reduce their theories to
practice, their tendency to dwell in the cloudland of the ideal rather
than to test it in action, that has often made them distrusted and
unpopular.

With our forefathers the phrase mens sana in corpore sano was a high
favorite. It was constantly quoted with approval by writers on hygiene
and sanitation, and used as the text or the finale of hundreds of
popular lectures. And yet we shall seek in vain for any evidence of
its practical usefulness. Its words are good and true, but passive and
actionless, not of that dynamic type where words are “words indeed,
but words that draw armed men behind them.”

Our age is of another temper. It yearns for reality. It no longer
rests satisfied with mere ideas, or words, or phrases. The modern
Ulysses would drink life to the dregs. The present age is dissatisfied
with the vague assurance that the Lord will provide, and, rightly or
wrongly, is beginning to expect the state to provide. And while this
desire for reality has its drawbacks, it has also its advantages. Our
age doubts absolutely the virtues of blind submission and resignation,
and cries out instead for prevention and amelioration. Disease is no
longer regarded, as Cruden regarded [vi]it, as the penalty and the
consequence of sin. Nature herself is now perceived to be capable of
imperfect work. Time was when the human eye was referred to as a
perfect apparatus, but the number of young children wearing spectacles
renders that idea untenable to-day.

Meanwhile the multiplication of state asylums and municipal hospitals,
and special schools for deaf or blind children and for cripples,
speaks eloquently and irresistibly of an intimate connection between
civics and health. There is a physical basis of citizenship, as there
is a physical basis of life and of health; and any one who will take
the trouble to read even the Table of Contents of this book will see
that for Dr. Allen prevention is a text and the making of sound
citizens a sermon. Given the sound body, we have nowadays small fear
for the sound mind. The rigid physiological dualism implied in the
phrase mens sana in corpore sano is no longer allowed. To-day the
sound body generally includes the sound mind, and vice versa. If
mental dullness be due to imperfect ears, the remedy lies in medical
treatment of those organs,—not in education of the brain. If lack of
initiative or energy proceeds from defective aëration of the blood due
to adenoids blocking the air tides in the windpipe, then the remedy
lies not in better teaching but in a simple surgical operation.

Shakespeare, in his wildwood play, saw sermons in stones and books in
the running brooks. We moderns find a drama in the fateful lives of
ordinary mortals, sermons in their physical salvation from some of the
ills that flesh is heir to, and books—like this of Dr. Allen’s—in
striving to teach mankind how to become happier, and healthier, and
more useful members of society.

Dr. Allen is undoubtedly a reformer, but of the modern, not the
ancient, type. He is a prophet crying in our present [vii]wilderness; but
he is more than a prophet, for he is always intensely practical,
insisting, as he does, on getting things done, and done soon, and done
right.

No one can read this volume, or even its chapter-headings, without
surprise and rejoicing: surprise, that the physical basis of effective
citizenship has hitherto been so utterly neglected in America;
rejoicing, that so much in the way of the prevention of incapacity and
unhappiness can be so easily done, and is actually beginning to be
done.

The gratitude of every lover of his country and his kind is due to the
author for his interesting and vivid presentation of the outlines of a
subject fundamental to the health, the happiness, and the well-being
of the people, and hence of the first importance to every American
community, every American citizen.

WILLIAM T. SEDGWICK

Massachusetts Institute of Technology

CONTENTS

CIVICS AND HEALTH

PART I. HEALTH RIGHTS

CHAPTER IToC

HEALTH A CIVIC OBLIGATION

In forty-five states and territories the teaching of hygiene with
special reference to alcohol and tobacco is made compulsory. To
hygiene alone, of the score of subjects found in our modern
grammar-school curriculum, is given statutory right of way for so many
minutes per week, so many pages per text-book, or so many pages per
chapter. For the neglect of no other study may teachers be removed
from office and fined. Yet school garrets and closets are full of
hygiene text-books unopened or little used, while of all subjects
taught by five hundred thousand American teachers and studied by
twenty million American pupils the least interesting to both teacher
and pupil is that forced upon both by state legislation. To complete
the paradox, this least interesting subject happens also to be the
most vital to the child, to the home, to industry, to social welfare,
and to education itself.

Whether the subject of hygiene is necessarily dull, whether the
statutes requiring regular instruction in the laws of health are
violated with impunity, whether health principles are flaunted by
health practice at school,—these are questions of immediate concern
to parents as a class, to employers as a class, to every pastor, every
civic leader, every health officer, every taxpayer.

Interviews with teachers and principals regarding the present apathy
to formal hygiene instruction have brought [4]out the following points
that merit the serious consideration of those who are struggling for
higher health standards.

1. There is many a slip ‘twixt the making of a law and its
enforcement. If laws regarding hygiene instruction are not enforced,
we should not be surprised. It has been nobody’s business to see
whether and how hygiene is being taught. The moral crusade spent
itself in forcing compulsory laws upon the statute books of every
state and territory. Making a fetish of Legislation, the advocates
of anti-alcohol and anti-tobacco instruction failed to see the truth
that experienced political reformers are but slowly coming to
see—Legislation which does not provide machinery for its own
enforcement is apt to do little good and frequently will do much
harm. Machinery, however admirably adapted to the work to be done,
will get out of order and become useless, or even harmful, unless
constantly watched and efficiently directed. Of what possible use is
it to say that state money may be withheld from any school board which
fails to enforce the law regarding instruction in hygiene, if state
officials never enforce the penalty? So long as the penalty is not
enforced for flagrant violation, what difference does it make whether
the reason is indifference, ignorance, or desire to thwart the law?
Fortunately, it is easy for each one of us to learn how often and in
what way the children in our community are being taught hygiene, and
how the schools of our state teach and practice the laws of health. If
either the spirit or the letter of the law regarding instruction in
hygiene is being violated, we can measure the penalty paid in health
and morals by our children and our community. We can learn whether
law, text-book, curriculum, or teacher should be changed. We can
insist upon discussion of the facts and upon remedies suggested by the
facts.

2. Teachers give as one reason for neglecting hygiene, that they are
often compelled to struggle with a curriculum which [5]requires more
than they are able to teach and more than pupils are able to learn in
the time allowed. While an overcharged curriculum may explain, it
surely does not justify, the violation of law and the dropping of
hygiene from our school curriculum. If there is any class of citizen
who should teach and practice respect for law as law, it is the
teacher. Parents, school directors, county and state superintendents,
university presidents, social workers, owe it not only to themselves,
but to the American school-teacher, either to repeal the laws that
enjoin instruction in hygiene or else so to adjust the curriculum that
teachers can comply with those laws. The present situation that
discredits both law and hygiene is most demoralizing to teacher,
pupil, and community. Many of us might admire the man teacher who
frankly says he never explains the evils of cigarettes because he
himself is an inveterate smoker of cigarettes. But what must we think
of the school system that shifts to such a man the right and the
responsibility of deciding whether or not to explain to underfed and
overstimulated children of the slums the truth regarding cigarettes?
If practice and precept must be consistent, shall the man be removed,
shall he change his habits, shall the law regarding instruction in
hygiene be changed, or shall other provision be made for bringing
child and essential facts together in a way that will not dull the
child’s receptivity?

3. Teachers are made to feel that while arithmetic and reading are
essential, hygiene is not essential. Whatever may be the facts
regarding the relative value of arithmetic and hygiene, whether or not
our state legislators have made a mistake in declaring hygiene to be
essential, are questions altogether too important for child and state
to be left to the discretion of the individual teacher or
superintendent. It is fair to the teachers who say they cannot afford
to turn aside from the three R’s to teach hygiene, to admit [6]that they
have not hitherto identified the teaching of hygiene with the
promotion of the physical welfare of children. Teachers awake to the
opportunity will sacrifice not only hygiene but any other subject for
the sake of promoting children’s health. They do not really believe
that arithmetic is more important than health. What they mean to say
is that hygiene, as taught by them, has not heretofore had an
appreciable effect upon their pupils’ health; that other agencies
exist, outside of the school, to teach the child how to avoid certain
diseases and how to observe the fundamental laws of health, whereas no
other agencies exist to give the child the essentials of arithmetic,
reading, and geography. “We teach (or try to teach) what our classes
are examined in. If you want a subject taught, you must test a class
in it and hold a teacher responsible for results, and examinations are
mercilessly unhygienic, you know.”

4. Teachers believe that they get better results for their children
from teaching hygiene informally and indirectly than from stated
formal lessons. Whether instruction should be informal or formal is
merely a question of method to be determined by results. What the
results are, can be determined by principals, superintendents, and
students of education. It is easy to understand how at the time of a
fever epidemic children could be taught as much in one week about
infection, disease germs, antiseptics, value of cleanliness, etc., as
in five or ten months when vivid illustration is lacking. Physicians
themselves learn more from one epidemic of smallpox than from four
years of book study. To make possible and to require a daily shower
bath will undoubtedly do more to inculcate habits of health than
repeated lessons about the skin, pores, evaporation, and discharge of
impurities.

If one illustration is better than ten lessons, if an open window is
worth more than all that text-books have to say [7]about ventilation, if
a seat adjusted to the child is better than an anatomical chart, this
does not mean that instruction in hygiene should cease. On the
contrary, it means that provision should be made for every teacher to
open windows, to adjust desks, to use the experience of individual
children for the education of the class. If the rank and file of
teachers have not hitherto been sufficiently observant of
physiological and hygienic facts, if they are unprepared from their
own lives to detect or to furnish illustrations for the child, this
again does not mean that the child should be denied the illustrations,
but that the teacher should either have instruction and experience to
incite interest and to stimulate powers of observation, or else be
asked to give place to another teacher who is able to furnish such
qualifications.

5. Children, like adults, can be interested in other people, in rules
of conduct, in social conditions, in living and working relations more
easily than in their own bodies. The normal, healthy child thinks
very little of himself apart from the other boys and girls, the games,
the studies, the animals, the nature wonders, the hardships that come
to him from the outside. So true is this that one of the best means of
mitigating or curing many ailments is to divert the child’s attention
from himself to things outside of himself that he can look at, hear,
enjoy. The power to concentrate attention upon oneself is a sign
either of a diseased body, a diseased mind, or a highly trained mind.
To study others and to recognize the similarity between others and
oneself is as natural as the body itself. Teachers are consulting this
line of easiest access to children’s attention when they honor
children according to cleanliness of hands, of teeth, of shoes. Human
interest attaches to what parks or excursions are doing for sickly
children, how welfare work is improving factory employees, how
smallpox is conquered by vaccination, how insurance companies [8]refuse
to take risks upon the lives of men or women addicted to the excessive
use of alcohol or tobacco.

Other people’s interests—tenement conditions, factory rules—can be
described in figures and actions that appeal to the imagination and
impress upon the mind pictures that are repeatedly reawakened by
experience and observation on the playground, at home, on the way to
school or to work. “Once upon a time—” will always arrest attention
more quickly than “The human frame consists—.” What others think of
me helps me to obey law—statutory, moral, or hygienic—more than what
I know of law itself. How social instincts dominate may be illustrated
by an experience in advertising a public bath near a thoroughfare
traveled daily by thousands of working girls. I prepared a card to be
distributed among these girls that began: “A cool, refreshing bath,
etc.” This card was criticised by one who knows the ways of girls and
women, as follows: “Of course you get no success when you have a man
stand on the street corner and pass out cards telling girls to get
clean. Every girl that is worth while is affronted by the
insinuation.” Acting upon this expert advice, we then got out a neatly
printed card reading as follows: “For a clear complexion, sprightly
step, and bounding vitality, visit the Center Market Baths, open from
6 A.M. to 9 P.M. daily.” The board of managers shook
their sage masculine heads and reluctantly gave permission to issue
these appeals. Woman’s judgment was vindicated, however, and the
advantage was proved of urging health for “society’s” sake rather than
for health’s sake, when the patronage of the bath jumped at once to
considerable proportions.

6. Other people’s habits of health influence our well-being quite as
much, if not more, than our own. Because we are social beings,
ability to get along with our families, our friends, our employers,
is—at least so it seems to most of us—quite as important as
individual health. For too [9]many of us, living hygienically is
absolutely impossible without inconveniencing and bothering the
majority of persons with whom we live. I remember a girl in
college,—a fresh-air fiend,—who every morning, no matter how cold,
threw the windows wide open. Then, with forty others, I thought this
girl a nuisance as well as a menace to health, but now, twenty years
afterwards, I find myself wanting to do the same thing. Professor
Patten, the economist, whom I shall quote many times because he is
particularly interested in the purpose of this book, was recently
dining at my house and illustrated from his own health the importance
of teaching hygiene so as to affect social as well as personal
standards. “To be true to my own health needs, I ought to have
declined nearly everything that has been offered me for dinner, but in
the long run, if I am going to visit, my eating what is placed before
me is better for society than making those who entertain me feel
uncomfortable.”

Most of us know what uphill work it is to live hygienically in an
unhygienic environment. I remember how hard it was to eat happily when
sitting beside a college professor who took brown pills before each
meal, yellow pills between each course, and a dose of black medicine
after the meal was over. Mariano, an Italian lad cured of bone
tuberculosis by out-of-door salt air at Sea Breeze, returned to his
tenement home an ardent apostle of fresh air day and night, winter and
summer. His family allowed him to open the window before going to bed,
but closed it as soon as he was asleep. Lawrence Veiller, our greatest
expert on tenement conditions, says: “To bathe in a tenement where a
family of six occupy three rooms often involves the sacrifice of
privacy and decency, which are quite as important to social betterment
as cleanliness.”

To live unhygienically where others live hygienically is quite as
difficult. Witness the speedy improvement of dissipated men when
boarding with country friends who eat [10]rationally and retire early. It
must have been knowledge of this fact that prompted the tramways of
Belfast to post conspicuous notices: “Spitting is a vile and filthy
habit, and those who practice it subject themselves to the disgust and
loathing of their fellow-passengers.” It is almost impossible to have
indigestion, blues, and headache when one is camping, particularly
where action and enjoyment fill the day. Our practical question is,
therefore, not “What shall I eat, how many hours shall I sleep, what
shall I wear,” but “How can I manage to get into an environment among
living and working conditions where the people I live with and want to
please, those who influence me and are influenced by me, make healthy
living easy and natural?”

7. Because the problems of health have to do principally with
environment,—home, street, school, business,—it is worth while
trying to relate hygiene instruction to industry and government, to
preach health from the standpoint of industrial and national
efficiency rather than of individual well-being. Since healthful
living requires the coöperation of all persons in a household, in a
group, or in a community, we must find some working programme that
will make it easy for all the members of the group to observe health
standards. A city government that spends taxes inefficiently can
produce more sickness, wretchedness, incapacity in one year than
pamphlets on health can offset in a generation. Failure to enforce
health laws is a more serious menace to health and morals than
drunkenness or tobacco cancer. Unclean streets, unclean dairies,
unclean, overcrowded tenements can do more harm than alcohol and
tobacco because they can breed an appetite that craves stimulants and
drugs. Others have taught how the body acts, what we ought to eat, how
we should live. We are concerned here not with repeating the laws of
health, but with a consideration of the mechanism that will make it
possible for us so to work together that we can observe those laws.

CHAPTER IIToC

SEVEN HEALTH MOTIVES AND SEVEN CATCHWORDS

In making a health programme as in making a boat, a garden, or a
baseball team, the first step is to look about and see what material
there is to work with. A baseball team will fail miserably unless the
captain places each man where he can play best. Gardening is
profitless when the gardener does not know the habits of plants and
the possibilities of different kinds of soil. So in planning a health
programme we must study our materials and use each where it will fit
best. The materials of first importance to a health programme in
civilized countries are men; for men working together can control
water sources, drainage, and ventilation, or else move away to
surroundings better suited to healthful living. Therefore the first
concern of the leader in a health crusade is the human kind he has to
work for and work with.

Seven kinds of man are to be found in every community, seven different
points of view with regard to health administration. Each individual,
likewise, may have seven attitudes toward health laws, seven reasons
for demanding health protection. These seven points of view, seven
stages of development, are clearly marked in the evolution of sanitary
administration throughout the civilized world. With few exceptions, it
is possible, by examining ourselves, our friends, and our communities,
to see where one motive begins and leaves off, giving way to or mixing
with one or more other motives. A friend once asked me if I could keep
this number seven from growing to eight or nine. Perhaps not. Perhaps
there are more kinds of people, [12]more health motives, more stages in
health progress; but I am sure of these seven, and certain that they
have been of great help to me in planning health crusades for the
state of New Jersey and for New York City. The number seven was not
reached hit-or-miss fashion, nor was it chosen for its biblical
prestige. On the contrary, it came as the result of studying health
administration in twoscore British and American cities, and of reading
scores of books on sanitary evolution.

Seven catchwords make it easy to remember the characteristics and the
source of every motive, every kind of person, and every stage in the
evolution of sanitary standards. These seven catchwords are:
Instinct, Display, Commerce, Anti-nuisance, Anti-slum,
Pro-slum, Rights. By the use of these catchwords any teacher,
parent, public official, educator, or social worker should be able to
size up the situation, the needs, and the opportunity of the
individuals or the communities for whom a health crusade is planned.

Instinct was the first health officer and made the first health
laws. Instinct warns us against unusual and offensive odors, sights,
and noises, just as it causes us to seek that which is agreeable.
Primitive man in common with other animals learned by sad experience
to avoid certain herbs as poisons; to bury or to move away from the
dead; to shun discolored drinking water. During the roaming period sun
and air and water acted as scavengers. When tribes settled down in one
spot for long periods, habits that had hitherto been inoffensive and
safe became noticeably injurious and unpleasant. Heads of tribes gave
orders prohibiting such habits and restricting disagreeable acts and
objects to certain portions of the camp. Instinct places outhouses on
our farms and then gradually removes them farther and farther from
dwellings. In many school yards, more particularly in country
districts and small towns, [13]outhouses are a crying offense against
animal instinct. In visiting slum districts in Irish and Scotch
cities, and in London, Paris, Berlin, and New York, I never found
conditions so offensive to crude animal instinct as those I knew when
a boy in Minnesota school yards, or those I have since seen in a Boy
Republic. But the evil is not corrected because it is not made
anybody’s business to execute instinct’s mandates. In the Boy Republic
the leaders were waiting for the children themselves to revolt, as
does primitive man.

Table I

Typhoid a Rural Disease[1]

Among large numbers of persons, in city as well as country, washing
the body is still a matter of instinct, a bath not being taken until
the body is offensive, the hands not being washed until their
condition interferes with the enjoyment of food or with one’s
treatment by others. There is a point of neglect beyond which instinct
will not [14]permit even a tramp to go. If cleanliness is next to
godliness, the average child is most ungodly by nature, for it loathes
the means of cleanliness and otherwise observes instinct’s health
warnings only after experience has punished or after other motives
from the outside have prompted action. The chief form of legislation
of the instinct age is provision of penalties for those who poison
food, water, or fellow-man. There are districts in America where
hygiene is supposed to be taught to children that are conscious of no
other sanitary legislation but that which punishes the poisoner.

Display has always been an active health crusader. Professor Patten
says the best thing that could happen to the slums of every city would
be for every girl and woman to be given white slippers, white
stockings, a white dress, and white hat. Why? Because they would at
once notice and resent the dirt on the street, in their hallways, and
in their own homes. People that have nothing to “spoil” really do not
see dirt, for it interferes in no way with their comfort so far as
they can see. Their windows are crusted with dust, their babies’ milk
bottles are yellow with germs. Who cares? Similar conditions exist
among well-to-do women who live on isolated farms with no one to
notice their personal appearance except others of the family who
prefer rest to cleanliness. But let the tenement mother or the
isolated farmer’s wife entertain the minister or the school-teacher,
the candidate for sheriff or the ward boss, let her go to Coney Island
or to the county fair, and at once an outside standard is set up that
requires greater regard for personal appearance and leads to “cleaning
up.”

Elbow sleeves and light summer waists have led many a girl to daily
bathing of at least those parts of the body that other people see.
Entertainments and sociables, Saturday choir practice and church have
led many a young man to bathe for others’ sake when quite satisfied
[15]to forego the ordeal so far as his own comfort and health were
concerned. Streets on which the well-to-do live are kept clean. Why?
Not because Madam Well-to-do cares so much for health, but because she
associates cleanliness with social prestige. It is necessary for the
display of her carriages and dresses, just as paved streets and a
plentiful supply of water for public baths and private homes were
essential to the display of Rome’s luxury. Generally speaking,
residence streets are cleaned in small towns just as waterworks are
introduced, to gratify the display motive of those who have lawns to
water and clothes to show.

Instinct strengthens the display motive. As every one can be
interested in instinct hygiene, so every one is capable of this
display motive to the extent that his position is affected by other
people’s opinion. It was love of display quite as much as love of
beauty that gave Greece the goddess Hygeia, the worship of whom
expressed secondarily a desire for universal health, and primarily a
love of the beautiful among those who had leisure to enjoy it.

Commerce brooks no preventable interference with profits, whether by
disease, death, impassable streets, or disabled men. The age of
chivalry was also the age of indescribable filth, plague, Black Death,
and spotted fever that cost the lives of millions. It would be
impossible in the civilized world to duplicate the combination of
luxury and filthy, disease-breeding conditions in the midst of which
Queen Bess and her courtiers held their revels. The first protest was
made, not by the church, not by sanitarians, but by the great
merchants who were unable to insure against loss and ruin from the
plagues that thrived on filth and overcrowding. By an interesting
coincidence the first systematic street cleaning and the first
systematic ship cleaning—maritime quarantine—date from the same
year, 1348 A.D.; the former in the foremost German [16]trading
town, Cologne, and the latter in Venice, the foremost trading town of
Italy. The merchants of Philadelphia and New York started the first
boards of health in the United States. For what purpose? To prevent
business losses from yellow fever. Desire for passable streets,
drains, waterworks, and strong boards of health has generally started
with merchants. For commercial reasons many of our states vote more
money for the protection of cattle than for the protection of human
life, and the United States votes millions for the study of hog
cholera, chicken pip, and animal tuberculosis, while neglecting
communicable diseases of men. No class in a community will respond
more quickly to an appeal for the rigid enforcement of health laws
than the merchant class; none will oppose so bitterly as that which
makes profits out of the violation of health laws.

Table II

Cost in Life Capital of Preventable Diseases[2]

[17]Anti-nuisance motives do not affect health laws until people with
different incomes and different tastes try to live together. In a
small town where everybody keeps a cow and a pig, piggeries and
stables offend no one; but when the doctor, the preacher, the
dressmaker, the lawyer, and the leading merchant stop keeping pigs and
cows, they begin to find other people’s stables and piggeries
offensive. The early laws against throwing garbage, fish heads,
household refuse, offal, etc., on the main street were made by kings
and princes offended by such practices. The word “nuisance” was coined
in days when neighbors lived the same kind of life and were not
sensitive to things like house slops, ash piles, etc. The first
nuisances were things that neighbors stumbled over or ran into while
using the public highway. Next, goats and other animals interfering
with safety were described as nuisances, and legal protection against
them was worked out. It has never been necessary to change the maxim
which originally defined a nuisance: “So use your own property that
you will not injure another in the use of his property.” The thing
that has changed and grown has been society’s knowledge of acts and
objects that prevent a man from enjoying his own property. To-day the
number of things that the law calls nuisances is so great that it
takes hundreds of pages to describe them. Stables and outhouses must
be set back from the street. Every man must dispose of garbage and
drainage on his own property. Stables and privies must be at least a
hundred feet from water reservoirs. Factories may not pollute streams
that furnish drinking water. Merchants may be punished if they put
banana skins in milk cans, or if they fail to scald and cleanse all
milk receptacles before returning them to wholesalers. Automobile
drivers may be punished for disturbing sleep. Anything that injures my
health will be declared a nuisance and abolished, if I can prove that
my health is being injured and that I am doing all I can to [18]avoid
that injury. No educational work will accomplish more for any
community than to make rich and poor alike conscious of nuisances that
are being committed against themselves and their neighbors. The rich
are able to run away from nuisances that they cannot have abated. If
proper publicity is given to living conditions among those who do not
resist nuisances, the presence of such conditions will itself become
offensive to the well-to-do, who will take steps to remove the
nuisance. Jacob Riis in this way made the slums a nuisance to rich
residents in New York City and stimulated tenement reform, building of
parks, etc.

Anti-slum motives originated in cities where there is a clear
dividing line between the clean and the unclean, the infected and the
uninfected, the orderly and the disorderly, high and low vitality. As
soon as one district becomes definitely known as a source of nuisance,
infection, and disease, better situated districts begin to make laws
to protect themselves. A great part of our existing health codes and a
very large part of the funds spent on health administration are
designed to protect those of high income against disease incident to
those of low income, high vitality against low vitality, houses with
rooms to spare against houses that are overcrowded. To the small town
and the country the slum means generally the near-by city whose papers
talk of epidemic scarlet fever, diphtheria, or smallpox. Cities have
only recently begun to experience anti-slum aversion to country
dairies whose uncleanliness brings infected milk to city babies, or to
filthy factories and farms that pollute water reservoirs and cause
typhoid. The last serious smallpox epidemic in the East came from the
South by way of rural districts that failed to notify the Pennsylvania
state board of health of the outbreak until the disease was scattered
broadcast. Every individual knows of some family or some district that
is immediately pictured when terms like “disease,” “epidemic,” “slum,”
are [19]pronounced. The steps worked out by the anti-slum motive to
protect “those who have” from disease arising from “those who have
not” are given on page 31.

A COUNTRY MENACE TO CITY HEALTH

Pro-slum motives are not exactly born of anti-slum motives, but,
thanks to the instinctive kindness of the human heart, follow promptly
after the dangers of the slum have been described. You and I work
together to protect ourselves against neglect, nuisance, and disease.
In a district by which we must pass and with which we must deal, one
of us or a neighbor or friend will turn our attention from our danger
to the suffering of those against whom we wish to protect ourselves.
Charles Dickens so described Oliver Twist and David Copperfield that
Great Britain organized societies and secured legislation to improve
the almshouse, school, and working and living conditions. When health
reports, newspapers, and charitable societies [20]make us see that the
slum menaces our health and our happiness, we become interested in the
slum for its own sake. We then start children’s aid societies,
consumer’s leagues, sanitary and prison associations, child-labor
committees, and “efficient government” clubs.

Rights motives are the last to be evolved in individuals or
communities. The well-to-do protect their instinct, their comfort,
their commerce, but run away from the slums and build in the secluded
spots or on the well-policed and well-cleaned avenues and boulevards.
Uptown is often satisfied with putting health officials to work to
protect it against downtown. Pro-slum motives are shared by too few
and are expressed too irregularly to help all of those who suffer from
crowded tenements, impure milk, unclean streets, inadequate schooling.
So long as those who suffer have no other protection than the
self-interest or the benevolence of those better situated, disease and
hardship inevitably persist. Health administration is incomplete until
its blessings are given to men, women, and children as rights that can
be enforced through courts, as can the right to free speech, the
freedom of the press, and trial by jury. There is all the difference
in the world between having one’s street clean because it is a danger
to some distant neighbor, or because that neighbor takes some
philanthropic interest in its residents, and because one has a right
to clean streets, regardless of the distant neighbor’s welfare or
interest. When the right to health is granted health laws are made,
and all men within the jurisdiction of the lawmaking power own health
machinery that provides for the administration of those laws. A system
of public baths takes the place of a bathhouse supported by charity; a
law restricting the construction and management of all tenements takes
the place of a block of model tenements, financed by some wealthy man;
medical examination of all school children takes the place of a
private dispensary; [21]a probation law takes the place of the friendly
visitor to the county jail.

Most of the rights we call inalienable are political rights no longer
questioned by anybody and no longer thought of in connection with our
everyday acts, pleasures, and necessities. When our political rights
were formulated in maxims, living was relatively simple. There was no
factory problem, no transportation problem, no exploitation of women
and children in industry. Our ancestors firmly believed that if the
strong could be prevented from interfering with the political rights
of the weak, all would have an equal chance. The reason that our
political maxims mean less to-day than two hundred years ago is that
nobody is challenging our right to move from place to place if we can
afford it, to trial by jury if charged with crime, to speak or print
the truth about men or governments. If, however, anybody should
interfere with our freedom in this respect, it would be of tremendous
help that everybody we know would resent such interference and would
point to maxims handed down by our ancestors and incorporated in our
national and state constitutions as formal expressions of unanimous
public opinion.

The time is past when any one seriously believes that political
freedom or personal liberty will be universal, just because everybody
has a right to talk, to move from place to place, to print stories in
the newspapers. The relation of man to man to-day requires that we
formulate rules of action that prevent one man’s taking from another
those rights, economic and industrial, that are as essential to
twentieth-century happiness as were political rights to
eighteenth-century happiness. Political maxims showed how, through
common desire and common action, steps could be taken by the
individual and by the whole of society for the protection of all.
Health rights, likewise, are to be obtained through common action. A
modern city must [22]know who is accountable when an automobile runs over
a pedestrian, when a train load of passengers lose their lives because
of an engineer’s carelessness, when an employee is incapacitated for
work by an accident for which he is not responsible, or when fever
epidemics threaten life and liberty without check. How can a child who
is prevented by removable physical defects from breathing through his
nose be enthusiastic over free speech? Of what use is freedom of the
press to those who find reading harder than factory toil? How futile
the right to trial by jury if removable physical defects make children
unable to do what the law expects! Who would not exchange rights of
petition for ability to earn a living? Children permanently
incapacitated to share the law’s benefits cannot appreciate the
privilege of pursuing happiness.

Succeeding chapters will enumerate a number of health rights and will
show through what means we can work together to guarantee that we
shall not injure the health of our neighbor and that our neighbor
shall not injure our health. The truest index to economic status and
to standards of living is health environment. The best criterion of
opportunity for industrial and political efficiency is the conditions
affecting health. The seven catchwords that describe seven motives to
health legislation and health administration, seven ways of
approaching health needs, and seven reasons for meeting them, should
be found helpful in analyzing the problem confronting the individual
leader. Generally speaking, we cannot watch political rights grow, but
health rights are evolved before our eyes all the time. If we wish, we
can see in our own city or township the steps taken, one by one, that
have slowly led to granting a large number of health rights to every
American.

FOOTNOTES:

CHAPTER IIIToC

WHAT HEALTH RIGHTS ARE NOT ENFORCED IN YOUR COMMUNITY?

Laws define rights. Men enforce them. For definitions we go to books.
For record of enforcement we go to acts and to conditions.[3] What
health rights a community pretends to enforce will, as a rule, be
found in its health code. What health rights are actually enforced can
be learned only by studying both the people who are to be protected
and the conditions in which these people live. A street, a cellar, a
milk shop, a sick baby, or an adult consumptive tells more honestly
the story of health rights enforced and health rights unenforced than
either sanitary code or sanitary squad. Not until we turn our
attention from definition and official to things done and dangers
remaining can we learn the health progress and health needs of any
city or state.

The health code of one city looks very much like the health code of
every other city. This is natural because those who write health codes
generally copy other codes. Even small cities are given complicated
sanitary legislative powers by state legislatures. Therefore those who
judge a community’s health rights by its health laws will get as
erroneous an impression as those who judge hygiene instruction in our
public schools from printed statements about the frequency and
character of such instruction. Advocates of health codes have thought
the battle won when boards of health were given almost unlimited power
to abate nuisances and told how to exercise those powers.

[24]

A DAIRY INSPECTOR’S OUTFIT

The slip ‘twixt law making and law enforcement is everywhere found. In
1864 New York state prohibited the sale of adulterated milk. Law after
law has been made since that time, giving health officials power to
revoke licenses of milk dealers and to send men to jail who violated
milk laws. We now know that no law will ever stop the present
frightful waste of infant lives, counted in thousands annually, unless
dairies are frequently inspected and forced to be clean; unless milk
is kept at a temperature of about fifty degrees on the train, in the
creamery, at the receiving station, and in the milk shop; unless
dealers scald and thoroughly cleanse cans in which milk is shipped;
unless licenses are taken from farmers, creameries, and retailers who
violate the law; unless magistrates use their power to fine or
imprison those who poison helpless babies by violating milk laws; and
unless mothers are taught to scald [25]and thoroughly cleanse bottles,
nipples, cups, and dishes from which milk is fed to the baby. We know
that these things are not being done except where men or women make it
their business to see that they are done. Experience tells us that
inspectors will not consistently do their duty unless those who direct
them have regular records of their inspections, study those records,
find out work not done properly or promptly, and insist upon thorough
inspection.

Whether work is done right, whether inspectors do their full duty,
whether babies are protected, can be learned only from statements in
black and white that show accurately the conditions of dairies and
milk shops, the character of milk found and tested by inspectors, and
the number of babies known to have been sick or known to have died
from intestinal diseases chiefly due to unsafe milk. Any teacher or
parent can learn for himself, or can teach children to learn, what
steps are taken to guarantee the right to pure milk by using a table
such as Table III. Whether conditions at the dairy make pure milk
impossible can be told by any one who can read the score card used by
New York City (Table IV).

Table III[26]

MILK INSPECTION WITHIN NEW YORK CITY, 1906

Table IV

[29]It is a great pity that we Americans have taken so long to learn that
laws do not enforce themselves, that even good motives and good
intentions in the best of officials do not insure good deeds. Thousands
of lives are being lost every year, millions of days taken from
industry and wasted by unnecessary sickness, millions of dollars spent
on curing disease, the working life of the nation shortened, the hours
of enjoyment curtailed, because we have not seen the great gap between
health laws and health-law enforcement. In our municipal, state, and
national politics we have made the same mistake of concentrating our
attention upon the morals and pretensions of candidates and officials
instead of judging government by what government does. Gains of men and
progress of law are useful to mankind only when converted into deeds
that make men freer in the enjoyment of health and earning power. In
protecting health, as in reforming government, an ounce of efficient
achievement is worth infinitely more than a moral explosion. One month
of routine—unpicturesque, unexciting efficiency—will accomplish more
than a scandal or catastrophe. Such routine is possible only when
special machinery is constantly at work, comparing work done with work
expected, health practice with health ideals. Where such machinery does
not yet exist, volunteers, civic leagues, boys’ brigades, etc., can
easily prove the need for it by filling out an improvised score card
for the school building, railroad station, business streets,
“well-to-do” and poor resident streets, such as follows:

Table V

Score Card for Citizen Use

[30]Until recently the most reliable test of health rights not enforced
was the number of cases of preventable, communicable, contagious,
infectious, transmissible diseases, such as smallpox, typhoid fever,
yellow fever, scarlet fever, diphtheria, measles, whooping cough. By
noticing streets and houses where these diseases occurred, students
learned a century ago that the darker and more congested the street
the greater the prevalence of fevers and the greater the chance that
one attacked would die. The well-to-do remove from their houses and
their streets the dirt, the decomposed garbage, and stagnant pools
from which fevers seem to spring. It was because fevers and congestion
go together that laws were made to protect the well-to-do, the
comfortable, and the clean against the slum. It is true to-day that if
you study your city and stick a pin in the map, street for street,
where infection is known to exist, you will find the number steadily
increase as you go from uncongested to congested streets and houses,
from districts of high rent to districts of low rent. Because it is
easier to learn the number of persons who have measles and diphtheria
and smallpox than it is to learn the incomes and living conditions
prejudicial to health, and because our laws grant protection against
communicable diseases to a child in whatever district he may be born,
the record of cases of communicable diseases has heretofore been the
best test of health rights unenforced. Even in country schools it
would make a good lesson in hygiene and civics to have the children
keep a record of absences on account of transmissible disease, and
then follow up the record with a search for conditions that gave the
disease a good chance.

But to wait for contagion before taking action has been found an
expensive way of learning where health protection is needed. Even when
infected persons and physicians are prompt in reporting the presence
of disease it is often [31]found that conditions that produced the
disease have been overlooked and neglected.

For example, smallpox comes very rarely to our cities to-day. Wherever
boards of health are not worried by “children’s diseases,” as is often
the case, and wait for some more fearful disease such as smallpox,
there you will find that garbage in the streets, accumulated filth,
surface sewers, congested houses, badly ventilated, unsanitary school
buildings and churches are furnishing a soil to breed an epidemic in a
surprisingly short time. Where, on the other hand, boards of health
regard every communicable disease as a menace to health rights, you
will find that health officials take certain steps in a certain order
to remove the soil in which preventable diseases grow. These steps,
worked out by the sanitarians of Europe and America after a century of
experiment, are seen to be very simple and are applicable by the
average layman and average physician to the simplest village or rural
community. How many of these steps are taken by your city? by your
county? by your state?

[32]With a chart showing what districts have the greatest number of
children and adults suffering from measles, typhoid fever, scarlet
fever, consumption, one can go within his own city or to a strange
city and in a surprisingly short time locate the nuisances, the
dangerous buildings, the open sewers, the cesspools, the houses
without bathing facilities, the dark rooms, the narrow streets, the
houses without play space and breathing space, the districts without
parks, the polluted water sources, the unsanitary groceries and milk
shops. In country districts a comparison of town with town as to the
prevalence of infection will enable one easily to learn where slop
water is thrown from the back stoop, whether the well, the barn, and
the privy are near together.

THE BABY, NOT THE LAW, IS THE TEST OF INFANT PROTECTION IN COUNTRY AND IN CITY

Testing health rights requires not only that there be a board of
health keeping track of and publishing every case of infection, but it
requires further that one community be compared with other communities
of similar size, and that each community be compared with itself year
for year. These comparisons have not been made and records do not
exist in many states.

FOOTNOTES:

CHAPTER IVToC

THE BEST INDEX TO COMMUNITY HEALTH IS THE PHYSICAL WELFARE OF SCHOOL CHILDREN

Compulsory education laws, the gregarious instinct of children, the
ambition of parents, their self-interest, and the activities of
child-labor committees combine to-day to insure that one or more
representatives of practically every family in the United States will
be in public, parochial, or private schools for some part of the year.
The purpose of having these families represented in school is not only
to give the children themselves the education which is regarded as a
fundamental right of the American child, but to protect the community
against the social and industrial evils and the dangers that result
from ignorance. Great sacrifices are made by state, individual
taxpayer, and individual parent in order that children and state may
be benefited by education. Almost no resistance is found to any demand
made upon parent or taxpayer, if it can be shown that compliance will
remove obstructions to school progress. If, therefore, by any chance,
we can find at school a test of home conditions affecting both the
child’s health and his progress at school, it will be easy, in the
name of the school, to correct those conditions, just as it will be
easy to read the index, because the child is under state control for
six hours a day for the greater part of the years from six to
fourteen.[4]

[34]

What, then, is this test of home conditions prejudicial to health that
will register the fact as a thermometer tells us the temperature, or
as a barometer shows moisture and air pressure? The house address
alone is not enough, for many children surrounded by wealth are denied
health rights, such as the right to play, to breathe pure air, to eat
wholesome food, to live sanely. Scholarship will not help, because the
frailest child is often the most proficient. Manners mislead, for,
like dress, they are but externals, the product of emulation, of other
people’s influence upon us rather than of our living conditions.
Nationality is an index to nothing significant in America, where all
race and nationality differences melt into Americanisms, all
responding in about the same way to American opportunity. No, our test
must be something that cannot be put on and off, cannot be left at
home, cannot be concealed or pretended, something inseparable from the
child and beyond his control. This test it has been conclusively
proved in Chicago, Boston, Brookline, Philadelphia, and particularly
in New York City, is the physical condition of the school child. To
learn this condition the child must be examined and reëxamined for
[35]the physical signs called for by the card on page 34. Weight, height,
and measurements are needed to tell the whole story.

When this card is filled out for every child in a class or school or
city, the story told points directly to physical, mental, or health
rights neglected. If for every child there is begun a special card,
that will tell his story over and over again during his school life,
noting every time he is sick and every time he is examined, the
progress of the community as well as of the child will be clearly
shown. Such a history card (p. 314) is now in use in certain New York
schools, as well as in several private schools and colleges.

Have you ever watched such an examination? By copying this card your
family physician can give you a demonstration in a very short time as
to the method and advantage of examination at school. The school
physician goes at nine o’clock to the doctor’s room in the public
school, or, if there is no doctor’s room, to that portion of the hall
or principal’s office where the doctor does his work. The teacher or
the nurse stands near to write the physician’s decision. The doctor
looks the child over, glances at his eyes, his color, the fullness of
his cheeks, the soundness of his flesh, etc. If the physician says
“B,” the principal or nurse marks out the other letter opposite to
number 1, so that the card shows that there is bad nutrition.

In looking at the teeth and throat a little wooden stick is used to
push down the tongue. There should be a stick for every child, so that
infection cannot possibly be carried from one to the other. If this is
impossible, the stick should be dipped in an antiseptic such as boric
acid or listerine. If, because of swollen tonsils, there is but a
little slit open in the throat, or if teeth are decayed, the mark is Y
or B. The whole examination takes only a couple of minutes, but the
physician often finds out in this short time facts that will save a
boy and his parents a great deal of trouble. Very often this
examination tells a story that overworked [36]mothers have studiously
concealed by bright ribbons and clean clothes. I remember one little
girl of fourteen who looked very prosperous, but the physician found
her so thin that he was sure that for some time she had eaten too
little, and called her anæmic. He later found that the mother had
seven children whom she was trying to clothe and shelter and feed with
only ten dollars a week. A way was found to increase her earnings and
to give all the children better living conditions,—all because of the
short story told by the examination card. In another instance the
card’s story led to the discovery of recent immigrant parents earning
enough, but, because unacquainted with American ways and with their
new home, unable to give their children proper care.

LOOKING FOR ENLARGED TONSILS AND BAD TEETH
Note the mouth breather waiting

The most extensive inquiry yet made in the United States as to the
physical condition of school children is that conducted by the board
of health in New York City since 1905. From March, 1905, to January 1,
1908, 275,641 children have been examined, and 198,139 or 71.9 per
cent have been found to have defects, as shown in Table VI.

Table VI[37]

Physical Examination of School Children—performed by the
Department of Health in the Borough of Manhattan, 1905-1907

It is generally believed that New York children must have more defects
than children elsewhere. If this assumption is wrong, if children in
other parts of the United States are as apt to have eye defects,
enlarged tonsils, and bad teeth as the children of the great
metropolis, then the army of children needing attention would be seven
out of ten, or over 14,000,000.

Whether these figures overstate or understate the truth, the school
authorities of the country should find out. The chances are that the
school in which you are particularly interested is no exception. To
learn what the probable number needing attention is, divide your total
by ten and multiply the result by seven.

[38]The seriousness of every trouble and its particular relation to school
progress and to the general public health will be explained in
succeeding chapters. The point to be made here is that the examination
of the school child discloses in advance of epidemics and breakdowns
the children whose physical condition makes them most likely to “come
down” with “catching diseases,” least able to withstand an attack,
less fitted to profit fully from educational and industrial
opportunity.

The only index to community conditions prejudicial to health that will
make known the child of the well-to-do who needs attention is the
record of physical examination. No other means to-day exists by which
the state can, in a recognized and acceptable way, discover the
failure of these well-to-do parents to protect their children’s health
and take steps to teach and, if necessary, to compel the parents to
substitute living conditions that benefit for conditions that injure
the child.

Among the important health rights that deserve more emphasis is the
right to be healthy though not “poor.” A child’s lungs may be weak,
breathing capacity one third below normal, weight and nutrition
deficient, and yet that child cannot contract tuberculosis unless
directly exposed to the germs of that disease. But such a child can
contract chronic hunger, can in a hundred ways pay the penalty for
being pampered or otherwise neglected. Physical examination is needed
to find every child that has too little vitality, no zest for play,
little resistance, even though sent to a private school and kept away
from dirt and contagion.

The New York Committee on the Physical Welfare of School Children
visited fourteen hundred homes of children found to have one or more
of the physical defects shown on the above card. While they found that
low incomes have more than their proper share of defects and of
unsanitary living conditions, yet they saw emphatically [39]also that low
incomes do not monopolize physical defects and unsanitary living
conditions. Many families having $20, $30, $40 a week gave their
children neither medical nor dental care. The share each income had in
unfavorable conditions is shown by the summary in the following table.

Table VII

Showing Per Cent Share of Physical Defects of Children,
Unfavorable Housing Conditions, and Child Mortality
found among each Family-income Group

The index should be read in all grades from kindergarten to high
school and college.

[40]Last winter the chairman of the Committee on the Physical Welfare of
School Children was invited to speak of physical examination before an
association of high-school principals. He began by saying, “This
question does not concern you as directly as it does the
grammar-school principals, but you can help secure funds to help their
pupils.” One after another the high-school principals present
told—one of his own daughter, another of his honor girls, a third of
his honor boys—the same story of neglected headaches due to eye
strain, breakdowns due to undiscovered underfeeding, underexercise, or
overwork. Are we coming to the time when the state will step in to
prevent any boy or girl in high school, college, or professional
school from earning academic honors at the expense of health? Harmful
conditions within schoolrooms and on school grounds will not be
neglected where pupils, teachers, school and family physicians, and
parents set about to find and to remove the causes of physical
defects.

Disease centers outside of school buildings quickly register
themselves in the schoolroom and in the person of a child who is
paying the penalty for living in contact with a disease center. If a
child sleeps in a dark, ill-ventilated, crowded room, the result will
show in his eyes and complexion; if he has too little to eat or the
wrong thing to eat, he will be underweight and undersized; if his
nutrition is inadequate and his food improper, he is apt to have eye
trouble, adenoids, and enlarged tonsils. He may have defective lung
capacity, due to improper breathing, too little exercise in the fresh
air, too little food. Existence of physical defects throws little
light on income at home, but conclusively shows lack of attention or
of understanding. Several days’ absence of a child from school leads,
in every well-regulated school, to a visit to the child’s home or to a
letter or card asking that the absence be explained. Even newly
arrived immigrants have learned the necessity and [41]the advantage of
writing the teacher an “excuse” when their children are absent.
Furthermore, neighbors’ children are apt to learn by friendly inquiry
what the teacher may not have learned by official inquiry, why their
playmate is no longer on the street or at the school desk. While
physicians are sometimes willing to violate the law that compels
notification of infection, rarely would a physician fail to caution an
infected family against an indiscriminate mingling with neighbors.
Whether the family physician is careless or not, the explanation of
the absence which is demanded by the school would give also
announcement of any danger that might exist in the home where the
child is ill.

If it be said that in hundreds of thousands of cases the child labor
law is violated and that therefore school examination is not an index
to the poverty or neglect occasioning such child labor, it should be
remembered that the best physical test is the child’s presence at
school. The first step in thorough physical examination is a thorough
school census,—the counting of every child of school age. Moreover, a
relatively small number of children who violate the child labor law
are the only members of the family who ought to be in school. Younger
children furnish the index and occasion the visit that should discover
the violation of law.

Appreciation of health, as well as its neglect, is indexed by the
physical condition of school children. Habits of health are the other
side of the shield of health rights unprotected. Physical examination
will discover what parents are trying to do as well as what they fail
to do because of their ignorance, indifference, or poverty. In so far
as parents are alive to the importance of health, the school
examination furnishes the occasion of enlisting them in crusades to
protect the public health and to enforce health rights. The Committee
on the Physical Welfare of School Children found many parents
unwilling to answer [42]questions as to their own living conditions until
told that the answers would make it easier to get better health
environment not only for their own children but for their neighbors’
children. Generally speaking, fathers and mothers can easily be
interested in any kind of campaign in the name of health and in behalf
of children. The advantage of starting this health crusade from the
most popular American institution, the public school,—the advantage
of instituting corrective work through democratic machinery such as
the public school,—is incalculable. To any teacher, pastor, civic
leader, health official, or taxpayer wanting to take the necessary
steps for the removal of conditions prejudicial to health and for the
enforcement of health rights of child and adult, the best possible
advice is to learn the facts disclosed by the physical examination of
your school children. See that those facts are used first for the
benefit of the children themselves, secondly for the benefit of the
community as a whole. If your school has not yet introduced the
thorough physical examination of school children, take steps at once
to secure such examination. If necessary, volunteer to test the eyes
and the breathing of one class, persuade one or two physicians to
coöperate until you have proved to parent, taxpayer, health official,
and teacher that such an examination is both a money-saving,
energy-saving step and an act of justice.

We shall have occasion to emphasize over and over again the fact that
it is the use of information and not the gathering of information that
improves the health. The United States Weather Bureau saves millions
of dollars annually, not because flags are raised and bulletins issued
foretelling the weather, but because shipowners, sailors, farmers, and
fruit growers obey the warnings. Mere examination of school children
does little good. The child does not breathe better or see better
because the school physician fills out a card stating that there is
[43]something wrong with his eyes, nose, and tonsils. The examination
tells where the need is, what children should have special attention,
what parents need to be warned as to the condition of the child, what
home conditions need to be corrected. If the facts are not used, that
is an argument not against obtaining facts but against disregarding
them.

In understanding medical examination we should keep clearly in mind
the distinction between medical school inspection, medical school
examination, and medical treatment at school. Medical inspection is
the search for communicable disease. The results of medical
inspection, therefore, furnish an index to the presence of
communicable diseases in the community. Medical examination is the
search for physical defects, some of which furnish the soil for
contagion. Its results are an index not only to contagion but to
conditions that favor contagion by producing or aggravating physical
defects and by reducing vitality. Medical treatment at school refers
to steps taken under the school roof, or by school funds, to remove
the defects or check the infection brought to light by medical
inspection and medical examination. Treatment is not an index. In
separate chapters are given the reasons for and against trying to
treat at school symptoms of causes that exist outside of school. When,
how often, and by whom inspection and examination should be made is
also discussed later. The one point of this chapter is this: if we
really want to know where in our community health rights are
endangered, the shortest cut to the largest number of dangers is the
physical examination of children at school,—private, parochial,
reformatory, public, high, college.

Apart from the advantage to the community of locating its health
problems, physical examination is due every child. No matter where his
schooling or at whose expense, every child has the right to advance as
fast as his own powers [44]will permit without hindrance from his own or
his playmates’ removable defects. He has the right to learn that
simplified breathing is more necessary than simplified spelling, that
nose plus adenoids makes backwardness, that a decayed tooth multiplied
by ten gives malnutrition, and that hypertrophied tonsils are even
more menacing than hypertrophied playfulness. He has the right to
learn that his own mother in his own home, with the aid of his own
family physician, can remove his physical defects so that it will be
unnecessary for outsiders to give him a palliative free lunch at
school, thus neglecting the cause of his defects and those of
fellow-pupils.

FOOTNOTES:

PART II. READING THE INDEX TO HEALTH RIGHTS

CHAPTER VToC

MOUTH BREATHING

If the physical condition of school children is our best index to
community health, who is to read the index? Unless the story is told
in a language that does not require a secret code or cipher, unless
some one besides the physician can read it, we shall be a very long
time learning the health needs of even our largest cities, and until
doomsday learning the health needs of small towns and rural districts.
Fortunately the more important signs can be easily read by the average
parent or teacher. Fortunately, too, it is easy to persuade mothers
and teachers that they can lighten their own labors, add to their
efficiency, and help their children by being on the watch for mouth
breathing, for strained, crossed, or inflamed eyes, for decaying
teeth, for nervousness and sluggishness. Years ago, when I taught
school in a Minnesota village, I had never heard of adenoids,
hypertrophied tonsils, myopia, hypermetropia, or the relation of these
defects and of neglected teeth to malnutrition, truancy, sickness, and
dullness. I now see how I could have saved myself several failures,
the taxpayers a great deal of money, the parents a great deal of
disappointment, and many children a life of inefficiency, had I known
what it is easy for all teachers and parents to learn to-day.

[46]

MOUTH BREATHERS BEFORE “ADENOID PARTY”

The features in the following cut are familiar to teachers the world
over. Parents may reconcile themselves to such lips, eyes, and mouths,
but seldom do even neglectful parents fail to notice “mouth
breathing.” Children afflicted by such features suffer torment from
playfellows whose scornful epithets are echoed by the looking-glass.
No fashion plate ever portrays such faces. No athlete, thinker, or
hero looks out from printed page with such clouded, listless eyes. The
more wonder, therefore, that the meaning of these outward signs has
not been appreciated and their causes removed; conclusive reason,
also, for not being misled by recent talk of mouth breathing,
adenoids, and enlarged tonsils, into the belief that the race is
physically deteriorating. Three generations ago Charles Dickens in his
Uncommercial Traveller pointed out a relation between open mouths
and backwardness and delinquency that would have saved millions of
dollars and millions of life failures had the civilized world
listened. He was speaking of delinquent girls from seventeen to twenty
years old in Wapping Workhouse: “I have never [47]yet ascertained why a
refractory habit should affect the tonsils and the uvula; but I have
always observed that refractories of both sexes and every grade,
between a Ragged School and the Old Bailey, have one voice, in which
the tonsils and uvula gain a diseased ascendency.”

To-day we are just beginning to see over again the connection between
inability to breathe through the nose and inability to see clearly
right from wrong and inability to want to do what teachers and parents
wish. Physical examinations show now, and might just as well have
shown fifty years ago, that the great majority of truants and juvenile
offenders have adenoids and enlarged tonsils. A recent examination
made by the New York board of health on 150 children in one school
made up from the truant school, the juvenile court, and Randall’s
Island, showed that only three were without some physical defect and
that 137 had adenoids and large tonsils. Dickens wrote his
observations in 1860; in 1854 the New York Juvenile Asylum was
started, and up to 1908 cared for 40,000 children; in 1860 William
Meyer pointed out, so that no one need misunderstand, the harmful
effects of adenoids. What would have been the story of juvenile
waywardness, of sickness, of educational advancement, had examinations
for defective breathing been started in 1853 or 1860 instead of 1905;
if one per cent of the attention that has been given to teaching mouth
breathers the ten commandments had been spent on removing the nasal
obstructions to intelligence?

A “DEGENERATE” MADE NORMAL BY REMOVAL OF ADENOIDS

William Hegel, who is pictured on page 48, before his tonsils and
adenoids were removed was described by his father in this way: “When
playing with other boys on the street he seems dazed, and sluggish to
grasp the various situations occurring in the course of the game. When
he decides to do something he runs in a heedless, senseless way, as if
running away,—will bump against something, [48]pedestrian or building,
before he comes to himself; seems dazed all the time. When told
something by his mother he giggles in the most exasperating way, for
which he receives a whipping quite often.” The father said the
whipping was of no avail. The child was restless, talkative, and
snored during sleep. He had an insatiable appetite. He was removed or
transferred from five different schools in New York City. To get
redress the father took him to the board of education, whence he was
referred to the assistant chief medical inspector of the department of
health, whose examination revealed immensely large fungous-looking
tonsils and excessive pharyngeal granulations (adenoids). He was
operated on at a clinic. The tonsils and adenoids removed are pictured
on the opposite page, reduced one third. After the operation the child
was visited by the assistant medical inspector. There was a marked
improvement in his facial expression,—he looked intelligent, was
alert and interested. When [49]asked how he felt, he answered, “I feel
fine now.” It required about fifteen minutes to get his history,
during all of which time he was responsive and interested, constantly
correcting statements of his father and volunteering other
information. Eleven days after the operation he was reported to have
had no more epileptic seizures. “Doesn’t talk in sleep. Doesn’t snore.
Doesn’t toss about the bed. Has more self-control. Tries to read the
paper. His immoderate appetite is not present.”

REASON ENOUGH FOR MOUTH BREATHING
Adenoid and tonsils reduced one third

While the open mouth is a sure sign of defects of breathing, it is not
true that the closed mouth, when awake and with other people, is proof
that there are no such defects. Children breathe through the mouth not
because they like to, not because they have drifted into bad habits,
not [50]because their parents did, not because the human race is
deteriorating, but because their noses are stopped up,—because they
must. A mouth breather is not only always taking unfiltered dirt germs
into his system but is always in the condition of a person who has
slept in a stuffy room. What extra effort adenoids mean can be
ascertained by closing the nostrils for a forenoon.

For many reasons it is perhaps unfortunate that we can breathe at all
when the nose is stopped up. If we could see with our ears as well as
with our eyes, we should probably not take as good care of our eyes.
In this respect the whole race has experienced the misfortune of the
man of whom the coroner reported, “Killed by falling too short a
distance.” Because we can breathe through the mouth we have neglected
for centuries the nasal passages. When a cold stops the nose we
necessarily breathe through the mouth. Unfortunately children make the
necessary effort required to breathe through the nose long before
other people notice the lines along the nose and the slow mind. Mouth
breathing will show with the child asleep, before the child awake
loses power to accommodate his effort to the task. Therefore the
importance of a physical test at school to detect the beginnings of
adenoids and large tonsils before these symptoms become obvious to
others.

No child should be exempted from this examination because of
apocryphal theories that only the poor, the slum child, the
refractory, or the unclean have defects in breathing. This very
afternoon a friend has told me of her year abroad with a girl of nine,
whose parents are very wealthy. The girl is anæmic. Her backwardness
humiliates her parents, especially because she gave great promise
until two years ago. High-priced physicians have prescribed for her.
It happens that they are too eminent to give attention to such simple
troubles as adenoids that [51]can be felt and seen. They are looking for
complications of the liver or inflammation of muscles at the base of
the brain. One celebrated French savant found the adenoids, assured
the mother that the child would outgrow them, and advised merely that
she be compelled to breathe through the nose. The mother and
nursemaids nag the child all day. The poor unwise mother sits up
nights to hold the child’s jaws tight in the hope that air coming
through the nose will absorb the adenoids. The mother is made nervous.
Of course this makes the child more nervous and adds to the evil
effects of adenoids. If the mother had the good fortune to be very
poor, she could not sit up nights, and would long ago have decided
either to let the child alone or else to have the trouble removed.

Adenoids are not a city specialty. Country earache is largely due to
adenoids or to inflammation that quickly leads to adenoids. In 415
villages of New York state twelve per cent were found to be mouth
breathers. For two summers I have known a lad named Fred. He lives at
the seashore. Throughout his twelve years he has lived in a veritable
El Dorado of health and nature beauty. Groves and dunes and flora vie
with the blues of ocean and sky in resting the eye and in filling the
soul with that harmony which is said to make for sound living. Yet to
a child, Fred’s schoolmates are experts on patent medicines and on the
heredity that is alleged to be responsible for bad temper, running
sores, tuberculosis, anæmia, and weak eyes. Freddie is particularly
favored. His well-to-do parents have supplied him with ponies, games,
and bicycles. Nothing prevents his breathing salt air fresh from the
north pole but hermetically sealed windows. The father thinks it
absurd to make a fuss over adenoids. Didn’t he have them when a boy,
and doesn’t he weigh two hundred pounds and “make good money”? The
mother never knew of operations for such trifles when [52]she taught
school; she supposes her boy needs an operation, but “just can’t bear
to see the dear child hurt.” As for Fred, he breathes through his
mouth, talks through his nose, grows indifferent to boy’s fun, fails
to earn promotion at school, and fears that “I won’t be strong in
spite of all the patent medicine I’ve taken.” Father, mother, and Fred
feel profound pity for the city child living so far from nature.

Adenoids are not monopolized by children whose parents are ignorant of
the importance of them and of physical examination. Last summer I was
asked by a small boy to buy some chocolate. A glance at his cigar box
with its two or three uninviting things for sale showed that the boy
was really begging. He had thick lips, open mouth, “misty” eyes, and a
nasal twang. I asked him if his teacher had not told him he had lumps
back of his nose and could not breathe right. He said, “No.” I
explained then that he could make a great deal more money if he talked
like other boys, stepped livelier, and breathed as other people
breathe. He said he had “been by a doctor onct but didn’t want to be
op’rated.” I turned to my companion and asked, “Have you never noted
those same lines on your boy’s face?” Although he had been lecturing
on mouth breathers, he had never noticed his own boy’s trouble. He
hastened home and found the infallible signs. The mother declared it
could not be true of her boy. About five months before, their family
physician had said of the child’s earache, “The same inflammation of
the nasal passages that causes earache causes adenoids; you must be on
the lookout.” Although in the country, the boy’s appetite was not good
and his zest for play had flagged. They had looked for the trouble to
back generations and in psychology books,—everywhere but at the boy’s
face, in his mouth, and in his nose. After the operation, which took
less than two minutes, the appetite was [53]ravenous, the eyes cleared,
and the spirit rebounded to its old buoyancy that craved worlds to
conquer.

The new personal experience made a deep impression upon my friend’s
mind. He wanted everybody to know how easy it was to overlook a
child’s distress. One person after another had a story to tell him;
even the janitor said: “You’d ought to have seen our John at sixteen.
He spent a week by the hospital.” The only people who do not seem to
know more than the new convert are the mouth breathers whom he
religiously stops on the street.

The indexes to adenoids and large tonsils for the teacher to read at
school are:

The adenoids and large tonsils discovered at school are an index:

The riot that occurred when the adenoids of children in a school on
the “East Side” in New York City were [54]removed without the preliminary
of convincing the parents as to the advantages of the operation was
merely a demand for the “right to knowledge,” which is never
overlooked with impunity. Reluctance to permit operation on a young
child, and the natural shrinking of a parent at seeing a child under
the surgeon’s knife, require the teacher or school physician or nurse
to answer fully the usual questions of the hesitant mother and father.

1. Is the operation necessary? Will the child not outgrow its
adenoids? Usually the adenoid growths atrophy or dry up after the age
of puberty. Adenoids are not uncommon in adults, however. The surgeon
general of the army reports that during the year 1905, out of 3004
operations on officers and enlisted men in service, there were 225
operations on the nose, mouth, and pharynx, 103 of which were
operations for adenoids and enlarged or hypertrophied tonsils.
Allowing the child to “outgrow” adenoids may mean not only that he is
being subjected to infection chronically but that his body is allowed
to be permanently deformed and his health endangered. Beginning at the
age of the second dentition, the bones of jaw, nose, throat, and chest
are undergoing important changes—nasal occlusion. Adenoids left to
atrophy—if large enough to cause mouth breathing—may mean atrophy of
this developing process, permanent disfiguration of face, and
permanent deformity of chest and lungs.

2. Will the growth recur? In a few cases it does recur; frequently
either because it was not desirable to make a complete removal of the
adenoid tissue or because the surgeon was careless. If the growths do
recur, then they must be removed again.

3. Is the operation a dangerous one?

4. Is an anæsthetic necessary?

5. Will the operation cure the child of all its troubles? These
questions are best answered by the process and [55]results of an “adenoid
party,” which was given especially for the benefit of this book, every
step and symptom of which were carefully studied.

The seven children pictured here were discovered by their school
physician to have moderately large adenoid growths,—one boy having
enlarged tonsils also.

MOUTH BREATHERS IMMEDIATELY AFTER “ADENOID PARTY”

The picture on page 46 was taken by flash light at 2.30 P.M.,
January 15, 1908. At 3 P.M. the principal escorted these
children into the operating room at Vanderbilt Clinic. The doctor
examined the throat and nose of each child, entered the name and age
of each, together with his diagnosis, on a clinic card, sending each
child into the next room after examination. He then called the first
boy and explained that it would hurt, but that it would be over in a
minute. The principal stood by and told him to be brave and remember
the five cents he could have for ice cream afterwards. The clinic
nurse tied a large towel about him and put him in her lap; with one
hand she held his clasped hands, while the other held his head back.
The doctor then took the little instrument—the curette—and pushed it
up back of the soft palate, and with one twist [56]brought out the
offending spongy lump. The boy’s head was immediately held over a
basin of running water. He was so occupied with spitting out the blood
that rushed down to choke him that he hadn’t time to cry before the
acute pain had ceased. The rush of cool air through his nostrils was
such a pleasurable sensation that he smiled as the school nurse
escorted him out into the hall to wait for his companions. At 3.30
P.M. all seven children were out in the hall, all seven
mouths were closed, and all seven faces were clothed with the sleepy,
peaceful expression that comes with rest from the prolonged labor of
trying to get enough air. At 3.45 P.M. they had been all
reëxamined by the doctor, and a few tag ends were picked out of the
nasopharynx of one child. At 4 P.M. the “party” had returned
to the Children’s Aid Society’s school and to the ice cream that
follows each adenoid party.

It is worth while to tell mothers stories of the “marvelous
improvement in school progress of those children whose brains have
been poisoned and starved by the accursed adenoid growths, and how
their bodies fairly bloom when the mysterious and awful incubus is
removed,” to use the words of one school principal. It is worth while
to show them “before” and “after” pictures, and “before” and “after”
children, and “before” and “after” school marks.

CHAPTER VIToC

CATCHING DISEASES, COLDS, DISEASED GLANDS

Deadly fevers, the plague, black death, cholera, malaria, smallpox,
taught mankind invaluable lessons. Millions of human beings died
before the mind of man devoted itself to preventing the diseases for
which no sure cure had been found. Efforts to conquer these diseases
were tardy because men were taught that some unseen power was
punishing men and governments for their sins. The difference between
the old and the new way is shown powerfully by a painting in the
Liverpool Gallery entitled “The Plague.” A mediæval village is strewn
with the dead and dying. Bloated, spotted faces look into the eyes of
ghouls as laces and jewelry are torn from bodies not yet cold. In the
foreground a muscular giant, paragon of conscious virtue, clad like
John the Baptist and Bible in hand, finds his way among his
plague-stricken fellow-townsmen, urging them to turn from their sins.
Modern efficiency learns of the first outbreak of the plague, isolates
the patient, kills rats and their fleas which spread the disease,
thoroughly cleanses or destroys, if necessary, all infected clothing,
bedding, floors, and walls, and makes it possible for us to go on
living for each other with a better chance of “bringing forth fruits
worthy for repentance.”

Where boards of health make it compulsory to report cases of sickness
due to contagion, health records are a reliable index to “catching”
diseases. But now that the chief infection is the kind that afflicts
children, we can read the index before the outbreak that calls in a
physician to diagnose the case. School examination shows which
[58]children have defects that welcome and encourage disease germs. It
points to homes that cultivate germs, and consequently menace other
homes. To locate children who have enlarged tonsils may prevent a
diphtheria epidemic. To detect in September those who are
undernourished, who have bad teeth, and who breathe through the mouth
will help forecast winter’s outbreaks of scarlet fever and measles.
One dollar spent at this season in examination for soil hospitable to
disease germs may save fifty dollars otherwise necessary for
inspection and cure of contagious diseases.

It is harder at first to interest a community in medical examination
than in medical inspection, because we are all afraid of “catching”
diseases, while few of us know how they originate and how they can be
prevented by correcting the unfavorable conditions which physical
examination of school children will bring to light.

Courses in germ sociology are therefore of prime necessity. How do
germs act? On what do they live? Why do they move from place to place?
What causes them to become extinct? With few exceptions, germs migrate
for the same reason as man,—search for food, love of conquest, and
love of adventure. When there is plenty of food they multiply rapidly.
Full of life, overflowing with vitality, they move out for new worlds
to conquer. Like human beings, they will do their best to get away
from a country that provides a scanty food supply. Like men and women,
they starve if they cannot eat. Like boys and girls, they avoid
enemies; the weak give way to the strong, the slow to the swift, the
devitalized to the vitalized.

Human sociology imprisons, puts to death, deprives of opportunity to
do evil, or reforms those who murder, steal, or slander. Germ
sociology teaches us to do the same with injurious germs. We imprison
them, we take away their food supply, we kill them outright, or we
starve them slowly. They have a peculiar diet, being especially
[59]partial to decomposing vegetable and animal matter and to what human
beings call dirt. By putting this diet out of their reach we make it
impossible for them to propagate their kind. By placing poison within
their reach or by forcing it upon them we can successfully eliminate
them as enemies. As the president of Mexico restored order “by setting
a thief to catch a thief,” so modern science is setting germs to kill
germs that harm crops and human stock. Of utmost consequence is it
that the body’s germ consumer—its pretorian guard—be always armed
with vitality ready to vanquish every intruding hostile germ. If we
are false to our guard, it will turn traitor and join invaders in
attacking us. But here, as in dealing with evils that originate with
human beings, an ounce of prevention is worth a ton of cure. The most
effectual way to eliminate germ diseases is to remove the cause—the
food supply of disease germs. The fact that many germs are plants, not
animals, does not weaken the analogy, for weeds do not get a chance in
well-tilled soil.

Perhaps the most notable recent example of government germ
extermination is the triumph over the yellow-fever and malaria
mosquito in Panama. When the French started to build a canal in
Panama, the first thing they did was to build a hospital. The hospital
was always full and the canal was given up. At the time the United
States proposed to re-attempt the work, it was thought that it could
not be done without great loss of life and without great labor
difficulties. Instead of taking the sickness for granted and enlarging
the French hospital, the chief medical inspector, Gorgas, took for
granted that there need be no unusual sickness if proper preventive
measures were taken. He knew what the French had not known, that the
yellow-fever scourge depends for its terrors upon mosquitoes.
Accordingly, with the aid of six thousand men and five million dollars
he set about to starve [60]out the few infected and infectious kinds of
mosquito,—the yellow-fever or house mosquito and the malaria or
meadow mosquito. He introduced waterworks and hydrants, paved the
streets, drained the swamps and pools in which they breed, and
instituted a weekly house-to-house inspection to prevent even so much
as a pail of stagnant water offering harbor to these enemies. The
grass of the meadows where the malaria mosquito breeds was cut short
and kept short within three hundred feet of dwellers,—as far as the
mosquito can fly. All ditches were disinfected with paraffin, and the
natives were forced to observe sanitary laws. President Roosevelt, in
his special message to Congress on the Panama Canal in 1906, stated
that in the weekly house-to-house visit of the inspectors at the time
he was in Panama but two mosquitoes were found. These were not of the
dangerous type. As a consequence of this sanitary engineering there is
very little sickness in Panama, the hospital is seldom one third full,
and the canal is progressing very much faster than was expected.
Panama, like Havana, is now safer than many American cities, because
cleaner and less hospitable to disease germs.

Any place where numbers of people are accustomed to assemble favors
the propagation of germs,—whether it be the meetinghouse, the
townhall, the theater, or the school. Every teacher can be the
sanitary engineer of her own schoolroom, school, or community by
coöperating with the school doctor, the town board of health, family
physicians, and mothers. Every teacher can exterminate disease by
applying the very same principles to her schoolroom as Chief Medical
Inspector Gorgas applied to Panama. Knowledge, disinfection, absolute
cleanliness, education, and inspection are the essential steps. First
she must know that “children’s diseases” are not necessary. She should
discountenance the old superstition that every child [61]must run the
gamut of children’s diseases, that every child must sooner or later
have whooping cough, measles, chicken pox, mumps, scarlet fever, just
as they used to think yellow fever and cholera inevitable. The price
of this terrible ignorance has been not only expense, loss of time,
acquisition of permanent physical defects, and loss of vitality, but,
for the majority of children, death before reaching five years of age.
All these “catching” diseases are germ diseases, which disinfection
can eliminate. The free use of strong yellow soap and disinfectants on
the school floor, windows, benches, desks, blackboards, pencils, in
the coat closets and toilets, plus the natural disinfectants, hot sun
and oxygen, will prevent the schoolroom from being a source of danger.
One or more of these germ-killing remedies must be constantly applied;
cleansing deserves a larger part in every school budget.

Often country towns are as ignorant of the existence of germs and of
the means of preventing the spread of disease as the woman in a small
country town who used daily to astound the neighbors by the “shower of
snow” she produced by shaking the bedding of her sick child out of the
window. Their astonishment was soon changed to panic when that shower
of snow resulted in a deadly epidemic of scarlet fever. Medical
inspection of New York City’s schools was begun after an epidemic of
scarlet fever was traced to a popular boy who passed around among his
schoolmates long rolls of skin from his fingers.

Much of the care exercised at school to prevent children’s diseases is
counteracted because children are exposed at home and in public places
to contagion, where ignorance more often than carelessness is the
cause of uncleanliness. By hygiene lessons, illustrating practically
the proper methods of cleaning a room, much may be done to enlist
school children in the battle against germs. Through the enthusiasm of
the children as well as through [62]visits to the homes parents may be
instructed as to the danger of letting well children sleep with sick
children; the wisdom of vaccination to prevent smallpox, of antitoxin
to prevent serious diphtheria, of tuberculin tests to settle the
question whether tuberculosis is present; why anything that gathers
dust is dangerous unless cleansed and aired properly; and why bedding,
furniture, floor coverings, and curtains that can be cleansed and
aired are more beautiful and more safe than carpets, feather beds,
upholstery, and curtains that are spoiled by water and sunshine; how
to care for the tuberculous member of the family, etc. Anti-social
acts may be prevented, such as carrying an infected child to the
doctor in a public conveyance, thereby infecting numberless other
people; sending infected linen to a common laundry; mailing a letter
written by an infected person without first disinfecting it; sending a
child with diphtheria to the store; returning to the dairy unscalded
milk bottles from a sick room.

The daily inspection of school children for contagious diseases by the
school physician has, where tried, been found to reduce considerably
the amount of sickness in a town. Such inspection should be
universally adopted. Moreover, the teacher should be conversant with
the early symptoms of these diseases so that on the slightest
suspicion the child may be sent home without waiting for the
physician’s call. Like the little girl who never stuttered except when
she talked, school children and school-teachers are rarely frightened
until too late to prevent trouble. The “easy” diseases such as
measles, whooping cough, etc., cost our communities more than the more
terrible diseases like typhoid and smallpox. During one typical week
ending May 18, 630 new cases of measles were reported to one
department of health. Obviously the nineteen deaths reported give no
conception of the suffering, the cost, the anxiety caused by this
preventable disease. The same [63]may be said of diphtheria and croup, of
which only thirty-two deaths are reported, but 306 cases of sickness.
Yet no one to-day will send a child to sleep with a playmate so as to
catch diphtheria and “be done with it.”

The most strategic point of attack is almost universally unrecognized.
That is the child’s mouth. Here the germs find lodgment, here they
find a culture medium—at the gateway of the human system. The mouth
is never out of service and is almost never in a state of true
cleanliness. Solid particles from the breath, saliva, food between the
teeth, and other débris form a deposit on the teeth and decompose in a
constant temperature of ninety-eight degrees Fahrenheit. In the normal
mouth from eight to twenty years of age the teeth present from twenty
to thirty square inches of dentate surface, constantly exposed to
ever-changing, often inimical, conditions. This bacterially infected
surface makes a fairly large garden plot. Every cavity adds to the
germ-nourishing soil. Dental caries—tooth decay—is a disease
hitherto almost universal from birth to death. Thus the air taken in
through the mouth becomes a purveyor of its poisonous emanations and
affects the lung tissues and the blood. Food and water carry hostile
germs down into the stomach. Thence they may be carried into any organ
or tissue, just as nourishment or poison is carried.

Moreover, the child with an unclean mouth not only infects and
reinfects himself but scatters germs in the air whenever he sneezes or
coughs. In a cold apartment where there is no appreciable current of
air a person can scatter germs for a distance of more than twenty-two
feet. Germs are also scattered through the air by means of salivary or
mucous droplets. It is this fact that makes colds so dangerous.

Table VIII

City of Manchester Education Committee

INFECTIOUS OR CONTAGIOUS DISEASES IN SCHOOLS INFORMATION FOR
TEACHERS

In the following diseases only the affected child is excluded

[66]Most people still think that colds are due to cold air or draughts
rather than to a cold germ, which finds a body unequipped with
resisting power, with its germ police off guard, exhausted from
overwork, or disaffected and ready to turn traitor if the enemy seems
stronger than our vitality. Sometimes it seems as if we contracted it
from a sneezing fellow-passenger, sometimes from a draught from an
open car window. An uninformed opponent of the theory that colds are a
germ disease wrote the following letter last winter to a New York
newspaper:

After the correspondent has learned that our ancestors had more colds
than we, had poorer health, and died twenty years younger, perhaps he
will listen to proof that his unclean warm air weakens the body and
makes it an easy prey to cold germs.

Many physicians preach and practice this fallacy as to fresh air and
colds, but few physicians now deny that influenza is a germ disease or
that a nose so irritated and so neglected as to secrete large
quantities of mucus is a better place for breeding disease germs than
a nose whose membranes are clean and not thus irritated.

[67]Until medical specialists are agreed, and until they have definitely
located the cold germ, we laymen must choose for ourselves a working
theory. The weight of opinion at the present time declares that colds
are due to germs. Strong membranes with good circulation and drainage
provide poor food for germs. Congested membranes furnish proper
conditions for propagation. The germ theory explains the spread of
germs from the nose to the passages of the head, and from head to
arteries and lungs.

A cold can always be charged to some one else. How many can be laid to
our account? There is one right that is universally not recognized,
and that is the right of protection from the germs showered in the air
we breathe, over the food we eat, by the sneezes of our unfortunate
neighbor at school, in the street car, at the restaurant. The chief
danger of a cold is to our neighbor, not to ourselves. A cold which a
strong person may throw off in a day or two may mean death to his
tuberculous neighbor. Though for our own health “lying up for a mere
cold” is an unnecessary bore, the failure to do so may deprive our
neighbor of a right greater than the right to protection against
scarlet fever or smallpox. Though formerly this statement would [68]not
have been true, rights change with conditions, and the fact that
to-day the three most deadly diseases are pneumonia, tuberculosis, and
diphtheria,—all diseases of the respiratory organs,—justifies the
assertion that we have a right to protection against colds. The
prevalence of colds, sore throats, irritated vocal cords, bad voices,
catarrh, bronchitis, laryngitis, and asthma in America to-day demands
summary measures. One can learn to sneeze into a handkerchief, not
into a companion’s face or into a room. School children can be taught
to avoid handkerchiefs on which mucus has dried. In the far distant
future we may be willing to use cheesecloth, and boil it or throw it
away, or, like the Japanese, use soft paper handkerchiefs and burn
them after using.

Table IX

Death Rate per 10,000 Population, Pneumonia and Bronchitis
Five-Year Period, 1896-1900

One child with a cold can infect a whole class or family, thus
depriving the class and family of the top of their vitality and
efficiency without their consent. Because a person is thought a
weakling who lies up for a “mere cold,” one is inclined to wish that
colds were as prostrating as typhoid, in which case there would be
some hope of their extermination.

The exclusion of children with colds from school deserves trial as a
check to children’s diseases. Many of these “catching” diseases start
with a cold in the head, as, for instance, measles, influenza, and
whooping cough. The first symptom of mumps, diphtheria, and scarlet
fever is a sore throat or swollen glands, which, because they commonly
accompany a cold, are not at first distinguished from it.

The first step for the teacher or mother in reading the index for
colds is to look into the coat closet for evidence of warm clothing
and overshoes, then to note whether the children put them on when they
go out for lunch or recess. Whether “cold” settles in the nasal
passages, ear, or stomach depends upon which is the weak spot.
Draughts, [69]thin soles, wet soles, exposure when perspiring, may be the
immediate cause of the nutritional or respiratory disturbances that
give cold germs a foothold. Adenoids, diseased teeth, inflamed ears,
may furnish the food supply. “There is no use treating children and
sending them on fresh-air trips as long as they have nutritional and
digestive disturbances due to bad teeth, or colds due to adenoids,”
said a physician when examining a party of children for a summer
outing. The great preventive measure to be taken for catching
diseases, colds, diseased glands,—in fact all germ diseases,—is the
repeated cleansing of those portions of the human body in which germs
may find lodgment,—the mouth, the nose, the eyes, and the ears.

In caring for young infants great pains is taken to cleanse all the
orifices daily, but as soon as the child washes himself this practice
is usually abandoned. Washing these gateways is far more important
than washing the surface of the body through which germs could not
possibly gain entrance into the system except through wounds.
Oftentimes the douching of the nostrils with salt water will stop a
cold at once. The mouth is the most important place of all, and the
teacher should take care of her pupils’ mouths first and foremost. As
bad teeth, enlarged tonsils, and adenoids harbor germs and putrescent
matter that vitiate every incoming and outgoing breath, these defects
should be immediately corrected. Are we coming to a time when a
thorough house-cleaning in the mouth of every child will take place
before he enters the schoolroom, preferably in the presence of the
teacher?

Two other “catching” diseases cause city schools a great deal of
trouble,—trachoma and pediculosis (head lice). There are probably no
two diseases more quickly transmitted from one person to another.
Almost before their presence is known, all children of a school or
all [70]persons of a group have contracted them. When at college twenty
men of my fraternity discovered almost at the same time that they had
an infectious eye trouble; yet we thought we were using different
towels and otherwise taking sanitary precautions. Last summer a Vassar
graduate took a party of tenement children for a country picnic. She
returned with head lice that required constant attention for weeks.
What then may we expect of children who live in homes where there is
neither water, time, nor privacy for bathing, where one towel must
serve a family of six, where mothers work for wages away from home and
see their children only before seven and after six?

Unfortunately for thousands of children, many parents still believe
these troubles will be outgrown. Last summer a fresh-air agency in New
York City arranged for several hundred school girls to go to a certain
camp for ten days each. The only condition was that the heads should
be free from lice and nits (eggs). From the list furnished by
school-teachers—girls supposed to have been cured by school
nurses—not one in five was accepted. A baby two weeks old, brought to
Caroline Rest, had already begun to suffer from this easily
preventable scourge. Of 1219 children examined in Edinburgh, Scotland,
909, or 69 per cent, had some skin disease, and 60 per cent had sores
due to head lice. Even when neglect has caused the loss of hair and
ugly sores on the head, mothers deceive themselves into believing that
some other cause is responsible.

Trachoma, if neglected, not only impairs the health of the eye, but
may cause blindness. Tears carry the germs from the eye to the face,
where they are taken up on handkerchiefs, towels, and fingers and
infect other eyes. Of late, thanks to school nurses and physicians and
hygiene instruction, American cities have found relatively little
trachoma except among recent immigrants. So dangerous is the germ and
so insidious its methods of propagation, [71]that a physician should be
summoned at once at the first sign of inflammation. Conjunctivitis is
due to a germ, and will spread unless checked. Since the board of
health of New York City has instituted the systematic examination of
the eyes of the children in the public schools, it has found fully one
third affected with some form of conjunctivitis. Many of these cases
are out-and-out trachoma, others acute conjunctivitis, and a larger
proportion are “mild trachoma.” This last form of the disease is found
to a great extent among children who have adenoids. The adenoids
should be regarded as a predisposing factor rather than a direct
cause. Therefore sore eyes are given as one of the indexes of
adenoids. When we consider that adenoids are made up of lymphoid
material, and that trachoma follicles are made up of the same sort of
tissue, it is not surprising that the two conditions are found in the
same child. The catarrhal inflammation produced by adenoids in the
nasal mucous membrane travels up the lachrymal duct and thus infects
the conjunctiva by contiguity.

In preventing pediculosis and infection of the eye vigilance and
cleanliness are indispensable. After the diseases are advanced, after
the germ colonies have taken title, some antiseptic or germ killer
more violent than water is needed,—kerosene for the hair or strong
green oil soap; for the eye, only what a physician prescribes.

CHAPTER VIIToC

EYE STRAIN

Wherever school children’s eyes have been examined, from six to nine
out of thirty are found to be nearsighted, farsighted, or otherwise in
need of attention. A child is dismissed from school for obstinately
declaring that the letter between c and t in “cat” is an o; “a
pupil in her fourth school year was recently brought to me by her
teacher with the statement that she did unreasonably poor work in
reading for an intelligent and willing child;” a boy is punished for
being backward. These three cases are typical. Examinations showed
that the first child was astigmatic and not obstinate; the boy had run
a pin into one eye ten years before and destroyed its sight; while the
second girl was found to be afflicted with diplopia, and in a friendly
chat told the following story: “I very often see two words where there
is only one. When I was a very little girl I used to write every word
twice. Then I was scolded for being careless. So I learned that I
must not say two words even when I saw them.” As Miss Alida S.
Williams, principal of Public School 33 in New York City, has in many
articles and addresses freely illustrated from school experience, the
art of seeing is acquired, not congenital, and every human being who
possesses it has learned it.

The large proportion of children suffering more or less seriously from
eye trouble has led many persons to suggest physical deterioration as
the cause. Eye specialists, however, assure us that eye troubles are
probably as old as man. Our tardiness in learning the facts regarding
these [73]troubles is due in part to the lack, until recently, of
instruments for examining the eye and for manufacturing glasses to
correct eye defects; in part, also, to the tendency of the medical
profession, which I shall repeatedly mention, to explain disorders by
causes remote and hard to find rather than by those near at hand.

About 1870 Dr. S. Weir Mitchell’s attention was called “to the marked
relief of headache, insomnia, and other reflex symptoms following the
correction of optical defects by glasses.” In 1874 and 1876 he wrote
two articles that “impressed upon the general profession the grave
significance of eye strain.” Since that time, “in Philadelphia at
least, no study of the rebellious cause of headache or of the obscure
nervous diseases has ever been considered complete until a careful
examination of the eyes has included them as a possible cause of the
disturbance.”

The new fact, therefore, is not weak eyes or strained eyes, but rather
(1) an increase in the regular misuse of eyes by school children,
seamstresses, stenographers, lawyers, etc.; and (2) the incipient
propaganda growing out of school tests that show the relation of eye
strain to headache, nervous diseases, stomach disorder, truancy,
backwardness.

Every school, private and parochial as well as public, should supply
itself with the Snellen card for testing eyes. Employers would do well
to have these cards in evidence also, for they may greatly increase
profits by decreasing inefficiency and risks. If there is no expert
optician near, apply for cards to your health board or school board;
failing there, write to your state health and school boards. In many
states rural teachers are already supplied with these cards by state
boards. In October, 1907, the New York state board of health sent out
cards, with instructions for their use, to 446 incorporated towns. The
state commissioner of education also sent a letter giving school
reasons for using the cards. Results from 415 schools having [74]shown
that nearly half the children had optical defects, it is proposed to
secure state legislation that will make eye tests obligatory in all
schools. Such a test in Massachusetts recently discovered twenty-two
per cent of the school children with defective vision, and from forty
to fifty thousand in need of immediate care by specialists.

POSITIONS OFTEN SUGGEST EYE STRAIN

Of course eye specialists,—oculists,—if skillful, know more about
eyes and eye troubles than general medical practitioners or teachers.
Preliminary eye tests, however, may be made by any accurate person who
can read. The Massachusetts state board of health reports that tests
made by teachers were “not less efficient” than tests made by
specialists. In June, 1907, a group of eminent oculists recommended to
the school board of New York [75]City that teachers make this first test
after being instructed by oculists. Persons interested in the schools
nearest them can quickly interest teachers and pupils by starting
tests with this card. In cities oculists can be found who will be glad
to explain to teachers, individually or in groups, how the cards
should be used and what dangers to avoid.

Nature intended the human eye to read the last line of this card at a
distance of ten feet. This conclusion is not a guess, but is based
upon the examination of thousands of eyes. In making the test, the
number of feet the eye ought to see is written as the denominator of
the fraction; the distance the eye can see clearly is the numerator.
If the child’s card reads, “Right eye 10/10, left eye 10/20,” it means
that the right eye sees without conscious strain the distance it is
intended to see, while the left eye must be within ten feet to see
what it ought to see twenty feet away.

The practical steps for a teacher to take in making eye tests are:

The limits of the card test must be constantly kept in mind: (1) it
does not register eye sickness due to dust, smoke, or disease germs;
(2) it does not show unconscious eye strain due to successful
accommodation. But it will discover a great part of the children who
most need care. Sooner or later, too, inflammation of the eyelids, due
to external causes, will affect the nerves of the eye and their power
to conceal by accommodation the eye’s defects. Just as we
unconsciously open the mouth when a cold stops up the nose, the eye
adapts itself to our needs without our realizing it. We expect it to
see. It sees. If our eyes are not made alike, they do their best to
work together. Like a good team of horses, the slow one hurries, the
fast one holds back a little. But if one eye is 10/15 and the other
10/10, they will both be unnatural and strained if both read the same
type. The effects of this strain frequently upset the stomach before
the eyes rebel. I learned that I needed eyeglasses after a case of
protracted indigestion, first diagnosed as “nervous” and later traced
to eyes. Thousands of upper-grade children and college students are
dieting for stomach trouble that will last until the eyes are relieved
of the undue and unrecognized strain. [78]To prove the influence of eye
strain on indigestion, persuade some obstinate parent to wear
improperly focused glasses for a day; she will then be willing to have
her child’s eyes attended to.

It is unfortunate that the eyes will overwork without protesting. For
years many persons suffer without learning that their eyes are unlike,
or, as often happens, that one eye does all the close range work. Even
when being tested, eyes will seem to see easily what requires a great
effort of “accommodation.” To prevent this self-deception skilled
oculists do not trust the eye card, but put a drug in the eye that
benumbs the muscles of accommodation. They cannot contract or expand
if they want to. The oculist then studies the length of the eye and
the muscle of accommodation. With this absolute knowledge of how each
eye is made he knows what is wrong, exactly at what angle light enters
the eye, whether objects are focused too soon or too late, exactly
what kind of eyeglasses or what operation upon the eye is needed to
enable it to do its work without undue straining or accommodation. So
unconsciously do the eyes accommodate themselves to the work expected
of them that not infrequently a child with seemingly perfect sight may
be more in need of glasses than the child with imperfect sight.
Practically, however, it is out of the question at the present time to
have the majority of children given a more thorough test than that
provided by the Snellen card. Where eye strains escape this test
teachers will find evidence in complaints of headache, nervousness,
sick stomach, chorea, or even epilepsy. The constant strain may also
cause red or inflamed lids. Parents and teachers must be on the
constant lookout for these symptoms of good sight persisting in spite
of imperfect eyes.

An epidemic of eyeglasses is usually the consequence of eye tests. So
naturally do we associate eyeglasses with [79]eye defects that some
people assert that the eye tests at school originate with opticians
more intent upon selling spectacles than upon helping children. In
fact, even among educators who proclaim the need for eye tests there
has been far more talk of eyeglasses than of removable conditions that
cause eye strain. The women principals of New York City have sounded
an alarm, and urge more attention to light and to reading position,
more rest, more play, more hand work, less home study and less eye
work at school, rather than more eyeglasses to conceal temporarily the
effect of abusing children’s eyes. Putting glasses on children without
changing causal conditions is like giving alcohol to consumptives. The
feeling of relief is deceptive. The trouble grows worse.

For some time to come eye tests will find eye troubles by the
wholesale in every industrial and social class, in country as well as
city schools. In 415 New York villages 48.7 per cent of school
children had defects of vision,—this without testing children under
seven,—while 11.3 per cent had sore eyes.

There are three possible ways of remedying defects: (1) changing the
eye by operation; (2) changing the light as it enters the eye by
eyeglasses; (3) decreasing the demands made upon the eye. To change
eyes or light requires a technical skill which few physicians as yet
possess. It will be remembered that it is but thirty years since the
medical profession in America first began to understand the relation
of eye defects to other defects. Until a generation of physicians has
been trained by medical colleges to learn the facts about the eye and
to apply scientific remedies, it is especially necessary that teachers
and parents reduce the demands made upon children’s eyes; oral can be
substituted for written work, manual for optical work, relaxed and
natural movement for discipline, outdoor exercise for less home study.
Other requirements are [80]suitable light and proper position, and
abolition of shiny paper, shiny blackboard, and fine print. Even after
it is easy to obtain the correction of eye defects it will still be
necessary to adapt the demands upon children’s eyes to the strength
and shape of those eyes. Because we are born farsighted, nearsighted,
and astigmatic, we must be watchful to eradicate conditions that
aggravate these troubles. Finally, there is no excuse whatever for
permitting the parent of any school child in the United States to
remain ignorant of the fact that it is just as absurd to go to the
druggist or jeweler for eyeglasses as to the hardware store for false
teeth.

The education of physician, oculist, and optician can be expedited by
eye tests in school and by the follow-up work of schools in removing
the prejudice of parents against glasses when needed. Because
knowledge of chemistry preceded knowledge of the human body, the
teaching of medicine still shows the effect of predilection for the
remote, the problematical, the impossible. This predilection has
influenced many specialists as well as many general practitioners,
both overlooking too frequently obvious causes that even intelligent
laymen can be taught to detect. Very naturally the man who makes money
out of attention to simple troubles has stepped into the field not as
yet occupied by the general practitioner and the specialist. Thus we
have the optician, the painless tooth extractor, and quack cures for
consumption. Opticians are placing before hundreds of thousands simple
truths about the eye not otherwise taught as yet. Because they make
their money by selling eyeglasses and because their special knowledge
pertains to glasses rather than to eyes they frequently fail to
recognize their limitations.

Physicians feel very strongly that it is as unethical for an optician
to fit eyeglasses without a physician’s prescription as for a
pharmacist to give drugs without a physician’s [81]prescription. The
justification for this feeling should be based not upon the commercial
motive of the optician but upon his ignorance. A physician uninformed
as to eye troubles is just as unsafe as an optician determined to sell
glasses. It must be made unethical and unprofessional for physician
and optician alike to prescribe in the dark. Laymen and physicians
must be taught that it is just as unethical and unprofessional for
oculists and physicians to fail to bring their knowledge within the
practical reach of the masses as for the optician to advertise his
wares. School tests will not have been used to their utmost
possibilities until optician and physician alike take the ethical
position that the first consideration is the patient’s welfare, not
their own profits. It must soon be recognized as unethical and
unprofessional for an optician who is also a skilled physician to
refer patients to a medical practitioner ignorant as to optical
science.

Whether opticians and physicians are unprofessional or unethical may
be told by reëxamination if the examiner is himself competent and
ethical. There is no better judge of their efficiency than the patient
himself, who can tell whether the results promised have been effected.
Whether the work of a country oculist is efficient and ethical can be
learned: (1) by teaching country school children to recognize eye
strain; (2) by comparing his results with those of other physicians.
As soon as one or two states have tested eyes, we shall have an
average by which to compare each class, school, and city with others
of their size under similar conditions. If a particular physician
finds half as many more or only half the average number, the
presumption will be that his results are inaccurate and warrant an
investigation. The interested teacher or parent can render an
inestimable service to her local school and to the children of her
state by taking steps to secure state laws compelling eye tests in all
schools.

[82]Finally, it must be remembered by teachers, employers, parents, and
all eye users that eyes are constantly changing; that eyes may need
glasses six months after they are examined and found sound; that
glasses change or develop the eye, so that they may be unnecessary and
harmful six months after they are prescribed, or the eye may require a
stronger glass; that eyeglasses become bent and scratched, so that
they worry and strain the eye; that a periodic examination is
essential to the health of the eye.

In caring for the health of the eye, we should also remember that our
eyes are our chief interpreters of the world that gives us problems,
profits, and pleasures. Out of gratitude, if not out of enlightened
self-interest, we owe our eyes protection, attention, and training, so
that without straining we shall always be able to see truth and
beauty.

CHAPTER VIIIToC

EAR TROUBLE, MALNUTRITION, DEFORMITIES

The presence of adenoids is a frequent cause of both slight and
aggravated deafness. Of 156 deaf mutes examined 59 per cent had
adenoids, while only 6 per cent of the general run of the children in
the neighborhood had this trouble. In mouth breathing, the current of
air entering the mouth draws out some of the air from the Eustachian
tube which ventilates the middle ear and unequalizes the atmospheric
pressure on the eardrum, causing it to sink in and to blunt the
hearing. An examination of the eardrums of school children in New York
who are mouth breathers showed a high percentage of deafness,
incipient or pronounced, accompanying adenoids. For example, of 9
mouth breathers selected from one class (average age 7-8 years), 6
were well-marked cases of deafness. Of 8 mouth breathers (average age
8-9 years), and of 5 mouth breathers (average age 5-6 years), all had
noticeable defects of hearing. Many adults that suffer from deafness
maintain that they never had any trouble in childhood. Yet the
evidences of nose and throat trouble in childhood persist and disprove
such statements. The foundations of deafness in later life are, in
most instances, laid in childhood. Since the majority of cases of ear
trouble occurring in school children accompany diseased conditions of
the nose and throat, the proper care of nose and throat will, in large
measure, balance the shortcomings of the aural examinations. Since the
examination of the drum itself is not practicable, especial care
should be given to the examination of the nose and throat.

[84]The figures published by New York City’s department of health show
that of 274,641 children examined from March, 1905, to January, 1908,
3540, or 1.2 per cent, gave evidence of defective hearing. Ear
specialists suggest that this small percentage results from employing
the whisper test at twenty feet. The whisper test at sixty feet has
been set by experts as a test of normal hearing. But preciseness with
this test is well-nigh impossible when we consider that the acoustics,
the quality of the examiner’s voice, the weather, the vowel or
consonant sounds, all are variable quantities. The watch test is
frequently used, but since a young teacher in her enthusiasm used an
alarm clock to make the test, specialists have decided that the volume
of sound differs in watches to such a degree as to make the watch test
unreliable. The examination of the eye has been reduced to
mathematical precision, due altogether to the anatomy of that organ.
As yet there is no instrument for the ear comparable to the
ophthalmoscope. The acoumeter is largely used by aurists and can be
obtained from the optician. This instrument has an advantage over the
whisper or watch tests in that its tick is uniform.

Each ear should be tested separately. Let the child place his finger
against the flap of one ear while the other is being tested. Then
compare the farthest distance from the ear at which the tick can be
heard with the normal, standard distance. During the test all sound
should be eliminated as far as possible and the eyes should be closed.
At a demonstration of ear testing at Teachers College, one student
stated that she could not hear the tick of the watch at a distance
greater than twenty inches. Then the tester walked noisily toward her,
leaving the watch on the desk, five feet away from the patient. She
heard it now. When the class burst out laughing she opened her eyes,
and, seeing the watch so far away, exclaimed, “Why, [85]I thought I
imagined it.” Be careful in testing a child to distinguish between
what he “thinks he imagines” and what he really hears. Because of the
difficulties of this test a doubt should be sufficient to warn the
teacher to send the child to be tested by an expert. Detection of
slight deafness may lead to the discovery of serious defects of nose
or throat. Inflammation from cold or catarrh may cause deafness, which
if neglected may permanently injure the ear. Often deafness is due to
an accumulation of wax. A running ear should receive immediate
attention, as it is an indication of inflammation which may imperil
the integrity of the eardrum, and, if neglected, may eat its way
through the thin partition between the ear and the brain and cause
death.

It should never be assumed that deafness is incurable. Stupidity,
inattention, and slowness to grasp a situation accompany difficulty of
hearing and should cause the teacher to examine the ears. No ear
trouble is negligible. Children and parents should be taught that the
normal ear is intended to hear for us, not to divert our attention to
itself. When the ear aches or “runs” or rumbles there is something
wrong, and it should be examined together with the throat and nose.

Nervousness

In New York City one child in ninety-one already examined has had the
form of nervous disease known as St. Vitus’s Dance, or chorea. So
prone are we to overlook moderate evils and moderate needs that the
child with aggravated St. Vitus’s Dance is apt to be cured sooner than
the child who is just “nervous.” Teachers cannot know whether
twitching eyes, emotional storms, constant motion of the fingers or
feet are due to chorea, to malnutrition, to eye strain, or to habits
acquired in babyhood or early childhood and continued for the
advantage that [86]accrues when discipline impends. Many a child
treasures as his chief asset in time of trouble the ability to lose
his temper, to have a “fit,” to exhibit nervousness that frightens
parent, teacher, or playmate, incites their pity, and wards off
punishment. The school examination will settle once for all whether
the trouble can be cured. The family physician will explain what steps
to take.

Tests of Malnutrition

We Americans were first interested in the physical examination of
school children by exaggerated estimates of the number of children who
are underfed. As fast as figures were obtained for eye defects,
breathing defects, bad teeth, some one was ready to declare that these
were results of underfeeding. Hence the conclusion: give children at
least one meal a day at school. Scientific men began to set us
straight and to give undernourishment a technical meaning,—soft
bones, flabby tissue, under size, anæmia. While too little food might
cause this condition, it was also explained that too much food of the
wrong sort, or even food of the right sort eaten irregularly or
hurriedly or poisoned by bad teeth, might also cause undernourishment,
including the extreme type known as malnutrition. In extreme instances
the symptoms enable an observant teacher who has learned to
distinguish between the pretty hair ribbon and clean collar and the
sunken, pale, or hectic cheek and lusterless eyes to detect the cause.
But as with eyes and nose, an unhealthy condition [87]of nourishment may
exist long before outward symptoms are noticeable. Therefore the value
of the periodic searching examination by the school physician.

SAME AGE, SAME SCHOOL, DIFFERENT NUTRITION

Bone Tuberculosis; Orthopedic Tests

Only recently have we laymen learned that knee trouble, clubfoot,
ankle sores, spine and hip troubles, scrofula, running sores at
joints, etc., are not hereditary and inevitable, but are rather the
direct result of carelessness on the part of adult consumptives. These
conditions in school are indices of homes and houses where
tuberculosis is or has been active, and of health boards that are or
have been inactive in checking the white plague. Early examination may
disclose the small lump on the child’s spine,—which one mother
diagnosed as inherited “round shoulders,”—and save a child from being
a humpback for life. Moreover, the examination of the crippled child’s
brothers and sisters will often show the beginnings of pulmonary
tuberculosis.

A GRIEVOUS PENALTY FOR NEGLECT BY ADULT CONSUMPTIVES

Enlarged Glands—Tuberculosis

In almost every class are one or more children who are proud of small
or big lumps under one or more jaws. Only physicians can find very
small lumps. Many family doctors will say, “Oh, he will outgrow
those,” or “Those lumps will be absorbed.” Like most other evils that
we “outgrow” or that pass away, these lumps shriek not to be
neglected. They mean interference with nourishment and prevent proper
action of the lymphatic system, as adenoids prevent free breathing.
Even when not actually infected with tubercle bacilli, they are
fertile soil for the production of these germs. If detected early,
they point to home conditions and personal habits that can be easily
corrected. In New York one child in four has these enlarged glands. If
the same proportion prevails in other parts of the United States,
there are 5,400,000 children whose strength is being needlessly
drained, many of whom, if neglected, will need repeated operations.

MODEL OF AMERICA’S FIRST HOSPITAL FOR SEASHORE FRESH-AIR
TREATMENT OF NONPULMONARY TUBERCULOSIS IN CHILDREN
To be erected at Rockaway Beach, New York City

CHAPTER IXToC

DENTAL SANITATION

“Have their teeth attended to first, and many of the eye defects will
disappear.” This was an unexpected contribution to the debate upon
free eyeglasses for the school children of New York City. So little do
most of us realize the importance of sound, clean teeth, and the
interrelation of stomach and sense nerves, that even the school
principals thought the eye specialist was exaggerating when he
declared that bad teeth cause indigestion and indigestion causes eye
strain.

“Bad” teeth mean to most people dirty teeth and offensive odors,
loose, crooked, or isolated teeth, or black stumps. Even among
dentists a great many, probably the majority, do not appreciate that
“bad” teeth mean indigestion, lowered vitality, plague spots for
contaminating sound teeth and for breeding disease germs. Until
recently the only rule about the teeth of new recruits in the United
States army was: “There must be two opposing molars on each side of
the mouth. It doesn’t matter how rotten these molars may be.” The
surgeon general was persuaded to change to “four opposing molars on
each side”; still nothing as to the condition of the two additional
molars! In the German army there is a regular morning inspection of
teeth and toothbrushes. Several German insurance companies give free
dental treatment to policy holders, not to bestow charity but to
increase profits.

Neglecting “baby teeth” and adenoids may mean crooked second teeth
that will cause: (1) hundreds of dollars for straightening; (2)
permanent business handicap because crooked teeth are disagreeable to
others, because mastication [90]is less perfect, and because a disfigured
mouth means dis-arranged nerves; or perhaps (3) large dental bills
because it is difficult to clean between cramped, crooked teeth.

Unfortunately the great majority of parents rarely think of their
children’s teeth until too late to preserve them intact. Even among
families where the rule of brushing the teeth twice daily prevails,
regular dental examination is often not required. Doctors and dentists
themselves have not been trained to realize that the teeth are a most
dangerous source of infection when unclean. Does your dentist insist
upon removing tartar and food particles beyond your reach, upon
polishing and cleansing, or does he regard these as vanity touches, to
be omitted if you are in a hurry?

INDUSTRIAL HANDICAPS DISCOVERED AT SCHOOL

Physicians send tuberculosis patients to hospitals or camps without
correcting the mouth conditions that make it impossible for the
patient to eat or swallow without infecting [91]himself. Tonics are given
to women whose teeth are breeding and harboring disease germs that
tear down vitality. Nurses watch their suffering patients and do the
heavier tasks heroically, but are not trained to teach the simple
truths about dental hygiene. The far-reaching results of neglect of
teeth will not be understood until greater emphasis is placed on the
bacteriology, the economics, the sociology, and the æsthetics of
clean, sound teeth. Whether or not there is at present a tendency to
exaggerate the importance of sound teeth, there is no difference of
opinion as to the fact that the teeth harbor virulent germs, that the
high temperature of the mouth favors germ propagation, that the twenty
to thirty square inches of surface constantly open to bacterial
infection offer an extensive breeding ground, and that the formation
of the teeth invites the lodgment of germs and of particles of food
injurious both to teeth and to other organs.

By scraping the teeth with the finger nail and noticing the odor you
can convince yourself of the presence of decomposing organic matter
not healthful to be carried into the stomach. By applying a little
iodine and then washing it off with water, your teeth may show stains.
These stains are called gelatinous plaques, which are transparent and
invisible to the naked eye except when colored by iodine. These
plaques protect the germs, which ferment and create the acid which
destroys tooth structure. Their formation can be prevented by vigorous
brushing and by eating hard food.

The individual with decayed teeth, even with unclean teeth, is open to
infection of the lungs, tonsils, stomach, glands, ears, nose, and
adenoid tissues. Every time food is taken, and at every act of
swallowing, germs flow over the tonsils into the stomach. Mouth
breathers with teeth in this condition cannot get one breath of
uncontaminated air, for every breath becomes infected with poisonous
emanations from the teeth. Bad teeth are frequently the sole [92]cause of
bad breath and dyspepsia, and can convey to the system tuberculosis of
the lungs, glands, stomach, or nose, and many other transmissible
diseases. They may also cause enlarged tonsils and ear trouble.

Apart from decomposing food and stagnant septic matter from saliva
injured by indigestion, and by sputum which collects in the healthy
mouth, there are in many infected mouths pus, exudations from the
irritated and inflamed gum margins, gaseous emanations from decaying
teeth, putrescent pulp tissue, tartar, and chemical poisons. Every
spray from such a mouth in coughing, sneezing, or even talking or
reading, is laden with microbes which vitiate the air to be breathed
by others. Indigestion from imperfect mastication and imperfect
salivation (themselves often due solely to bad teeth) is far less
serious than indigestion from germ infection. Germs taken into the
stomach can so change the composition of saliva (a natural
disinfectant when healthy) as to render it no longer able to kill
germs. Indigestion may result in excess of uric acid and toxic
material, so that the individual becomes subject to gout and
rheumatism, which in turn frequently destroy the bony support of the
teeth and bring about Riggs’s Disease. The last named is a prevalent
and disfiguring disease, whose symptom is receding gums. The
irritating toxins deposited on the teeth cause inflammation of the
tissues at the gum margins. The gums withdraw more and more from
sections of the teeth; the poisons get underneath and work back toward
the roots; the infection increases and hastens the loosening of the
teeth. I know of a man who had all of his teeth extracted at
twenty-one years of age, because he was told that this was the only
treatment for this disease, which was formerly thought to be
incurable. Yet thorough cleansing and removal of this matter from
under the edges of the gums, disinfection, a few visits to the
dentist, will stop the recession but cannot regain lost ground.

[93]Among those who regularly use the toothbrush, instinct, comfort, or
display is the ruling motive, while a small percentage have evolved to
the anti-nuisance stage, where the æsthetic standard of their group
forbids any member to neglect his teeth. The anti-slum and pro-slum
motives for mouth cleanliness and dental sanitation have been awakened
in but one or two places. A significant pro-slum activity is the
dental clinic organized by forty volunteer dentists, acting for an
industrial school maintained by the New York Children’s Aid Society.

NEW YORK CHILDREN’S AID SOCIETY’S DENTAL CLINIC FOR SCHOOL CHILDREN

Here 550 children have been examined, 447 teeth extracted, 284 teeth
filled, 200 teeth treated for diseased pulp (and only 24 sets
cleaned), 40 dentists taking turns in giving time to this work. The
equipment cost but $239; cards and stationery, $72; incidentals, $33.
The principal attends the clinic, because in her presence no child is
willing to confess fear or unwillingness. To supplement this work, the
dentists have prepared for free distribution a leaflet which tells in
short, clear sentences how to care for the teeth.

Such a leaflet should be given out at dispensaries, hospitals, dental
offices, schools, and from many Sunday schools and missions.[5]

[95]The time for the schools to begin is when the child is first
registered. Examination and reëxamination must be accompanied by
explanation of the serious disadvantages of neglected teeth, and the
physical, social, and economic advantages of clean, sound teeth.
Instruction at school must be followed by education of parents. The
school or health authorities should examine the teeth of all children
before issuing work certificates. Finally, the dental, medical, and
nursing professions and the press must be enlisted in the school’s
campaign for dental hygiene. The Dental Hygiene Council of
Massachusetts should be copied in all states.

A preliminary examination of teeth can be made by parent or teacher.
Crooked, loose, dirty, or black teeth or receding gums can be detected
by a layman’s naked eye. In fact, children can be interested in
finding the most obvious defects in their own or their brothers’
teeth. There could be no better first lesson than to ask each pupil to
look in a hand mirror and to count each tooth obviously needing a
cleaning or a filling. The most urgent need can thus be ascertained
without expert aid. But because parent, teacher, or child cannot
discover defects does not prove that dental care is not imperative;
hence the importance of examination by a dentist or by a physician
competent to discover dental needs. If a private, public, or parochial
school has no paid visiting dentist, a zealous school officer can, at
least in large towns, persuade one or more dentists or physicians to
make a few first tests to confirm the teacher’s findings, and to
persuade the community that regular examination and reëxamination are
necessary and a saving of pain, beauty, and money.

Reëxamination is necessary because decay may start the day after a
dentist has pronounced a tooth sound. For most of us twice a year is
often enough. A reëxamination should be made upon the slightest
suspicion of decay, breaking, or loosening.

[96]Educational use should be made by the teacher of the results of school
examination. Children cannot be made self-conscious and cleanly by
telling them that their teeth will ache three or five years from now.
They can be made to brush or wash their teeth every morning and every
night if they once realize that cavities can be caused only by mouth
garbage. All decay of human teeth starts from the outside through the
enamel that covers the soft bone of the tooth. This enamel can be
destroyed by accidentally cracking or breaking it, or by acids eating
into it. These acids come from (1) particles of food allowed to remain
in the teeth; (2) tartar, etc., that adheres to the teeth and can be
removed only by a dentist; (3) saliva brought up from an
ill-conditioned stomach. Even where the enamel is destroyed, absolute
cleanliness will prevent serious decay of the tooth. A perfectly clean
tooth will not decay. Generally speaking, unless particles of food or
removable acids remain on or between the teeth long enough to
decompose, teeth cannot decay. Decay always means, therefore,
uncleanliness. To unclean teeth is due in large part the offensive
odor of many schoolrooms.

AN ARMENIAN SCHOOL GIRL

Uncleanliness becomes noticeable to our neighbors sooner or later.
There is no offense we are so reluctant to commit as that of having
uncleanliness of our bodies disagreeable to those about us. Very young
children will make every effort in their power to live up to the
school’s standard of cleanliness. The other side to this reason for
having clean teeth is vanity. Because all cleanliness is beautiful to
us, clean teeth are one attribute of beauty that all of us can
possess.

Habits of cleanliness are easily fixed. In the most crowded, most
overworked section of large cities visitors from “uptown” are
surprised by the children’s bright hair ribbons, clean aprons, clean
faces, and smoothly combed hair. It will be easy to add clean teeth to
the list of things necessary to personal and family standing. Armenian
children [97]are taught to clean their teeth after eating, even if only
an apple between meals. They covet “beautiful teeth.” American
standards will soon prevent these Armenians from cleaning their teeth
in public, but desire for beautiful teeth will stay, and will remind
them to care for their teeth in private. As coarse food gives way to
sugars and soft foods, stiff toothbrushes must supplement tongue and
toothpicks.

Strong as are the instinct and display motives in cleaning teeth, both
parents and children need to be reached through the commerce motive.
Instinct makes children afraid of the dentist, or content when the
tooth stops aching. Display may be satisfied with cleaning the front
teeth, as many boys comb only the front hair or as girls hide dirty
scalps under pompadours and pretty ribbons. Desire to save money may
give stronger reasons for not going to the dentist than instinct and
comfort can urge for going. But parents can be made to see, as can
children after they begin to picture themselves as wage earners, that
a dentist in time saves nine, and that no regular family investment
will earn more money than the price of prompt and regular dental care.
A problem in arithmetic would be convincing, if, by questions such as
those on page 98, we could compare the family cost of neglecting teeth
with the cost of toothbrushes, bicarbonate of soda, pulverized chalk
or tooth powder, early and repeated examination by a dentist, and
treatment when needed.

The result will show that the money spent for one good “house
cleaning” of one child at fourteen or eighteen exceeds the cost of
keeping clean and in repair the teeth of the entire family. How
effective and economical is thorough cleaning is confessed by an
eminent dentist, who taught an assistant to clean his patients’ teeth.
“Do you know,” he said, “I had to stop it, so perceptibly did my work
decrease.” The total time required to examine school children for
teeth needing attention is much less than the time now lost by absence
from school or wasted at school on account of toothache.

WON BY THE ECONOMIC ARGUMENT

To remind school children regularly of dental hygiene is not more
important than for the school to remind parents repeatedly of the many
reasons for attending to their children’s teeth. It is not enough,
however, to send one message to parents. Illustrated lectures,
mothers’ meetings, demonstrations at hospitals and fresh-air homes are
all very serviceable, but listening is a poor substitute for
understanding. Schools should see that parents understand the
æsthetics, the economics, the humanity of dental hygiene. [99]The best
test of whether the parent has understood is the child’s tooth.

Dental examination of children applying for work certificates gives
the health and school authorities a means of enforcing their precepts.
When no child is allowed to go to work whose teeth cause malnutrition
or disgust, the news will spread, and both child and parent will see
clearly the grave need for dental care.

Finally, local papers can be interested. They will print almost
anything the teacher sends about the need for dental care. They like
particularly facts about the number of cavities found, the number of
children needing care, efforts made to procure care, and new facts
about diseases that can be caused by bad teeth or about diseases that
can injure teeth. Teachers can persuade dentists and physicians to
write stories. No newspaper will refuse to print such statements as
this: “A tuberculous patient in six weeks lost ground steadily. I
persuaded him to go to a dentist to clean the vestibule to his
digestive system, and to have a set of false teeth. He enjoys his
meals, and has gained twelve pounds in six weeks.” Popular magazines
and newspapers mention teeth seldom, because those who best know the
interesting vital things are making money, not writing articles or
otherwise concerning themselves with dental education. It is said that
of forty thousand American dentists not over eleven thousand are
readers of dental journals, and probably not three hundred contribute
to professional [100]literature. One dentist who is working for the
children’s clinic described above, when asked by the board of
education to lecture to the people on the care of the teeth and to
recommend simple, readable books, told me that he knew no good books
to suggest.

Five obstacles exist to practicing what is here preached:

Additional reasons these for cleanliness that will make the dentist
serviceable for his knowledge rather than for his time and gold.

Good dentists really “come too high” for both the poor and the
comfortably situated. Families in New York City that have four or five
thousand dollars a year hesitate to go to a dentist whom they
thoroughly trust, because his time is worth more than they feel they
can afford to pay.

The “free-extraction” dental parlors undoubtedly are doing a vast
amount of harm. In every city are dental quacks that injure
wage-earning adults as much as soothing-sirup quacks injure babies.
Instead of teaching people to preserve their teeth, they extract, and
then, by dint of overpersuading by a pretty cashier hired for the
purpose, make a contract for a gold crown or a false set at an
exorbitant price. A reputable dentist has said that a dental parlor
can do more damage to the welfare of the race in a few months than a
well-intentioned man in the profession can repair in a lifetime. Its
question is not, What can I do for this patient? but What is there in
this mouth for me? Many “parlors” never expect to see the same [101]person
twice, because they do not make him comfortable or gain his
confidence; they put a filling in on top of decayed matter or even
diseased pulp; put in plates and bridges that do not fit; charge more
than the examination at first leads one to expect; refuse to correct
mistakes; deny having ever seen the patient before. Yet true and
severe as this arraignment is, many of these parlors, with their
liveried “runners in,” are doing an educational service not otherwise
provided; it is conceivable that in many cities they are doing less
harm by their malpractice than well-intentioned men in the profession
by neglect of public needs or by failure to organize facilities for
meeting those needs.

I realize that advertising is “unethical” among dentists as among
physicians. Humbug and imposition are supposed to go inevitably with
self-advertising by the methods used in selling shoes or automobiles.
Therefore such advertising is prohibited. But what seems to be
forgotten in this definition of ethics is that the need and the
opportunity for dental care must be advertised in some way, if we are
ever to control diseases and evils due to bad teeth. The rich that one
dentist can help are able to pay for his good taste, his neat
attendants, his automobile, his club dues, his vacations at
fashionable resorts, his hours without work, his standard of living.
All of these things advertise him, just as hospital appointments and
social position may and do advertise successful physicians. The
patients of moderate means that one dentist can treat cannot afford to
pay for rent, time disengaged, and indirect advertising. Either they
must have free treatment, must go without treatment, or must go to a
dental parlor where dental needs are organized so that a very large
number will contribute to rent and display. It is out of the question
to have both dentists and patients so distributed and prices so
adjusted that dentists can make a good living by charging what the
patient can afford, and at the same time admit of every [102]patient being
properly treated when necessary. Judging from every other branch of
work, the solution of the problem lies partly in free care for those
who can pay nothing or very little, and partly in coöperative
treatment through the heretofore objectionable dental parlors. If
instead of inveighing against advertisers, honorable and capable
dentists worked through dental and medical societies to secure
adequate public supervision of dental practice, more progress would be
made against dental malpractice.

Dental clinics will quickly follow the publication of facts that
schools should gather. In some places these should be separate; but at
first the best thing is to make every hospital, every children’s home,
every settlement a clinic, and every school an examining center. A
skilled dentist informs me: “The demand that will follow examination
of school children’s teeth will make it profitable for young dentists
to adopt a coöperative scheme, where several young men hire a parlor
in a cheap district, and, under the supervision of some experienced
dentist, give good advice at reasonable rates. This is the best
antidote to the dental parlor which exploits the public so
shamelessly.” Bellevue Hospital in New York is the first general
hospital to establish regular dental examination; others will
undoubtedly soon follow.

Dental education for profit rather than for instruction and for health
has been the rule. Even where universities have put in dental courses,
they have demanded a net profit from tuition. Instead of protecting
society against men incapable of caring for teeth, the schools have
marketed certificates to as large numbers as slowly enlightened
self-interest would permit. Much progress has been made toward uniform
standards of admission and graduation, but dental colleges sadly need
the light and the inspiration of school facts about teeth.

Of fourteen dental journals in America, only one has the advancement
of dental science as its first reason for [103]existence. Thirteen are
trade journals. Not one of these would print articles proving that the
supplies advertised by their backers were inimical to dental hygiene.
Many dental colleges still retain on their faculties agents or editors
in the pay of supply houses, Harvard’s new dental school being a
notable exception. This trade motive tolerates and encourages the
disreputable practices of existing dental parlors. Largely because of
this prostitution of the dental profession, patients generally neglect
the repairing and cleansing of the teeth and the sterilizing of the
mouth from which germs are carried to all parts of the body. Dental
journalism for the sale of supplies cannot outlive the dentist’s
reading of the school’s index.

Many dentists will say that they must learn dentistry before they
learn the economics and sociology of clean teeth. Being a young
profession, it is natural that dentistry should first devote itself to
learning its own mechanics,—the tricks of the trade—how to fill
teeth. But the fact that it took the medical profession centuries to
begin to feel responsibility for community health is no reason why the
social sense of the dentist should be dormant for centuries or
decades. We need training and exercise to determine what kind of
filling will be most comfortable and most serviceable; whether the
pulp of the teeth needs treating or removing before the filling is
inserted; whether it is worth while to fill a deciduous or baby tooth.
Sociology will never take the place of dental technic. The few
dentists who have studied the social significance and social
responsibility of their profession declare, however, that careless
workmanship and indifferent education of patients continue chiefly
because dentists themselves do not see the community’s interest in
dental hygiene. The school can socialize or humanize the dental
profession if teachers themselves possess the social sense and make
known the facts about the need for dental care among school children.

FOOTNOTES:

CHAPTER XToC

ABNORMALLY BRIGHT CHILDREN

What is commonly considered abnormal brightness in a school child is
often a tendency to live an abnormal physical life. Being a child
bookworm means that time is spent indoors that should be spent playing
games with one’s fellows. Excellence in the activities of children,
not ability to imitate the activities of adults, should be the test of
child brightness. To be able to hit a bull’s-eye, to throw a ball
accurately, to calculate the swing of a curve or the bound of a
“grounder,” these are tests of brightness quite as indicative of
mental power as the ability to win highest marks in school, while less
injurious to physical power. The child who is abnormally bright
requires special treatment just as much as the child who is abnormally
dull. The former as well as the latter must have his abnormal
condition corrected if he is to grow into a normally bright man.

The college man who sacrifices health to “marks” is thus described by
the director of physical training at Harvard University:

For the protection of these physical defective grinds it is suggested
to put a physical qualification upon the candidates of Phi Beta Kappa
and their awards of scholarship. If scholarship men cannot be induced
to take time to improve their physique for fear of lowering their
college standing, then give them credit for standing in physical
work.

[105]The abnormally bright, at whatever age, is as much a subject for
examination and treatment as the child with adenoids and pulmonary
tuberculosis. Such attention will increase the percentage of
abnormally bright schoolmates who figure in active business in later
life. Moreover, it will decrease the number of high school
superintendents who declare that their honor pupils are physical
wrecks.

There are children who develop very rapidly, both physically and
mentally, and whose mental superiority is not at the expense of their
bodies. Protection of such children requires that their minds be
permitted to progress as rapidly as bodily health justifies. It is as
cruel to keep back a physically and mentally superior child, as to
push the physically or mentally defective beyond his powers. Worry and
fatigue can be produced by lack of interest as well as by overwork.
“Normal” should not be confused with “average.” To keep a bright child
back with the average child—marking time till the dull ones catch
up—is to make him abnormal. The tests that we have employed for
grading pupils are either the tests of age in years or of mental
capacity. The first takes no account of slowness or rapidity of
physiological development,—of physiological age. The second
encourages mental activity at the expense of physique. The entrance of
a child into school, the promotion from one class to another, the
entrance into college, are thus determined either by the purely
artificial test of age or by the individual teacher’s discretion.
There is nothing to prevent the ambitious teacher or the ambitious
parent from pushing a child into kindergarten at four, high school at
twelve, college at fifteen. If this cannot be done at the public
school, a private school is resorted to. A community of college
professors once started a school for faculty children. A tremendous
pressure was put upon these scions of intellectual aristocracy to
enter the high school at twelve. No thought was given to the
ventilation of the school. The [106]windows were so arranged that they
could not be opened without the air blowing on some child’s back. “You
could cut the air with a knife” was a description given by one
sensible professor who had taken his sturdy girl of seven away from
the school, because he feared that in this environment she would
become like the other little puny, pale, undersized children of that
school.

The University of Pennsylvania has instituted a psychological clinic.
Parents and teachers are invited to bring any deviation from the usual
or the expected to the attention of this clinic. Every month a
bulletin is published called the Psychological Clinic, which will be
found of great service in dealing with the abnormally bright as well
as with the abnormally dull. Naturally the well-to-do and the rich are
the first to take advantage of these special facilities for
ascertaining just what work should be done by a precocious child or by
the mentally and morally retarded.

Abnormal brightness means power to be happy and to be serviceable that
is above the average. Every school can be a miniature psychological
clinic. While every teacher cannot be an expert, national and state
superintendents can constantly remind teachers that the abnormally
bright are also abnormally apt to neglect physical welfare and to
endanger future mental power.

CHAPTER XIToC

NERVOUSNESS OF TEACHER AND PUPIL

Nervousness of teacher and pupil deserves special mention. So
universal is this physical defect that we take it for granted,
especially for teachers. Teachers themselves feel that they need not
even apologize for nervousness, in fact they too frequently use it as
an excuse for impatience, ugly temper, discourtesy, and unfairness.
Children, slates, papers, parents, blackboards “get on their nerves.”
Nervousness of teacher causes nervousness of pupils and adds to the
evil results of mouth breathing, bad teeth, eye strain, and
malnutrition. These conditions, added to bad ventilation, bad light,
and an overcrowded schoolroom, render the atmosphere thoroughly
charged with electricity—nerves—toward the end of the day. Lack of
oxygen to breathe as well as inability to breathe it; lack of
well-printed books and good light, as well as lack of the power to use
them; toothache, earache, headache, deplete the vitality of both
teacher and pupil.

Most of the disturbances at school are but outward signs of
unwholesome physical conditions. If the teacher attempts to treat
these causes by crushing the child, she makes confession of her own
nervousness and inadequacy and visits her own suffering upon her
pupils. A transfixing glance prolonged into an overbearing stare, a
loud, sharp voice, a rough manner, are successful only so far as they
work on the nervousness of her pupil. She finds that it is temporarily
effective, and so by her example and practice sets the child an
example in losing control of himself. The position often assumed by
school children when before authority, [108]of hands held stiffly at the
side, head drooped, and roving eye, does not mean control: it means a
crushed spirit, hypocrisy, or brooding anarchy. The mother or teacher
who obtains obedience by clapping her hands, pointing her finger,
distorting her face, is copying in her own home the attitudes of caste
in India, of serfdom in Russia, the discipline of the prison the world
over, a modern reminder of the power of life and death or of physical
torture.

A young college girl unfamiliar with the ways of the public school was
substituting in the highest grammar grade. The time for civics
arrived. Here, she thought, is a subject in which I can interest them.
The boys showed a vast amount of press information, as well as decided
opinions on the politics of the day. The candidates which they elected
for the position of ideal American patriot were Rockefeller, Lincoln,
and Sharkey the prize fighter. During the ensuing debate, which gave
back to Lincoln his proper rank, the boys in the back of the room had
moved forward and were sharing seats with the boys in the front. Every
boy was engrossed in the discussion. The room was in perfect
order,—not, however, according to the ideas of the principal, who
entered at that moment to see how the new substitute was managing the
class, famed for its bad boys. With the stern look of a Simon Legree
she demanded, “How dare you leave your seats!” When one child started
to explain she shouted: “How dare you speak without permission! Don’t
you know your teacher never permits it? Every boy take his own seat at
his own desk.” This principal was far more to be pitied than the boys,
for they had before them the prospect of “work papers” and a grind
less monotonous and more productive than the principal’s discipline.
She was a victim of a nerve-racking system, more sinned against than
sinning.

There is nothing in school life per se to cause nervousness. Given a
well-aired, sunny room, where every child [109]has enough fresh air to
breathe, where he can see without strain, where he has a desk fitted
to his body and work fitted to his maximum abilities, a teacher who is
physically strong and mentally inspiring, and plenty of play space and
play time, there will be no nervousness. One who visits vacation
schools is struck with the difference in the atmosphere from that of
the winter day schools. Here are the same rooms, the same children,
and in many cases the same teachers, but different work. Each child is
busy with a bright, interested, happy expression and easy attitude.
Some are at nature study, some are weaving baskets, making dresses,
trimming hats, knitting bright worsted sacks and mittens for the
winter. Boys are at carpentering, raffia, or wrought-iron work. In
none of the rooms is the absolute unity or the methodical order of the
winter schoolroom, but rather the hum of the workroom and the order
that comes from a roomful of children interested in the progress of
their work. This condition only illustrates what a winter schoolroom
might be were physical defects corrected or segregated, windows open,
light good, and work adapted to the child.

VACATION SCHOOL INTEREST: AN ANTIDOTE TO NERVOUSNESS

[110]Nervousness is not a monopoly of city teachers and city pupils. In
country schools that I have happened to know, nervous children were
the chief problem. Nervousness led in scholarship, in disorder, in
absences, in truancy, and in backwardness. After reading MacDonald’s
Annals of a Quiet Neighborhood, I became interested in one or two
particularly nervous children, just to see if I could overcome my
strong dislike for them. To one boy I gave permission to leave the
room or to go to the library whenever he began to lose his
self-control. My predecessors had not been able to control him by the
rod. A few weeks after Willie’s emancipation from rules, the county
superintendent was astonished to see that the county terror led my
school in history, reading, and geography.

Had I known what every teacher should be taught in preparation,—the
relation of eye strain, bad teeth, adenoids, “overattention,” and
malnutrition to nervousness and bad behavior,—I could have restored
many “incorrigibles” to nerve control. Had I been led at college to
study child psychology and child physiology, I should not have
expected a control that was possible only in a normal adult.[6] In its
primary aspect the question of nervousness in the schoolroom is purely
physiological, and the majority of principals and teachers are not
trained by professional schools how to deal with it. Normal schools
should teach the physical laws which govern the child’s development;
should show that the pupil’s mental, moral, and physical nature are
one and inseparable; that children cannot at one time be docile,
sickly, and intelligent,—perfect mentally and imperfect physically.
Until teachers are so taught, the condition cannot be changed that
makes of our schools manufactories of nervous teachers and pupils.

[111]Country nervousness, like city nervousness, is of three kinds: (1)
that caused by defective nervous systems; (2) that resulting from
physical defects other than defects of the nervous system, but
reacting upon it; (3) that due to habit or to lack of self-control.
Children who suffer from a defective nervous system should, in city
schools, be segregated where they can have special care under constant
medical supervision. Such children in schools too small for special
classes should be given special treatment. Their parents should know
that they have chorea, which is the same trouble as St. Vitus’s Dance,
although often existing in a degree too mild to attract attention.
Special treatment does not mean that such children should be permitted
to interfere with the school progress of other children. In many rural
schools, where special privileges cannot be given children suffering
with chorea without injury to other children, it would be a kindness
to the unfortunates, to their parents, and to all other children, were
the parents requested to keep such children at home.

Nervousness that results from removable physical defects—eye strain,
adenoids, indigestion, earache—will be easily detected by physical
examination, and easily corrected by removing the physical defect.

Preventable nervousness due to “habit” can be quite as serious in its
effects upon the mind and health as the other two forms of
nervousness. Twitching the face, biting the nails, wetting the lips,
blinking the eyelids, continually toying with something, being in
perpetual motion and never relaxing, always changing from one thing to
the next, being forever on the rush, never accomplishing anything, are
common faults of both teacher and pupil. We call them mannerisms or
tricks of personality. They are readily imitated by children. I once
knew a young lawyer who had started life as an oyster dealer, whose
power of imitation helped to make him responsive to both helpful and
harmful influences. After [112]being at the same table for two weeks with
a talented man whom he admired, he acquired the latter’s habit of
constantly twitching his shoulder and making certain gestures. These
habits in turn quickly produced a nervousness that interfered with his
power to reason straight.

Nervousness is often confused with aggressiveness, initiative,
confidence. “Think twice before you jump, and perhaps you won’t want
to jump” is a very difficult rule to follow for any one whose bodily
movements are not under perfect control.

It is said that the confusion of city life causes habits of
nervousness. Unfortunately no one knows whether the city children or
the country children have the highest percentage of nervousness. There
is a general feeling that city life causes an unwholesome degree of
activity, yet one finds that those people in the city who least notice
the elevated railway are those whose windows it passes. City noises
irritate those who come from the country, or the city man on returning
to the city from the country, but a similar irritation is felt by the
city-bred man on coming to the country. Mr. Dooley’s description of a
night in the country with the crickets and the mosquitoes and the
early birds shows that it is the unusual noise rather than the volume
or variety of noises that wreck nerves. At the time of the opening of
the New York schools in 1907 a newspaper published an editorial on
“Where can the city child study?” showing that in New York the
curriculum, the schoolhouse, and the tenements are so crowded and so
noisy that study is practically impossible. Lack of sleep, lack of a
quiet place in which to study at school and at home, are causes for
nervousness, whether these conditions are in the city or in the
country. What evidence is there that the country curriculum is less
crowded or country work better adjusted to the psychological and
physiological age of the country pupil? The index is there; it should
be read.

[113]In breaking habits of nervousness the first step is to explain how
easily habits are formed, why their effects may be serious, and how a
little attention will correct them. When a habit loses its mystery it
becomes unattractive. Children will take an interest in coöperating
with each other and with the teacher in curing habits acquired either
at home or at school. My pupils greatly enjoyed overcoming the habit
of jumping or screaming after some sudden noise. I told them how, when
a boy, my imagination had been very much impressed by one of
Thackeray’s characters, the last remnant of aristocratic traditions,
almost a pauper, but possessing one attribute of nobility,—absolute
self-control. When his house burned he stood with his ankles crossed,
leaning on his cane, the only onlooker who was not excited. For months
I imitated that pose, using sticks and rakes and fork handles. The
result was that when I taught school, a scream, a broken desk, or
unusual noise outside reminded me of my old aristocrat in time to
prevent my muscles from jumping. In a very short time several fidgety
and nervous girls and boys had learned to think twice and to relax
before jumping.

One test of thorough relaxation in a dentist’s chair proves the folly
of tightening one’s muscles. When in school or out the remedy for
nervousness is relaxation. The discipline that prohibits a pupil from
stretching or changing his posture or seat is as much to be condemned
as that which flourishes the rod. It has been said of our schools that
children are not worked to death but bored to death. Wherever a room
must be stripped of all beauty and interest to induce concentration,
wherever the greater part of the teacher’s time must be spent in
keeping order, there is confession either of inappropriateness of the
present curriculum or of the failure of teacher and text-book to
present subjects attractive to the pupils. Nervous habits will be
inevitable until the pupil’s attention is obtained through interest.
[114]Sustained interest will be impossible until teacher and pupil alike
practice relaxation, not once a morning or twice a day, not during
recess or lunch hour, but whenever relaxation is needed.

In overcoming nervousness of teacher and pupil, both must be
interested in home causes as well as school causes of that
nervousness. Time must be found to ask questions about those causes
and to discuss means for removing them. Naturally it will be
embarrassing for a very nervous teacher to discuss nervousness with
children,—until after she has overcome her own lack of nerve
stability. To help her or to compel her to learn the art of relaxation
of bodily and of mental control is the duty and the privilege of the
school physician, of her doctor, and of superintendent and trustees.
The outside point of view is necessary, because of the peculiar fact
that almost every nervous person believes that he has unusually good
control over his nerves, just as a man in the midst of his anger will
declare that he is cool and self-controlled. Had Robert Burns been
thinking of the habit of nervousness he could not have thought of a
better cure than when he wrote:

FOOTNOTES:

CHAPTER XIIToC

HEALTH VALUE OF “UNBOSSED” PLAY AND PHYSICAL TRAINING

A boy without play means a father without a job. A boy without
physical training means a father who drinks. When people have
wholesome, well-disciplined bodies there will be less demand for
narcotics as well as for medicines. On these three propositions
enthusiasm has built arguments for city parks and playgrounds, for
school gymnastics, and for temperance instruction. We have tried the
remedies and now realize that too much was expected of them. Neither
movement appreciated the mental and physical education of spontaneous
games and play.

Like hygiene instruction, physical training was made compulsory by law
in many states, and, like hygiene instruction, physical training had
to yield to the pressure of subjects in which children are examined.
At the outset both were based upon distorted psychology and
physiology. Of late physical training has been revived “to correct
defects of the school desk and to relieve the strain of too prolonged
study periods.” In New York grammar schools ten minutes a day for the
lower grades, and thirty minutes a week for the higher grades, are set
aside for physical training. With the exception of eighteen schools
where apparatus is used, the exercise has been in the class rooms. It
consists of what are known as “setting-up exercises,”—deep breathing
and arm movements for two minutes between each study period, often
forgotten until it is time to go home, when the children are tired and
need it least. Many teachers so conduct these exercises that children
keenly enjoy them.

[116]

SERVICEABLE RELIEF FROM SCHOOL STRAIN, BUT A POOR SUBSTITUTE FOR OUTDOOR PLAY

Like hygiene instruction, physical training preceded physical
examination. Generally speaking, it has not yet, either in schools or
in colleges, been related to physical needs of the individual pupil.
In fact, there is no guarantee that it is not in many schools working
a positive injury on defective children or imposing a defective
environment on healthy children. Formal exercises in cramped space, in
ill-ventilated rooms, with tight belts and heavy shoes, are conceded
to be pernicious. Formal exercises should never be given to any child
without examination and prescription by a physician. Children with
heart weakness, enlarged tonsils, adenoid growths, spinal curvature,
uneven shoulders, are frequently seen doing exercises for which they
are physically unfit, and which but serve to deplete further their
already low vitality. Attention might be called to many a class
engaged in breathing exercises when by actual count over half the boys
were holding their mouths open. Special exercises are needed by
children who show some marked [117]defect like flat foot, flat chest, weak
abdominal muscles, habitual constipation, uneven shoulders, spinal
trouble, etc.

That no physical training should be provided for normal children is
the belief of many leading trainers. This special training is useful
to develop athletes or to correct defects. Like massage, osteopathy,
or medicine, it should follow careful diagnosis. The time is coming
when formal indoor gymnasium exercises for normal pupils or normal
students will be considered an anomaly. There is all the difference in
the world between physical development and what is called physical
training. The test of physical development is not the hours spent upon
a prescribed course of training, but the physical condition determined
by examination. To be refused permission to substitute an hour’s walk
for an hour’s indoor apparatus work is often an outrage upon health
laws. Given a normal healthy body, plenty of space, and plenty of
playtime, the spontaneous exercise which a child naturally chooses is
what is really health sustaining and health giving.

Mere muscular development artificially obtained through the devices of
a gymnasium is inferior to the mental and moral development produced
by games and play in the open air. Eustace Miles, M.D., amateur tennis
player of England, says:

The “healthy-mindedness” and “physical morality” which play and games
foster rarely result from physical training as a business, at stated
times, indoors, under class direction. It is too much like taking
medicine. A certain breakfast food is said to have lost much of its
[118]popularity since advertised as a health food. When the National
Playground Association was organized President Roosevelt cautioned its
officers against too frequent use of the word “supervision” on the
ground that supervision and direction were apt to defeat the very
purpose of games and to stultify the play spirit. Is the little girl
on the street who springs into a hornpipe or a jig to the tune of a
hurdy-gurdy, or even the boy who runs before automobiles or trolley
cars or under horses’ noses, getting less physical education than
those who play a round game in silence under the supervision of a
teacher in the school basement, or who stretch their arms up and down
to the tune of one, two, three, four, five, six? Who can doubt that
the much-pitied child of the tenement playing with the contents of the
ash can in the clothes yard or with baby brother on the fire escape is
developing more originality, more lung power, and better arteries than
the child of fortune who is led by the hand of a governess up and down
Fifth Avenue.

Children have not forgotten how to play, but adults have forgotten to
leave space in cities, and time out of school, home work, and factory
work in which children may play. Again, the child—whether a city
child or a country child—rarely needs to be taught how to play.
Teaching him games will not produce vitality. Games are the
spontaneous product of a healthy body, active mind, and a joy in
living. Give the children parks and piers, roof gardens and
playgrounds in which they may play, and leave the rest to them. Give
them time away from school and housework, and leave the rest to them.
Instead of lamenting the necessity for playing in the streets, let us
reserve more streets for children’s play. There are too many students
of child welfare whose reasoning about play and games is like that of
a lady of Cincinnati, who, upon reading the notice of a child-labor
meeting, said: “Well, I am glad to see there is going to be a meeting
here for child labor. It is high time [119]some measure was taken to keep
the children off the streets.” Physical examinations would prove that
streets are safer and better than indoor gymnasiums for growing
children. Intelligent physical training will train children to go out
of doors during recess; will train pupils and teachers not to use
recess for study, discipline, or eating lunch.

SPONTANEOUS PLAY ON ONE OF NEW YORK CITY’S SCHOOL ROOF PLAYGROUNDS

“After-school” conditions are quite as important as physical training
and gymnastics at school. Not long ago a nurse was visiting a sick
tenement mother with a young baby. She found a little girl of twelve
standing on a stool over a washtub. This child did all the housework,
took care of the mother and two younger children, got all the meals
except supper, which her father got on his return from work. As the
nurse removed the infant’s clothes to give it a bath, the little girl
seized them and dashed them into the tub. “Yes, I am pretty tired when
night comes,” she confessed. This child has prototypes in the country
as well as the city, and she did not need physical training. She did
not lack initiative or originality. She did need playmates, open air,
a run in the park, and “fun.”

[120]The educational value of games and outdoor play should be weighed
against the advantages of lowering the compulsory school age, and of
bridging over the period from four to seven with indoor kindergarten
training. Neither physical training nor education is synonymous with
confinement in school. The whole tendency of Nature’s processes in
children is nutritional; it is not until adolescence that she makes
much effort to develop the brain. Overuse of the young mind results,
therefore, in diverting natural energy from nutritive processes to
hurried growth of the overstimulated brain. The result is a type of
child with a puny body and an excitable brain,—the neurotic. The
young eye, for example, is too flat (hypermetropic)—made to focus
only on objects at a distance. Close application to print, or even to
weaving mats or folding bits of paper accurately, causes an overstrain
on the eye, which not only results in the chronic condition known as
myopia,—short-sightedness,—so common to school children, but which
acts unfavorably on the constitution and on the whole development of
the child. At the recent International Congress of School Hygiene in
London, Dr. Arthur Newsholme, medical officer of health of Brighton,
made a plea for the exclusion of children under five years of age from
schools. “During the time the child is in the infant department it has
chiefly to grow. Nutrition and sleep are its chief functions. Paints,
pencils, paper, pins, and needles should not be handled in school by
children below six.” Luther Burbank, in an article on “The Training of
the Human Plant,” says:

Not every child can have these blessings of the country, but every
child can be protected from the stifling of the nature instinct of
play by formal indoor “bossed” exercises, whether called games,
physical training, gymnastics, or Delsarte.

NEW YORK CITY’S SCHOOL FARM DOES NOT STIFLE NATURE INSTINCT

The answer to the protest against too early and too constant
confinement in school has always been: “Where will the child be if out
of school? Will its environment at home not work a worse injury to its
health? Will not the street injure its morals?” Because we have not
yet worked out a method of supervising the health of those children
who are not in school, it does not follow that such supervision is
impossible. Perhaps the time will come when there will be state
supervision over the health of children from birth, parents being
expected to present them once a year at school for examination by the
school physician. In this way defects can be corrected and health
measures [122]devised to build up a physique that should not break down
under the strain of school life. For children whose mothers work
during the day, and for those whose home environment is worse than
school, it might be cheaper in the long run to assign teachers to
protect them from injury while they play in a park, roof garden, or
out-of-door gymnasium. If parks and playgrounds come too slowly, why
not adopt the plan advocated by Alida S. Williams, a New York
principal, of reserving certain streets for children between the hours
of three and five, and of diverting traffic to other streets less
suitable for children’s play? So great is the value—mentally,
morally, and physically—of out-of-door play that it has even been
suggested that the substitution of such play for school for all
children up to the age of ten would insure better minds and sounder
physiques at fifteen. It is generally admitted that the child who
enters school at eight rather than at six will be the gainer at
twelve. What a travesty upon education to insist upon schooling for
children because they are apt to be run over on the street, or to be
neglected at home, to shoot craps, or belong to a gang and develop bad
morals.

Educators will some day be ashamed to have made the schools the
catch-all or the court-plaster for the evils of modern industry.
Instead of pupils and mothers going to the school, enough hygiene
teachers, and play teachers, and district physicians could be employed
with the money now spent on indoor instruction to do the
house-to-house visiting urged in many chapters of this book. Such a
course of action would have an incalculable effect on the reduction of
tuberculosis, not only in making healthier physiques but by
inculcating habits of outdoor life and love of fresh air. The danger
of those contagious diseases which ravish childhood would be greatly
reduced. An ambition for physical integrity would make unnatural
living unpopular. Competition in games with children of the same
[123]physical class develops accuracy, concentration, dispatch,
resourcefulness, as much as does instruction in arithmetic. Smoking
can easily be discredited among boys trying to hit the bull’s-eye. A
boy would sooner give up a glass of beer than the championship in
rifle shooting or a “home run.”

The influence of the “spirit of the game” on practical life has been
described thus by New York’s director of physical training, Dr. Luther
H. Gulick:

CHAPTER XIIIToC

VITALITY TESTS AND VITAL STATISTICS

Two things will disclose the strength or weakness of a bank and the
soundness or unsoundness of a nation’s banking policy, namely, a
financial crisis or an expert audit. A searching audit that analyzes
each debit and each credit frequently shows that a bank is solvent
only because it is not asked to pay its debts. It continues to do
business so long as no obvious weaknesses appear, analogous to
measles, adenoids, or paralysis. A frequent disorder of banking
results from doing too big a business on too little capital, in making
too many loans for the amount of cash held ready to pay depositors
upon demand. This disorder always comes to light in a crisis—too
late. It can be discovered if looked for in advance of a crisis. Many
individuals and communities are likewise physically solvent only
because their physical resources are not put to the test. Weaknesses
that lie near the surface can be discovered before a crisis by
physical examination for individuals and sanitary supervision for
communities. Whether individuals or communities are trying to do too
much business for their health capital, whether the health reserves
will pay debts that arise in a crisis, whether we are ill or well
prepared to stand a run on our vitality, can be learned only by
carefully analyzing our health reserves. Health debits are compared
with health credits for individuals by vitality tests, for communities
by vital statistics.

Of the many vitality tests none is practicable for use in the ordinary
class room. Scientific training is just as necessary for such tests as
for discovering the quality of [125]the blood, the presence or absence of
tubercle bacilli in the sputum, diphtheria germs in throat mucus, or
typhoid germs in milk. But scientific truth, the results of scientific
tests, can be made of everyday use in all class rooms. State and
national headquarters for educators, and all large cities, can afford
to engage scientists to apply vitality tests to school children for
the sake of discovering, in advance of physical breakdown and before
outward symptoms are obvious, what curriculum, what exercise, what
study, recreation, and play periods are best suited to child
development. It will cost infinitely less to proceed this way than to
neglect children or to fit school methods to the loudest, most
persistent theory.

The ergograph is an interesting strength tester. It takes a picture
(1) of the energy exerted, and (2) of the regularity or fitfulness of
the manner in which energy is exerted. Perhaps the time will come when
science and commerce will supply every tintype photographer with an
ergograph and the knowledge to use it. Then we shall hear at summer
resorts and fairs, “Your ergograph on a postal card, three for a
quarter.” We can step inside, harness our middle finger to the
ergograph, lift it up and down forty-five times in ninety seconds, and
lo! a photograph of our vitality! If we have strong muscles or good
control, the picture will be like this:

Fig. 1. Ergogram of T.R., a strong, healthy
girl, before taking 40 minutes’ work in the gymnasium. Weight used,
3.5 kg. Distance lifted, 151 cm. Work done, 528.5 kg.-cm.

[126]If weak and nervous, we shall look like this before taking exercise:

Fig. 2. Ergogram of C.E., a weak and somewhat nervous girl, before taking
40 minutes’ work in the gymnasium. Weight used, 3.5 kg. Distance lifted, 89 cm. Work done, 311.5 kg.-cm.

And like this after gymnasium exercise:

Fig. 3. Ergogram of C.E. after taking 40
minutes’ work in the gymnasium, showing that the exercise proved very
exhausting. Weight used, 3.5 kg. Distance lifted, 55 cm.

In Chicago, two of whose girls are above photographed, the physician
was surprised to have four pupils show more strength late in the day
than in the morning. “Upon investigation it was found that the teacher
of the four pupils had been called from school, and that they had no
regular work, but had been sent to another room and employed
themselves, as they said, in having a good time.” The chart on page
127 shows the effect of the noon recess and of the good time after
three o’clock.

Chicago’s child-study experts concluded after examining a large number
of children:

Fig. 4.

To these conclusions certain others should be added, not as settled
beyond any possibility of modification, but as being fairly indicated
by these tests.

Physiological age, according to studies made in New York City, should
be considered in grading, not only for physical culture classes but for
all high school or continuation classes. Dr. C. Ward Crampton,
assistant physical director, while examining boys in the first grade of
the High School of Commerce, noticed a greater variation in physical
advancement than in years. He kept careful watch of the educational
progress and discovered three clear divisions: (1) boys arrived at
puberty,—postpubescent; (2) boys approaching maturity,—pubescent; (3)
boys not yet approaching maturity,—prepubescent.

The work in lower grades they had all passed satisfactorily, but in
high school only the most advanced class [130]did well. Practically none
of the not-yet-maturing boys survived and few of the almost mature. In
other words, the high school course was fitted to only one of the
three classes of boys turned out of the grammar schools. The others
succumbed like hothouse azaleas at Christmas time, forced beyond their
season. Physiological age, not calendar years or grammar school
months, should determine the studies and the companions of children
after the tenth year. Physiological strength and vitality, not ability
to spell or to remember dates, should be the basis of grading for play
and study and companionship among younger children. Vitality, power to
endure physically, should be the test of work and recreation for
adults. Physicians may be so trained to follow directions issued by
experts that physical examinations will disclose the chief enemies of
vitality and the approximate limits of endurance.

Teachers may train themselves to recognize signs of fatigue in school
children and to adapt each day’s, each hour’s work to the endurance of
each pupil. One woman principal has written:

Because adults at work and at play reluctantly submit themselves to
vitality tests, because few scientists are beseeching individuals to
be tested, because almost no one yearns to be tested, the promotion of
adult vitality and of community vitality can best be hastened by
demanding complete vital statistics. Industrial insurance companies
and mutual benefit societies are doing much to educate laborers
regarding the effect upon vitality of certain dangerous and unsanitary
trades, and of certain unhygienic habits, such as alcoholism and
nicotinism. Progress is slower than it need be because state boards of
health are not gathering sufficiently complete information about
causes of sickness and death. American health and factory inspection
is not even profiting, as it should, from British, German, and French
statistics. Statistics are in ill repute because the truth is not
generally known that our boasted sanitary improvements are due chiefly
to the efficient use of vital statistics by statesmen sanitarians.[7]

The vital statistics of greatest consequence are not the number of
deaths or the number of births, not even the number of deaths from
preventable diseases, but rather the number of cases of sickness from
transmissible diseases. The cost and danger to society from
preventable diseases, such as typhoid, diphtheria, scarlet fever,
measles, are imperfectly represented by the number of deaths. Medical
skill could gradually reduce death rates in the face of [132]increasing
prevalence of infectious disease. With few exceptions, only those
patients who refuse to follow instructions will die of measles,
diphtheria, or smallpox. The scarlet-fever patient who recovers and
goes to church or school while “peeling” can cause vastly more
sickness from scarlet fever than a patient who dies. Dr. W. Leslie
Mackenzie, who has recently written The Health of the School Child,
said ten years ago, while health officer of Leith:

The best guarantee against such loss, the best protection of health,
and the most essential element of vital statistics is prompt, complete
record of cases of sickness. Statistics of sickness are confined to
sickness from transmissible diseases, because we have not yet arrived
at the point where we recognize the state’s right to require
information, except when the sick person is a menace to the health of
other persons.

The annual report of a board of health should give as clear a picture
of a community’s health during the past week or past quarter as the
ergograph gives of the pupils mentioned on page 126. As ragged,
rapidly shortening lines show nervousness and depleted vitality, so
charts and diagrams can be made to show the needless waste of infant
life during the summer months, the price paid for bad ventilation in
winter time, when closed windows cause the sickness-and-death line
from diphtheria and scarlet fever to shoot up from the summer level.
In cities it is now customary for health boards to report weekly the
number of deaths from transmissible diseases. Health officers will
[133]gladly furnish facts as to cases of sickness, if citizens request
them. Newspapers will gladly publish such information if any one will
take the pains to supply it. Wherever newspapers have published this
information, it quickly takes its place with the weather reports among
the news necessities. Marked changes are commented on editorially.
Children can easily be interested, as can adults, in filling out week
by week a table that will show increases and decreases in preventable
sickness due to transmissible diseases.

Table X

Cases of Infectious and Contagious Diseases Reported

In cities where physicians are not compelled to notify the health
board of danger centers,—that is, of patients sick from measles,
smallpox, or diphtheria,—and in smaller communities where notices are
sent only to state boards of health, parents will find it difficult to
take a keen interest in vital statistics. But if teachers would start
at the beginning of the year to record in such a table the days of
absence from school because of transmissible disease, both they and
their pupils would discover a new interest in efficient health
administration. After a national board of [134]health is organized we may
reasonably expect that either state boards of education or state
boards of health will regularly supply teachers with reports that will
lead them to compare the vitality photographs of their own schools and
communities with the vitality photographs of other schools and other
communities working under similar conditions. Then children old enough
to study physiology and hygiene will be made to see the
happiness-giving possibilities of vitality tests and vital statistics.

VITAL STATISTICS CAN MAKE DISEASE CENTERS AS OBVIOUS AND AS OFFENSIVE AS THE SMOKE NUISANCE

Instead of discussing the theory of vital statistics, or the extent to
which statistics are now satisfactory, it would be better for us at
this point to make clear the significance of the movement for a
national fact center for matters pertaining to personal, industrial,
and community vitality. [135]Five economic reasons are assigned for
establishing a national department of health:

Among the branches of the work proposed for the national bureau are
the following: infant hygiene; health education in schools;
sanitation; pure food; registration of physicians and surgeons;
registration of drugs, druggists, and drug manufacturers; registration
of institutions of public and private relief, correction, detention
and residence; organic diseases; quarantine; immigration; labor
conditions; [136]disseminating health information; research libraries and
equipment; statistical clearing house for information.

Given such a national center for health facts or vital statistics,
there will be a continuing pressure upon state, county, and city
health officers, upon physicians, hospitals, schools, and industries
to report promptly facts of birth, sickness, and death to national and
state centers able and eager to interpret the meaning of these facts
in such simple language, and with such convincing illustrations, that
the reading public will demand the prompt correction of preventable
evils.

Our tardiness in establishing a national board of health that shall do
this great educational work is due in part to the fact that American
sanitarians have frequently chosen to do things when they should
have chosen to get things done. Almost every state has its board of
health, with authority to require registration of births, deaths, and
sickness due to transmissible disease; with few exceptions the heads
of these state boards have spent their energies in abating nuisances.
In a short time they have degenerated into local scavengers, because
they have shown the public neither the meaning of the vital statistics
gathered nor its duty to support efficient health administration.

The state reports of vital statistics have not been accurate;
therefore in many states we have the anomalous situation of an
aggressive veterinary board arousing the farmer and the consumer of
milk to the necessity of protecting the health of cattle, and an
inactive, uninformed state board of health failing to protect the
health of the farmer and the consumer.

Vital statistics presume efficient health administration. An
inefficient health officer will not take the initiative in gathering
health statistics. If some one else compels him to collect vital
statistics, or furnishes him with statistics, they are as a lantern to
a blind man. Unless some one [137]also compels him to make use of them,
unless we remove the causes of transmissible or infectious diseases
and check an epidemic when we first hear of it, the collection of
information is of little social value. “Statistics” is of the same
derivation as “states” and “statesmen.” Statistics have always been
distinguished from mere facts, in that statistics are instruments in
the hands of the statesman. Wherever the term “statistics” is applied
to social facts it suggests action, social control of future
contingencies, mastery of the facts whose action they chronicle. The
object of gathering social facts for analysis is not to furnish
material for future historians. They are to be used in shaping future
history. They are facts collected with a view to improving social
vitality, to raising the standard of life, and to eliminating
permanently those forces known to be destructive to health. Unless
they are to be used this way, they are of interest only to the
historical grub. No city or state can afford to erect a statistical
office to serve as a curiosity shop. Unless something is to be done to
prevent the recurrence of preventable diseases annually experienced by
your community or your school, it is not reasonable to ask the public
printer to make tables which indicate the great cost of this
preventable sickness. A tax collector cannot discharge his duties
unless he knows the address of every debtor. The police bureau cannot
protect society unless it knows the character and haunts of offenders.
A health officer cannot execute the law for the protection of
society’s health unless he knows the haunts and habits of diseases.
For this he must look to vital statistics.

But the greatest service of vital statistics is the educational
influence. Health administration cannot rise far above the hygienic
standards of those who provide the means for administering sanitary
law. The taxpaying public must believe in the economy, utility, and
necessity of efficient health administration. Power and funds come
[138]from town councils and state legislatures. To convince and move these
keepers of the purse, trustworthy vital statistics are indispensable.
Information will be used for the benefit of all as soon as it is
possessed by all.

Fortunately the gathering of vital statistics is not beyond the power
of the kind of health officer that is found in small cities and in
rural communities. If years of study of mathematics and of the
statistical method were required, we should despair of obtaining light
within a century. But the facts we want are, for the most part,
common, everyday facts, easily recognizable even by laymen; for
example, births, deaths, age at death, causes of death, cases of
transmissible diseases, conditions found upon examination of children
applying for work certificates, etc. Where expert skill is required,
as at state and national headquarters, it can be found. Every layman
can train himself to use skillfully the seven ingredients of the
statistical method which it is his duty to employ, and to know when to
pay for expert analysis and advice. We can all learn to base judgment
of health needs upon the seven pillars,—desire to know, unit of
inquiry, count, comparison, percentages, classification, and summary.

FOOTNOTES:

CHAPTER XIVToC

IS YOUR SCHOOL MANUFACTURING PHYSICAL DEFECTS?

Last year a conference on the physical welfare of school children was
told by a woman principal: “Of course we need physicians to examine
our children and to teach the parents, but many of us principals
believe that our school curriculum and our school environment
manufacture more physical defects in a month than all your physicians
and nurses will correct in a year.” At the same meeting the physical
director of schools of New York City appealed eloquently for
“biological engineers” at school, who would test the child’s strength
as building engineers are employed to test the strength of beams and
foundations.[8] As explanation for the need of the then recently
organized National School Hygiene Association, he elaborated the
proposition that school requirements and school environment damage
child health. “Ocular defects are in direct ratio to the length of
time the pupil has attended school…. A desk that is too high may
easily be the indirect agent for causing scoliosis, producing myopia
or astigmatism…. Physically examine school children by all means,
but do not fail to examine school desks.”

Fifty schools in different parts of New York City were examined last
year with especial reference to the factors likely to cause or to
aggravate physical defects.[9] The results, [140]tabulated and analyzed,
prove that the woman principal was right; many schools are so built or
so conducted, many school courses are so devised or so executed, that
children are inevitably injured by the environment in which the
compulsory education law forces them to spend their formative years.

ONE OF NEW YORK CITY’S ROOF PLAYGROUNDS

Recently I noticed that our little office girl, so anæmic and nervous
when she left school that we hesitated to employ her, was becoming
rosy and spirited. The child herself explained the change: “I like it
better. I have more money to spend. I get more outdoor exercise, and
then, oh, the room is so much sunnier and there is more air and the
people are all so nice!” And these were just the necessities which
were lacking in the school from which she came. Moreover, it is a fair
commentary on the school work and the school hygiene in too many of
our towns and cities to-day. “I like it better” means that school work
is not adapted to the dominant interests of the child, that the
curriculum includes subjects remote from the needs and ambitions of
the modern school child, and fails to include certain other subjects
which it recognizes as useful and necessary, and [141]therefore finds
interesting. “I have more money to spend” means that this little girl
was able to have certain things, like a warm, pretty dress, rubbers,
or an occasional trolley ride, which she longed for and needed. “I get
more outdoor exercise” means that there was no open-air playground for
her school, that “setting up” exercises were forgotten, that recess
was taken up in rushing home, eating lunch, and rushing back again,
and that “after school” was filled up with “helping mother with the
housework.” “The office is so much sunnier and I get more air”
accounts for the increase in vitality; and “the people are all so
nice,” for the happy expression and initiative which the
undiscriminating discipline at school had crushed out.

BONE TUBERCULOSIS IS ONE OF THE PENALTIES FOR DRY SWEEPING AND FEATHER DUSTERS

For such unsanitary conditions crowded sections of great cities have
no apologies to make to rural districts. A wealthy suburb recently
learned that there was overcrowding in every class room, and that one
school building was so unsanitary as to be a menace to the community.
Unadjustable desks, dry sweeping, feather dusters, shiny blackboards,
harassing discipline that wrecks nerves, excessive home study and
subjects that bore, are not peculiar to great [142]cities. In a little
western town a competition between two self-governing brigades for
merit points was determined by the amount of home study; looking back
fifteen years, I can see that I was encouraging anæmic and
overambitious children to rob themselves of play, sleep, and vitality.
Many a rural school violates with impunity more laws of health than
city factories are now permitted to transgress.

After child labor is stopped, national and state child labor
committees will learn that their real interest all the time has been
child welfare, not child age, and will be able to use much of the old
literature, simply substituting for “factory” the word “school” when
condemning “hazardous occupations likely to sap [children’s] nervous
energy, stunt their physical growth, blight their minds, destroy their
moral fiber, and fit them for the moral scrap heap.”

Many of the evils of school environment the teacher can avert, others
the school trustee should be expected to correct. So far as unsanitary
conditions are permitted, the school accentuates home evils, whereas
it should counteract them by instilling proper health habits that will
be taken home and practiced. Questions such as were asked in Miss
North’s study will prove serviceable to any one desiring to know the
probable effect of a particular school environment upon children
subject to it. Especially should principals, superintendents,
directors, and volunteer committeemen apply such tests to the public,
parochial, or private school, orphanage or reformatory for which they
may be responsible.

I. Neighborhood Health Resources

VACATION-SCHOOL PLAY CLINIC ON A “VACANT” CITY LOT
OWNED BY THE ROCKEFELLER INSTITUTE FOR MEDICAL RESEARCH

II. Effect of School Equipment upon Health

AN ATTEMPT TO OVERCOME THE DISADVANTAGES OF CONGESTION—A BOYS’ HIGH SCHOOL, NEW YORK CITY

[146]III. The Class Room as a Place of Confinement

IV. Exercise and Recreation

HOME WORKSHOPS NEED FRESH AIR

V. The School Janitor and Cleaners

SCHOOL WORKSHOPS ALSO NEED FRESH AIR

VI. Requirements of Curriculum

By reducing the harm done by old buildings and by the traditions of
curriculum and discipline, teachers can do a great deal. Perhaps they
cannot move the windows or the desks, but they can move the children.
If they cannot insure sanitary conditions for home study, they can cut
down the home study. If the directors do not provide proper
blackboards, they can do less blackboard work. They can make children
as conscious, as afraid, and as resentful of dirty air as of dirty
teeth. They can make janitors believe that “dry sweeping” or “feather
dusting” may give them consumption, and leave most of the dirt in the
room to make work for the next day; that adjustable desks are made to
fit the child’s legs and back, not the monkey wrench; that the
thermometer in the schoolroom is a safer guide to heat needed than a
boiler gauge in the basement; that fresh air heated by coal is cheaper
for the school fund than stale air heated by bodies and by bad breath.
Finally, they can make known to pupils, to parents, to principals and
superintendents, to health officials and to the public, the extent to
which school environment violates the precepts of school hygiene.

If the state requires the attendance of all children between the ages
of five and fourteen at school for five hours a day, for five days in
the week, for ten months in the year, then it should undertake to see
that the machinery it provides for the education of those children for
the greater part of the time for nine years of their lives—the
formative years of their lives—is neither injuring their health nor
retarding their full development.

If the amount of “close-range” work is rapidly manufacturing myopic
eyes; if bad ventilation, whether due to [151]faulty construction or to
faulty management, is preparing soil for the tubercle bacillus; if
children with contagious diseases are not found and segregated; if
desks are so ill adapted to children’s sizes and physical needs that
they are forming crooked spines; if too many children are crowded into
one room; if lack of air and light is producing strained eyes and
malnutrition; if neither open air, space, nor time is provided for
exercise, games, and physical training; if school discipline is
adapted neither to the psychology nor the physiology of child or
teacher, then the state is depriving the child of a greater right than
the compulsory education law forces it to endure. Not only is the
right to health sacrificed to the right to education, but education
and health are both sacrificed.

In undertaking to enforce the compulsory education law, to put all
truants and child laborers in school, the state should be very sure
for its own sake that it is not depriving the child of the health on
which depends his future usefulness to the state as well as to
himself.

Table XI

Effects of a Child Labor Law

Increase in Chicago Attendance

FOOTNOTES:

CHAPTER XVToC

THE TEACHER’S HEALTH

“Teachers, gentlemen, no less than pupils, have a heaven-ordained
right to work so adjusted that the highest possible physical condition
shall be maintained automatically.” This declaration thundered out by
an indignant physician startled a well-meaning board of school
directors. The teacher’s right to health was, of course, obvious when
once mentioned, and the directors concluded:

Too little concern has hitherto been shown for the vitality of
teachers in private or public schools and colleges. Without protest,
and without notice until too late, teachers often neglect their own
health at home and at school,—recklessly overwork, undersleep, and
undernourish; ruin their eyes, their digestion, and their nerves.
School-teachers are frequently “sweated” as mercilessly as factory
operatives. The time has come to admit that a school environment which
destroys the health of the teacher is as unnecessary and reprehensible
as an army camp that spreads typhoid among a nation’s defenders. A
school curriculum or a college tradition that breaks down teachers is
as inexcusable as a gun that kills the gunner when discharged.
[153]Experience everywhere else proves that periodic physical examinations
and health precautions, not essays about “happy teachers—happy
pupils,” are indispensable if teachers’ health rights are to be
protected.

Physical tests are imposed upon applicants for teachers’ licenses by
many boards of education. In New York City about three per cent of
those examined are excluded for defects of vision, of hearing, of
probable endurance. Once a teacher, however, there is no further
physical examination,—no way of discovering physical incapacity,
nothing to prevent a teacher from exposing class after class to
pulmonary tuberculosis contracted because of overwork and
underventilation. The certainty of salary increase year by year and of
a pension after the twentieth year will bribe many a teacher to
overtax her own strength and to jeopardize her pupils’ health.

Seldom do training schools apply physical tests to students who intend
to become teachers. One young girl says that before starting her
normal course she is going to the physician of the board of education
for examination, so as to avoid the experience of one of her friends,
who, after preparing to be a teacher, was rejected because of
pulmonary tuberculosis. During her normal course no examination will
be necessary. Overwork during the first year may cause pulmonary
tuberculosis, and in spite of her foresight she, too, may be rejected
four years hence.

The advantages of physical examination upon beginning and during the
courses that prepare one for a teacher are so obvious that but little
opposition will be given by prospective teachers. The disadvantages to
teacher and pupil alike of suffering from physical defects are so
obvious that every school which prepares men and women for teachers
should make registration and certification dependent upon passing a
satisfactory physical test. No school should engage a teacher who has
not good proof that she can do the [154]required work without injury to
her own or her pupils’ health. Long before physicians can discover
pulmonary tuberculosis they can find depleted vitality which invites
this disease. Headaches due to eye trouble, undernourishment due to
mouth breathing, preventable indigestion, are insidious enemies that
cannot escape the physical test.

Three objections to physical tests for teachers will be urged, but
each loses its force when considered in the light of general
experience.

1. A sickly teacher is often the most efficient teacher in a school
or a county. It is true that some sickly teachers exert a powerful
influence over their pupils, but in most instances their influence and
their efficiency are due to powers that exist in spite of devitalizing
elements. Rarely does sickness itself bring power. It must be admitted
that many a man is teaching who would be practicing law had his health
permitted it. Many a woman’s soul is shorn of its self-consciousness
by suffering. But even in these exceptional instances it is probable
that children are paying too dearly for benefits directly or
indirectly traceable to defects that physical tests would exclude.

2. There are not enough healthy candidates to supply our schools.
This is begging the question. In fact, no one knows it is true. On the
contrary, it is probable that the teacher’s opportunity will make even
a stronger appeal to competent men and women after physical soundness
and vitality are made conditions of teaching,—after we all believe
what leading educators now believe, that the highest fulfillment of
human possibilities requires a normal, sound body, abounding in
vitality.

3. Examination by a physician, especially if a social acquaintance,
is an unnecessary embarrassment. The false modesty that makes
physical examination unwelcome to many adults, men as well as women,
is easily overcome when the advantages of such examination are
understood. [155]It is likewise easy to prove to a teacher that the loss
of time required in having the examination is infinitesimal compared
with the loss of time due to ignoring physical needs. The programme
for school hygiene outlined in Chapter XXVII, Part IV, assumes that
state and county superintendents will provide for the examination of
teachers as well as of pupils.

TEACHERS WILL PREFER PHYSICAL EXAMINATIONS TO FORCED VACATIONS
Boston Society for Relief and Study of Tuberculosis

Because the health of others furnishes a stronger motive for
preventive hygiene than our own health, it is probable that the
general examination of teachers will come first as the result of a
general conviction that unhealthy teachers positively injure the
health of pupils and retard their mental development. Children at
school age are so susceptible and imitative that their future habits
of body and mind, their dispositions, their very voices and
expressions, are influenced by those of their teachers. Experts in
child [156]study say that a child’s vocal chords respond to the voices and
noise about him before he is able to speak, so that the tones of his
voice are determined before he is able to express them. This influence
is also marked when the child begins to talk. Babies and young
children instinctively do what adults learn not to do only by
study,—follow the pitch of others’ voices. Can we then overestimate
the effect upon pupils’ character of teachers who radiate vitality?

The character and fitness, aside from scholarship, of applicants for
teachers’ licenses are now subjected by the board of examiners of New
York City to the following tests:

These tests probably exclude few applicants who should be admitted.
Experience proves that they include many who, for their own sake and
for children’s sake, should be rejected. The moral character, physical
fitness, quality of voice, personal bearing, self-command, executive
ability, [157]capacity for supervision, are qualities that are modified by
conditions. The voice that is satisfactory in conference with an
examiner may be strident and irritating when the teacher is impatient
or is trying to overcome street noises. On parade applicants are
equally cleanly; this cannot be said of teachers in the service,
coming from different home environments. Self-command is much easier
in one school than in another. Physical fitness in a girl of twenty
may, during one short year of teaching, give way to physical
unfitness. Therefore the need for periodic tests by principal,
superintendent, and school board, to determine the continuing
fitness of a teacher to do the special task assigned to her, based
upon physical evidence of her own vitality and of her favorable
influence upon her pupils’ health and enjoyment of school life.
Shattered nerves due to overwork may explain a teacher’s shouting:
“You are a dirty boy. Your mother is a dirty woman and keeps a dirty
store where no decent people will go to buy.” A physical examination
of that unfortunate teacher would probably show that she ought to be
on leave of absence, rather than, by her overwork and loss of control,
to cause the boys of her class to feel what one of them expressed:
“Grandmother, if she spoke so of my mother I would strike her.”

Just as there should be a central bureau to count and correct the open
mouths and closed minds that clog the little old red schoolhouse of
the country, so a central bureau should discover in the city teacher
as well as in the country teacher the ailments more serious than
tuberculosis that pass from teacher to pupil; slovenliness, ugly
temper, frowning, crossness, lack of ambition, cynicism,—these should
be blackballed as well as consumption, contagious morphine habit, and
contagious skin disease. Crooked thinking by teacher leads to crooked
thinking by pupil. Disregard of health laws by teacher encourages
unhygienic living by pupils. A man whose fingers are yellow, nerves
[158]shaky, eyes unsteady, and mind alternately sleepy and hilarious from
cigarettes, cannot convey pictures of normal, healthy physical living,
nor can he successfully teach the moral and social evils of
nicotinism. Both teacher and pupil have a right to the periodic
physical examination of teachers that will give timely warning of
attention needed. Until there is some system for giving this right to
all teachers in private, parochial, charitable, and public schools, we
shall produce many nervous, acrid, and physically threadbare teachers,
where we should have only teachers who inspire their pupils with a
passion for health by the example of a good complexion, sprightly
step, bounding vitality, and forceful personality born of hygienic
living.

PART III. COÖPERATION IN MEETING HEALTH OBLIGATIONS

CHAPTER XVIToC

EUROPEAN REMEDIES: DOING THINGS AT SCHOOL

Recently I traveled five hundred miles to address an audience on
methods of fitting health remedies to local health needs. I told of
certain dangers to be avoided, of results that had always followed
certain remedies, of motives to be sought and used, of community ends
to seek. Not knowing the local situation, I could not tell them
exactly what to do next, or how or with whom to do it; not seeing the
patient or his symptoms, I did not diagnose the disease or prescribe
medicine. Several members of the audience who were particularly
anxious to start a new organization on a metropolitan model were
disappointed because they were told, not just how to organize, but
rather how to find out what sort of organization their town needed.
They were right in believing that it was easier to copy on paper a
plan tried somewhere else, than to think out a plan for themselves.
They had forgotten for the time being their many previous
disappointments due to copying without question some plan of social
work, just as they copy Paris or New York fashions. They had not
expected to leave this meeting with the conviction that while the
ends of sanitary administration may be the same in ten communities,
health machinery should fit a particular community like a
tailor-made suit.

[160]American-like, they had a mania for organization. I once heard an aged
kindergartner—the savant of an isolated German village—describe my
fellow-Americans as follows: “Every American belongs to some
organization. The total abstainers are organized, the brewers are
organized, the teachers are organized, the parents are organized, the
young people and even the juniors are organized. Finally, those who
belong to no organization go off by themselves and organize a society
of the unorganized.” Love of organization and love of copying have
given us Americans a feverish desire for what we see or read about in
Europe. When we talk about our European remedies we try to make
ourselves believe that we are broad-minded and want to learn from
others’ experience. In a large number of cases our impatient demand
for European remedies is similar to the schoolboy’s desire to show off
the manners, the slang, or the clothes picked up on his first visit
away from home. With many travelers and readers European remedies or
European ways are souvenirs of a pleasant visit, to be described like
a collection of postal cards, a curious umbrella, a cane associated
with Alpine climbing, or a stolen hymnal from an historic cathedral.

Experience proves, however, that just as Roman walls and Norman
castles look out of place in New York and Kansas, so European laws and
European remedies are too frequently misfits when tried by American
schools, hospitals, or city governments. Yesterday a Canadian
clergyman, after preaching an eloquent sermon, met a professional
beggar on the street in New York City and emptied his purse—of
Canadian money! Quite like this is the enthusiastic demand of the
tourist who has seen or read about “the way it’s done in Germany.” The
trouble is that European remedies are valued like ruins, by their
power to interest, by their antiquity or picturesqueness, or, like the
beggar, by their power to stimulate temporary emotion. [161]But we do not
sleep in ruins, go to church regularly in thirteenth-century abbeys,
or live under the remedies that fire our imagination. We do not
therefore see their everyday, practical-result side.

The souvenir value of European remedies is due to the assumption that
no better way was open to the European, and that the remedy actually
does what it is intended to do. Because free meals are given at school
to cure and prevent undernourishment, it is taken for granted that
undernourishment stops when free meals are introduced; therefore
America must have free meals. Because it is made compulsory in a
charming Italian village for every child to eat the free school meal,
it is taken for granted that the children of that village have no
physical defects; therefore let Kansas City, Seattle, and Boston
introduce compulsory free meals. But when one goes to Europe to see
exactly how those much-advertised, eulogized remedies operate from day
to day, it is often necessary to write, as did a great American
sanitarian recently, of health administration in foreign cities
continually held up as models to American cities: “In spite of the
rules and theories over here, the patient has better care in New York
City.”

We have been asked of late to copy several very attractive European
remedies for the physiological ills of school children, and for the
physical deficiencies of the next generation of adults: breakfasts or
lunches, or both, at school for all children, rich as well as poor,
whether they want school nourishment or not; school meals for the poor
only; school meals to be given the poor, but to be bought by those who
can afford the small sum required; free eyeglasses for the poor, for
poor and well-to-do, for those who wish them, for those who need them
whether they want to wear eyeglasses or not; free dental care; free
surgical treatment; free rides and outings during summer and winter;
country children to visit the metropolis, city children to visit
country [162]and village; free treatment in the country of all children
whose parents are consumptives; free rides on street cars to and from
school; city-owned street railways that will prevent congestion by
making the country accessible; city-built tenements to prevent
overcrowding, dark rooms, insufficient air and light; free coal, free
clothes, free rent for those whose parents are unable to protect them
properly against hunger and cold. Every one of these remedies is
attractive. Every one is being tried somewhere, and can be justified
on emotional, economic, and educational grounds, if we think only of
its purpose. Let us view them with the eyes of their advocates.

Would it not be nice for country children to know that toward the end
of the school year they would be given an excursion to the largest
city of their state, to its slums, its factories, parks, and art
galleries? They would grow up more intelligent about geography. They
would read history, politics, sociology, and civil government with
greater interest. They would have less contracted sympathies. They
might even decide that they would rather live their life in the
spacious country than in the crowded, rushing city.

City children, on the other hand, would reap worlds of physical
benefit and untold inspiration from periods of recreation and study in
the country, with its quiet, its greens and bronzes and yellows, its
birds and animals, its sky that sits like a dome on the earth, its
hopefulness. Winter sleigh rides and coasting would give new vigor and
ambition. Why spend so much on teaching physiology, geography, and
nature study, if in the end we fail to send the child where alone
nature and hygiene tell their story? Why tax ourselves to teach
history and sociology and commercial geography out of books when
excursions to the city and country will paint pictures on the mind
that can never be erased? What more attractive or more reasonable than
appetizing, warm meals, or cool salads and drinks for [163]the boys and
girls who carry their little dinner pails and baskets down the long
road where everything runs together in summer and everything freezes
in winter? One needs little imagination to see the “smile that won’t
come off,” health, punctuality, and school interest resulting from the
school meal.

Again, if children must have teeth filled and pulled, eyes tested and
fitted for glasses, adenoids and enlarged tonsils removed, surely the
school environment offers the least affrighting spot for the tragedy.
Thence goblins long ago fled. There courage, real or feigned, is
brought to the surface by the anxious, critical, competitive interest
of one’s peers.

A SOUTH IRELAND ARGUMENT FOR “DOING THINGS”

The economic defense of these remedies is many-sided. An English
drummer once instructed me during a railroad journey from southern to
northern Ireland. As we entered the fertile fields of Lord Dunraven’s
estate near Athlone, I expressed sympathy for other countries
impoverished of soil, of wealth, and of thrift. My instructor replied:
“It would pay the government to bring them all to this land free once
a year, just to show them what they are missing.” That his idea of an
investment is sound has been proved by railroads and land companies
and even by states, who give away excursions to entice settlers and
buyers. Ambition at almost any cost is cheaper than indifference to
opportunity. It would be cheaper for our American taxpayer to send
school children to city and country than to pay the penalty for having
a large number of citizens with narrow interests, unconscious of the
struggles and joys of [164]their co-citizens. Free meals, free books, free
rides, free eyeglasses, are cheaper than free instruction for the
second, third, and sixth terms in studies not passed because of
physical defects,—infinitely cheaper than jails and almshouses,
truant officers and courthouses.

The demoralizing results of giving “something for nothing” did not
follow free schooling or free text-books. Perhaps they would not
follow the free remedies that we are asked to copy from Europe. In
fact, the word “free” is the wrong word. These remedies rather require
coöperation of parent with parent. It has demoralized nobody because
the streets are cleaned by all of us, country roads made by the
township, police paid for by taxes and not by volunteer subscription.

The man whose children do not need glasses or nourishment or operation
for adenoids would find it cheaper to pay for European remedies than
for the useless schooling of boys unable to get along in school
because of removable defects. An unruly, uninterested boy sitting
beside your boy in public school, a pampered, overfed, undisciplined
child sitting beside yours at private school, is taxing you without
your consent and doing your child injury that may prove irreparable.

It costs $2.50 to furnish a child with eyeglasses. It costs $25 to $50
to give that child a year’s schooling. If the child cannot see right
and fails in his studies, we have lost a good investment and, after
one year so lost, we are out $22.50. In two years we have lost $47.50.
But, what is more serious, we have discouraged that boy. Used to
failure in school, his mind turns to other things. He is made to think
that it is useless for him to try for first place. Perhaps he can play
ball, and excels. He chooses a career of ball playing. Valuable years
are lost.

Initiative and competition are not interrupted any more by free
eyeglasses and free operation for adenoids than by [165]free schooling.
There is only one place in the world where there is less competition
or less struggle than among the ignorant, and that is among the
ignorant and unwell. The boy who can’t see the blackboard, who can’t
learn to spell, who can’t breathe through his nose, and can’t be
interested, doesn’t compete at all with the bright, healthy boy.
Remove the adenoids, give glasses, make interest possible, and fitness
to survive takes a higher level because larger numbers become fit to
survive.

Professor Patten says that it is easier to support in the almshouse
than in competitive industry a man who cannot earn more than $1.50 a
day. The question, therefore, regarding European remedies is not, To
what general theory do they belong? but, What will they accomplish?
How do they compare with other remedies of which we know?

CHAPTER XVIIToC

AMERICAN REMEDIES: GETTING THINGS DONE

In New York City there is a committee called the Committee on the
Physical Welfare of School Children. The word “welfare” was used
rather than “condition” because the committee proposed to use whatever
facts it could gather for the improvement of home and school
conditions prejudicial to child welfare. The following programme was
adopted:

The committee grew out of the discussion, in the year 1905, of the
following proposition: To insure a race physically able to receive
our vaunted free education, we must provide at school free meals, free
eyeglasses, free medical [167]and dental care. Thanks to the
superintendent of schools of New York City, to Robert Hunter’s
Poverty, to John Spargo’s Bitter Cry of the Children, hundreds of
thousands of American citizens were made to realize for the first time
that a large proportion of our school children are in serious need of
medical, dental, or ocular attention, or of better nourishment.

Because physicians, dentists, oculists, hospitals, dispensaries,
relief agencies, had seemingly been unconscious of this serious state
of affairs, they had no definite, constructive remedy to propose.
Their unpreparedness served to strengthen the arguments for the
European method of doing things. France, Germany, Italy, England,
had found it necessary to do things at school. Arguing from their
experience, it was only a matter of time when American cities must
follow their example. Why not, therefore, begin at once to deal
radically with the situation and give school meals, school eyeglasses,
etc.? Those who organized the Committee on the Physical Welfare of
School Children realized the danger of trying to settle so great a
question with the little definite information then available. If
doing things at school were to be adopted as a principle and
logically carried out, vast sums must be added to the present cost of
the public school system. Complications would arise with private and
parochial schools, whose children might have quite as serious physical
defects, even though not educated by public funds. It would be
difficult to obtain proper rooms for medical and dental treatment and
meals, and perhaps still more difficult to insure proper food, skilled
oculists, dentists, surgeons, and physicians. No one was clear as to
how the problem was to be solved by small cities and rural districts,
whose needy children are no less entitled to public aid simply because
their numbers are smaller. Great as were the difficulties, however,
the committee saw that difficulties are in themselves no reason for
not doing the right thing. On the [168]other hand, if doing things at
school is wrong, if school meals fail to correct and remove physical
defects, great social and educational wrong would result from New
York’s setting an example that would not only misdirect funds and
attention in that city, but would undoubtedly lead other cities to
move in the wrong direction. Right could be hastened, wrong could be
prevented more effectually by facts than by any amount of theory.
School meals had been made a political issue in England. The arguments
supporting them were stronger than any possible arguments against
them, except proof that they would be less effective in helping
children than other means that might be proposed. If the American
people must choose between sickly, unteachable, dull children without
school meals, on the one hand, and bright, teachable, healthy children
plus school meals, on the other hand, they will not hesitate because
of expense or eighteenth-century objections to “socialism.”

During one year of investigation and of getting things done the
committee has prepared three studies for publication: (1) a report on
the home conditions of fourteen hundred school children of different
nationalities, found by school physicians to have defects of vision,
breathing, hearing, teeth, and nourishment; (2) an examination of
fifty schools—curriculum, buildings, home-study requirements, play
space and playtime, physical culture—in an attempt to answer the
question, How far does school environment directly cause or aggravate
physical defects of school children; (3) a comparative study of
methods now employed in a hundred cities to record, classify, and make
public significant school facts.

The results of the first year’s work prove conclusively that physical
defects are not caused solely by the inability of parents to pay for
proper food. Among the twenty significant facts reported by the
committee are the following:

From twenty such statements of fact and from its experience in
getting things done for one year, the committee drew fifteen
practical conclusions, among which the following deserve emphasis
here:

1. The only new thing about the physical defects of school
children is not their existence, but our recent awakening to their
existence, their prevalence, their seriousness if neglected, and
their cost to individual children, to school progress, to
industry, and to social welfare.

2. Physical deterioration, applied to America’s school children,
is a misnomer. No evidence whatever has been given that the
percentage of children suffering from physical defects in 1907 is
greater than the percentage of children suffering from such
defects in 1857. On the contrary, the small proportion of defects
that are not easily removable, as well as a vast amount of
evidence from medical experience and vital statistics, indicates
that, if a comparison were possible, the children of 1907 would be
found to have sounder bodies and fewer defects than their
predecessors of fifty years ago. If there is an exception to this
statement, it is probably defects of vision, with regard to which
school authorities and oculists seem to agree that confinement in
school for longer [170]hours and more constant application under
unfavorable lighting conditions have caused a marked increase.
Positive evidence as to tendencies will be easily obtained after
thorough physical examination has been carried on for a
generation.

3. The effect of massing facts as to physical defects of school
children should not be to cause alarm, but to stimulate remedial
and preventive measures, to invoke congratulations and aggressive
optimism, not doleful pessimism and palliative measures born of
despair.

THE DARK-HALL EVIL IS HERE INDEXED BY ADENOIDS.

4. The causes of physical defects are not confined to “marginal”
incomes, but, while more apt to be present in families having
small incomes, are found among all incomes wherever there exist
bad ventilation, insufficient outdoor exercise, improper light,
irregular eating, overeating, improper as well as insufficient
food, lack of medical, dental, and ocular attention.

5. Whatever may be said of free meals at school as a means of
insuring punctual attendance or better attention, they are
inadequate to correct physical conditions that home and street
environment produce.

6. To remove physical defects, causal conditions among all income
classes should be treated, and not merely symptoms revealed at
school by children of the so-called poor.

7. Parents can and will correct the greater part of the defects
discovered by the physical examination of school children, if
shown what steps to take. Where parents refuse to do what can be
proved to be within their power, and where existing laws are
nonenforced or inadequate, the segregation of children having
physical defects in special classes might prove an effective
stimulus to obstinate parents.

8. Where parents are unable to pay for medical, dental, and ocular
care and proper nourishment, private philanthropy must either
provide adequately or expect the state to step in and assume the
duty.

9. Private dispensaries and hospitals must either arrange
themselves to treat cases and to educate communities as to the
importance of detecting and correcting physical defects, or must
expect the state to provide hospital and dispensary care. Until
private hospitals and dispensaries take steps to prevent people
[171]with adequate incomes from imposing upon them for free treatment,
it is difficult to make out a case against free eyeglasses and
free meals for school children.

10. Either private philanthropy or the state must take steps to
procure more dental clinics and an educational policy on the part
of the dental profession that will prevent the exploitation of the
poor when dental care is needed.

11. The United States Bureau of Education is the only agency with
authority and equipment adequate to secure from all sections of
the country proper attention to the subject. Nothing in the world
can prevent free meals, free eyeglasses, free medical care, free
material relief at school, unless educational use is made by each
community of the facts learned through physical examination to
correct home, school, and street conditions that produce and
aggravate physical defects. The national bureau can mass
information in such a way as to convince budget makers in city,
county, and state to vote gladly the funds necessary to promote
the physical welfare of school children.

How the committee got things done is often referred to. There is
something about a request for coöperation, whether by schools or by
any other agency, that enlists the interest of those whose help is
asked. The reason is not that people are flattered by requests to
serve on committees, or that human nature finds it difficult to be
unfriendly or unkind. On the contrary, men and women are by nature
social; there is more joy in giving than in withholding, in working
with others than in working alone. Men and women, official and
volunteer agencies, will coöperate with school-teachers when invited,
for the same reason and [172]with the same readiness that ninety-nine
farmers out of a hundred, on the prairie or in the mountain, will
welcome a request for food and lodging.

WHERE “GETTING THINGS DONE” IS POSSIBLE BUT “DOING THINGS” INEFFECTIVE

Mothers will naturally take a greater interest in the welfare of their
children if held responsible for proper food and proper home
surroundings than if not reminded of their responsibility. In New York
City a woman district superintendent of schools, Miss Julia Richman,
has organized a unique “social settlement.” She and several
school-teachers occupy a house, known as “The Teachers’ House.” This
is their residence. Here they are subject to neither intrusion nor
importunity; no clubs or classes are held here; visitors are treated
as guests, not as beneficiaries. The purpose these teachers have in
living together is to work out the methods of interesting private and
official leaders in community needs disclosed at school.

[173]Where clubs and social gatherings are held in school buildings, it is
not unusual for a thousand mothers, recent immigrants, to meet
together in one hall to hear talks on the care of children. Thus,
instead of principals, teachers, and physicians taking the place of
mothers (which they nowhere have succeeded in doing), they do succeed
in harnessing mothers to the school programme. It may take two, three,
or ten visits to get a particular mother to do the necessary thing for
her child, but when once convinced and once inspired to do that thing,
she will go on day in and day out doing the right thing for that child
and for all others in her home. It may take a year to convert a police
magistrate whose sympathy for delinquent parents and truant children
is an active promoter of disorder; but a magistrate convinced,
efficient, and interested is worth a hundred volunteer visitors. To
get things done in this way for a hundred thousand children costs less
in time and money than to do the necessary things for one thousand
children.

CHAPTER XVIIIToC

COÖPERATION WITH DISPENSARIES AND CHILD-SAVING AGENCIES

Scientists agree that the human brain is superior to the animal brain,
not because it is heavier, but because it is finer and better supplied
with nerves. As one writer has said, the human brain is better
“wired,” has better organized “centrals.” A poor system of centrals
will spoil a telephone service, no matter how many wires it provides.
An independent wire is of little use, because it will not reach the
person desired at the other end. The ideal system is that which almost
instantly connects two persons, no matter how far away or how many
other people are talking at the same time on other wires.

ADEQUATE RELIEF RECOGNIZES THE FAMILY AS THE UNIT

The school that tries to do everything for its pupils without using
other existing agencies for helping children[10] will be like the man
who refuses to connect his telephone with a central switch board, or
like a bank that will not use the central clearing house. As one
telephone center can enable scores of people to talk at once, and as
one clearing house can make one check pay fifty debts, so hospital and
relief agencies enable a teacher who employs “central” to help several
times as many children as she alone can help.

It seems easier for a teacher to give twenty-five cents to a child in
distress than to see that the cause of the misery is removed. In New
York City there are over five hundred school principals, under them
are over fifteen thousand [175]teachers, and the average attendance of
children is about six hundred thousand, representing one hundred and
fifty thousand homes. If teachers give only to those children who ask
for help, many will be neglected. In certain sections of the city
principals have combined to establish a relief fund to be given out to
children who need food, clothes, shoes, etc. One principal had to stop
replacing stolen overcoats because, when it was known that he had a
fund, an astonishingly large number of overcoats disappeared. At
Poughkeepsie school children get up parties, amateur vaudeville,
minstrel shows, basket picnics, to obtain food and clothing for
children in distress. They are, of course, unable to help parents or
children not in school. Of this method a district superintendent in
New York said to his teachers and principals: “For thirty-two years I
have been working in the schools of this district. I have given food
and shoes to thousands of children. I know that however great our
interest in a particular child when it comes to us with trouble at
home, our duty as teachers prevents us from following our gift into
the home and learning the cause of the child’s trouble. This last
winter we have made an experiment in using a central society, which
makes it a business to find out what the family needs, to supply
necessaries, country board, medicine, etc. We now know that we can put
a slip of paper with the [176]name and address of the child into a general
hopper and it will come out eyeglasses, food, rent, vacation parties,
as the need may be.”

Relief at home through existing agencies was brought about by the
distribution of cards like those on opposite page, which offer winter
and summer coöperation.

FRESH-AIR AGENCIES LIKE SEA BREEZE PREFER TO AID CHILDREN IN ORDER OF NEED

When these cards were first distributed several teachers went from
room to room, asking children who needed help to raise the hand. In
many cases parents were very angry that their children should have
asked for help. But help given in instances like the following soon
proved to teachers that they could afford the time necessary to notice
children who appeared neglected, when so much good would ensue:

The father is sick and unable to work. They cannot get clothes for
the children, who are not attending school on that account.
Children were provided with shoes and clothes.

November 30, 1907, a school principal reported that six children
in one family needed underwear. A visitor discovered that one of
the boys who had the reputation of being unruly and light-fingered
also had adenoids. He was taken to a hospital for operation, and
was later interested in his school work.

[177]

[178]A little girl was unruly and truant. No attempt was made to keep
her at school, but she was reported to the Committee on the
Physical Welfare of School Children. The parents could not control
her. The girl was taken for examination by a specialist and found
to be feeble-minded. Later she was sent to a custodial institute.

Another little girl was nine years old, but could not talk. A
University Extension Society worker found that she was not kept at
school because it was too much trouble. The child was taken to a
physician who operated and corrected the tongue-tie.

A girl of twelve said she must stay home to “help mother.” The
mother was found to be a janitress, temporarily incapacitated by
rheumatism. A substitute was provided until the mother was well,
and all the children were properly clad for school.

After the adenoid operations in a New York school that occasioned
the East Side riots of 1906, the physicians and principals who had
persuaded parents to permit the operations were fearful lest the
summer in unsanitary surroundings might make the demonstration
less complete. Over forty children in three parties were sent away
for the summer, where they had wholesome food and all the milk
they could drink and fresh air day and night. When they returned
in the fall the principal wrote: “The improvement in each
individual is simply marvelous. We shall try to continue this
condition and shall constantly urge the parents to keep up the
good work by means of proper food and fresh air.”

In none of these instances could the teachers have accomplished equal
results for the individual children or for the families without
neglecting school duties. By informing other agencies as to children’s
needs, teachers started movements that have since helped practically
every school child in New York City. Dispensaries are setting aside
separate hours for school children; fresh-air agencies are giving
preference to children found by teachers or school physicians to be in
physical need; relief agencies are making “rush orders” of every note
from teachers; the health board is more active because volunteer
agencies [179]have added their voice to that of teacher and health officer
in demanding adequate funds for physical examination of school
children.

“CENTRAL” FOUND THE MOTHER SICK IN A HOSPITAL, THE
FATHER KILLED—THE CHILDREN WERE BOARDED IN THE COUNTRY UNTIL THE MOTHER RECOVERED

Coöperation is at present easier in New York than in any other city.
Charitable societies, hospitals, dispensaries, are probably more
keenly alive to their responsibilities and are at least more apt to
have acquired the habit of coöperation when asked. Yet even here I
have been told repeatedly by teachers: “If we have to wait for that
hospital or that charitable society, our children will go barefoot.”
In small communities where hospital and relief agencies are for
emergencies only and generally inactive, it seems that the first thing
to do is to ask some friends to establish a small relief fund, just as
it is easier to give a child a five-cent [180]meal than to teach its
mother how to prepare its food. But the school-teacher will find that
it takes very much less energy to arouse the relief society than to
maintain her own relief work. In fact, in many cities nothing could do
more to strengthen hospitals and charitable societies than to put them
in touch with the needs of school children. For a principal to make
known the fact that school children are neglected will help the
charitable society and hospital to get the funds necessary to do their
part better than they are now doing it and better than the school
could ever do it. Finally, one reason for a breakdown of charitable
societies is not their own inadequacy, but rather the failure of the
[181]school and church to make use of an agency better equipped than
themselves to give material relief. The teacher sees the child every
day, while the relief society will never see it and has no reason to
see it until some one calls attention to it. The very first step, and
an indispensable one in relief policy, is for teachers to be on the
lookout for children not adequately provided for, and then have the
physical evidence discovered at school followed to the home for the
cause of the child’s distress.

HOME-TO-HOME INSTRUCTION IN COOKING
Anæmic condition of child due to bad cooking, not to lack of income

Coöperation removes the cause of distress; doing may aggravate it.
Teachers would do well to draw up for themselves a chart which will
show exactly what part of the community’s work can be best done by
their school. On the following page is charted the social work now
being conducted at the Massachusetts General Hospital, Boston. So far
as agencies exist to deal with any individual or family problem coming
into the social-work square, the hospital aims to utilize that agency.
Its own direct dealing with neurasthenics, with hygiene education,
with sexual deviates, is primarily for the purpose of giving adequate
treatment to the needy, and secondarily to demonstrate how adequate
treatment should be organized for the community. Please to note that
governmental agencies are not mentioned in Dr. Cabot’s chart. This
does not mean that he would not emphasize the importance of those
agencies, but that up to the present time, for the particular cases
dealt with in his clinics, governmental agencies can be reached most
effectively through the private charitable agencies in the reference
square. So the teacher will frequently find that the relief bureau,
children’s society, public education association, or church can get
better results for her pupils from public health and correctional
agencies than can she by writing directly.

[182]

[183]In country districts no plan has yet been worked out for adequate
relief. Fortunately, however, the distress is generally of such a
kind, and the teacher so well acquainted with all the parents of her
district, that it will not be difficult to procure such attention as
is necessary. Country schools should be furnished by county and state
superintendents with clear directions for getting the treatment
afforded in the immediate vicinity. Where teachers are alone in seeing
the need for coöperation they can quickly interest young and old,
physicians, dentists, pastors, health officers, in home visiting,
street cleaning, nursing, helping truants, needed changes of
curriculum, etc. Getting things done is easy because it is human to
love the doing; getting things done is doing of the highest order.

FOOTNOTES:

CHAPTER XIXToC

SCHOOL SURGERY AND RELIEF OBJECTIONABLE, IF AVOIDABLE

The popular arguments for free meals, free relief, free medical
treatment at school, are based upon the assumption that there are but
two ways to travel, one leading to a physically sound, moral,
teachable child, the other to an undernourished, subnormal, backward
child. They tell us we must choose either school meals or
malnutrition, school eyeglasses or defective vision, free coal or
freezing poor, free rent or people sleeping on the streets, free
dental clinics at school or indigestion and undernourishment, free
operation at school for adenoids or backward, discouraged pupils. If
there is no other alternative than neglect of the child, if we must
either waste fifty dollars in giving a child education that he is
physically unable to take, or pay two, three, four, or even fifty
dollars to fit him for that education, the American people will not
hesitate. Whether there are other roads to healthy children, whether
it is cheaper and better for the school to see that outside agencies
prepare the child for education rather than itself to take the place
of those outside agencies, is a question of fact, not of theory.

Facts prove, as we have seen, that there is more than one way to
prevent malnutrition. Parents can be taught to attend to their
children; hospitals and dispensaries will furnish eyeglasses where
parents are unable to pay for them; charitable societies will go back
of the need for eyeglasses to the conditions that produce that need
and will do vastly more for the child than can eyeglasses alone. If
[185]parents, hospitals, dispensaries, and charitable societies will attend
to children’s needs, then relief at school is unnecessary, even though
it may seem desirable.

The objection to school surgery should be clearly before us, so that
we can judge of the two methods that are open to us,—treatment at
school vs. treatment away from school.

Society is so organized that the treatment of serious physical defects
and social needs at school would upset the machinery a very great
deal. For the school to do for its children whatever they may need
during their school years will require the setting up of a miniature
society in every school building or under every school board. Unless
schools are to equip themselves to take the place of all existing
facilities for relief and surgery, children would not be so well taken
care of as at present. It should not be forgotten that the physical
welfare of the school child is the most accurate index to the physical
needs of the community. After all, the child lives for six important
years before coming to the school and leaves at the early age of
fourteen or fifteen; even while attending school it sleeps at home and
is influenced more by home and street standards of ventilation,
cleanliness, and morality than by conditions at school. It would seem,
therefore, the wider use of the school’s influence to use the child’s
appeal to strengthen every agency having to do with community health,
rather than to concentrate upon the child himself. If babies were
properly cared for up to the sixth year, the protection of the school
child’s health would be infinitely easier. To take our eyes from the
child not yet in school and from the child just out of school is to
make the mistake that so many advocates of the child labor movement
have made of going whither and only so far as our interest leads us
and of not continuing until our work is accomplished.

“DOING THINGS” THROUGH MODEL TENEMENTS

Do we want to make of our schools miniature hospitals, dispensaries,
relief bureaus, parks? Or shall we use the [186]momentum of society’s
interest in the school child to put within the reach of every school
building adequate hospitals, dispensaries, relief centers, and parks
for school child and adult? Shall every little school have its
library, or shall the child be taught at school how to use the same
library that [187]is available to his parents and older brothers and
sisters? If the library is to be under the school roof, if dispensary
and relief hospital are to be conducted on the same site as the
school, shall they be known as dispensary, library, relief bureau,
each under separate management, or shall [188]they be known as school
under the management of school principal and superintendent? So
complicated and many-sided is the problem of working together with
one’s neighbor for mutual benefit that it is a safe rule for the
schools to adopt: We shall do nothing that is unnecessary or
extravagant. We shall have done our part if we do well what no one
else can do. Whatever any agency can do better than we, we shall leave
to that agency. Work that another agency ought to have done and has
left undone, we shall try to have done by that agency.

IMMEDIATELY OPPOSITE THE MODEL TENEMENTS, BUT UNINFLUENCED
“Getting things done” by the Tenement House Department their special need

I know a hospital where a welfare nurse was recently employed. Within
a few blocks were three different relief agencies and two
visiting-nurse’s associations, having among them over one hundred
visitors and nurses going to all sections of Manhattan. This nurse had
the choice of telephoning to one of these agencies and asking it to
call at the needy home of one of her hospital patients, or of going to
the home herself. Had she chosen to use another agency, she could have
been the means of furnishing the kind of help needed in every needy
home discovered in her hospital rounds, but she chose to do the
running about herself and thus of helping ten families where she ought
to have helped five hundred. Much the same condition confronts the
school that tries to do all extra work for its child instead of seeing
that the work is done. Illustration is afforded by the New York
tenement department. Whereas European cities have built a few model
tenements, New York City secured a law declaring that everybody who
built a tenement and everybody who owned a tenement should provide
sanitary surroundings. At the present time a philanthropist, by
spending two million dollars, could give sanitary surroundings to
thirty-five families; by spending each year the interest on one tenth
that sum he could insure the enforcement of the tenement laws
affecting every tenement resident in New York City.

[189]If schools are to perform surgical operations, they are in danger of
being sued for malpractice; discipline will be interfered with.
Finally, let us not forget that we are dealing with buildings,
teachers, and school institutions as they exist. Where education is
made compulsory, the unpleasant and the controversial should be kept
out of school. Because a democratic institution, the American school
should represent at all times a maximum of general agreement.

To take palliative measures to public schools not only leaves
undone remedial work necessary for the health of public school
children but neglects entirely the still large numbers who go to
parochial, private pay, and private free schools; no one has had the
temerity to suggest that the public shall force upon nonpublic schools
a system of free operations, free eyeglasses, free meals.

Civilization has painstakingly developed a large number of agencies
for the education and protection of mankind. Of these agencies the
school is but one. Its first and peculiar function is to teach and to
train. This it can do better than any other agency or combination of
agencies. In attempting to “bring all life under the school roof,” we
use but a small part of our resources. Instead of persuading each of
the agencies for the promotion of health to do its part for school
children, we set up the school in competition with them. Thus in
trying to do things for school children we are in danger of
crippling agencies equipped to do things for both school children and
their parents, for babies before they come to school, and for wage
earners after they leave school.

Getting things done will lead schools to study underlying causes;
doing things has heretofore caused schools to confine themselves to
symptoms. Getting things done will leave the school free to
concentrate its attention upon school problems; doing things will
lead it afield into the problem of medicine, surgery, restaurant
keeping, and practical charity.