PART II. READING THE INDEX TO HEALTH RIGHTS
CHAPTER V[ToC]
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.
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 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, 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 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 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 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 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 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:
1. Inability to breathe through the nose.
2. A chronically running nose, accompanied by frequent nose-bleeds and a cough to clear the throat.
3. Stuffy speech and delayed learning to talk. "Common" is pronounced "cobbéd"; "nose," "dose"; and "song," "sogg."
4. A narrow upper jaw and irregular crowding of the teeth.
5. Deafness.
6. Chorea or nervousness.
7. Inflamed eyes and conjunctivitis.
The adenoids and large tonsils discovered at school are an index:
1. To children needlessly handicapped in school work.
2. To teachers needlessly burdened.
3. To whole classes held back by afflicted children.
4. To breeding grounds for disease.
5. To homes where children's diseases and tuberculosis are most likely to break out and flourish.
6. To parents who need instruction in their duty to their children, to themselves, and to their neighbors, and who are ignorant of the way in which "catching" diseases originate and spread.
The riot that occurred when the adenoids of children in a school on the "East Side" in New York City were 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 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 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 VI[ToC]
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 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 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 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 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 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 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
Four columns are omitted: (1) Interval between Exposure to Infection and the First Signs of the Disease; (2) Day from Onset of Illness on which Rash appears; (3) Period of Exclusion from School after Exposure to Infection; (4) Period of Exclusion from School of Person suffering from the Disease
In the following diseases only the affected child is excluded
| Erysipelas. Child should not return till all swelling and peeling of skin has disappeared. | Ringworm on Scalp. Child should be excluded till cured. Very difficult to cure and often takes a very long time. |
| Ophthalmia. Child should not return till all traces have disappeared. | Phthisis (Consumption). If in advanced stage and coughing much or spitting, child should be excluded. (Infection from breath and dried spit floating in the air as dust.) |
| Scabies or Itch. Child should be excluded until cured. | |
| Ringworm on Skin. Child should be excluded till cured. This takes only a few days if properly treated. | Impetigo (Contagious Sore). Child should be excluded until cured. A week or ten days should suffice. |
| A. BROWN RITCHIE, Medical Officer to Education Committee. | |
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:
In addition to the Society for the Suppression of Noises there should be in this town a Society for the Suppression of "Fresh-Air" Fiends. The newspapers report an epidemic of pneumonia, grippe, and colds. It is almost entirely due to the fact that the average New Yorker is compelled to live, move, and have his being from daylight to midnight in a succession of draughts of cold air caused by the insanity of overfed male and female hogs, who, with blood almost bursting through their skins, demand "fresh air" in order to keep from suffocating. Everywhere a man goes, day or night, he is in a draught caused by the crazy ideas about fresh air.
Our wise ancestors, who as a rule lived much longer than we do, and had much better health, said:
"If the wind should blow through a hole,
God have mercy on your soul."
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.
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 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
| England and Wales | 22.70 |
| Scotland | 27.40 |
| Stockholm | 26.70 |
| London | 31.20 |
| Berlin | 16.10 |
| Vienna | 39.70 |
| Christiania | 21.30 |
| Boston | 30.60 |
| Chicago | 24.20 |
| Philadelphia | 25.10 |
| New York City | 36.60 |
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, 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 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, 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 VII[ToC]
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 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 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 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:
1. Scrutinize the faces for a strained or worried expression while reading or writing, for squint eyes, for unnatural positions, and for improper distances (more or less than nine inches) from eye to book.
2. Select for first tests the children who obviously need attention and will be obviously benefited. Use the eye test to help trace the cause of headaches, nervousness, inattention.
3. Let the children mark off the distances with a foot rule and chalk, going as high as twenty. Be sure to get the best light in the room.
4. Start all children on the ten-foot line. If a child cannot read at ten feet the letter which should be seen at that distance, move the child forward, have it step forward and backward, and note the result carefully. It is better to have ten separate letters of exactly the right size and the same size than a row of letters on one card, as in the Snellen test, otherwise memory will aid the eye, or, as happened recently, a whole class may agree to feign remarkable nearsightedness or farsightedness by confusing letters learned in advance from the card. If the Snellen card is used, and if it is more convenient to have both child and card stationary, satisfactory results will be obtained by having the child read from large letters down as far as he can see.
5. Have the child read from right to left, from left to right, or skip about so that memory cannot aid the eye.
6. Test each eye separately. I was twenty-five years old before I learned that my left eye did practically all of the close sight work. A grown woman discovered just a few days ago that she was almost blind in the left eye; when she rubbed the right one while reading she was shocked to find that she could see nothing with the left eye.
7. If the card is stationary and the child moved, and if only one size of the letter is used, put in the denominator the number of feet at which the normal eye should see clearly, and in the numerator the distance at which each eye and both together can easily see. If the regular Snellen card is used containing letters of different size, place in the denominator the number of the lowest line each eye and both eyes together can read easily, and in the numerator the number of feet from card to eye.
8. Explain the result to the child, to his fellows, to his parents. If the left eye reads 10/20 and the right eye 10/30, it means that neither eye is normal, and that reading small type is a constant strain, even though unnoticed. The right eye must be within ten feet to read what it should read at twenty feet. The left eye must be within ten feet to read what it should read at thirty feet. If the two eyes read at ten, it means that in working together they successfully strain for a result that is not worth what it is costing. When eyes thus unconsciously see what they are not intended to see, it is only a matter of time when stomach and nervous system will announce that the strain can no longer be borne. Indigestion, dislike of study, restlessness follow. If, however, the eyes are so near the normal that their story reads 12/10 or 8/10, the strain will be negligible for the present. If, on the other hand, the only difficulty is a confusion of x and z with c and g, it means that there is a strain due to astigmatism, and that the child should be sent to an oculist.
9. Teach children and parents (and practice what you preach) the urgent importance of periodic reëxamination, just as you would teach them to visit a dentist twice a year. This is needed by those who wear eyeglasses, and more particularly by those who have recently put them on. Moreover, as shown below, it is needed by children able to pass satisfactorily the Snellen test.
10. Acquire the habit of reading the eye for evidence of temperate or intemperate living, sleeping, eating, dancing, drinking, and smoking. Inflamed eyes are results,—signals of danger. "The organ may be faultless in construction and in its work poor, because of nerve exhaustion, or, in a less and more easily recoverable degree, nerve fatigue." If unusual eye conditions are not readily explained by mode of living or by eye tests, an oculist should be consulted.
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. 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 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 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 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.
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 VIII[ToC]
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.
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, 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 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 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 IX[ToC]
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 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 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 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.
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]
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.
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 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.
| How many members in your family? How many teeth have they? How many teeth have they lost? How many false teeth have they? How many teeth have been filled? What is the total cost to date? How many days have been lost from work because of toothache? How many teeth are now decayed? What will it cost to have them attended to? | What does a toothbrush cost? How many do you need in one year? How much does tooth powder cost? How much is needed for one year? How much would two examinations a year by a dentist cost? |
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. 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 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:
1. The expensiveness of proper dentistry.
2. The untrustworthiness of cheap dental service and "painless" dental parlors; the domination of the supply houses wishing to sell instruments and other supplies.
3. The ethical objection to any kind of advertising or to work by wholesale.
4. The lack of dispensaries.
5. The profit-making basis of dental education.
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 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 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 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:
[5] The Teeth and Their Care, by Thaddeus P. Hyatt, D.D.S., is a short, concise treatment of the principles of dental sanitation.
CHAPTER X[ToC]
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:
A drooping head, a pale face, dull, sunken eyes, flat chest and rounded shoulders, with emaciated limbs, soft flabby muscles, and general lack of good physical, mental, and moral tone.
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.
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 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 XI[ToC]
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, 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 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
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.
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 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.
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. 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:
Oh wad some power the giftie gie us
To see oursel's as ithers see us;
It wad frae mony a blunder free us,
And foolish notion.
FOOTNOTES:
[6] The Unconscious Mind by Schofield, The Study of Children and their School Training by Dr. Frances Warner, and The Development of the Child by Nathan Oppenheimer show clearly the physical and mental limitations and possibilities of children.
CHAPTER XII[ToC]
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.
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 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:
I do not consider a mere athlete to be a really healthy man. He has no more right to be called a really healthy man than the foundations or scaffolding of a house have a right to be called a house. They become a good house, and, indeed, they are indispensable to a good house, but at present the good house exists only in potentiality.
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 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 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."
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:
The curse of modern child life in America is overeducation, overconfinement, overrestraint. The injury wrought to the race by keeping too young children in school is beyond the power of any one to estimate. The work of breaking down the nervous systems of the children of the United States is now well under way. Every child should have mud pies, grasshoppers, and tad-poles, wild strawberries, acorns, and pine cones, trees to climb and brooks to wade in, sand, snakes, huckleberries, and hornets, and any child who has been deprived of these has been deprived of the best part of his education.
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 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 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:
Play is the spontaneous enlistment of the entire personality in the pursuit of some coveted end. We do not have to pursue the goal; we wish to—it is our main desire. This is the way in which greatest discoveries, fortunes, and poems are made. It is the way in which we take the responsibilities and problems of life that makes it either a deadly bore—a mere dull round of routine and drudgery—or the most interesting and absorbing game, capable of enlisting all the energy and enthusiasm we have to put into it. The people who accomplish things are the people who play the game. They let themselves go; they are not afraid. Under the stimulus and enthusiasm of play muscles contract more powerfully and longer than under other conditions. Blood pressure is higher in play. It is far more interesting to play the game than to work at it. When you work you are being driven, when you play you are doing the driving yourself. We play not by jumping the traces of life's responsibilities, but by going so far beyond life's compulsions as to lose sight of the compulsion element. Play up, play up, and play the game.
CHAPTER XIII[ToC]
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 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.
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:
1. In general there is a distinct relationship in children between physical condition and intellectual capacity, the latter varying directly as the former.
2. The endurance (ergographic work) of boys is greater than that of girls at all ages, and the difference seems to increase after the age of nine.
3. There are certain anthropometric (body measurements) indications which warrant a careful and thorough investigation into the subject of coeducation in the upper grammar grades.
4. Physical condition should be made a factor in the grading of children for school work, and especially for entrance into the first grade.
5. The great extremes in the physical condition of pupils in the upper grammar grades make it desirable to introduce great elasticity into the work of these grades.
6. The classes in physical culture should be graded on a physical instead of an intellectual basis.
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.
1. The pubescent period is characterized by great and rapid changes in height, weight, strength of grip, vital capacity, and endurance. There seems to accompany this physical activity a corresponding intellectual and emotional activity. It therefore is a period when broad educational influences are most needed. From the pedagogic standpoint it is preëminently a time for character building.
2. The pubescent period is characterized by extensive range of all physical features of the individuals in it. Hence, although a period fit for great activity of the mass of children, it is also one of numerous individual exceptions to this general law. During this period a greater per cent of individuals than usual pass beyond the range of normal limits set by the mass. It is a time, therefore, when the weak fail and the able forge to the front, and hence calls for a higher degree than usual of individualization of educational work and influence.
3. Unidexterity is a normal condition. Rapid and marked accentuation of unidexterity is a pubescent change. On the whole, there is a direct relationship between the degree of unidexterity and the intellectual progress of the pupil. At any given age of school life bright or advanced pupils tend toward accentuated unidexterity, and dull or backward pupils tend toward ambidexterity.... Training in ambidexterity is training contrary to a law of child life.
4. Boys of school age at the Bridewell (reform school) are inferior in all physical measurements to boys in the ordinary schools, and this inferiority seems to increase with age.
5. Defects of sight and hearing are more numerous among the dull and backward pupils. These defects should be taken into consideration in the seating of pupils. Only by removing the defects can the best advancement be secured.
6. The number of eye and ear defects increases during the first years of school life. The causes of this increase should be investigated, and, as far as possible, removed.
7. There are certain parts of the school day when pupils, on the average, have a higher storage of energy than at other periods. These periods should be utilized for the highest forms of educational work.
8. The stature of boys is greater than that of girls up to the age of eleven, when the girls surpass the boys and remain greater in stature up to the age of fourteen. After fourteen, girls increase in stature very slowly and very slightly, while boys continue to increase rapidly until eighteen.
9. The weight of the girl surpasses that of the boy about a year later than her stature surpasses his, and she maintains her superiority in weight to a later period of time than she maintains her superiority in height.
10. In height, sitting, girls surpass boys at the same age as in stature, namely, eleven years, but they maintain their superiority in this measurement for one year longer than they do in stature, which indicates that the more rapid growth of the boy at this age is in the lower extremities rather than in the trunk.
11. Commencing at the age of thirteen, strength of grip in boys shows a marked accentuation in its rate of increase, and this increase continues as far as our observations extend, namely, to the age of twenty. In girls no such great acceleration in muscular strength at puberty occurs, and after sixteen there is little increase in strength of grip. The well-known muscular differentiation of the sexes practically begins at thirteen.
12. As with strength of grip, so with endurance as measured by the ergograph; boys surpass girls at all ages, and this differentiation becomes very marked after the age of fourteen, after which age girls increase in strength and endurance but very slightly, while after fourteen boys acquire almost exactly half of the total power in these two features which they acquire in the first twenty years of life.
13. The development of vital capacity bears a striking resemblance to that of endurance, the curves representing the two being almost identical.
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 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:
School programmes, after they have been based upon the laws of a child's development, should provide for frequent change of subject, alternating studies requiring mental concentration with studies permitting motor activity, and arranging for very short periods of the former. Anæmic children should be relieved of all anxiety as to the results of their efforts, and only short hours of daylight work required of them. The disastrous consequences of eye strain should be understood by all in charge of children who are naturally hypermetropic. The ventilation of a class room is far more important than its decoration or even than a high average percentage in mathematics, and the lack of pure air is one of the auxiliary causes of nervous exhaustion in both pupils and teachers. Deficient motor control is a most trustworthy indication of fatigue in children, and teachers may safely use it as a rough index of the amount of effort to be reasonably expected of their pupils. Facial pallor or feverish flushes are both evidences of overtasking, and either hints that fatigue has already begun. As to unfavorable atmospheric conditions, the teacher herself will undoubtedly realize them as soon as the children, but she should remember that effort carried to the point of exhaustion, injurious as it is in an adult, is yet less harmful than it is to the developing nerve centers of the child.
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 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:
Death is the ultimate and most severe injury that any disease can inflict, but short of death there may be disablement, permanent or temporary, loss of wages, loss of employment, loss of education, increase of home labor, increase of sickness outlays, increase of worry, anxiety and annoyance, disorganization of the household, general impairment of social efficiency.
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 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
| WEEK ENDING | |||||||||||||
| Oct. 26 | Nov. 2 | Nov. 9 | Nov. 16 | Nov. 23 | Nov. 30 | Dec. 7 | Dec. 14 | Dec. 21 | Dec. 28 | Jan. 4 | Jan. 11 | Jan. 18 | |
| Tuberculosis pulmonalis | 350 | 350 | 317 | 364 | 345 | 337 | 422 | 360 | 354 | 308 | 344 | 432 | 402 |
| Diphtheria and croup | 313 | 264 | 283 | 331 | 282 | 343 | 326 | 369 | 338 | 347 | 308 | 370 | 406 |
| Measles | 142 | 212 | 203 | 261 | 293 | 323 | 472 | 471 | 517 | 346 | 581 | 691 | 803 |
| Scarlet fever | 208 | 228 | 231 | 252 | 278 | 323 | 372 | 397 | 417 | 426 | 478 | 562 | 585 |
| Smallpox | — | 1 | — | 1 | — | — | 2 | 4 | 3 | 2 | — | 2 | — |
| Varicella | 40 | 83 | 91 | 162 | 136 | 115 | 167 | 160 | 198 | 123 | 98 | 199 | 169 |
| Typhoid fever | 106 | 105 | 107 | 123 | 86 | 77 | 71 | 62 | 35 | 42 | 37 | 55 | 36 |
| Whooping cough | 6 | 13 | 15 | 14 | 27 | 9 | 8 | 12 | 19 | 3 | 25 | 24 | 14 |
| Cerebro-spinal meningitis | 6 | 11 | 3 | 4 | 4 | 8 | 15 | 13 | 7 | 6 | 11 | 16 | 13 |
| Total | 1171 | 1267 | 1250 | 1512 | 1451 | 1535 | 1855 | 1844 | 1888 | 1603 | 1882 | 2351 | 2428 |
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 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. Five economic reasons are assigned for establishing a national department of health:
1. To enable society to increase the percentage of exceptional men of each degree, many of whom are now lost through preventable accidents, and also to increase the total population.
2. To lessen the burden of unproductive years by increasing the average age at death.
3. To decrease the burden of death on the productive years by increasing the age at death.
4. To lessen the cost of sickness. It is estimated that if illness in the United States could be reduced one third, nearly $500,000,000 would be saved annually.
5. To decrease the amounts spent on criminality that can be traced to overcrowded, unwholesome, and unhygienic environment.
In addition to the economic gain, the establishment of a national department of health would gradually but surely diminish much of the misery and suffering that cannot be measured by statistics. Sickness is a radiating center of anxiety; and often death in the prime of life closes the gates of happiness on more than one life. Let us not forget that the "bitter cry of the children" still goes up to heaven, and that civilization must hear, until at last it heeds, the imprecations of forever wasted years of millions of lives.
If progress is to be real and lasting, it must provide whatever bulwarks it can against death, sickness, misery, and ignorance; and in an organization such as a national department of health, adequately equipped,—a vast preventive machine working ceaselessly,—an attempt at least would be made to stanch those prodigal wastes of an old yet wastrel world.
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; 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 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 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:
[7] Dr. Arthur Newsholme's Vital Statistics should be in public libraries and on the shelves of health officers, public-spirited physicians, and school superintendents.
CHAPTER XIV[ToC]
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, 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 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 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
1. Is the district congested?
2. Is congestion growing?
3. How far away is the nearest public park?
a. Is it large enough?
b. Has it a playground or beauty spot?
c. Has it swings and games?
d. Is play supervised?
e. Have children of different ages equal opportunities, or do the large children monopolize the ground?
f. Are children encouraged by teachers and parents to use this park?
4. Are the streets suitable for play?
a. Does the sun reach them?
b. Are they broad?
c. Are they crowded with traffic?
5. How far away is the nearest public bath?
a. Has it a swimming pool?
b. Has it showers?
c. Is it used as an annex to the school?
VACATION-SCHOOL PLAY CLINIC ON A "VACANT" CITY LOT
OWNED BY THE ROCKEFELLER INSTITUTE FOR MEDICAL RESEARCH
II. Effect of School Equipment upon Health
1. Is there an indoor yard?
a. Is the area adequate or inadequate?
b. Is the floor wood, cement, or dirt?
c. Is the heat adequate or deficient?
d. Is the ventilation adequate or deficient?
e. Is the daylight adequate, deficient, or almost lacking?
f. Is there equipment for light gymnastics and games?
g. Is it used out of school hours; by special classes, athletic teams, etc., or by pupils generally?
2. Is there an outdoor yard?
a. Is the area ample or inadequate?
b. Is the area mainly occupied by toilets?
c. Is the daylight sufficient or deficient?
d. For how many hours does the sun reach it?
e. Is it equipped for games?
f. How much larger ought it to be?
g. Is it used out of school hours; by special classes, athletic teams, etc., or by pupils generally?
3. Is there a gymnasium?
a. Is it large enough?
b. Is it used for a gymnasium?
c. Is it cut up into class rooms?
d. Is it used out of school hours; by special classes, athletic teams, etc., or by pupils generally?
4. Is there a roof playground?
a. Is there open ventilation?
b. Is it used in the daytime?
c. Is it used at night?
d. Is it used during the summer?
e. Is it monopolized by the larger children?
f. Is it used out of school hours; by special classes, athletic teams, etc., or by pupils generally?
5. Are washing facilities adequate?
a. How many pupils per washbasin?
b. Are there individual towels?
c. Have eye troubles been spread by roller towels?
d. Are only clean towels permitted?
e. Are there bathing facilities; are these adequate?
f. Are swimming pools used for games, contests, etc.?
g. Are bathing facilities used out of school hours?
h. Who is responsible for cleanliness of towels, washbasins, and swimming pools?
i. How often is water changed in swimming pool, or is it constantly changing?
6. Is adequate provision made for clean drinking water?
a. Are sanitary fountains used that prevent contamination of faucet or water?
b. How often are cups or faucets cleaned?
7. Is provision made for airing outer clothing?
a. Are children permitted to pile their clothing in the class room?
b. Are there hooks for each child?
c. Are lockers provided with wire netting to permit ventilation?
d. Are lockers or hooks in the halls or in the basement?
e. Have you ever thought of the disciplinary and social value of cheap coat hangers to prevent wrinkling and tearing?
AN ATTEMPT TO OVERCOME THE DISADVANTAGES OF CONGESTION—A BOYS' HIGH SCHOOL, NEW YORK CITY
III. The Class Room as a Place of Confinement
1. How many sittings are provided?
a. How many pupils are there?
2. What is the total floor area?
a. What proportion is not occupied by desks?
3. Are the seats adjustable?
a. Are the seats adjusted to pupils?
b. Where desks are adjustable, are short children seated in low desks, or are children seated according to class or according to discipline exigencies without regard to size of desk?
c. Are seats placed properly with reference to light?
4. Is the light ample and proper?
a. For how many hours must artificial light be used in the daytime?
b. Is artificial light adequate for night work?
c. Does the reflection of light from blackboard and walls injure the eye?
d. Are the blackboards black enough?
e. Are the walls too dark?
f. Is the woodwork too dark?
g. Are window panes kept clean?
5. Is the air always fresh?
a. Is ventilation by open windows?
b. Is ventilation artificial?
c. Does the ventilating apparatus work satisfactorily?
d. Are the windows thrown open during recess, and after and before school?
e. Do unclean clothes vitiate the atmosphere?
f. Do unclean persons vitiate the atmosphere?
g. Does bad breath vitiate the atmosphere?
h. Are pupils and parents taught that unclean clothes, unclean persons, and bad breath may decrease the benefits of otherwise adequate ventilation and seriously aggravate the evils of inadequate ventilation?
6. Is the temperature properly regulated?
a. Has every class room a thermometer?
b. Are teachers required to record the thermometer's story three or more times daily?
c. Is excess or deficiency at once reported to the janitor?
7. Are the floors, walls, desks, and windows always clean?
a. How often are they washed?
b. Is twice a year often enough?
c. Do the floors and walls contain the dust of years?
d. Is dry sweeping prohibited?
e. Has wet sawdust or even wet sand been tried?
f. Has oil ever been used to keep down surface dust on floors?
g. Are feather dusters prohibited?
h. Are dust rags moist or dry?
i. Is an odorless disinfectant used?
8. Does overheating prevail?
a. Do you know teachers and principals who protest against insufficient ventilation, particularly against mechanical ventilation, while they themselves are "in heavy winter clothing in a small room closely sealed, the thermometer at 80 degrees"?
IV. Exercise and Recreation
1. How much time and at what periods is exercise provided for in the school schedule?
a. Indoors?
b. Outdoors?
2. How much exercise indoors and outdoors is actually given?
3. Are the windows open during exercise?
4. Is exercise suited to each child by the school physician after physical examination, or are all children compelled to take the same exercise?
5. Whose business is it to see that rules regarding exercise are strictly enforced?
6. Do clouds of dust rise from the floor during exercise and play?
7. Are children deprived of exercise as a penalty?
8. Should hygiene talks be considered as exercise?
HOME WORKSHOPS NEED FRESH AIR
V. The School Janitor and Cleaners
1. Do they understand the relation of cleanliness to vitality?
2. Is their aim to do the least possible amount of work, or to attain the highest possible standard of cleanliness?
3. Will the teacher's complaint of uncleanliness be heeded by trustees? If so, is the teacher not responsible for uncleanliness?
4. Have you ever tried to stimulate the pride of janitors and cleaners for social service?
a. Have you ever tried to show them how much work they save themselves by thorough cleansing?
b. Have you ever shown them the danger, to their own health, of dust and dirt that may harbor infection and reduce their own vitality?
5. What effort is made to instruct janitors and cleaners by your school trustees or by your community?
6. Have you explained to pupils the important responsibility of janitors for the health of those in the tenements, office buildings, or schools?
a. Do you see in this an opportunity to emphasize indirectly the mother's responsibility for cleanliness of home?
SCHOOL WORKSHOPS ALSO NEED FRESH AIR
VI. Requirements of Curriculum
1. How much home study is there?
a. How much is required?
b. What steps are taken to prevent excessive home study?
c. Are light and ventilation conditions at home considered when deciding upon amount of home study?
2. Is the child fitted to the curriculum, or is the curriculum fitted to the child?
a. Does failure or backwardness in studies lead to additional study hours or to regrading?
b. Are there too many subjects?
c. Are the recitation periods too long?
d. Are the exercise periods too short and too few?
e. Is there too much close-range work?
f. Is it possible to give individual attention to individual needs so as to awaken individual interest?
3. Is follow-up work organized to enlist interest of parents, or, if necessary, of outside agencies in fitting a child to do that for which, if normal, he would be physically adapted?
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 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:
[8] The Sanitation of Public Buildings, by William Paul Gerhard, contains a valuable discussion of how the school may avoid manufacturing physical defects.
[9] By Professor Lila V. North, Baltimore College for Women, for the New York Committee on the Physical Welfare of School Children, 105 East 22d Street, New York City.
CHAPTER XV[ToC]
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:
1. School conditions that injure child health also injure teacher health.
2. Poor health of teacher causes poor health of pupil.
3. Poor health of pupil often causes poor health of teacher.
4. Adequate protection of children requires adequate protection of their teachers.
5. Teachers have a right to health protection for their own sake as well as for their children's sake.
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. 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 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. 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 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:
1. Moral character as indicated in the record of the applicant as a student or teacher or in other occupation, or as a participant in an examination.
2. Physical fitness for the position sought, reference being had here to all questions of physical fitness other than those covered in a physician's report as to "sound health."
3. Satisfactory quality and use of voice.
4. Personal bearing, cleanliness, appearance, manners.
5. Self-command and power to win and hold the respect of teachers, school authorities, and the community.
6. Capacity for school discipline, power to maintain order and to secure the willing obedience and the friendship of pupils.
7. Business or executive ability,—power to comprehend and carry out and to accomplish prescribed work, school management as relating to adjustment of desks, lighting, heating, ventilation, cleanliness, and attractiveness of schoolroom.
8. Capacity for supervision, for organization and administration of a school, and for the instructing, assisting, and inspiring of teachers.
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, 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 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.