It was stopped all right—stopped so short that there were no more of these operations done in school buildings. But with the overcrowded conditions in the clinics, the next move was up to me. I brought the matter up at the next meeting of the Section on Laryngology of the Academy of Medicine. What I wanted was assurance that, instead of this wholesale slaughter of innocents which, I shrewdly suspected, included many cases which did not need operations at all, the hospitals would take all justifiable school cases, give them a skilled operator, use approved anaesthetics and supply twenty-four hours of post-operative care before sending the child home. I said that, if they would not cooperate to that reasonable extent, I would open our own hospitals. The assembled laryngologists took that for mere bluster and said “No.”
So I bided my time, caught the city fathers in a melting mood and obtained an appropriation for six small hospitals, city-run, specializing in nose-and-throat operations, staffed by men from our own medical force who were sent to get special training in this sort of work. They were beautiful little hospitals, with the latest equipment and surpassing technical standards. Then we started sending to them all school cases that were really operable, bringing in the children the evening before, operating under nitrous oxide gas and oxygen in the morning, keeping them all day surrounded by toys and ice cream and sending them home fit and cheerful that night. In six years we removed thousands upon thousands of adenoids and tonsils without a single fatality or a single instance of septic sore throat or post-operative bleeding—that last due in no small measure to our routine use of the new “thromboplastin” which had just been perfected by Dr. Alfred Hess. Our one difficulty was of a gratifying kind: the children had such a good time that it was sometimes a task to get them to go home. These hospitals were maintained for about five years. Then the general hospitals of the city agreed to follow the same procedure and we gladly turned the work back to them.
The small but all-important details of human nature’s peculiarities never left us alone. They were usually our worst enemies till we began to understand and turned them into allies. Even in something so obviously insignificant as the name of an organization. Back in 1909, when our work at the Bureau was just getting solidly under way, a group of child hygiene people, myself included, decided to form an association for the exchange and promotion of child welfare ideas. We called ourselves, at some length, “The American Association for the Study and Prevention of Infant Mortality.” It was a small organization, but vigorous, and usually lacking funds in its early days. Presently we had a meeting in Boston’s Faneuil Hall and the Mayor of Boston, an astute politician by definition, introduced me when I made my speech. He had a terrific struggle with that interminable name and gave it up in despair. Afterward, he said to me:
“I’m always glad to welcome people to Boston, doctor. But if you don’t change the name of your society, I am never going to welcome you here again. And by the way,” he went on, “do you have trouble raising money?” I said that we usually did. “It’s that name,” he said. “Nobody is going to write anything as long as that on a check. By the time they get halfway through, they will change their minds.” There is a lesson in that for a good many long-named societies.
That was one of the reasons why we changed the name to “The American Child Hygiene Association.” The “Child” came in naturally for we were extending its interests, and our own, to cover the field of childhood. One of the things I learned early was that you cannot separate the child into categories. The baby’s health is dependent upon the pre-natal period; healthy babies become healthy pre-school children; health in school children is largely dependent upon the years that have gone before, and adult health is mainly dependent upon health during the whole period of childhood. The child had to be taken as a whole; if we divided our efforts into work for different age-groups it was just for efficiency: every period of the baby’s or child’s life was bound up with every other period.
The American Child Hygiene Association was a vigorous and inspiring society. I later became its president, and during my entire career there was no other organization that gave me so much of the association of people of like minds and interest and inspiration. In 1923, when Herbert Hoover became its president, it amalgamated with The Child Health Organization of America, which had been founded a few years before by Dr. L. Emmett Holt, the eminent author of that mothers’ Bible, The Care and Feeding of Children. The combined organization, as “The American Child Health Association,” was dissolved only in 1935, merging in one direction with The National Education Association and in the other with The American Public Health Association. Through its many years of work and its many changes in name, it was a tower of strength to all who were interested in child health. That fact, that there seems no longer to be a need for organizations of that specialized type, is a tribute to the firm establishment of child hygiene work today.
I know how dreary it is to look down the list of organizations for this and that and how easy it is to wonder what they are all about and why they exist. There are far too many, without doubt; and of committees on various subjects there is no end. I resigned from twenty-six committees when I retired, and I might have belonged to many more with little effort. In some curious way, these committees seemed always to be made up of much the same people: Lillian Wald, Annie Goodrich and I seemed to be peripatetic members of most of them. I remember one night when one of these committees was meeting in the United Charities Building, our door was suddenly flung open and a reporter from The Sun looked in. “What are you calling yourselves tonight?” was his greeting. But in my field, at least, organizations were the breath of life. In order to get cooperation from all types of people, I had advisory committees on every conceivable phase of my work. Someone has said that a committee is an organization that takes three months to do what any able-bodied man can accomplish in half an hour. They took a great deal of time out of life, were usually tiresome, only occasionally helpful, but they gave the members a sense of importance that made them cooperative and so they seemed to be worth while.
But I founded one organization of which I have always been proud. It still exists and is a most valuable part of our city’s affairs. This started as “The Association of Baby Health Stations.” When we started our baby health stations, we found three other private organizations already in the field. One was the Nathan Straus Milk Stations, another the Diet Kitchen, under the presidency of Mrs. Henry Villard, and the third a group of baby milk-dispensaries financed and managed by Mrs. Adrienne Joline. In order that we might not duplicate the work of one another, I asked them to meet with me and form this little organization. They were all most cooperative and for a year or more the society functioned in this small way. The New York Milk Committee paid the salary of a secretary and the Department of Health furnished an office, stenographic aid and postage. In a short time it was evident that the same sort of cooperative concern was needed for older children. In this latter field, there was serious overlapping of work and much confusion. So our little group became “The Children’s Welfare Federation” and so remains to this day.
The Children’s Welfare Federation is a clearing house for the city for all organizations which touch the welfare of the child. It was, so far as I have been able to discover, the first organization which drew together the functions of all sorts of allied agencies. Under the direction of Miss Mary Arnold, who was its most efficient secretary, it has served a great need and can be turned to at any time to find the right organization for any type of child care from pre-natal work to psychiatry. Now, no child need longer have her ear syringed six times each day by the nurses from three organizations; now no baby need die while its mother waits until someone can find a hospital to receive it; now no baby need go without breast milk and no child need lack a vacation. Today over two hundred and fifty organizations belong to the Children’s Welfare Federation and this type of organization exists in practically all of the large communities in the United States.
That
was the gradually encouraging thing about the whole development of the Bureau of Child Hygiene. There was a lot of stupidity, a great deal of waste motion, much ignorance to be combated, but always the enthusiasm and devotion of the doctors and nurses of the Bureau. The idea was good; we tried to work it out with common sense, and through the mass of detail and discouragement it was spreading. People didn’t really like to see children die.
CHAPTER VIII
I LIKE TO REMEMBER THE AMUSING EPISODES OF my life; possibly because they stood out in contrast to the alternating monotony and difficulties of most days. At the time, my work seemed super-exciting, but as I look back over the years they seem to have merged into each other and to have flowed onward like days on shipboard, without beginning and without end and much alike in their seemingly endless, unbroken progression. The good was mixed with the bad; the funny with the serious. But that, of course, is common to all lives.
Some of the most joyous interludes were caused by the letters that used to come to the school nurses from mothers of children who had been sent home with some physical defect or other. One proved very valuable for publicity purposes. It was reproduced in several magazines and innumerable newspapers and attributed to many and varied sources. But we had the original note. The boy was sent home because he was so obviously in need of a bath. The letter from the mother came promptly: “Dear Teacher,” it read, “Ikey aint no rose. Don’t smell him—learn him.” There was less imagination but a considerable sense of emphatic rhetoric about this one: “Dear Nurse: As for his nose, it don’t need it. As for his tonsils, he was born with them. As for his teeth, he’ll get new ones. Please mind your own business.”
To the time when we were giving the Schick test to children to determine the presence of immunity to diphtheria, belongs this gem (it may be remembered that the year 1922 was just about the high water mark of Rudolph Valentino’s popularity in “The Sheik”) : “Dear Teacher: I’ve read the book and I’ve seen the movie and I don’t want my boy to have none of it.” And I remember vividly an irate mother who came to my office and demanded to see me. She brandished one of the printed forms used by the nurses: “What does this mean?” she demanded. “My boy is as bright as any.” I took the form; it was evident the nurse was a time-saver, for instead of “poor nutrition” she had written “poor nut.”
These experiences serve as avenues for me to look down as I think back over this incredibly complicated task of trying to assure health to one million, two hundred thousand school children. I may laugh when I think of these stories but they also carry me back to the tangled problem of school medical inspection. We met and mastered the almost overwhelming occurrence of contagious eye and skin diseases; we did our share in reducing the incidence of the ordinary contagious diseases common in child life, but we never made any impression upon the problem of physical defects so common during childhood and, so far as I know, that problem has never been even faintly solved by anyone. Since its inception, school medical inspection has cost untold millions of dollars and received the earnest attention of the greatest experts in the child health field. It is still a dismal failure and this money might have been spent with better results in almost any other field of public health.
Perhaps that problem has always haunted me because it was the inefficient horrors of school medical inspection which constituted my initiation into public health work. I assisted at its birth and then followed the poor little thing throughout its entire anaemic history, and my opinion of its validity is much the same today as it was when I first encountered its forlorn beginnings. Because of the great expense of this work, its major importance in public health and its entire failure, I shall speak again about it at greater length. Here I can only refer to the belief that we must have more and more doctors and nurses, that we must cover a larger and larger field and that we must convince more and more parents of the vital necessity of having their children’s physical defects remedied. Other cities have followed this line of thought and, when money was forthcoming, increased their forces, still with no appreciable results. Several cities, failing to get the necessary appropriations, speeded up their work, announced a physical examination of every child every year and made a farce of the whole proceeding. The statistics were sickeningly commonplace in the way in which they repeated themselves.
In New York City, it was economically impossible to induce the city fathers to appropriate enough money to provide for an annual physical examination. The fantastic expense involved made us try to compromise on an examination when the child entered school, another about the fourth grade and the final one when the child was ready to leave school. The trouble was that we were not dealing in babies this time. The mere name, “baby,” holds a rhetorical and emotional appeal that will touch the heart of even the most hardened holder of the city’s purse strings. But there was no comparable way to dramatize the older children’s failing vision, decayed teeth and diseased lungs. Parents, as a class, were far from cooperative. We would send the child home with a card telling of the physical defect found and asking the mother to take her child to her doctor, get his advice and then report back to the nurse. The returns were so disappointing that we appealed to the medical profession in general. We devised a new system by which the original examination could be made by the family physician and a report sent to us. This meant a vast saving in expenditure of money and we hoped for a big response. In the earliest years about sixteen percent of the examinations were done by the family doctor. And then the mothers began to realize that they did not have to spend their own money for this purpose. Gradually, the whole burden was shifted back to our overworked staff. There was no way to defeat the natural human instinct to refuse to pay for anything you can get free.
And overworked our doctors and nurses certainly were. There seemed so much to be done and so little time to do it. The pressure from the Board of Education and even from the Department of Health itself was a driving force. I had my strong suspicion that our examinations were very superficial and of little account. We did not undress the children and only too often there were innumerable layers of clothing to hide their bodies and make listening difficult. A large and powerful organization interested in child welfare began publicly reproaching us for inefficiency, on the ground that we could not be doing efficient physical examinations without undressing the children. To quiet them, I apprehensively instructed a few of the staff, all women, to undress the girls and always to have the nurse or mother present when this was done. And then another storm broke. At least two of the New York newspapers chose to make front page news, with glaring headlines, of stories of schoolgirls being insulted and stripped by brutal Health Department doctors, all broadcast with pictures of the insulted girls and much journalistic indignation. An investigation immediately exploded these ridiculous charges but we could not go on with this method. We had to do the best we might with the children fully dressed. I then asked committees of specialists to go about the schools and check up on our examinations. When the figures of their results were given to me, I was immensely cheered to find that with the same children, the results of our staff and of these efficient doctors varied by hardly a fraction of one percent. Even the heart specialists were startlingly close in their findings to the results of our staff examinations though heart lesions are notoriously difficult to diagnose even without clothing to mask the sounds.
We might be fairly sure that our diagnoses were accurate but getting these children treated was a totally different matter. The basic theory of public health work precludes any treatment of a disease unless it is a contagious disease which may become a public menace. When one considers that the greater part of our children came from families who had no excess money and that their physical defects were not too prominent, it was exceedingly difficult to induce these parents to pay some doctor to treat an ailment that seemingly did not cripple the child. The nurses would make from two to twelve visits to each of these homes; they would offer to take the children to a free clinic.
But either fear or plain neglect offered a sufficient rebuff. With every effort we could make, we could rarely get more than thirty-five percent of the children treated and this thirty-five percent represented a very much smaller fraction of the total number of children in the schools who needed attention. It was disheartening work and I am sure our experience was duplicated in every medical inspection system in the country. Nor have matters improved since the early days; the proportion of children who are cared for in any adequate manner still remains disturbingly low.
Later we turned more and more to public health education to prepare the way. It was far easier to induce a mother to adjust the artificial light so that her child’s eyes might not be strained when reading, to teach families how to give their children the proper food and rest that might prevent undernourishment and to break their prejudice against night air in bedrooms, than to start with an ignorant mind to combat and demand immediate medical treatment. Our diplomatic method of approach when the Schick test was first introduced may stand as an example of the way we sought to induce mothers to try some measure of child care. The chief point of leverage is always the fact that, although the average mother will go a long way with you, she does so only when she is convinced in her own mind that whatever is proposed will be good for her child. We were working among an almost wholly foreign population; today, with the restricted immigration and the building up of a more American citizenry, it may not be so difficult as it used to be. But I doubt if ignorance, fear and neglect can be considered as belonging to any racial group. We are all a little apprehensive of the unknown. And, other things being equal, the younger the child the more the mother will try to protect it against intrusive strangers with curious ideas.
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