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Title: Civics and Health
Author: Allen, William H.
Language: English
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    [Illustration: LOUIS AGASSIZ
    "A natural law is as sacred as a moral principle"]



                        CIVICS AND HEALTH

                                BY

                         WILLIAM H. ALLEN

             SECRETARY, BUREAU OF MUNICIPAL RESEARCH

FORMER SECRETARY OF THE NEW YORK COMMITTEE ON PHYSICAL WELFARE OF
   SCHOOL CHILDREN, AUTHOR OF "EFFICIENT DEMOCRACY" AND "RURAL
      SANITARY ADMINISTRATION IN PENNSYLVANIA," JOINT AUTHOR
            OF "SCHOOL REPORTS AND SCHOOL EFFICIENCY"


                       WITH AN INTRODUCTION

                                BY

                       WILLIAM T. SEDGWICK

PROFESSOR OF BIOLOGY IN THE MASSACHUSETTS INSTITUTE OF TECHNOLOGY

                         GINN AND COMPANY
               BOSTON · NEW YORK · CHICAGO · LONDON



                   ENTERED AT STATIONERS' HALL

                         COPYRIGHT, 1909
                       BY WILLIAM H. ALLEN

                       ALL RIGHTS RESERVED

                              910.4

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



INTRODUCTION


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

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

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

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

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

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

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

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

                                         WILLIAM T. SEDGWICK

  MASSACHUSETTS INSTITUTE OF TECHNOLOGY



CONTENTS


PART I. HEALTH RIGHTS

CHAPTER                                                           PAGE
      I. HEALTH A CIVIC OBLIGATION                                   3

     II. SEVEN HEALTH MOTIVES AND SEVEN CATCHWORDS                  11

    III. WHAT HEALTH RIGHTS ARE NOT ENFORCED IN YOUR COMMUNITY?     23

     IV. THE BEST INDEX TO COMMUNITY HEALTH IS THE PHYSICAL
         WELFARE OF SCHOOL CHILDREN                                 33


PART II. READING THE INDEX TO HEALTH RIGHTS

      V. MOUTH BREATHING                                            45

     VI. CATCHING DISEASES, COLDS, DISEASED GLANDS                  57

    VII. EYE STRAIN                                                 72

   VIII. EAR TROUBLE, MALNUTRITION, DEFORMITIES                     83

     IX. DENTAL SANITATION                                          89

      X. ABNORMALLY BRIGHT CHILDREN                                104

     XI. NERVOUSNESS OF TEACHER AND PUPIL                          107

    XII. HEALTH VALUE OF "UNBOSSED" PLAY AND PHYSICAL TRAINING     115

   XIII. VITALITY TESTS AND VITAL STATISTICS                       124

    XIV. IS YOUR SCHOOL MANUFACTURING PHYSICAL DEFECTS?            139

     XV. THE TEACHER'S HEALTH                                      152


PART III. COÖPERATION IN MEETING HEALTH OBLIGATIONS

    XVI. EUROPEAN REMEDIES: DOING THINGS AT SCHOOL                 159

   XVII. AMERICAN REMEDIES: GETTING THINGS DONE                    166

  XVIII. COÖPERATION WITH DISPENSARIES AND CHILD-SAVING
         AGENCIES                                                  174

    XIX. SCHOOL SURGERY AND RELIEF OBJECTIONABLE, IF AVOIDABLE     184

     XX. PHYSICAL EXAMINATION FOR WORKING PAPERS                   190

    XXI. PERIODICAL PHYSICAL EXAMINATION AFTER SCHOOL AGE          201

   XXII. HABITS OF HEALTH PROMOTE INDUSTRIAL EFFICIENCY            208

  XXIII. INDUSTRIAL HYGIENE                                        218

   XXIV. THE LAST DAYS OF TUBERCULOSIS                             229

    XXV. THE FIGHT FOR CLEAN MILK                                  252

   XXVI. PREVENTIVE "HUMANIZED" MEDICINE: PHYSICIAN AND TEACHER    268


PART IV. OFFICIAL MACHINERY FOR ENFORCING HEALTH RIGHTS

  XXVII. DEPARTMENTS OF SCHOOL HYGIENE                             283

 XXVIII. PRESENT ORGANIZATION OF SCHOOL HYGIENE IN NEW YORK CITY   296

   XXIX. OFFICIAL MACHINERY FOR ENFORCING HEALTH RIGHTS            302

    XXX. SCHOOL AND HEALTH REPORTS                                 310

   XXXI. THE PRESS                                                 322


PART V. ALLIANCE OF HYGIENE, PATRIOTISM, AND RELIGION

  XXXII. DO-NOTHING AILMENTS                                       329

 XXXIII. HEREDITY BUGABOOS AND HEREDITY TRUTHS                     335

  XXXIV. INEFFECTIVE AND EFFECTIVE WAYS OF COMBATING ALCOHOLISM    343

   XXXV. IS IT PRACTICABLE IN PRESENTING TO CHILDREN THE EVILS
         OF ALCOHOLISM TO TELL THE TRUTH, THE WHOLE TRUTH, AND
         NOTHING BUT THE TRUTH?                                    357

  XXXVI. FIGHTING TOBACCO EVILS                                    363

 XXXVII. THE PATENT-MEDICINE EVIL                                  369

XXXVIII. HEALTH ADVERTISEMENTS THAT PROMOTE HEALTH                 378

  XXXIX. IS CLASS INSTRUCTION IN SEX HYGIENE PRACTICABLE?          384

     XL. THE ELEMENT OF TRUTH IN QUACKERY; HYGIENE OF THE MIND     391

    XLI. "A NATURAL LAW IS AS SACRED AS A MORAL PRINCIPLE"         398

  INDEX                                                            405



CIVICS AND HEALTH



PART I. HEALTH RIGHTS



CHAPTER I

HEALTH A CIVIC OBLIGATION


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

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

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

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

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

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

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

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

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

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

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

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

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

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



CHAPTER II

SEVEN HEALTH MOTIVES AND SEVEN CATCHWORDS


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

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

Seven catchwords make it easy to remember the characteristics and the
source of every motive, every kind of person, and every stage in the
evolution of sanitary standards. These seven catchwords are:
_Instinct_, _Display_, _Commerce_, _Anti-nuisance_, _Anti-slum_,
_Pro-slum_, _Rights_. By the use of these catchwords any teacher,
parent, public official, educator, or social worker should be able to
size up the situation, the needs, and the opportunity of the
individuals or the communities for whom a health crusade is planned.

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


TABLE I

TYPHOID A RURAL DISEASE[1]

==========================================+============+==============
                                          | Average    | Average
                                          | Per Cent   | Typhoid Fever
                                          | of Rural   | Death Rate
                                          | Population | per 100,000
------------------------------------------+------------+--------------
Five states in which the urban            |            |
population was more than 60% of the total |     30     |     25
                                          |            |
Six states in which the urban population  |            |
was between 40% and 60%                   |     49     |     42
                                          |            |
Seven states in which the urban           |            |
population was between 30% and 40%        |     67     |     38
                                          |            |
Eight states in which the urban           |            |
population was between 20% and 30%        |     75     |     46
                                          |            |
Twelve states in which the urban          |            |
population was between 10% and 20%        |     87     |     62
                                          |            |
Twelve states in which the urban          |            |
population was between 0 and 10%          |     95     |     67
==========================================+============+==============

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

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

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

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

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


TABLE II

COST IN LIFE CAPITAL OF PREVENTABLE DISEASES[2]

=============+============+===========================================
             |            | Multiply by the number of deaths for each
             | Estimated  | age group to learn the cost in life
             | Value of   | capital to your community in loss of life
     Age     | Human Life | from one or all preventable diseases.
-------------+------------+-------------------------------------------
  0-5 years  |   $1,500   |
  5-10  "    |    2,300   |
 10-15  "    |    2,500   |
 15-20  "    |    3,000   |
 20-25  "    |    5,000   |
 25-30  "    |    7,500   |
 30-35  "    |    7,000   |
 35-40  "    |    6,000   |
 40-45  "    |    5,500   |
 45-50  "    |    5,000   |
 50-55  "    |    4,500   |
 55-60  "    |    4,500   |
 60-65  "    |    2,000   |
 65-70  "    |    1,000   |
 70-    "    |    1,000   |
=============+============+===========================================

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

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

    [Illustration: A COUNTRY MENACE TO CITY HEALTH]

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

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

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

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

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

FOOTNOTES:

[1] Prepared by Dr. John S. Fulton, secretary of the state board of
health, Maryland, and quoted by Dr. George C. Whipple in _Typhoid
Fever_.

[2] Marshall O. Leighton, quoted in Whipple's _Typhoid Fever_.



CHAPTER III

WHAT HEALTH RIGHTS ARE NOT ENFORCED IN YOUR COMMUNITY?


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

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

    [Illustration: A DAIRY INSPECTOR'S OUTFIT]

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

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


TABLE III

MILK INSPECTION WITHIN NEW YORK CITY, 1906

======================================+===============+===============
                                      |   New York    | Each borough
                                      +-------+-------+-------+-------
                                      | Stores| Wagons| Stores| Wagons
                                      +-------+-------+-------+-------
FIELD                                 |       |       |       |
 Permits issued during 1906           |       |       |       |
 Permits revoked during 1906          |       |       |       |
   For discontinuance of selling      |       |       |       |
   For violation of law               |       |       |       |
 Average permits in force in 1906     |       |       |       |
                                      |       |       |       |
INSPECTION                            |       |       |       |
 Regular inspections                  |       |       |       |
 Inspections at receiving stations    |       |       |       |
 Total                                |       |       |       |
 Average inspections per permit per   |       |       |       |
  year                                |       |       |       |
 Specimens examined                   |       |       |       |
 Samples taken                        |       |       |       |
                                      |       |       |       |
CONDITIONS FOUND                      |       |       |       |
 Inspections finding milk above 50°   |       |       |       |
 % of such discoveries to total       |       |       |       |
   inspections                        |       |       |       |
 Inspections finding adulteration     |       |       |       |
    Warning given                     |       |       |       |
    Prosecuted                        |       |       |       |
 % of adulterations found to          |       |       |       |
   inspections                        |       |       |       |
                                      |       |       |       |
 Rooms connected contrary to          |       |       |       |
  sanitary code                       |       |       |       |
 Ice box badly drained                |       |       |       |
 Ice box unclean                      |       |       |       |
 Store unclean                        |       |       |       |
 Utensils unclean                     |       |       |       |
 Milk not properly cooled             |       |       |       |
 Infectious disease                   |       |       |       |
                                      |       |       |       |
 Persons found selling without permit |       |       |       |
                                      |       |       |       |
ACTION TAKEN                          |       |       |       |
 DESTRUCTION OF MILK                  |       |       |       |
  Lots of milk destroyed for being    |       |       |       |
    over 50°                          |       |       |       |
  Quarts so destroyed                 |       |       |       |
  Lots of milk destroyed for being    |       |       |       |
   sour                               |       |       |       |
  Quarts so destroyed                 |       |       |       |
  Lots of milk destroyed for being    |       |       |       |
    otherwise adulterated             |       |       |       |
  Quarts so destroyed                 |       |       |       |
  Total quarts destroyed              |       |       |       |
                                      |       |       |       |
 NOTICES ISSUED                       |       |       |       |
  To drain and clean ice box          |       |       |       |
  To clean store                      |       |       |       |
                                      |       |       |       |
 CRIMINAL ACTIONS BEGUN               |       |       |       |
  For selling adulterated milk        |       |       |       |
  For selling without permit          |       |       |       |
  For interference with inspector     |       |       |       |
  Total                               |       |       |       |
======================================+===============+===============


TABLE IV

                               Perfect Score 100%
                               Score allowed ...%
File No............

                    DEPARTMENT OF HEALTH
                 (Thirteen items are here omitted)

=Dairy Inspection=             =Division of Inspections=

 1 Inspection No. ...... Time ...... A. P. M. Date ...... 190
 2 All persons in the households of those engaged in producing or handling
   milk are ...... free from all infectious disease ......
 3 Date and nature of last case on farm ......
 4 A sample of the water supply on this farm taken for analysis ......
   190... and found to be ......

====================================================+=========+=======
                 STABLE                             | Perfect | Allow
----------------------------------------------------+---------+-------
 5 COW STABLE is ... located on elevated ground     |         |
   with no stagnant water, hog pen, or privy        |         |
   within 100 feet                                  |    1    |  ...
 6 FLOORS are ... constructed of concrete or        |         |
   some nonabsorbent material                       |    1    |  ...
 7 Floors are ... properly graded and water-tight   |    2    |  ...
 8 DROPS are ... constructed of concrete, stone,    |         |
   or some nonabsorbent material                    |    2    |  ...
 9 Drops are ... water-tight                        |    2    |  ...
10 FEEDING TROUGHS, platforms, or cribs are ...     |         |
   well lighted and clean                           |    1    |  ...
11 CEILING is constructed of ... and is ... tight   |         |
   and dust proof                                   |    2    |  ...
12 Ceiling is ... free from hanging straw, dirt,    |         |
   or cobwebs                                       |    1    |  ...
13 NUMBER OF WINDOWS ... total square feet ...      |         |
   which is ... sufficient                          |    2    |  ...
14 Window panes are ... washed and kept clean       |    1    |  ...
15 VENTILATION consists of ... which is             |         |
   sufficient 3, fair 1, insufficient 0             |    3    |  ...
16 AIR SPACE is ... cubic feet per cow which is     |         |
   ... sufficient (600 and over--3) (500 to         |         |
   600--2) (400 to 500--1) (under 400--0)           |    3    |  ...
17 INTERIOR of stable painted or whitewashed on     |         |
   ... which is satisfactory 2, fair 1, never 0     |    2    |  ...
18 WALLS AND LEDGES are ... free from dirt, dust,   |         |
   manure, or cobwebs                               |    2    |  ...
19 FLOORS AND PREMISES are ... free from dirt,      |         |
   rubbish, or decayed animal or vegetable matter   |    1    |  ...
20 COW BEDS are ... clean                           |    1    |  ...
21 LIVE STOCK, other than cows, are ... excluded    |         |
   from rooms in which milch cows are kept          |    2    |  ...
22 There is ... direct opening from barn into       |         |
   silo or grain pit                                |    1    |  ...
23 BEDDING used is ... clean, dry, and absorbent    |    1    |  ...
24 SEPARATE BUILDING is ... provided for cows       |         |
   when sick                                        |    1    |  ...
25 Separate quarters are ... provided for cows      |         |
   when calving                                     |    1    |  ...
26 MANURE is ... removed daily to at least 200      |         |
   feet from the barn ( ... ft.)                    |    2    |  ...
27 Manure pile is ... so located that the cows      |         |
   cannot get at it                                 |    1    |  ...
28 LIQUID MATTER is ... absorbed and removed        |         |
   daily and ... allowed to overflow and saturate   |         |
   ground under or around cow barn                  |    2    |  ...
29 RUNNING WATER supply for washing stables is      |         |
   ... located within building                      |    1    |  ...
30 DAIRY RULES of the Department of Health are      |         |
   ... posted                                       |    1    |  ...
                                                    |         |
                 COW YARD                           |         |
31 COW YARD is ... properly graded and drained      |    1    |  ...
32 Cow yard is ... clean, dry, and free from        |         |
   manure                                           |    2    |  ...
                                                    |         |
                     COWS                           | Perfect | Allow
33 COWS have ... been examined by veterinarian ...  |         |
   Date  ... 190  Report was                        |    3    |  ...
34 Cows have ... been tested by tuberculin, and     |         |
   all tuberculous cows removed                     |    5    |  ...
35 Cows are ... all in good flesh and condition     |         |
   at time of inspection                            |    2    |  ...
36 Cows are ... all free from clinging manure and   |         |
   dirt. (No. dirty ... )                           |    4    |  ...
37 LONG HAIRS are ... kept short on belly, flanks,  |         |
   udder, and tail                                  |    1    |  ...
38 UDDER AND TEATS of cows are ... thoroughly       |         |
   cleaned before milking                           |    2    |  ...
39 ALL FEED is ... of good quality and all grain    |         |
   and coarse fodders are ... free from dirt and    |         |
   mold                                             |    1    |  ...
40 DISTILLERY waste or any substance in a state     |         |
   of fermentation or putrefaction is ... fed       |    1    |  ...
41 WATER SUPPLY for cows is ... unpolluted and      |         |
   plentiful                                        |    2    |  ...
                                                    |         |
              MILKERS AND MILKING                   |         |
42 ATTENDANTS are ... in good physical condition    |    1    |  ...
43 Special Milking Suits are ... used               |    1    |  ...
44 Clothing of milkers is ... clean                 |    1    |  ...
45 Hands of milkers are ... washed clean before     |         |
   milking                                          |    1    |  ...
46 MILKING is ... done with dry hands               |    2    |  ...
47 FORE MILK or first few streams from each teat    |         |
   is ... discarded                                 |    2    |  ...
48 Milk is strained at ... and ... in clean         |         |
   atmosphere                                       |    1    |  ...
49 Milk strainer is ... clean                       |    1    |  ...
50 MILK is ... cooled to below 50° F. within two    |         |
   hours after milking and kept below 50° F.        |         |
   until delivered to the creamery ... °            |    2    |  ...
51 Milk from cows within 15 days before or 5 days   |         |
   after parturition is ... discarded               |    1    |  ...
                                                    |         |
                  UTENSILS                          |         |
52 MILK PAILS have ... all seams soldered flush     |    1    |  ...
53 Milk pails are ... of the small-mouthed design,  |         |
   top opening not exceeding 8 inches in diameter.  |         |
   Diameter ...                                     |    2    |  ...
54 Milk pails are ... rinsed with cold water        |         |
   immediately after using and washed clean with    |         |
   hot water and washing solution                   |    2    |  ...
55 Drying racks are ... provided to expose milk     |         |
   pails to the sun                                 |    1    |  ...
                                                    |         |
                   MILK HOUSE                       |         |
56 MILK HOUSE is ... located on elevated ground     |         |
   with no hog pen, manure pile, or privy within    |         |
   100 feet                                         |    1    |  ...
57 Milk house has ... direct communication with     |         |
    ... building                                    |    1    |  ...
58 Milk house has ... sufficient light and          |         |
   ventilation                                      |    1    |  ...
59 Floor is ... properly graded and water-tight     |    1    |  ...
60 Milk house is ... free from dirt, rubbish, and   |         |
   all material not used in the handling and        |         |
   storage of milk                                  |    1    |  ...
61 Milk house has ... running or still supply of    |         |
   pure clean water                                 |    1    |  ...
62 Ice is ... used for cooling milk and is cut      |         |
   from ...                                         |    1    |  ...
                                                    |         |
                    WATER                           |         |
63 WATER SUPPLY for utensils is from a ... located  |         |
    ... feet deep and apparently is ... pure,       |         |
    wholesome, and uncontaminated                   |    5    |  ...
64 Is ... protected against flood or surface        |         |
   drainage                                         |    2    |  ...
65 There is ... privy or cesspool within 250 feet   |         |
   ( ... feet) of source of water supply            |    2    |  ...
66 There is ... stable, barnyard, or pile of        |         |
   manure or other source of contamination within   |         |
   200 feet ( ... feet) of source of water supply   |    1    |  ...
                                                    |---------|
                                                    |  100    |
----------------------------------------------------+---------+-------

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


TABLE V

SCORE CARD FOR CITIZEN USE

=======================================================+=======+======
                                                       |Perfect|Allow
-------------------------------------------------------+-------+------
_Schoolhouse_                                          |       |
  Well ventilated, 20; badly, 0-10                     |   20  | ...
  Cleaned regularly, 20; irregularly, 0-10             |   20  | ...
  Feather duster prohibited, 10                        |   10  | ...
  No dry sweeping, 10                                  |   10  | ...
  Has adequate play space, 10; inadequate, 0-5         |   10  | ...
  Has clean drinking water, 10                         |   10  | ...
  Has clean outbuildings and toilet, 20: unclean, 0-10 |   20  | ...
                                                       | ------|
                                                       |  100  |
                                                       |       |
_Church and Sunday School_                             |       |
  Well ventilated, 20; badly, 0-10                     |   20  | ...
  Heat evenly distributed, 20; unevenly, 0-10          |   20  | ...
  Cleaned regularly, 20; irregularly, 0-10             |   20  | ...
  Without carpets, 20                                  |   20  | ...
  Without plush seats, 20                              |   20  | ...
                                                       | ------|
                                                       |  100  |
                                                       |       |
_Streets_                                              |       |
  Sewerage underground, 20; surface, 0-10              |   20  | ...
  No pools neglected, 10                               |   10  | ...
  No garbage piled up, 10                              |   10  | ...
  Swept regularly, 20; irregularly, 0-10               |   20  | ...
  Sprinkled and flushed, 10                            |   10  | ...
  Has baskets for refuse, 10                           |   10  | ...
  All districts equally cleaned, 20; unequally, 0-10   |   20  | ...
                                                       | ------|
                                                       |  100  |
-------------------------------------------------------+-------+------

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

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

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

  1. Notification of danger when it is first recognized.

  2. Registration at a central office of facts as to each dangerous
  thing or person.

  3. Examination of the seat of danger to discover its extent, its
  cost, and new seats of danger created by it.

  4. Isolation of the dangerous thing or person.

  5. Constant attention to prevent extension to other persons or
  things.

  6. Destruction or removal of disease germs or other causes of
  danger.

  7. Analysis and record, for future use, of lessons learned by
  experience.

  8. Education of the public to understand its relation to danger
  checked or removed, its responsibility for preventing a recurrence
  of the same danger, and the importance of promptly recognizing and
  checking similar danger elsewhere.

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

    [Illustration: THE BABY, NOT THE LAW, IS THE TEST OF INFANT
    PROTECTION IN COUNTRY AND IN CITY]

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

FOOTNOTES:

[3] A striking demonstration of law enforcement that followed lawmaking
is given in _The Real Triumph of Japan_, L.L. Seaman, M.D.



CHAPTER IV

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


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

    [Illustration: (Facsimile) PHYSICAL RECORD.]

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

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

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

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

    [Illustration: LOOKING FOR ENLARGED TONSILS AND BAD TEETH
    Note the mouth breather waiting]

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


TABLE VI

PHYSICAL EXAMINATION OF SCHOOL CHILDREN--PERFORMED BY THE DEPARTMENT OF
HEALTH IN THE BOROUGH OF MANHATTAN, 1905-1907

=============================================+==========+===========
                                             | Total    | Percentage
---------------------------------------------+----------+-----------
Number of children examined                  | 275,641  |    100
Number of children needing treatment         | 198,139  |   71.9
_Defects found:_                             |          |
  Malnutrition                               |  16,021  |    5.8
  Diseased anterior or posterior cervical    |          |
    glands                                   | 125,555  |   45.5
  Chorea                                     |   3,776  |    1.3
  Cardiac disease                            |   3,385  |    1.2
  Pulmonary disease                          |   2,841  |    1.0
  Skin disease                               |   4,557  |    1.6
  Deformity of spine, chest, or extremities  |   4,892  |    1.7
  Defective vision                           |  58,494  |   21.2
  Defective hearing                          |   3,540  |    1.2
  Obstructed nasal breathing                 |  43,613  |   15.8
  Defective teeth                            | 136,146  |   49.0
  Deformed palate                            |   3,625  |    1.3
  Hypertrophied tonsils                      |  75,431  |   27.4
  Posterior nasal growths                    |  46,631  |   16.9
  Defective mentality                        |   7,090  |    2.5
=============================================+==========+=========

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

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

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

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

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

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


TABLE VII

SHOWING PER CENT SHARE OF PHYSICAL DEFECTS OF CHILDREN, UNFAVORABLE
HOUSING CONDITIONS, AND CHILD MORTALITY FOUND AMONG EACH FAMILY-INCOME
GROUP

========================+=============================================
                        |         WEEKLY FAMILY INCOME
                        +-----+------+------+------+------+------+----
                        |     |      |      |      |      | $30  |
                        |$0-10|$10-15|$16-19|$20-25|$25-29| and  |$100
                        |     |      |      |      |      | over |
                        +-----+------+------+------+------+------+----
                        | %   |  %   |  %   |  %   |  %   |  %   |  %
------------------------+-----+------+------+------+------+------+----
Proportion to total     |     |      |      |      |      |      |
  families              | 8.4 | 32.7 | 15.2 | 23.8 |  3.9 | 15.6 | 100
                        |     |      |      |      |      |      |
_Physical defects_:     |     |      |      |      |      |      |
  Malnutrition          |13.8 | 43.4 | 12.4 | 17.9 |  3.4 |  9.  |  "
  Enlarged glands       | 8.6 | 37.4 | 14.6 | 22.6 |  3.6 | 13.2 |  "
  Defective breathing   | 9.6 | 32.3 | 15.5 | 24.4 |  2.8 | 15.4 |  "
  Bad teeth             | 8.1 | 32.2 | 15.3 | 24.5 |  4.8 | 15.1 |  "
  Defective vision      | 8.2 | 34.6 | 16.5 | 22.1 |  1.4 | 17.3 |  "
                        |     |      |      |      |      |      |
_Unfavorable housing    |     |      |      |      |      |      |
  conditions_:          |     |      |      |      |      |      |
  Dark rooms            | 8.2 | 35.4 | 18.1 | 18.4 |  3.8 | 15.9 |  "
  Closed air shaft      | 6.9 | 30.2 | 18.9 | 26.4 |  3.2 | 19.6 |  "
  No baths              |10.1 | 38.5 | 16.5 | 19.7 |  4.4 | 10.8 |  "
  Paying over 25% rent  | 8.6 | 27.6 | 21.7 | 14.7 |  ... | 27.6 |  "
                        |     |      |      |      |      |      |
_Child Mortality_:      |     |      |      |      |      |      |
  Families losing       |     |      |      |      |      |      |
   children             |10.3 | 35.5 | 14.7 | 20.5 |  5.4 | 13.6 |  "
  Families losing no    |     |      |      |      |      |      |
   children             | 6.4 | 30.1 | 15.7 | 26.9 |  2.4 | 18.6 |  "
  Children dead         |11.7 | 36.2 | 13.1 | 20.8 |  6.1 | 12.1 |  "
  Infants dying from    |     |      |      |      |      |      |
   intestinal diseases  | 8.9 | 37.6 | 18.3 | 18.8 |  4.  | 12.4 |  "
  Children working      | 4.2 | 19.5 | 13.2 | 30.3 | 11.5 | 21.3 |  "
========================+=============================================

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

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

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

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

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

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

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

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

FOOTNOTES:

[4] Sir John E. Gorst in _The Children of the Nation_ reads the index of
the health of school children in the United Kingdom; John Spargo, in
_The Bitter Cry of the Children_, and Simon N. Patten in _The New Basis
of Civilization_, suggest the necessity for reading the index in the
United States and for heeding it.



PART II. READING THE INDEX TO HEALTH RIGHTS



CHAPTER V

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.

    [Illustration: 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?

    [Illustration: 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."

    [Illustration: 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.

    [Illustration: 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

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

-----------+------------------------------+------------+------------------
DISEASE    | PRINCIPAL SIGNS AND SYMPTOMS | Method of  | REMARKS
           |                              | Infection  |
-----------+------------------------------+------------+------------------
Measles    |_Begins like cold in the      |            |After effects
           |head_, with _feverishness,    |            |often severe.
           |running nose, inflamed and    |            |Period of greatest
           |watery eyes, and sneezing_;   |            |risk of infection
           |small crescentic groups of    | Breath and |first three or
           |_mulberry-tinted spots_ appear| discharges |four days, before
           |about the third day; _rash    | from nose  |the rash appears.
           |first seen on forehead and    | and mouth. |May have repeated
           |face_. The rash varies with   |            |attacks. Great
           |heat; may almost disappear if |            |variation in type
           |the air is cold, and come out |            |of disease.
           |again with warmth.            |            |
-----------+------------------------------+------------+------------------
German     |Illness usually slight. Onset |            |
Measles    |sudden. _Rash often first     |            |
           |thing noticed;_ no cold in    | Breath and |
           |head. Usually have            | discharges |After effects
           |_feverishness_ and _sore      | from nose  |slight.
           |throat_, and the _eyes may    | and mouth  |
           |be inflamed. Rash_ something  |            |
           |between Measles and Scarlet   |            |
           |Fever, variable.              |            |
-----------+------------------------------+------------+------------------
Chicken    |Sometimes begins with         |            |When children
Pox        |feverishness, but is _usually |            |return, examine
           |very mild_ and without sign   |            |head for
           |of fever. _Rash_ appears on   |            |overlooked spots.
           |second day as _small pimples_,|            |All spots should
           |which in about a day become   |            |have disappeared
           |filled with _clear fluid_.    | Breath and |before child
           |This fluid then becomes       | crust of   |returns. A mild
           |_matter_, and then the _spot  | spots.     |disease and
           |dries up_and _the crust falls |            |seldom any after
           |off_.                         |            |effects.
           |                              |            |
           |May have _successive crops of |            |
           |of rash_ until tenth day.     |            |
-----------+------------------------------+------------+------------------
Whooping   |_Begins like cold in the      |            |After effects
Cough      |head_, with _bronchitis_ and  |            |often very severe
           |_sore throat_, and a _cough_  |            |and the disease
           |which is _worse at night_.    | Breath and |causes great
           |Symptoms may at first be very | discharges |debility. Relapses
           |mild. Characteristic          | from nose  |are apt to occur.
           |_"whooping" cough_ develops   | and mouth. |Second attack
           |in about a fortnight, and the |            |rare. Specially
           |spasm of coughing often ends  |            |infectious for
           |with _vomiting_.              |            |first week or two.
           |                              |            |If a child is sick
           |                              |            |after a bout of
           |                              |            |coughing, it is
           |                              |            |most probably
           |                              |            |suffering from
           |                              |            |whooping cough.
           |                              |            |
           |                              |            |Great variation in
           |                              |            |type of disease.
-----------+------------------------------+------------+------------------
Mumps      |Onset may be sudden, beginning|            |
           |with sickness and fever, and  |            |
           |_pain about the angle of the  | Breath and |Seldom leaves
           |jaw_. The _glands become      | discharges |after effects.
           |swollen and tender_, and the  | from nose  |Very infectious.
           |_jaws stiff_, and the _saliva | and mouth. |
           |sticky_.                      |            |
-----------+------------------------------+------------+------------------
Scarlet    |The _onset is usually sudden_,| Breath,    |Dangerous both
Fever or   |with _headache, languor,      | discharges |during attack and
Scarlatina |feverishness, sore throat_,   | from nose  |from after effects.
           |and often the child is _sick_.| and mouth, |Great variation
           |Usually within twenty-four    | particles  |in type of disease.
           |hours the _rash_ appears, and | of skin,   |Slight attacks
           |is _finely spotted, evenly    | and        |as infectious as
           |diffused_, and _bright red_.  | discharges |severe ones. Many
           |The _rash_ is seen first on   | from       |mild cases not
           |the _neck and upper part of   | suppuratory|diagnosed and many
           |chest_, and lasts three to    | glands or  |concealed. The
           |ten days, when it fades and   | ears. Milk |peeling may last
           |the _skin peels in scales,    | specially  |six to eight weeks.
           |flakes_, or even _large       | apt to     |A second attack is
           |pieces_. The _tongue_ becomes | convey     |rare. When scarlet
           |whitish, with bright red      | infection. |fever is occurring
           |spots. The eyes are not watery|            |in a school, all
           |or congested.                 |            |cases of sore
           |                              |            |throat should be
           |                              |            |sent home.
-----------+------------------------------+------------+-------------------
Diphtheria |Onset insidious, may be rapid | Breath and |Very dangerous
           |or gradual. Typically _sore   | discharges |both during attack
           |throat_, great weakness, and  | from nose, |and from after
           |swelling of glands in the     | mouth, and |effects. When
           |neck, about the angle of the  | ears.      |diphtheria is
           |jaw. The back of the throat,  |            |occurring in a
           |tonsils, or palate may show   |            |school all children
           |_patches_ like pieces of      |            |suffering from sore
           |yellowish-white kid. The most |            |throat should be
           |pronounced symptom is great   |            |excluded. There is
           |debility and lassitude, and   |            |great variation of
           |there may be little else      |            |type, and mild
           |noticeable. There may be      |            |cases are often not
           |hardly any symptoms at all.   |            |recognized but are
           |                              |            |as infectious as
           |                              |            |severe cases. There
           |                              |            |is no immunity from
           |                              |            |further attacks.
           |                              |            |Fact of existence
           |                              |            |of disease
           |                              |            |sometimes
           |                              |            |concealed.
-----------+------------------------------+------------+-------------------
Influenza  |_Begins with feverishness,    | Breath and |Excessively
           |pain in head, back_, and      | discharges |infectious. After
           |_limbs_, and usually _cold in | from nose  |effects often very
           |the head_.                    | and mouth. |serious and
           |                              |            |accompanied with
           |                              |            |great prostration
           |                              |            |and nervous
           |                              |            |debility.
-----------+------------------------------+------------+--------------
Smallpox   |The illness is usually well   | Breath,    |Peculiarly
           |marked and the onset rather   | all        |infectious. When
           |sudden, with _feverishness,   | discharges,|smallpox occurs in
           |severe backache, and          | and        |connection with a
           |sickness_. About third day    | particles  |school or with any
           |a _red rash_ of _shotlike     | of skin    |of the children's
           |pimples_, felt below the skin,| or scabs.  |homes, an endeavor
           |and seen first about the      |            |should be made to
           |_face_ and _wrists. Spots     |            |have all persons
           |develop_ in _two days_, then  |            |over seven years
           |form _little blisters_, and   |            |of age
           |in other two days become      |            |revaccinated.
           |_yellowish_ and filled with   |            |
           |matter. _Scabs_ then form,    |            |Cases of modified
           |and these fall off about      |            |smallpox--in
           |the fourteenth day.           |            |vaccinated
           |                              |            |persons--may be,
           |                              |            |and often are, so
           |                              |            |slight as to
           |                              |            |escape detection.
           |                              |            |Fact of existence
           |                              |            |of disease may be
           |                              |            |concealed. Mild
           |                              |            |or modified
           |                              |            |smallpox as
           |                              |            |infectious as
           |                              |            |severe type.
-----------+------------------------------+------------+-----------------
=In the following diseases only the affected child is excluded=

=Erysipelas.= Child should not      | =Ringworm on Scalp.= Child should
 return till all swelling and       |  be excluded till cured. Very
 peeling of skin has disappeared.   |  difficult to cure and often takes
                                    |  a very long time.
=Ophthalmia.= Child should not      |
 return till all traces have        | =Phthisis= (=Consumption=). If in
 disappeared.                       |  advanced stage and coughing much
                                    |  _or spitting_, child should be
=Scabies or Itch.= Child should be  |  excluded. (Infection from breath
 excluded until cured.              |  and dried spit floating in the air
                                    |  as dust.)
=Ringworm on Skin.= Child should be |
 excluded till cured. This takes    | =Impetigo= (=Contagious Sore=).
 only a few days if properly        |  Child should be excluded until
 treated.                           |  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

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.

    [Illustration: 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

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.

    [Illustration: 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.

    [Illustration: 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.

    [Illustration: 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

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?

    [Illustration: 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.

    [Illustration: 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.

    [Illustration: (leaflet)]

 +----------------------------------------------------------------------+
 | A DENTAL CATECHISM                 =When should they be cleansed?=   |
 |                                                                      |
 | =What are the teeth for?=          Immediately after the morning and |
 |                                    noonday meals and before going to |
 | To masticate food; that is,        bed.                              |
 | grind it into fine particles,                                        |
 | mix it with saliva, and so         =By what means should they be     |
 | begin its digestion; also to       cleansed?=                        |
 | aid in speaking and singing.                                         |
 |                                    By a moderately stiff brush,      |
 | =How long should they last?=       water, and floss silk.            |
 |                                                                      |
 | To the very end of life.           =How should these be used?=       |
 |                                                                      |
 | =How do we lose them?=             The brush should be first used in |
 |                                    a general way, high up on the     |
 | By decay, by loosening, and by     gums length-wise of the jaws, to  |
 | accident.                          remove large particles and        |
 |                                    stimulate the gums, then the      |
 | =What causes teeth to decay?=      brush and the teeth should be     |
 |                                    carefully rinsed with water. The  |
 | Particles of food decaying in      brush should next be used with a  |
 | contact with them.                 rolling or circular motion, so    |
 |                                    that the bristles will follow the |
 | =Where does food lodge?=           lines of all the grooves and      |
 |                                    spaces in which the particles of  |
 | All along the edges of the gums,   food have lodged, and so brush    |
 | in the spaces between the teeth,   them out. Then again the mouth    |
 | and in the crevices of their       should be rinsed with water.      |
 | grinding surfaces.                                                   |
 |                                    =Should the gums be brushed?=     |
 | =Can we prevent this loss?=                                          |
 |                                    Yes, moderate friction helps to   |
 | Yes, to a large extent.            keep them healthy.                |
 |                                                                      |
 | =How can we do it?=                =How can the spaces between the   |
 |                                    teeth be reached?=                |
 | By using the teeth properly and                                      |
 | by keeping them clean and the      By dental floss silk passed       |
 | gums healthy.                      between the teeth, drawn          |
 |                                    carefully back and forth till it  |
 | =What does using them properly     reaches the gum, pressed firmly   |
 | mean?=                             against the side of each tooth in |
 |                                    turn and drawn out towards the    |
 | 1. Using sufficient hard or        grinding end of the tooth, and    |
 | fibrous food to give the teeth     this repeated several times in    |
 | and gums full exercise.            each space.                       |
 |                                                                      |
 | 2. Taking time enough to           =Should tooth powder or paste be  |
 | masticate food thoroughly before   used?=                            |
 | swallowing.                                                          |
 |                                    Usually once a day.               |
 | =How often should teeth be                                           |
 | cleansed?=                                                           |
 |                                                                      |
 | As often as they are used.                                           |
 +----------------------------------------------------------------------+

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.

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.

    [Illustration: AN ARMENIAN SCHOOL GIRL]

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?     What does a toothbrush cost?

 How many teeth have they?            How many do you need in one
                                      year?
 How many teeth have they lost?
                                      How much does tooth powder
 How many false teeth have they?      cost?

 How many teeth have been filled?     How much is needed for one
                                      year?
 What is the total cost to date?
                                      How much would two examinations
 How many days have been lost         a year by a dentist cost?
 from work because of toothache?

 How many teeth are now decayed?

 What will it cost to have them
 attended to?

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.

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.

    [Illustration: WON BY THE ECONOMIC ARGUMENT]

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

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

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.

    [Illustration: 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

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.

    [Illustration: 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.

    [Illustration: 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.

    [Illustration: 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

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:

    [Illustration: 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:

    [Illustration: 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:

    [Illustration: 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.

    [Illustration: 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. | Nov. | Nov. | Nov. | Nov. | Nov. | Dec.
                 |  26  |  2   |  9   |  16  |  23  |  30  |  7
-----------------+------+------+------+------+------+------+------
Tuberculosis     |      |      |      |      |      |      |
  pulmonalis     | 350  | 350  | 317  | 364  | 345  | 337  | 422
Diphtheria and   |      |      |      |      |      |      |
  croup          | 313  | 264  | 283  | 331  | 282  | 343  | 326
Measles          | 142  | 212  | 203  | 261  | 293  | 323  | 472
Scarlet fever    | 208  | 228  | 231  | 252  | 278  | 323  | 372
Smallpox         |  --  |   1  |  --  |   1  |  --  |  --  |   2
Varicella        |  40  |  83  |  91  | 162  | 136  | 115  | 167
Typhoid fever    | 106  | 105  | 107  | 123  |  86  |  77  |  71
Whooping cough   |   6  |  13  |  15  |  14  |  27  |   9  |   8
Cerebro-spinal   |      |      |      |      |      |      |
  meningitis     |   6  |  11  |   3  |   4  |   4  |   8  |  15
-----------------+------+------+------+------+------+------+------
Total            | 1171 | 1267 | 1250 | 1512 | 1451 | 1535 | 1855
=================+======+======+======+======+======+======+======

=================+=========================================
                 |             WEEK ENDING
                 +------+------+------+------+------+------
                 | Dec. | Dec. | Dec. | Jan. | Jan. | Jan.
                 |  14  |  21  |  28  |  4   |  11  |  18
-----------------+------+------+------+------+------+------
Tuberculosis     |      |      |      |      |      |
  pulmonalis     | 360  | 354  | 308  | 344  | 432  | 402
Diphtheria and   |      |      |      |      |      |
  croup          | 369  | 338  | 347  | 308  | 370  | 406
Measles          | 471  | 517  | 346  | 581  | 691  | 803
Scarlet fever    | 397  | 417  | 426  | 478  | 562  | 585
Smallpox         |   4  |   3  |   2  |  --  |   2  |  --
Varicella        | 160  | 198  | 123  |  98  | 199  | 169
Typhoid fever    |  62  |  35  |  42  |  37  |  55  |  36
Whooping cough   |  12  |  19  |   3  |  25  |  24  |  14
Cerebro-spinal   |      |      |      |      |      |
  meningitis     |  13  |   7  |   6  |  11  |  16  |  13
-----------------+------+------+------+------+------+------
Total            | 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.

    [Illustration: 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

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.

    [Illustration: 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.

    [Illustration: 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?

    [Illustration: 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?

    [Illustration: 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?

    [Illustration: 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?

    [Illustration: 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

                            Grades 4-9

########                                                1901-1902

#############                                           1902-1903

######################################################  1903-1904

                            Grades 9-15

#######################                                 1901-1902

####################                                    1902-1903

######################################################  1903-1904

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

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.

    [Illustration: 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.



PART III. COÖPERATION IN MEETING HEALTH OBLIGATIONS



CHAPTER XVI

EUROPEAN REMEDIES: DOING THINGS AT SCHOOL


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

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

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

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

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

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

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

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

    [Illustration: A SOUTH IRELAND ARGUMENT FOR "DOING THINGS"]

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

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

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

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

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

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



CHAPTER XVII

AMERICAN REMEDIES: GETTING THINGS DONE


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

 1. _Study of the physical welfare of school children._

    a. Examination of board of health records of children needing
       medical, dental, or ocular care, and better nourishment.

    b. Home visitation of such children, in order to ascertain
       whether their need arises from deficient income or from other
       causes.

    c. Effort to secure proper treatment, either from parents or
       from free clinics or other established agencies.

    d. Effort to secure proper physical surroundings of children
       while at school--playgrounds, baths, etc.


 2. _Effort to secure establishment of such a system of school
    records and reports_ as will disclose automatically significant
    school facts,--e.g. regarding backward pupils, truancy,
    regularity of attendance, registered children not attending,
    sickness, physical defects, etc.

 3. _Effort to utilize available information regarding school needs_
    so as to stimulate public interest and thus aid in securing
    adequate appropriations to meet school needs.

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

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

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

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

  1. Physical defects found in public schools are, for the most
  part, such as frequently occur in wealthy families and do not of
  themselves presume as the cause insufficient income. Of 145
  reported for malnutrition, 44 were from families having over $20
  weekly.

  2. Few of the defects can be corrected by nourishment alone;
  plenty of fresh air, outside nourishment at school, or extra
  nourishment at home will not entirely counteract the influences of
  bad ventilation and bad light in school buildings. Country
  children have adenoids, bad teeth, and malnutrition. Plenty of
  food will not prevent bad teeth and bad ventilation from causing
  adenoids, enlarged tonsils, and malnutrition.

  3. Children whose parents have long lived in the United States
  need attention quite as much as the recent immigrant.

  4. A large part of the defects reported could be produced by
  conditions due directly to neglect of teeth.

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

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

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

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

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

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

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

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

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

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

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

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

    [Illustration: THE DARK-HALL EVIL IS HERE INDEXED BY ADENOIDS.]

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

    [Illustration: WHERE "GETTING THINGS DONE" IS POSSIBLE BUT
    "DOING THINGS" INEFFECTIVE]

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

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



CHAPTER XVIII

COÖPERATION WITH DISPENSARIES AND CHILD-SAVING AGENCIES


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

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

    [Illustration: ADEQUATE RELIEF RECOGNIZES THE FAMILY AS THE
    UNIT]

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

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

    [Illustration: FRESH-AIR AGENCIES LIKE SEA BREEZE PREFER TO AID
    CHILDREN IN ORDER OF NEED]

    [Illustration: (Facsimile of flyer for the New York Association
    for Improving the Condition of the Poor.)]

 +--------------------------------------------------------------------+
 | =For School Children=                                              |
 |                                                                    |
 | Compulsory education implies the ability of all families, even the |
 | poorest, to take advantage of school benefits. This means that     |
 | children should be fed properly, clad comfortably, and healthfully |
 | housed.                                                            |
 |                                                                    |
 | The New York Association for Improving the Condition of the Poor   |
 | aims to coöperate with school-teachers in every part of Manhattan  |
 | and The Bronx to insure comfort and prevent suffering among school |
 | children, their parents, and younger brothers and sisters. On one  |
 | day last winter we received appeals from school principals and     |
 | teachers in behalf of twenty-nine families. Within six hours every |
 | family was visited, emergent aid in food and coal provided for     |
 | many, and orders given for shoes and dresses and coats required by |
 | the children of school age. During the winter we gave not only     |
 | clothing, groceries, food, and rent, but found work for older boys |
 | and parents, taught mothers to prepare food properly, and sent a   |
 | visiting cleaner to make sick mothers comfortable and to get the   |
 | children ready for school.                                         |
 |                                                                    |
 | In a word, we followed that need, the surface evidence of which    |
 | comes to the attention of the teacher, back into the home and its  |
 | conditions, aiding throughout the period when the family was       |
 | unable to do justice by the school child.                          |
 |                                                                    |
 | In many instances the home income was sufficient, but the home     |
 | management inefficient. Probably such homes could be more          |
 | effectively benefited through educational work emanating directly  |
 | from the school.                                                   |
 |                                                                    |
 | We can be reached by telephone (348, 349, and 1873 Gramercy) from  |
 | 9 A.M. to 12 M. Letters or postal cards should be addressed to     |
 | Mrs. H. Ingram, Superintendent, 105 East 22d Street. Reference     |
 | slips will be gladly furnished upon application.                   |
 |                                                                    |
 |           The New York Association for Improving                   |
 |           1843  *  the Condition of the Poor  *  1905              |
 |                                                                    |
 |     =Teachers of Manhattan and The Bronx=                          |
 |                                                                    |
 |     _Do you know of such children as these:_                       |
 |                                                                    |
 |     1. Convalescent children now out of school, who would be       |
 |     benefited by a stay at the seashore in May or June?            |
 |                                                                    |
 |     2. Children in school whose anæmic condition would be          |
 |     greatly improved by a week at Sea Breeze during July or        |
 |     August?                                                        |
 |                                                                    |
 |     3. Small brothers and sisters (and tired mothers) who may      |
 |     need outings or special help?                                  |
 |                                                                    |
 |     The New York Association for Improving the Condition of the    |
 |     Poor will act promptly. Write or telephone (348 Gramercy).     |
 +--------------------------------------------------------------------+

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

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

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

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

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

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

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

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

    [Illustration: "CENTRAL" FOUND THE MOTHER SICK IN A HOSPITAL,
    THE FATHER KILLED--THE CHILDREN WERE BOARDED IN THE COUNTRY
    UNTIL THE MOTHER RECOVERED]

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

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

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

  [Illustration: CHART OF SOCIAL WORK, MASSACHUSETTS GENERAL HOSPITAL]

                   +-----------------------------------+
                   | _Work for the Tuberculous_        |
                   |                                   |
                   | 1. Tuberculosis classes           |
                   | 2. Reference to other agencies    |
                   | 3. Examination of children        |
                   | 4. Stimulation of suburbs         |
                   +-----------------------------------+
                                     |
                                     |
                                     |
+--------------------------------+   |   +--------------------------------+
| _Psychiatric Work_             |   |   | _Work for Hygienic Conditions_ |
|                                |   |   |                                |
| 1. For neurasthenics and       |   |   | 1. Individual instruction      |
|    hysterics                   |   |   | 2. Convalescent homes          |
| 2. For defectives              |   |   | 3. Industrial hygiene          |
| 3. For stammerers              |   |   | 4. Home hygiene                |
| 4. For epileptics              |   |   |                                |
+--------------------------------+   |   +--------------------------------+
                        \            |            /
                         \           |           /
                          \          |          /
                           \         |         /
                            \        |        /
                             \       |       /
                              \      |      /
                               +-----|-----+
                               |           |
                               /SOCIAL WORK\
                              /|   M.G.H.  |\
                             / +---/|\-----+ \
                            /     / | \       \
                           /     /  |  \       \
                          /     /   |   \       \
                         /     /    |    \       \
                      +-------/-----|-----\-------\---+
                      | _References to Other Agencies_|
                      |                               |
                     /|1. Hospitals and sanatoriums   |
                    / |2. Associated charities        |\
                   /  |3. Societies for children      | \
                  /   |4. District and visiting nurses|  \
                 /    |5. Settlements                 |   \
                /     |6. Homes--temporary or not     |    \
               /     /|7. Employment agencies         |     \
              /     / +-------------|-----------------+      \
+------------/-----/----+           |              +--\-------\----------+
| _Ward Work_           |           |              |                     |
|                       |           |              | _Work for           |
| 1. With cases soon to |           |              |  Cases of           |
|    be discharged      |           |              |  Varicose Ulcer_    |
| 2. Cases needing      |           |              |                     |
|    friendly offices   |           |              |                     |
+-------------/---------+           |              +---------\-----------+
             /                      |                         \
+-----------/-----------+           |           +--------------\----------+
| _Work for             |           |           | _Assistance to M.G.H._  |
|  Sexual Deviates_     | +---------|---------+ | Financial investigation |
|                       | |  _Assistance to   | |                         |
| 1. Unmarried but      | |   Other Agencies_ | |(a) of Cases asking free |
|    pregnant           | |                   | | treatment               |
| 2. Diseased           | | 1. Steering cases | |(b) of Cases presumably  |
| 3. Exposed            | | 2. Coöperation    | | able to pay a physician |
+-----------------------+ +-------------------+ +-------------------------+

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

FOOTNOTES:

[10] The importance of recognizing the family as the unit of social
treatment is presented in Edward T. Devine's _Principles of Relief_, and
in Homer Folks's _Care of Dependent, Defective, and Delinquent
Children_.



CHAPTER XIX

SCHOOL SURGERY AND RELIEF OBJECTIONABLE, IF AVOIDABLE


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

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

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

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

    [Illustration: "DOING THINGS" THROUGH MODEL TENEMENTS]

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

    [Illustration: IMMEDIATELY OPPOSITE THE MODEL TENEMENTS, BUT
    UNINFLUENCED
    "Getting things done" by the Tenement House Department their
    special need]

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

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

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

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

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



CHAPTER XX

PHYSICAL EXAMINATION FOR WORKING PAPERS


There is no sacred right to work when our work involves injury to
ourselves and to our neighbor. Work at the expense of health is an
unjustifiable tax upon the state. It is the duty of society to protect
itself against such depletion of national efficiency.

Three classes of workmen need special attention: (1) those who are
physically unfit to work; (2) those who are physically unfitted for the
work they are doing; (3) those who are subjected to unhealthful
surroundings while at work. Viewing these three classes from the
standpoint of their neighbors, we have three social rights that should
be enforced by law: (1) the right to freedom from unhealthy work; (2)
the right to work fitted to the body; (3) the right to healthy
surroundings at work.

It is undoubtedly true that just as the sick child may be found at the
head of his class, so unhealthy men and women are often good business
managers, good salesmen, good typewriters, successful capitalists. They
excel, however, not because of their ill health, but in spite of it,
excepting of course those instances where men and women, because of ill
health, have devoted to business an attention that would have been
given to recreation if bad health had not deprived recreation of its
pleasure. As statistics in school have proved that the majority of
mentally superior children are also physically superior, so statistics
will probably prove that the number of the "sick superior" among the
working classes is very small, while the danger of inefficiency that
comes from physical defect is very great.

There is one time in the individual's working life when the state may
properly step in and demand an inventory of physical resources, and
that is when the child asks the state for permission to go to work.
Strategically, this is probably the most important of all contact as
yet provided between society and the future wage earner. Here at the
threshold of his industrial career the boy may be told for what work he
is physically fitted, what physical defects need to be remedied, what
physical precautions he needs to take, in order to do justice to
himself and his opportunity.

Every year from two to three million children leave the public schools
of this country to join the army of workers. The percentage of those
recruits who have physical defects needing attention is undoubtedly
great; how great we shall never know until the benefits of physical
examination are given to all of them. What steps is your state taking
to ascertain the physical fitness of the children who present
themselves each year for working papers? How does it insure itself
against the risk of their defective eyesight, chorea, deafness, or
general debility? Does it inform children of their defects, or tell
them how they may increase their earning power by correcting these
defects? What effort does it make to induce children to avoid dangerous
trades, or trades that are particularly dangerous for their physiques?

At the close of school last spring I had my secretary look in upon the
New York board of health and see what demands that city makes upon its
boys and girls before allowing them to drive its machinery, to run its
elevators, to match its colors, to sew on its buttons, to set its type,
to carry its checks to the bank. The officer at the door of the room
where the children were being examined, greeted her as follows: "You
must bring your child with you; bring his birth certificate or swear
that he is fourteen years old, and bring a signed statement from his
teacher that he has been in school for one hundred and thirty
consecutive days within twelve months." "Is there no physical
examination or test?" she asked. "No, no," he answered impatiently. Yet
the board of health certifies that "said child has in our opinion
reached the normal development of a child of its age, and is in sound
health and is physically able to perform the work which it intends to
do." In addition the blank calls for place and date of birth, color of
hair and of eyes, height, weight, and facial marks. Volunteer societies
in practically every state in the Union have been working for years to
have it made a criminal offense to employ a child who has not been in
school a minimum of days after a stated age (12, 13, 14, 15). Even in
New York, however, the center of this agitation, no strong demand was
made upon the board of health to apply a physical-fitness test as well
as an age test until 1908 when examination for working papers was added
to the programme for child hygiene. Yet who does not know girls and
boys of sixteen less fit for factory or shop work than other boys and
girls of twelve? It is the fetich of age which has made possible the
"democracy" that permits a child of fourteen to work all day on
condition that he go to school at night!

    [Illustration: CHILDREN ENLISTING IN THE INDUSTRIAL ARMY]

    [Illustration: WAITING TO BE EXAMINED FOR WORKING PAPERS
    An excellent opportunity for physical-fitness tests]

So great is the risk of defective, sickly, or intemperate employees,
that in some trades employers take every precaution to exclude them.
One man with defective eyesight or unsteady nerves may cost a railroad
thousands of dollars. As insurance companies rank trades as first-,
second-, or third-class risks, so many factories, from long experience,
debar men with certain characteristics which have been found
detrimental to business. The Interborough Rapid Transit Company of New
York City examines all applicants for employment, as to age, weight,
height, keenness of vision, hearing, color perception, lungs, hearts,
arteries, alcoholism, and nicotinism. Those who fall below the standard
are rejected, but in each case the physical condition is explained to
the applicant. Where defects are removable or correctable, the
applicant is told what to do and invited to take another test after
treatment. Moreover, accepted employees are periodically reëxamined.
While designed to increase company profits and to reduce company
losses, this examination obviously decreases the employees' losses
also, and increases the certainty of work and prospect of promotion.

Our states, and many of our industries, still have the attitude of a
certain manufacturer who employs several hundred boys and girls. I
asked him what tests he employed. "I look over a long line of the
applicants and say," pointing his finger, "I want you, and you, and
you; the rest may go." I asked him if he made a point of picking out
those who looked strong. "No. The work is easy, sitting down all day
long and picking over things. I select those whose faces I like. Yes,
there is one question we now ask of all the girls. One day a girl in
the workroom had an epileptic fit and it frightened everybody and upset
the work so that the foreman always asks, 'Do you have fits? Because if
you do, you can't work here.'" He makes no attempt to determine the
physical fitness and endurance of the children employed, because when
the strength of one is spent there is always another to step into her
place.

Because the apprentice's future is of no value to the manufacturer, the
state must restrict the manufacturer's freedom to spend like water
society's capital,--the health of the coming generation. Could there be
a grosser mis-management of society's business than to permit trade to
waste children on whose education society spends so many millions
yearly? The most effective and most timely remedy is physical
examination as a condition of the work certificate. A simple, easily
applied, inexpensive measure that imposes only a legitimate restriction
upon individual freedom, it is absolutely necessary in order to get to
the bottom of the child labor problem. If thoroughly applied, children
of the nation will no longer be exploited by unscrupulous or
indifferent employers, nor will their health be hazarded by lack of
discriminating examination that rejects the obviously sick and favors
the apparently robust. Furthermore, knowledge that this test will be
applied when work certificates are required, will be an incentive to
the school boy and girl to keep well. Tell a boy that adenoids or weak
lungs will keep him from getting a job, and you will make him a strong
advocate of operation and of fresh air. Show him that his employers
will not wish his services when his week is out if he is physically
below par, and he will gladly submit to a board of health examination
and ask to be told what his defects are and how to correct them.

    [Illustration: CHILDREN AT WORK BELOW BOTH AGE LIMIT AND
    VITALITY LIMIT
    National Child Labor Committee]

Some there are who will object to this appeal to the child's economic
instinct. This objection does not remove the instinct. The normal child
is greedy for a job. His greed, as well as that of the manufacturer and
parent, is responsible for much of the child labor; his greed for
activity, for association, for money, and so for work. A little boy
came into my office and wanted to hire as an office boy. I looked at
him and said: "My little fellow, you ought to be in school. What do you
want to hire out here for?" He said, "I am tired of school; nothing
doing." He doesn't care about work for its own sake; he doesn't care
about wealth for its own sake; he wants to get into life; to be where
there is "something doing." In this lies one potent argument for
vocational training. To tell a boy of his physical needs just before he
has taken his first business step is to put him everlastingly in our
debt. Then he is responsive, and, fortunately for the extreme cases,
necessarily dependent, for he knows that his refusal would stand
between himself and his ambition.

When boys and girls go for work certificates to Dr. Goler, medical
officer of health at Rochester, he requires not merely evidence of age
and of schooling, but examines their eyes for defective vision and for
disease, their teeth for cavities and unhealthy gums, and their noses
and throats for adenoids and enlarged tonsils. If a boy has sixteen
decayed teeth, Dr. Goler explains to him that teeth are meant to be not
only ornaments and conveniences, but money getters as well. The boy
learns that decayed teeth breed disease, contaminate food, interfere
with digestion, make him a disagreeable companion and a less efficient
worker. If he will go and have them put into proper condition he will
enjoy life better and earn good wages sooner. After the teeth are
attended to the boy secures his work certificate. If the boy's mother
protests in tears or in anger that her boy does not work with his
teeth, she learns what she never learned at school, that sound teeth
help pay the rent. If a girl applicant for working papers has adenoids,
she is asked to look in the mirror and to notice how her lips fail to
meet, how the lower jaw drops, how much better she looks with her jaws
and lips together. She is told that other people breathe through the
nose, and that perhaps the reason she dislikes school and does not feel
as she used to about play is that she cannot breathe through her nose
as she used to. She is shown that her nose is stopped up by a spongy
substance, as big as the end of her little finger, which obstruction
can be easily removed. She is shown adenoids and enlarged tonsils that
have been removed from some other girl, and is so impressed with the
before-operation and after-operation contrast and by the story of the
other girl's rapid increase in wages, that she and her mother both
decide not to wait for the adenoids to disappear by absorption. After
the operation they come back with proof that the trouble is gone, and
get the "papers." Similar instruction is given when defects of vision
seriously interfere with a child's prospects of getting ahead in his
work, or when evidence of incipient tuberculosis makes it criminal to
put a child in a store or factory.

    [Illustration: THE GRENFELL ASSOCIATION FINDS MOUTH BREATHERS AT
    WORK IN LABRADOR]

No law as yet authorizes the health officer of Rochester to refuse work
certificates to children physically unfit to become wage earners. A
higher law than that which any legislature can pass or revoke, has
given Dr. Goler power over children and parents, namely, interest in
children and knowledge of the industrial handicap that results from
physical defects. This higher law authorizes every health officer in
the United States to examine the school child before issuing a work
certificate, to tell the child and his parents what defects need to be
removed, for what trades he is physically unfitted, what trades will
not increase his physical weakness, and to what trade he is physically
adapted.

We should not forget that a large proportion of our children never
apply for work certificates; some because they never intend to work;
some because they expect to remain in school until sixteen or later;
some because they live on farms, in small towns, or in cities and
states where prohibition of child labor is not enforced. Because there
is no reason for this large proportion of children to visit a board of
health, some substitute must be found. This substitute has been already
suggested by principals and district superintendents in New York City,
who claim that the natural place for the examination of children is the
school and not health headquarters. Developing the idea that the school
should pronounce the child's fitness to leave school and to engage in
work, we are led to the suggestion that the state, which compels
evidence that every child, rich or poor, is being taught during the
compulsory school age, shall also at the age of fourteen or sixteen
require evidence that the child is physically fit to use his education,
and that it shall not, because of preventable ill health, prove a
losing investment.

Parochial and private schools, the ultra-religious and ultra-rich, may
resent for a time public supervision of the physical condition of
children who do not ask for work certificates. This position will be
short-lived, because however much we may disagree about society's right
to control a child's act after his physical defects are discovered, few
of us will question the state's duty to tell that child and his
parents the truth about his physical needs before it accepts his labor
or permits him to go to college, to "come out," to "enter society," or
to live on an income provided by others. Thus an invaluable
commencement present can be given by the state to children in country
schools and to those compelled to drop out of fourth or fifth grades of
city schools.

    [Illustration: THE HEALTH DEPARTMENT'S CLINICAL CARE AND HOME
    INSTRUCTION COME AFTER WAGE LOSSES, WHILE WORK CERTIFICATES
    PRECEDE BREAKDOWNS FROM TUBERCULOSIS]

A brief test of this method of helping children, such as is now being
made by several boards of health at the instance of the National Bureau
of Labor, will prove conclusively that parents are grateful for the
timely discovery of these defects which handicap because of their
existence, not because of their discovery. Of the cadets preparing for
war at West Point, it has recently been decided that those "who in the
physical examinations are found to have deteriorated below the
prescribed physical standard will be dropped from the rolls of the
academy." Shall not cadets preparing for an industrial life and
citizenship be given at least a knowledge of an adequate physical
standard? To allow the school child to deteriorate whether before or
after going to work is only to waste potential citizenship. Citizens
who use themselves up in the mere getting of a living have no surplus
strength or interest for overcoming incompetence in civic business, or
for achieving the highest aim of citizenship,--the art of
self-government for the benefit of all the governed.



CHAPTER XXI

PERIODICAL PHYSICAL EXAMINATION AFTER SCHOOL AGE


Governor Hughes, in his address to the students in Gettysburg College,
pleaded for such lives that strength would be left for the years of
achievement. How many men and women can you count who are squandering
their health bank account? How many do you know who are now physically
bankrupt? The man who is prodigal of his health may work along all
right for years, never realizing until the test comes that he is
running behind in his vitality. The test may be hard times, promotion,
exposure to cold, heat, fever, or a sudden call for all his control in
avoiding accident. If his vitality fails to stand the test, his career
may be ruined, "all for the want of a horseshoe nail": because of no
health bank account to draw upon in time of need,--failure; because of
vitality depleted by alcohol, tobacco, overeating, underexercise, or
too little sleep,--no power to resist contagious diseases; because of
ignorance of existing lung trouble,--a year or more of idleness,
perhaps poverty for his family; or there is neglected ear or eye
trouble,--and thousands of lives may be lost because the engineer
failed to read the signals.

Adults are now examined when applying for insurance or accident
policies, for work on railroads, for service in the army and on the
police and fire forces of cities that provide pensions. It is somewhat
surprising that the hundreds of thousands who carry life insurance
policies have not realized that a test which is rigorously imposed for
business reasons by insurance companies can be applied by individuals
for business reasons. Generations hence the state will probably
require of every person periodic physical examination after school age.
Decades hence business enterprises will undoubtedly require evidence of
health and vitality from employees before and during employment, just
as schools will require such evidence from teachers. It is, after all,
but a step from the police passport to the health passport. Why should
we not protect ourselves against enemies to health and efficiency as
well as against enemies to order? But for the present we must rely upon
the intelligence of individuals to recognize the advantage to
themselves, their families, and their employers, of knowing that their
bodies do not harbor hidden enemies of vitality and efficiency. From a
semi-annual examination of teeth to a semi-annual physical examination
is but a short step when once its effectiveness is seen by a few in
each community.

    [Illustration: THE OLD SOUTHFIELD, NOW ANCHORED AT BELLEVUE
    HOSPITAL'S DOCK, NEW YORK CITY, GIVES DAILY LESSONS IN THE
    PREVENTABLE TAX LEVIED BY TUBERCULOSIS]

Ignorance of one's physical condition is a luxury no one can afford. No
society is rich enough to afford members ignorant of physical
weaknesses prejudicial to others' health and efficiency. Every one of
us, even though to all appearances physically normal, needs the
biological engineer. New conditions come upon us with terrific
rapidity. The rush of work, noise, dust, heat, and overcrowding of
modern industry make it important to have positive evidence that we
have successfully adapted ourselves to these new conditions. Only by
measuring the effects of these environmental forces upon our bodies can
we prevent some trifling physical flaw from developing into a chronic
or acute condition. As labor becomes more and more highly specialized,
the body of the laborer is forced to readapt itself. The kind of work a
man does determines which organs shall claim more than their share of
blood and energy. The man who sets type develops keenness of vision and
manual dexterity. The stoker develops the muscles of his arms and back,
the engineer alertness of eye and ear. All sorts of devices have been
invented to aid this specialization of particular organs, as well as to
correct their imperfections: the magnifying glass, the telescope, the
microscope, extend the powers of the eye; the spectacle or an operation
on the eye muscles enables the defective eye to do normal work. A man
with astigmatism might be a policeman all his life, win promotion, and
die ignorant of his defect; whereas if the same man had become a
chauffeur, he might have killed himself and his employer the first
year, or, if an accountant, he might have been a chronic dyspeptic from
long-continued eye strain. It is a soul tragedy for a man to attempt a
career for which he is physically unadapted.[11] It is a social tragedy
when men and women squander their health. A great deal of the success
attributed to luck and opportunity, or unusual mental endowment, is in
reality due to a chance compatibility of work with physique. To secure
such compatibility is the purpose of physical examination after school
age.

If the periodic visit to the doctor is the first law of adult health,
still more imperative is the law that competent physicians should be
seen at the first indication of ill health. Even when competent
physicians are at hand, parents and teachers should be taught what
warning signs may mean and what steps should be taken. In Germany
insurance companies find that it saves money to provide free medical
and dental care for the insured. Department stores, many factories and
railroads, have learned from experience that they save money by
inducing their employees to consult skilled physicians at the first
sign of physical disorder. Many colleges, schools, and "homes" have a
resident physician. Wherever any large number of people are assembled
together,--in a hotel, factory, store, ship, college, or school,--there
should be an efficient consulting physician at hand. If people are
needlessly alarmed, it is of the utmost importance to show them that
there is nothing seriously wrong. Therefore visits to the consulting
physician should be encouraged.

The reader's observation will suggest numerous illustrations of pain,
prolonged sickness, loss of life, that could have been prevented had
the physician been semi-annually visited. A strong man, well educated,
with large income, personally acquainted with several of the foremost
physicians of New York City, after suffering two weeks from pains "that
would pass away," was hurriedly taken to a hospital at three o'clock in
the morning, operated upon immediately, and died at nine. A business
man of means put off going to a physician for fifteen years, for fear
he would be told that his throat trouble was tobacco cancer, or
incipient tuberculosis, or asthma; a physical examination showed that a
difficulty of breathing and chronic throat trouble were due to a
growth in the nose, corrected in a few minutes by operation.

A celebrated economist was forced to give up academic work, and
consecrated his life to painful and chronic dyspepsia because of eye
trouble detected upon the first physical examination. A woman secretary
suffered from alleged heart trouble; paralysis threatened, continuous
headache and blurred vision forced her to give up work and income; a
physical examination found the cause in nasal growths, whose removal
restored normal conditions. A woman lecturer on children's health heard
described last summer a friend's experience with receding gums: "'Why,
I never heard of that disease.' she said. 'Don't you know you have it
yourself'? I asked. She had never noticed that her gums were growing
away in little points on her front teeth. I touched the uncovered
portion and she winced. That ignorance has meant intense pain and ugly
fillings. If it had gone longer, it might have meant the loss of her
front teeth." A teacher lost a month from nervous prostration; physical
examination would have discovered the eye trouble that deranged the
stomach and produced the nerve-racking shingles which forced him to
take a month's vacation. A journalist lost weeks each year because of
strained ankles; since being told that he had flat foot, and that the
arch of his foot could be strengthened by braces and specially made
shoes, he has not lost a minute. A relief visitor, ardent advocate of
the fresh-air, pure-milk treatment for tuberculosis, had a "little
cough" and an occasional "cold sweat"; medical friends knew this, but
humored her aversion to examination; when too late, she submitted to an
examination and to the treatment which, if taken earlier, would most
certainly have cured her. A mother's sickness cost a wage-earning
daughter nearly $3000; softening of the brain was feared; after six
years of suffering and unnecessary expense, physical examination
disclosed an easily removable cause, and for two years she has
contributed to the family income instead of exhausting it. Untold
suffering is saved many a mother by knowledge of her special physical
need in advance of her baby's birth. Untold suffering might be saved
many a woman in business if she could be told in what respects she was
transgressing Nature's law.

    [Illustration: NEW YORK CITY'S TUBERCULOSIS SANATORIUM AT
    OTISVILLE IS SENDING HOME APOSTLES OF SEMI-ANNUAL EXAMINATIONS]

    [Illustration: BOSTON'S PICTURESQUE DAY CAMP FOR TUBERCULOSIS
    PATIENTS IS TEACHING THE NEED FOR A PERIODIC INVENTORY OF
    PHYSICAL RESOURCES]

To encourage periodic physical examination is not to encourage morbid
thinking of disease. One reason for our tardiness in recognizing the
need for thorough physical examination is the doctor's tradition of
treating symptoms. After men and women are intelligent enough to demand
an inventory of their physical resources,--a balance sheet of their
physical assets and liabilities,--physicians will study the whole man
and not the fraction of a man in which they happen to be specializing
or about which the patient worries. By removing the mystery of bodily
ailments and by familiarizing ourselves with the essentials to healthy
living, we find protection against charlatans, quacks, faddists, and
experimenters. By taking a periodic inventory of our physical resources
we discharge a sacred obligation of citizenship.

FOOTNOTES:

[11] See _Dangerous Trades_, compiled by Thomas Oliver; also list of
reports by the United States Bureau of Labor.



CHAPTER XXII

HABITS OF HEALTH PROMOTE INDUSTRIAL EFFICIENCY


Education's highest aim is to train us to do the right thing at the
right moment without having to think. The technic of musician,
stenographer, artist, electrician, surgeon, orator, is gained only from
patient training of the body's reflex muscles to do brain work.[12] The
lower nerve centers are storehouses for the brain energy, just as
central power houses are used for storing electric energy to be spent
upon demand. From habit, not from mental effort, we turn to the right,
say "I beg pardon" when we step on another's foot, give our seats to
ladies or to elderly persons, use acceptable table manners. No person
seems "to the manner born" who has to think out each act necessary to
"company manners." How numerous are the mental and physical processes
essential to good manners no one ever recognizes but the very bashful
or the uncouth person trying to cultivate habits of unconsciousness in
polite society. The habit of living ethically enables us to go through
life without being tempted to steal or lie or do physical violence. No
person's morals can be relied upon who is tempted constantly to do
immoral acts; ethical training seeks to incapacitate us for committing
unethical deeds and to habituate us to ethical acts alone.

Eight different elements of industrial efficiency are concerned with
the individual's health habits,--the industrial worker, his industrial
product, his employer, his employer's profit, his trade or profession,
its product, his nation, national product. Obviously few men have so
little to do that they have time to think out in detail how this act or
that indulgence will affect each of these eight factors of industrial
efficiency. Once convinced, however, that all of these elements are
either helped or injured by the individual's method of living, each one
of us has a strong reason for imposing habits of health upon all
industries, upon employees and operatives, upon all who are a part of
industrial efficiency. When these eight relations are seen, parents and
teachers have particularly strong reasons for inculcating habits of
health in their children.

That industrial inefficiency results from chronic habits of unhealthy
living is generally recognized. The alcoholic furnishes the most vivid
illustration. The penalties suffered by him and his family are grave
enough, but because he has not full possession of his faculties he is
unpunctual, wastes material, disobeys instructions, endangers others'
lives, decreases the product of his trade and of his employer, lessens
the profits of both, depresses wages, increases insurance and business
risks. Because no one can foresee when the "drop too much" will be
taken, industry finds it important to know that the habit of drinking
alcoholics moderately has not been acquired by train dispatcher,
engineer, switchman, chauffeur. Because the habit of drinking
moderately is apt, among lower incomes, to go hand in hand with other
habits injurious to business and fatal to integrity, positions of trust
in industry seek men and women who have the habit of declining drink.

In the aggregate, milder forms of unhealthy living interfere with
industrial efficiency even more than alcoholism. Many capable men and
women, even those who have had thorough technical training, fail to win
promotion because their persons are not clean, their breath offensive,
their clothes suggestive of disorderly, uncleanly habits. Persons of
extraordinary capacity not infrequently achieve only mediocre results
because they fail to cultivate habits of cleanliness and health. An
employer can easily protect his business from loss due to alcoholism
among his own employees; but loss through employees' constipation,
headache, bad ventilation at home, irregular meals, improper diet, too
many night parties, nicotinism, personal uncleanliness, is loss much
harder to anticipate and avoid. Because evil results are less vivid, it
is also hard to convince a clerk that intemperance in eating, sleeping,
and playing will interfere with his earning capacity and his enjoyment
capacity quite as surely as intemperance in the use of alcohol and
nicotine. Where employees are paid by the piece, instead of by the
hour, day, or week, the employer partially protects himself against
uneven, sluggish, slipshod workmen; but, other things being equal, he
awards promotion to those who are most regular and who are most often
at their best, for he finds that the man who does not "slump" earns
best profits and deserves highest pay.

    [Illustration: THESE PATIENTS ON THE OLD SOUTHFIELD ARE TAXING
    THEIR UNIONS AND THEIR TRADES AS WELL AS THEIR FAMILIES AND THE
    TUBERCULOSIS COMMITTEE]

There are exceptions, it is true, where both industrial promotion and
industrial efficiency are won by people who violate laws of
health,--but at what cost to their efficiency? Your efficiency should
be measured not by some other person's advancement, but by what you
yourself ought to accomplish; while the effect of abusing your physical
strength is shown not only in the shortening of your industrial life
and in the diminishing returns from your labor, but by the decrease of
national and trade efficiency. "Sweating" injures those who buy and
those in the same trade who are not "sweated" just as truly as it
injures the "sweated."

    [Illustration: HABITS OF HEALTH AMONG DAIRYMEN MEAN SAFE MILK
    FOR BABIES]

What are the health habits that should become instinctive and
effortless for every worker? What acts can we make our lower nerve
centers--our subconscious selves--do for us or remind us to do? The
following constitutes a daily routine that should be as involuntary as
the process of digestion:

  1. Throw the bedding over the foot of the bed.

  2. Close the window that has been open during the night.

  3. Drink a glass of water.

  4. Bathe the face, neck, crotch, chest, armpits (finishing if not
  beginning with cold water), and particularly the eyes, ears, and
  nose. If time and conveniences permit, bathe all over.

  5. Cleanse the finger nails.

  6. Cleanse the teeth, especially the places that are out of sight
  and hard to reach.

  7. Breakfast punctually at a regular hour. Eat lightly and only
  what agrees with you. If you read a morning paper, be interested
  in news items that have to do with personal and community
  vitality.

  8. Visit the toilet; if impracticable at home, have a regular time
  at business.

  9. Have several minutes in the open air, preferably walking.

  10. Be punctual at work.

  11. As your right by contract, insist upon a supply of fresh air
  for your workroom with the same emphasis you use in demanding
  sufficient heat in zero weather.

  12. Eat punctually at noon intermission; enjoy your meal and its
  after effects.

  13. Breathe air out of doors a few minutes, preferably walking.

  14. Resume business punctually.

  15. Stop work regularly.

  16. Take out-of-door exercise--indoor only when fresh air is
  possible--that you enjoy and that agrees with you.

  17. Be regular, temperate, and leisurely in eating the evening
  meal; eat nothing that disagrees with you.

  18. Spend the evening profitably and pleasantly and in ways
  compatible with the foregoing habits.

  19. Retire regularly at a fixed hour, making up for irregularity
  by an earlier hour next night.

  20, 21, 22. Repeat 4, 6, 8.

  23. Turn underclothes wrong side out for ventilation.

  24. Open windows.

  25. Relax mind and body and go to sleep.

No man chronically neglects any one of the above rules without reducing
his industrial efficiency. No man chronically neglects all of them
without becoming, sooner or later, a health bankrupt.

In addition to this daily routine, there are certain other acts that
should become habitual:

  1. Bathing less frequently than once a week is almost as dangerous
  to health as it is to attractiveness.

  2. Distaste for unclean linen or undergarments and for acts or
  foods that interfere with vitality should become instinctive.

  3. Excesses in eating or playing should be automatically corrected
  the next day and the next. Parties we shall continue to have. It
  will be some time before reasonable hours and reasonable
  refreshments will prevail. Meanwhile it is probably better for an
  individual to sacrifice somewhat his own vitality for the sake of
  the union, the class, or the church. While trying to improve group
  habits, one can acquire the habit of not eating three meals in
  one, of eating less next day, of sleeping longer next night, of
  being particularly careful to have plenty of outdoor air.

  4. Visits to the dentist twice a year at least, and whenever a
  cavity appears, even if only a week after the dentist has failed
  to find one; whenever the gums begin to recede; and whenever
  anything seems to be wrong with the teeth.

  5. Periodic physical examination by a physician.

  6. Examination by a competent physician whenever any disorder
  cannot be satisfactorily explained by violation of the daily
  routine or by interruption of business or domestic routine.

Health habits do not become instinctive until a continued, conscious
effort is made to accustom the body to them. When this is once done,
however, the body not only attends to its primary health needs
automatically, but it rebels at their omission, as surely as does the
stomach at the omission of dinner. Witness the discomfort of the
consumptive, trained to fresh air at a sanatorium, when he returns to
his overheated and underventilated home, or the actual pain experienced
in readjusting our own healthy bodies to the stuffy workroom or
schoolroom after a summer vacation out of doors. I heard a consumptive
say that he left a sanatorium for a day class after trying for three
nights to sleep in an unventilated ward. For many people the regular
morning bath is at first a trial, then a pleasure, and finally a need;
if omitted, the body feels thirsty and dissatisfied, the eyes sleepy,
and the spirit flags early in the day.

    [Illustration: IMPROVISED SEASIDE HOSPITAL FOR NONPULMONARY
    TUBERCULOSIS AT SEA BREEZE TEACHES PASSERS-BY THE FRESH-AIR
    GOSPEL]

Cold baths are not essential or even good for everybody. The same diet
or the same amount of food or time for eating is not of equal value for
all. The temperature of bath water, the kind and quality of food, are
influenced by one's work and one's cook. Set rules about these things
do more harm than good. Such questions must be decided for each
individual,--by his experience or by the advice of a physician,--but
they must be decided and the decisions converted into health habits if
he would attain the highest efficiency of which he is capable. Here
again our old contrast between "doing things" and "getting things done"
applies. Get your body to attend to the essential needs for you, and
get it to remind you when you let the exigencies of life interfere.
Don't burden your mind every day with work that your body will do for
you if properly trained.

    [Illustration: CRIPPLED CHILDREN LEAVING SEA BREEZE HOSPITAL FOR
    BONE TUBERCULOSIS FIND STALE AIR OFFENSIVE BY NIGHT OR BY DAY]

Obstacles to habits of health are numerous; therefore the importance of
correcting those habits of factory, family, trade, city, or nation that
make health habits impracticable. We must change others' prejudices
before we can breathe clean air on street cars without riding outside.
When one's co-workers are afraid of fresh air, ventilation of shop,
store, and office is impossible. So long as parents fear night air,
children cannot follow advice to sleep with windows open. Unless the
family coöperates in making definite plans for the use of toilet and
bath for each member, constipation and bad circulation are sure to
result. Indigestion is inevitable if employees are not given lunch
periods and closing hours that permit of regular, unhurried meals.
Cleanliness of person costs more than it seems to be worth where cities
fail either to compel bath tubs in rented apartments or to erect public
baths. A temperate subsistence on adulterated, poisonous, or drugged
foods might be better for one's health than gormandizing on pure foods.
No recipe has ever been found for bringing up a healthy baby on
unclean, infected milk; for avoiding tuberculosis among people who are
compelled to work with careless consumptives in unclean air; or for
making a five-story leap as safe as a fire escape. Perfect habits of
health on the part of an individual will not protect him against
enervation or infection resulting from inefficient enforcement of
sanitary codes by city, county, state, and national authorities.

    [Illustration: AT JUNIOR SEA BREEZE, TEACHING MOTHERS THE HEALTH
    ROUTINE FOR BABIES]

The "municipalization" or "public subsidy" of health habits is
indispensable to protecting industrial efficiency. Public lavatories,
above or below ground, have done much to reduce inefficiency due to
alcoholism, constipation of the bowels, and congestion of the kidneys.
Theaters, churches, and assembly rooms could be built so as to drill
audiences in habits of health instead of fixing habits of uncleanly
breathing. Street flushing, drinking fountains, parks and breathing
spaces, playgrounds and outdoor gymnasiums, milk, food, and drug
inspection, tenement, factory, and shop supervision, enforcement of
anti-spitting penalties, restriction of hours of labor, prohibition of
child labor,--these inculcate community habits of health that promote
community efficiency. It is the duty of health boards to compel all
citizens under their jurisdiction to cultivate habits of health and to
punish all who persistently refuse to acquire these habits, so far as
the evils of neglect become apparent to health authorities. The
unlimited educational opportunity of health boards consists in their
privilege to point out repeatedly and cumulatively the industrial and
community benefits that result from habits of health, and the
industrial and community losses that result from habits of unhealthy
living.

FOOTNOTES:

[12] Serviceable guides to personal habits of health are _Aristocracy of
Health_ by Mary Foote Henderson, and _Efficient Life_ by Dr. Luther H.
Gulick.



CHAPTER XXIII

INDUSTRIAL HYGIENE


To call the movement for better factory conditions the "humanizing of
industry" implies that modern industry not influenced by that movement
is brutalized. The brutalizing of industry was due chiefly to a general
ignorance of health laws,--an ignorance that registers itself clearly
and promptly in factory and mine. It is not that a man is expected to
do too much, but that too little is expected of the human body. The
present recognition of the body's right to vitality is not because the
employer's heart is growing warmer, or because competition is less
vicious, but because the precepts of hygiene are found to be practical.
Where better ventilation used to mean more windows and repair bills, it
now means greater output. Where formerly a comfortable place in which
to eat lunch meant giving up a workroom and its profits, it now means
25 per cent more work done in all workrooms during the afternoon. The
general enlightenment as to industrial hygiene has been accelerated by
the awakening that always follows industrial catastrophes, by the
splendid crusade against tuberculosis, and by compulsory notification
and treatment of communicable diseases.

Catastrophes, however, have dominated the vocabulary that describes
factory "welfare work." Because accidents such as gas in mines, fire in
factories, fever in towns, and epidemics of diseases incident to
certain trades were beyond the power of the workers themselves to
control or prevent, wage earners have come to be looked upon as
helpless victims of the cupidity and inhumanity of their employers.
This attitude has weakened the usefulness of many bodies organized to
promote industrial hygiene. Although the term "industrial hygiene" is
broad enough to include all sanitary and hygienic conditions that
surround the worker while at work, it is restricted by some to the
efforts made by altruistic or farsighted employers in the interest of
employees; others think of prohibitions and mandates, in the name of
the state, that either prevent certain evils or compel certain
benefits; for too few it refers to what the wage earner does for
himself.

Pity for the employee has caused the motive power of the employee to be
wastefully allowed to atrophy. Yet when a man becomes an employee, he
does not forfeit any right of citizenship, nor does being an employee
relieve him from the duties of citizenship. In too many cases it has
been overlooked that a worker's carelessness about habits of health, as
well as about his machinery, causes accidents and increases industrial
diseases. Too often the worker himself is responsible for uncleanliness
and lack of ventilation and his own consequent lack of vitality. A
study into the conditions of ventilation and cleanliness of workers'
homes will prove this.

Knowing that a light, well-aired, clean, safe factory would not of
itself insure healthy men, many employers have built and supplied
houses for their workmen at low rents. Just as these employers failed
to see that they could reach more people and secure more permanent
results if they demanded that tenement laws and the sanitary code be
enforced as well as the laws for the instruction of children in
hygiene, so the employee has failed to see that he is a part of the
public that passes laws and determines the efficiency of factory
inspection. The enforcement of state legislation for working hours,
proper water and milk supply, proper teaching of children, proper
tenement conditions, efficient health administration, is dependent upon
the interest and activity of the public, of which the working class is
no small or uninfluential part.

    [Illustration: COUNTRY CLUB HOUSE FOR NEW YORK SOCIAL WORKERS
    Given by the founder of Caroline Rest Educational Fund]

The first and most important step in securing hygienic rights for
workingmen is to make sure that they know the rights that the law
already gives them. Men still throw out their chests when talking of
their rights. The posting of the game laws in a club last summer, and
the instruction of all the natives of the countryside in regard to
their rights as against those of outsiders, meant that for the first
time in their history the game laws were enforced. All the natives,
instead of poaching as has been their wont, joined together in
protecting club property from intruding outside sportsmen. Poachers
were caught and served with the full penalties of the law. Over winter
fires these people's heroism will grow, but their respect for law will
grow also, and it is doubtful if the game laws can be violated in that
section so long as the tradition of this summer's work lives. And so
it would be in a factory, if employees once realized that by uniting
they could, as citizens, enforce health rights in the factory.

The hygiene of the workshop is not the same problem as the hygiene of
the home and schoolhouse, because there are by-products of factory work
that contaminate the air, overheat the room, and complicate the
ordinary problems of ventilation. Certain trades are recognized as
"dangerous trades." The problem of adequate government control of
factories is one for a sanitary engineer. It has to do with
disease-bearing raw material that comes to a factory, disease-producing
processes of manufacture. There is need for revision of the
dangerous-trade list. Many of the industries not so classed should be;
many of the so-called dangerous trades can be made comparatively
harmless by devices for exhausting harmful by-products. Industrial
diseases should be made "notifiable," so that they can be controlled by
the factory or health department. It is those trades that are dangerous
because of remediable unsanitary and unhygienic conditions which demand
the employer's attention. Complaints should be made by individuals when
carelessness or danger becomes commonplace.

The manner in which many organizations have tried to better working
conditions is similar to the manner in which Europeans are trying to
help defective school children. Here, as there, is the difference
between _doing things_ and _getting things done_. Here more than there
is the tendency to exaggerate legislation and to neglect enforcement of
law. Instead of harnessing the whole army of workingmen to the crusade
and strengthening civic agencies such as factory, health, and tenement
departments, houses are built and given to men, clubs are formed to
amuse factory girls, amateur theatricals are organized. All this is
called "welfare work." "What is welfare work?" reads the pamphlet of a
large national association. "It is especial consideration on the part
of the employer for the welfare of his employees." In the words of this
pamphlet, the aim of this association "is to organize the best brains
of the nation in an educational movement toward the solution of some of
the great problems related to social and industrial progress." The
membership is drawn from "practical men of affairs, whose acknowledged
leadership in thought and business makes them typical representatives
of business elements that voluntarily work together for the general
good." As defined by this organization, welfare work is something given
to the employee by the employer for the welfare of both. It is not
something the employee himself does to improve his own working
conditions.

  We are told that employees should assume the management of welfare
  work.

  Should they install sanitary conveniences? Of course not.

  Would they know the need of a wash room in a factory if they never
  had had one? No.

  Should they manage lunch rooms? A few employers have attempted
  unsuccessfully to turn over the management of the lunch rooms to
  the employees, the result being that one self-sacrificing
  subofficial in each concern would find the burden entirely on his
  shoulders before working hours, during working hours, and after
  working hours. Employees cannot attend committee meetings during
  working hours, and they are unwilling to do so afterwards, for
  they generally have outside engagements. Furthermore, the
  employees know nothing about the restaurant business. If they did,
  they would probably be engaged in it instead of in their different
  trades. All experiments along this line of which we have heard
  have failed. The so-called "democratic idea," purely a fad, never
  has been successfully operated.

  Many employers would introduce welfare work into their
  establishments were it not for the time and trouble needed for its
  organization. The employment of a welfare director removes this
  obstacle. Successful prosecution of welfare work requires
  concentration of responsibility. All of its branches must be under
  the supervision of one person, or efforts in different directions
  may conflict, or special and perhaps pressing needs may escape
  attention. Pressure of daily business routine usually relegates
  welfare work to the last consideration, but the average employer
  is interested in his men and is willing to improve their condition
  if only their needs are brought to his attention.

    [Illustration: FIRST LESSONS IN INDUSTRIAL HYGIENE]

 +--------------------------------------------------------------------+
 | =Consumption=                                                      |
 |                                                                    |
 | Is chiefly caused by the Filthy Habit of                           |
 |                                                                    |
 | =SPITTING=                                                         |
 |                                                                    |
 | TAKE THIS CARD HOME                                                |
 |                                                                    |
 | And show it to your family, friends, and neighbors                 |
 |                                                                    |
 | Consumption is a disease of the lungs, which is taken from others, |
 | and is not simply caused by colds, although a cold may make it     |
 | easier to take the disease.                                        |
 |                                                                    |
 | The matter coughed up and sneezed out by consumptives is full of   |
 | living germs or "tubercle bacilli" too small to be seen. These     |
 | germs are the cause of consumption, and when they are breathed     |
 | into the lungs they set up the disease.                            |
 |                                                                    |
 | DON'T GET CONSUMPTION YOURSELF                                     |
 |                                                                    |
 | Keep as well as possible, for the healthier your body, the harder  |
 | for the germs of consumption to gain a foothold. Every person      |
 | should observe the following rules:                                |
 |                                                                    |
 |                                                                    |
 |     =DON'T= live, study, or sleep in rooms where there is no       |
 |        fresh air. Fresh air and sunlight kill the consumption      |
 |        germs and other germs causing other diseases; therefore     |
 |        have as much of both in your room as possible.              |
 |                                                                    |
 |     =DON'T= live in dusty air; keep rooms clean; get rid of dust   |
 |        by cleaning with damp cloths and mops. =DON'T= sweep with   |
 |        a dry broom.                                                |
 |                                                                    |
 |     =KEEP= one window partly open in your bedroom at night, and    |
 |        air the room two or three times a day.                      |
 |                                                                    |
 |     =DON'T= eat with soiled hands. Wash them first.                |
 |                                                                    |
 |     =DON'T= put hands or pencils in the mouth, or any candy or     |
 |        chewing gum other persons have used.                        |
 |                                                                    |
 |     =DON'T= keep soiled handkerchiefs in your pockets.             |
 |                                                                    |
 |     =TAKE= a warm bath at least once a week.                       |
 |                                                                    |
 |     =DON'T= neglect a cold or a cough, but go to a doctor or       |
 |        dispensary.                                                 |
 +--------------------------------------------------------------------+

    [Illustration: WELFARE WORK THAT COUNTS]

 +-------------------------------------------------------------------+
 | =HOW TO GET WELL IF YOU HAVE CONSUMPTION=                         |
 |                                                                   |
 | If you or any one in your family have consumption, you must obey  |
 | the following rules if you wish to get well:                      |
 |                                                                   |
 |      =DON'T= waste your money on patent medicines or advertised   |
 |         cures for consumption, but go to a doctor or dispensary   |
 |         (see last page). If you go in time, you can be cured; if  |
 |         you wait, it may be too late.                             |
 |                                                                   |
 |      =DON'T= drink whisky or other forms of liquor.               |
 |                                                                   |
 |      =DON'T= sleep in the same bed with any one else, and, if     |
 |         possible, not in the same room.                           |
 |                                                                   |
 |   =Good food, fresh air, and rest are the best cures. Keep out    |
 |   in the fresh air and in the sunlight as much as possible.=      |
 |                                                                   |
 |      =KEEP= your windows open winter and summer, day and night.   |
 |                                                                   |
 |      =IF= properly wrapped up you will not catch cold.            |
 |                                                                   |
 |      =GO= to a sanatorium while you can and before it is too      |
 |         late.                                                     |
 |                                                                   |
 |  =The careful and clean consumptive is not dangerous to those     |
 |  with whom he lives and works.=                                   |
 |                                                                   |
 |  =Don't give consumption to others.=                              |
 |                                                                   |
 |  Many grown people and children have consumption without knowing  |
 |  it, and can give it to others. Therefore every person, even if   |
 |  healthy, should observe the following rules:                     |
 |                                                                   |
 |      =DON'T SPIT= on the sidewalks, playgrounds, or on the        |
 |         floors or hallways of your home or school. It spreads     |
 |         disease, and is dangerous, indecent, and unlawful.        |
 |                                                                   |
 |      =WHEN YOU MUST SPIT=, spit in the gutters or into a spittoon |
 |         half filled with water.                                   |
 |                                                                   |
 |      =DON'T COUGH OR SNEEZE= without holding a handkerchief or    |
 |         your hand over your mouth or nose.                        |
 +-------------------------------------------------------------------+
 $/

This method of promoting the welfare of the worker may have been a
necessary step in the development of industrial hygiene. Undoubtedly it
has succeeded, in many cases, in bringing to an employer's
consciousness the needs of his workmen, in accustoming employees to
higher sanitary standards, and in teaching them to demand health rights
from their employers. In many cases, however, "welfare work" has
miseducated both employer and employee. The fact that "the so-called
democratic idea, purely a fad, has never been successfully operated,"
is due to the interpretation given to "democratic idea." The two
alternatives in the paragraph above quoted are lunch rooms, wash rooms,
as gifts from employers to employees, or lunch rooms and wash rooms to
be furnished by employees at their own expense. The true democratic
idea, however, is that factory conditions detrimental to health shall
be prohibited by factory legislation, and this legislation enforced by
efficient factory inspectors, regardless of what may be given to
employees above the requirement of hygiene.

Until employees are more active as citizens and more sensitive to
hygienic rights, it is desirable that welfare directors be employed in
factories to arbitrate between employer and employee, to raise the
moral standard of a factory settlement, to organize amusements.

Welfare work at its best is a method of dividing business profits among
all who participate in making these profits. Too often welfare
secretaries teach employees how to be happy in the director's way,
rather than in their own way. This adventitious position increases
suspicion on both sides, disturbs the discipline of the foreman,
weakens rather than strengthens the worker's efficiency, because it
depends upon other things than work well done and the relation of
health to efficiency. In a small factory town the owner of a large
cotton mill has recognized the financial benefit of physically strong
workers, and is trying the experiment of a welfare director. The man
himself works "with his sleeves up." The social worker has an office in
the factory. A clubhouse is fitted up for the mill hands to make merry
in. A room in the factory is reserved for a lunch room, with plants,
tables, and chairs for the comfort of the women. Parties are given by
the employer to the employees, which he himself attends. He has thrown
himself into whatever schemes his director has suggested. The director
complained that the reason the new lunch room was not more popular was
because a piano was needed. A second-hand one would not do, for that
would cultivate bad taste in music. This showed the employer that soon
everything would be expected from the "big house on the hill." An event
which happened at the time when the pressure was greatest on him for
the piano, convinced him that his employees could supply their real
needs without any trouble or delay. The assistant manager was about to
leave, and in less than a week five hundred dollars was raised among
the workers for his farewell gift. Walking home that night late from
his office the owner was attracted by the sound of jollity, and saw a
little room jammed full of mill people enjoying the improvised music of
a mouth organ played to the accompaniment of heels. He resolved
henceforth to train his employees to do his work well and to earn more
pay,--and to let them amuse themselves. From that time on he refused to
be looked upon as the _deus ex machina_ of the town. He decided that
the best way to give English lessons to foreigners was to improve the
school. His beneficence in supplying them with pure water at the mill
did not prevent a ravaging typhoid epidemic because the town water was
not watched. He saw that the best way to improve health was to
strengthen the health board and to make his co-workers realize that
they were citizens responsible for their own privileges and rights.

Emergency hospitals and Y.M.C.A. buildings are sad substitutes for
safety devices and automatic couplers. Christmas shopping in November
is less kind than prevention of overwork in December. Night school and
gymnastic classes are a poor penance for child labor and for work
unsuited to the body. The left hand cannot dole favors enough to offset
the evils of underpay, of unsanitary conditions, of inefficient
enforcement of health laws tolerated by the right hand.

Just because a man is taking wages for work done, is no reason why he
should forfeit his rights as a citizen, or allow his children, sisters,
neighbors, to work in conditions which decrease their efficiency and
earning power. What the employee can do for himself as a citizen,
having equal health rights with employers, he has never been taught to
see. Factory legislation is state direction of industries so far as
relates to the safety, health, and moral condition of the people,--and
which embraces to-day, more than in any other epoch, the opinion of the
workers themselves. No government, however strong, can hope
successfully to introduce social legislation largely affecting personal
interests until public opinion has been educated to the belief that the
remedies proposed are really necessary. Until schools insist upon a
better ventilation than the worst factories, how can we expect to find
children of working age sensitive to impure air? Where work benches are
more comfortable than school desks, where drinking water is cleaner and
towels more sanitary, however unsanitary they may be, than those found
in the schoolhouse, the worker does not realize that they menace his
right to earn a living wage as much as does a temporary shut-down.

Employers are by no means solely to blame for unhealthy working
conditions. A shortsighted employee is as anxious to work overtime for
double pay as a shortsighted employer is to have him. Among those who
are agitating for an eight-hour day are many who, from self-interest or
interest in the cause, work regularly from ten to sixteen hours.

Would it help to punish employees for working in unhealthy places? The
highest service that can be rendered industrial hygiene is to educate
the industrial classes to recognize hygienic evils and to coöperate
with other citizens in securing the enforcement of health rights.



CHAPTER XXIV

THE LAST DAYS OF TUBERCULOSIS


If the historian Lecky was right in saying that the greatest triumphs of
the nineteenth century were its sanitary achievements, the Lecky of the
twenty-first century will probably honor our generation not for its
electricity, its trusts, and its scientific research, but for its
crusade against the white plague and for its recognition of health
rights. Thanks to committees for the prevention of tuberculosis,--local,
state, national, international,--we are fast approaching the time when
every parent, teacher, employer, landlord, worker, will see in
tuberculosis a personal enemy,--a menace to his fireside, his income,
and his freedom. Just as this nation could not exist half slave, half
free, we of one mind now affirm that equal opportunity cannot exist
where one death in ten is from a single preventable disease.[13]

Of no obstacle to efficient living is it more true than of
tuberculosis, that the remedy depends upon enforcing rather than upon
making law, upon practice rather than upon precept, upon health habits
rather than upon medical remedies, upon coöperation of lay citizens
rather than upon medical science or isolated individual effort. Without
learning another fact about tuberculosis, we can stamp it out if we
will but apply, and see that officers of health apply, lessons of
cleanliness and natural living already known to us.

    [Illustration: DR. TRUDEAU'S "LITTLE RED COTTAGE" AT
    SARANAC--BIRTHPLACE OF OUT-OF-DOOR TREATMENT IN AMERICA]

Perhaps the most striking results yet obtained in combating
tuberculosis are those of the Massachusetts General Hospital in Boston.
To visit its tuberculosis classes reminds one more of the sociable than
the clinic. In fact, one wonders whether the milk diet and the rest
cure or the effervescing optimism and good cheer of the physicians and
nurses should be credited with the marvelous cures. The first part of
the hour is given to writing on the blackboard the number of hours that
the class members spent out of doors the preceding week. So great was
the rivalry for first place that the nurse protested that a certain boy
in the front row gave himself indigestion by trying to eat his meals in
ten or fifteen minutes. It was then suggested that twenty hours a day
would be enough for any one to stay out of doors, and that plenty of
time should be taken for meals with the family and for cold baths,
keeping clean, etc. Interesting facts gathered by personal interviews
of two physicians with individual patients are explained to the whole
class. Next to the number of hours out of doors, the most interesting
fact is the number of hours of exercise permitted. A man of forty, the
head of a family, beamed like a school child when told that, after
nearly a year of absolute rest, he might during the next week exercise
ten minutes a day. A graduate drops in, the very picture of health,
weighing two hundred pounds. An apparently hopeless case would brighten
up and have confidence when told that this strong, handsome man has
gained fifty pounds by rest, good cheer, fresh air, all on his own
porch. One young man, just back from a California sanatorium where he
progressively lost strength in spite of change of climate, is now
returning to work and is back at normal weight.


    [Illustration: OUTDOOR LIFE CHART.]

    [Illustration: FIGHTING TUBERCULOSIS IN THE MOUNTAINS--SARANAC]

Every patient keeps a daily record, called for by the following
instructions:

  Make notes of temperature and pulse at 8, 12, 4, and 8 o'clock,
  daily; movements of bowels; hours in open air; all food taken;
  total amount of milk; total amount of oil and butter; appetite;
  digestion; spirits; cough (amount, chief time); expectoration
  (amount in 24 hours, color, nature); exercise (if allowed), with
  temperature and pulse 15 minutes after exercise; sweats; visitors.

The following simple instructions can be followed in any home, even
where open windows must take the place of porches:

  Rest out of doors is the medicine that cures consumption. Absolute
  rest for mind and body brings speedy improvement. It stops the
  cough and promotes the appetite. The lungs heal more quickly when
  the body is at rest. Lie with the chest low, so the blood flow in
  the lungs will aid to the uttermost the work of healing. The rest
  habit is soon acquired. Each day of rest makes the next day of
  rest easier, and shortens the time necessary to regain health. The
  more time spent in bed out of doors the better. Do not dress if
  the temperature is above 99 degrees, or if there is blood in the
  sputum. It is life in the open air, not exercise, that brings
  health and strength. Just a few minutes daily exercise during the
  active stage of the disease may delay recovery weeks or months.
  Rest favors digestion, exercise frequently disturbs digestion.
  When possible have meals served in bed. Never think the rest
  treatment can be taken in a rocking-chair. If tired of the cot,
  shift to the reclining chair, but sit with head low and feet
  elevated. Do not write letters. Dictate to a friend. Do not read
  much and do not hold heavy books. While reading remain in the
  recumbent posture.

    [Illustration: FIGHTING TUBERCULOSIS IN DAY CAMPS--BOSTON]

Once having learned the simple facts that must be noted and the simple
laws that must be followed, once having placed oneself in a position
to secure the rest, the fresh air, and the health diet, no better next
steps can be taken than to observe the closing injunction in the rules
for rest:

  There are few medicines better than clouds, and you have not to
  swallow them or wear them as plasters,--only to watch them.
  Keeping your eyes aloft, your thoughts will shortly clamber after
  them, or, if they don't do that, the sun gets into them, and the
  bad ones go a-dozing like bats and owls.

    [Illustration: THE BACK OF A STREET-CAR TRANSFER, SUNDAYS, NEW
    YORK CITY]

 +--------------------------------------------------------------------+
 |  CONSUMPTION IN EARLY STAGES CAN BE CURED                          |
 |                                                                    |
 |  Take your case in time to a good physician or to a dispensary and |
 |  you may be cured--DO NOT WAIT.                                    |
 |                                                                    |
 |  Consumption is "caught" mainly through the spit of consumptives.  |
 |                                                                    |
 |  Friends of Consumption--Dampness, Dirt, Darkness, Drink.          |
 |                                                                    |
 |  Enemies of Consumption--Sun, Air, Good Food, Cleanliness.         |
 |                                                                    |
 |  If you have tuberculosis do not give it to others by spitting;    |
 |  even if you have not, set a good example by refraining from a     |
 |  habit always dirty and often dangerous.                           |
 |                                                                    |
 |  _The Committee on the Prevention of Tuberculosis_                 |
 |  _Of the Charity Organization Society_                             |
 |                                                                    |
 |  (By Courtesy of Siegel Cooper Co.)                                |
 +--------------------------------------------------------------------+

Important as are sanatoriums in mountain and desert, day or night camps
within and near cities, milk and egg clinics, home visiting, change of
air and rest for those who are known to be tuberculous, their
importance is infinitesimal compared with the protection that comes
from clean, healthy environment and natural living for those not known
to be tuberculous. This great fact has been recognized by the various
bodies now engaged in popularizing the truth about tuberculosis by
means of stationary and traveling exhibits, illustrated lectures,
street-car transfers, advertisements, farmers' institutes,
anti-spitting signs in public vehicles and public buildings, board of
health instructions in many languages, magazine stories, and press
reports of conferences. This brilliant campaign of education shows what
can be done by national, state, and county superintendents of schools,
if they will make the most of school hygiene and civics.


    [Illustration: AN EXAMPLE IN COÖPERATION THAT ANTI-TUBERCULOSIS
    CRUSADERS SHOULD FOLLOW]

 +-------------------------------------------------------------------+
 | CIRCULAR ISSUED BY                                                |
 |                                                                   |
 | The Committee of Sanitation of the Central Federated Union of     |
 | New York                                                          |
 |                                                                   |
 | The Committee on the Prevention of Tuberculosis of the Charity    |
 | Organization Society                                              |
 |                                                                   |
 | 105 East 22d Street, New York City                                |
 |                                                                   |
 |        *       *       *       *       *                          |
 |                                                                   |
 | Don't Give Consumption to Others                                  |
 |                                                                   |
 | Don't Let Others Give It to You                                   |
 |                                                                   |
 |        *       *       *       *       *                          |
 |                                                                   |
 | =How to Prevent Consumption=                                      |
 |                                                                   |
 | =The spit and the small particles coughed up and sneezed out by   |
 | consumptives, and by many who do not know that they have          |
 | consumption, are full of living germs too small to be seen. THESE |
 | GERMS ARE THE CAUSE OF CONSUMPTION.=                              |
 |                                                                   |
 |                                                                   |
 |     =DON'T SPIT on the sidewalks--it spreads disease, and it is   |
 |     against the law.=                                             |
 |                                                                   |
 |     =DON'T SPIT on the floors of your rooms or hallways.=         |
 |                                                                   |
 |     =DON'T SPIT on the floors of your shop.=                      |
 |                                                                   |
 |     =WHEN YOU SPIT, spit in the gutters or into a spittoon.=      |
 |                                                                   |
 |     =Have your own spittoons half full of water, and clean them   |
 |     out at least once a day with hot water.=                      |
 |                                                                   |
 |     =DON'T cough without holding a handkerchief or your hand      |
 |     over your mouth.=                                             |
 |                                                                   |
 |     =DON'T live in rooms where there is no fresh air.=            |
 |                                                                   |
 |     =DON'T work in rooms where there is no fresh air.=            |
 |                                                                   |
 |     =DON'T sleep in rooms where there is no fresh air.=           |
 |                                                                   |
 |     =Keep at least one window open in your bedroom day and        |
 |     night.=                                                       |
 |                                                                   |
 |     =Fresh air helps to kill the consumption germ.=               |
 |                                                                   |
 |     =Fresh air helps to keep you strong and healthy.=             |
 |                                                                   |
 |     =DON'T eat with soiled hands--wash them first.=               |
 |                                                                   |
 |     =DON'T NEGLECT A COLD or a cough.=                            |
 |                                                                   |
 |                                                                   |
 |   =How to Cure Consumption=                                       |
 |                                                                   |
 |     =DON'T WASTE YOUR MONEY on patent medicines or advertised     |
 |       cures for consumption, but go to a doctor or a              |
 |       dispensary. If you go in time YOU CAN BE CURED; if you      |
 |       wait until you are so sick that you cannot work any         |
 |       longer, or until you are very weak, it may be too late;     |
 |       at any rate it will in the end mean more time out of work   |
 |       and more wages lost than if you had taken care of           |
 |       yourself at the start.=                                     |
 |                                                                   |
 |     =DON'T DRINK WHISKY, beer, or other intoxicating drinks;      |
 |       they will do you no good, but will make it harder for you   |
 |       to get well.=                                               |
 |                                                                   |
 |     =DON'T SLEEP IN THE SAME BED with any one else, and, if       |
 |       possible, not in the same room.=                            |
 |                                                                   |
 |     =GOOD FOOD, FRESH AIR, AND REST are the best cures. Keep in   |
 |       the sunshine as much as possible, and KEEP YOUR WINDOWS     |
 |       OPEN, winter and summer, night and day. Fresh air, night    |
 |       and day, is good for you.=                                  |
 |                                                                   |
 |     =GO TO A HOSPITAL WHILE YOU CAN AND BEFORE IT IS TOO LATE.    |
 |       There you can get the best treatment, all the rest, all     |
 |       the fresh air, and all the food which you need.=            |
 |                                                                   |
 |     =THE CAREFUL AND CLEAN CONSUMPTIVE IS NOT DANGEROUS TO THOSE  |
 |       WITH WHOM HE LIVES AND WORKS=                               |
 +-------------------------------------------------------------------+

Is it not significant that America's national movement is due primarily
to the organizing capacity of laymen in the New York Charity
Organization Society rather than to schools or hospitals? Most of the
local secretaries are men whose inspiration came from contact with the
non-medical relief of the poor in city tenements. The secretary of the
national association is a university professor of anthropology, who has
also a medical degree. The child victim's plea--Little Jo's Smile--was
nationalized by an association of laymen, aided by the advertising
managers of forty magazines. The smaller cities of New York state are
being aroused by a state voluntary association that for years has
visited almshouses, insane asylums, and hospitals. These facts I
emphasize, for they illustrate the opportunity and the duty of the lay
educator, whether parent, teacher, labor leader, or trustee of
hospital, orphanage, or relief society.

Three fundamental rules of action should be established as firmly as
religious principles:

  1. The public health authorities should be told of every known and
  every suspected case of tuberculosis.

  2. For each case proved by examination of sputum to be
  tuberculous, the public-health officers should know that the germs
  are destroyed before being allowed to contaminate air or food.

  3. Sick and not yet sick should practice habits of health that
  build up vitality to resist the tubercle bacilli and that abhor
  uncleanliness as nature abhors a vacuum.

    [Illustration: FIGHTING TUBERCULOSIS WITH A NATIONAL
    ORGANIZATION]

All laws, customs, and environmental conditions opposed to the
enforcement of these three principles must be modified or abolished. If
the teachers of America will list for educational use in their own
communities the local obstacles to these rules of action, they will see
exactly where their local problem lies. The illustrations that are
given in this book show in how many ways these rules of action are now
being universalized. Three or four important steps deserve especial
comment:

  1. Compulsory notification of all tuberculous cases.

  2. Compulsory removal to hospital of those not able at home to
  destroy the bacilli, or compulsory supervision of home care.

  3. Examination of all members of a family where one member is
  discovered to be tuberculous.

  4. Special provision for tuberculous teachers.

  5. Protection of children about to enter industry but predisposed
  to tuberculosis.

  6. Prohibition of dry cleaning of schools, offices, and streets.

  7. Tax provision for educational and preventive work.

Compulsory notification was introduced first in New York City by
Hermann M. Biggs, M.D., chief medical officer: 1893, partially
voluntary, partially compulsory; 1897, compulsory for all. Physicians
who now hail Dr. Biggs as a statesman called him persecutor, autocrat,
and violator of personal freedom fifteen years ago. Foreign sanitarians
vied with American colleagues in upbraiding him for his exaggeration of
the transmissibility of consumption and for his injustice to its
victims. As late as 1899 one British expert particularly resented the
rejection of tuberculous immigrants at Ellis Island, and said to me,
"Perhaps if you should open a man's mouth and pour in tubercle bacilli
he might get phthisis, but compulsory notification is preposterous." In
1906 the International Congress on Tuberculosis met in Paris and
congratulated New York upon its leadership in securing at health
headquarters a list of the known disease centers within its borders; in
1906 more than twenty thousand individual cases were reported, ten
thousand of these being reported more than once. To know the nature and
location of twenty thousand germ factories is a long step toward
judging their strength and their probable product. To compulsory
notification in New York City is largely due the educational movements
of the last decade against the white plague, more particularly the
growing ability among physicians to recognize and to treat conditions
predisposing to the disease. As in New York City, the public should
provide free of cost bacteriological analysis of sputum to learn
positively whether tuberculosis is present. Simpler still is the
tuberculin test of the eyes, with which experiments are now being made
on a large scale in New York City, and which bids fair to become cheap
enough to be generally used wherever physical examinations are made.
This test is known as Calmette's Eye Test. Inside the eyelid is placed
a drop of a solution--95 per cent alcohol and tuberculin. If
conjunctivitis develops in twenty-four hours, the patient is proved to
have tuberculosis. Some physicians still fear to use this test. Others
question its proof. The "skin test" is also being thoroughly tried in
several American cities and, if finally found trustworthy, will
greatly simplify examination for tuberculosis. Dr. John W. Brannan,
president of Bellevue and Allied Hospitals, New York City, is to report
on skin and eye tuberculin tests for children at the International
Congress on Tuberculosis, mentioned later.

    [Illustration: FIGHTING TUBERCULOSIS BY ORGANIZED COÖPERATIVE
    DISPENSARY WORK]

    [Illustration: FIGHTING BONE TUBERCULOSIS AT SEA BREEZE, WHERE
    EYE AND SKIN TUBERCULIN TESTS ARE BEING MADE]

Compulsory removal of careless consumptives is yet rare. One obstacle
is the lack of hospitals. In New York ten thousand die annually from
tuberculosis and fifty thousand are known to have it, yet there are
only about two thousand beds available. So long as the patients anxious
for hospital care exceed the number of beds, it does not seem fair to
give a bed to some one who does not want it. On the other hand, it
should not be forgotten that patients are taken forcibly to smallpox
and scarlet-fever hospitals, not for their own good, but for the
protection of others. The last person who should be permitted to stay
at home is the tuberculous person who is unable, unwilling, or too
ignorant to take the necessary precautions for others' protection. A
rigid educational test should be applied as a condition of remaining at
home without supervision.

The objections to compulsory removal are two: (1) it is desired to make
sanatorium care so attractive that patients will go at the earliest
stage of the disease; (2) an unwilling patient can defeat the
sanitarian's effort to help him and others. The alternative for
compulsory removal is gratuitous, and, if need be, compulsory,
supervision of home care, such as is now given in New York City. In
Brighton, England, Dr. Newsholme treats his municipal sanatorium as a
vacation school, giving each patient one month only. Thus one bed helps
twelve patients each year. Almost any worker can spare one month and in
that time can be made into a missionary of healthy living.

Family examining parties were begun in New York by Dr. Linsly R.
Williams, for the relief agency that started the seaside treatment of
bone tuberculosis. Many of the crippled children at Sea Breeze were
found to have consumptive fathers or mothers. In one instance the
father had died before Charlie had "hip trouble." Long after we had
known Charlie his mother began to fail. She too had consumption. Family
parties were planned for 290 families. Weights were taken and careful
examination made, the physician explaining that predisposition means
defective lung capacity or deficient vitality. Of 379 members,
supposedly free from tuberculosis, sixteen were found to have
well-marked cases. (Of twenty Boston children whose parents were in a
tuberculosis class, four had tuberculosis.) In one instance the father
was astonished to learn not only that he was tuberculous, but that he
had probably given the disease to the mother, for whom he was tenderly
concerned. Of special benefit were the talks about teeth and
nourishment, and about fresh air and water as germ killers. One
examination of this kind will organize a family crusade against
carelessness.

    [Illustration: FIGHTING TUBERCULOSIS IN SMALL CITIES
    New York State Charities Aid Association]

Tuberculous teachers ought to be excluded from schoolrooms not merely
because they may spread tuberculosis, but because they cannot do
justice to school work without sacrifices that society ought not to
accept. A tuberculous teacher ought to be generous enough to permit
public hospitals to restore her strength or enterprising enough to
join tuberculosis classes. It is selfish to demand independence at the
price which is paid by schools that employ tuberculous teachers.

    [Illustration: FIGHTING BONE TUBERCULOSIS WITH SALT WATER AND
    SALT AIR]

Predisposition to tuberculosis should be understood by every child
before he is accepted as an industrial soldier. Many trades now
dangerous would be made safe if workers knew the risk they run, and if
society forbade such trades needlessly to exhaust their employees. A
perfectly sound man is predisposed to tuberculosis if he elects to work
in stale, dust-laden air. Ill-ventilated rooms, cramped positions, lack
of exercise in the open air, prepare lungs to give a cordial reception
to tubercle bacilli. Rooms as well as persons become infected.
Fortunately, opportunities to work are so varied in most localities
that workers predisposed to tuberculosis may be sure of a livelihood in
an occupation suited to their vitality. Destruction of germs in the
air, in carpets, on walls, on streets, is quite as important as
destruction of germs in lungs. Why should not tenants and workers
require health certificates stating that neither house nor working
place is infected with tubercle bacilli? Some cities now compel the
disinfection of premises occupied by tuberculous persons _after_ their
removal. Landlords, employers, tenants, and employees can easily be
taught to see the advantage of disinfecting premises occupied by
tuberculous cases _before_ detection.

    [Illustration: FIGHTING FEATHER DUSTERS IS ONE OBJECT OF SEA-AIR
    HOSPITALS FOR BONE TUBERCULOSIS]

Dry cleaning, feather dusters, dust-laden air, will disappear from
schoolrooms within twenty-four hours after school-teachers declare that
they shall disappear. We have no right to expect street cleaners,
tenement and shop janitors, or overworked mothers to be more careful
than school-teachers. Last year I said to a janitress, "Don't you
realize that you may get consumption if you use that feather duster?"
Her reply caused us to realize our carelessness: "I don't want any more
than I've got now." Shall we some day have compulsory examination and
instruction of all cleaners, starting with school cleaners?

    [Illustration: FIGHTING TUBERCULOSIS IN OPEN TENTS]

Taxing is swift to follow teaching in matters of health. Teachers can
easily compute what their community loses from tuberculosis. The totals
will for some time prove a convincing argument for cleanliness of air,
of body, and of building wherever the community is responsible for air,
building, and body. The annual cost of tuberculosis to New York City is
estimated at $23,000,000 and to the United States at $330,000,000. The
cost of exterminating it will be but a drop in the bucket if
school-teachers do their part this next generation with the twenty
million children whose day environment they control for three fourths
of the year, and whose habits they can determine.

The first meeting in America of the International Congress on
Tuberculosis was held at Washington, D.C., September 21 to October 12,
1908. For many years the proceedings of this congress will undoubtedly
be the chief reference book on the conquest of tuberculosis.[14]

How many aspects there are to this problem, and how many kinds of
people may be enlisted, may be seen from the seven section names: I.
Pathology and Bacteriology; II. Sanatoriums, Hospitals, and
Dispensaries; III. Surgery and Orthopedics; IV. Tuberculosis in
Children--Etiology, Prevention, and Treatment; V. Hygienic, Social,
Industrial, and Economic Aspects; VI. State and Municipal Control of
Tuberculosis; VII. Tuberculosis in Animals and Its Relation to Man.

    [Illustration: FIGHTING TUBERCULOSIS IN CHEAP SHACKS, $125 PER
    BED, OTISVILLE, NEW YORK]

How many-sided is the responsibility of each of us for stamping out
tuberculosis is shown by the preliminary programme of the eight
sessions of Section V. These topics suggest an interesting and
instructive year's study for clubs of women, mothers, or teachers, or
for advanced pupils.


I. ECONOMIC ASPECTS OF TUBERCULOSIS

1. The burdens entailed by tuberculosis:

    a. On individuals and families.
    b. On the medical profession.
    c. On industry.
    d. On relief agencies.
    e. On the community.
    f. On social progress.

 2. The cost of securing effective control of tuberculosis:

    a. In large cities.
    b. In smaller towns.
    c. In rural communities.


II. ADVERSE INDUSTRIAL CONDITIONS

 1. Incidence of tuberculosis according to occupation.

 2. Overwork and nervous strain as factors in tuberculosis.

 3. Effect of improvements in factory conditions on the health of
    employees.

 4. Legitimate exercise of police power in protecting the life and
    health of employees.


III. THE SOCIAL CONTROL OF TUBERCULOSIS

 1. Outline of a comprehensive programme for:

    a. National, state, and municipal governments.
    b. Departments of health and departments of public relief.
    c. Private endowments.
    d. Voluntary associations for educational propaganda.
    e. Institutions, such as schools and relief agencies, which
       exist primarily for other purposes.

 2. A symposium on the relative value of each of the features in an
    aggressive campaign against tuberculosis:

    a. Compulsory registration.
    b. Free sputum examination.
    c. Compulsory removal of unteachable and dangerous cases.
    d. Laboratory research.
    e. Hospital.
    f. Sanatorium.
    g. Dispensary.
    h. The tuberculosis class.
    i. Day camp.
    j. Private physician.
    k. Visiting nurse.
    l. After-care of arrested cases.
    m. Relief fund.
    n. Climate.
    o. Hygienic instruction,--personal and in class.
    p. Inspection of schools and factories.
    q. Educational propaganda.


IV. EARLY RECOGNITION AND PREVENTION

 1. Importance of discovering the persons who have tuberculosis
    before the disease has passed the incipient stage.

 2. Examination of persons known to have been exposed or presumably
    predisposed.

 3. Systematic examination of school children during their course
    and on leaving school to go to work.

 4. Professional advice as to choice of occupation in cases where
    there is apparent predisposition to disease.


V. AFTER-CARE OF ARRESTED CASES

 1. Instruction in healthful trades in the sanatorium.

 2. Training for professional nursing in institutions for the care
    of tuberculous patients.

 3. Farm colonies.

 4. Convalescent homes or cottages.

 5. Aid in securing suitable employment on leaving the sanatorium.

 6. How to deal with the danger of a return to unfavorable home
    conditions.


VI. EDUCATIONAL METHODS AND AGENCIES

 1. Special literature for general distribution.

 2. Exhibits and lectures.

 3. The press.

 4. Educational work of the nurse.

 5. Labor organizations.

 6. Instruction in schools of all grades.

 7. Presentation and discussion of leaflets awarded prizes by the
    congress.


VII. PROMOTION OF IMMUNITY

 1. Development of the conception of physical well-being.

 2. Measures for increasing resistance to disease:

    a. Parks and playgrounds.
    b. Outdoor sports.
    c. Physical education.
    d. Raising the standards of living: housing, diet,
       cleanliness.

 3. Individual immunity and social conditions favorable to general
    immunity.


VIII. RESPONSIBILITY OF SOCIETY FOR TUBERCULOSIS

 1. A symposium of representative

    a. Citizens.
    b. Social workers.
    c. Employers.
    d. Employees.
    e. Physicians.
    f. Nurses.
    g. Educators.
    h. Others.

Cash prizes of one thousand dollars each are offered: (1) for the best
evidence of effective work in the prevention or relief of tuberculosis
by any voluntary association since 1905; (2) for the best exhibit of a
sanatorium for working classes; (3) for the best exhibit of a furnished
home for the poor, designed primarily to prevent, but also to permit
the cure of tuberculosis.

    [Illustration: BOSTON FIGHTS TUBERCULOSIS WITH A COMPREHENSIVE PLAN
    _A-D, F, H-J_, private hospitals and agencies reporting cases to
    the official center; _E_, home care; _K, L, M_, day camp and
    hospitals for incipient and advanced cases]

A white-plague scrapbook containing news items, articles, and
photographs will prove an interesting aid to self-education or to
instruction of children, working girls' clubs, or mothers' meetings.
Everybody ought to enlist in this war, for the fight against
tuberculosis is a fight for cleanliness and for vitality, for a fair
chance against environmental conditions prejudicial to efficient
citizenship.

So sure is the result and so immediate the duty of every citizen that
Dr. Biggs wrote in 1907: _In no other direction can such large results
be achieved so certainly and at such relatively small cost. The time is
not far distant when those states and municipalities which have not
adopted a comprehensive plan for dealing with tuberculosis will be
regarded as almost criminally negligent in their administration of
sanitary affairs and inexcusably blind to their own best economic
interests._

FOOTNOTES:

[13] The best literature on tuberculosis is in current magazines and
reports of anti-tuberculosis crusaders. For a scientific, comprehensive
treatment, libraries and students should have _The Prevention of
Tuberculosis_ (1908) by Arthur Newsholme, M.D. A popular book is _The
Crusade against Tuberculosis_, by Lawrence F. Flick, of the Henry Phipps
Institute for the Study, Treatment, and Prevention of Tuberculosis.

[14] Those desiring copies this year or hereafter will do well to write
to The National Association for the Study and Prevention of
Tuberculosis, 105 East 22d St., New York City. The congress is under the
control of the National Association and is managed by a special
committee appointed by it. Even after a national board of health is
established, the National Association for the Study and Prevention of
Tuberculosis will continue to be a center for private interest in public
protection against tuberculosis. One of its chief functions is the
preparation and distribution of literature to those who desire it.



CHAPTER XXV

THE FIGHT FOR CLEAN MILK


"With the approval of the President and with the coöperation of the
Department of Agriculture,[15] the [national quarantine] service has
undertaken to prepare a complete report upon the milk industry from
farm to the consumer in its relation to the public health." This
promise of the United States Treasury insures national attention to the
evils of unclean milk and to the sanitary standards of farmer and
consumer. Nothing less than a national campaign can make the vivid
impression necessary to wean dairymen of uncleanly habits and mothers
of the ignorant superstition that babies die in summer just because
they are babies. When two national bureaus study, learn, and report,
newspapers will print their stories on the first page, magazines will
herald the conclusions, physicians will open their minds to new truths,
state health secretaries will carry on the propaganda, demagogues and
quacks will become less certain of their short-cut remedies, and
_everybody will be made to think_.

The evolution of this newly awakened national interest in clean milk
follows the seven stages and illustrates the seven health motives
presented in Chapter II. I give the story of Robert M. Hartley because
he began and prosecuted his pure-milk crusade in a way that can be
duplicated in any country town or small city.

Robert M. Hartley was a strong-bodied, strong-minded, country-bred man,
who started church work in New York City almost as soon as he arrived.
He distributed religious tracts among the alleys and hovels that
characterized lower New York in 1825. Meeting drunken men and women one
after another, he first wondered whether they were helped by tracts,
and then decided that the mind befogged with alcohol was unfit to
receive the gospel message. Then for fifteen years he threw himself
into a total-abstinence crusade, distributing thousands of pamphlets,
calling in one year at over four thousand homes to teach the industrial
and moral reasons for total abstinence. Finally, he began to wonder
whether back of alcoholism there was not still a dark closet that must
be explored before men could receive the message of religion and
self-control. So in 1843 he organized the New York Association for
Improving the Condition of the Poor, which ever since has remembered
how Hartley found alcoholism back of irreligion, and how back of
alcoholism and poverty and ignorant indifference he found indecent
housing, unsanitary streets, unwholesome working conditions, and impure
food.

    [Illustration: FIGHTING INFANT MORTALITY BY A SCHOOL FOR MOTHERS
    IN THE HEART OF NEW YORK CITY,--JUNIOR SEA BREEZE]

    [Illustration: PROVIDING AGAINST GERM GROWTH AND ADAPTING MILK
    TO THE INDIVIDUAL BABY'S NEED,--ROCHESTER'S MODEL DAIRY]

Hartley's instinct started the first great pure-milk agitation in this
country. While visiting a distillery for the purpose of trying to
persuade the owner to invest his money in another business, he noticed
that "slops smoking hot from the stills" were being carried to cow
stables. He followed and was nauseated by the sights and odors. Several
hundred uncleaned cows in low, suffocating, filthy stables were being
fed on "this disgusting, unnatural food." Similar disgust has in many
other American cities caused the first effort to better dairy
conditions. Hartley could never again enjoy milk from distillery cows.
Furthermore, his story of 1841 made it impossible for any readers of
newspapers in New York to enjoy milk until assured that it was not
produced by distillery slops. The instinctive loathing and the
discomfort of buyers awakened the commerce motives of milk dealers, who
covered their wagons with signs declaring that they "no longer" or
"never" fed cows on distillery refuse. But Hartley could not stop when
the anti-nuisance stage was reached. He did not let up on his fight
against impure or adulterated milk until the state legislature declared
in 1864 that _every baby, city born or country born, no matter how
humble its home, has the right to pure milk_.

 +-------------------------------------------------------------------+
 |  =Clean Milk for New York City=                                   |
 |                                                                   |
 |  =CONFERENCE=                                                     |
 |                                                                   |
 |  =ROOM 44, N.Y. ACADEMY OF MEDICINE=                              |
 |  =No. 17 WEST 43D STREET=                                         |
 |                                                                   |
 |  =November 20th, 1906, Tuesday 3 p.m. and 8 p.m.=                 |
 |                                                                   |
 |                                                                   |
 |  =ESSENTIAL FACTS AS TO NEW YORK CITY=                            |
 |                                                                   |
 |  =Manhattan's Infant Mortality=                                   |
 |  (=UNDER 5 YRS.=)                                                 |
 |                                                                   |
 |    June to September, 1904, 4428                                  |
 |    June to September, 1905, 4687                                  |
 |    June to September, 1906, 4428                                  |
 |                                                                   |
 |  =Daily Consumption of Milk=                                      |
 |                                                                   |
 |    1,600,000 qts.                                                 |
 |    ¼ in quart bottles                                             |
 |    ¾ in 40-quart cans                                             |
 |    "Certified," 10,000 quarts                                     |
 |    "Inspected," 3,000 quarts                                      |
 |    24 to 48 hours old on arrival                                  |
 |                                                                   |
 |  =Comes from=                                                     |
 |                                                                   |
 |    30,000 dairies, 40 to 400 miles distant                        |
 |    600 creameries--105 proprietors                                |
 |    10 city railroad depots                                        |
 |                                                                   |
 |  =Sold in=                                                        |
 |                                                                   |
 |    12,000 places, mostly from cans                                |
 |    Sale of skim milk prohibited                                   |
 |                                                                   |
 |  =Milk Law Violations, 1905=                                      |
 |                                                                   |
 |    Destroyed, 39,618 quarts                                       |
 |    Arrests, 806                                                   |
 |    Fines, $16,435                                                 |
 |                                                                   |
 |  =New York City Inspectors=                                       |
 |                                                                   |
 |    14 in country since July; might make rounds not oftener than   |
 |      once a year                                                  |
 |        (For 3 yrs. before, only 2; previously none)               |
 |    16 in city, might make rounds in 30 to 40 days                 |
 |        (Before July, 14)                                          |
 |                                                                   |
 |                                                                   |
 |  =POINTS OF AGREEMENT=                                            |
 |                                                                   |
 |  =Cleanliness is the supreme requisite, from cow to consumer=     |
 |                                                                   |
 |    Cows must be healthy, persons free from contagious diseases,   |
 |     premises clean, water pure, utensils clean, cans and bottles  |
 |     sterile, shops sanitary                                       |
 |                                                                   |
 |  =Temperature is second essential=                                |
 |                                                                   |
 |    50° F. or lower at dairy                                       |
 |    45° F. at creamery                                             |
 |    45° F. or less during transportation                           |
 |    Not above 50° when sold to the consumer                        |
 |                                                                   |
 |  =As to Pasteurization=                                           |
 |                                                                   |
 |    Not necessary for absolutely clean milk                        |
 |    Destroys benign as well as harmful germs                       |
 |    Disease germs develop more rapidly than in pure raw milk       |
 |    True, 155° for 30 minutes to 167° for 20 minutes               |
 |       Cost per quart, estimated, ¼ to ½ ct.                       |
 |    Commercial, 165° for 15 seconds                                |
 |      Cost per quart, negligible                                   |
 |                                                                   |
 |  =As to Inspection=                                               |
 |                                                                   |
 |    _Some_ inspection needed within the city                       |
 |    _Some_ inspection needed of dairy and creamery                 |
 |                                                                   |
 |                                                                   |
 |  =WHAT NEXT STEPS SHOULD NEW YORK TAKE?=                          |
 |                                                                   |
 |  =Skim Milk=                                                      |
 |                                                                   |
 |    Should its sale be permitted?                                  |
 |    Under what conditions?                                         |
 |    How would this affect price of whole milk?                     |
 |                                                                   |
 |  =Pasteurization=                                                 |
 |                                                                   |
 |    Should pasteurization be made compulsory?                      |
 |      For what portion of the supply?                              |
 |      At whose expense?                                            |
 |    Would it increase price of milk?                               |
 |    Does it render inspection unnecessary?                         |
 |    Does it reduce need for inspection?                            |
 |    Should sale of repasteurized milk or cream be permitted?       |
 |    Should bottles show whether true or commercial pasteurization  |
 |      is used?                                                     |
 |                                                                   |
 |  =Infants' Milk Depots=                                           |
 |                                                                   |
 |    Should they use pasteurized or clean milk?                     |
 |    Are municipal depots desirable?                                |
 |    Should private philanthropy support depots?                    |
 |    How many depots would be required in New York City?            |
 |    Is Rochester experience applicable to New York City?           |
 |    What educational work is possible in connection with milk      |
 |      depots?                                                      |
 |                                                                   |
 |                                                                   |
 |  =Model Milk Shops=                                               |
 |                                                                   |
 |    What may safely be sold in connection with milk?               |
 |    Should law discourage other than model shops?                  |
 |    Are present sanitary laws rigid enough?                        |
 |    Should private capital be encouraged to establish shops?       |
 |    Is it practicable to prohibit use of cans?                     |
 |    What provision can be demanded for proper refrigeration?       |
 |    What for receiving milk before business hours when delivered   |
 |      from stations?                                               |
 |    What for sterilization of utensils and bottles?                |
 |    What for attendants' dress and care of person?                 |
 |    Would such restrictions increase price?                        |
 |                                                                   |
 |  =Inspection=                                                     |
 |                                                                   |
 |    Is it practicable by inspection alone to secure a clean milk   |
 |      supply?                                                      |
 |    Will it protect against more dangerous forms of infection?     |
 |    How many inspectors does New York City need?                   |
 |      Within the city?                                             |
 |      Among country dairies and creameries?                        |
 |    How many inspectors should the state employ?                   |
 |                                                                   |
 |  =Legislation=                                                    |
 |                                                                   |
 |    What needed as to diseased cattle?                             |
 |    What as to diseases of persons producing or handling milk?     |
 |    Is present sanitary code sufficient?                           |
 |    Shall law require sterilization of all milk cans and bottles   |
 |      by milk company or creamery before returned to farms or      |
 |      refilled?                                                    |
 |    Shall sealing cans at creameries be required?                  |
 |    Shall transferring from one can to another or from can to      |
 |      bottle in open street be made a misdemeanor?                 |
 |    Shall pollution of milk cans and bottles be made a             |
 |      misdemeanor?                                                 |
 |    Shall bacterial standard be established?                       |
 |    Is state supervision now adequate?                             |
 |    What further legislation is needed?                            |
 |    Does present law prescribe adequate penalties?                 |
 |                                                                   |
 |  =Education=                                                      |
 |                                                                   |
 |    Should state system of lectures before agricultural institutes |
 |      be extended?                                                 |
 |    Should Maryland plan of traveling school be adopted as means   |
 |      of reaching producer?                                        |
 |    What can be done to assist Teachers College in its plan for    |
 |      milk exhibit?                                                |
 |    What can be done to teach mothers to detect unclean milk and   |
 |      to care properly for milk purchased?                         |
 |    How can tenement mothers keep milk at proper temperature?      |
 |    Can nothing be done to increase the supply and cheapen the     |
 |      price of ice?                                                |
 |    Is it desirable that a local committee be formed to coöperate  |
 |      with the Department of Health and County Medical Society?    |
 +-------------------------------------------------------------------+

Unfortunately Hartley and his contemporaries had never heard of disease
germs that are carried by unclean milk into the human stomach. Science
had not yet proved that many forms of barnyard filth could do quite as
much harm as distillery refuse. Commerce had not invented milk bottles
of glass or paper. The law of 1864 failed in two particulars: (1) it
did not demand cleanliness from cow to consumer; (2) it did not provide
means for its own enforcement, for learning whether everything and
everybody that had to do with milk was clean. Not knowing of germs and
their love for a warm climate and warm food, they naturally did not
prohibit a temperature above fifty degrees from the time of milking to
the time of sale. How much has been left for our generation to do to
secure pure milk is illustrated by the opening sentence of this
chapter, and more specifically by the programme of a milk conference
held in New York in November, 1906, the board of health joining in the
call. The four-page folder is reproduced in facsimile (excepting the
names on the fourth page), because it states the universal problem, and
also because it suggests an effective way to stimulate relevant
discussion and to discourage the long speeches that spoil many
conferences.

This conference led to the formation of a milk committee under the
auspices of the association founded by Hartley. Business men,
children's specialists, journalists, clergymen, consented to serve
because they realized the need for a continuing public interest and a
persisting watchfulness. Such committees are needed in other cities and
in states, either as independent committees or as subcommittees of
general organizations, such as women's clubs, sanitary leagues, county
and state medical societies. Teachers' associations might well be
added, especially for rural and suburban districts where they are more
apt than any other organized body to see the evils that result from
unclean milk. The New York Milk Committee set a good example in paying
a secretary to give his entire time to its educational programme,--a
paid secretary can keep more volunteers and consultants busy than could
a dozen volunteers giving "what time they can spare." Thanks chiefly to
the conference and the Milk Committee's work, several important results
have been effected. The general public has realized as never before
that two indispensable adjectives belong to safe milk,--_clean_ and
_cool_. Additional inspectors have been sent to country dairies;
refrigeration, cans, and milk have been inspected upon arrival at
night; score cards have been introduced, thanks to the convincing
explanations of their effectiveness by the representatives of the
Bureau of Animal Industry of the national Department of Agriculture;
8640 milch cows were inspected by veterinary practitioners (1905-1907),
to learn the prevalence of bovine tuberculosis (of these thirty-six per
cent reacted to the tuberculin test); state societies and state
departments have been aroused to demand an efficient live-stock
sanitary board; magistrates have fined and imprisoned offenders against
the milk laws, where formerly they "warned"; popular illustrated milk
lectures were added to the public school courses; illustrated cards
were distributed by the thousand, telling how to keep the baby well;
finally, private educational and relief societies, dispensaries,
settlements, have been increasingly active in teaching mothers at home
how to prepare baby's milk. In 1908 a Conference on Summer Care of
Babies was organized representing the departments of health and
education, and fifty private agencies for the care of sick babies and
the instruction of mothers. The superintendent of schools instructed
teachers to begin the campaign by talks to children and by giving out
illustrated cards. Similar instructions were sent to parochial schools
by the archbishop.

    [Illustration: NIGHT INSPECTION OF COUNTRY MILK UPON ARRIVAL IN
    NEW YORK CITY]

As elsewhere, there are two schools of pure-milk crusaders: (1) those
who want cities to _do things_, to pasteurize all milk, start milk
farms, milk shops, or pure-milk dispensaries; and (2) those who want
cities and states to _get things done_. So far the New York Milk
Committee has led the second school and has opposed efforts to
municipalize the milk business. The leader of the other school is the
noted philanthropist, Nathan Strauss, who has established
pasteurization plants in several American and European cities. The
discussion of the two schools, similar in aim but different in method,
is made more difficult, because to question philanthropy's method
always seems to philanthropy itself and to most bystanders an
ungracious, ungrateful act. As the issue, however, is clean milk, not
personal motive, it is important that educators and parents in all
communities benefit from the effective propaganda of both schools,
using what is agreed upon as the basis for local pure-milk crusades,
reserving that which is controversial for final settlement by research
over large fields that involve hundreds of thousands of tests.

    [Illustration: A NEW YORK MILK COMMITTEE'S INFANT DEPOT AND
    SCHOOL FOR MOTHERS]

Pasteurization, municipal dairies, municipal milk shops, municipal
infant-milk depots, are the four chief remedies of the _doing things_
school. European experience is cited in support of each. We are told
that cow's milk, intended by nature for an infant cow with four
stomachs, is not suited, even when absolutely pure, to the human
infant's single stomach. Cow's milk should be modified, weakened,
diluted, to fit the digestive powers of the individual infant; hence
the municipal depot or milk dispensary that provides exactly the right
milk for each baby, prescribed by municipal physicians and nurses who
know. That the well-to-do and the just-past-infancy may have milk as
safe as babies receive at the depot, municipalization of farm and milk
shop is advocated. Some want the city to run only enough farms and milk
shops to set a standard for private farmers, as has been done in
Rochester. This is city ownership and operation for educational
purposes only. Finally, because raw milk even from clean dairies may
contain germs of typhoid, scarlet fever, or tuberculosis,
pasteurization is demanded to kill every germ. There are advocates of
pasteurization that deprecate the practice and deny that raw milk is
necessarily dangerous; they favor it for the time being until farms and
shops have acquired habits of cleanliness. Likewise many would prefer
private pasteurization or laws compelling pasteurization of all milk
offered for sale; but they despair of obtaining safe milk unless city
officials are held responsible for safety. Why wait to discuss
political theories about the proper sphere for government, when, by
acting, hundreds of thousands of lives can be saved annually? These
methods of _doing things_ will not add to the price of milk; it is, in
fact, probable that the reduction in the cost of caring for the sick
and for inspecting farms and shops will offset the net cost of depots,
farms, and dairies.

    [Illustration: ONE OF ROCHESTER'S SCHOOLS IN CLEANLINESS]

    [Illustration: ROCHESTER'S MODEL DAIRY FARM]

As to pasteurization, its cost is negligible, while the cost of
cleanliness is two, four, or ten cents a quart. Whether ideally clean
milk is safe or not, raw milk that is not clean is unfit for human
consumption. All cities should compel evidence of pasteurization as a
condition of sale. Large cities should have their own pasteurizing
plants, just as many cities now have their own vaccine farms and
antitoxin laboratories. Parents in small towns and in the country
should be taught to pasteurize all milk.

The _getting things done_ school admits the need for modified milk of
strength suited to the infant's stomach; affirms the danger of milk
that contains harmful germs; demands educational work by city, state,
and nation; confesses that talk about cleanliness will not make milk
safe. On the other hand, it denies that raw milk is necessarily
dangerous; that properly modified, clean, raw milk is any safer when
pasteurized; that talking about germ-proof milk insures germ
extinction. It maintains that pasteurization kills benign germs
essential to the life of milk, and that after benign germs are killed,
pasteurized milk, if exposed to infection, is more dangerous than raw
milk, for the rapid growth of harmful germs is no longer contested by
benign germs fighting for supremacy. While it is admitted that raw milk
produced under ideal conditions may become infected by some person
ignorant of his condition, and before detection may cause typhoid,
scarlet fever, or consumption, it has not been proved that such
instances are frequent or that the aggregate of harm done equals that
which pasteurized milk may do. Pasteurization does not remove chemical
impurities; boiling dirt does not render it harmless. The remedy for
germ-infected milk is to keep germs out of milk. The remedy for unclean
milk is cleanliness of cow, cow barn, cowyard, milker, milk can,
creamery, milk shop, bottle, nipple. If the sale of unclean milk is
prevented, farmers will, as a matter of course, supply clean milk. By
teaching farmers and milk retailers the economic advantages of
cleanliness they will cultivate habits that guarantee a clean milk
supply. By punishing railroads and milk companies that transport milk
at a temperature which encourages germ growth, and by dumping in the
gutter milk that is offered for sale above 50 degrees, the
refrigerating of milk will be made the rule. Purging magistrates'
courts of their leniency toward dealers in impure, dangerous milk is
better than purging milk of germs. Boiling milk receptacles will save
more babies than boiling milk. Teaching mothers about the care of
babies will bring better results than giving them a false sense of
safety, because only one of many dangers has been removed by
pasteurization. Educating consumers to demand clean milk and to
support aggressive work by health departments leaves fewer evils
unchecked than covering up uncleanliness by pasteurization.

    [Illustration: NEW YORK MILK COMMITTEE'S GRAPHIC METHOD OF
    SHOWING BABIES' PROGRESS]

    [Illustration: PRODUCING WINTER CONDITIONS IN MIDSUMMER BY
    PROPER REFRIGERATION FOR MILK IN FREIGHT CARS]

When doctors disagree what are we laymen to do? We can take an
intelligent interest in the inquiries that are now being made by city,
state, and national governments. Because everybody believes that clean
milk is safer than unclean milk, that milk at 50 degrees will not breed
harmful germs, we can demand milk inspection that will tell our health
officers and ourselves which dealers sell only clean milk at 50 degrees
and never more than 60 degrees, that never shows over 100,000 colonies
to the cubic centimeter. We can get our health departments to publish
the results of their scoring of dairies and milk shops in the papers,
as has been done in Montclair. We can tell our health officers that the
best results in fighting infant mortality are at Rochester, which city,
winter and summer, by inspection, correspondence, and punishment,
educates farmers and dealers in cleanliness, not only censuring when
dirty or careless, but explaining how to make more money by being
clean. Finally, mothers can be taught at home how to cleanse the
bottles, the nipples, all milk receptacles, and all things in rooms
where milk is kept. Absolutely clean milk of proper temperature _at the
shop_ may not safely be given to a baby in a dirty bottle. Infant milk
depots, pasteurization, the best medical and hospital care, breast
feeding itself, cannot prevent high baby mortality if mothers are not
clean. The most effective volunteer effort for pure milk is that which
first makes the health machinery do its part and then teaches, teaches,
teaches mothers and all who have to do with babies.

    [Illustration: NEITHER PASTEURIZATION NOR INSPECTION CAN MAKE IT
    SAFE TO SELL "DIP MILK" UNDER SUCH UNCLEAN CONDITIONS]

"Clean air, clean babies, clean milk," has been the slogan of Junior
Sea Breeze,--a school for mothers right in the heart of New York's
upper East Side. In the summer of 1907 twenty nurses went from house to
house telling 102,000 mothers how to keep the baby well. This was the
only district that had fewer baby deaths than for 1906. Had other parts
of the city shown the same gain, there would have been a saving of 1100
babies. The following winter a similar work was conducted by nurses
from the recently founded Caroline Rest, which has an educational fund
for instruction of mothers in the care of babies, especially babies not
yet born and just born. Heretofore the baby has been expected to cry
and to have summer complaint before anybody worried about the treatment
it received. If the baby lived through its second summer, it was
considered great good fortune. Junior Sea Breeze and Caroline Rest
start their educational work before the baby is sick, in fact, before
it is born. Their results have been so notable that several well-to-do
mothers declare that they wish they too might have a school.
Dispensaries and diet kitchens and more particularly maternity wards of
hospitals, family physicians, nurses, and midwives, should be required
to know how to teach mothers to feed babies regularly, the right
quantities, under conditions that insure cleanliness whether the breast
or the bottle is used. Perhaps some day no girl will be given a
graduating certificate, or a license for work, teaching, or marriage,
until she has demonstrated her ability to give some mother's baby
"clean air, clean body, clean milk."

FOOTNOTES:

[15] Libraries should obtain all reports on milk, Bureau of Animal
Industry, Washington, D.C.



CHAPTER XXVI

PREVENTIVE "HUMANIZED" MEDICINE: PHYSICIAN AND TEACHER


No profession, excepting possibly the ministry, is regarded with
greater deference than the medical profession. Our ancestors listened
with awe and obedience to the warnings and behests of the medicine man,
bloodletter, bonesetter, family doctor. In modern times doctors have
disagreed with each other often enough to warrant laymen in questioning
the infallibility of any individual healer or any sect, whether
homeopath, allopath, eclectic, osteopath, or scientist. Yet to this day
most of us surround the medical profession or the healing art with an
atmosphere of necromancy. Even after we have given up faith in drugs or
after belief is denied in the reality of disease and pain, we revere
the calling that concerns itself, whether gratuitously or for pay, with
conquering bodily ills.

Self-laudation continues this hold of the medical profession upon the
lay imagination. One physician may challenge another's faults, ridicule
his remedies, call his antitoxin dangerous poison, but their common
profession he proudly styles "the most exalted form of altruism." Young
men and women beginning the study or the practice of medicine are
exhorted to continue its traditions of self-denial, and in their very
souls to place human welfare before personal or pecuniary advancement.
Newspapers repeat exhortation and laudation. We laymen pass on the
story that we know is not universally true,--physicians know,
physicians apply what they know without consciousness of error,
physicians must be implicitly trusted.

For a physician to give poison when he means to give food is worse, not
better, than for a layman to make the same mistake. Neither the moral
code nor the law of self-preservation enjoins a tuberculous mother to
take alcohol or to sleep in an unventilated room, even if an uninformed
physician prescribes it. Instruction in physiology and hygiene would be
futile if those who are educated as to the elementary facts of hygiene
and physiology must blindly follow blind physicians. A family doctor
who gives cod-liver oil for anæmia due to adenoids may do a child as
much harm as a nurse who drugs the baby to make it sleep. The physician
who refuses to tell the board of health when smallpox or typhoid fever
first breaks out takes human life just as truly as if he tore up the
tracks in front of an express train. This is another way of saying that
parents and teachers must fit themselves to know whether the family
physician and their community's physicians are efficient practitioners
and teachers. Every one can learn enough about the preventable causes
of sickness and depleted vitality to insist upon the ounce of education
and prevention that is better than a pound of cure.

For its sins of omission, as for its sins of commission, the medical
profession shares responsibility with laymen. For years leading
educators, business men, hospital directors, public officials, have
known that communicable diseases could be stamped out. The methods have
been demonstrated. There is absolutely no excuse to-day for epidemics
of typhoid in Trenton, Pittsburg, or Scranton, for epidemics of scarlet
fever in the small towns of Minnesota, for uninterrupted epidemics of
tuberculosis everywhere. Had either laymen, physicians, or
school-teachers made proper use of the knowledge that has been in
text-books for a generation, this country would be saving thousands of
lives and millions of dollars every year. Our _doing_ and _getting
done_ have lagged behind our _knowing_.

The failure of physicians to "socialize" or "humanize" their knowledge
is due to two causes: (1) no one has been applying _result tests_ to
the profession as a whole and to the state in its capacity as doctor,
testing carefully the sickness rate, the death rate, and the expense
rate of preventable diseases; (2) physicians themselves have not needed
to know, either at college or in practice, the tax levied upon their
communities by preventable sickness. Public schools can do much to
secure result tests for individual physicians, for the profession as a
whole, and for boards of health. Schooling in preventive medicine, or,
better named, schooling in preventive hygiene, will fit physicians to
do their part in eradicating preventable disease.

Preventive hygiene is not an essential part of the training of American
physicians or nurses to-day. Not only are there no colleges of
preventive hygiene, but medical schools have not provided individual
courses. It is possible for a man to graduate with honors from our
leading medical colleges without knowing what "vital statistics" means.
Even boards of health, their duties and their educational
opportunities, are not understood by graduates; it is an accident if
the "social and economic aspects of medical practice," "statistical
fallacies," "hospital administration," "infant mortality," are familiar
terms. It is for this reason, rather than because physicians are
selfish, that indispensable and beneficent legislation is so generally
opposed by them when the prerogatives of their profession seem in
danger. Practically every important sanitary advance of the past
century has been fought at the outset by those whose life work should
have made them see the need. Physicians bitterly attacked compulsory
vaccination, medical inspection of schools, compulsory notification of
communicable diseases. What is perhaps more significant of the
physician's indifference to preventive hygiene is the fact that most of
the sanitary movements that have revolutionized hygienic conditions in
America owe their inception and their success to laymen, for example,
tenement-house reform, anti-child labor and anti-tuberculosis crusades,
welfare work in factories, campaigns for safety appliances, movement
for a national board of health, prison, almshouse, and insane-asylum
reform, schools for mothers, and milk committees. The first hospital
for infectious diseases, the first board of health, the first
out-of-door sea-air treatment of bone tuberculosis in the United
States, were the result of lay initiative.

Dr. Hermann M. Biggs says that in America the greatest need of the
medical profession and of health administration is training that will
enable physicians and lay inspectors to use their knowledge of
preventive hygiene for the removal of living and working conditions
that cause preventable sickness. A physician without knowledge of
preventive hygiene is simply doing a "general repair" business.

For a few months in 1907 New York City had a highly efficient
commissioner of street cleaning, who, in spite of the unanimous
protests and appeals of the press, refused to give up the practice of
medicine. Hitherto the board of health of that city has been unable to
obtain the full time of its physicians because professional standards
give greater credit to the retail application of remedies than to the
wholesale application of preventives.

Statesmanship as well as professional ability is expected of physicians
in the leading European cities, more particularly of those connected
with health departments. There it is not felt that a medical degree is
of itself a qualification for sanitary or health work. After the
professional course, physicians must take courses in preventive hygiene
and in health administration. Medical courses include such subjects as
vital statistics, duties of medical officers of health, sanitary
legislation, state medicine.

The needless cost for one year of "catching" diseases in New York City
would endow in perpetuity all the schools and lectureships and journals
necessary to teach preventive hygiene in every section of this great
country. That city alone sacrifices twenty-eight thousand lives
annually to diseases that are officially called preventable. The yearly
burial cost of these victims of professional and community neglect is
more than a million dollars. When to the doctor bills, wages lost,
burial cost of those who die are added the total doctor bills, wages
lost, and other expenses of the sick who do not die, we find that one
city loses in dollars and cents more every year from communicable
diseases than is spent by the whole United States for hospitals and
boards of health.

Many diseases and much sickness are preventable that are not
communicable. Indigestion due to bad teeth is not itself communicable,
but it can be prevented. One's vitality may be sapped by irregular
eating or too little sleep; others will not catch the trouble, although
too often they imitate the harmful habits. Adenoids and defective
vision are preventable, but not contagious. Spinal curvature and flat
foot are unnecessary, but others cannot catch them. Preventive hygiene,
however, should teach the physician's duty to educate his patient and
his community regarding all controllable conditions that injure or
promote the health.

In the absence of special attention to preventive medicine new truth is
forced to fight its way, sometimes for generations, before it is
accepted by the medical profession. So strong are the traditions of
that profession and so difficult is it for the unconventional or
heterodox individual to retain the confidence of conservative patients,
that the forces of honorable medical practice tend to discourage
research and invention. The man who discovers a surgical appliance is
forced by the ethics of his profession either to commercialize it and
lose his professional standing, or to abide the convenience of his
colleagues and their learned organizations in testing it. Rather than
be branded a quack, charlatan, or crank, the physician keeps silent as
to convictions which do not conform to the text-books. Many a
life-saving, health-promoting discovery which ought to be taken up and
incorporated into general practice from one end of the country to the
other, and which should be made a part of the minimum standard of
medical practice and medical agreement, must wait twenty-five or fifty
years for recognition.

    [Illustration: THE DISCIPLE OF FRESH AIR AND HOME INSTRUCTION IS
    STILL AN OUTCAST IN SCORES OF HOSPITALS]

For want of a school of preventive medicine to emphasize universally
every new truth, the medical colleges are permitted to remain
twenty-five or fifty years behind absolutely demonstrated facts as to
medical truth and medical practice. In 1761 a German physician,
Avenbruger, after discovering that different sounds revealed diseased
tissue, used "chest tapping" in the diagnosis of lung trouble. In 1815
Lëannec discovered that sound from the chest was more distinct through
a paper horn. On that principle the modern stethoscope is built. He
made an accurate diagnosis of tuberculosis, and while suffering from
that disease treated himself as a living clinical study. In 1857
Pasteur proved the presence of germs "without which no putrefaction, no
fermentation, no decay of tissue takes place." In 1884 Trudeau started
the first out-of-door care of pulmonary tuberculosis in America. In
1892 Biggs secured the compulsory notification of pulmonary
tuberculosis. In 1904 began our first out-of-door sea-air treatment for
bone tuberculosis. Yet there are thousands of physicians to-day who
sincerely believe that they are earning their fees, who, from houses
shut up like ovens, give advice to patients for treatment of
tuberculosis, who prescribe alcohol and drugs, who diagnose the disease
as malaria for fear patients will be scared, who oppose compulsory
registration, and who never look for the tuberculous origin of crippled
children. Just think of its being possible, in 1908, for a tuberculous
young man of thirty to pay five dollars a day to a sanatorium whose
chief reliance is six doses of drugs a day!

In 1766 America's first dentist came to the United States. By 1785
itinerant dentists had built up a lucrative practice. In 1825 a course
of lectures on dentistry was delivered before the medical class at the
University of Maryland. As early as 1742 treatises were written "Upon
Dentition and the Breeding of Teeth in Children." In 1803 the
possibility of correcting irregularities was pointed out, as was the
pernicious effect of tartar on the teeth in 1827. In 1838 attempts were
made to abolish, "in all common cases, the pernicious habit of tooth
drawing." In 1841 treatises were written on the importance of
regulating the teeth of children before the fourteenth year and on the
importance of preserving the first teeth. Yet in 1908 it is necessary
to write the chapter on Dental Sanitation. Few physicians, whether in
private practice or hospitals or just out of medical college, consider
it necessary to know the conditions of the mouth before prescribing
drugs for physical illness.

Osteopathy furnishes an up-to-date illustration. Discredited by the
medical profession, by medical journals and medical schools, it has in
fifteen years built up a practice of eight thousand men, having from
one to three years' training, including over one hundred physicians
with full medical training plus a course in osteopathy. There were
means of learning fifteen years ago what was truth and what was
quackery about the practice of osteopathy. By refusing to look for its
truth and by concentrating attention upon its quackery the medical
profession has lost fifteen years. Whereas the truth of osteopathy
should have been adopted by the medical colleges and a knowledge of its
possibilities and limitations required of every practicing physician, a
position has been reached where alleged quackery seems in several
important points to be discrediting the sincerity, the intelligence,
and the efficiency of orthodox medicine. No appeal to the natural can
be stronger, no justification of schools of preventive medicine more
complete, than the following paragraph from an osteopathic physician
who is among the small number who, having both the medical and
osteopathic degrees, see both the possibilities and limitations of
manual surgery and demand the inclusion of this new science in the
medical curriculum.

  The physical method of treating disease presents a tremendous and
  significant departure from the empiricism of medicine and the
  experimentation of dietetics, the restricted fields of
  electricity, suggestion, water cures, and massage. The patient as
  an individual is not treated; the disease as a disease is not
  treated; the symptoms are not treated; but the entire physical
  organism, with its many parts and diverse functions, is
  exhaustively examined until each and every abnormal condition,
  whether of structure or of function, causing disease and
  maintaining symptoms, is found and administered to with the skill
  of a definite art, based upon the data of an exact science.

Likewise the truths underlying Christian Science have been disdained by
medical schools and medical experts, just as its spiritual truth has
been disdained by religious leaders, until it has grown to such
strength that laymen are almost forced to question the sincerity and
the efficacy of the conventional in religion as well as medicine. In
May, 1907, the Emmanuel Church in Boston organized a clinic for the
purpose of utilizing for neurasthenics particularly both the spiritual
and the physical truths underlying religion and the various branches of
medical science. Daily papers and magazines are giving a great deal of
space to this experiment in "psychotherapy," which is discussed in the
chapter on Mental Hygiene. Schools and chairs in preventive hygiene
would soon give to the medical profession a point of view that would
welcome every new truth, such as the alliance of religion and medicine,
and estimate its full worth promptly. Truth seeking would be not only
encouraged but made a condition of professional standing.

Just what attitude any particular physician takes can be learned by the
teacher or parents whose children he treats. If he pooh-poohs or
resents board of health regulations as to isolation of scarlet-fever
patients, he is a dangerous man, no matter how noble his personal
character. If he says cross-eyes will straighten, weak eyes will
strengthen, or nose-stopping adenoids "absorb," he is bound to do harm.
If he says tuberculosis is incurable, noncommunicable, hereditary, or
curable by drugs, or if he tries to cure cancer by osteopathy, he can
do more injury than an insane criminal. If he fails to teach a mother
how to bathe, feed, and clothe the baby, how to ventilate a room for
the sick or the well, he is an expensive luxury for family or for
school, and belongs to an age that knew neither school nor preventive
hygiene. If he takes no interest in health administration; if he
overlooks unclean milk or unclean streets, open sewers, and unsanitary
school buildings, street cars, churches, and theaters; if he does not
help the health board, the public hospitals, the schools, the factory,
and tenement departments enforce sanitary laws, he is derelict as a
citizen and as a member of an "exalted profession." If he sees only
the patients he himself treats or one particular malady, he is derelict
as a teacher, no matter how charming his personality or how skilled in
his specialty. If a school physician is slovenly in his work, if he
spends fifteen minutes when he is paid for an hour, should the
efficient school-teacher conceal the fact from her superiors because he
is a physician? If private hospitals misrepresent facts or compromise
with political evils for the sake of a gift of public money, their
offense is more heinous because of their exalted purpose. The test of a
physician's worth to his patients and to his community is not what he
is or what he has learned, and not what his profession might be, but
what happens to patient and to community. Human welfare demands that
the medical profession be judged by what it does, not by what it might
do if it made the best possible use of its knowledge or its
opportunity.

    [Illustration: TOO MANY PHYSICIANS AND EVEN MATERNITY HOSPITALS
    FAIL TO TEACH MOTHERS, EITHER BEFORE OR AFTER BABIES ARE BORN
    Caroline Rest Educational Fund was given to show the value of
    such teaching]

A dispensary that treats more patients than it can care for properly is
no better than a street-car company that chronically provides too few
seats and too many straps. Unless physicians test themselves and their
profession by results, we shall be compelled to "municipalize the
medical man." Preventable sickness costs too much, causes too much
wretchedness, and hampers too many modern educational and industrial
activities to be neglected. If the medical profession does not fit
itself to serve general interests, then cities, counties, and states
will take to themselves the cure as well as the prevention of
communicable and other preventable sickness. Human life and public
health are more precious than the medical profession, more important
even than theories and traditions against public interference in
private matters. The unreasoning opposition of medical men to
government protection of health, their concentration on cure, and their
tardy emphasis on prevention have forced many communities to stumble
into the evil practices mentioned in Chapter XVI. Incidentally, the
best physicians have learned that the prosperity of their profession
increases with every increase in the general standard of living. It is
the man in the ten-room house not the man in one room who supports
physicians in luxury. It is the healthy man and the healthy community
that value efficient medical service.

Many American cities maintain dispensaries and hospitals for the poor.
Whether they will go to the logical conclusion of engaging physicians
to give free treatment to all regardless of income depends largely upon
what the next generation of private physicians do. The state already
says when a physician's training fits him to practice. It will soon
expect him to pass rigid examinations in the social and economic
aspects of his profession,--its educational opportunity, vital
statistics, sick and death rates. Will it need to municipalize him in
order to protect itself?

Obviously the teacher or parent should not begin cooperation with
physicians by lecturing them or by assuming that they are selfish and
unwilling to teach. The best first step is to ask questions that they
should be able to answer:

  What causes cholera morbus or summer complaint? When does milk
  harm the baby? How can unclean milk be made safe? Whose fault is
  it that the milk is sold unclean and too warm? What agencies help
  sick babies? What is the health board doing to teach mothers?

Or, if a school physician, the teacher can ask:

  Why not remove these adenoids? What causes them? When will they
  disappear by absorption? What harm can they do in the meantime?
  How long would an operation take? Would it hurt very much? What
  would be the immediate effects? Why not act at once? What
  provisions are there in town for such operations? Why have the
  physicians paid so little attention to breathing troubles? What
  could your state do to interest physicians in school hygiene? Will
  the school physician talk to a mothers' meeting? What agencies
  will give outings to sick children? What dispensaries are
  accessible? Who is the proper person to organize a public health
  league?

Physicians love to teach. If teachers and parents will love to learn
and will ask the right questions, all physicians can be converted into
hygiene missionaries, heralds of a statesmanship that guarantees health
rights to all.


LICENSING THE PRACTITIONER

Three parties are interested in setting a high standard for physicians,
dentists, druggists, nurses, and veterinary surgeons--the profession
itself, the schools that educate, and the general public on whom the
arts are practiced. The schools and the practitioners are, for the most
part, primarily interested in protecting a monopoly of skill. Their
interest in restrictive legislation is analogous to that of the labor
union which limits the number of apprentices. This trade unionism among
professional colleges and professional graduates of these colleges has
gradually developed a higher and higher standard that results in
greater protection to the public. The first step is generally to demand
that all persons entering a profession after a given date shall prove
to the state their ability to "practice" without injury to clients. It
is almost impossible to get such laws through unless the original law
exempts all persons by whatever name, who are practicing the art in
question at the time the law is passed. Whether we are speaking of
medicine, law, dentistry, accountancy, osteopathy, or barbering, this
has been the history of compulsory restriction and of state
examinations.

As with regard to most other legislation, the enforcement of the law
lags behind its definition. Moreover nothing is done after a man has
passed a certain examination to see that he remains fit and safe to
treat the public. Because no supervision is provided except on the day
of examination, it is possible for men and women to fill their brains
for a week or two weeks with the information necessary to pass what
coaches and tutors have learned will, in all probability, be asked.
Forever after, the public is left to protect itself. Out of this
condition have arisen the evil, unethical, and unprofessional practices
represented particularly by painless dentists, by ignorant or dishonest
physicians, and by osteopaths and careless nurses.

The machinery for preventing these evils is discussed in Chapter XXIX.
Suffice it here to present to parents and teachers the need for
examination in advance of certification that will show whether or not
those who make a livelihood by caring for others' health are equipped
to mitigate rather than aggravate evils, and for further tests by which
the public can learn from time to time which, among those professional
men who are protected by the public against competition, continue to be
safe. Finally, if, as will be clearly seen, it is desirable that what
we call professional ethics persist and that self-advertisement be
discouraged, society must, for its own protection, adopt some other
means than epithets to correct the evils of self-advertisement and
quackery. Even though we admit the responsibility of each citizen when
he goes to the house of a private practitioner who has made no other
effort to lure him thither than to place a card in the window, it must
be seen that we cannot hold responsible for their choice men and women
who receive through newspapers, magazines, or circulars convincing
notices that Dr. So-and-So or the Integrity Company or the Peerless
Dental Parlor will place at their disposal, at prices within their
reach, skill and devotion absolutely beyond their reach at the office
of an efficient private practitioner. Some way must be found by which
departments of health will currently impose tests of methods and
results upon physicians, opticians, pharmacists, manufacturers of
medicine, and dentists.

As laymen become more intelligent regarding their own bodies and
healthy living, it grows harder and harder for quacks and incompetents
to mislead and exploit them. Better than any possible outside safeguard
is hygienic living. Fortunately, we can all learn the simple tests of
environment and of living necessary to the selection of physicians,
dentists, and opticians, or other "architects of health" whose
efficiency and integrity are beyond question.



PART IV. OFFICIAL MACHINERY FOR ENFORCING HEALTH RIGHTS



CHAPTER XXVII

DEPARTMENTS OF SCHOOL HYGIENE


The term "school hygiene" generally suggests no other school than the
public school. State laws say nothing about compulsory hygiene in
military academies, ladies' seminaries, or other preparatory and
finishing schools. Yet when one thinks of it, one must conclude that
the right to health and to healthful school environment cannot
equitably be confined to the children whose tuition is given at public
expense. There is a better way to check "swollen" fortunes than by
ruining the health of "fortune's children." The waste and danger of
slow-minded, noticeably inefficient children are no less when parents
are rich than when parents are poor. There is no justification for
neglecting the health of children in parochial schools, in private
schools for the well-to-do or rich, or in commercial schools for the
ambitious youth of lower income strata. Nor has the commercial,
parochial, private school, or college, any clearer right than the
public school to injure or to fail to promote pupils' health. So far as
school hygiene is advisable, so far as it is right to make hygiene
compulsory, its personal and social benefits should be shared by
children of school age without regard to income, and its laws should be
enforced by all teachers, principals, and officers that have to do
with school. In presenting a programme for school hygiene this chapter
refers to the hygiene taught, the hygiene practiced, the hygiene not
taught, and the hygiene not practiced in buildings and on grounds where
children and youth are at school, whether these children are in
kindergarten or high school, in reformatory or military academy, in
charitable school, or in finishing and preparing center for society's
juniors.

The question of the local, state, and national machinery by which
proper standards of school hygiene shall be made effective will be
taken up after we have considered individual steps in a comprehensive
programme for school hygiene.

1. _Thorough physical examination of all candidates for teachers'
positions and periodic reëxamination of accepted teachers._

Teachers would be grateful to be told in time their own physical needs
and the relations of their vitality to the vitality of their pupils.
Are your teachers examined? Do they know the laws of health and the
signs of child health? Are they permitted to continue in schoolrooms
after tuberculosis is discovered? Are normal graduates given physical
tests before being permitted to teach and before being permitted to
give four years to preparation for teaching?

2. _Thorough physical examination of every single child in every single
school upon entering and periodically during school life._

We believe a vast number of things that "ain't so" about the health of
country children as compared with city children, of private-school
children as compared with public-school children. Where do we find more
degenerate men, physically and morally, than in so-called "American
settlements," where, for generations, children have had all outdoors to
play in, except when in homes and schoolhouses that are seldom cleansed
and seldom ventilated? Open mouths and closed minds clog the "little
red schoolhouse"; there headaches do not suggest eye strain; there
deafness and running ears are frankly attributed to scarlet fever which
everybody must have with all the other "catching" diseases, the earlier
the better; there colds begin in December and run until March, to the
serious injury of attendance and promotion records; there bone
tuberculosis is called "knee trouble" or "spine trouble in the family";
there boys like my little friend Fred count the bottles of cod-liver
oil they take to cure adenoids that could be removed in two minutes.

The index to community life and community living conditions should be
read in the country, not only for the country's sake, but also for the
sake of the city whose milk and water, poisoned in the country, cause
thousands of deaths annually, besides annual sick bills exceeding many
times over the Russell Sage and Carnegie Foundations, which we rightly
call munificent. Reading the index of private schools and colleges is
important for their children and youth, but still more important for
the community upon which unbridled passion, inability to work or to
spend properly, inconsequential thinking, mediæval ideals of caste,
etc., can inflict greater injuries than can typhoid fever or cholera.

The physical record of each child should be kept from date of entrance
to date of leaving school, showing condition at successive
examinations, absence because of illness, etc.

3. _Thorough physical examination of children when leaving school, or
when passing compulsory school age, as a condition to "working papers"
and to "coming out."_

To give working papers to children seriously handicapped by physical
defects is to buy future industrial trouble, hospital and poorhouse
bills. A boy with adenoids, a girl with eye trouble, should not be
permitted to begin the fight for self-support without at least being
clearly shown that the correction of these defects will increase their
earning power. At present a schoolgirl with incipient tuberculosis, or
predisposed to that disease, can get working papers, go to a hammock or
tobacco factory, work long hours, breathe bushels of dust, deplete her
vitality, spread tuberculosis among her co-workers and home associates,
infect a tenement,--and all this without any help or advice or any
protection from society until she is too sick to work and her physician
notifies the health department that she is a danger center. We may
disagree about society's right to control a child's act after the
defects are discovered, but who will question society's duty to tell
that child and her parents the truth about her physical needs before it
accepts her labor or permits her to "enter society"?

4. _Supervision by physicians of hygiene practiced in schoolrooms and
on playgrounds._

Superintendent Maxwell, of New York City, and other educational leaders
urge teachers to do their utmost to learn the physical conditions and
home environment of the individual child, and to fit school treatment
to the individual possibilities and handicaps. But experience proves
conclusively that try as they will, teachers and principals have
neither the special knowledge nor the time to acquire the special
knowledge requisite to use the facts disclosed by the physical
examination of school children. Physicians and nurses are needed, not
so much for treating children, as for teaching children, parents,
teachers, family and dispensary physicians.

Private schools have visiting physicians who may be consulted; they
need physicians to supervise, with power to examine or to require
certificates of examination. The Committee on the Physical Welfare of
School Children found that when a visitor was detailed for that purpose
it was easy to secure the coöperation of parents, teachers, family
physicians, dispensaries, school boards, and charitable societies. The
Hawthorne Club's school secretary has been similarly successful in
Boston, as have those of Hartley House, Greenwich House, and the Public
Education Association in New York.

5. _Restriction of study hours at school and at home to limits
compatible with health._

Whether the hours of study at school and at home are excessive cannot
be learned from treatises on pedagogics or physiology. Because children
differ in vitality as in ability to learn, the maximum limit for study
hours should be determined by the individual child's physical
condition. When the Japanese went to war with Russia the highest
authority in the field was the army surgeon. To this fact was largely
due the astonishingly small amount of sickness and the high fighting
capacity and endurance of the Japanese, working under unfavorable
conditions. No board of school superintendents or board of directors,
no state superintendent of schools or college professor, has the right
to compel or to allow study hours beyond the maximum compatible with
the individual student's physical condition and endurance. The
physician responsible for school hygiene should have an absolute veto
upon any educational policy, method, or environment demonstrably
detrimental to children's vitality.

6. _Establishment of a "follow-up" plan to insure action by parents to
correct physical defects and to attend to physical needs._

The advantages of _getting things done_ over _doing things_ have been
repeatedly emphasized. In smaller cities and in rural districts it is
particularly important for schools to get things done better by
existing local agencies, such as churches, health and street-cleaning
departments, hospitals, clinics, medical and sanitary societies, trade
unions, young people's societies, and women's clubs. Where parents who
have been followed up and taught, obstinately or ignorantly refuse to
attend to their children's needs, the segregation of the physically
defective or needy will encourage the coöperation of children
themselves in persuading parents to act intelligently for the child's
sake. No child wants to remain "queer" or "dopey" or behind his peers.
The city superintendent of schools for New York City has asked for laws
compelling parents to permit operations and punishing them for
neglecting to take steps, within their power, to remove physical
defects discovered at school.

    [Illustration: TEACHING A MOTHER TO CARE FOR ONE CHILD INSURES
    BETTER CARE FOR ALL HER CHILDREN]

7. _Physiological age should influence school classification and school
curriculum._ On this subject the studies of Dr. C. Ward Crampton,
referred to in the chapter on Vitality Tests, are invaluable and as
convincing as they are revolutionary. Scientists accept his proof that
our present high school curriculum is ill adapted to a large proportion
of children; the "physiologically too young" drop out; only the
physiologically mature succeed. The two physiological ages should be
given different work. Children whose bodies yearn for pictures,
muscular and sense expression, should be given a chance in school for
normal development. Analysis should wait for action. Organized play and
physical training antedated physical examination in our schools. Like
the curriculum they often disregard physiological age, doing harm
instead of good. Facts as to physical condition and physiological
development would enable us to utilize the momentum of these two to
broaden school hygiene and to insure proper physical supervision. Only
good would result from adopting Leipsic's plan of having school
children examined without clothing, in the presence of parents if
parents desire. Expensive? Not so expensive as high school "mortality"
due to maladjusted curriculums that force the great majority of boys
and girls to drop out before graduation and ruin the health of a large
fraction of those who remain.

8. _Construction of school building and of curriculum so that, when
properly conducted, they shall neither produce nor aggravate physical
defects._

When the state for its own protection compels a child to go to school,
it pledges itself not to injure itself by injuring the child. Thousands
of children are now being subjected to conditions in school far more
injurious than the factory and shop conditions against which the
national and state child labor committees have aroused universal
indignation. Two illuminating studies of school buildings in New York
City were made last year by the Committee on the Physical Welfare of
School Children, and later by the Board of Education. Similar studies
should be made of every schoolroom. Whereas our discussions of
buildings and curriculum have hitherto proceeded largely from abstract
principles of light, ventilation, heating, and pedagogics, these two
reports deal with rooms, equipment, courses of study, and school habits
as they are, with obvious detrimental effects on child victims.
Numerous questions that it is practicable to answer are given in
Chapter XIV.

What and when to build can be better determined after we have learned
the what and the where of present equipment.

In passing it is worth while to note that in large cities teachers are
frequently forced to choose between bad ventilation and street noises.
From Boston comes the suggestion that we avoid noises and evils of
congestion by building schoolhouses for city children on the outskirts
in the midst of fields, transporting, and, if necessary, feeding
children at public expense. While it is true that the public funds now
spent in attempting to cure physical and moral ills would purchase
ample country reservations, the practical next step seems to be to
provide ample play space and breathing space within the city for every
school building already erected, and without fail for all buildings to
be erected hereafter.

9. _Hygiene should be so taught that children will cultivate habits of
health and see clearly the relation of health and vitality to present
happiness and future efficiency._ Social rather than personal, public
rather than private, health needs emphasis. Children can be shown how
their health affects their neighbor; why money spent for health boards
is a better investment than money given to corrupt politicians; that
the cost of accepting Thanksgiving turkey or a park picnic from a
political leader who encourages inefficient government is sickness,
misery, deficient schooling, lifelong handicap; that children and
adults have health rights in school and factory, on street and
playground, which the law will protect if only they know when these
rights are infringed.

10. _Central supervision of school hygiene._ In private and public,
boarding and day, country and city, reformatory and military,
commercial and high schools, the index--physical welfare of school
children--should be read and interpreted. Headquarters should learn
whether or not physical examinations are made and whether harmful
conditions are corrected. So far as public schools are concerned,
"headquarters" means for cities the fact center that informs city
superintendent or school board; for rural schools, it means the county
superintendent's office. Whether city or county headquarters have the
facts and act accordingly should be known by state superintendents.
Whether state superintendents are demanding the facts and educating the
county and city headquarters of their states should be known to the
national commissioner of education and by him published for all the
world. Some people think the state health board should be responsible,
others the state educational authority. The important thing is to make
some one officer responsible. Methods can be easily worked out if the
need is conceded. Legislatures will gladly confer the powers necessary
to reading the index of all public schools.

As for parochial and private schools, they may resent for a time public
supervision of their hygiene teaching and practice. However, the case
could be so presented that they would ask for it, because it would help
not only their pupils and society but the schools themselves. No
religious belief or private investment can afford to admit that it
disregards child health; state supervision would require nothing more
than evidence of adequate school hygiene.

11. _Information gained at school regarding conditions prejudicial to
community health should be published and made the basis of an
aggressive campaign for the enforcement of sanitary laws._ Ten thousand
uses can be made of the information gained at school, ten thousand
forces can be made to do educational work, but only a few kinds of work
can be done effectively at school. Franklin Ford has said: "You can
relate school to all life, but you cannot bring all life under the
school roof." As Chapters XVI-XVIII make clear, to socialize the point
of view of dispensaries and hospitals is more effective than to put
clinics in school buildings. To _do for_ or _give to_ people who can
help themselves is to _give up_ and _do up_ power of self-help.

Machinery that must some day exist for the execution of this programme
will be approximately the following:

  I. NATIONAL MACHINERY

  1. Clearing house for facts regarding school hygiene as taught and
  practiced in all schools under the Stars and Stripes; this to be a
  part of the National Bureau of Education.

  2. Scientific research to be conducted by the National Bureau of
  Education or by the future National Board of Health.


  II. STATE MACHINERY

  1. Clearing house for facts regarding school hygiene taught and
  practiced in all schools within state limits; this to be
  maintained by the state educational authorities.

  2. Agents to make special inquiries as to practice and teaching of
  school hygiene.

  3. Agents to inspect and to instruct county superintendents,
  county physicians, teachers, normal schools, etc.

  4. A bureau of experts--architect, sanitarian, teacher--whose
  approval must be obtained before any school building can be
  erected. (A plan which brought excellent results when applied by
  state boards to charitable institutions, hospitals for the insane,
  etc.)

  5. Standard making by normal schools, state universities,
  hospitals, or other educational and correctional institutes under
  direct state management.


  III. COUNTY MACHINERY

  1. Clearing house for facts regarding school hygiene taught and
  practiced in all schools within county limits; this to be
  maintained by the county superintendent of schools.

  2. Physician and nurse to organize inspection and instruction for
  rural schools, to give lessons and make demonstrations at county
  institutes, to show teachers how to interest physicians, dentists,
  health officers, and parents in the physical welfare of school
  children.


  IV. TOWN AND TOWNSHIP MACHINERY

  1. Teachers intelligent as to physical needs, as to sanitation of
  buildings, etc.

  2. An examining physician, to be salaried where the population
  justifies; elsewhere to work as a volunteer in coöperation with
  teacher and with county physician.

  3. Physical history of each child from date of entrance to date of
  leaving school, to be kept up to date by teacher.


  V. CITY MACHINERY

  1. A division to be known as the Department of School Hygiene,
  headed by an officer who gives his entire time to that department.

  2. A subcommittee of the Board of Education.

  3. Clearing house for facts regarding school hygiene taught and
  practiced in all schools within city limits.

  4. Specialists to examine applicants for teaching positions, and
  to reëxamine teachers to determine fitness for continuance, for
  promotion, and for special assignments.

  5. A bureau for inspection and control of all hygiene of school
  buildings, old and new, with power to compel repairs or to reject
  plans that do not make adequate sanitary provision.

  6. Similar supervision of curriculum and of study hours
  prescribed.

  7. A bureau for the inspection and control of curriculum, required
  home study, exercise, physical training, etc., so far as relates
  to the health of pupils, and to the physical ability of children
  to be in certain grades or to be promoted. This will decide the
  duration of lessons, frequency of intermissions, sequence of
  subjects, time and method of recess throughout the various grades.

  8. Supervision of indoor and outdoor playgrounds, roof gardens,
  indoor and outdoor gymnasiums, swimming pools, etc.

  9. Supervision of instruction in school hygiene.

  10. A staff of inspectors for communicable diseases of pupils and
  teachers, to be subject to the board of education or the board of
  health.

  11. A staff of examiners adequate to examine all children and
  teachers at least once a year for defects of eye, ear, teeth,
  nose, throat, lungs, spine, bones, glands, etc., and for weight
  and height to be under the control of the board of education or
  the board of health. The expense would not be as great as the
  penalty paid for omitting such examination.

  12. A staff of nurses to assist medical examiners to give children
  practical demonstrations in cleanliness, to teach mothers the care
  of children both at their homes and in mothers' meetings, to
  enlist the coöperation of family physician and neighborhood
  facilities, such as hospitals, dispensaries and relief agencies,
  magistrates' courts and probation officers,--all to be under the
  control of the board of education or the board of health.

Whether inspectors, examiners, and nurses shall be directed by the
board of education or the board of health is a question that it is
impossible to decide without knowledge of local conditions. So far as
state and county organizations are concerned, it is clear that whatever
the boards of health may do, it will be necessary for state and county
superintendents of education to equip themselves with the machinery
above recommended. In cities it is quite clear that a board of
education should be responsible for all of the machinery suggested,
excepting the three divisions that have to do with work hitherto
considered as protection against transmissible diseases, namely,
inspection, examination, district visiting. In Cleveland these are
school duties. In New York they are duties of the health department.
Boston has school nurses and health department physicians. The state
law of Massachusetts provides that where health boards do not examine
school children, school boards may spend money for the purpose.

As to inspection for transmissible diseases, it seems quite clear that
health boards should not delegate their authority or responsibility to
any other body, for they alone are accountable to their communities for
protection against contagion. It is clear, too, that in the interest of
community health, departments of health are justified in pointing out
in advance of contagion those children most likely to become a menace.
Similar grounds of public interest justify the health boards in sending
nurses and physicians to the home as a means of getting things done.

Dr. Biggs feels that responsibility for the physical welfare of school
children will strengthen health work in all cities, and, given proper
interest on the part of school officials, should make possible
universal coöperation in a constructive programme. On the other hand,
he believes that division of responsibility between school and health
boards will weaken both in their appeals for funds and for support of a
constructive programme. I have heard principals and superintendents
maintain also that the moral effect of a visit to the school by a
representative of the health board vested with powers of that board was
much greater than a visit by a representative of the school board. They
further allege that a physician coming from the outside is more apt to
see things that need correction and less apt to accept excuses than an
inspector who feels that he belongs to the same working group as the
school-teacher. Because the follow-up work in the homes incident to
successful use of knowledge gained at school involves so many sanitary
remedies, it is theoretically better organization to hold the health
authority responsible.



CHAPTER XXVIII

PRESENT ORGANIZATION OF SCHOOL HYGIENE IN NEW YORK CITY


Many of the elements of the machinery outlined in the preceding chapter
already exist in New York City. All of them brought together, either by
amalgamation or by proper coördination, would present a very strong
front. Unfortunately, however, there is not only unsatisfactory team
work, but the efficiency of individual parts is seriously questioned by
the heads of the health and school departments.

The inspection for contagious diseases, the examination for physical
defects, the follow-up work by nurses and physicians, are in charge of
the department of health. Physical training and athletics for
elementary and high schools, winter recreation centers, and vacation
playgrounds are under directors and assistants employed by the board of
education. Heretofore inadequate powers and inadequate assistance for
training or for research have been given to the physical director.

The city superintendent of schools, in his report for the year 1907,
presented to the board of education in January, 1908, declares that the
"present arrangements have been inadequate.... In only 248
schools--less than half the total number--were any examinations for
possible diseases made. In these 248 schools not more than one third of
the pupils were examined. It is only a few months since any
examinations for physical defects were made outside of the boroughs of
Manhattan and The Bronx, and then only on account of the New York
Committee on the Physical Welfare of School Children."

As is so often the case, it is difficult to decide the merits of a
method that has not been efficiently executed. The department of health
has not hitherto done its best in its school relations. The
commissioner of health, in a public interview, expresses resentment at
the strictures by the school authorities. Yet in 1907 he permitted to
accumulate an unexpended balance of $33,000 specifically voted for
school inspectors, and repeatedly tried to have this amount transferred
to other purposes. The interest of the Bureau of Municipal Research in
municipal budgets that tell for what purposes money is voted and then
prevent transfers without full publicity, preserved this particular
fund. Moreover, the discussion that prevented its diversion from
physical examinations strengthened the health department's interest in
this important responsibility. Neither physicians nor nurses have been
adequately supervised. Instead of seeing that defects were removed, the
department of health sent out postal cards like the following:

    [Illustration: (Notice Example)]

 +-----------------------------------------------------------------------+
 |         "This Notice Does NOT Exclude This Child From School"         |
 |                                                                       |
 |                          DEPARTMENT OF HEALTH                         |
 |                          THE CITY OF NEW YORK                         |
 |                                                                       |
 |                            _Oct. 2, 190_6_                            |
 |                                                                       |
 | The parent or guardian of ___________________________________________ |
 |  of____________________________________attending P.S.__51___________  |
 | is hereby informed that a physical examination of this child seems to |
 | show an abnormal condition of the ___________________________________ |
 | ___Eyes, Nose, Throat and Teeth______________________________________ |
 | _____________________________________________________________________ |
 | Remarks__Is Anaemic__________________________________________________ |
 | _____________________________________________________________________ |
 |                                                                       |
 | Take this child to your family physician for treatment and advice.    |
 | Take this card with you to the family physician.                      |
 |                                                                       |
 |                                       THOMAS DARLINGTON, M.D.,        |
 |                                               Commissioner of Health. |
 |                                                                       |
 | HERMANN M. BIGGS, M.D.,                                               |
 |          General Medical Officer                                      |
 +-----------------------------------------------------------------------+

From 118,000 such notices sent out only 9600 replies were received, of
which only one in twenty stated that attention had actually been given
the needy child. The department had been satisfied with evidence that
family physicians had advised parents properly, as in the case of the
child above reported:

    [Illustration: (Card example)]

 +----------------------------------------------------------------------+
 |                   TAKE THIS CARD TO YOUR PHYSICIAN                   |
 |                                                                      |
 |         The Physician in charge is requested to fill out and         |
 |        forward this postal after he has examined this child.         |
 |                                                                      |
 | I have this day examined ___________________________________________ |
 | of P.S. __51______________ and find the following condition:         |
 |                                                                      |
 | __As reported, Also enlarged (unclear) glands_______________________ |
 | and advised as follows:__operation for adenoids and tonsils_________ |
 | _____Dental treatment at Cornell. Fresh air ________________________ |
 | _____outing at Sea Breeze Eyes wait.________________________________ |
 |                                                                      |
 |                                             Respectfully yours,      |
 |                                          _______P.L. OB___________   |
 | Date __Oct. 9, 1906______                _________________________   |
 |                                                                      |
 +----------------------------------------------------------------------+

For a candid, complete criticism of the medical examination work up to
June, 1908, consult the report of the Bureau of Municipal Research,
presented to the Washington Congress of Public Education Associations
in October, 1908, by Commissioner of Health, Dr. Darlington. The
bureau's study is entitled _A Bureau of Child Hygiene_, and, in
addition to the story of medical examination in New York City schools,
gives the blank forms adopted for use in September, 1908. Important as
are the facts given in this study, its greatest value, its authors
declare, is in its account of "the method of intelligent self-criticism
and experiment which alone enables a public department to keep its
service abreast of public needs."

The Bureau of Municipal Research made its study for the purpose of
learning whether the disappointing results emphasized by the school
authorities were due to "dual responsibility in the school--that of the
board of education and that of the department of health"--and to "lack
of power or inclination to compel parents to remedy defects," or to
_deficient administration_ of power and inclination by health
officials. Coöperating with school physicians and nurses in three
schools, 1442 children were examined, of whom 1345, or 93.2 per cent,
had 3458 defects that needed treatment. The postal-card notice was
followed by an interview with the parent either at school or at home.
Only 4.2 per cent of the total number of parents refused to act, 81 per
cent secured or permitted treatment for one or more defects, while 15
per cent promised to take the proper steps at the earliest possible
date. Three fourths of the parents acted after one personal interview.
"The net average result of a day's work by a nurse was the actual
treatment of over five children, three of them completely, and two of
them for one or more defects,"--sixty cents per child!

    [Illustration: A PHOTOGRAPH OF MOUTH BREATHING MAY MAKE
    COMPULSION UNNECESSARY]

Having established the willingness--even eagerness--of parents to do
all in their power to remove defects that handicapped their children,
it was obviously the duty of the health department so to organize its
work that it could insure the education of parents. The new Bureau of
Child Hygiene gives foremost place to instruction of parents in care of
babies, in needs of school children, and in the importance of physical
examination when enlisting in the industrial army. Whether this work is
well done is learned by result tests applied at headquarters, where
work done and results are reported daily and summarized weekly. No
longer will it be possible, without detection, for one physician to
find only eye trouble and to neglect all other defects; for two
inspectors examining different children in the same school to report
results differing by 100 per cent; for physicians in different schools
to find one 18 per cent, another 100 per cent with defects; for two
inspectors examining identical children to agree on 51 out of 101 cases
of vision, on 49 out of 96 cases of adenoids, or 3 out of 10 cases of
skin disease.

So conclusive were the results of follow-up work efficiently supervised
by the department of health, that school officials are, for the
present, inclined to waive the demand for the transfer of physicians
and nurses to the board of education, and to substitute education for
compulsion with parents who obstinately refuse to take proper remedial
measures for their children when reported defective.

This present plan requires the entire working time of inspectors and
nurses for school work. Thus New York has for the present definitely
abandoned the plan of having the district inspection for contagious
diseases done by school physicians. The purpose of the change is not to
reduce danger of infection, which was negligible, but to increase the
probability of scientific attention to school children.

Before a final settlement is made for New York City there should be
tests showing what the school authorities would do if physicians and
nurses were subordinate to them. It is conceivable that one physician
working from nine to five would accomplish more than six physicians
working the alleged three hours a day. So imperative are the demands of
school hygiene that it seems probable that in New York and in other
large cities school physicians, whether paid by the board of health or
the board of education, must be expected to be at the service of school
children, subject to the call of school officers, during as many hours
of the day as teachers themselves must give. It is even conceivable
that effective use of the knowledge gained by physical examinations of
school children, and by those responsible for school hygiene, will
require evening office hours or evening visits to homes, and regular
Saturday office hours and Saturday visits by school physicians and
nurses. Finally, it must be expected that the programme for school
hygiene will need the special attention of physicians and nurses during
the summer months, and other vacation periods when children and parents
alike have time to receive and to carry out their instructions.

One danger in New York City is that the board of education, like the
board of health, when compelled to choose between so-called standard,
necessary, traditional duty and school hygiene, will sacrifice the
latter. The school authorities, without any more funds and without
physicians and nurses, could already have made, had they desired, eye
tests and breathing tests sufficiently accurate to detect the majority
of children needing attention. The outcome of the discussion as to the
jurisdiction of the two boards will undoubtedly be to interest both in
their joint responsibility for children's welfare, and to increase the
attention given by both to the physical condition of the child when he
presents himself for registration as a wage earner.



CHAPTER XXIX

OFFICIAL MACHINERY FOR ENFORCING HEALTH RIGHTS


The argument for _getting things done_ presumes adequate active
machinery, official and private, for _doing things_ that schools are
being urged to do. The chapter on Departments of School Hygiene
suggests local, county, state, and national machinery necessary (1) to
protect the child from injuries due to school environment, school
methods, and school curriculum; (2) to getting those things done for
the child at home and on the street, need for which is disclosed by
physical and vitality tests at school. It is unreasonable to confine
the school to the activities above outlined unless health machinery,
adequate to the demands placed upon it by school and other community
needs, is devised and kept in order.

Generally speaking, adequate health machinery is already provided for
by city charters and by the state laws under which villages, townships,
and counties are organized. Quite as generally, however, machinery and
methods of adequate administration are undeveloped. How much machinery
has already been set to work by New York City is shown by the
accompanying chart. A useful exercise for individuals or school classes
wishing to study health administration would be to chart in this way
the machinery actually at work in their locality, county, and state.
Even for New York it should be remembered that this chart does not
include national quarantine, the state protection of the port, the
state dairy and health commissions, or the state and national food
inspection. To get an idea of the vast amount of attention given
to health in New York City there should be added to this chart the work
of many departments other than the department of health. The building
bureau, tenement-house department, board of water supply, sewage
commission, street cleaning, public baths and comfort stations, the
department of water, gas, and electricity, and finally the department
of hygiene and physical training in the public schools.

    [Illustration: CHART SHOWING HOW NEW YORK CITY'S DEPARTMENT OF
    HEALTH EXERCISES IT'S AUTHORITY
    Courtesy of Bureau of Municipal Research]

Five elements of adequate machinery are generally lost sight of:

  1. The voter.

  2. The nonvoter, subject to health laws and often apt to violate
  them.

  3. The mayor, governor, or president who appoints health officers.

  4. The council, board of aldermen, legislature, or congress that
  enacts health laws.

  5. The police courts and the judiciary--police, circuit and
  supreme--that decide whether society has suffered from violation
  of law and what penalties should be inflicted for such violation.

Legislative bodies have hitherto slighted their responsibilities toward
public health. The chairman of a committee on public health of a state
legislature was heard to remark, "I asked for that committee because
there isn't a blooming thing to do." If voters, nonvoters, and health
officials will follow the suggestion of this book to secure school and
health reports that will disclose community and health needs, it will
be increasingly difficult for legislators to refuse funds necessary to
efficient health administration.

To the courts tradition has required such deference that one hesitates
to find out in how far they have been responsible in the past for the
nonenforcement of health laws. Yet nothing is more obstructive of
sanitary progress than the failure of magistrates to enforce adequate
penalties for truancy, adulteration of milk, maintaining a public
nuisance, defiling the air with black smoke, offering putrid meats for
sale, running an unclean lodging house, defying tenement-house or
factory regulations, working children under age and overtime, spitting
in public places, or failing to register transmissible diseases.[16]

The appointing officer cannot, of course, be held responsible unless
voters and nonvoters know in how far his appointees are inefficient,
and in how far he himself has failed to do his utmost to secure funds
necessary to efficiency. Too frequently appointments to health
positions have been made on political grounds, and catastrophes have
been met by blundering incapacity. The political appointee has been
made the scapegoat, and the appointing officer, whether mayor,
governor, or president, has regained public confidence by replacing an
old with a new incompetent.

In order to have health machinery work properly, the appointing officer
should not be allowed to shift responsibility for failure to his
subordinates. For example, it was recently found in New York City that
while the tenement-house commissioner was being condemned for failing
to enforce the law, he had turned over to the corporation counsel, also
appointed by the mayor, for prosecution ten thousand "violations" to
which no attention whatever had been paid!

The voter, nonvoter, appointing officer, legislative officer, and
judicial officer determine the character and purpose of machinery and
are analogous to the surveyors, stock-holders, directors, and
constructors who provide railroads with tracks and with running stock.
The actual running force of health department or railroad is what is
meant by its official machinery. What this machinery should be depends,
of course, upon the amount of business to be done, and differs with
the size of the district and the character of population to be served.

    [Illustration: FOR PUSH-CART FOOD, INSPECTION IS PARTICULARLY
    NEEDFUL]

Local health machinery should guarantee protection against the evils
mentioned in preceding chapters. In general, one man is better than
three to execute, although three may be better than one to legislate.
Where small communities do not wish to have the entire state sanitary
code rigidly administered, they can adopt New York's method of a
legislative board of three members, headed by an executive, whose
business it is to act, not talk; to watch subordinates, and to enforce
rigidly and continuously ordinances passed by the board. The National
Bureau of Census places under the general heading Health and Sanitation
the following activities: health administration, street cleaning and
refuse disposal, sewers and sewage disposal. Sanitarians generally
emphasize also the health significance of efficient water service.

A community's health programme should be clearly outlined in the annual
budget. Where health work is given funds without specification of the
kinds of work to be done, serious evils may be overlooked and lesser
evils permitted to monopolize the energies of health officers. Again,
after money has been voted to prevent an evil, records should be made
of work done when done, and of money spent when spent, so that any
diversion will be promptly made known. The best present guides to
budget making, to educational health reports, and to records that show
efficiency or inefficiency of health administrators are the budget and
report of the department of health for New York City, and the story of
their evolution told in _Making a Municipal Budget_, by the Bureau of
Municipal Research.

To find out whether local machinery is adequate, the reader must
enumerate the things that need to be done in his community, remembering
that in all parts of the United States to-day there are sanitary laws
offering protection against dangers to health, excepting some dangers
not understood until recently, such as child labor, dangerous trades,
lack of safety devices. Adequate local protection, however, will not
become permanent until adequate state machinery is secured.

State health machinery should be of two kinds,--fact-gathering and
executive supervision through inspection. The greatest service of state
boards of health is to educate localities as to their own needs, using
the experience of all communities to teach each community in how far
its health administration menaces itself and its neighbors. In addition
to registration of contagious diseases, facts as to deaths and births
should be registered. State health boards should "score" communities as
dairies and milk shops are now being scored by the National Bureau of
Animal Industries and several boards of health. When communities
persist in maintaining a public nuisance and in failing to enforce
health laws, state health machinery should be made to accomplish by
force what it has failed to accomplish by education.

    [Illustration: NATIONAL MACHINERY HAS STIMULATED LOCAL MILK
    INSPECTION AND STATE DAIRY INSPECTION]

States alone can cope adequately with dangers to milk and water sources
and to food. The economic motive of farmers has developed strong
veterinary boards for the protection of cattle. Similar executive
precaution must soon be taken by cities for the protection of babies
and adults of the human species. It is far more economical to insure
clean dairies, clean water sources, and wholesome manufactured foods by
state inspectors than by local inspectors. At present the task of
obtaining clean milk and clean water falls upon the few cities
enlightened enough and rich enough to finance the inspection of
community foods. Once tested, it would be very easy to prove that
properly supported state health authorities will save many times the
cost of their health work in addition to thousands of lives.

County or district machinery is little known in America. For that
reason rural sanitary administration is neglected and rural hospitals
are lacking. In the British Isles rural districts are given almost as
careful inspection as are cities. Houses may not be built below a
certain standard of lighting, ventilation, and conveniences.
Outbuildings must be a safe distance from wells. Dairies must be kept
clean. Patients suffering from transmissible diseases may be removed by
force to hospitals. What is more to the point, rural hospitals have
proved that patients cared for by them are far more apt to recover than
patients cared for much more expensively and less satisfactorily at
home, while less likely to pollute water and milk sources or otherwise
to endanger health.

With national machinery the chapter on Vital Statistics has already
dealt. We shall undoubtedly soon have a national board of health. Like
the state boards, its first function should be educative. In addition,
however, there are certain administrative functions where inefficiency
may result in serious losses to nation, state, and locality. National
quarantine, national inspection of meats, foods, and drugs are
administrative functions of vital consequence to every citizen.
Authorities are acquainted at the present time with the fact that the
sanitary administration of the army and navy is unnecessarily and
without excuse wasteful of human energy and human life. In the Spanish
American War 14 soldiers died of disease for 1 killed in battle; in the
Civil War 2 died of disease to 1 killed in battle; during the wars of
the last 200 years 4 have died of disease for 1 killed in battle. Yet
Japan in her war with Russia, by using means known to the United States
Army in 1860, gave health precedence over everything else and lost but
1 man to disease for 4 killed in battle. Diseases are still permitted
to make havoc with American commerce because the national government
does not apply to its own limits the standards which it has
successfully applied to Cuba and Panama.

"The Japanese invented nothing and had no peculiar knowledge or skill;
they merely took occidental science and used it. The remarkable thing
is not what they did, but that they were allowed to do it. It is a
terrible thing that Congress should choose to make one of its rare
displays of economy in a matter where a few thousand dollars saved
means, in case our army should have anything to do, not only the
utterly needless and useless loss of thousands of lives, but an
enormous decrease of military efficiency, and might, conceivably, make
all the difference between victory and defeat."

FOOTNOTES:

[16] The technic and principles of municipal engineering have been
treated in detail in _Principles of Sanitary Science and the Public
Health_, by William T. Sedgwick, and in _Municipal Sanitation in the
United States_, by Charles N. Chapin, M.D.



CHAPTER XXX

SCHOOL AND HEALTH REPORTS


For every school-teacher or school physician responsible for the
welfare of children at school, there are fifty or more parents
responsible for the physical welfare of children at home. Therefore it
is all important for parents to know how to read the index for their
own children, for their children's associates, and for their community.
School reports and health reports should tell clearly and completely
the story of the school child's physical needs.

    [Illustration: NECESSARY TO EFFICIENT DEMOCRACY]

It is impracticable at the present time to expect a large number of men
and women to be interested in the reports published by school and
health boards, for, with few exceptions, little effort is made to write
these reports so that they will interest the parent. Fortunately, a
small number of persons wishing to be intelligent can compel public
officials to ascertain the necessary facts and to give them to the
public. So backward is the reporting of public business that at the
present time there is probably no service that a citizen can render his
community which would prove of greater importance than to secure proper
publicity from health and school boards.

Generally speaking, these published reports fail to interest the
citizen, not because officials wish to conceal, but because officials
do not believe that the public is interested. A mayor of Philadelphia
once furnished a notable exception. He called at the department of
health and complained against publishing the number of cases of typhoid
and smallpox lest stories in the newspapers "frighten the city and
injure business." A sanitary inspector who was in the room asked if
Philadelphia's business was more important than the health of
Philadelphia's citizens. As a result of her "impertinence" the
inspector was removed. That same year an epidemic of smallpox spread
through all the rural districts and cities of Pennsylvania, because
physicians thought it would be kinder to the patients not to make known
to their neighbors the presence of so disagreeable a disease. Almost
all health and school authorities, however, can be made to see the
advantage of taking the public into their confidence, because public
confidence means both public recognition and greater success in
obtaining funds. With more funds comes the power to do more work.

Other details with regard to health reports will be found in the
chapter on Vital Statistics. As to school reports, little thought has
been given in the past to their educational possibilities. A book was
recently published--_School Reports and School Efficiency_--by the
Committee on the Physical Welfare of School Children, which tells the
origins of school reports; contains samples of reports from one hundred
cities; gives lists of questions frequently answered, occasionally
answered, and never answered; and shows how to study a particular
report so as to learn whether or not important questions are answered.
The United States commissioner of education has organized among state
and city superintendents special committees on uniform and adequate
reporting. His aggressive leadership is welcomed by school men
generally, and promises vast benefits.

Just because the physical welfare of the school child is an index to
health needs, the school report can put into one statement for a city
or a state the story told by the index. The accompanying card tells
facts that the individual teacher and individual parent want to know
about a child, what a superintendent wants to know about all children,
and what a community wants to know about all children. A modification
of this card will soon be adopted in New York City. It is both a card
index and a card biography of the individual boy or girl. It is
expected to follow the child from class to class, each teacher telling
the story of his physical welfare and his progress. When the boy goes
to a new school or new grade, his new teacher can see at a glance not
only what subjects have given him trouble, but what diseases or
physical defects have kept him out of school or otherwise retarded his
progress. With this card it is easy to take a hundred children of the
same age and the same grade, to put down in one column those who have
eye defects, and in another those who have no eye defects, for every
school, every district, and for the schools as a whole. Schools that
use these record cards are enabled, by thus classifying the total, to
learn where the defects of children are, how serious the problem is,
how many days children lose from school because of preventable defects,
and in what section of the city the defects are most prevalent.

The mere reporting of facts will stimulate teachers, principals, and
parents to give attention. For example, assume a table:

           FIELD OF INSPECTION

 Total number of public schools              7
 Public schools under inspection             3
 Public schools not under inspection         4

The reader wonders why four schools are neglected and which particular
schools they are. Let the next table read:

           EXAMINATION

 Total registration in all schools        1500
 Number of children examined               500
 Number of children not examined          1000

Parents begin to wonder whether or not their children were examined,
and why the taxes spent for school examination of all children go to
one third of the children. The next table arrests attention:

           TREATMENT

 Number needing treatment                  200
 Number known to have been treated          50
 Number not known to have been treated     150

We ask, at once, if examination is worth while, and if treatment really
corrects the defects, saves the pupil's time and teacher's time,
discovers many defects; and we want to find out whether the one hundred
and fifty reported not treated have since been attended to.

    [Illustration: PUPIL'S RECORD]

    [Illustration: DEPARTMENT OF HEALTH CITY OF NEW YORK REPORT]

Again, if three out of five of those examined need treatment, people
will wonder whether among the thousand not examined there is the same
proportion--three out of five, or six hundred--who have some trouble
that needs attention. Having begun to wonder, they will ask questions,
and will expect the board of health or the school physicians to see
that the questions are answered. As has been proved in New York,
taxpayers and the press will go farther and will demand that the annual
budget provide for making general next year the benefits found to
result last year from a test of health policies.

The story of the prevalence of contagious diseases in school children
could be told by a table such as is now in use by New York's department
of health:


TABLE XII

PREVALENCE OF CONTAGIOUS DISEASES IN SCHOOL CHILDREN

(Case rate schools)

KEY:
A: In School
B: Among Absentee
=========+========================================+======================
         |                                        |  COMMUNICABLE
         |    GENERAL COMMUNICABLE DISEASES[1]    | DISEASES OF EYE
 SCHOOL  |                                        |   AND SKIN[2]
         +----------------------------------------+----------+-----------
         |           NUMBER           |           |          |
         +----------+-----------+-----+ Number per|          |Number
         |Found by  | Reported  |     | 1000      |Number    |per 1000
         |Inspectors|     by    |     | Registered|found by  |Registered
         +-----+----+ Attending +     + in Schools+Inspectors|in Schools
         | A   |  B | Physician |Total| Inspected |and Nurses|Inspected
---------+-----+----+-----------+-----+-----------+----------+-----------
A        |     |    |           |     |           |          |
B        |     |    |           |     |           |          |
C        |     |    |           |     |           |          |
=========+=====+====+===========+=====+===========+==========+===========
  [1] Smallpox, diphtheria, scarlet fever, measles, chicken pox, mumps,
      and whooping cough; excluded when found.
  [2] Trachoma and other contagious eye diseases, ringworm, impetigo,
      scabies, favus, and pediculosis; excluded only for persistent
      nontreatment.

Another table shows the following facts for each disease:


TABLE XIII

CONTAGIOUS DISEASES FOUND IN SCHOOLS BY INSPECTORS AND NURSES

(Number and disposition of cases)


KEY:
A: Diphtheria          J: Other
B: Scarlet fever       K: Ringworm
C: Measles             L: Impetigo
D: Smallpox            M: Scabies
E: Chicken pox         N: Favus
F: Whooping cough      O: Pediculosis
G: Mumps               P: Miscellaneous
H: Total               Q: Total
I: Trachoma

===================+=======================+===========================
                   |     GENERAL           | COMMUNICABLE DISEASES
                   |  COMMUNICABLE         |   OF EYE AND SKIN
                   |    DISEASES           |-----+---------------------
                   |                       | EYE |        SKIN
                   +--+--+--+--+--+--+--+--+--+--+--+--+--+--+--+--+---
                   | A| B| C| D| E| F| G| H| I| J| K| L| M| N| O| P| Q
-------------------+--+--+--+--+--+--+--+--+--+--+--+--+--+--+--+--+---
Cases found in     |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
 school            |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
Cases excluded     |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
 from school       |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
Cases treated in   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
 school            |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
Cases instructed   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
 in school or      |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
 evidence of       |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
 treatment         |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
 furnished         |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
Number of          |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
 treatments        |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
Number of          |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
 instructions      |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
===================+==+==+==+==+==+==+==+==+==+==+==+==+==+==+==+==+===

The story of noncontagious physical defects found and treated is set
forth in the following table:


TABLE XIV

MEDICAL EXAMINATION OF SCHOOL CHILDREN: NONCONTAGIOUS PHYSICAL DEFECTS
FOUND AND TREATED, 1906

==============+=============================+=============================+
              |           SCHOOL A          |           SCHOOL B          |
              |--------------+--------------+--------------+--------------|
              |   Found      |   Reported   |   Found      |   Reported   |
              |              |   Treated    |              |   Treated    |
              |-----+--------+-----+--------+-----+--------+-----+--------|
  DEFECTS     | No. |  % of  | No. |  % of  | No. |  % of  | No. |  % of  |
              |     | Total  |     |Defects |     | Total  |     |Defects |
              |     |Defects |     | Found  |     |Defects |     | Found  |
              |     | Found  |     |        |     | Found  |     |        |
--------------+-----+--------+-----+--------+-----+--------+-----+--------+
Adenoids      |     |        |     |        |     |        |     |        |
              |     |        |     |        |     |        |     |        |
Nasal         |     |        |     |        |     |        |     |        |
 breathing    |     |        |     |        |     |        |     |        |
Hyper-trophied|     |        |     |        |     |        |     |        |
 tonsils      |     |        |     |        |     |        |     |        |
Defective     |     |        |     |        |     |        |     |        |
 palate       |     |        |     |        |     |        |     |        |
Defective     |     |        |     |        |     |        |     |        |
 hearing      |     |        |     |        |     |        |     |        |
Defective     |     |        |     |        |     |        |     |        |
 vision       |     |        |     |        |     |        |     |        |
Defective     |     |        |     |        |     |        |     |        |
 teeth        |     |        |     |        |     |        |     |        |
Bad nutrition |     |        |     |        |     |        |     |        |
Diseased      |     |        |     |        |     |        |     |        |
 anterior     |     |        |     |        |     |        |     |        |
 cervical     |     |        |     |        |     |        |     |        |
 glands       |     |        |     |        |     |        |     |        |
Diseased      |     |        |     |        |     |        |     |        |
 posterior    |     |        |     |        |     |        |     |        |
 cervical     |     |        |     |        |     |        |     |        |
 glands       |     |        |     |        |     |        |     |        |
Heart disease |     |        |     |        |     |        |     |        |
Chorea        |     |        |     |        |     |        |     |        |
Pulmonary     |     |        |     |        |     |        |     |        |
 disease      |     |        |     |        |     |        |     |        |
Skin disease  |     |        |     |        |     |        |     |        |
Deformity     |     |        |     |        |     |        |     |        |
 of spine     |     |        |     |        |     |        |     |        |
Deformity     |     |        |     |        |     |        |     |        |
 of chest     |     |        |     |        |     |        |     |        |
Deformity of  |     |        |     |        |     |        |     |        |
 extremities  |     |        |     |        |     |        |     |        |
Defective     |     |        |     |        |     |        |     |        |
 mentality    |     |        |     |        |     |        |     |        |
  Total       |     |        |     |        |     |        |     |        |
==============+=====+========+=====+========+=====+========+=====+========+

==============+=============================+
              |           SCHOOL C          |
              |--------------+--------------|
              |   Found      |   Reported   |
              |              |   Treated    |
              |-----+--------+-----+--------|
  DEFECTS     | No. |  % of  | No. |  % of  |
              |     | Total  |     |Defects |
              |     |Defects |     | Found  |
              |     | Found  |     |        |
--------------+-----+--------+-----+--------+
Adenoids      |     |        |     |        |
              |     |        |     |        |
Nasal         |     |        |     |        |
 breathing    |     |        |     |        |
Hyper-trophied|     |        |     |        |
 tonsils      |     |        |     |        |
Defective     |     |        |     |        |
 palate       |     |        |     |        |
Defective     |     |        |     |        |
 hearing      |     |        |     |        |
Defective     |     |        |     |        |
 vision       |     |        |     |        |
Defective     |     |        |     |        |
 teeth        |     |        |     |        |
Bad nutrition |     |        |     |        |
Diseased      |     |        |     |        |
 anterior     |     |        |     |        |
 cervical     |     |        |     |        |
 glands       |     |        |     |        |
Diseased      |     |        |     |        |
 posterior    |     |        |     |        |
 cervical     |     |        |     |        |
 glands       |     |        |     |        |
Heart disease |     |        |     |        |
Chorea        |     |        |     |        |
Pulmonary     |     |        |     |        |
 disease      |     |        |     |        |
Skin disease  |     |        |     |        |
Deformity     |     |        |     |        |
 of spine     |     |        |     |        |
Deformity     |     |        |     |        |
 of chest     |     |        |     |        |
Deformity of  |     |        |     |        |
 extremities  |     |        |     |        |
Defective     |     |        |     |        |
 mentality    |     |        |     |        |
  Total       |     |        |     |        |
==============+=====+========+=====+========+

The effect of a report telling what schools have enough seats, proper
ventilation, adequate medical inspection, safe drinking water, ample
play space, and what schools are without these necessities is to cause
the reader to rank the particular school that he happens to know; i.e.
he says, "School A is better equipped than School B; or, School C is
neglected." County and state superintendents in many states have
acquired the habit of ranking schools according to the number of
children who pass in arithmetic, algebra, etc. It would greatly further
the cause of public health and, at the same time, advance the interest
of education if state superintendents would rank individual schools,
and if county superintendents would rank individual schools, _according
to the number of children found to have physical defects, the number
afflicted with contagious diseases, and the number properly treated_.

It is difficult to compare one school with another, because it is
necessary to make subtractions and divisions and to reduce to
percentages. It would not be so serious for a school of a thousand
pupils as for a school of two hundred, to report 100 for adenoids. To
make it possible to compare school with school without judging either
unfairly, the state superintendent of schools for Connecticut has made
tables in which cities are ranked according to the number of pupils,
average attendance, per capita cost, etc. As to each of these headings,
cities are grouped in a manner corresponding to the line up of a
battalion, "according to height." A general table is then shown, which
gives the ranking of each city with respect to each important item.
Applied to schools, this would work out as follows:


TABLE XV

TABLE OF RANKING-SCHOOLS ARRANGED ALPHABETICALLY

=============================================================
       |
SCHOOL |               RANK IN
-------+----------+----------+----------+----------+---------
       | Register | Defects  | Children | Children | Children
       |          |  Found   | Needing  | Treated  |   not
       |          |          | Treatment|          | Treated
-------+----------+----------+----------+----------+---------
   A   |    10    |    11    |    11    |    12    |    6
   B   |    20    |    22    |    22    |    24    |   12
   C   |    30    |    33    |    30    |    36    |   18
=======+==========+==========+==========+==========+=========

Such a table fails to convey its significance unless the reader is
reminded that rank 18 in children not treated is as good a record for a
school that ranks 30 in register as is rank 6 for a school that ranks
10 in register.

The Connecticut report makes a serious mistake in failing to arrange
schools according to population. If this were done, schools of a size
would be side by side and comparison would be fair. When, as in the
above table, schools are arranged alphabetically, a school with four
thousand pupils may follow or precede a school with four hundred
pupils, and comparison will be unfair and futile.

Where, on the other hand, schools are arranged in order of register, a
table will show whether schools confronted with practically the same
problems, the same number of defects, the same number of children
needing treatment, are equally successful, or perhaps equally inactive,
in correcting these defects. The following table brings out clearly
marked unequal achievement in the face of relatively equal need.


TABLE XVI

TABLE OF RANKING-SCHOOLS ARRANGED ACCORDING TO REGISTER, NOT
ALPHABETICALLY

=============================================================
       |
       |                       RANK IN
SCHOOL +----------+----------+----------+----------+---------
       | Register | Defects  | Children | Children | Children
       |          |  Found   | Needing  | Treated  |   not
       |          |          | Treatment|          | Treated
-------+----------+----------+----------+----------+---------
   A   |     9    |     9    |     9    |     9    |    9
   X   |    10    |    10    |    10    |    14    |    6
   H   |    11    |    11    |    11    |    17    |    3
=======+==========+==========+==========+==========+=========

If the number of schools in a state is so large that it is unlikely
that people will read the table of ranking because of the difficulty of
finding their own school, an alphabetical table might be given that
would show where to look in the general ranking table for the school or
schools in which the reader is interested.

Experience will demonstrate to public school superintendents the
strategic advantage of putting together all the things they need and of
telling the community over and over again just what needs there are,
what penalties are paid for want of them, and what benefits would
result from obtaining them. If health needs of school children were
placed side by side with mental results, the relation would come out so
clearly that parents, school boards, and taxpayers would realize how
inextricably they are bound together and would see that health needs
are satisfied. To this end superintendents should require teachers to
keep daily reports of school conditions.


TABLE XVII

WEEKLY CLASS-ROOM SCHEDULE

===========+================+========================+==============
          |    Temperature  |          Cleaning      |  Exercise
          +-----+-----+-----+-----+-----+------------+------+-------
          |     |     |     |     |     |            |  In  |Out of
          |10.30|12.00| 2.00| Dry | Wet |Disinfecting| Room | Room
----------+-----+-----+-----+-----+-----+------------+------+-------
Monday    |     |     |     |     |     |            |      |
Tuesday   |     |     |     |     |     |            |      |
Wednesday |     |     |     |     |     |            |      |
Thursday  |     |     |     |     |     |            |      |
Friday    |     |     |     |     |     |            |      |
==========+=====+=====+=====+=====+=====+============+======+=======

The teacher's daily report of the temperature of a schoolroom, taken
three times a day, tells the parent exactly what is the efficiency of
the ventilating and heating apparatus in the particular school in which
he is interested; whereas the report of the department of buildings
gives only the number of schools which have an approved system of
ventilation and steam heat. School authorities may or may not know that
this system of ventilation is out of order, that the thermometer in the
indoor playground of School A stood at forty degrees for many days in
winter. But they must know it when the principal of School A sends in a
daily record; the school board, the parents, or the press will then
see that the condition is remedied. If the condition is due to lack of
funds, funds will never be forthcoming so long as the condition is
concealed.

Similar results will follow publicity of overcrowding, too little play
space, dry cleaning of school buildings, etc. The intent of such
reporting is not to "keep tabs" on the school-teacher, the school
child, the janitor, the principal, superintendent, or board, but to
insure favorable conditions and to correct bad conditions. This is done
best by giving everybody the facts. The objective test of the
efficiency of a method throws emphasis on the method, not on the motive
of those operating it. The blackboard method of publishing facts
concentrates attention upon the importance of those facts and enlists
aid in the attainment of the end sought.



CHAPTER XXXI

THE PRESS


The president of Princeton University declares that for several decades
we have given education that does not instruct and instruction that
does not educate. Others tell us that because we read daily papers and
magazines our minds become superficial, that our power to concentrate
or memorize is weakened,--that we read so much of everything that we
learn little of anything. As the habit of reading magazines and
newspapers is constantly increasing, I think we must assume that it has
come to stay. If we cannot check it, we can at least turn it to good
advantage, systematize it, and discipline ourselves.

Among the subjects continually described in newspapers and magazines,
and even on billboards and in street-car advertising, is the subject of
hygiene. No greater service can be rendered the community than for
those who are conducting discussions of health to teach people how to
read correctly this mass of information regarding health, to separate
misinformation from information, and to apply the lessons learned to
personal and public hygiene. There is no better way of doing this than
to teach a class or a child to clip out of magazines and newspapers all
important references to health, and then to classify these under the
subject-matter treated. A teacher, parent, or club leader might
practice by using the classification of subjects outlined in the
Contents of this book. It is surprising how rapidly one builds up a
valuable collection serviceable for talks or papers, but more
particularly for giving one a vital and intelligent interest in
practical health topics.

Interested in comparing the emphasis placed on health topics in a
three-cent paper having a small circulation with a penny paper having
twenty times the circulation, I made during one week thirty-eight
clippings from the three-cent paper and ninety-five from the penny
paper. The high-priced paper had no editorial comment within the field
of health, whereas the penny paper had three columns, in which were
discussed among other things: _The Economics of Bad Teeth_; _Need for
Individual Efficiency_; _"Good Fellows" Lower Standard of Living by
Neglecting their Families_. The penny paper advertised fifty-two foods,
garments, whiskies, patent medicines, or beautifiers urged upon health
grounds. In the three-cent paper twenty-six out of thirty-eight items
advertised food, clothing, patent medicine, or whisky. One issue of a
monthly magazine devoted to woman's interests contained twenty-eight
articles and editorials and fifty-five advertisements that concern
health,--thirty-seven per cent of total reading matter and thirty-seven
per cent of total advertisement.

Excellent discipline is afforded by this clipping work. It is
astonishing how few men and women, even from our better colleges, know
how to organize notes, clippings, or other data, so that they can be
used a few weeks later. There is a satisfaction in seeing one's material
grow, as is remembered by all of us, in making picture scrapbooks or
collections of picture postal cards and stamps. "Collections" have
generally failed for want of classification,--putting things of a kind
together. Chronological arrangement is uninteresting because
unprofitable. One never knows where to find a picture, or a stamp, or a
health clipping. Clippings, like libraries, will be little used if not
properly catalogued so that use is easy. If a health-clipping collection
is attempted, there are four essentials: (1) arrangement by topic; (2)
inclusion of advertisements; (3) inclusion of items from magazines; (4)
cross references.

For classification, envelopes can be used or manila cards 10×12 inches.
The teacher, parent, or advanced student will probably think the
envelope most useful because most easily carried and filed,--most
likely to be used. But clippings should be bound together in orderly
appearance, or else it will be disagreeable working with them.
Children, however, will like the pasting on sheets, which show clearly
the growth of each topic. Envelopes or cards should not have clippings
that deal with only one health topic. Unless a test is made to see how
many health references there are in a given period, it should be made a
rule not to clip any item that does not contain something new,--some
addition to the knowledge already collected.

Advertisements will prove interesting and educative. When newspapers
and magazines announce some new truth, the commercial motive of
manufacturer or dealer sees profit in telling over and over again how
certain goods will meet the new need. Children will soon notice that
the worst advertisements appear in the papers that talk most of
"popular rights," "justice," and "morality." They will be shocked to
see that the popular papers accept money to tell falsehoods about fake
cures. They will be pleased that the best monthly magazines contain no
such advertisements. They will challenge paper or magazine, and thus
will be enlisted while young in the fight against health advertisements
that injure health.

To clip articles from magazines will seem almost irreverent at first.
But the reverence for magazines and books is less valuable to education
than the knowledge concealed in them. Except where families preserve
all magazines, clippings will add greatly to their serviceability.

The art of cross-referencing is invaluable to the organized mind. The
purpose of classifying one's information is not to show how much there
is, but to answer questions quickly and to guide constructive thinking.
A clipping that deals with _alcoholism_, _patent medicine_, and
_tuberculosis_ must be posted in three places, or cross-referenced;
otherwise it will be used to answer but one question when it might
answer three. If magazines may not be cut, it will be easy to record
the fact of a useful article by writing the title, page, and date on
the appropriate index card, or inclosing a slip so marked in the proper
envelope.

While it is true that the most important bibliography one can have in
his private library is a classification of the material of which he
himself has become a part while reading it, there are a number of
health journals that one can profitably subscribe for. In fact, it is
often true that the significant discoveries in scientific fields, or
the latest public improvements, such as parks, bridges, model
tenements, will not be appreciated until one has read in health
journals how these improvements affect the sickness rate and the
enjoyment rate of those least able to control their living conditions.
The physician and nurse in their educational work for hospitals are
distributors of health propaganda.

Wherever there is a local journal devoted to health, parents, teachers,
educators, and club leaders would do well to subscribe and to hold this
journal up to a high standard by quoting, thanking, criticising it. In
New Jersey, for example, is a monthly called the _New Jersey Review of
Charities and Corrections_ that deals with every manner of subject
having to do with public health as well as with private and public
morality and education.

A similar journal, intended for national instruction, is _The Survey_,
whose topical index for last year enumerates two hundred and thirty-two
articles dealing with subjects directly connected with public hygiene,
e.g.:

  Schools, 6; school inspection, 3; eyes,--school children, 1; sex
  instruction in the schools, 2; psychiatric clinic, special
  children, 2; industrial education, 5; child labor, 18;
  playgrounds, 26; alley, crap, playing in streets, 3; labor
  conditions, 18; industrial accidents, 10; wage-earner's
  insurance, 4; factory inspection, 1; consumer's league, 3; women's
  work, 6; tuberculosis, 23; hospitals, dispensaries (social), 5;
  tenement reform, 10; living conditions, 2; baths, 1; public
  comfort stations, 2; lodging houses, 1; clean streets, 6; clean
  milk, 6; smoke, 1; noises, 1; parks, 1; patent medicines, 2;
  sanitary code, 1; mortality statistics, 2; social settlements and
  public health, 1; midwives, 1; children's bureau, 1; juvenile and
  adult delinquent, 25; dependent, defective, and insane, 7; blind,
  5; cripples, 1; homes for aged, 1; inebriates, 3; Traveler's Aid
  Committee, 1; infant mortality, 2; social diseases, 2.

       *       *       *       *       *

_The National Hospital Record_, the _Dietetic and Hygienic Gazette_,
the _Journal of Nursing_, are three other magazines primarily intended
for nurses and physicians, but full of suggestive material for
unprofessional readers. National magazines concerned with health, but
seeking popular circulation, are _Good Health_ and _Physical Culture_.
In England there is a special magazine called _Children's Diseases_,
which could be of great help to a school library for special reference.
The same can be said of the _Psychological Clinic_, _Pediatrics_, and
other technical journals published in this country. For many persons,
to make the best use of any one copy of these magazines, clipping is of
course impossible, but noting on a card or envelope is practicable.

Of late many of the national popular magazines have several columns
devoted to health. We have not appreciated the educational
possibilities of these columns. In most large cities there are monthly
book reviews which may be profitably consulted in learning the new
thought in the health field. If teachers would either write their
experience or ask questions, if children knew that in a certain
magazine or newspaper questions as to ventilation, bathing, exercise,
would be answered, they would take a keen interest in the progress of
discussions. The large daily papers make a great feature of their
health hints. It is not their fault if questioners care more about
cosmetics and hair bleaches than about the fresh-air cure of headaches.
They will coöperate with teachers and parents in securing more general
discussion of other problems than beauty doctoring.

Finally, persons wanting not only to have intelligence as to matters
promoting health, but actually to exert a helpful influence in their
community, ought to want the published reports of the mayor, health
department, the public schools, and other institutions, noting
carefully all that is said about conditions relating to health and
about efforts made to correct all unfavorable conditions. The best
literature of our day, with regard to social needs, appears in the
reports of our public and private institutions and societies. Of
increasing value are the publications of the national government
printing office. Because it is no one's business to find out what
valuable material is contained in such reports, and because no
educational museum is comparing report with report, those who live
nearest to our health problems and who see most clearly the health
remedies, are not stimulated to give to the public their special
knowledge in an interesting, convincing way.

Teaching children how to find health lessons in public documents will
advance the cause of public ethics as well as of public health. At the
New York State Conference of Charities, of 1907, one official
complained that the physicians made no educational use of their
valuable experience for public education. He stated that a study of
medical journals and health articles in popular magazines revealed the
fact that the number of papers prepared by physicians in state
hospitals averaged one to a doctor for every five or six years of
service. This state of affairs is even more exaggerated in strictly
educational institutions. Columbia University has recently instituted a
series of lectures to be given by its professors to its professors, so
that they may have a general knowledge of the work being done in other
fields besides their own at their own university. This is equally
important for teachers and heads of departments in elementary schools.
It is now admitted by most educators that elementary schools and young
children present more pedagogical difficulties and pressing biological
problems than higher schools. If teachers and parents would realize
that their method of solving the health problems that arise daily in
the schoolroom and in the home would interest other mothers and
teachers, their spirit of coöperation would soon be reflected in school
journals, popular magazines, and daily newspapers.



PART V. ALLIANCE OF HYGIENE, PATRIOTISM, AND RELIGION



CHAPTER XXXII

DO-NOTHING AILMENTS


"Men have died, from time to time, and worms have eaten them, but not
for love"--_nor for work_. Work of itself never killed anybody nor made
anybody sick. Work has caused worry, mental strain, and physical
breakdown, only when men while working have been deprived of air, sun,
light, exercise, sleep, proper food at the proper time, opportunity to
live and work hygienically. Fortunately for human progress, doing
nothing brings ailments of its own and has none of the compensations of
work. As the stomach deprived of substantial food craves unnatural
food,--sweets, stimulants,--so the mind deprived of substantial,
regular diet of wholesome work turns to unwholesome, petty, fantastic,
suspicious, unhappy thoughts. This state of mind, combined with the
lack of bodily exercise that generally accompanies it, reacts
unfavorably on physical health. An editor has aptly termed the
do-nothing condition as a self-inflicted confinement:

  A great deal of the misery and wretchedness among young men that
  inherit great fortunes is caused by the fact that they are
  practically in jail. They have nothing to do but eat, drink, and
  enjoy themselves, and they cannot understand why their lives are
  dull.

  We have had the owner of a great railroad system pathetically
  telling the public that he is unhappy. That is undoubtedly true,
  because with all his race horses, and his yachts, and all the
  things that he imagines to be pleasures, he is not really doing
  anything.

  If he were running one little railroad station up the road,
  handling the freight, fussing about dispatches, living above the
  railroad station in two rooms, and buying shoes in a neighboring
  village for fifteen children he would be busy and happy.

  But he cannot be happy because he is in prison,--in a prison of
  money, a prison that is honorable because it gives him everything
  that he wants, and he wants nothing.

A New York newspaper that circulates among the working classes where
young men and women are inclined to associate health and happiness with
doing nothing recently gave two columns to "Dandy Jim," the richest dog
in the world. Dandy Jim's mistress left him a ten-thousand-dollar
legacy. During his lifetime he wore diamonds. Every day he ate candy
that cost eighty cents a pound. The coachman took him driving in the
park sunny afternoons. He had no cares and nothing to work for. His
food came without effort. He had fatty degeneration of the vital
organs. He was pampered, coddled, and killed thereby. Thousands of men
and women drag out lives of unhappiness for themselves and others
because, like Dandy Jim, they have nothing to work for, are pampered,
coddled victims of fatty degeneration. When President Butler of
Columbia University finds it necessary to censure "the folly and
indifference of the fathers, vanity and thoughtless pride of the
mothers" who encourage do-nothing ailments; and when the editor of the
_Psychological Clinic_ protests that the fashionable private schools
and the private tutor share with rich fathers and mothers
responsibility for life failures,--it is time that educators teach
children themselves the physical and moral ailments and disillusions
that come from doing nothing.

Ten years ago a stenographer inherited two hundred and fifty thousand
dollars. Her dream of nothing to do was realized. She gave up her
strenuous business life. Possessions formerly coveted soon clogged her
powers of enjoyment. She imagined herself suffering from various
diseases, shut herself up in her house, and refused to see any one. She
grew morbid and was sure that every person who approached her had some
sneaking, personal, hostile motive. Though always busy, she
accomplished little. Desultory work, procrastination, and
self-indulgence destroyed her power of concentration. She could not
think long enough on one subject to think it out straight, therefore
she was constantly deceived in her friends and interests. She first
trusted everybody, then mistrusted everybody. Infatuation with every
new acquaintance was quickly followed by suspicion. For years she was a
very sick woman, a victim of do-nothing ailments.

Doing nothing has of late been seriously recommended to American
business men. They are advised to retire from active work as soon as
their savings produce reasonable income. It is true, this suggestion
has been made as an antidote to greed rather than for the happiness of
the business man. What retiring from business is apt to mean, is
indicated by a gentleman who at the age of sixty decided to sell his
seat on the New York Stock Exchange and to enjoy life. He became
restless and very miserable. He threw himself violently into one thing
after another; in less than a year he became an ill, broken old man,
after trying vainly to buy back his business.

Both mind and body were made to work. The function of the brain is to
think to a purpose, just as the function of the heart is to pump blood.
The habit of doing nothing is very easily formed. The "out-of-work"
soon become "the work-shy." Having too little to do is worse for the
body and mind than having too little to eat. Social reformers emphasize
the bad effect on society of vagrancy. Evils of indiscriminate relief
to the poor are vividly described year after year. The philanthropist
is condemned, who, by his gifts, encourages an employee's family to
spend what they do not earn, and to shun work. Yet the idleness of the
tramp, street loafer, and professional mendicant is a negligible evil
compared with the hindrance to human progress caused by the idleness of
the well-to-do, the rich, the educated, the refined, the "best" people.
It is as much a wrong to bring up children in an atmosphere of
do-nothingism, as to refuse to have their teeth attended to or to have
glasses fitted to weak eyes.

From the point of view of community welfare it is far more serious for
the rich child to be brought up in idleness or without a purpose than
for the poor child to become a public charge. Not only has society a
right to expect more from rich children in return for the greater
benefits they enjoy, but so long as rich children control the
expenditure of money, they control also the health and happiness of
other human beings. Unless taught the value and joy of wholesome work
they cannot themselves think straight, nor are they likely to want to
understand how they can use their wealth for the benefit of mankind. To
quote President Butler again:

  The rich boy who receives a good education and is trained to be a
  self-respecting member of the body politic might in time share on
  equal terms the chance of the poor boy to become a man of genuine
  influence and importance on his own account, just as now by the
  neglect, or worse, of his parents the very rich boy is apt to be
  relegated to the limbo of curiosities, and too often of decadence.

Nervous invalids make life miserable for themselves and for others,
when often their sole malady is lack of the right kind of work to do.

Suiting work to interest and interest to work is an economy that should
not be overlooked. The energy spent in forcing oneself to do a
distasteful task can be turned to productive channels when work is made
pleasurable. The fact is frequently deplored that whereas formerly a
man became a full-fledged craftsman, able to perform any branch of his
trade, he is now confined to doing special acts because neither his
interest nor his mind is called into play. Work seems to react
unfavorably on his health. He has not the pride of the artisan in the
finished product, for he seldom sees it. He does a task. His employer
is a taskmaster. He decides that work is not good for him as easily as
when a school-boy he grasped the meaning of escape from his lessons. By
failing to fit studies to a student's interest, or by failing to insure
a student's interest in his studies, schools and colleges miseducate
young men and young women to look upon all work as tasks, as
discipline, necessary but irksome, and to be avoided if possible. Just
as there is a way of turning all the energy of the play instinct into
school work, so there is a way of interesting the factory and office
worker in his job. However mechanical work may be, there is always the
interest in becoming the most efficient worker in a room or a trade.
Routine--accurate and detailed work--does not mean the stultification
of the imagination. It takes more imagination to see the interesting
things in statistical or record work than to write a novel. Therefore
employers should make it a point to help their employees to realize the
significance of the perfection of each detail and the importance of
each man's part. The other day a father said to me, "I want my boys to
be as ashamed to do work in which they are not interested as to accept
graft." When interest in work and efficiency in work are regarded as of
more importance than the immediate returns for work, when it is as
natural for boys and girls to demand enjoyment and complete living in
work as it is to thrill at the sight of the Stars and Stripes,
do-nothing ailments will be less frequent and less costly.

Work--that one enjoys--is an invaluable unpatented medicine. It can
make the sick well and keep the well from getting sick. It is the chief
reliance of mental hygiene. "I should have the grippe if I had time,"
said a business woman to me the other day; but she did not have time,
hence she did not have the grippe.

    If you're sick with something chronic,
    And you think you need a tonic,
            Do something.
    There is life and health in doing,
    There is pleasure in pursuing;
    Doing, then, is health accruing--
            Do something.

    And if you're seeking pleasure,
    Or enjoyment in full measure,
            Do something.
    Idleness, there's nothing in it;
    'Twill not pay you for a minute--
            Do something.



CHAPTER XXXIII

HEREDITY BUGABOOS AND HEREDITY TRUTHS


One of the red-letter days of my life was that on which I learned that
I could not have inherited tuberculosis from two uncles who died of
consumption. For years I had known that I was a marked victim. Silently
I carried my tragedy, suspecting each cold and headache to be the
telltale messenger that should let others into my secret. He was a
veritable emancipator who informed me that heredity did not work from
uncle to nephew; that not more than a predisposition to consumption
could pass even from parent to child; that a predisposition to
consumption would come to nothing without the germ of the disease and
the environmental conditions which favor its development; and that if
those so predisposed avoid gross infection, lead a healthy life, and
breathe fresh air they are as safe as though no tuberculous lungs had
ever existed in the world. Some years later I learned to understand the
other side of the case; I realized how I had been in real danger of
contracting consumption in the darkened, ill-ventilated sick room of
the uncle who taught me my letters and gave me my ideal of God's
purpose in sending uncles to small boys.

There are two distinct things which make each individual life: the
living stuff, the physical basis of life, handed down from parent to
child; and the environmental conditions which surround it and play upon
it and rouse its reactions and its latent possibilities. It is like the
seed and the cultivation. You cannot grow corn from wheat, but you can
grow the best wheat, or you may let your crop fail through careless
handling.

It is well that we should think seriously about the part played by
heredity, for the living stuff of the future depends upon our sense of
responsibility in this regard. The intelligent citizen would do well to
read such a book as J. Arthur Thompson's _Heredity_ (1908), in which
the latest conclusions of science are clearly and soundly set forth.

The main problem of to-day, however, is to use well the talents that we
have. Here two things should always be kept in mind: First, the
inherited elements which make up our minds and bodies are complex and
diverse. Health and strength are inherited as well as disease and
weakness; they have indeed a better chance of survival. In the most
unpromising ancestry there are latent potentialities which may be made
fruitful by effort. No limit whatever can be set to the possibilities
of improvement in any individual.

In the second place, if science has shown anything more clearly than
the importance of heredity, it is the importance of environment. This
influence upon human lives is within our control, and it is a grave
error to neglect what lies clearly within our power and to bemoan what
does not. Science has wrought no benefits greater than those which
result from drawing a clear line between heredity bugaboos and heredity
truths. An overemphasis on the hereditary factor in development at the
expense of the environmental factor, I call a heredity bugaboo; and it
is a tendency which cannot be too strongly condemned. To fight against
the sins and penalties of one's grandfather is a forlorn task that
quickly discourages. To overcome diseases of environment, of shop and
street, of house and school, seems, on the contrary, an easy task.
Heredity bugaboos dishearten, enervate, encourage excesses and neglect.
Heredity truths stimulate remedial and preventive measures.

We may well watch with interest the progress of eugenics, that new
science which biologists and sociologists hope will some day remake the
very living stuff of the human race. But meanwhile let us take up with
hope and courage and enthusiasm the great hemisphere of human fate
which lies within our grasp. Good food and fresh air, well-built
cities, enlightened schools and well-ordered industries, stable and
free and expert government,--given these things, we can transform the
world with the means now at our disposal. We can reap, if we will,
splendid possibilities now going to waste, and by intelligent
biological and sociological engineering we can hand on to the next
generation an environmental inheritance which will make their task far
easier than ours.

"Physical deterioration" is a bugaboo that is discovered by some in
heredity and by others in modern industrial evils. The British director
general called attention a few years ago to the fact that from forty to
sixty per cent of the men who were being examined for military service
were physically unfit. A Commission on Physical Deterioration was
appointed to investigate the cause, and to learn whether the low
physical standard of the would-be Tommy Atkins was due to inherited
defects. The results of this study were published in a large volume
called _Report on Physical Deterioration, 1904_, in which is set forth
a positive programme for obtaining periodically facts as to the
physique of the nation. In the course of the commission's exhaustive
investigation there was found no evidence that any progressive
deterioration was going on in any function of the body except the
teeth. "There are happily no grounds for associating dental degeneracy
with progressive physical deterioration." The increase in optical
defects is attributed not to the deterioration of the eye, but to
greater knowledge, more treatment, and better understanding of the
connection between optical defects and headache.

    [Illustration: Testing Environment--House Score]

 +--------------------------------------------------------------------+
 |           DEFINITIONS OF TERMS USED IN HOUSE SCORE CARD            |
 |                                                                    |
 | LIGHT--Light enough to read easily in every part.                  |
 |                                                                    |
 | GLOOMY--Not light enough to read easily in every part, but enough  |
 | readily to see one's way about when doors are closed.              |
 |                                                                    |
 | DARK--Too dark to see one's way about easily when doors are        |
 | closed.                                                            |
 |                                                                    |
 | WELL VENTILATED--With window on street or fair-sized yard (not     |
 | less than 12 ft. deep for a five-story tenement house not on a     |
 | corner), or on a "large," "well-ventilated" court open to the sky  |
 | at the top: "large" being for a court entirely open on one side to |
 | the street or yard in a five-story tenement, not less than 6 ft.   |
 | wide from the wall of the building to the lot line; for a court    |
 | inclosed on three sides and the other on the lot line in a         |
 | five-story tenement, not less than 12×24 ft., "well ventilated"    |
 | meaning either entirely open on one side to the street or yard, or |
 | else having a tunnel at the bottom connecting with the street or   |
 | yard.                                                              |
 |                                                                    |
 | FAIRLY VENTILATED--With window opening on a shallow yard or on a   |
 | narrow court, open to the sky at the top, or else with 5×3 inside  |
 | window (15 ft. square) opening on a well-ventilated room in same   |
 | apartment.                                                         |
 |                                                                    |
 | BADLY VENTILATED--With no window on the street, or on a yard, or   |
 | on a court open to the sky, and with no window, or a very small    |
 | window, opening on an adjoining room.                              |
 |                                                                    |
 | IN GOOD REPAIR--No torn wall paper, broken plaster, broken         |
 | woodwork or flooring, nor badly shrunk or warped floor boards or   |
 | wainscoting, leaving large cracks.                                 |
 |                                                                    |
 | IN FAIR REPAIR--Slightly torn or loose wall paper, slightly broken |
 | plaster, warped floor boards and wainscoting.                      |
 |                                                                    |
 | IN BAD REPAIR--Very badly torn wall paper or broken plaster over a |
 | considerable area, or badly broken woodwork or flooring.           |
 |                                                                    |
 | (Rooms not exactly coinciding with any of the three classes are to |
 | be included in the one the description of which comes nearest to   |
 | the condition.)                                                    |
 |                                                                    |
 | SINKS: GOOD--Iron, on iron supports with iron back above to        |
 | prevent splashing of water on wall surface, in light location,     |
 | used for one family. Water direct from city water mains or from a  |
 | CLEAN roof tank.                                                   |
 |                                                                    |
 | BAD--Surrounded by wood rims with or without metal flushings,      |
 | space beneath inclosed with wood risers; dark location, used by    |
 | more than one family; water from dirty roof tank.                  |
 |                                                                    |
 | FAIR--Midway between above two extremes. (Sinks not exactly        |
 | coinciding with any of the three classes are to be included in the |
 | one the description of which comes nearest to the condition.)      |
 |                                                                    |
 | WATER-CLOSET: GOOD--Indoor closet. In well lighted and ventilated  |
 | location, closet fixture entirely open underneath, abundant water  |
 | flush.                                                             |
 |                                                                    |
 | FAIR--Indoor closet, poor condition--badly lighted and ventilated  |
 | location, fixture inclosed with wood risers, or poor flush.        |
 |                                                                    |
 | POOR--Yard closet--separate water-closet in individual compartment |
 | in the yard.                                                       |
 |                                                                    |
 | BAD--School sink--sewer-connected privy, having one continuous     |
 | vault beneath the row of individual toilet compartments.           |
 +--------------------------------------------------------------------+

The commission hoped "that the facts and opinions they have collected
will have some effect in allaying the apprehensions of those who, as it
appears, on insufficient grounds, have made up their minds that
progressive deterioration is to be found among people generally." In
regard to the facts which started the fear, the report says: (1) the
evidence adduced in the director general's memorandum was inadequate to
prove that physical deterioration had affected the classes referred to;
(2) no sufficient material (statistical or other) is at present
available to warrant any definite conclusions on the question of the
physique of the people by comparison with data obtained in past times.

    [Illustration: THE BEST INHERITANCE IS A MOTHER WHO KNOWS HOW TO
    KEEP HER BABY WELL]

The topics dealt with in the report refer to only a partial list of
conditions that need to be carefully studied before we can know what
environment heredity we are preparing for those who follow us:


  I. AS TO BABIES

  Training of mothers, provident societies and maternity funds,
  feeding of infants, milk supply, milk depots, sterilization and
  refrigeration of milk, effect of mother's employment upon infant
  mortality, still births, cookery, hygiene and domestic economy,
  public nurseries, crèches.


  II. AS TO CHILDREN

  Anthropometric measurements, sickness and open spaces, medical
  examination of school children, teeth, eyes, and ears, games and
  exercises for school children, open spaces and gymnastic
  apparatus, physical exercise for growing girls and growing boys,
  clubs and cadet corps, feeding of elementary school children,
  partial exemption from school, special schools for "retarded"
  children, special magistrate for juvenile cases, juvenile smoking,
  organization of existing agencies for the welfare of lads and
  girls, education, school attendance in rural districts, defective
  children.


  III. AS TO LIVING AND WORKING CONDITIONS

  Register of sickness, medical certificates as to causes of death,
  overcrowding, building and open spaces, register of owners of
  buildings, unsanitary and overcrowded house property, rural
  housing, workshops, coal mines, etc., medical inspection of
  factories, employment of women in factories, labor colonies,
  overfatigue, food and cooking, cooking grates, adulteration, smoke
  pollution, alcohol, syphilis, insanity.


  IV. AS TO HEALTH MACHINERY

  Medical officers of health, local, district, and national boards,
  health associations.

Scientists of the next generation will continue to differ as to
heredity truths and heredity bugaboos unless records are kept now,
showing the physical condition of school children and of applicants for
work certificates and for civil service and army positions. The British
investigators declared that "anthropometric records are the only
accredited tests available, and, if collected on a sufficient scale,
they would constitute the supreme criterion of physical deterioration,
or the reverse.... The school population and the classes coming under
the administration of the Factory Acts offer ready material for the
immediate application of such tests." In addition to the physical tests
proposed in other chapters, there is great educational opportunity in
the records of private and public hospitals. Every nation, every state,
and every city should enlist all its educational and scientific forces
to ascertain in what respects social efficiency is endangered by
physical deficiencies that can be avoided only by restricting
parenthood, and the environmental deficiencies that can be avoided by
efficient health machinery.

The greatest of all heredity truths are these: (1) the deficiencies of
infants are infinitesimal compared with the deficiencies of the world
with which we surround them; (2) each of us can have a part in
begetting for posterity an environment of health and of opportunity.



CHAPTER XXXIV

INEFFECTIVE AND EFFECTIVE WAYS OF COMBATING ALCOHOLISM


Wherever the Stars and Stripes fly over school buildings it is made
compulsory to teach the evils of alcoholism. For nearly a generation
the great majority of school children of the United States have been
taught that alcohol, in however small quantities, is a poison and a
menace to personal and national health and prosperity. Yet during this
very period the per capita consumption of every kind of alcoholic
beverage has increased. Whereas 16.49 gallons of spirituous liquors
were consumed per capita of population in 1896, 22.27 gallons were used
in 1906. Obviously the results of methods hitherto in vogue for
combating alcoholism are disappointing.

Why this paradoxical relation of precept to practice? Why is this, the
most hygiene-instructed country in the world, the Elysium of the
patent-medicine and cocaine traffic? If we have only the expected
divergence of achievement from ideal, then there is nothing for us to
do but to congratulate ourselves and posterity upon the part played by
compulsory legislation in committing all states and territories to
hygiene instruction in all public schools. If, on the other hand, our
disappointment is due to ineffective method, then the next step is to
change our method.

The chief purpose of school hygiene has hitherto been not to promote
personal and community health, but to lessen the use of alcohol and
tobacco. Arguments were required against whisky, beer, cigars, and
cigarettes. As the strongest arguments would probably make the most
lasting impression upon the school child and the best profits for
author and bookseller, writers vied with one another in the rhetoric
and hyperbole of platform agitation. What effect would it have upon you
if you were exhorted frequently during the next eight years to avoid
tobacco because a mother once killed a child by washing its head in
tobacco water? What is the effect on the mind of a boy or a girl who
sees that the family doctor, the minister, the teacher, the judge, the
governor, the President, and the philanthropist use tobacco and
alcoholic beverages, when taught that "boys who use tobacco and
alcoholic beverages will find closed in their faces the doors to
strength, good health, skill in athletics, good scholarship, long life,
best companions, many business positions, highest success"? It is
probably true that "a boy once drank some whisky from a flask and died
within a few hours." But that story is about as typical of boys and of
whisky as that a boy once drank whisky from a flask and did not die for
ninety years afterwards, or that George Washington drank whisky and
became the Father of his Country.

How special pleading has dominated the teaching of school hygiene is
illustrated by a recent book which, for the most part, successfully
breaks away from the narrow point of view and the crude methods
hitherto prevailing. It presents the following facts concerning New
York City:

 Saloons                                                 10,821
 Arrests                                                133,749
 Expense of police department                       $10,199,206
 Police courts, jails, workhouses, reformatories      1,310,411
 Hospitals, asylums, and other charities              4,754,380

It is fair to the author to state that she does not declare in so many
words that the shutting up of the saloons would obviate all the arrests
and all the hospital, jail, and charity bills. Instead of _wipe out_
she says _shrivel_. No truth would have been lost by avoiding all
misrepresentation.

The author probably felt as I did when I took my total abstainer's
protest to a celebrated scientist who had exposed certain misstatements
regarding the effect of small quantities of alcohol: "Is not the
untruth of these exaggerated statements less dangerous than the untruth
of dispassionate, scientific statement? So long as the child mind takes
in only an impression, is it not better to write this impression
indelibly?" He sadly but indulgently replied, "And in what other
studies would you substitute exaggeration for truth?"

The reaction has already begun against exaggeration in hygiene
text-books, against drawing lessons from accidental or exceptional
cases of excessive use of alcohol, against classing moderate drinking
and smoking with drunkenness as sins of equal magnitude, and against
overlooking grave social and industrial evils that threaten children
far earlier and more frequently than do tobacco and alcohol. Instead of
adding an ell to the truth, text-book writers are now adding only an
inch or two at a time. No longer do we favor highly colored charts that
picture in purple, green, and black the effect of stimulants and
narcotics upon the heart and brain, the stomach, the liver, the knee,
and the eardrum, _assuming that all resultant evils are concentrated in
one organ_. Menacing habits, such as overeating and indulgence in
self-pity, are beginning to receive attention. It is also true that
physiology and anatomy are progressively made more interesting.
Publishers are looking for the utmost originality compatible with the
purpose of the present laws and with the only effective public
sentiment that has hitherto been interested in the interpretation of
those laws.

A score of improvements in the method of carrying out a small ideal
will not take the place of enlarging that ideal. If existing laws stand
in the way of broadening the purpose of school hygiene, let the laws be
changed. If text-book publishers stand in the way, let us induce or
compel them to get out of the way. If we fear rumsellers, their money,
and the insidious political methods that they might employ to bring in
undertruth if overtruth is once sacrificed, let us go to our
communities and locate the rumseller's guns, draw their fire, tell the
truth about their opposition, and educate the public to overcome it.
If, on the other hand, misguided teetotalism stands in the way, then,
as one teetotaler, I suggest that we prove, as we can, in our
respective communities that there is a better way of inculcating habits
of temperance and self-restraint than by telling untruths, overtruths,
or half truths about alcohol and tobacco. Let us prove, as we can, that
a subject vital to every individual, to every industry, and to every
government is now prevented from fulfilling its mission not by its
enemies but by its friends. We can learn the character of hygiene
instruction in our schools and the interest taken in it by teachers,
principals, and superintendents. We can learn how teachers practice
hygiene at school, and how the children of our communities are affected
by the hygiene instruction now given. Finally, we can compel a public
discussion of the facts, and action in accordance with facts. Without
questioning anybody's avowed motive, we can learn how big that motive
is and how adequate or inadequate is the method of executing it.

Alcohol and tobacco really occupy but a very small share of the
interest and attention of even those men and women by whom they are
habitually used. Hygiene, on the other hand, is of constant,
uninterrupted concern. Why, therefore, should it be planned to have
alcohol and tobacco displace the broader subject of personal and public
hygiene in the attention and interest of children throughout the school
life? Beyond the text-book and schoolroom a thousand influences are at
work to teach the social evils, the waste of energy, and the
unhappiness that always accompany the excessive use--and frequently
result from a moderate use--of stimulants and narcotics. Of the many
reasons for not drinking and smoking, physiology gives those that
least interest and impress the child. The secondary effects, rather
than the immediate effects, are those that determine a child's action.
Most of the direct physiological effects are, in the majority of
instances, less serious in themselves than the effects of overeating,
of combining milk with acids, of eating irregularly, of neglecting
constipation. Were it not for the social and industrial consequences of
drunkenness and nicotinism, it is doubtful if the most lurid picture of
fatty degeneration, alcoholic consumption, hardened liver, inactive
stomach lining, would outweigh the pleasing--and deceiving--sensations
of alcoholic beverages and cigarettes.

The strong appeal to the child or man is the effect these habits have
upon his mother, his employer, his wife, his children. The vast
majority of us will avoid or stop using anything that makes us
offensive to those with whom we are most intimately associated, and to
those upon whom our professional and industrial promotion depends.
Children will profit from drill in and out of school in the science of
avoiding offense and of giving happiness, but unless the
categories--_acts that give offense_ and _acts that give
happiness_--are wide enough to include the main acts committed in the
normal relations of son, companion, employer, husband, father, and
citizen, those who set out to avoid alcohol and tobacco find themselves
ill equipped to carry the obligations of a temperate, law-abiding
citizen.

Things do not happen as described in the early text-book. Other things
not mentioned hinder progress and happiness. The child at work resents
the mis-education received at school and suspects that he has been
following false gods. The enemies that cause him trouble come from
unexpected sources. He finds it infinitely easier to eschew alcohol and
tobacco than to avoid living conditions that insidiously undermine his
aversion to stimulants and narcotics. The reasons for avoiding
stimulants in the interest of others are more numerous and more cogent
than the reasons for avoiding stimulants and narcotics for one's own
sake. The altruistic reasons for shunning stimulants and narcotics
cannot be implanted in the child unless he sees the evil of excess _per
se_ in anything and everything, and unless he becomes thoroughly
grounded in the life relations and health relations to which he must
adapt himself.

Unclean streets, unclean milk, congested tenements, can do more harm
than alcohol and tobacco, because they breed a physique that craves
stimulants and drugs. Adenoids and defective vision will injure a
larger proportion of the afflicted than will alcohol and tobacco,
because they earlier and more certainly substitute discouragement for
hope, handicap for equal chance. Failure to enforce health laws is a
more serious menace to health and morals than drunkenness or tobacco
cancer.

If it is true that we must attack the problem of alcohol from the
standpoint of its social and industrial effects, we are forced at once
to consider the machinery by which cities and governments control the
manufacture and sale of alcohol. It is not an exaggeration to say that
courses in regulating the traffic in alcohol are more necessary than
courses in the effects of alcohol upon digestion and respiration.

If Sunday closing of saloons, local option, high license, and
prohibition have failed, there is no evidence that the failure is due
to the principles underlying any one of these methods. Until more
earnest effort is made to study the effects of these methods, the
results of their enforcement and the causes of their nonenforcement, no
one is justified in declaring that either policy is successful or
unsuccessful. It is very easy to select from the meager facts now
available convincing proofs both that prohibition does not prohibit and
that high license leads to increased drunkenness. The consequence is
that the movements to control, restrict, or prohibit the use of alcohol
are emotional, not rational.

It is impossible to keep emotion, sensation, sentiment, at white heat.
Most extremists worship legislation and do not try to keep interest
alive by telling every week or every month new facts about the week or
the month before. No new fuel is added to the anti-saloon fire, which
gradually cools and dies down. Not so, however, with those who make
money by the sale of intoxicants. The greater the opposition, the more
brains, the more effort, the more money they put into overcoming or
circumventing that opposition. Fuel is piled on and the bonfire is fed
freely. Every day the anti-restriction bonfire becomes larger and
larger, and the anti-saloon bonfire becomes smaller and smaller. By
carefully selecting their facts, by counting the number of arrests for
drunkenness and the number of saloons open on Sunday, by reiteration of
their story the pro-saloonists gradually win recruits from the
opposition, and, when the next election comes, their friends outnumber
their enemies and the "dry" policy of a city, county, or state is
reversed.

The failures attributed to prohibitive or restrictive measures are
probably no more numerous than the failures of government in other
respects. The present ambassador from England, James Bryce, writing his
_American Commonwealth_, declared that municipal government was
America's "most conspicuous failure." The mayor of Toledo, writing in
1907, says, "There has been a pessimism, almost enthusiastic, about the
city." These failures are due not to any lack of desire for good
government, not to any fundamental evils of cities, but to the fact
that municipal reform, like the crusade against alcohol, has been based
upon emotionalism, not upon definite proof. Reformers have been unable
to lead in the right direction, because they have looked at their
lantern instead of their road. Not having cumulative information as to
government acts, they have been unable to keep their fires burning. To
illustrate: in November, 1907, the governor of New York state, the
mayor of New York City, and reformers of national reputation eulogized
the tenement-house department; yet this department, whose founding was
regarded as a national benefaction, was the only department of the city
government that did not receive an increase for 1908. It is in the
position of temperance legislation, the facts of whose enforcement or
nonenforcement are not promptly and continuously made public.

Fear of the negro victim of alcoholism, social evils of intemperance,
whether among white or black, industrial uncertainty and waste due to
alcoholism, are the three chief motives that have swept alcohol traffic
out of the greater part of the South. Knowledge of physiological evils
has had little influence, except as it may have rendered more
acceptable the claim that alcoholism is a disease against which there
is no insurance except abolition of alcohol as a beverage. Religious
revivals, street parades by day and by night, illustrated banners,
personal intercession, lines of women and children at the polls, made
it necessary for voters to make known their intention, and made it
extremely difficult for respectable men, engaged in respectable
business, to vote for saloons. Some states have gone so far as to
prohibit the manufacture of alcoholic stimulants, even though not
offered for sale within state limits. In Georgia wine cannot be used at
the communion service, nor can druggists sell any form of liquor except
pure alcohol. In Louisiana it is illegal for representatives of "wet
districts" to solicit orders for liquor in any of the "dry districts."
In Texas the sale of liquor in dining cars is forbidden, and the
traveler may not even drink from his own flask. Congress is being urged
by senators and congressmen, as well as by anti-saloon advocates, to
pass laws prohibiting common carriers from delivering alcoholics to any
"dry" community. The more optimistic anti-saloon workers believe it is
but a matter of a short time when Congress will pass laws prohibiting
the manufacture or sale of alcoholic beverages within any limits
protected by the United States Constitution.

Southern states have been warned that they could not afford the
depreciation of real estate values, of rents, and of business that
would surely follow the "confiscation of capital" and "interference
with personal liberty." This warning has been met by plausible
arguments that the buyers of legitimate and nonpoisonous commodities
could pay better rents, better profits on business and on real estate,
if freed from the uneven fight against temptation to drink. The
argument that schools and streets and health must suffer if the license
money was withdrawn, has been met by the plausible argument that the
ultimate taxpayer--the family that wants clothing, food, and
shelter--will save enough money to be able to spend still larger sums
than heretofore upon education, health, and public safety.

For the first time dealers in alcohol recognize the possibility of a
great national movement and of national prohibition. Both the defects
in methods hitherto used to oppose saloon legislation and the reasons
for meeting the present situation by new methods are presented in the
May issue (1907) of the _Transactions of the American Brewing
Institute_. Under the title, "Social Order and the Saloon--the Measure
of the Brewer's Responsibility," Mr. Hugh F. Fox, known throughout the
Union as a defender of child rights, advocate of probation and
children's courts, promoter of health and education, outlined a plan
for research that is indispensable to the proper settling of this great
question. Whether brewer or anti-saloon leaguist, total abstainer or
moderate drinker, employer or trade unionist, it is necessary to the
intelligent control of alcohol that each of us approach this momentous
question of control or abolition of the saloon in the spirit expressed
in this paper, whose thoroughness and whose social point of view would
do credit to a church conference. The address is quoted and its
questions copied because both show how much depends upon knowing
whether laws are enforced and how much greater is the difficulty of
coping with a conciliatory antagonist who professes willingness to
submit to tests of evidence.

  The regulation of the liquor business involves fundamental
  questions of the function and scope of government, and there is
  hardly any department of organized human activity that has been
  the subject of so much experiment and futile tinkering.... The
  only people who are perfectly consistent are the prohibitionists,
  whose policy is abolition. Let us, however, try to detach
  ourselves from any personal interest that we may have in the
  subject, and consider it impartially as a matter of public
  concern.

  What the brewer as an individual cannot do, the brewers as an
  organization have done successfully in many places in spite
  sometimes of official negligence, corruption, or incapacity. The
  Texas Brewers' Association is reported as having successfully
  prosecuted two thousand cases against keepers of disreputable
  resorts during the past three years. The object of their campaign
  was to purify the retail liquor trade from unclean and law-defying
  elements.

  The greatest gain that has come to society, as distinguished from
  the individual, through the temperance movement is its effect in
  unconsciously informing the public that the regulation and
  administration of licensing is in itself a great and vital
  problem; and as a secondary result of such agitation, I should
  cite the growing sensitiveness of all persons in the business to
  the power of public opinion.

  The recognition by brewers of the force of public opinion is a
  recent affair. In former years they were totally indifferent to
  it, if indeed they did not openly flout it. Even now their appeal
  to public sentiment is mainly a special plea for defensive
  purposes, and has little or no educational value. Brewers have
  opposed practically every effort to effect a change in excise
  laws, often without any convincing reason, but simply because the
  proposed change involved temporary inconvenience and uncertainty,
  and perhaps a temporary loss. The brewing trade has utterly failed
  to develop a constructive programme in connection with the public
  regulation of its affairs. It does not seem to have any fixed
  principles or positive convictions as to excise methods and liquor
  laws. Its policy has been that of an opportunist, at the best,--or
  an obstructionist, at the worst. As in all other industries which
  affect the welfare of the people, reforms have been forced from
  the outside, with no help from within. Of course this is equally
  true of insurance and railroad corporations, of food purveyors,
  mine owners, cotton merchants, and a score of other interests. It
  is due not merely to human selfishness but to shortsightedness; in
  other words, to a lack of statesmanship.

  To call your opponents hypocrites, cranks, fakirs, and fanatics
  may relieve your feelings, but it doesn't convince anybody, and
  only hurts a just cause. It is foolish to question the motives of
  men who, without thought of personal gain, are trying to remedy
  the evils of inebriety.

  The church is perfectly right in urging total abstinence upon the
  individual. The only path of safety lies in abstinence for some
  individuals....

  The recognition of the right of a community to establish its own
  licensing conditions carries with it the right of the community to
  determine whether there shall be any licenses at all!

  To make the discussion of this subject as fruitful as possible, I
  venture to submit the following questions for your consideration.
  None of them involve any direct moral issue, but there is an
  honest difference of opinion about each one of them, and they are
  certainly of vital importance in determining the course of wise
  and just administration.

  What has been the effect of high license?

  How much public revenue should the traffic yield?

  Does high license stimulate unlawful trade?

  How much license tax should be imposed upon local bottlers and
  grocers? Should they be allowed to peddle beer or to sell it in
  single bottles?

  Should the place or the individual be licensed?

  Should the licensing authorities be appointive or elective? By
  whom should they be appointed, and for what term of office?

  Have the courts made good or bad licensing authorities? Where the
  courts issue licenses, what has been the effect on the court?

  Should the licensing authority alone have the power to revoke a
  license, and discretion to withhold a license?

  How can the licensing authority enforce the law? Should it not be
  independent of the police?

  What should be the penalty for breach of the law? Do not severe
  penalties miscarry?

  On what plea, and under what conditions, should licenses be
  transferred?

  What has been the effect of limiting the number of saloons?

  Should limitation be according to area or to population?

  Is there any relation between the number of saloons and the volume
  of consumption?

  What should be the limit to the hours of selling?

  Should saloons be allowed to become places of entertainment?

  How can the sale of liquor by druggists be controlled?

  How can spurious drinking clubs be prevented or controlled?

  How can the operation of disreputable hotels be prevented? What
  should be the definition of a hotel? Who should define it? By whom
  should it be licensed? What special privileges should be given to
  it?

  How can the "back-room" evil be stopped? Is it legal (i.e.
  constitutional) to prohibit the sale or serving of liquor to
  women?

  Has the removal of screens reduced the volume of consumption? Has
  it improved the character of saloons? Has it solved the problem of
  Sunday prohibition for any length of time? What has been the
  general effect of it in the tenement districts?

  Should the state undertake to regulate the liquor business or to
  enforce liquor laws?

  Is it possible to devise any working plan which will apply with
  equal effectiveness and equity in communities of compact and of
  scattered population?

  Should, or should not, the principle of self-government be
  carefully preserved in the whole scheme of legislation to regulate
  the liquor business?

Whether the present prohibition wave shall wash away the legalized
saloon, as ocean waves have from time to time engulfed peninsulas,
islands, and whole continents, depends upon the power of American
educators and American officials to answer right such questions as the
foregoing. The great danger is that we shall, as usual, over-emphasize
lawmaking, underemphasize lawbreaking, and go to sleep during the next
two or three years when we should be wide-awake and constantly active
in seeing that the law is enforced. Unless exactly the same principles
of law enforcement are applied in "dry districts" as we have urged for
eradication of smallpox, typhoid, scarlet fever, and adenoids, local
and city prohibition are doomed to failure. There must be:

  1. Inspection to discover disease centers--"blind pigs," "blind
  tigers," etc.

  2. Compulsory notification by parents and landlords, and by police
  and other officials.

  3. Prompt investigation upon complaint from private citizens.

  4. Prompt removal of the disease and disinfection of the center.

  5. Segregation of individual units that disseminate disease,
  whether bartender, saloon keeper, owner of premises, or
  respectable wholesaler, none of whom should be permitted to shift
  to another the responsibility for violating liquor laws.

  6. Persistent publicity as to the facts regarding enforcement and
  violation, so that no one, whether saloon leaguist or anti-saloon
  leaguist, shall be uninformed as to the current results of "dry"
  laws.

It is perfectly safe to assume that none of these things will be done
consistently unless funds are provided to pay one or more persons in
each populous locality to give their entire time to the enforcement of
laws, just as the improvement of other ills of municipal government
require the constant attention of trained investigators. Cogent
arguments for such funds have recently appeared in the _New York
Evening Post's_ symposium on "How to Give Wisely," by Mrs. Emma Garrett
Boyd, of Atlanta, and Miss Salmon, of Vassar College.

If the saloon is here to stay, we must all agree that it is a frightful
waste of human energy and of educational momentum to be appealing for
its abolition when we might be hastening its proper control. On the
other hand, if the saloon is destined to be abolished as a public
nuisance and a private wrong, as a menace to industry and social order,
is it not a frightful, unforgivable waste of energy to permit
prohibition laws to fail, and thus to discredit the principle of
prohibition? Philanthropists have provided millions for scientific
research, for medical research, for the study of tuberculosis, and for
the study of living conditions. It is to be hoped that a large
benefaction, or that an aggregation of small benefactions, will apply
to governmental attempts to regulate the sale of alcohol those methods
of scientific research which have released men from the thraldom of
ignorance and diseases less easily preventable than alcoholism.



CHAPTER XXXV

IS IT PRACTICABLE IN PRESENTING TO CHILDREN THE EVILS OF ALCOHOLISM TO
TELL THE TRUTH, THE WHOLE TRUTH, AND NOTHING BUT THE TRUTH?


If children are taught that the most effective way of combating
alcoholism is to insure the enforcement of existing laws and to profit
from lessons taught by such enforcement; if children are taught that
the strongest reasons for total abstinence are social, economic, and
industrial rather than individual and physiological,--there is much to
be gained and little to lose from telling them the truth, the whole
truth, and nothing but the truth about alcohol. To stimulate a child's
imagination by untruths about alcohol is as vicious as to stimulate his
body with alcohol. Whisky drinking does not always lead to drunkenness,
to physical incapacity, to short life, or to obvious loss of vitality.
Beer drinking is not always objected to by employers. Neither crime,
poverty, immorality, lack of ambition, nor ignorance can always be
traced to alcohol. On the contrary, it is unquestionably true that the
majority of the nation's heroes have used alcoholics moderately or
excessively for the greater part of their lives. It is probably true
that among the hundred most eminent officials, pastors, merchants,
professors, and scientists of to-day, the great majority of each class
are moderate users of one or more forms of alcoholics. Overeating of
potatoes or cake or meat, sleeping or working in ill-ventilated rooms,
neglect of constipation, may occasion physiological and industrial
injuries that are not only as grave in themselves as the evils of
moderate drinking, but, in addition, actually tempt to moderate
drinking.

All of this can be safely admitted, because whether parents and
teachers admit it or deny it, children by observation and by reading
will become convinced that up to the year 1908 the noblest and the most
successful men of America, as well as the most depraved and least
successful, have used alcoholics. To be candid enough to admit this
enables us to gain a hold upon the confidence and the intelligence of
children and youth that will strengthen our arguments, based upon
social and industrial as well as physiological grounds, against running
the risks that are inevitably incurred by even the moderate use of
alcohol.

Other things being equal, the same man will do better work without
alcohol than with alcohol; the same athlete will be stronger and more
alert without alcohol than with alcohol; the clerk or lawyer or teacher
will win promotion earlier without alcohol than with alcohol; man or
woman will grow old quicker with than without alcohol. Other things
being equal, a man of fifty will have greater confidence in a total
abstainer than in a man of identical capacity who uses alcohol
moderately; a mother will give better vitality and better care to her
children without than with alcohol; a policeman or fireman or
stenographer is more apt to win promotion without than with alcohol.
Whatever the physical ailment, there is in every instance a better
remedy for an acute trouble, and infinitely better remedies for
deep-seated troubles, than alcoholics.

The percentage of failure to use alcoholics moderately is so high, the
uncertainty as to a particular individual's ability to drink moderately
is so great, as to lead certain insurance companies, first, to give
preference to men who never use alcoholics, and later, to refuse to
insure moderate drinkers. Life insurance companies have the general
rule that habitual drinkers are bad risks, as the alcohol habit is
prejudicial to health and longevity; but they have no means of studying
the risk of moderate drinkers, because, except where alcohol has
already left a permanent impression upon the system, the indications
are by no means such as to enable the medical examiner to trace its
existence with certainty. For this reason the life insurance companies
have little effect in _preventing_ alcoholism. Though they are agreed
that habitual drinkers ought to be declined altogether, only a few
companies have taken the decided stand of declining them. "Habitual
drinkers, if not too excessive, are admitted into the general class
where the expected mortality, according to the experience of the
Pennsylvania Mutual Life Insurance Company, is 80 per cent, as against
56 per cent for the temperate class. Though it is only necessary to
look over the death losses presented each day to see that intemperance
in the use of liquors, as shown by cirrhosis of the liver, Bright's
disease, diseases of the heart, brain, and nervous system, is the cause
of a large proportion of the deaths, these companies prefer to grade
the premiums accordingly rather than to decline habitual drinkers
altogether. While this is partly due to the difficulty and expense of
diagnosis, it is more probably due to an objection to take a definite
stand on the temperance question."

Thus the insurance companies' rules touch only the confirmed drinker,
whose physique is often irreparably injured. One company writes: "Men
who have been intemperate and taken the Keeley or other cures are never
accepted until five years have elapsed from the date of taking the
cure, and only when it can be conclusively shown that during the whole
period they have refrained entirely from the use of alcoholic liquor,
and that their former excesses have not in any way impaired the
physical risk."

Thus far American insurance companies are doing little preventive and
educational work on the alcohol question, though they have the very
best means at their command for so doing. According to the Metropolitan
Life Insurance Company nine tenths of the school children in New York
City are insured by them, and an even greater proportion of workingmen.
Even though this is done "at twice the normal cost," the most cursory
medical examination is given and no attempt is made to instruct them in
the relation of their physical condition to their working power, or in
the evils of the alcohol and the smoking habits.

Naturally the moderate drinker is first rejected for positions where an
occasional overindulgence would be most noticeable and most serious.
The manager of a large factory tells his men: "You cannot work here
unless you are sober. If you must drink at parties, stay at home if
necessary until 12 o'clock the next day and sleep it off, but don't
come here till you are straight. We cannot afford it." Occasionally his
men stay at home and not a word is said, but the minute they are found
at work in an unsteady condition they are summarily discharged. From
this position it is but a step to that of an upholsterer in New York
City, who prints on his order blanks, "No drinking man employed." His
company recently discharged a man after twenty years of service because
a customer for whom this man was working detected a whisky breath. Men
reported to trade unions for frequent intoxication are blacklisted. A
certain financial corporation permits no liquor on its grounds or in
its lunch rooms. The head of one of its large branches was heard to say
recently that he would discharge on the spot a man who showed evidences
of drinking, even though he had previously worked faithfully for years.

Rejection of moderate drinkers by business houses is not done on moral
grounds alone, but because experience has proved the danger of
employing men who have not their faculties fully under control _all_
the time they are at work. The rules are especially strict for men
working for a railroad or street railway company. The Pennsylvania
Railroad Company replied to my inquiry as to their custom of
discriminating against drinking men in these words: "We have no printed
rules in regard to this except in a general way,--that no employee is
allowed to go into a saloon during his hours of work or wearing the
company's uniform. Of course the men are promptly discharged or
disciplined if they show the effects of liquor while on duty, and the
whole tendency of the administration of the rules is to get rid of any
men who are habitual drinkers, but the administration of the rules and
discipline is left to the superintendent of each division." The
Interborough Rapid Transit Company of New York has these printed rules
for the physical standard required for applicants for employment:

  1. _Examination of heart and arteries._ Rejection of candidates
  showing excessive or long-continued use of tobacco and alcohol,
  with explanation of condition, causes, and dangers of continued
  use. Warning to chiefs of departments regarding those accepted who
  show tendency to drink at times, but whose physical examination
  does not disclose sufficient evidence to warrant their
  disqualifications. Foremen and chiefs of departments to be
  notified and to carry out the policy of employing only men who are
  at all times sober and not under the influence of alcohol at all.

  2. _On reëxamination of employees._ Warning to or rejection of
  those showing, on physical examination, indulgence to excess of
  alcohol, tobacco, or drugs. Warning to chief of department of
  evidence of such habits on part of any employee examined for any
  reason, but retained in service of the company with injunction to
  chief of department to speak with such employee and have him under
  proper supervision.

The blacklisting of habitual drinkers by their union, and the growing
tendency on the part of large corporations, factories, and business
houses to take a decided stand against drinking, are having a marked
effect in reducing drunkenness where it does most harm. This practice
has been declared by John Bach McMasters, the noted American historian,
to have exerted a stronger influence in promoting temperance and total
abstinence than all the temperance crusades from Hartley's time to the
prohibition wave of 1907. The school, by instructing children how the
alcohol habit will affect their chances of business success, future
usefulness as citizens, and enjoyment of life, will inevitably reduce
the evils of alcohol. By teaching based on facts that intimately
concern the life of the child, as well as by caring for his health and
his environment, the schools can help supplant the desire for alcohol
with other more healthy desires.

No truth about alcohol is more important than that the craving for
alcohol or something just as bad will exist side by side with imperfect
sanitation, too long hours of work, food that fails to nourish, lack of
exercise, rest, and fresh air. Conditions that produce bounding
vitality and offer freedom for its expression at work and at play will
supplant the craving for stimulants. Finally, the great truth contained
in the last chapter must be taught, that success in coping with
alcoholism is a community task requiring efficient government above all
else.



CHAPTER XXXVI

FIGHTING TOBACCO EVILS


"It is not necessarily vicious or harmful to soothe excited nerves."
This editorial comment explains, even if it condemns while trying to
justify, the tobacco habit. To soothe excited nerves by lying to them
about their condition and by weakening where we promise to nourish, is
vicious and harmful just as other lying and robbery are vicious and
harmful. Yet two essential facts in dealing with tobacco evils must be
considered: tobacco does soothe excited nerves, and the harm done to
the majority of smokers seems to them to be negligible. For these two
reasons the tobacco user, unless frightened by effects already visible,
refuses to listen to physiological arguments against his amiable
self-indulgence. Cheerfully he admits the theoretical possibility that
by its method of soothing nerves tobacco kills nerve energy. But in all
sincerity he points to men who have found the right stopping point up
to which tobacco hurts less perhaps than coffee or tea, candy or
lobster, overeating or undersleeping. Therefore the physician, the
bishop, the school superintendent, candidly run the necessary risk for
the sake of nerve soothing and sociability.

Less harm would be done by tobacco if it were more harmful. Like so
many other food poisons, its use in small quantities does not produce
the prompt, vivid, unequivocal results that remove all doubt as to the
user's injuries and intemperance. As inability to see the physiological
effect upon himself encourages the tobacco user to continue smoking or
chewing, so failure to identify evil physiological effects upon the
smoker encourages the nonuser to begin smoking or chewing. A very few
smokers give up the habit because they fear its results, but too often
the man who can see the evil results would rather give up almost
anything else. The one motive that most frequently stops inveterate
smoking--fear--is the least effective motive in dissuading those who
have not yet acquired the habit; every young man, unless already
suffering from known heart trouble, thinks he will smoke moderately and
without harm. Unfortunately, every boy who begins to smoke succeeds in
picturing to himself the adult who shows no surface sign of injury from
tobacco, rather than some other boy who has been stunted physically,
mentally, and morally by cigarettes.

For adult and child, therefore, it behooves us to find some other
weapons against tobacco evils in addition to fear of physiological
injuries. Among these weapons are:

1. Enforcement of existing laws that make it an offense against society
for dealer, parent, or other person to furnish children under sixteen
with tobacco in any form; and raising the age limit to twenty-one, or
at least to eighteen.

2. Enforcement of restrictions as to place and time when smoking is
permitted.

3. Agitation against tobacco as a private and public nuisance.

4. Explanation of commercial advantages of abstinence.

Because the childish body quickly shows the injurious effects of what
in adults would be called moderate smoking, the proper physical
examination of school children will reveal injuries which in turn will
show where and to what extent the cigarette evil exists among the
children of a community. Even the scientists who claim that "in some
cases tobacco aids digestion," or that "tobacco may be used without bad
effects when used moderately by people who are in condition to use it,"
declare emphatically that tobacco "must not be used in any form by
growing children or youths." Prohibitive laws can be rigidly enforced
if a small amount of attention is given to organizing the strong
public sentiment that exists against demoralizing children by tobacco.
Thus children and youths will not need to make a decision regarding
their own use of tobacco until after other arguments than physiological
fear have been used for many years by parent, teacher, and society.

One effective weapon is the sign on a ferryboat or street car: "No
smoking allowed on this side," or "Smoking allowed on three rear seats
only." Public halls and vehicles in increasing numbers either prohibit
smoking altogether or put smokers to some considerable inconvenience.
The trouble involved in going to places where smoking is permitted
tends gradually to irritate the nerves beyond the power of tobacco to
soothe. Again, many men would rather not soothe their excited nerves
after five, than have their nerves excited all day waiting for freedom
to smoke. Restrictions as to time or place make possible and expedite
still further restrictions. Thus gradually the army of occasional
smokers or nonsmokers is being recruited from the army of regular
smokers.

The anti-nuisance motive follows closely upon the drawing of sharp
lines of time and place for the use of tobacco. Like treason, smoking
in the presence of nonsmokers can be considered respectable only when
the numbers who profess and practice it are numerous. If the two
first-mentioned weapons are effectively used, there will be an
increasing proportion of nonsmokers and not-yet-smokers who will give
attentive ear to proof that nicotinism is a nuisance. The physical
evidences of the cigarette habit can easily be made distasteful to all
nonsmokers if frankly pointed out,--the yellow fingers, the yellow
teeth, the nasty breath, the offensive excretions from the pores that
saturate the garments of all who cannot afford a daily change of
underwear. The anti-nuisance argument is always insidious and abiding.
In the presence of nonsmokers accustomed to regard tobacco using as a
nuisance, smokers become self-conscious and sensitive. Men and women
alike would prefer a reputation for cleanliness to the pleasures of
tobacco. The educational possibility of fighting tobacco with the name
"nuisance" was recognized the other day by an editorial that protested
against a law to prevent women from using cigarettes in restaurants.
"The way for any man who has the desire to reform some woman addicted
to the cigarette habit is insidiously and gently to point out the
injurious effects on her appearance. Cigarette smoking stains a woman's
fingers and discolors her teeth. It also tends to make her complexion
sallow and to detract from the rubiness of her lips. It bedims the
sparkle of her eyes. It makes her less attractive mornings." Chewing
has practically disappeared, not because it ceased to soothe excited
nerves but because it was seen to be a nasty nuisance.

Finally, the selfishness of the smoker is a nuisance that continues
only because it has not been called by its right name. "Do you mind if
I smoke?" was a polite question two hundred years ago when tobacco was
rare enough to make smoking a distinction, or fifty years ago when
everybody smoked at home and in public. But it is effrontery to-day
when people do mind, when smoking pollutes the air of drawing room and
office, and while soothing the excited nerves of the smoker lowers the
vitality of nonsmokers compelled to breathe smoke-laden air. It is
selfish to intrude upon others a personal weakness or a personal
appetite. It is selfish to divert from family purposes to "soothing
excited nerves" even the small amounts necessary to maintain the cigar
or cigarette habit. It is selfish to run the risk of shortening one's
life, of reducing one's earning capacity. Because the tobacco habit is
selfish it is anti-social and a nuisance, and should be fought by
social as well as personal weapons, as are other recognized nuisances,
such as spitting in public or offensive manners.

The economic motive for avoiding and for eliminating tobacco is gaining
in strength. The soothing qualities of all drugs are found to be
expensive to physical and business energy if enjoyed during business
hours. Strangely enough, employers who smoke are quite as apt as are
nonsmokers, to forbid the use of tobacco by employees at work. Some of
this seeming inconsistency is due to a dislike for cheaper tobacco or
for mixed brands in one atmosphere; some of it is due to the smoker's
knowledge that "soothing nerves" and sustained attention do not go hand
in hand, while "pipe dreams" and unproductive meditation are fast
companions; finally no little of the opposition to tobacco in business
is due to fear of fire. These various motives, combining with the
anti-nuisance motive among nonsmokers, have led many business
enterprises to prohibit the use of tobacco in any form on their
premises or during business hours, even when on the premises of others.
Notable examples are railroads that permit no passenger trainman to use
tobacco while on duty. (Freight trainmen are restricted more tardily
because the risk of damages is less and the anti-nuisance objection is
wanting.)

From penalizing excessive use and prohibiting moderate use in business
hours, it is a short cut to choosing men who never use tobacco and thus
never suffer any of its effects and never exhibit any of its offensive
evidences. No young man expects to obtain a favorable hearing if he
offers himself for employment while smoking or chewing tobacco.
Business men dislike to receive tobacco-scented messengers. Cars and
elevators contain signs prohibiting lighted cigars or cigarettes.
Insurance companies reject men who show signs of excessive use of
tobacco. Why? Because they are apt to die before their time. The
Interborough Rapid Transit Company of New York City rejects applicants
for motormen and conductors "for excessive or long-continued use of
tobacco." Why? Because, other things being equal, such men are more
apt to lose their nerve in an emergency and to fail to read signals or
instructions correctly.

Armed with these weapons against tobacco, parents and teachers can
effectively introduce physiological arguments against excessive use,
against use by those who suffer from nervous or heart trouble, and
against any use whatever by those who have not reached physical
maturity. By avoiding physiological arguments that children will
not--cannot--believe contrary to their own eyes, parents and teachers
are able to speak dogmatically of that which children will
believe,--injuries to children, evils of excess, restrictions as to
time and place, and offensiveness to nonsmokers. But even here it is
wrong, as it is inexpedient, to leave the physical strength of the next
generation to the persuasive power of parents and teachers or to the
faith and knowledge of minors. Society should protect all minors
against their own ignorance, their own desires, the ignorance of
parents and associates, and against the economic motive of tobacco
sellers by machinery that enforces the law.



CHAPTER XXXVII

THE PATENT-MEDICINE EVIL


  "Dhrugs," says Dock O'Leary, "are a little iv a pizen that a
  little more iv wud kill ye. Ye can't stop people fr'm takin'
  dhrugs, an' ye might as well give thim somethin' that will look
  important enough to be inthrojuced to their important and fatal
  cold in th' head. If ye don't, they'll leap f'r th' patent
  medicines. Mind ye, I haven't got annything to say agin' patent
  medicines. If a man wud rather take them thin dhrink at a bar or
  go down to Hop Lung's f'r a long dhraw, he's within his rights.
  Manny a man have I known who was a victim iv th' tortures iv a
  cigareet cough who is now livin' comfortable an' happy as an opeem
  fiend be takin' Dr. Wheezo's Consumption Cure." The Dock says th'
  more he practices medicine th' more he becomes a janitor with a
  knowledge iv cookin'. He says if people wud on'y call him in
  befure they got sick he'd abolish ivry disease in th' ward except
  old age and pollyticks.

Thus Mr. Dooley with his usual wit and insight tells the American
people why they spend over two hundred million dollars annually on
patent medicines. Americans consume more drugs and use more patent
medicines than the people of any other country on the civilized globe.
Self-medication has grown to tremendous proportions. Everywhere--in
cars, on transfers, on billboards, in magazines, in newspapers, in the
mails--are advertised medicines to cure disease and devices to promote
health. When we consider that electric cars contain from thirty-two to
fifty-two advertisements each, three fourths of which are directly or
indirectly concerned with health; when we multiply these by the number
of cars actually in use in American cities; when we consider the number
of advertisements in magazines and daily papers, and the enormous
circulation of these papers and magazines; when we consider that an
increasingly large proportion of advertising space is devoted to
health,--we begin to realize the cumulative power for good or for evil
that health advertisements must have.

To illustrate advertisements devoted to health to-day, I have kept
clippings for one week of news items, editorials, and advertisements in
a penny and a three-cent paper, and had them classified according to
the subjects treated:

===================+=========================+========================
                   |     PENNY PAPER         |  THREE-CENT PAPER
                   +------+---------+--------+-----+---------+--------
                   | News |Editorial| Adver- | News|Editorial| Adver-
                   | Item |         |tisement| Item|         |tisement
-------------------+------+---------+--------+-----+---------+--------
Milk               |  3   |   --    |   2    |  3  |   --    |   2
Teeth              |  --  |    1    |   2    |  -- |   --    |   1
Shoes              |  --  |   --    |   4    |  -- |   --    |   1
Food               |  1   |   --    |   --   |  1  |   --    |   4
Alcohol            |  1   |   --    |   5    |  3  |   --    |   7
Tuberculosis       |  --  |   --    |   1    |  1  |   --    |   --
Patent medicine    |  --  |   --    |  17    |  -- |   --    |   --
Constipation cures |  --  |   --    |   4    |  -- |   --    |   5
Eyes               |  3   |   --    |   5    |  1  |   --    |   --
Beauty             |  2   |   5     |   8    |  -- |   --    |   6
General            |  8   |   3     |   3    |  5  |   --    |   --
-------------------+------+---------+--------+-----+---------+--------
  Total            | 18   |   9     |  51    | 14  |   --    |  26
===================+======+=========+========+=====+=========+========

The following list of health topics was treated in the advertisements,
editorials, and articles of a popular monthly periodical devoted to
women:

=========================+=========+===========+===============
                         | ARTICLE | EDITORIAL | ADVERTISEMENT
-------------------------+---------+-----------+---------------
Babies                   |   1     |   --      |    11
Soaps and powders        |  --     |   --      |     5
Beauty                   |   3     |   --      |     6
Quack cures              |  --     |    2      |    --
Tooth powders            |  --     |   --      |     4
Household                |   1     |   --      |     5
Food and cooking         |   1     |   --      |    14
Clothes                  |  13     |   --      |     5
Teaching sex laws        |   1     |    2      |    --
Medicine                 |   4     |    1      |    --
-------------------------+---------+-----------+---------------
  Total                  |  24     |    5      |    50
=========================+=========+===========+===============

Besides the classic patent medicines, such as Lydia Pinkham's Vegetable
Compound, Castoria, Cod Liver Oil, etc., there are "Colds Cured in One
Day," "Appendixine," health foods, massage vibrators, violet rays,
Porosknit underwear, sanitary tooth washes, soaps, vitopathic,
naturopathic, and faith cures. New ones appear every day,--enough to
make a really sick person dizzy, let alone a person suffering from
imaginary ailments. All seem to outline my particular symptoms. After
they have flamed at me in red letters in the surface cars, pursued me
in the elevated and underground, accompanied me out into the country
and back again to the city, greeted me each morning in the daily paper
and in my daily mail, each week or each month in the periodical, the
coincidence of a familiar package on a drug-store counter seems to be
providential and therefore irresistible. I know that I ought to be
examined by a physician, but I am busy and not unwilling to gamble for
my health; it cannot kill me and there is a chance that it will cure
me. If there is nothing the matter with us, we may be cured by our
faith. If we are taking a cure for consumption, the morphine in it may
lull us into thinking we feel better. If we are taking a tonic for
spring fever, the cheap alcohol may excite us into thinking our
vitality has been heightened. Soothing sirup soothes the baby, often
doping its spirit for life, or soothing it into a sleep from which it
never wakes.

In spite of the fact that the "Great American Fraud" has been exposed
repeatedly in newspapers and magazines of wide circulation, the appeal
of the quack still catches men and women of intelligence. The other
night a friend went out to a dinner and conference with a lawyer in the
employ of the national government. Annoyed by a nagging headache, he
made for the nearest drug store and ordered a "headache powder." He
admitted that it was an awful dose, but he had been told that it always
"did the business." He knew the principle was bad, confessed to a
scorn for friends of his whom he knew to be bromo-seltzer fiends, but
he had the headache and the work to do--a sure cure and a quick one
seemed imperative. The headache was due to overwork, indigestion,
constipation. Plain food and quiet sleep was what he needed most. But
the dinner conference plus the headache was the unanswerable argument
for a dose with an immediate result.

Last winter an Irish maid slowly lost her rosy cheeks and grew
hollow-eyed and thin. She was taken to a specialist who discovered a
rapidly advancing case of consumption. He said that owing to the girl's
ignorance, stupidity, and homesickness, her only chance of recovery was
to return to the "auld countrie" at once. The girl agreed to go, but
insisted on a few days "to talk it over with her cousins in New York."
After two weeks had elapsed she was found in a stuffy, overcrowded New
York tenement. She had found a doctor who had given her a little bottle
of medicine for two dollars, which would cure her in the city. It was
futile to protest. Days in the unventilated tenement and nights in a
"dark room" meant that she would never live to finish the bottle.

For a year Miss H. took a patent preparation for chronic catarrh. It
seemed to "set her up"; but it so undermined her strength, through its
artificial nerve spur, that chronic catarrh was followed by
consumption. It later transpired that the cure's chief ingredient was
whisky, and cheap whisky. A good grandmother, herself a vigorous
temperance agitator and teetotaler, offered to pay for it as long as my
friend would take it faithfully. The irony of it makes one wonder how
many earnest advocates of total abstinence are in reality addicted to
the liquor habit.

Last summer a district nurse of the summer corps who visited city
babies under two years of age encountered in the hallway of a tenement
a bevy of frenzied women. A baby lay on the bed gasping and "rolling
its eyes up into the top of its head." The nurse asked the frightened
mother what she had been giving it. "Nothing at all," said the woman.
But a telltale bottle of soothing sirup showed that the child was dying
from morphine poisoning. Happily the nurse came in time to save it.

Is it not pitiful, this grasping for a poison in an extremity; this
seizing of a defective rope to escape the fire?

    [Illustration: LEARNING HOW TO KEEP BABY WELL WITHOUT PATENT
    MEDICINES
    Recreation Pier, New York City, Summer, 1908]

The patent-medicine evil cannot be cured by occasional exposure or by
overexposure. Nor can it be cured by legislation, legislation,
legislation, unless laws are rigidly enforced.

Occasional exposure is no better than occasional advertising of good
things. The patent-medicine business thrives on constant, not
occasional, advertising. Leading advertisers expect so little from the
first notice that they would not take the trouble to write out a single
advertisement. That is the reason merchants charge advertising in the
programmes of church, festival, and glee-club concert to charity, not
to business. Warning people once does no more lasting good than sending
a child to school once a month. The exposure of patent-medicine evils
must be as constant as efforts to sell the medicines.

Overexposure is ineffective. It is the evils of patent medicines that
do harm, not their name and not their patents. The medical profession
has in vain protested against proprietary medicines. Ethical barriers
cannot be erected by resolution. Calling things unethical does not make
them unethical. The mere patenting of medicines for profit does not
make the medicine injurious any more than the mere mixing of unpatented
drugs makes a physician safe. Physicians who would not themselves
patent a drug will use certain patented drugs whose ingredients are
known to be safe and uniform. True exposure of patent-medicine evils
will enable the average physician and the average layman to distinguish
the dangerous from the safe, the fraud from the genuine, lies from
truths.

Legislation is needed to crystallize modern knowledge and to establish
in courts the right to protection against the evils of patent
medicines. The national Pure Food Law, passed January 1, 1907, and now
in force throughout the country, requires on the "labels of all
proprietary medicines entering into interstate commerce, a statement of
the quantity or proportion of any alcohol, morphine, opium, heroin,
chloroform, cannabis indica, chloral hydrate, or acetanilid, or any
derivative or preparation of any such substance contained therein; this
information must be in type not smaller than eight-point capital
letters; also _the label shall embody no statement which shall be false
or misleading in any particular_." This law does not forbid patent
medicines nor the use of alcohol and narcotics in patent medicines; it
merely says, "Let the label tell, that all who _buy_ may read." It does
not require that all who _run_ may read, for _it does not say that
advertisements of a patent medicine shall tell the truth about its
ingredients or its action on the human body_; only that the label on
the bottle shall tell. The object of this law is to explain to the
consumer the exact nature of the medicine. But to the majority of
people the word "acetphenitidin" on the label of a headache medicine
does not explain. The new order that requires manufacturers to
substitute acetanilid for acetphenitidin does no more than replace fog
with mist. Protection requires legislation that cannot be evaded by
technical terms. The present law requires that packages must be
properly labeled _on entering the state_. To carry out the national
law, state laws should make it an offense for dealers to have in their
possession proprietary medicines without explanatory labels that
explain. Where state laws to this effect do not exist, the packages
once in the state may be deprived of their labels and sold as secret
remedies, thus nullifying the whole effect of the national law.

Enforcement must be insured. Impure drugs may do as much harm as patent
medicines containing harmful drugs. In New York a vigorous campaign was
recently inaugurated by the department of health to drive out impure
drugs. Drugs are dangerous enough at their best. When they are not what
they pretend to be, whether patented or not, they may take life. One
extreme case where a patient's heart was weakened when it ought to have
been strengthened, led to the discovery that practically all of one
particular drug offered for sale in New York City was unfit to use and
calculated to kill in the emergency where alone it would be used.
Yesterday four lives and several million dollars were lost in a New
York fire because the hose was rotten or weak. As inspection and
testing were needed to insure hose equal to emergency pressure, so
inspection and testing of patent medicines and drugs are needed to make
legislation effectual.

Legislation and enforcement should reach the newspaper, magazine,
billboard, street car, that advertises a falsehood or less than the
essential truth regarding drugs, foods, and patent medicines. Public
sentiment condemns the advertising of many opportunities to commit
crime or to be disorderly or indecent or to injure one's neighbor. The
facts about hundreds of nostrums can be absolutely determined. The
advertising agency, whether secular or religious, that carries
misrepresentation of drugs and foods should be forbidden circulation
through the mails. The existence of such advertisements should be made
evidence of complicity in a public offense and punished accordingly.
Treat them as we treated the Louisiana lottery. Boards of health,
instead of furnishing names to druggists and manufacturers who want to
sell patent foods and medicines, should print circulars exposing
frauds, and punish so far as the law permits.

While trying to secure adequate legislation and efficient
administration of the above-mentioned standards, there is much that can
be done by individuals and clubs. We can give preference to those
journals that refuse drug and food advertisements unless evidence is
produced that the truth is told and that the goods are not harmful. We
can refuse to have in the house a paper or journal which prints notices
that lie or that conceal the truth. If this drastic measure would cut
us off entirely from daily papers, we could choose the least offensive
and petition it to exclude specific lying methods. When it preaches
health, honesty, and philanthropy, we can cut out of one issue the
noble editorial and the exploiting advertisements and send them to the
editor with our protest. Knowledge of the ingredients and dangers of
patent medicines should be a prerequisite for the practice of medicine
or pharmacy. We can help bring about such conditions, and we can
patronize physicians who send patients to drug stores that cater to
intelligence rather than to ignorance.

Fighting patent-medicine evils is a civic duty to be accomplished by
civic coöperation, not private effort. It is impossible to organize
unofficial educational agencies that can offset the cumulative, lying
advertisement. Personal opposition is but the beginning. Official
machinery must be set running and kept running so as to protect the
public health against the commercial motive that preys upon ignorance
and easily inspired faith.



CHAPTER XXXVIII

HEALTH ADVERTISEMENTS THAT PROMOTE HEALTH


It is usually considered futile to attempt to defeat the devil with his
own methods, because he knows so much better how to use them. But abuse
does not do away with use, and the success of quacks in reaching the
people demands our respect. There is no reason why their methods, based
on a knowledge of human nature and human psychology, should not be
employed to appeal to needs rather than to weaknesses. A good thing may
lie unused because of lack of advertisement. Vitality is coming to be
the passion of the American people. It is on this sincere passion that
fakirs have so long traded.

There can be no doubt that advertisements of health-promoting goods are
quite as profitable as health advertisements that injure health, when
equally effective methods are used to make them reach the public. The
tradition has been repeatedly mentioned in this book that the better
the doctor, the less he advertises himself, except in medical and
scientific journals that notoriously fail to reach the people. The same
is too often true of reputable remedies and goods. The theory that
these things stand or fall on their merits is not borne out by
practical experience,--conspicuously in the case of "fake" remedies.
Purely philanthropic undertakings for the advancement of health fail,
if not placed before the people whom they aim to help in an attractive,
convincing form. Failure to advertise a worthy cause limits its
usefulness, and is therefore unjustifiable, whether we speak of
medicine, legal aid, or dental clinics.

An intensive study of the methods used to advertise patent medicines
will suggest means of extending the usefulness of health-promoting
goods. Aside from clever methods of suggestion that lead many people to
take medicine for imaginary ailments, especially seasonal ailments,
patent-remedy advertisers have employed (as an argument for the
efficiency of their cures) scientific theory, bacterial origin of
diseases, recent medical or physiological discoveries, and state and
national movements for promoting health. In fact, they have turned to
their own uses the very law that seeks to control them and the
exposures that seek to exterminate them. Whatever may be the merits of
Castoria, the "Don't Poison Baby" advertisement on the following page,
printed just after the accompanying "Babies Killed by Patent
Medicines," which appeared in a home journal, was surely a clever bit
of advertising. Upon an editorial in a daily paper on the relation of
eyeglasses to headache and indigestion, an optician based a promise of
immediate relief for these ailments if he himself were patronized. The
recent investigations of the Department of Agriculture, and of
Professors Chittenden and Fisher, in regard to foodstuffs, are proving
helpful to food quacks and advertisers of pills for constipation and
indigestion. Since the passage of the Pure Food Law one health food is
advertised in a column headed "Pure Food."

When the season for pneumonia comes around numerous medicines are "sure
cures" for grippe and pneumonia. "Rosy teachers look better in the
schoolroom than the sallow sort," is surely a good introduction to a
new food. Woman's vanity sells many a remedy advertised to counteract
the "vandal hand of disease, which robs her of her beauty, yellows and
muddies her complexion, lines her face, pales cheek and lip, dulls the
brilliancy of her eye, which it disfigures with dark circles, aging her
before her time." Who in your town is as good a friend to "owners of
bad breath" as the advertiser who tells them that they "whiff out odor
which makes those standing near them turn their heads away in
disgust"? The climax of effective educational advertising as well as of
consummate presumption and villainy is reached in the notice of an
alcoholic concoction that uses the headline, "Medical Supervision
Needed to Prevent the Spread of Consumption in the Schools." Thus
grafting itself on the successful results of the medical examination in
the Massachusetts schools, it enlists the aid of teachers, trades on
the fear of tuberculosis, even indorses the fresh-air treatment. So
convincing was this appeal that it was reprinted in the news columns
of a daily paper in New York as official advice to school children.

    [Illustration: Don't Poison Baby.]

So clever are these methods of advertising and so successful are they
in reaching great numbers of people, that if reputable physicians would
take lessons of them, they might conduct a health crusade that would
exterminate tuberculosis, diminish the use of alcohol and tobacco, and
save thousands of babies that die unnecessarily. The theory of
patent-medicine advertising is sound. It emphasizes the joys of health,
the beauty of health, the earning power of health. It adapts its
message to season, event, and need. It offers testimonials of real
persons cured. It is all-appealing, promising, convincing,--a fearful
menace to health when the remedies offered are dishonest, a universal
opportunity for promoting health if the cure is genuine.

A classic example of health advertising that promotes health is
Sapolio. The various hygiene lessons that have promoted Sapolio have
done much to raise the standard of living in the United States. Few
eminent physicians have done so much for public health as the "Poor
M.D. of Spotless Town who scoured the country for miles around, but the
only case he could find was a case of Sapolio."

Recent press discussions about furnishing free eyeglasses to the
children in the public schools have so enlightened people as to the
need for expert examination of their eyes that opticians will be forced
to employ competent oculists to make the preliminary examination and to
see that the glasses are properly adjusted. In spite of the long
mis-education by makers of corsets, the persistent advertising of "good
health" and "common-sense" waists has gained an increasing number of
recruits from the ranks of the self-persecuting. It is only a matter of
time when the term "stylish" will be transferred to the advocates of
health, because advertisers who tell the truth will, if persistent,
gain a larger patronage than advertisers of falsehoods; there is
profit in retaining old customers. The advertisement of a window device
for "Fresh air while you sleep" will make prevention of tuberculosis
more profitable than "sure cures" that lie and kill.

A man deserves profit who sends this message to millions of readers:

  There are three kinds of cleanliness:

  First, the ordinary soap-and-water cleanliness.

  Second, the so-called "beauty" cleanliness.

  Third, prophylactic cleanliness, or the cleanliness that "guards
  against disease."

But the man who sells soap ought to be the one to use this
advertisement, not a man who sells toothwash that, when pure, is little
better than water, that is seldom pure, and that always hurts the
teeth. Many children and adults are being cured of flat foot by men who
make money by selling shoes designed to strengthen the arch of the
foot. Millions would never know how to discover the evil effects upon
themselves of coffee and alcohol except for money-making
advertisements. Little Jo's Smile taught a nation that the majority of
crippled children are victims of neglect on the part of adult
consumptives.

Certain it is that advertising is an art promoted by the severest
competition of the cleverest brains. It is a force which we cannot
afford to ignore. If we can harness it to the promotion of aids to
health, it will do more good than all the hygiene books ever written.
To this end we must educate ourselves to distinguish between goods
which do what they profess to do and those which do not. A good eye
opener would be to keep for a week clippings from a high-priced daily
paper, a penny daily paper, and one or two representative magazines,
including a religious paper. Teachers and parents can very easily
interest children in such clippings. Moreover, they can use the
bulletin method, the stereopticon exhibit, the _cumulative
illustration_ of a fact, which is the essence of successful
advertising. Boards of health can use all the typographical aids to
clear understanding,--cuts, diagrams, interesting anecdotes. In New
York both the health board and the school board have issued circulars
and given illustrated lectures, some of them being in school and some
on public squares. Medical and sanitary societies and other educators
can be induced to follow what a successful business man has called the
three cardinal rules of advertising:

  First, put your advertisement where it will be seen. (Tell your
  story where it will be heard.)

  Second, write it so that people will read it. (Tell it so that
  people will understand it.)

  Third, tell the truth, so that people will believe it.



CHAPTER XXXIX

IS CLASS INSTRUCTION IN SEX HYGIENE PRACTICABLE?


Among remedies for preventable disease and preventable poverty, the
following was urged at a national conference for the betterment of
social conditions: "We have been too prudish. Because we have been
unwilling to teach school children the evils of violating sex hygiene,
we have been unsuccessful in combating evils justly attributable to
ignorance on the part of girls as to the duties and dangers of
motherhood." This point of view is shared by so many men and women that
a national body was organized in 1905 to promote the teaching of sex
hygiene,--the Society for Sanitary and Moral Prophylaxis. This society
has its headquarters in New York, and distributes at cost lectures and
essays. The second of its educational pamphlets is addressed to
teachers, and is entitled "Instruction in the Physiology and Hygiene of
Sex." The introduction asks eleven questions of the teachers as
follows:

  1. Do you wish a pamphlet on sex subjects to hand to your pupils?
  Why?

  2. Do you wish separate pamphlets for boys and girls?

  3. For what age limits and social conditions do you wish them?

  4. What topics do you wish the pamphlets for boys to "handle"?

  5. What topic do you wish the pamphlet for girls to "handle"?

  6. If you think one pamphlet sufficient for both sexes, what
  should it consider?

  7. How far do you go in teaching sexual hygiene or reproduction?
  By what method?

  8. What special difficulties do you find in teaching it?

  9. What special need of teaching it have you found?

  10. What special benefits (or otherwise) have you noticed from
  teaching it?

  11. What criticisms (favorable or otherwise) do you encounter?

The difficulty of introducing formal instruction in sex hygiene, even
in the upper grades of public and private schools, is hinted at in the
pamphlet. The purpose of the publishing society as given in its
constitution is "to eliminate the spread of diseases which have their
origin in the social evil." Although sex hygiene does not begin with
sex immorality, almost every text-book on sex hygiene, and almost every
pamphlet urging class instruction in sex hygiene, begins with sex
immorality. Yet only the exceptional school child is in danger of
violating sex morals, while every school child needs instruction in sex
hygiene.

Instruction in sex hygiene, whether at school or at home, should deal
with sex normality, sex health, sex temperance. Instruction in sex
immorality is objectionable, not merely because it offends prudists,
not because it is difficult, but because it can be shown by experience
to be less efficacious than training in sex health.

To expect fear to prompt sex hygiene is to make a mistake that has
retarded the development of sound measures in the treatment of
offenders against criminal law. For centuries man failed in attempts to
fit the punishment to the crime. To deter men from committing crime by
holding up a threat of prolonged and dreadful punishment has been found
futile. Individuals take the risk because they think they will escape
detection. It is an axiom of criminal procedure that a would-be
offender is deterred by the certainty, not by the severity, of
punishment. The modern theory of probation is, that children and adults
may be best led away from evil practices by crowding out old influences
with newer and stronger interests. Occupations that are wholesome are
made to rival diversions or occupations that are harmful and criminal.

    [Illustration: OBJECT LESSONS FOR INSTRUCTION IN SEX HEALTH
    Note the uncomfortable, unhealthy overdressing]

Abnormal conditions of mind and body in regard to sex can almost always
be traced to general physical ill health or to an unhealthy moral
environment. Cure and prevention require two kinds of treatment within
reach of parents and teachers: (1) build up the child's physical
condition; and (2) give him other interests. Proper physical care, and
work adjusted to body and mind, may be relied upon to do infinitely
more to promote sex hygiene than instruction, either at home or at
school, in immoral sex diseases. That sex morality is weak and
untrustworthy which is based upon fear of sex diseases. Like alcoholism
and nicotinism, the saddest results of sex diseases are social and
economic. The strongest reasons against such diseases are economic and
social, not physiological.

    [Illustration: THE STUDY OF INFANT HEALTH IS CONDUCIVE TO
    PURE-MINDEDNESS
    Note the simple, comfortable, hygienic dress]

Once having made up our minds to concentrate the teaching of sex
hygiene upon sex health rather than upon sex immorality, upon sex
functions rather than upon sex diseases, the chief objection to school
instruction and to instruction in class will disappear. Our school
text-books in history, literature, and biology abound in references to
sex distinctions, sex functions, and sex health. In enumerating the
daily routine of health habits I mentioned daily bathing of the armpits
and crotch. There is nothing in this injunction to offend or injure a
boy or girl. If studies and physical training are to be adapted to
physiological age, and if children are to know why they are graded
according to physiological age as well as mental brightness, we shall
soon be talking of mature, maturing and not-yet-maturing girls and
boys, so that everybody will be instructed in sex hygiene without
offense. Any teacher who can explain the family troubles of King Henry
VIII without becoming self-conscious can easily learn to look a class
of girls and boys in the face and explain how a mother's health will
injure her baby before its birth, why breast-fed babies are more apt to
live than bottle-fed babies, why it is as important for the mother to
keep a nursing breast absolutely clean as to clean the nipple of a
nursing bottle. Words whispered by children, or marked in dictionaries,
to be stealthily and repeatedly looked upon and talked over with other
children, lose all their glamour when pronounced by a teacher.

In these days of state subsidy of school libraries the child is hard to
find who has not free access to books of fiction full of voluptuous
allusions that make undesirable impressions which only blunt, candid
discussion of sex facts can make harmless. Children now learn, whether
in fashionable private schools or crowded slums, practically all that
is lascivious and unwholesome about sex. For teachers to explain that
which is wholesome and pure will disinfect the minds of most children
and protect them against miseducation.

Class instruction in hygiene is practicable for all matters pertaining
to normal sex health. Girls of thirteen should be taught in classes the
fact and meaning of menstruation, and its grave importance to the
health, in order that they may care for themselves not only before,
during, and immediately after the menstrual period, but throughout the
month, in order that menstruation itself shall not be unnecessarily
painful, enervating, and harmful to efficiency. It is not yet advisable
to discuss dangers peculiar to girls or dangers peculiar to boys in
mixed classes. Generally speaking, it is undesirable that men teachers
discuss girls' troubles with girl pupils. But why should it not become
possible for women teachers to explain health dangers peculiar to girls
to classes of boys?

Individual instruction in sex matters should be reserved for the
diseased mind, for the boy or girl who has already been morbidly
instructed. Discussion of immoral sex diseases should be confined to
individual talk. This field teachers have already entered. Repeated
physical examination of children will detect symptoms of sex
abnormality. When detected, the fact and the meaning should be
explained to the individual by school physician, school nurse, or
school-teacher. While much can be done through mothers' meetings and
through individual instruction of parents, the most effective means of
improving the general attitude towards sex health is to give the simple
truth to the millions of children who have not yet left school. Armed
with the A B C's of sex hygiene at school, boys and girls will be
prepared to select employment, associates, and newspapers that will
permit normal, healthy sex development. Men and women who are leading
normal lives, who have plenty of work, sleep, fresh air, nourishing
food, amusement, and exercise are unlikely to be sexually abnormal.

After all, the question of instruction in sex hygiene will quickly
settle itself when it is made a condition of a teacher's certificate
that the applicant shall himself or herself know the personal and
social reasons for sex health. The woman who does not know how to take
care of her own sex health, the man who is ignorant of a woman's
special needs, cannot do justice to the requirements of arithmetic,
language, and discipline. Whether men and women teachers are mentally,
physically, and morally equipped to be sexually normal and to teach the
law of sex health will be disclosed as soon as trustees and
superintendent dare to ask the necessary questions. Whether an
instructor's personality will enable him to fill the minds of children
with interests more wholesome, more absorbing than obscene stories or
morbid sex curiosity can also be learned. When school-teachers are
prepared to teach the social and economic aspects of general health
they will quickly solve the problem of instruction in sex health.

Just one word about country morality. It is customary to deplore the
influence of large cities on the young. Of late, however, there has
been a tendency to question whether, after all, sex morality is apt to
be higher in the country than in the city. Parents and teachers in
small towns and in rural districts will do well to take an inventory of
the influences surrounding their children. It will always be impossible
to give country children city diversions. One great disadvantage of
country children frequently counter-acts the beneficial influence of
out-of-door living; namely, isolation. The city child is practically
always in or about to be in the sight of, if not in the presence of,
other people. Numbers and close contact with people, though they be
strangers, mean restraint and pervading social conscience. City
children find it difficult to have good times in pairs. No amount of
instruction of rural pupils in sex hygiene will take the place of
amusements and entertainments for groups of children, forming thus a
special antidote for "two's company, three's a crowd." Liberating and
standardizing normal intersex relations and discouraging cramped social
intersex relations are more urgent needs than instruction in sex
diseases. A working environment that permits pure-mindedness will do
more to inculcate a reverence for sex cleanliness and for parenthood
than lectures and essays on moral prophylaxis.



CHAPTER XL

THE ELEMENT OF TRUTH IN QUACKERY; HYGIENE OF THE MIND


Patent medicines and other forms of quackery could not pay such
enormous dividends unless there was some truth in their claims; unless
their victim found some beneficial return for his money. They win
confidence because they raise hopes and combat fear. They do cure
thousands of people of fear and of "ingrowing thoughts." In so doing
they remove the sole cause of much disability.[17] In so doing they are
merely applying by wholesale principles of mental hygiene that are
legitimately used by physicians, tradesmen, teachers, and parents who
deal successfully with nervousness.

Quackery makes cures and makes money because of the undoubted influence
of mind in causing and in removing those ailments that originate in
fear, imagination, or morbid introspection. A few years ago a little
out-of-the-way town in southern Minnesota was visited by train loads of
the sick and crippled from miles around. Miraculous cures were heralded
broadcast. Life-long cripples left wagon loads of crutches and braces
to decorate the little church with the enchanted transom. People who
had not walked for years returned to their homes cured. The marvels of
famous shrines were fast being duplicated when the church authorities
at St. Paul issued an explanation of the alleged miraculous appearance
of biblical figures in the transom of the new church. The outlines of a
mother carrying a baby had been vaguely impressed in the transom glass
when molten. When the mystery was explained the excursions and the
cures stopped.

Nearly every physician and practically every medical charlatan can
count scores of cures of ailments that had previously defied the skill
of eminent physicians. A child's bumps actually stop aching after the
mother or nurse kisses the abused spot. Invalids forget their
limitations under stress of some great excitement or some intense
desire for pleasures incompatible with invalidism. Many a physician of
reputation owes his success in great part to the discriminating use of
the _placebo_,--a bread pill designed to supplant the patient's fear
with confidence. Hypnotism and "suggestion" have been successfully used
to cure alcoholism and to fill patients' minds with conviction stronger
than the fear that produced the sickness. A well-known writer and
preacher cures insomnia by auto-suggestion, telling himself he is
sleepy, is very sleepy, is going to sleep, is almost asleep, is fast
asleep. Treatment by osteopathy has been followed by disappearance of
diseases that cannot possibly be cured by osteopathy. Christian Science
has restored to health and happy usefulness hundreds of thousands of
chronic invalids. Verily is hygiene of the mind an important factor in
the civics of health.

Fear can originate with mind. Fear produces fear. Fear disarranges
circulation of the blood and the nourishment of muscle and nerve. Fear
can produce many bodily disorders which in turn feed fear. Fear cannot
last unless bodily symptoms exist or arise to justify and feed it. Fear
can be cured and removed in two ways: (1) by driving away fear and
releasing bodily disorders from its thraldom; (2) by removing the
disorders and making fear impossible to the logical mind. An enforced
sea voyage begins with the disorder; a clever, buoyant physician begins
with the fear. Patent-medicine proprietors, quacks, and fakes of every
kind begin by displacing the fear with hope or cheer; the physical
disorders frequently vanish by the same window as fear. For _fear_
write _self-pity_, _morbid self-consciousness_, _hypertrophied
submission_; to _hope_ and _cheer_ add _smile_, _relaxation_, and
_zest_; and we have the chief elements of mental hygiene and the reason
why intelligent as well as unintelligent men like to be swindled by
medical or other quacks.

The social aspects of mental hygiene are particularly important. Once
admitting the power of the mind to decrease vitality, we recognize the
duty of seeming happy, buoyant, cheerful, vital, at least when with
others, for the sake of others' minds and bodies. Secondly, we find the
duty to refrain from commenting on others' appearance in a way that
will start "ingrowing thoughts." A "grouchy" foreman can give blues and
indigestion to a roomful of factory girls. A self-pitying teacher can
check the heart beats of her class, cause arteries and lungs to
contract, and deprive the brain of fresh blood. An oversympathetic
neighbor can put a strong man to bed by discovering signs of nervous
disintegration. Shall we gradually work out a code of mental hygiene
rights and nuisances that will require compulsory notification of the
"blues" and compulsory segregation of every person unable to "smile
dull care away"? Is the time coming when boards of health will
accompany infection leaflets with messages such as this from James
Whitcomb Riley:

    Talk health. The dreary, never-changing tale
    Of mortal maladies is worn and stale.
    You cannot charm or interest or please
    By harping on that minor chord, disease.

    "Whatever the weather may be," says he,
    "Whatever the weather may be,
    It's the songs ye sing, and the smiles ye wear,
    That's a-making the sun shine everywhere."

Mental hygiene has hitherto enjoyed an evil reputation and has been
condemned to generally evil associations, because the rank and file
have been ignorant of hygiene of every kind. Medical science has so
long enveloped itself in mystery that it is in danger now of becoming
discredited and of falling heir to the mantle of quackery.

Quacks often get social and economic results more agreeable to the
patient and more helpful to society than orthodox medicine. "When
traitors become numerous enough treason becomes respectable." So when
mental hygiene succeeds, it becomes science for the case in question,
and for that case orthodox medicine loses its respectability. For the
layman there is no safety except in having intelligence enough to know
whether his trouble has defied the sincere application of mental
treatment, auto-suggestion, and loyalty to the health ideal.

Mental hygiene admits the existence of dental cavities, scarlet fever
germs, adenoids, cross-eyes, uncleanliness, broken legs, inflamed eyes,
overeating. The organic, structural defects which are to be sought by
physical examination are all admitted by mental hygienists. They work
for an orderly, daily routine and affirm the penalties of its
violation. They would even favor going periodically to a physician,
provided that we never go to him except when organic or structural
disorders may safely be assumed from the fact that cheer and relaxation
treatment does not give relief. Unhygienic living and mind cure cannot
go together. The mind that tries to deceive itself cannot cure either
mind or body. The man who violates the habits of health cannot patch
his injuries or conceal the ravages of dissipation by mental hygiene.
Here is the great advantage of knowing how to live hygienically, of
observing habits of health, and then concerning ourselves not with
ourselves, but with conditions of living for all those whose health can
be affected by our health, or can affect our health and efficiency.

The most recent practical application of mental hygiene for moral and
physical uplifting is the "moral clinic" or "psychotherapeutic" clinic
established by Emmanuel Church in Boston. This clinic represents the
union of three forces,--religion, medical diagnosis, mental hygiene. As
a result of this alliance it is anticipated that both religion and
medicine will be humanized, socialized, vitalized, made to express more
accurately and more consistently that community consciousness and that
yearning for equal opportunity and equal happiness which constitute the
profoundest religious impulse. No person is treated at this moral
clinic whose trouble is organic or structural. In determining whether
the case belongs to this clinic, expert medical diagnosis is relied
upon rather than the credulity of the patient or the zeal of the
clergyman. Medical scientists of highest repute can consistently
coöperate, because they recognize two scientific facts: first, that
many troubles are due primarily to mental disorder; and, second, the
greatest asset of the human mind is that something called religion,
which is no less real and potent because peculiar to each individual.
Whatever may be that deepest current of thought and feeling, whatever
that synthetic philosophy, that explanation of being, which guides my
life, it can be of inestimable aid if enlisted in an effort to secure
normal vitality of mind and body.

The controlling motive of the moral clinic has proved infectious. There
is reason to believe that the alliance of medicine and religion has
come to stay, and that the present excitement over psychotherapeutics
will settle down into a scientific utilization of religious motive and
medical knowledge to prevent mental and moral disease. Unwholesome,
morbid, self-centered thought is driven out. A recognition of others'
claims takes its place. Hypnotism, suggestion, and group enthusiasm are
used to their utmost possibilities. The success of the Boston moral
clinic is due to establishing in the mind of the neurasthenic, the
alcoholic, the world-weary, and the purposeless a truer conception of
the pleasures that result from vitality and from altruistic effort.

It is too early to classify by kind of functional disorder the patients
treated. Results from one patient have been described in newspapers as
follows:

  A school-teacher, as a result of nervous collapse, had lost
  control, began to fear the children under her care, and thought of
  relinquishing her profession. She was instructed in the art of
  self-control and the control of others; the notion of fear was
  dislodged and a sentiment of love for her little charges took its
  place. In the course of a few weeks this conscientious and
  experienced teacher regained her poise and found herself
  performing her duties better than ever before.

Many alcoholics have for months given evidences of complete cure.
Stories almost incredible are quickening pastor and physician alike
throughout the country. After individual treatments are given, after
religious motive is appealed to, and the soul stirred to heed the
lessons of religion, medicine, and sociology, patients are given the
work cure. Thus a branch of social service is established, where
after-treatment is given to the patient whose thoughts have been turned
from himself to others. All of a sudden the church finds itself in need
of definite knowledge as to opportunities for altruistic work, as to
definite community needs not met, as to people in distress who can be
relieved by volunteers, as to agencies which can be called upon to
coöperate both in treating the individual and in utilizing his energies
for others' benefits.

Because a relatively small percentage of men and women are
neurasthenic, melancholy, morbid, alcoholic, the lesson of the moral
clinic is most serviceable when extended for the benefit of the "not
yet alcoholic" and the "not quite neurasthenic." In other words,
individuals in thinking of themselves must learn the health value and
soul value of purpose that centers in others' happiness. That thing
which we have called tact in personality, and which in the past was
discovered by induction, namely, the law of mental hygiene and the
control it gives over others' health, must be taught in schools to
children by wholesale, must be taught in medical and theological
schools, to all physicians and all pastors. This alliance of medicine
and religion, which is at present confined to one or two moral clinics,
should be incorporated into education, into social work, into church
work, becoming thus a part of civilization's normal point of view.

Mental hygiene cannot survive conscious violation of the fundamental
laws of medicine and religion. The alliance of medicine and religion
will prove utterly futile unless habits of living and of thinking are
inculcated that conform to nature's law of self-preservation and to
God's law of brotherly love. Self-centered religion, like self-centered
medicine, destroys both body and soul.

FOOTNOTES:

[17] The alliance of mental hygiene, medicine, and religion is discussed
in the Emmanuel Church book, _Religion and Medicine; the Moral Control
of Nervous Disorders_; also in its bulletins, _Religion and Medicine_.



CHAPTER XLI

"A NATURAL LAW IS AS SACRED AS A MORAL PRINCIPLE"


When a grammar-school boy I learned from the game "Quotations" that
Louis Agassiz, scientist, had written the sentence with which I
introduce a final appeal for living that will permit physical and civic
efficiency. Agassiz has been called "America's greatest educator," and
again "the finest specimen yet discovered of the genus _homo_, of the
species _intelligens_." The story of his long life as teacher of
teachers reads like a romance. But among his gifts to education and
citizenship none can be made to mean more than the simple proposition
that natural law is as sacred as a moral principle. All who remember
this "beatitude" will be helped to solve many perplexing problems of
dress, diet, play, education, philanthropy, morals, and civics.

Reverence for the natural carries with it a distaste for the unnatural.
Those who obey natural law soon come to regard its violation as a
nuisance when not immoral. On the other hand, compromise with the
unnatural, like compromise with vice, quickly leads first to toleration
and thence to interest and practice. Therefore the importance of giving
children Agassiz's conception of the sacredness of the laws that govern
the human body. A passion for the natural is a strong foundation for
habits of health and a priceless possession for one who wishes to know
morality in its highest sense.

"Natural" is less attractive to us than it would be had Agassiz first
interpreted it for us rather than Rousseau or present-day exponents of
"the simple life," "back to nature," and "back to the land." It is too
often forgotten that no one sins against natural law more grievously
than the primitive man or the isolated man in daily contact with
non-human nature. Communing with nature seems not only to require
communing with man but to give joys in proportion as the nature lover
is concerned for the human society of which he is a part. Natural law
does not become a moral principle until man is benefited or injured by
man's use of nature's resources within and about him. Natural living
according to natural law must be something sounder, more beautiful, and
more progressive than can be read into or out of mountains, trees,
brooks, and sky, or primitive society.

Natural law points to a Nature Fore as well as a Nature Back, to a
Nature Up and Beyond as well as a Nature Down and Behind. The Nature
that was yesterday will not do for to-morrow, any more than a man is
willing to give up his nature aspirations for the careless, animal ways
of romping childhood. Civilization is constantly urged at each step to
repeat the prayer of Holmes's old man who dreams for the Autocrat of
the Breakfast Table:

    Oh for one hour of youthful joy!
      Give back my twentieth spring!
    I'd rather laugh a bright-haired boy
      Than reign a gray-beard king!

    Off with the wrinkled spoils of age!
      Away with learning's crown!
    Tear out life's wisdom-written page,
      And dash its trophies down!

    One moment let my life blood stream
      From boyhood's fount of flame!
    Give me one giddy, reeling dream
      Of life all love and fame!

But every experiment in turning back exalts the present and the future.
Gifts as well as problems are seen to come with complexity, and
civilization flatly refuses to relinquish these gifts. Sound maturity
is better than youth or age:

    The smiling angel dropped his pen,--
      "Why, this will never do;
    The man would be a boy again,
      And be a father too!"

Problems of health and of civics can never be solved by appealing to
Nature Back, when only the few could be healthy, when one baby in three
died in infancy, when old age was toothless and childish, when
infection ravished nations, when the average life was twenty years
shorter than now, and when unspeakable filth was tolerated in air,
street, and house. They can all be solved by appeals to Nature Fore,
which holds up an ideal of mankind physically able to enjoy all the
benefits and to conquer all the dangers of civilization. It is not
looking back, but looking in and forward that reveals what natural law
promises to those who obey it.

By using numerous tests which have been suggested in preceding chapters
we can learn how far we and our communities obey natural law when
working and playing. Health for health's sake has nowhere been urged.
On the contrary, healthful living has been frankly valued for its aid
to efficient living by individual and by community; wherefore the
emphasis upon others' health and upon the civic aspects of our own
health. Tests furnish us with the technic necessary to efficient
living; civics, with the larger reason; natural law, with the "pillar
of fire by night" to help us choose our path among habits and pleasures
whose immediate results upon efficient living cannot easily be
determined.

Fashions, tastes, mannerisms, personal indulgences, have been left for
Agassiz to deal with. Generally speaking, we all know of numerous acts
committed and numerous acts omitted in our daily routine that convict
us of not living up to our knowledge of physiology and hygiene,--wearing
tight shoes or tight corsets, drinking strong coffee, smoking, reading
while reclining, failing to insure clean air and clean bodies. Then
there are other acts whose omission or commission violate no physical
law so far as we can see, but whose unnaturalness we concede,--putting
chalk on the eyebrows, wearing false hair or curious puffs, putting
perfumery in the bath or on handkerchiefs, assuming artificial poses of
body or mouth. These violations of natural law are forced upon us by
"style" or "custom" or family convenience. When we come to choose
between following fashions and disobeying them, we generally decide that
it is better to do a foolish or slightly harmful thing than to occasion
criticism, mirth, or even special notice by our dress or our
abstemiousness.

Last night I went to a dinner party at eight. I ate and ate a great
variety of palatable foods that Nature Back never knew. After two hours
of eating I imbibed for two hours the tobacco smoke of the gentlemen
who made up the party. I knew that eight o'clock was too late for me to
begin eating, that two hours was too long to eat, that the tobacco of
others was bad for my health and for to-day's efficiency. All this I
knew when I accepted the invitation to dinner. I went with no intention
of preventing others from smoking or of lecturing my host or his chef
or his guests for the unhygienic practices of our day. Yet the physical
ills were more than offset by certain definite gains to the school
children of New York that will result from last night's meeting.
Natural law was abated in part. But I declined certain dishes that
would not agree with me, helped myself sparingly of many dishes,
avoided tobacco and wines, and by a three-mile walk in the open air, a
bath, and a good long night's sleep have almost recovered my right to
talk of the sacredness of natural law.

Nature Back says I should not have gone to this dinner. But I was
compelled to go. I know I am going to others. I cannot do my work
unless I overdraw my current health account. Nature Fore tells me that
effective coöperation with others will frequently require me to eat at
the dinner hour of others, to retire at others' sleeping time, to wear
what others will approve, to violate natural law. But Nature Fore also
tells me how to build up a health reserve so that I can meet these
emergencies without endangering my health credit.

Nature Back demands "dress reform." Nature Fore tells me that I can
march in step with my contemporaries without either attracting
attention or discrediting and affronting natural law. Passion for the
natural has effected numerous reforms in dress, diet, and social
habits, until commerce provides a natural adaptation of practically
every fashion. With regard to few things is it necessary to-day for any
one who reads magazines to do violence to bodily health for fashion's
sake. We may wear what we will, eat what we prefer, decline what is
unnatural for us, without inviting censure. The debauches of those
unfortunate people who live an unnatural, purposeless existence, affect
such a small number that their laws need not be considered here.
Natural law makes obedience to itself attractive; hence commerce is
rapidly learning to cater to distaste for the unnatural. With few
exceptions, only temporary concessions to unnatural living are required
in order to dress and act conventionally.

Nature Back throws little light upon conditions necessary for modern
labor. It can do nothing but demand the abolition of the factory, the
big store, the tenement, the school. Nature Fore says we cannot abolish
the means of working out the highest forms of coöperation. But we can
make them compatible with natural living. We can modify conditions so
that earning a livelihood will not compel workers to violate natural
law at any or all times. The greatest need of factory and tenement
reform is for parents and teachers to make a religion of Nature Fore
and to instill its principles in the minds of children. Parents and
teachers must live the natural before they can make children love the
natural. Parents and teachers cannot possibly be natural in this day,
cannot live or love natural law unless they know the machinery by which
their communities are combating conditions prejudicial to health,
morals, and civic efficiency.



INDEX


Adenoids. See _Mouth breathing_

Administration, health:
  steps in evolution, 11-22;
  knowledge of needs, 220;
  machinery, 302-309;
  in combating alcoholism, 362;
  departments of health:
    (1) New York City, 26, 27, 47, 48, 61, 71, 84, 296-298, 302;
    (2) general, 265, 281

Advertisements:
  motives for, 8;
  for dental parlors, 100;
  for consumptives, 234;
  by physicians, 281;
  educational, in newspapers and magazines, 323;
  "no smoking" signs, 365;
  of patent medicines, 369;
  that promote health, 378-383

Agassiz, Louis, 398, 400

Air, night, 216.
  See _Fresh air_

Alcoholism, 343-362;
  compulsory instruction in, 3;
  insurance companies against, 7;
  disqualifies for railroad service, 193;
  depletes vitality, 201;
  results, 209;
  Hartley's fight against, 253;
  injures the tuberculous, 274;
  ineffective ways of combating, 343;
  incited by bad living conditions, 348;
  injury to negroes, 350;
  so-called moderate use, 358;
  labor unions blacklist drunkards, 361;
  social dangers, 386;
  mental hygiene, 392, 396

Animal sanitation, 252, 260, 307

Association for Improving the Condition of the Poor, New York, 177,
    236, 253


Babies. See _Milk_

Bathing:
  motives for, 8, 13;
  a social requirement, 14;
  cold-water, 214

Beauty, reason for health, 15

Bibliography:
  A Bureau of Child Hygiene (Bureau of Municipal Research), 298;
  Annals of a Quiet Neighborhood (MacDonald), 110;
  Aristocracy of Health (Henderson), 208;
  Bitter Cry of the Children (Spargo), 33, 167;
  Bulletins of Emmanuel Church, 391;
  Bureau of Municipal Research, publications, 298;
  Care of Dependent, Defective, and Delinquent Children (Folks), 174;
  Charities and the Commons, 325;
  Child Growth (Newsholme), 120;
  Children of the Nation (Gorst), 33;
  Children's Diseases, 326;
  Clean Milk for New York City, 255;
    clippings, 370, 382;
    white-plague scrapbook, 250;
  Committee on Physical Welfare of School Children, programme, 166,
    three studies, 168;
  Crusade against Tuberculosis (Flick), 229;
  Dangerous Trades (Oliver), 203;
  Dental Catechism, 94;
  Dentistry, lectures and treatises, 274;
  Deterioration, Physical, report on, 339;
  Development of the Child (Oppenheimer), 110;
  Dietetic and Hygienic Gazette, 326;
  Efficient Life (Gulick), 208;
  Environment of Child at School (North), 142;
    Pure Food (U.S. Department of Agriculture), 379;
  Good Health, 326;
  Health of the School Child (Mackenzie), 132;
  Heredity (Thompson), 336;
  How to Give Wisely, 355;
  International Congress, Tuberculosis, programme, 246-249;
  Journal of Nursing, 326;
  Making a Municipal Budget (Bureau of Municipal Research), 306;
  Milk Industry, 252;
  Municipal Sanitation in the United States (Chapin), 304;
  National Hospital Record, 326;
  New Basis of Civilization (Patten), 33;
  New Jersey Review of Charities and Corrections, 325;
  Pediatrics, 326;
  Physical Culture, 326;
  Poverty (Hunter), 167;
    press and magazines, 322-328;
  Prevention of Tuberculosis (Newsholme), 229;
  Principles of Relief (Devine), 174;
  Principles of Sanitary Science and the Public Health (Sedgwick), 304;
  Psychological Clinic, 106, 326, 330;
  Real Triumph of Japan (Seaman), 23;
  Religion and Medicine (Emmanuel Church), 391;
  reports of schools, 166;
  reports of schools and health, 310-321;
  reports of institutions and societies, 327;
  reports of state and national conferences of charities and
    corrections, 327;
  reports of United States bureau of labor, 203;
  Sanitation of Public Buildings (Gerhard), 139;
  School Reports and School Efficiency (Snedden and Allen), 311;
  Social Order and the Saloon (Fox), 351;
  Study of Children and their School Training (Warner), 110;
  Study of School Buildings in New York City, 289;
  Teeth and their Care (Hyatt), 94;
  Training of the Human Plant (Burbank), 120;
  Typhoid Fever (Whipple), 13, 16;
  Uncommercial Traveller (Dickens), 46;
  Unconscious Mind (Schofield), 110;
  Vital Statistics (Newsholme), 131

Biggs, Hermann M., M.D., 237, 251, 271, 274, 295

Boston, 34, 155, 161, 241, 250, 290, 395

Boston Society for the Relief and Study of Tuberculosis, 155

Boyd, Emma Garrett, 355

Brannan, John Winters, M.D., 240

Breath, bad, 360, 379

Brightness, abnormal, 104-106

Bronchitis, 67

Brookline, 34

Budget:
  should provide for cleansing, 61;
  and tuberculosis, 237;
  annual health programme, 306;
  reforms in New York City, 350

Burbank, Luther, 120

Bureau of Municipal Research, 298, 306

Butler, Nicholas Murray, LL.D., 330, 332


Cabot, Richard C., M.D., 181

Calmette's Eye Test, 238

Carnegie Foundation, 285

Caroline Rest, 70, 267

Catching diseases:
  cost of, 16;
  unenforced laws, 30;
  steps in eradicating, 31;
  germ sociology, 57, 71;
  favorable soil at school, 58;
  instruction concerning, 62;
  mouth a breeding ground for, 63;
  information for bathers, 64;
  dangers of, 131;
  reasons for national board of health, 135;
  cost of, in New York City, 272;
  remedies urged, 384

Charity Organization Society, New York, 236, 239

Chicago, 34

Chicken-pox, 64

Child Hygiene, Bureau of:
  working-paper tests, 192;
  established, New York City, 298;
  programme, 299

Child labor:
  compulsory school attendance, 140;
  welfare or age test, 142;
  movement's limitations, 185;
  national and local committees, 33, 192;
  physical-fitness tests, 194

Children's Aid Society, New York, 56, 93

Child-saving agencies:
  coöperation with schools, 174-183;
  do-nothingism in, 332

Chorea. See _Nervousness_

Christian Science, 276, 392

Christmas shopping, 227

Cigarettes. See _Tobacco_

Cincinnati, 118

Cleanliness:
  acquired taste, 14;
  beauty of, 96;
  personal uncleanliness, 210;
  cost of, 216;
  dry cleaning dangerous, 244;
  in fighting tuberculosis, 250

Cleveland, Ohio, 294

Clippings:
  scrapbook, 250;
  envelope method, 324;
  advertisements, 382

Coffee, strong, 401

Colds, 63-69

College, physical tests, 39

Committee on Physical Welfare of School Children, New York, 39-41, 166,
    168, 178, 286, 290, 311

Compulsory laws:
  school hygiene, 3;
  purpose of, 33;
  registration of catching diseases, 57;
  removal of tuberculosis cases, 237;
  notification of tuberculosis, 237, 274;
  hygiene, for private schools, 283;
  to remove physical defects, 288;
  restricting alcoholism, 343

Conference on Summer Care of Babies, New York, 260

Congestion:
  evils avoided, 290;
  and alcoholism, 348

Conjunctivitis, 71. See _Eyes_

Connecticut's school reports, 318

Constipation, 210, 216, 347, 357

Consumption. See _Tuberculosis_

Corsets, 381, 401

Cost:
  of preventable diseases, 16;
  of bad breath, 98;
  of diseases to nation, 135;
  of tuberculosis, 245

Crampton, C. Ward, M.D., 129, 289


Dangerous trades, 191

Darlington, Thomas, M.D., 297

Death rates:
  of bronchitis, 67;
  of pneumonia, 67;
  how to reduce, 131

Defects, physical:
  index of community needs, 33-44;
  removable, of children, 22;
  schools manufacture, 139;
  income distribution, 169

Delinquency, and mouth breathing, 47

Dental Hygiene Council, 95

Dental sanitation, 89-103;
  surface for breeding germs, 63;
  dentists, 93;
  state organizations, 95;
  clinics needed, 171;
  insurance companies treat teeth, 204;
  family instruction, 245;
  indigestion, 272;
  early treatises, 274;
  advertising parlors, 281

Devine, Professor Edward T., 174

Diet:
  cooking lessons at home, 180;
  overeating, 201, 347;
  improper, 210;
  proper and regular, 212;
  adapted to need, 214, 401;
  kitchens, 267;
  irregular eating, 272, 347

Diet kitchens, 267

Diphtheria, 18, 65

Dispensaries and hospitals:
  dental supervision, 102;
  coöperate with schools, 174-183, 185;
  welfare nurse, 188;
  emergency, 227;
  to prevent duplication, 239;
  lack of, 240;
  teach baby feeding, 261;
  inefficient, 278;
  social interest of, 292

Doing things at school, 159-165;
  free meals, 44, 161, 171;
  may hurt, 181;
  cripple social agencies, 185, 189;
  danger of malpractice, 184, 189;
  analogous to model tenements, 186

Do-nothing ailments, 329-334


Ear trouble, 83-85;
  periodic tests for, 201, 207

Edinburgh, 70

Ellis Island, 238

Environment:
  health problem, 9;
  tests, 120, 320;
  injurious school, 139-150;
  effect on physique, 203;
  and tuberculosis, 229-251;
  do-nothing ailments, 329;
  within our control, 336;
  in combating liquor, 362

Epidemics, 18, 38

Epilepsy, 47, 49

Ergograph, 125-127

Erysipelas, 65

Ethics, professional, 81, 101, 281

Eugenics, and heredity, 336

European remedies, 159-165

Eye trouble, 72-82;
  in high school, 40;
  catching diseases, 69-71;
  caused by bad teeth, 89;
  eyeglasses, free, 161, 164, 171, 184;
  in business, 193;
  examination for adults, 201;
  tuberculin test, 238;
  inefficient inspection of, 300;
  teachers' test, 301

Examination, physical:
  of school children, 33-138;
  best test of health needs, 33-44;
  individual record of, 35, 312;
  Snellen test, 73, 77;
  of teachers, 153;
  for work certificates, 190-200, 237, 301;
  by railroads, 193;
  at West Point, 199;
  periodic after school, 201-207, 218, 228;
  semi-annual, 202;
  tuberculin tests, 240;
  stripped, at Leipsic, 289;
  follow-up work, 295-300;
  of teachers and sex hygiene, 389


Family:
  unit of social treatment, 174;
  examining parties, 237, 241;
  tuberculosis histories, 241

Fear and bodily disorders, 392

Flick, Lawrence F., M.D., 229

Follow-up work, 295-301

Fox, Hugh F., 351

Fresh air:
  others' standards of, 9;
  fiends, 66;
  outings, 176, 178;
  economic value of, 195;
  ventilation at school, 142;
  ventilation at home, 210;
  ventilation at work, 212;
  ventilation at sanatoriums, 214;
  ventilation at churches and theaters, 217.
  See _Air_


Georgia, 350

Germany, 160, 204

Germs, disease:
  in milk bottles, 14;
  isolation, 31;
  germ sociology, 57-71;
  dental sanitation, 89-103;
  locating germ factories, 238;
  tuberculosis, 234

Getting things done, 166-173;
  doing of highest kind, 183;
  study underlying causes, 189;
  by local agencies, 287

Glands, 88

Goler, George W., M.D., 196

Gorgas, William C., M.D., 59

Government. See _Administration_

Greenwich House, 287

Grenfell Association, 197

Grippe, 379

Gulick, Luther H., M.D., 123, 208


Habits of health, 208-217;
  combat tobacco, 364;
  mental hygiene, 394;
  and Nature Fore, 400

Hartley House, 287

Hartley, Robert M., 252

Havana, 60

Hawthorne Club, 287

Headache, 210

Heredity, 335-342

High schools need physical tests, 39

Hip trouble. See _Tuberculosis_

Home conditions:
  indexed by epidemics, 32;
  indexed at school, 33;
  among different incomes, 39;
  cooking instructions, 180;
  weighing parties, 241;
  score card, 337;
  promote alcoholism, 348

Hughes, Governor Charles E., 201

Hunter, Robert, 167

Hyatt, Thaddeus P., D.D.S., 94


Impetigo, 65

Income, 34, 38, 39

India, 108

Indigestion:
  anti-social, 10;
  due to teeth, 272

Individual record card, 35, 312-314

Industrial hygiene:
  educates laborers, 131;
  factory conditions, 221, 227;
  factory reforms, 403;
  employers, 3, 210, 218, 360, 367;
  employees, 202, 211, 219, 228, 360

Influenza, 65-68

Ingram, Helene, 177

Insomnia, 392

Inspection:
  of milk, 26, 259;
  score cards, 27, 29, 337;
  of school children, 43, 61, 296;
  of factories, 131;
  of milch cows, 260;
  of transmissible diseases, 295;
  of foods, 307

Instinct, motive to health, 12, 14, 94

International Congress on tuberculosis, 238, 245

Itch, 65


Japan, 23, 287, 309

Junior Sea Breeze, 267


Kansas City, 161

Kidney trouble, 217


Labrador, 197

Lavatories, public, 217

Laws:
  nonenforcement demoralizing, 4;
  define rights, 23;
  when not enforced, 25;
  should not injure health, 151;
  enforcement better than character, 219;
  regarding milk, 258;
  licensing practitioners, 280;
  need machinery, 303, 348;
  to control liquor, 343, 355;
  test of prohibition, 353;
  on patent medicine, 373;
  on pure foods, 379

Leipsic, 289

Louisiana, 350, 376

Lung trouble. See _Tuberculosis_


Machinery, health:
  unsatisfactory coordination, 296;
  necessary, 302-309;
  five elements, 303

Mackenzie, W. Leslie, M.D., 132

Magistrates:
  promote disorder, 173;
  enforce health laws, 303

Malnutrition, 35;
  income distribution, 39;
  signs and tests, 86;
  prevention of, 184;
  education of family, 241

Massachusetts, 74

Maxwell, Superintendent William H., 286, 288

Measles, 64

Mental hygiene, 391-397;
  blues, anti-social, 10;
  hospital welfare work, 182;
  moral clinics, 276, 291, 295;
  and insomnia, 392

Meyer, William, M.D., 47

Milk:
  unclean dairies, 10;
  scalding receptacles of, 17;
  carries typhoid, 18;
  inspector's outfit, 24;
  tests of protection, 25;
  score cards, 26, 259, 337;
  public should know, 219;
  fight for pure, 252-267;
  New York conferences, 255, 260;
  breast feeding, 266

Milk committee, New York, 258, 260

Minnesota, 45, 269

Misgovernment causes sickness, 10

Mitchell, S. Weir, M.D., 73

Montclair, 265

Mosquitoes, 59, 307

Motives, seven health, 11-22, 377

Mouth breathing, 45-56;
  and delinquency, 47;
  adenoid parties, 55;
  causes deafness, 83;
  injures baby teeth, 89;
  industrial disadvantage of, 195;
  in Labrador, 197;
  preventable defect, 272;
  inefficient inspection of, 300


National Association for the Study and Prevention of Tuberculosis, 236, 246

National Board of Health, 133, 292, 308

National Bureau of Labor, 199

National Bureau of Census, 305

National Bureau of Animal Industry, 306

National Bureau of Education, 171, 292

National Playground Association, 118

National School Hygiene Association, 139

Nature Fore and Nature Back, 398-403

Negroes and alcoholism, 350

Nervousness, 85;
  and school life, 108;
  physical defects, 110;
  preventable, 111;
  causes of, 112;
  habit, 111, 113;
  from tobacco, 363

Neurasthenia. See _Mental Hygiene_

New Jersey, 12

Newsholme, Arthur, M.D., 120, 131, 229, 241

New York City, 16, 25, 34

New York Juvenile Asylum, 47

New York state, 12, 24

New York State Charities Aid Association, 236, 242

Nicotinism. See _Tobacco_

Normal schools, 110

North, Professor Lila V., 142

Notification of diseases, 31, 41

Nuisances, 17, 18, 23, 366

Nurses at school, 230, 286, 293, 300.
  See _Milk_


Oliver, Thomas, 203

Orthopedics. See _Tuberculosis_

Ophthalmia, 65

Oppenheimer, Nathan, M.D., 110

Osteopathy, 275


Panama, 59

Parents:
  and school hygiene, 3;
  interested by examinations, 41;
  should coöperate with physician, 279;
  interested in school examinations, 297;
  need health reports, 310;
  heredity, 335-342;
  nicotinism, 368

Parks and playgrounds, 7, 32, 118, 122, 142, 186, 290, 294

Parochial schools, 189, 198

Patent medicines:
  evils of, 369-377;
  advertisements, 380

Patten, Professor Simon N., 9, 14, 33, 165

Pediculosis, 69-71

Pennsylvania, 311

Philadelphia, 34

Phthisis. See _Tuberculosis_

Physical training, 115-117;
  in New York City, 296;
  and sex hygiene, 387

Physician:
  preventive medicine, 268-282;
  and eyes, 81;
  semi-annual visit to, 204;
  self-advertisement, 378;
  school, 173, 286, 293, 315

Physiological age, 105, 289, 387

Pittsburgh, 269

Plague, 15, 57

Pneumonia, 67, 379

Preventable diseases:
  those not communicable, 272.
  See _Catching Diseases_

Private schools, 189, 198, 283, 291, 330

Prohibition laws, 348, 350, 355

Pro-slum motive, 19-20

Public Education Association, New York, 287, 298

Publicity, 45, 81, 99, 292, 310-321, 382


Quarantine, first, 15;
  national, 308


Records:
  of disease centers, 31;
  defective, 32;
  individual, 35, 312-314

Reform's failure, 349

Registration:
  of diseases, 31

Relief, material:
  sound principles of, 174;
  at school, 175, 179, 184;
  indiscriminate, harmful, 332

Richman, Julia, 172

Riggs disease, 92

Rights:
  political, 21;
  not enforced, 23-32;
  of workmen at work, 190;
  machinery for enforcing, 283-322

Riis, Jacob, 18

Ringworm, 65

Rochester, N.Y., 262, 266

Rome, 15

Roosevelt, Theodore, 60, 118

Rural districts:
  encourage disease, 13;
  compared, 32;
  physical defects, 74;
  schools unsanitary, 141;
  hygiene in Great Britain, 308

Russia, 108


Sage Foundation, 285

St. Vitus's dance, 111

Salmon, Professor Lucy M., 355

Scabies, 65.
  See _Itch_

Scarlatina, 65

Scarlet fever:
  thrives in slums, 18;
  signs and method of infection, 65;
  "peeling," 132;
  compulsory removal of cases, 240;
  germ carried in milk, 264

School hygiene:
  and employers, 3;
  instruction compulsory, 3-10;
  practice of, 5, 18;
  biological engineering, 139, 203, 339;
  departments of, 283-293;
  in New York City, 294, 296-301

Score cards, 27, 29, 259, 337

Scranton, 269

Sea Breeze fresh-air home, 176

Sea Breeze seaside hospital, 9, 240

Seaman, L.L., M.D., 23

Seattle, 161

Sedgwick, Professor William T., 304

Sex hygiene, 384-389

Sexual deviates, 182

Shoes, tight, 401

Sickness, preventable, cost of, 278

Sleep and vitality, 201, 272

Slum, a menace, 13, 20

Smallpox:
  epidemics great teachers, 6;
  conquered by vaccination, 7;
  neglected in rural Pennsylvania, 18;
  comes rarely to cities, 31;
  compulsory removal of cases, 240

Snedden, Professor David S., 33, 165, 311

Snellen eye test, 73, 77

Society for Sanitary and Moral Prophylaxis, 384

Southern states, 351

Spargo, John, 33, 167

Spitting, 223, 235

State activity, 4, 73, 121, 236, 292, 306

Statistics, object of, 131, 134, 333

Strauss, Nathan, 260

Streets, 15, 122, 217, 254, 348

Study hours, too long, 287

Sweating, 152, 211


Taxes, taxpayers. See _Budget_

Teacher's health:
  tests of, 152-158

Teachers:
  social work, 172;
  health passport, 202;
  for tuberculous pupils, 237;
  excluded when tuberculous, 242;
  and physicians, 279;
  physical examination of, 284;
  use of alcohol, 358;
  cigarettes, 368;
  use clippings, 382

Teeth. See _Dental Sanitation_

Temperance. See _Alcoholism_

Tenement reforms, 20, 186, 209, 304, 403

Thompson, J. Arthur, 336

Tobacco:
  instruction at school, 3;
  economic injuries of, 201;
  forbidden to employees, 210;
  evils of nicotinism, 363-368, 386

Tonsils, hypertrophied, 44

Trachoma, 69-71

Trudeau, E.L., M.D., 274

Tuberculosis:
  pupils excluded from school because of, 65;
  aggravated by colds, 68;
  bone tuberculosis, 87, 88, 236;
  and bad teeth, 90, 99;
  in teachers, 153;
  examination for working papers, 191;
  periodical examination for, 201;
  last days of, 229-251;
  eye and skin tests for, 240;
  tests of cows, 260;
  carried in milk, 264;
  out-of-door treatment, 274;
  only predisposition to, inherited, 335

Typhoid:
  a rural disease, 13;
  carried in milk, 264


University Extension Society, 178


Vacation schools, playgrounds, 109, 296

Veiller, Lawrence, 9

Vitality tests and statistics, 124-138


Water, drinking:
  reason for works, 15;
  factories pollute, 17;
  fountains, 217;
  public responsibility for, 226;
  protecting sources, 307

Welfare work, 7, 221-225

West Point, 199

Wheeler, Herbert L., D.D.S., 93

Whipple, George C., Ph. D., 13, 16

White plague. See _Tuberculosis_

Whooping cough, 64

Williams, Alida S., 72, 122

Williams, Linsly R., M.D., 241

Work:
  physical examination for working papers, 190-200, 285;
  healthful habits, 208-217;
  unpatented medicine, 334.
  See _Industrial Hygiene_


Young Men's Christian Association, 227

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