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diff --git a/21353.txt b/21353.txt new file mode 100644 index 0000000..76a5872 --- /dev/null +++ b/21353.txt @@ -0,0 +1,14320 @@ +The Project Gutenberg EBook of Civics and Health, by William H. Allen + +This eBook is for the use of anyone anywhere at no cost and with +almost no restrictions whatsoever. You may copy it, give it away or +re-use it under the terms of the Project Gutenberg License included +with this eBook or online at www.gutenberg.org + + +Title: Civics and Health + +Author: William H. Allen + +Contributor: William T. Sedgwick + +Release Date: May 8, 2007 [EBook #21353] + +Language: English + +Character set encoding: ASCII + +*** START OF THIS PROJECT GUTENBERG EBOOK CIVICS AND HEALTH *** + + + + +Produced by Jeannie Howse, Juliet Sutherland and the Online +Distributed Proofreading Team at https://www.pgdp.net + + + + + + + + + * * * * * + + +-----------------------------------------------------------+ + | Transcriber's Note: | + | | + | Inconsistent hyphenation in the original document has | + | been preserved. | + | | + | Some text in this document has been moved to avoid | + | multi-page tables being inserted mid-paragraph. | + | | + | Obvious typographical errors have been corrected in this | + | text. For a complete list, please see the end of this | + | document. | + | | + +-----------------------------------------------------------+ + + * * * * * + + + + + [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 Athenaeum 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 aeration 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. COOePERATION IN MEETING HEALTH OBLIGATIONS + + XVI. EUROPEAN REMEDIES: DOING THINGS AT SCHOOL 159 + + XVII. AMERICAN REMEDIES: GETTING THINGS DONE 166 + + XVIII. COOePERATION 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 +cooeperation 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 deg. | | | | + % 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 deg. | | | | + 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 deg. F. within two | | + hours after milking and kept below 50 deg. F. | | + until delivered to the creamery ... deg. | 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 reexamined 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 anaemic. 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 cooeperate 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 anaemic. 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, anaemia, 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 "cobbed"; "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 anaesthetic 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 +reexamined 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 mediaeval 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 cooeperating 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 debris 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 reexamination, 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 reexamination 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, anaemia. 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 aesthetics 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 aesthetic 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 reexamination 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 reexamination are necessary and a saving of +pain, beauty, and money. + +Reexamination 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 reexamination 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 aesthetics, 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 cooeperative 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 cooeperative 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 cooeperating +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 preeminently 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. Anaemic 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 anaemic 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 anaemic 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. COOePERATION 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 +cooeperation 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 cooeperation, 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 +cooeperate 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 + +COOePERATION 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 cooeperation. + + [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 cooeperate 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 anaemic 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] + +Cooeperation 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 cooeperation 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 + Anaemic condition of child due to bad cooking, not to lack of + income] + +_Cooeperation_ 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. Cooeperation | | 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 cooeperation 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 reexamined. +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 cooeperates 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 cooeperate +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 cooeperation 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 COOePERATION 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 COOePERATIVE + 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 cooeperation 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. | + | 1/4 in quart bottles | + | 3/4 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 deg. F. or lower at dairy | + | 45 deg. F. at creamery | + | 45 deg. F. or less during transportation | + | Not above 50 deg. 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 deg. for 30 minutes to 167 deg. for 20 minutes | + | Cost per quart, estimated, 1/4 to 1/2 ct. | + | Commercial, 165 deg. 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 cooeperate | + | 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 anaemia 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 +Leannec 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 reexamination 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, mediaeval 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 cooeperation 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 cooeperation 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 cooeperation 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 reexamine 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 cooeperation 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 cooeperation 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 cooerdination, 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. Cooeperating 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 10x12 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 cooeperate 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 cooeperation 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 12x24 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 5x3 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, creches. + + + 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 reexamination 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 cooeperation, 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 +cooeperate, 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 +cooeperate 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 cooeperation 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 cooeperation. 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: + cooeperation 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; + cooeperate 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 cooeperate 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 + + * * * * * + + +-----------------------------------------------------------+ + | Typographical errors corrected in text: | + | | + | Page 60: heath replaced with health | + | | + | Text moved to avoid splitting paragraphs with tables: | + | | + | First half of last paragraph on page 25, moved to page | + | 29, following Table III and Table IV on pages 26 to 28. | + | First half of last paragraph on page 63, moved to page | + | 66, following Table VIII on pages 64 to 65. | + | First half of last paragraph on page 181, moved to page | + | 183, following Illustration on page 182. | + | Continuation of paragraph begun on page 222, moved from | + | page 225 to the end of the paragraph on page 222, to | + | precede text ads/Illustrations on pages 223 and 224. | + | Continuation of paragraph begun on page 254, moved from | + | page 258 to the end of the paragraph on page 254, to | + | precede Conference information on pages 255 to 257. | + | First half of last paragraph on page 337, moved to page | + | 340, following Score Cards on pages 338 and 339. | + | | + +-----------------------------------------------------------+ + + * * * * * + + + + + + +End of the Project Gutenberg EBook of Civics and Health, by William H. 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