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+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: ISO-8859-1
+
+*** 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 Athenæum Press
+         GINN AND COMPANY · PROPRIETORS · BOSTON · U.S.A.
+
+
+
+
+INTRODUCTION
+
+
+It is a common weakness of mankind to be caught by an idea and
+captivated by a phrase. To rest therewith content and to neglect the
+carrying of the idea into practice is a weakness still more common. It
+is this frequent failure of reformers to reduce their theories to
+practice, their tendency to dwell in the cloudland of the ideal rather
+than to test it in action, that has often made them distrusted and
+unpopular.
+
+With our forefathers the phrase _mens sana in corpore sano_ was a high
+favorite. It was constantly quoted with approval by writers on hygiene
+and sanitation, and used as the text or the finale of hundreds of
+popular lectures. And yet we shall seek in vain for any evidence of its
+practical usefulness. Its words are good and true, but passive and
+actionless, not of that dynamic type where words are "words indeed, but
+words that draw armed men behind them."
+
+Our age is of another temper. It yearns for reality. It no longer rests
+satisfied with mere ideas, or words, or phrases. The modern Ulysses
+would drink life to the dregs. The present age is dissatisfied with the
+vague assurance that the Lord will provide, and, rightly or wrongly, is
+beginning to expect the state to provide. And while this desire for
+reality has its drawbacks, it has also its advantages. Our age doubts
+absolutely the virtues of blind submission and resignation, and cries
+out instead for prevention and amelioration. Disease is no longer
+regarded, as Cruden regarded it, as the penalty and the consequence of
+sin. Nature herself is now perceived to be capable of imperfect work.
+Time was when the human eye was referred to as a perfect apparatus, but
+the number of young children wearing spectacles renders that idea
+untenable to-day.
+
+Meanwhile the multiplication of state asylums and municipal hospitals,
+and special schools for deaf or blind children and for cripples, speaks
+eloquently and irresistibly of an intimate connection between civics
+and health. There is a physical basis of citizenship, as there is a
+physical basis of life and of health; and any one who will take the
+trouble to read even the Table of Contents of this book will see that
+for Dr. Allen prevention is a text and the making of sound citizens a
+sermon. Given the sound body, we have nowadays small fear for the sound
+mind. The rigid physiological dualism implied in the phrase _mens sana
+in corpore sano_ is no longer allowed. To-day the sound body generally
+includes the sound mind, and vice versa. If mental dullness be due to
+imperfect ears, the remedy lies in medical treatment of those
+organs,--not in education of the brain. If lack of initiative or energy
+proceeds from defective aëration of the blood due to adenoids blocking
+the air tides in the windpipe, then the remedy lies not in better
+teaching but in a simple surgical operation.
+
+Shakespeare, in his wildwood play, saw sermons in stones and books in
+the running brooks. We moderns find a drama in the fateful lives of
+ordinary mortals, sermons in their physical salvation from some of the
+ills that flesh is heir to, and books--like this of Dr. Allen's--in
+striving to teach mankind how to become happier, and healthier, and
+more useful members of society.
+
+Dr. Allen is undoubtedly a reformer, but of the modern, not the
+ancient, type. He is a prophet crying in our present wilderness; but
+he is more than a prophet, for he is always intensely practical,
+insisting, as he does, on getting things done, and done soon, and done
+right.
+
+No one can read this volume, or even its chapter-headings, without
+surprise and rejoicing: surprise, that the physical basis of effective
+citizenship has hitherto been so utterly neglected in America;
+rejoicing, that so much in the way of the prevention of incapacity and
+unhappiness can be so easily done, and is actually beginning to be
+done.
+
+The gratitude of every lover of his country and his kind is due to the
+author for his interesting and vivid presentation of the outlines of a
+subject fundamental to the health, the happiness, and the well-being of
+the people, and hence of the first importance to every American
+community, every American citizen.
+
+                                         WILLIAM T. SEDGWICK
+
+  MASSACHUSETTS INSTITUTE OF TECHNOLOGY
+
+
+
+
+CONTENTS
+
+
+PART I. HEALTH RIGHTS
+
+CHAPTER                                                           PAGE
+      I. HEALTH A CIVIC OBLIGATION                                   3
+
+     II. SEVEN HEALTH MOTIVES AND SEVEN CATCHWORDS                  11
+
+    III. WHAT HEALTH RIGHTS ARE NOT ENFORCED IN YOUR COMMUNITY?     23
+
+     IV. THE BEST INDEX TO COMMUNITY HEALTH IS THE PHYSICAL
+         WELFARE OF SCHOOL CHILDREN                                 33
+
+
+PART II. READING THE INDEX TO HEALTH RIGHTS
+
+      V. MOUTH BREATHING                                            45
+
+     VI. CATCHING DISEASES, COLDS, DISEASED GLANDS                  57
+
+    VII. EYE STRAIN                                                 72
+
+   VIII. EAR TROUBLE, MALNUTRITION, DEFORMITIES                     83
+
+     IX. DENTAL SANITATION                                          89
+
+      X. ABNORMALLY BRIGHT CHILDREN                                104
+
+     XI. NERVOUSNESS OF TEACHER AND PUPIL                          107
+
+    XII. HEALTH VALUE OF "UNBOSSED" PLAY AND PHYSICAL TRAINING     115
+
+   XIII. VITALITY TESTS AND VITAL STATISTICS                       124
+
+    XIV. IS YOUR SCHOOL MANUFACTURING PHYSICAL DEFECTS?            139
+
+     XV. THE TEACHER'S HEALTH                                      152
+
+
+PART III. COÖPERATION IN MEETING HEALTH OBLIGATIONS
+
+    XVI. EUROPEAN REMEDIES: DOING THINGS AT SCHOOL                 159
+
+   XVII. AMERICAN REMEDIES: GETTING THINGS DONE                    166
+
+  XVIII. COÖPERATION WITH DISPENSARIES AND CHILD-SAVING
+         AGENCIES                                                  174
+
+    XIX. SCHOOL SURGERY AND RELIEF OBJECTIONABLE, IF AVOIDABLE     184
+
+     XX. PHYSICAL EXAMINATION FOR WORKING PAPERS                   190
+
+    XXI. PERIODICAL PHYSICAL EXAMINATION AFTER SCHOOL AGE          201
+
+   XXII. HABITS OF HEALTH PROMOTE INDUSTRIAL EFFICIENCY            208
+
+  XXIII. INDUSTRIAL HYGIENE                                        218
+
+   XXIV. THE LAST DAYS OF TUBERCULOSIS                             229
+
+    XXV. THE FIGHT FOR CLEAN MILK                                  252
+
+   XXVI. PREVENTIVE "HUMANIZED" MEDICINE: PHYSICIAN AND TEACHER    268
+
+
+PART IV. OFFICIAL MACHINERY FOR ENFORCING HEALTH RIGHTS
+
+  XXVII. DEPARTMENTS OF SCHOOL HYGIENE                             283
+
+ XXVIII. PRESENT ORGANIZATION OF SCHOOL HYGIENE IN NEW YORK CITY   296
+
+   XXIX. OFFICIAL MACHINERY FOR ENFORCING HEALTH RIGHTS            302
+
+    XXX. SCHOOL AND HEALTH REPORTS                                 310
+
+   XXXI. THE PRESS                                                 322
+
+
+PART V. ALLIANCE OF HYGIENE, PATRIOTISM, AND RELIGION
+
+  XXXII. DO-NOTHING AILMENTS                                       329
+
+ XXXIII. HEREDITY BUGABOOS AND HEREDITY TRUTHS                     335
+
+  XXXIV. INEFFECTIVE AND EFFECTIVE WAYS OF COMBATING ALCOHOLISM    343
+
+   XXXV. IS IT PRACTICABLE IN PRESENTING TO CHILDREN THE EVILS
+         OF ALCOHOLISM TO TELL THE TRUTH, THE WHOLE TRUTH, AND
+         NOTHING BUT THE TRUTH?                                    357
+
+  XXXVI. FIGHTING TOBACCO EVILS                                    363
+
+ XXXVII. THE PATENT-MEDICINE EVIL                                  369
+
+XXXVIII. HEALTH ADVERTISEMENTS THAT PROMOTE HEALTH                 378
+
+  XXXIX. IS CLASS INSTRUCTION IN SEX HYGIENE PRACTICABLE?          384
+
+     XL. THE ELEMENT OF TRUTH IN QUACKERY; HYGIENE OF THE MIND     391
+
+    XLI. "A NATURAL LAW IS AS SACRED AS A MORAL PRINCIPLE"         398
+
+  INDEX                                                            405
+
+
+
+
+CIVICS AND HEALTH
+
+
+
+
+PART I. HEALTH RIGHTS
+
+
+
+
+CHAPTER I
+
+HEALTH A CIVIC OBLIGATION
+
+
+In forty-five states and territories the teaching of hygiene with
+special reference to alcohol and tobacco is made compulsory. To hygiene
+alone, of the score of subjects found in our modern grammar-school
+curriculum, is given statutory right of way for so many minutes per
+week, so many pages per text-book, or so many pages per chapter. For
+the neglect of no other study may teachers be removed from office and
+fined. Yet school garrets and closets are full of hygiene text-books
+unopened or little used, while of all subjects taught by five hundred
+thousand American teachers and studied by twenty million American
+pupils the least interesting to both teacher and pupil is that forced
+upon both by state legislation. To complete the paradox, this least
+interesting subject happens also to be the most vital to the child, to
+the home, to industry, to social welfare, and to education itself.
+
+Whether the subject of hygiene is necessarily dull, whether the
+statutes requiring regular instruction in the laws of health are
+violated with impunity, whether health principles are flaunted by
+health practice at school,--these are questions of immediate concern to
+parents as a class, to employers as a class, to every pastor, every
+civic leader, every health officer, every taxpayer.
+
+Interviews with teachers and principals regarding the present apathy to
+formal hygiene instruction have brought out the following points that
+merit the serious consideration of those who are struggling for higher
+health standards.
+
+1. _There is many a slip 'twixt the making of a law and its
+enforcement._ If laws regarding hygiene instruction are not enforced,
+we should not be surprised. It has been nobody's business to see
+whether and how hygiene is being taught. The moral crusade spent itself
+in forcing compulsory laws upon the statute books of every state and
+territory. Making a fetish of _Legislation_, the advocates of
+anti-alcohol and anti-tobacco instruction failed to see the truth that
+experienced political reformers are but slowly coming to
+see--_Legislation which does not provide machinery for its own
+enforcement is apt to do little good and frequently will do much harm._
+Machinery, however admirably adapted to the work to be done, will get
+out of order and become useless, or even harmful, unless constantly
+watched and efficiently directed. Of what possible use is it to say
+that state money may be withheld from any school board which fails to
+enforce the law regarding instruction in hygiene, if state officials
+never enforce the penalty? So long as the penalty is not enforced for
+flagrant violation, what difference does it make whether the reason is
+indifference, ignorance, or desire to thwart the law? Fortunately, it
+is easy for each one of us to learn how often and in what way the
+children in our community are being taught hygiene, and how the schools
+of our state teach and practice the laws of health. If either the
+spirit or the letter of the law regarding instruction in hygiene is
+being violated, we can measure the penalty paid in health and morals by
+our children and our community. We can learn whether law, text-book,
+curriculum, or teacher should be changed. We can insist upon discussion
+of the facts and upon remedies suggested by the facts.
+
+2. _Teachers give as one reason for neglecting hygiene, that they are
+often compelled to struggle with a curriculum which requires more than
+they are able to teach and more than pupils are able to learn in the
+time allowed._ While an overcharged curriculum may explain, it surely
+does not justify, the violation of law and the dropping of hygiene from
+our school curriculum. If there is any class of citizen who should
+teach and practice respect for law as law, it is the teacher. Parents,
+school directors, county and state superintendents, university
+presidents, social workers, owe it not only to themselves, but to the
+American school-teacher, either to repeal the laws that enjoin
+instruction in hygiene or else so to adjust the curriculum that
+teachers can comply with those laws. The present situation that
+discredits both law and hygiene is most demoralizing to teacher, pupil,
+and community. Many of us might admire the man teacher who frankly says
+he never explains the evils of cigarettes because he himself is an
+inveterate smoker of cigarettes. But what must we think of the school
+system that shifts to such a man the right and the responsibility of
+deciding whether or not to explain to underfed and overstimulated
+children of the slums the truth regarding cigarettes? If practice and
+precept must be consistent, shall the man be removed, shall he change
+his habits, shall the law regarding instruction in hygiene be changed,
+or shall other provision be made for bringing child and essential facts
+together in a way that will not dull the child's receptivity?
+
+3. _Teachers are made to feel that while arithmetic and reading are
+essential, hygiene is not essential._ Whatever may be the facts
+regarding the relative value of arithmetic and hygiene, whether or not
+our state legislators have made a mistake in declaring hygiene to be
+essential, are questions altogether too important for child and state
+to be left to the discretion of the individual teacher or
+superintendent. It is fair to the teachers who say they cannot afford
+to turn aside from the three R's to teach hygiene, to admit that they
+have not hitherto identified the teaching of hygiene with the promotion
+of the physical welfare of children. Teachers awake to the opportunity
+will sacrifice not only hygiene but any other subject for the sake of
+promoting children's health. They do not really believe that arithmetic
+is more important than health. What they mean to say is that hygiene,
+as taught by them, has not heretofore had an appreciable effect upon
+their pupils' health; that other agencies exist, outside of the school,
+to teach the child how to avoid certain diseases and how to observe the
+fundamental laws of health, whereas no other agencies exist to give the
+child the essentials of arithmetic, reading, and geography. "We teach
+(or try to teach) what our classes are examined in. If you want a
+subject taught, you must test a class in it and hold a teacher
+responsible for results, and examinations are mercilessly unhygienic,
+you know."
+
+4. _Teachers believe that they get better results for their children
+from teaching hygiene informally and indirectly than from stated formal
+lessons._ Whether instruction should be informal or formal is merely a
+question of method to be determined by results. What the results are,
+can be determined by principals, superintendents, and students of
+education. It is easy to understand how at the time of a fever epidemic
+children could be taught as much in one week about infection, disease
+germs, antiseptics, value of cleanliness, etc., as in five or ten
+months when vivid illustration is lacking. Physicians themselves learn
+more from one epidemic of smallpox than from four years of book study.
+To make possible and to require a daily shower bath will undoubtedly do
+more to inculcate habits of health than repeated lessons about the
+skin, pores, evaporation, and discharge of impurities.
+
+If one illustration is better than ten lessons, if an open window is
+worth more than all that text-books have to say about ventilation, if
+a seat adjusted to the child is better than an anatomical chart, this
+does not mean that instruction in hygiene should cease. On the
+contrary, it means that provision should be made for every teacher to
+open windows, to adjust desks, to use the experience of individual
+children for the education of the class. If the rank and file of
+teachers have not hitherto been sufficiently observant of physiological
+and hygienic facts, if they are unprepared from their own lives to
+detect or to furnish illustrations for the child, this again does not
+mean that the child should be denied the illustrations, but that the
+teacher should either have instruction and experience to incite
+interest and to stimulate powers of observation, or else be asked to
+give place to another teacher who is able to furnish such
+qualifications.
+
+5. _Children, like adults, can be interested in other people, in rules
+of conduct, in social conditions, in living and working relations more
+easily than in their own bodies._ The normal, healthy child thinks very
+little of himself apart from the other boys and girls, the games, the
+studies, the animals, the nature wonders, the hardships that come to
+him from the outside. So true is this that one of the best means of
+mitigating or curing many ailments is to divert the child's attention
+from himself to things outside of himself that he can look at, hear,
+enjoy. The power to concentrate attention upon oneself is a sign either
+of a diseased body, a diseased mind, or a highly trained mind. To study
+others and to recognize the similarity between others and oneself is as
+natural as the body itself. Teachers are consulting this line of
+easiest access to children's attention when they honor children
+according to cleanliness of hands, of teeth, of shoes. Human interest
+attaches to what parks or excursions are doing for sickly children, how
+welfare work is improving factory employees, how smallpox is conquered
+by vaccination, how insurance companies refuse to take risks upon the
+lives of men or women addicted to the excessive use of alcohol or
+tobacco.
+
+Other people's interests--tenement conditions, factory rules--can be
+described in figures and actions that appeal to the imagination and
+impress upon the mind pictures that are repeatedly reawakened by
+experience and observation on the playground, at home, on the way to
+school or to work. "Once upon a time--" will always arrest attention
+more quickly than "The human frame consists--." What others think of me
+helps me to obey law--statutory, moral, or hygienic--more than what I
+know of law itself. How social instincts dominate may be illustrated by
+an experience in advertising a public bath near a thoroughfare traveled
+daily by thousands of working girls. I prepared a card to be
+distributed among these girls that began: "A cool, refreshing bath,
+etc." This card was criticised by one who knows the ways of girls and
+women, as follows: "Of course you get no success when you have a man
+stand on the street corner and pass out cards telling girls to get
+clean. Every girl that is worth while is affronted by the insinuation."
+Acting upon this expert advice, we then got out a neatly printed card
+reading as follows: "For a clear complexion, sprightly step, and
+bounding vitality, visit the Center Market Baths, open from 6 A.M. to 9
+P.M. daily." The board of managers shook their sage masculine heads and
+reluctantly gave permission to issue these appeals. Woman's judgment
+was vindicated, however, and the advantage was proved of urging health
+for "society's" sake rather than for health's sake, when the patronage
+of the bath jumped at once to considerable proportions.
+
+6. _Other people's habits of health influence our well-being quite as
+much, if not more, than our own._ Because we are social beings, ability
+to get along with our families, our friends, our employers, is--at
+least so it seems to most of us--quite as important as individual
+health. For too many of us, living hygienically is absolutely
+impossible without inconveniencing and bothering the majority of
+persons with whom we live. I remember a girl in college,--a fresh-air
+fiend,--who every morning, no matter how cold, threw the windows wide
+open. Then, with forty others, I thought this girl a nuisance as well
+as a menace to health, but now, twenty years afterwards, I find myself
+wanting to do the same thing. Professor Patten, the economist, whom I
+shall quote many times because he is particularly interested in the
+purpose of this book, was recently dining at my house and illustrated
+from his own health the importance of teaching hygiene so as to affect
+social as well as personal standards. "To be true to my own health
+needs, I ought to have declined nearly everything that has been offered
+me for dinner, but in the long run, if I am going to visit, my eating
+what is placed before me is better for society than making those who
+entertain me feel uncomfortable."
+
+Most of us know what uphill work it is to live hygienically in an
+unhygienic environment. I remember how hard it was to eat happily when
+sitting beside a college professor who took brown pills before each
+meal, yellow pills between each course, and a dose of black medicine
+after the meal was over. Mariano, an Italian lad cured of bone
+tuberculosis by out-of-door salt air at Sea Breeze, returned to his
+tenement home an ardent apostle of fresh air day and night, winter and
+summer. His family allowed him to open the window before going to bed,
+but closed it as soon as he was asleep. Lawrence Veiller, our greatest
+expert on tenement conditions, says: "To bathe in a tenement where a
+family of six occupy three rooms often involves the sacrifice of
+privacy and decency, which are quite as important to social betterment
+as cleanliness."
+
+To live unhygienically where others live hygienically is quite as
+difficult. Witness the speedy improvement of dissipated men when
+boarding with country friends who eat rationally and retire early. It
+must have been knowledge of this fact that prompted the tramways of
+Belfast to post conspicuous notices: "Spitting is a vile and filthy
+habit, and those who practice it subject themselves to the disgust and
+loathing of their fellow-passengers." It is almost impossible to have
+indigestion, blues, and headache when one is camping, particularly
+where action and enjoyment fill the day. Our practical question is,
+therefore, not "What shall I eat, how many hours shall I sleep, what
+shall I wear," but "How can I manage to get into an environment among
+living and working conditions where the people I live with and want to
+please, those who influence me and are influenced by me, make healthy
+living easy and natural?"
+
+7. _Because the problems of health have to do principally with
+environment,--home, street, school, business,--it is worth while trying
+to relate hygiene instruction to industry and government, to preach
+health from the standpoint of industrial and national efficiency rather
+than of individual well-being._ Since healthful living requires the
+coöperation of all persons in a household, in a group, or in a
+community, we must find some working programme that will make it easy
+for all the members of the group to observe health standards. A city
+government that spends taxes inefficiently can produce more sickness,
+wretchedness, incapacity in one year than pamphlets on health can
+offset in a generation. Failure to enforce health laws is a more
+serious menace to health and morals than drunkenness or tobacco cancer.
+Unclean streets, unclean dairies, unclean, overcrowded tenements can do
+more harm than alcohol and tobacco because they can breed an appetite
+that craves stimulants and drugs. Others have taught how the body acts,
+what we ought to eat, how we should live. We are concerned here not
+with repeating the laws of health, but with a consideration of the
+mechanism that will make it possible for us so to work together that we
+can observe those laws.
+
+
+
+
+CHAPTER II
+
+SEVEN HEALTH MOTIVES AND SEVEN CATCHWORDS
+
+
+In making a health programme as in making a boat, a garden, or a
+baseball team, the first step is to look about and see what material
+there is to work with. A baseball team will fail miserably unless the
+captain places each man where he can play best. Gardening is profitless
+when the gardener does not know the habits of plants and the
+possibilities of different kinds of soil. So in planning a health
+programme we must study our materials and use each where it will fit
+best. The materials of first importance to a health programme in
+civilized countries are men; for men working together can control water
+sources, drainage, and ventilation, or else move away to surroundings
+better suited to healthful living. Therefore the first concern of the
+leader in a health crusade is the human kind he has to work for and
+work with.
+
+Seven kinds of man are to be found in every community, seven different
+points of view with regard to health administration. Each individual,
+likewise, may have seven attitudes toward health laws, seven reasons
+for demanding health protection. These seven points of view, seven
+stages of development, are clearly marked in the evolution of sanitary
+administration throughout the civilized world. With few exceptions, it
+is possible, by examining ourselves, our friends, and our communities,
+to see where one motive begins and leaves off, giving way to or mixing
+with one or more other motives. A friend once asked me if I could keep
+this number seven from growing to eight or nine. Perhaps not. Perhaps
+there are more kinds of people, more health motives, more stages in
+health progress; but I am sure of these seven, and certain that they
+have been of great help to me in planning health crusades for the state
+of New Jersey and for New York City. The number seven was not reached
+hit-or-miss fashion, nor was it chosen for its biblical prestige. On
+the contrary, it came as the result of studying health administration
+in twoscore British and American cities, and of reading scores of books
+on sanitary evolution.
+
+Seven catchwords make it easy to remember the characteristics and the
+source of every motive, every kind of person, and every stage in the
+evolution of sanitary standards. These seven catchwords are:
+_Instinct_, _Display_, _Commerce_, _Anti-nuisance_, _Anti-slum_,
+_Pro-slum_, _Rights_. By the use of these catchwords any teacher,
+parent, public official, educator, or social worker should be able to
+size up the situation, the needs, and the opportunity of the
+individuals or the communities for whom a health crusade is planned.
+
+_Instinct_ was the first health officer and made the first health laws.
+Instinct warns us against unusual and offensive odors, sights, and
+noises, just as it causes us to seek that which is agreeable. Primitive
+man in common with other animals learned by sad experience to avoid
+certain herbs as poisons; to bury or to move away from the dead; to
+shun discolored drinking water. During the roaming period sun and air
+and water acted as scavengers. When tribes settled down in one spot for
+long periods, habits that had hitherto been inoffensive and safe became
+noticeably injurious and unpleasant. Heads of tribes gave orders
+prohibiting such habits and restricting disagreeable acts and objects
+to certain portions of the camp. Instinct places outhouses on our farms
+and then gradually removes them farther and farther from dwellings. In
+many school yards, more particularly in country districts and small
+towns, outhouses are a crying offense against animal instinct. In
+visiting slum districts in Irish and Scotch cities, and in London,
+Paris, Berlin, and New York, I never found conditions so offensive to
+crude animal instinct as those I knew when a boy in Minnesota school
+yards, or those I have since seen in a Boy Republic. But the evil is
+not corrected because it is not made anybody's business to execute
+instinct's mandates. In the Boy Republic the leaders were waiting for
+the children themselves to revolt, as does primitive man.
+
+
+TABLE I
+
+TYPHOID A RURAL DISEASE[1]
+
+==========================================+============+==============
+                                          | Average    | Average
+                                          | Per Cent   | Typhoid Fever
+                                          | of Rural   | Death Rate
+                                          | Population | per 100,000
+------------------------------------------+------------+--------------
+Five states in which the urban            |            |
+population was more than 60% of the total |     30     |     25
+                                          |            |
+Six states in which the urban population  |            |
+was between 40% and 60%                   |     49     |     42
+                                          |            |
+Seven states in which the urban           |            |
+population was between 30% and 40%        |     67     |     38
+                                          |            |
+Eight states in which the urban           |            |
+population was between 20% and 30%        |     75     |     46
+                                          |            |
+Twelve states in which the urban          |            |
+population was between 10% and 20%        |     87     |     62
+                                          |            |
+Twelve states in which the urban          |            |
+population was between 0 and 10%          |     95     |     67
+==========================================+============+==============
+
+Among large numbers of persons, in city as well as country, washing the
+body is still a matter of instinct, a bath not being taken until the
+body is offensive, the hands not being washed until their condition
+interferes with the enjoyment of food or with one's treatment by
+others. There is a point of neglect beyond which instinct will not
+permit even a tramp to go. If cleanliness is next to godliness, the
+average child is most ungodly by nature, for it loathes the means of
+cleanliness and otherwise observes instinct's health warnings only
+after experience has punished or after other motives from the outside
+have prompted action. The chief form of legislation of the instinct age
+is provision of penalties for those who poison food, water, or
+fellow-man. There are districts in America where hygiene is supposed to
+be taught to children that are conscious of no other sanitary
+legislation but that which punishes the poisoner.
+
+_Display_ has always been an active health crusader. Professor Patten
+says the best thing that could happen to the slums of every city would
+be for every girl and woman to be given white slippers, white
+stockings, a white dress, and white hat. Why? Because they would at
+once notice and resent the dirt on the street, in their hallways, and
+in their own homes. People that have nothing to "spoil" really do not
+see dirt, for it interferes in no way with their comfort so far as they
+can see. Their windows are crusted with dust, their babies' milk
+bottles are yellow with germs. Who cares? Similar conditions exist
+among well-to-do women who live on isolated farms with no one to notice
+their personal appearance except others of the family who prefer rest
+to cleanliness. But let the tenement mother or the isolated farmer's
+wife entertain the minister or the school-teacher, the candidate for
+sheriff or the ward boss, let her go to Coney Island or to the county
+fair, and at once an outside standard is set up that requires greater
+regard for personal appearance and leads to "cleaning up."
+
+Elbow sleeves and light summer waists have led many a girl to daily
+bathing of at least those parts of the body that other people see.
+Entertainments and sociables, Saturday choir practice and church have
+led many a young man to bathe for others' sake when quite satisfied to
+forego the ordeal so far as his own comfort and health were concerned.
+Streets on which the well-to-do live are kept clean. Why? Not because
+Madam Well-to-do cares so much for health, but because she associates
+cleanliness with social prestige. It is necessary for the display of
+her carriages and dresses, just as paved streets and a plentiful supply
+of water for public baths and private homes were essential to the
+display of Rome's luxury. Generally speaking, residence streets are
+cleaned in small towns just as waterworks are introduced, to gratify
+the display motive of those who have lawns to water and clothes to
+show.
+
+Instinct strengthens the display motive. As every one can be interested
+in instinct hygiene, so every one is capable of this display motive to
+the extent that his position is affected by other people's opinion. It
+was love of display quite as much as love of beauty that gave Greece
+the goddess Hygeia, the worship of whom expressed secondarily a desire
+for universal health, and primarily a love of the beautiful among those
+who had leisure to enjoy it.
+
+_Commerce_ brooks no preventable interference with profits, whether by
+disease, death, impassable streets, or disabled men. The age of
+chivalry was also the age of indescribable filth, plague, Black Death,
+and spotted fever that cost the lives of millions. It would be
+impossible in the civilized world to duplicate the combination of
+luxury and filthy, disease-breeding conditions in the midst of which
+Queen Bess and her courtiers held their revels. The first protest was
+made, not by the church, not by sanitarians, but by the great merchants
+who were unable to insure against loss and ruin from the plagues that
+thrived on filth and overcrowding. By an interesting coincidence the
+first systematic street cleaning and the first systematic ship
+cleaning--maritime quarantine--date from the same year, 1348 A.D.; the
+former in the foremost German trading town, Cologne, and the latter in
+Venice, the foremost trading town of Italy. The merchants of
+Philadelphia and New York started the first boards of health in the
+United States. For what purpose? To prevent business losses from yellow
+fever. Desire for passable streets, drains, waterworks, and strong
+boards of health has generally started with merchants. For commercial
+reasons many of our states vote more money for the protection of cattle
+than for the protection of human life, and the United States votes
+millions for the study of hog cholera, chicken pip, and animal
+tuberculosis, while neglecting communicable diseases of men. No class
+in a community will respond more quickly to an appeal for the rigid
+enforcement of health laws than the merchant class; none will oppose so
+bitterly as that which makes profits out of the violation of health
+laws.
+
+
+TABLE II
+
+COST IN LIFE CAPITAL OF PREVENTABLE DISEASES[2]
+
+=============+============+===========================================
+             |            | Multiply by the number of deaths for each
+             | Estimated  | age group to learn the cost in life
+             | Value of   | capital to your community in loss of life
+     Age     | Human Life | from one or all preventable diseases.
+-------------+------------+-------------------------------------------
+  0-5 years  |   $1,500   |
+  5-10  "    |    2,300   |
+ 10-15  "    |    2,500   |
+ 15-20  "    |    3,000   |
+ 20-25  "    |    5,000   |
+ 25-30  "    |    7,500   |
+ 30-35  "    |    7,000   |
+ 35-40  "    |    6,000   |
+ 40-45  "    |    5,500   |
+ 45-50  "    |    5,000   |
+ 50-55  "    |    4,500   |
+ 55-60  "    |    4,500   |
+ 60-65  "    |    2,000   |
+ 65-70  "    |    1,000   |
+ 70-    "    |    1,000   |
+=============+============+===========================================
+
+_Anti-nuisance_ motives do not affect health laws until people with
+different incomes and different tastes try to live together. In a small
+town where everybody keeps a cow and a pig, piggeries and stables
+offend no one; but when the doctor, the preacher, the dressmaker, the
+lawyer, and the leading merchant stop keeping pigs and cows, they begin
+to find other people's stables and piggeries offensive. The early laws
+against throwing garbage, fish heads, household refuse, offal, etc., on
+the main street were made by kings and princes offended by such
+practices. The word "nuisance" was coined in days when neighbors lived
+the same kind of life and were not sensitive to things like house
+slops, ash piles, etc. The first nuisances were things that neighbors
+stumbled over or ran into while using the public highway. Next, goats
+and other animals interfering with safety were described as nuisances,
+and legal protection against them was worked out. It has never been
+necessary to change the maxim which originally defined a nuisance: "So
+use your own property that you will not injure another in the use of
+his property." The thing that has changed and grown has been society's
+knowledge of acts and objects that prevent a man from enjoying his own
+property. To-day the number of things that the law calls nuisances is
+so great that it takes hundreds of pages to describe them. Stables and
+outhouses must be set back from the street. Every man must dispose of
+garbage and drainage on his own property. Stables and privies must be
+at least a hundred feet from water reservoirs. Factories may not
+pollute streams that furnish drinking water. Merchants may be punished
+if they put banana skins in milk cans, or if they fail to scald and
+cleanse all milk receptacles before returning them to wholesalers.
+Automobile drivers may be punished for disturbing sleep. Anything that
+injures my health will be declared a nuisance and abolished, if I can
+prove that my health is being injured and that I am doing all I can to
+avoid that injury. No educational work will accomplish more for any
+community than to make rich and poor alike conscious of nuisances that
+are being committed against themselves and their neighbors. The rich
+are able to run away from nuisances that they cannot have abated. If
+proper publicity is given to living conditions among those who do not
+resist nuisances, the presence of such conditions will itself become
+offensive to the well-to-do, who will take steps to remove the
+nuisance. Jacob Riis in this way made the slums a nuisance to rich
+residents in New York City and stimulated tenement reform, building of
+parks, etc.
+
+_Anti-slum_ motives originated in cities where there is a clear
+dividing line between the clean and the unclean, the infected and the
+uninfected, the orderly and the disorderly, high and low vitality. As
+soon as one district becomes definitely known as a source of nuisance,
+infection, and disease, better situated districts begin to make laws to
+protect themselves. A great part of our existing health codes and a
+very large part of the funds spent on health administration are
+designed to protect those of high income against disease incident to
+those of low income, high vitality against low vitality, houses with
+rooms to spare against houses that are overcrowded. To the small town
+and the country the slum means generally the near-by city whose papers
+talk of epidemic scarlet fever, diphtheria, or smallpox. Cities have
+only recently begun to experience anti-slum aversion to country dairies
+whose uncleanliness brings infected milk to city babies, or to filthy
+factories and farms that pollute water reservoirs and cause typhoid.
+The last serious smallpox epidemic in the East came from the South by
+way of rural districts that failed to notify the Pennsylvania state
+board of health of the outbreak until the disease was scattered
+broadcast. Every individual knows of some family or some district that
+is immediately pictured when terms like "disease," "epidemic," "slum,"
+are pronounced. The steps worked out by the anti-slum motive to
+protect "those who have" from disease arising from "those who have not"
+are given on page 31.
+
+    [Illustration: A COUNTRY MENACE TO CITY HEALTH]
+
+_Pro-slum_ motives are not exactly born of anti-slum motives, but,
+thanks to the instinctive kindness of the human heart, follow promptly
+after the dangers of the slum have been described. You and I work
+together to protect ourselves against neglect, nuisance, and disease.
+In a district by which we must pass and with which we must deal, one of
+us or a neighbor or friend will turn our attention from our danger to
+the suffering of those against whom we wish to protect ourselves.
+Charles Dickens so described Oliver Twist and David Copperfield that
+Great Britain organized societies and secured legislation to improve
+the almshouse, school, and working and living conditions. When health
+reports, newspapers, and charitable societies make us see that the
+slum menaces our health and our happiness, we become interested in the
+slum for its own sake. We then start children's aid societies,
+consumer's leagues, sanitary and prison associations, child-labor
+committees, and "efficient government" clubs.
+
+_Rights_ motives are the last to be evolved in individuals or
+communities. The well-to-do protect their instinct, their comfort,
+their commerce, but run away from the slums and build in the secluded
+spots or on the well-policed and well-cleaned avenues and boulevards.
+Uptown is often satisfied with putting health officials to work to
+protect it against downtown. Pro-slum motives are shared by too few and
+are expressed too irregularly to help all of those who suffer from
+crowded tenements, impure milk, unclean streets, inadequate schooling.
+So long as those who suffer have no other protection than the
+self-interest or the benevolence of those better situated, disease and
+hardship inevitably persist. Health administration is incomplete until
+its blessings are given to men, women, and children as rights that can
+be enforced through courts, as can the right to free speech, the
+freedom of the press, and trial by jury. There is all the difference in
+the world between having one's street clean because it is a danger to
+some distant neighbor, or because that neighbor takes some
+philanthropic interest in its residents, and because one has a right to
+clean streets, regardless of the distant neighbor's welfare or
+interest. When the right to health is granted health laws are made, and
+all men within the jurisdiction of the lawmaking power own health
+machinery that provides for the administration of those laws. A system
+of public baths takes the place of a bathhouse supported by charity; a
+law restricting the construction and management of all tenements takes
+the place of a block of model tenements, financed by some wealthy man;
+medical examination of all school children takes the place of a private
+dispensary; a probation law takes the place of the friendly visitor to
+the county jail.
+
+Most of the rights we call inalienable are political rights no longer
+questioned by anybody and no longer thought of in connection with our
+everyday acts, pleasures, and necessities. When our political rights
+were formulated in maxims, living was relatively simple. There was no
+factory problem, no transportation problem, no exploitation of women
+and children in industry. Our ancestors firmly believed that if the
+strong could be prevented from interfering with the political rights of
+the weak, all would have an equal chance. The reason that our political
+maxims mean less to-day than two hundred years ago is that nobody is
+challenging our right to move from place to place if we can afford it,
+to trial by jury if charged with crime, to speak or print the truth
+about men or governments. If, however, anybody should interfere with
+our freedom in this respect, it would be of tremendous help that
+everybody we know would resent such interference and would point to
+maxims handed down by our ancestors and incorporated in our national
+and state constitutions as formal expressions of unanimous public
+opinion.
+
+The time is past when any one seriously believes that political freedom
+or personal liberty will be universal, just because everybody has a
+right to talk, to move from place to place, to print stories in the
+newspapers. The relation of man to man to-day requires that we
+formulate rules of action that prevent one man's taking from another
+those rights, economic and industrial, that are as essential to
+twentieth-century happiness as were political rights to
+eighteenth-century happiness. Political maxims showed how, through
+common desire and common action, steps could be taken by the individual
+and by the whole of society for the protection of all. Health rights,
+likewise, are to be obtained through common action. A modern city must
+know who is accountable when an automobile runs over a pedestrian, when
+a train load of passengers lose their lives because of an engineer's
+carelessness, when an employee is incapacitated for work by an accident
+for which he is not responsible, or when fever epidemics threaten life
+and liberty without check. How can a child who is prevented by
+removable physical defects from breathing through his nose be
+enthusiastic over free speech? Of what use is freedom of the press to
+those who find reading harder than factory toil? How futile the right
+to trial by jury if removable physical defects make children unable to
+do what the law expects! Who would not exchange rights of petition for
+ability to earn a living? Children permanently incapacitated to share
+the law's benefits cannot appreciate the privilege of pursuing
+happiness.
+
+Succeeding chapters will enumerate a number of health rights and will
+show through what means we can work together to guarantee that we shall
+not injure the health of our neighbor and that our neighbor shall not
+injure our health. The truest index to economic status and to standards
+of living is health environment. The best criterion of opportunity for
+industrial and political efficiency is the conditions affecting health.
+The seven catchwords that describe seven motives to health legislation
+and health administration, seven ways of approaching health needs, and
+seven reasons for meeting them, should be found helpful in analyzing
+the problem confronting the individual leader. Generally speaking, we
+cannot watch political rights grow, but health rights are evolved
+before our eyes all the time. If we wish, we can see in our own city or
+township the steps taken, one by one, that have slowly led to granting
+a large number of health rights to every American.
+
+FOOTNOTES:
+
+[1] Prepared by Dr. John S. Fulton, secretary of the state board of
+health, Maryland, and quoted by Dr. George C. Whipple in _Typhoid
+Fever_.
+
+[2] Marshall O. Leighton, quoted in Whipple's _Typhoid Fever_.
+
+
+
+
+CHAPTER III
+
+WHAT HEALTH RIGHTS ARE NOT ENFORCED IN YOUR COMMUNITY?
+
+
+Laws define rights. Men enforce them. For definitions we go to books.
+For record of enforcement we go to acts and to conditions.[3] What
+health rights a community pretends to enforce will, as a rule, be found
+in its health code. What health rights are actually enforced can be
+learned only by studying both the people who are to be protected and
+the conditions in which these people live. A street, a cellar, a milk
+shop, a sick baby, or an adult consumptive tells more honestly the
+story of health rights enforced and health rights unenforced than
+either sanitary code or sanitary squad. Not until we turn our attention
+from definition and official to things done and dangers remaining can
+we learn the health progress and health needs of any city or state.
+
+The health code of one city looks very much like the health code of
+every other city. This is natural because those who write health codes
+generally copy other codes. Even small cities are given complicated
+sanitary legislative powers by state legislatures. Therefore those who
+judge a community's health rights by its health laws will get as
+erroneous an impression as those who judge hygiene instruction in our
+public schools from printed statements about the frequency and
+character of such instruction. Advocates of health codes have thought
+the battle won when boards of health were given almost unlimited power
+to abate nuisances and told how to exercise those powers.
+
+    [Illustration: A DAIRY INSPECTOR'S OUTFIT]
+
+The slip 'twixt law making and law enforcement is everywhere found. In
+1864 New York state prohibited the sale of adulterated milk. Law after
+law has been made since that time, giving health officials power to
+revoke licenses of milk dealers and to send men to jail who violated
+milk laws. We now know that no law will ever stop the present frightful
+waste of infant lives, counted in thousands annually, unless dairies
+are frequently inspected and forced to be clean; unless milk is kept at
+a temperature of about fifty degrees on the train, in the creamery, at
+the receiving station, and in the milk shop; unless dealers scald and
+thoroughly cleanse cans in which milk is shipped; unless licenses are
+taken from farmers, creameries, and retailers who violate the law;
+unless magistrates use their power to fine or imprison those who poison
+helpless babies by violating milk laws; and unless mothers are taught
+to scald and thoroughly cleanse bottles, nipples, cups, and dishes
+from which milk is fed to the baby. We know that these things are not
+being done except where men or women make it their business to see that
+they are done. Experience tells us that inspectors will not
+consistently do their duty unless those who direct them have regular
+records of their inspections, study those records, find out work not
+done properly or promptly, and insist upon thorough inspection.
+
+Whether work is done right, whether inspectors do their full duty,
+whether babies are protected, can be learned only from statements in
+black and white that show accurately the conditions of dairies and milk
+shops, the character of milk found and tested by inspectors, and the
+number of babies known to have been sick or known to have died from
+intestinal diseases chiefly due to unsafe milk. Any teacher or parent
+can learn for himself, or can teach children to learn, what steps are
+taken to guarantee the right to pure milk by using a table such as
+Table III. Whether conditions at the dairy make pure milk impossible
+can be told by any one who can read the score card used by New York
+City (Table IV).
+
+
+TABLE III
+
+MILK INSPECTION WITHIN NEW YORK CITY, 1906
+
+======================================+===============+===============
+                                      |   New York    | Each borough
+                                      +-------+-------+-------+-------
+                                      | Stores| Wagons| Stores| Wagons
+                                      +-------+-------+-------+-------
+FIELD                                 |       |       |       |
+ Permits issued during 1906           |       |       |       |
+ Permits revoked during 1906          |       |       |       |
+   For discontinuance of selling      |       |       |       |
+   For violation of law               |       |       |       |
+ Average permits in force in 1906     |       |       |       |
+                                      |       |       |       |
+INSPECTION                            |       |       |       |
+ Regular inspections                  |       |       |       |
+ Inspections at receiving stations    |       |       |       |
+ Total                                |       |       |       |
+ Average inspections per permit per   |       |       |       |
+  year                                |       |       |       |
+ Specimens examined                   |       |       |       |
+ Samples taken                        |       |       |       |
+                                      |       |       |       |
+CONDITIONS FOUND                      |       |       |       |
+ Inspections finding milk above 50°   |       |       |       |
+ % of such discoveries to total       |       |       |       |
+   inspections                        |       |       |       |
+ Inspections finding adulteration     |       |       |       |
+    Warning given                     |       |       |       |
+    Prosecuted                        |       |       |       |
+ % of adulterations found to          |       |       |       |
+   inspections                        |       |       |       |
+                                      |       |       |       |
+ Rooms connected contrary to          |       |       |       |
+  sanitary code                       |       |       |       |
+ Ice box badly drained                |       |       |       |
+ Ice box unclean                      |       |       |       |
+ Store unclean                        |       |       |       |
+ Utensils unclean                     |       |       |       |
+ Milk not properly cooled             |       |       |       |
+ Infectious disease                   |       |       |       |
+                                      |       |       |       |
+ Persons found selling without permit |       |       |       |
+                                      |       |       |       |
+ACTION TAKEN                          |       |       |       |
+ DESTRUCTION OF MILK                  |       |       |       |
+  Lots of milk destroyed for being    |       |       |       |
+    over 50°                          |       |       |       |
+  Quarts so destroyed                 |       |       |       |
+  Lots of milk destroyed for being    |       |       |       |
+   sour                               |       |       |       |
+  Quarts so destroyed                 |       |       |       |
+  Lots of milk destroyed for being    |       |       |       |
+    otherwise adulterated             |       |       |       |
+  Quarts so destroyed                 |       |       |       |
+  Total quarts destroyed              |       |       |       |
+                                      |       |       |       |
+ NOTICES ISSUED                       |       |       |       |
+  To drain and clean ice box          |       |       |       |
+  To clean store                      |       |       |       |
+                                      |       |       |       |
+ CRIMINAL ACTIONS BEGUN               |       |       |       |
+  For selling adulterated milk        |       |       |       |
+  For selling without permit          |       |       |       |
+  For interference with inspector     |       |       |       |
+  Total                               |       |       |       |
+======================================+===============+===============
+
+
+TABLE IV
+
+                               Perfect Score 100%
+                               Score allowed ...%
+File No............
+
+                    DEPARTMENT OF HEALTH
+                 (Thirteen items are here omitted)
+
+=Dairy Inspection=             =Division of Inspections=
+
+ 1 Inspection No. ...... Time ...... A. P. M. Date ...... 190
+ 2 All persons in the households of those engaged in producing or handling
+   milk are ...... free from all infectious disease ......
+ 3 Date and nature of last case on farm ......
+ 4 A sample of the water supply on this farm taken for analysis ......
+   190... and found to be ......
+
+====================================================+=========+=======
+                 STABLE                             | Perfect | Allow
+----------------------------------------------------+---------+-------
+ 5 COW STABLE is ... located on elevated ground     |         |
+   with no stagnant water, hog pen, or privy        |         |
+   within 100 feet                                  |    1    |  ...
+ 6 FLOORS are ... constructed of concrete or        |         |
+   some nonabsorbent material                       |    1    |  ...
+ 7 Floors are ... properly graded and water-tight   |    2    |  ...
+ 8 DROPS are ... constructed of concrete, stone,    |         |
+   or some nonabsorbent material                    |    2    |  ...
+ 9 Drops are ... water-tight                        |    2    |  ...
+10 FEEDING TROUGHS, platforms, or cribs are ...     |         |
+   well lighted and clean                           |    1    |  ...
+11 CEILING is constructed of ... and is ... tight   |         |
+   and dust proof                                   |    2    |  ...
+12 Ceiling is ... free from hanging straw, dirt,    |         |
+   or cobwebs                                       |    1    |  ...
+13 NUMBER OF WINDOWS ... total square feet ...      |         |
+   which is ... sufficient                          |    2    |  ...
+14 Window panes are ... washed and kept clean       |    1    |  ...
+15 VENTILATION consists of ... which is             |         |
+   sufficient 3, fair 1, insufficient 0             |    3    |  ...
+16 AIR SPACE is ... cubic feet per cow which is     |         |
+   ... sufficient (600 and over--3) (500 to         |         |
+   600--2) (400 to 500--1) (under 400--0)           |    3    |  ...
+17 INTERIOR of stable painted or whitewashed on     |         |
+   ... which is satisfactory 2, fair 1, never 0     |    2    |  ...
+18 WALLS AND LEDGES are ... free from dirt, dust,   |         |
+   manure, or cobwebs                               |    2    |  ...
+19 FLOORS AND PREMISES are ... free from dirt,      |         |
+   rubbish, or decayed animal or vegetable matter   |    1    |  ...
+20 COW BEDS are ... clean                           |    1    |  ...
+21 LIVE STOCK, other than cows, are ... excluded    |         |
+   from rooms in which milch cows are kept          |    2    |  ...
+22 There is ... direct opening from barn into       |         |
+   silo or grain pit                                |    1    |  ...
+23 BEDDING used is ... clean, dry, and absorbent    |    1    |  ...
+24 SEPARATE BUILDING is ... provided for cows       |         |
+   when sick                                        |    1    |  ...
+25 Separate quarters are ... provided for cows      |         |
+   when calving                                     |    1    |  ...
+26 MANURE is ... removed daily to at least 200      |         |
+   feet from the barn ( ... ft.)                    |    2    |  ...
+27 Manure pile is ... so located that the cows      |         |
+   cannot get at it                                 |    1    |  ...
+28 LIQUID MATTER is ... absorbed and removed        |         |
+   daily and ... allowed to overflow and saturate   |         |
+   ground under or around cow barn                  |    2    |  ...
+29 RUNNING WATER supply for washing stables is      |         |
+   ... located within building                      |    1    |  ...
+30 DAIRY RULES of the Department of Health are      |         |
+   ... posted                                       |    1    |  ...
+                                                    |         |
+                 COW YARD                           |         |
+31 COW YARD is ... properly graded and drained      |    1    |  ...
+32 Cow yard is ... clean, dry, and free from        |         |
+   manure                                           |    2    |  ...
+                                                    |         |
+                     COWS                           | Perfect | Allow
+33 COWS have ... been examined by veterinarian ...  |         |
+   Date  ... 190  Report was                        |    3    |  ...
+34 Cows have ... been tested by tuberculin, and     |         |
+   all tuberculous cows removed                     |    5    |  ...
+35 Cows are ... all in good flesh and condition     |         |
+   at time of inspection                            |    2    |  ...
+36 Cows are ... all free from clinging manure and   |         |
+   dirt. (No. dirty ... )                           |    4    |  ...
+37 LONG HAIRS are ... kept short on belly, flanks,  |         |
+   udder, and tail                                  |    1    |  ...
+38 UDDER AND TEATS of cows are ... thoroughly       |         |
+   cleaned before milking                           |    2    |  ...
+39 ALL FEED is ... of good quality and all grain    |         |
+   and coarse fodders are ... free from dirt and    |         |
+   mold                                             |    1    |  ...
+40 DISTILLERY waste or any substance in a state     |         |
+   of fermentation or putrefaction is ... fed       |    1    |  ...
+41 WATER SUPPLY for cows is ... unpolluted and      |         |
+   plentiful                                        |    2    |  ...
+                                                    |         |
+              MILKERS AND MILKING                   |         |
+42 ATTENDANTS are ... in good physical condition    |    1    |  ...
+43 Special Milking Suits are ... used               |    1    |  ...
+44 Clothing of milkers is ... clean                 |    1    |  ...
+45 Hands of milkers are ... washed clean before     |         |
+   milking                                          |    1    |  ...
+46 MILKING is ... done with dry hands               |    2    |  ...
+47 FORE MILK or first few streams from each teat    |         |
+   is ... discarded                                 |    2    |  ...
+48 Milk is strained at ... and ... in clean         |         |
+   atmosphere                                       |    1    |  ...
+49 Milk strainer is ... clean                       |    1    |  ...
+50 MILK is ... cooled to below 50° F. within two    |         |
+   hours after milking and kept below 50° F.        |         |
+   until delivered to the creamery ... °            |    2    |  ...
+51 Milk from cows within 15 days before or 5 days   |         |
+   after parturition is ... discarded               |    1    |  ...
+                                                    |         |
+                  UTENSILS                          |         |
+52 MILK PAILS have ... all seams soldered flush     |    1    |  ...
+53 Milk pails are ... of the small-mouthed design,  |         |
+   top opening not exceeding 8 inches in diameter.  |         |
+   Diameter ...                                     |    2    |  ...
+54 Milk pails are ... rinsed with cold water        |         |
+   immediately after using and washed clean with    |         |
+   hot water and washing solution                   |    2    |  ...
+55 Drying racks are ... provided to expose milk     |         |
+   pails to the sun                                 |    1    |  ...
+                                                    |         |
+                   MILK HOUSE                       |         |
+56 MILK HOUSE is ... located on elevated ground     |         |
+   with no hog pen, manure pile, or privy within    |         |
+   100 feet                                         |    1    |  ...
+57 Milk house has ... direct communication with     |         |
+    ... building                                    |    1    |  ...
+58 Milk house has ... sufficient light and          |         |
+   ventilation                                      |    1    |  ...
+59 Floor is ... properly graded and water-tight     |    1    |  ...
+60 Milk house is ... free from dirt, rubbish, and   |         |
+   all material not used in the handling and        |         |
+   storage of milk                                  |    1    |  ...
+61 Milk house has ... running or still supply of    |         |
+   pure clean water                                 |    1    |  ...
+62 Ice is ... used for cooling milk and is cut      |         |
+   from ...                                         |    1    |  ...
+                                                    |         |
+                    WATER                           |         |
+63 WATER SUPPLY for utensils is from a ... located  |         |
+    ... feet deep and apparently is ... pure,       |         |
+    wholesome, and uncontaminated                   |    5    |  ...
+64 Is ... protected against flood or surface        |         |
+   drainage                                         |    2    |  ...
+65 There is ... privy or cesspool within 250 feet   |         |
+   ( ... feet) of source of water supply            |    2    |  ...
+66 There is ... stable, barnyard, or pile of        |         |
+   manure or other source of contamination within   |         |
+   200 feet ( ... feet) of source of water supply   |    1    |  ...
+                                                    |---------|
+                                                    |  100    |
+----------------------------------------------------+---------+-------
+
+It is a great pity that we Americans have taken so long to learn that
+laws do not enforce themselves, that even good motives and good
+intentions in the best of officials do not insure good deeds. Thousands
+of lives are being lost every year, millions of days taken from
+industry and wasted by unnecessary sickness, millions of dollars spent
+on curing disease, the working life of the nation shortened, the hours
+of enjoyment curtailed, because we have not seen the great gap between
+health laws and health-law enforcement. In our municipal, state, and
+national politics we have made the same mistake of concentrating our
+attention upon the morals and pretensions of candidates and officials
+instead of judging government by what government does. Gains of men and
+progress of law are useful to mankind only when converted into deeds
+that make men freer in the enjoyment of health and earning power. In
+protecting health, as in reforming government, an ounce of efficient
+achievement is worth infinitely more than a moral explosion. One month
+of routine--unpicturesque, unexciting efficiency--will accomplish more
+than a scandal or catastrophe. Such routine is possible only when
+special machinery is constantly at work, comparing work done with work
+expected, health practice with health ideals. Where such machinery does
+not yet exist, volunteers, civic leagues, boys' brigades, etc., can
+easily prove the need for it by filling out an improvised score card
+for the school building, railroad station, business streets,
+"well-to-do" and poor resident streets, such as follows:
+
+
+TABLE V
+
+SCORE CARD FOR CITIZEN USE
+
+=======================================================+=======+======
+                                                       |Perfect|Allow
+-------------------------------------------------------+-------+------
+_Schoolhouse_                                          |       |
+  Well ventilated, 20; badly, 0-10                     |   20  | ...
+  Cleaned regularly, 20; irregularly, 0-10             |   20  | ...
+  Feather duster prohibited, 10                        |   10  | ...
+  No dry sweeping, 10                                  |   10  | ...
+  Has adequate play space, 10; inadequate, 0-5         |   10  | ...
+  Has clean drinking water, 10                         |   10  | ...
+  Has clean outbuildings and toilet, 20: unclean, 0-10 |   20  | ...
+                                                       | ------|
+                                                       |  100  |
+                                                       |       |
+_Church and Sunday School_                             |       |
+  Well ventilated, 20; badly, 0-10                     |   20  | ...
+  Heat evenly distributed, 20; unevenly, 0-10          |   20  | ...
+  Cleaned regularly, 20; irregularly, 0-10             |   20  | ...
+  Without carpets, 20                                  |   20  | ...
+  Without plush seats, 20                              |   20  | ...
+                                                       | ------|
+                                                       |  100  |
+                                                       |       |
+_Streets_                                              |       |
+  Sewerage underground, 20; surface, 0-10              |   20  | ...
+  No pools neglected, 10                               |   10  | ...
+  No garbage piled up, 10                              |   10  | ...
+  Swept regularly, 20; irregularly, 0-10               |   20  | ...
+  Sprinkled and flushed, 10                            |   10  | ...
+  Has baskets for refuse, 10                           |   10  | ...
+  All districts equally cleaned, 20; unequally, 0-10   |   20  | ...
+                                                       | ------|
+                                                       |  100  |
+-------------------------------------------------------+-------+------
+
+Until recently the most reliable test of health rights not enforced was
+the number of cases of preventable, communicable, contagious,
+infectious, transmissible diseases, such as smallpox, typhoid fever,
+yellow fever, scarlet fever, diphtheria, measles, whooping cough. By
+noticing streets and houses where these diseases occurred, students
+learned a century ago that the darker and more congested the street the
+greater the prevalence of fevers and the greater the chance that one
+attacked would die. The well-to-do remove from their houses and their
+streets the dirt, the decomposed garbage, and stagnant pools from which
+fevers seem to spring. It was because fevers and congestion go together
+that laws were made to protect the well-to-do, the comfortable, and the
+clean against the slum. It is true to-day that if you study your city
+and stick a pin in the map, street for street, where infection is known
+to exist, you will find the number steadily increase as you go from
+uncongested to congested streets and houses, from districts of high
+rent to districts of low rent. Because it is easier to learn the number
+of persons who have measles and diphtheria and smallpox than it is to
+learn the incomes and living conditions prejudicial to health, and
+because our laws grant protection against communicable diseases to a
+child in whatever district he may be born, the record of cases of
+communicable diseases has heretofore been the best test of health
+rights unenforced. Even in country schools it would make a good lesson
+in hygiene and civics to have the children keep a record of absences on
+account of transmissible disease, and then follow up the record with a
+search for conditions that gave the disease a good chance.
+
+But to wait for contagion before taking action has been found an
+expensive way of learning where health protection is needed. Even when
+infected persons and physicians are prompt in reporting the presence of
+disease it is often found that conditions that produced the disease
+have been overlooked and neglected.
+
+For example, smallpox comes very rarely to our cities to-day. Wherever
+boards of health are not worried by "children's diseases," as is often
+the case, and wait for some more fearful disease such as smallpox,
+there you will find that garbage in the streets, accumulated filth,
+surface sewers, congested houses, badly ventilated, unsanitary school
+buildings and churches are furnishing a soil to breed an epidemic in a
+surprisingly short time. Where, on the other hand, boards of health
+regard every communicable disease as a menace to health rights, you
+will find that health officials take certain steps in a certain order
+to remove the soil in which preventable diseases grow. These steps,
+worked out by the sanitarians of Europe and America after a century of
+experiment, are seen to be very simple and are applicable by the
+average layman and average physician to the simplest village or rural
+community. How many of these steps are taken by your city? by your
+county? by your state?
+
+  1. Notification of danger when it is first recognized.
+
+  2. Registration at a central office of facts as to each dangerous
+  thing or person.
+
+  3. Examination of the seat of danger to discover its extent, its
+  cost, and new seats of danger created by it.
+
+  4. Isolation of the dangerous thing or person.
+
+  5. Constant attention to prevent extension to other persons or
+  things.
+
+  6. Destruction or removal of disease germs or other causes of
+  danger.
+
+  7. Analysis and record, for future use, of lessons learned by
+  experience.
+
+  8. Education of the public to understand its relation to danger
+  checked or removed, its responsibility for preventing a recurrence
+  of the same danger, and the importance of promptly recognizing and
+  checking similar danger elsewhere.
+
+With a chart showing what districts have the greatest number of
+children and adults suffering from measles, typhoid fever, scarlet
+fever, consumption, one can go within his own city or to a strange city
+and in a surprisingly short time locate the nuisances, the dangerous
+buildings, the open sewers, the cesspools, the houses without bathing
+facilities, the dark rooms, the narrow streets, the houses without play
+space and breathing space, the districts without parks, the polluted
+water sources, the unsanitary groceries and milk shops. In country
+districts a comparison of town with town as to the prevalence of
+infection will enable one easily to learn where slop water is thrown
+from the back stoop, whether the well, the barn, and the privy are near
+together.
+
+    [Illustration: THE BABY, NOT THE LAW, IS THE TEST OF INFANT
+    PROTECTION IN COUNTRY AND IN CITY]
+
+Testing health rights requires not only that there be a board of health
+keeping track of and publishing every case of infection, but it
+requires further that one community be compared with other communities
+of similar size, and that each community be compared with itself year
+for year. These comparisons have not been made and records do not exist
+in many states.
+
+FOOTNOTES:
+
+[3] A striking demonstration of law enforcement that followed lawmaking
+is given in _The Real Triumph of Japan_, L.L. Seaman, M.D.
+
+
+
+
+CHAPTER IV
+
+THE BEST INDEX TO COMMUNITY HEALTH IS THE PHYSICAL WELFARE OF SCHOOL
+CHILDREN
+
+
+Compulsory education laws, the gregarious instinct of children, the
+ambition of parents, their self-interest, and the activities of
+child-labor committees combine to-day to insure that one or more
+representatives of practically every family in the United States will
+be in public, parochial, or private schools for some part of the year.
+The purpose of having these families represented in school is not only
+to give the children themselves the education which is regarded as a
+fundamental right of the American child, but to protect the community
+against the social and industrial evils and the dangers that result
+from ignorance. Great sacrifices are made by state, individual
+taxpayer, and individual parent in order that children and state may be
+benefited by education. Almost no resistance is found to any demand
+made upon parent or taxpayer, if it can be shown that compliance will
+remove obstructions to school progress. If, therefore, by any chance,
+we can find at school a test of home conditions affecting both the
+child's health and his progress at school, it will be easy, in the name
+of the school, to correct those conditions, just as it will be easy to
+read the index, because the child is under state control for six hours
+a day for the greater part of the years from six to fourteen.[4]
+
+    [Illustration: (Facsimile) PHYSICAL RECORD.]
+
+What, then, is this test of home conditions prejudicial to health that
+will register the fact as a thermometer tells us the temperature, or as
+a barometer shows moisture and air pressure? The house address alone is
+not enough, for many children surrounded by wealth are denied health
+rights, such as the right to play, to breathe pure air, to eat
+wholesome food, to live sanely. Scholarship will not help, because the
+frailest child is often the most proficient. Manners mislead, for, like
+dress, they are but externals, the product of emulation, of other
+people's influence upon us rather than of our living conditions.
+Nationality is an index to nothing significant in America, where all
+race and nationality differences melt into Americanisms, all responding
+in about the same way to American opportunity. No, our test must be
+something that cannot be put on and off, cannot be left at home, cannot
+be concealed or pretended, something inseparable from the child and
+beyond his control. This test it has been conclusively proved in
+Chicago, Boston, Brookline, Philadelphia, and particularly in New York
+City, is the physical condition of the school child. To learn this
+condition the child must be examined and reëxamined for the physical
+signs called for by the card on page 34. Weight, height, and
+measurements are needed to tell the whole story.
+
+When this card is filled out for every child in a class or school or
+city, the story told points directly to physical, mental, or health
+rights neglected. If for every child there is begun a special card,
+that will tell his story over and over again during his school life,
+noting every time he is sick and every time he is examined, the
+progress of the community as well as of the child will be clearly
+shown. Such a history card (p. 314) is now in use in certain New York
+schools, as well as in several private schools and colleges.
+
+Have you ever watched such an examination? By copying this card your
+family physician can give you a demonstration in a very short time as
+to the method and advantage of examination at school. The school
+physician goes at nine o'clock to the doctor's room in the public
+school, or, if there is no doctor's room, to that portion of the hall
+or principal's office where the doctor does his work. The teacher or
+the nurse stands near to write the physician's decision. The doctor
+looks the child over, glances at his eyes, his color, the fullness of
+his cheeks, the soundness of his flesh, etc. If the physician says "B,"
+the principal or nurse marks out the other letter opposite to number 1,
+so that the card shows that there is bad nutrition.
+
+In looking at the teeth and throat a little wooden stick is used to
+push down the tongue. There should be a stick for every child, so that
+infection cannot possibly be carried from one to the other. If this is
+impossible, the stick should be dipped in an antiseptic such as boric
+acid or listerine. If, because of swollen tonsils, there is but a
+little slit open in the throat, or if teeth are decayed, the mark is Y
+or B. The whole examination takes only a couple of minutes, but the
+physician often finds out in this short time facts that will save a boy
+and his parents a great deal of trouble. Very often this examination
+tells a story that overworked mothers have studiously concealed by
+bright ribbons and clean clothes. I remember one little girl of
+fourteen who looked very prosperous, but the physician found her so
+thin that he was sure that for some time she had eaten too little, and
+called her anæmic. He later found that the mother had seven children
+whom she was trying to clothe and shelter and feed with only ten
+dollars a week. A way was found to increase her earnings and to give
+all the children better living conditions,--all because of the short
+story told by the examination card. In another instance the card's
+story led to the discovery of recent immigrant parents earning enough,
+but, because unacquainted with American ways and with their new home,
+unable to give their children proper care.
+
+    [Illustration: LOOKING FOR ENLARGED TONSILS AND BAD TEETH
+    Note the mouth breather waiting]
+
+The most extensive inquiry yet made in the United States as to the
+physical condition of school children is that conducted by the board of
+health in New York City since 1905. From March, 1905, to January 1,
+1908, 275,641 children have been examined, and 198,139 or 71.9 per cent
+have been found to have defects, as shown in Table VI.
+
+
+TABLE VI
+
+PHYSICAL EXAMINATION OF SCHOOL CHILDREN--PERFORMED BY THE DEPARTMENT OF
+HEALTH IN THE BOROUGH OF MANHATTAN, 1905-1907
+
+=============================================+==========+===========
+                                             | Total    | Percentage
+---------------------------------------------+----------+-----------
+Number of children examined                  | 275,641  |    100
+Number of children needing treatment         | 198,139  |   71.9
+_Defects found:_                             |          |
+  Malnutrition                               |  16,021  |    5.8
+  Diseased anterior or posterior cervical    |          |
+    glands                                   | 125,555  |   45.5
+  Chorea                                     |   3,776  |    1.3
+  Cardiac disease                            |   3,385  |    1.2
+  Pulmonary disease                          |   2,841  |    1.0
+  Skin disease                               |   4,557  |    1.6
+  Deformity of spine, chest, or extremities  |   4,892  |    1.7
+  Defective vision                           |  58,494  |   21.2
+  Defective hearing                          |   3,540  |    1.2
+  Obstructed nasal breathing                 |  43,613  |   15.8
+  Defective teeth                            | 136,146  |   49.0
+  Deformed palate                            |   3,625  |    1.3
+  Hypertrophied tonsils                      |  75,431  |   27.4
+  Posterior nasal growths                    |  46,631  |   16.9
+  Defective mentality                        |   7,090  |    2.5
+=============================================+==========+=========
+
+It is generally believed that New York children must have more defects
+than children elsewhere. If this assumption is wrong, if children in
+other parts of the United States are as apt to have eye defects,
+enlarged tonsils, and bad teeth as the children of the great
+metropolis, then the army of children needing attention would be seven
+out of ten, or over 14,000,000.
+
+Whether these figures overstate or understate the truth, the school
+authorities of the country should find out. The chances are that the
+school in which you are particularly interested is no exception. To
+learn what the probable number needing attention is, divide your total
+by ten and multiply the result by seven.
+
+The seriousness of every trouble and its particular relation to school
+progress and to the general public health will be explained in
+succeeding chapters. The point to be made here is that the examination
+of the school child discloses in advance of epidemics and breakdowns
+the children whose physical condition makes them most likely to "come
+down" with "catching diseases," least able to withstand an attack, less
+fitted to profit fully from educational and industrial opportunity.
+
+The only index to community conditions prejudicial to health that will
+make known the child of the well-to-do who needs attention is the
+record of physical examination. No other means to-day exists by which
+the state can, in a recognized and acceptable way, discover the failure
+of these well-to-do parents to protect their children's health and take
+steps to teach and, if necessary, to compel the parents to substitute
+living conditions that benefit for conditions that injure the child.
+
+Among the important health rights that deserve more emphasis is the
+right to be healthy though not "poor." A child's lungs may be weak,
+breathing capacity one third below normal, weight and nutrition
+deficient, and yet that child cannot contract tuberculosis unless
+directly exposed to the germs of that disease. But such a child can
+contract chronic hunger, can in a hundred ways pay the penalty for
+being pampered or otherwise neglected. Physical examination is needed
+to find every child that has too little vitality, no zest for play,
+little resistance, even though sent to a private school and kept away
+from dirt and contagion.
+
+The New York Committee on the Physical Welfare of School Children
+visited fourteen hundred homes of children found to have one or more of
+the physical defects shown on the above card. While they found that low
+incomes have more than their proper share of defects and of unsanitary
+living conditions, yet they saw emphatically also that low incomes do
+not monopolize physical defects and unsanitary living conditions. Many
+families having $20, $30, $40 a week gave their children neither
+medical nor dental care. The share each income had in unfavorable
+conditions is shown by the summary in the following table.
+
+
+TABLE VII
+
+SHOWING PER CENT SHARE OF PHYSICAL DEFECTS OF CHILDREN, UNFAVORABLE
+HOUSING CONDITIONS, AND CHILD MORTALITY FOUND AMONG EACH FAMILY-INCOME
+GROUP
+
+========================+=============================================
+                        |         WEEKLY FAMILY INCOME
+                        +-----+------+------+------+------+------+----
+                        |     |      |      |      |      | $30  |
+                        |$0-10|$10-15|$16-19|$20-25|$25-29| and  |$100
+                        |     |      |      |      |      | over |
+                        +-----+------+------+------+------+------+----
+                        | %   |  %   |  %   |  %   |  %   |  %   |  %
+------------------------+-----+------+------+------+------+------+----
+Proportion to total     |     |      |      |      |      |      |
+  families              | 8.4 | 32.7 | 15.2 | 23.8 |  3.9 | 15.6 | 100
+                        |     |      |      |      |      |      |
+_Physical defects_:     |     |      |      |      |      |      |
+  Malnutrition          |13.8 | 43.4 | 12.4 | 17.9 |  3.4 |  9.  |  "
+  Enlarged glands       | 8.6 | 37.4 | 14.6 | 22.6 |  3.6 | 13.2 |  "
+  Defective breathing   | 9.6 | 32.3 | 15.5 | 24.4 |  2.8 | 15.4 |  "
+  Bad teeth             | 8.1 | 32.2 | 15.3 | 24.5 |  4.8 | 15.1 |  "
+  Defective vision      | 8.2 | 34.6 | 16.5 | 22.1 |  1.4 | 17.3 |  "
+                        |     |      |      |      |      |      |
+_Unfavorable housing    |     |      |      |      |      |      |
+  conditions_:          |     |      |      |      |      |      |
+  Dark rooms            | 8.2 | 35.4 | 18.1 | 18.4 |  3.8 | 15.9 |  "
+  Closed air shaft      | 6.9 | 30.2 | 18.9 | 26.4 |  3.2 | 19.6 |  "
+  No baths              |10.1 | 38.5 | 16.5 | 19.7 |  4.4 | 10.8 |  "
+  Paying over 25% rent  | 8.6 | 27.6 | 21.7 | 14.7 |  ... | 27.6 |  "
+                        |     |      |      |      |      |      |
+_Child Mortality_:      |     |      |      |      |      |      |
+  Families losing       |     |      |      |      |      |      |
+   children             |10.3 | 35.5 | 14.7 | 20.5 |  5.4 | 13.6 |  "
+  Families losing no    |     |      |      |      |      |      |
+   children             | 6.4 | 30.1 | 15.7 | 26.9 |  2.4 | 18.6 |  "
+  Children dead         |11.7 | 36.2 | 13.1 | 20.8 |  6.1 | 12.1 |  "
+  Infants dying from    |     |      |      |      |      |      |
+   intestinal diseases  | 8.9 | 37.6 | 18.3 | 18.8 |  4.  | 12.4 |  "
+  Children working      | 4.2 | 19.5 | 13.2 | 30.3 | 11.5 | 21.3 |  "
+========================+=============================================
+
+The index should be read in all grades from kindergarten to high school
+and college.
+
+Last winter the chairman of the Committee on the Physical Welfare of
+School Children was invited to speak of physical examination before an
+association of high-school principals. He began by saying, "This
+question does not concern you as directly as it does the grammar-school
+principals, but you can help secure funds to help their pupils." One
+after another the high-school principals present told--one of his own
+daughter, another of his honor girls, a third of his honor boys--the
+same story of neglected headaches due to eye strain, breakdowns due to
+undiscovered underfeeding, underexercise, or overwork. Are we coming to
+the time when the state will step in to prevent any boy or girl in high
+school, college, or professional school from earning academic honors at
+the expense of health? Harmful conditions within schoolrooms and on
+school grounds will not be neglected where pupils, teachers, school and
+family physicians, and parents set about to find and to remove the
+causes of physical defects.
+
+Disease centers outside of school buildings quickly register themselves
+in the schoolroom and in the person of a child who is paying the
+penalty for living in contact with a disease center. If a child sleeps
+in a dark, ill-ventilated, crowded room, the result will show in his
+eyes and complexion; if he has too little to eat or the wrong thing to
+eat, he will be underweight and undersized; if his nutrition is
+inadequate and his food improper, he is apt to have eye trouble,
+adenoids, and enlarged tonsils. He may have defective lung capacity,
+due to improper breathing, too little exercise in the fresh air, too
+little food. Existence of physical defects throws little light on
+income at home, but conclusively shows lack of attention or of
+understanding. Several days' absence of a child from school leads, in
+every well-regulated school, to a visit to the child's home or to a
+letter or card asking that the absence be explained. Even newly arrived
+immigrants have learned the necessity and the advantage of writing the
+teacher an "excuse" when their children are absent. Furthermore,
+neighbors' children are apt to learn by friendly inquiry what the
+teacher may not have learned by official inquiry, why their playmate is
+no longer on the street or at the school desk. While physicians are
+sometimes willing to violate the law that compels notification of
+infection, rarely would a physician fail to caution an infected family
+against an indiscriminate mingling with neighbors. Whether the family
+physician is careless or not, the explanation of the absence which is
+demanded by the school would give also announcement of any danger that
+might exist in the home where the child is ill.
+
+If it be said that in hundreds of thousands of cases the child labor
+law is violated and that therefore school examination is not an index
+to the poverty or neglect occasioning such child labor, it should be
+remembered that the best physical test is the child's presence at
+school. The first step in thorough physical examination is a thorough
+school census,--the counting of every child of school age. Moreover, a
+relatively small number of children who violate the child labor law are
+the only members of the family who ought to be in school. Younger
+children furnish the index and occasion the visit that should discover
+the violation of law.
+
+Appreciation of health, as well as its neglect, is indexed by the
+physical condition of school children. Habits of health are the other
+side of the shield of health rights unprotected. Physical examination
+will discover what parents are trying to do as well as what they fail
+to do because of their ignorance, indifference, or poverty. In so far
+as parents are alive to the importance of health, the school
+examination furnishes the occasion of enlisting them in crusades to
+protect the public health and to enforce health rights. The Committee
+on the Physical Welfare of School Children found many parents unwilling
+to answer questions as to their own living conditions until told that
+the answers would make it easier to get better health environment not
+only for their own children but for their neighbors' children.
+Generally speaking, fathers and mothers can easily be interested in any
+kind of campaign in the name of health and in behalf of children. The
+advantage of starting this health crusade from the most popular
+American institution, the public school,--the advantage of instituting
+corrective work through democratic machinery such as the public
+school,--is incalculable. To any teacher, pastor, civic leader, health
+official, or taxpayer wanting to take the necessary steps for the
+removal of conditions prejudicial to health and for the enforcement of
+health rights of child and adult, the best possible advice is to learn
+the facts disclosed by the physical examination of your school
+children. See that those facts are used first for the benefit of the
+children themselves, secondly for the benefit of the community as a
+whole. If your school has not yet introduced the thorough physical
+examination of school children, take steps at once to secure such
+examination. If necessary, volunteer to test the eyes and the breathing
+of one class, persuade one or two physicians to coöperate until you
+have proved to parent, taxpayer, health official, and teacher that such
+an examination is both a money-saving, energy-saving step and an act of
+justice.
+
+We shall have occasion to emphasize over and over again the fact that
+it is the use of information and not the gathering of information that
+improves the health. The United States Weather Bureau saves millions of
+dollars annually, not because flags are raised and bulletins issued
+foretelling the weather, but because shipowners, sailors, farmers, and
+fruit growers obey the warnings. Mere examination of school children
+does little good. The child does not breathe better or see better
+because the school physician fills out a card stating that there is
+something wrong with his eyes, nose, and tonsils. The examination tells
+where the need is, what children should have special attention, what
+parents need to be warned as to the condition of the child, what home
+conditions need to be corrected. If the facts are not used, that is an
+argument not against obtaining facts but against disregarding them.
+
+In understanding medical examination we should keep clearly in mind the
+distinction between medical school inspection, medical school
+examination, and medical treatment at school. Medical inspection is the
+search for communicable disease. The results of medical inspection,
+therefore, furnish an index to the presence of communicable diseases in
+the community. Medical examination is the search for physical defects,
+some of which furnish the soil for contagion. Its results are an index
+not only to contagion but to conditions that favor contagion by
+producing or aggravating physical defects and by reducing vitality.
+Medical treatment at school refers to steps taken under the school
+roof, or by school funds, to remove the defects or check the infection
+brought to light by medical inspection and medical examination.
+Treatment is not an index. In separate chapters are given the reasons
+for and against trying to treat at school symptoms of causes that exist
+outside of school. When, how often, and by whom inspection and
+examination should be made is also discussed later. The one point of
+this chapter is this: if we really want to know where in our community
+health rights are endangered, the shortest cut to the largest number of
+dangers is the physical examination of children at school,--private,
+parochial, reformatory, public, high, college.
+
+Apart from the advantage to the community of locating its health
+problems, physical examination is due every child. No matter where his
+schooling or at whose expense, every child has the right to advance as
+fast as his own powers will permit without hindrance from his own or
+his playmates' removable defects. He has the right to learn that
+simplified breathing is more necessary than simplified spelling, that
+nose plus adenoids makes backwardness, that a decayed tooth multiplied
+by ten gives malnutrition, and that hypertrophied tonsils are even more
+menacing than hypertrophied playfulness. He has the right to learn that
+his own mother in his own home, with the aid of his own family
+physician, can remove his physical defects so that it will be
+unnecessary for outsiders to give him a palliative free lunch at
+school, thus neglecting the cause of his defects and those of
+fellow-pupils.
+
+FOOTNOTES:
+
+[4] Sir John E. Gorst in _The Children of the Nation_ reads the index of
+the health of school children in the United Kingdom; John Spargo, in
+_The Bitter Cry of the Children_, and Simon N. Patten in _The New Basis
+of Civilization_, suggest the necessity for reading the index in the
+United States and for heeding it.
+
+
+
+
+PART II. READING THE INDEX TO HEALTH RIGHTS
+
+
+
+
+CHAPTER V
+
+MOUTH BREATHING
+
+
+If the physical condition of school children is our best index to
+community health, who is to read the index? Unless the story is told in
+a language that does not require a secret code or cipher, unless some
+one besides the physician can read it, we shall be a very long time
+learning the health needs of even our largest cities, and until
+doomsday learning the health needs of small towns and rural districts.
+Fortunately the more important signs can be easily read by the average
+parent or teacher. Fortunately, too, it is easy to persuade mothers and
+teachers that they can lighten their own labors, add to their
+efficiency, and help their children by being on the watch for mouth
+breathing, for strained, crossed, or inflamed eyes, for decaying teeth,
+for nervousness and sluggishness. Years ago, when I taught school in a
+Minnesota village, I had never heard of adenoids, hypertrophied
+tonsils, myopia, hypermetropia, or the relation of these defects and of
+neglected teeth to malnutrition, truancy, sickness, and dullness. I now
+see how I could have saved myself several failures, the taxpayers a
+great deal of money, the parents a great deal of disappointment, and
+many children a life of inefficiency, had I known what it is easy for
+all teachers and parents to learn to-day.
+
+    [Illustration: MOUTH BREATHERS BEFORE "ADENOID PARTY"]
+
+The features in the following cut are familiar to teachers the world
+over. Parents may reconcile themselves to such lips, eyes, and mouths,
+but seldom do even neglectful parents fail to notice "mouth breathing."
+Children afflicted by such features suffer torment from playfellows
+whose scornful epithets are echoed by the looking-glass. No fashion
+plate ever portrays such faces. No athlete, thinker, or hero looks out
+from printed page with such clouded, listless eyes. The more wonder,
+therefore, that the meaning of these outward signs has not been
+appreciated and their causes removed; conclusive reason, also, for not
+being misled by recent talk of mouth breathing, adenoids, and enlarged
+tonsils, into the belief that the race is physically deteriorating.
+Three generations ago Charles Dickens in his _Uncommercial Traveller_
+pointed out a relation between open mouths and backwardness and
+delinquency that would have saved millions of dollars and millions of
+life failures had the civilized world listened. He was speaking of
+delinquent girls from seventeen to twenty years old in Wapping
+Workhouse: "I have never yet ascertained why a refractory habit should
+affect the tonsils and the uvula; but I have always observed that
+refractories of both sexes and every grade, between a Ragged School and
+the Old Bailey, have one voice, in which the tonsils and uvula gain a
+diseased ascendency."
+
+To-day we are just beginning to see over again the connection between
+inability to breathe through the nose and inability to see clearly
+right from wrong and inability to want to do what teachers and parents
+wish. Physical examinations show now, and might just as well have shown
+fifty years ago, that the great majority of truants and juvenile
+offenders have adenoids and enlarged tonsils. A recent examination made
+by the New York board of health on 150 children in one school made up
+from the truant school, the juvenile court, and Randall's Island,
+showed that only three were without some physical defect and that 137
+had adenoids and large tonsils. Dickens wrote his observations in 1860;
+in 1854 the New York Juvenile Asylum was started, and up to 1908 cared
+for 40,000 children; in 1860 William Meyer pointed out, so that no one
+need misunderstand, the harmful effects of adenoids. What would have
+been the story of juvenile waywardness, of sickness, of educational
+advancement, had examinations for defective breathing been started in
+1853 or 1860 instead of 1905; if one per cent of the attention that has
+been given to teaching mouth breathers the ten commandments had been
+spent on removing the nasal obstructions to intelligence?
+
+    [Illustration: A "DEGENERATE" MADE NORMAL BY REMOVAL OF
+    ADENOIDS]
+
+William Hegel, who is pictured on page 48, before his tonsils and
+adenoids were removed was described by his father in this way: "When
+playing with other boys on the street he seems dazed, and sluggish to
+grasp the various situations occurring in the course of the game. When
+he decides to do something he runs in a heedless, senseless way, as if
+running away,--will bump against something, pedestrian or building,
+before he comes to himself; seems dazed all the time. When told
+something by his mother he giggles in the most exasperating way, for
+which he receives a whipping quite often." The father said the whipping
+was of no avail. The child was restless, talkative, and snored during
+sleep. He had an insatiable appetite. He was removed or transferred
+from five different schools in New York City. To get redress the father
+took him to the board of education, whence he was referred to the
+assistant chief medical inspector of the department of health, whose
+examination revealed immensely large fungous-looking tonsils and
+excessive pharyngeal granulations (adenoids). He was operated on at a
+clinic. The tonsils and adenoids removed are pictured on the opposite
+page, reduced one third. After the operation the child was visited by
+the assistant medical inspector. There was a marked improvement in his
+facial expression,--he looked intelligent, was alert and interested.
+When asked how he felt, he answered, "I feel fine now." It required
+about fifteen minutes to get his history, during all of which time he
+was responsive and interested, constantly correcting statements of his
+father and volunteering other information. Eleven days after the
+operation he was reported to have had no more epileptic seizures.
+"Doesn't talk in sleep. Doesn't snore. Doesn't toss about the bed. Has
+more self-control. Tries to read the paper. His immoderate appetite is
+not present."
+
+    [Illustration: REASON ENOUGH FOR MOUTH BREATHING
+    Adenoid and tonsils reduced one third]
+
+While the open mouth is a sure sign of defects of breathing, it is not
+true that the closed mouth, when awake and with other people, is proof
+that there are no such defects. Children breathe through the mouth not
+because they like to, not because they have drifted into bad habits,
+not because their parents did, not because the human race is
+deteriorating, but because their noses are stopped up,--because they
+must. A mouth breather is not only always taking unfiltered dirt germs
+into his system but is always in the condition of a person who has
+slept in a stuffy room. What extra effort adenoids mean can be
+ascertained by closing the nostrils for a forenoon.
+
+For many reasons it is perhaps unfortunate that we can breathe at all
+when the nose is stopped up. If we could see with our ears as well as
+with our eyes, we should probably not take as good care of our eyes. In
+this respect the whole race has experienced the misfortune of the man
+of whom the coroner reported, "Killed by falling too short a distance."
+Because we can breathe through the mouth we have neglected for
+centuries the nasal passages. When a cold stops the nose we necessarily
+breathe through the mouth. Unfortunately children make the necessary
+effort required to breathe through the nose long before other people
+notice the lines along the nose and the slow mind. Mouth breathing will
+show with the child asleep, before the child awake loses power to
+accommodate his effort to the task. Therefore the importance of a
+physical test at school to detect the beginnings of adenoids and large
+tonsils before these symptoms become obvious to others.
+
+No child should be exempted from this examination because of apocryphal
+theories that only the poor, the slum child, the refractory, or the
+unclean have defects in breathing. This very afternoon a friend has
+told me of her year abroad with a girl of nine, whose parents are very
+wealthy. The girl is anæmic. Her backwardness humiliates her parents,
+especially because she gave great promise until two years ago.
+High-priced physicians have prescribed for her. It happens that they
+are too eminent to give attention to such simple troubles as adenoids
+that can be felt and seen. They are looking for complications of the
+liver or inflammation of muscles at the base of the brain. One
+celebrated French savant found the adenoids, assured the mother that
+the child would outgrow them, and advised merely that she be compelled
+to breathe through the nose. The mother and nursemaids nag the child
+all day. The poor unwise mother sits up nights to hold the child's jaws
+tight in the hope that air coming through the nose will absorb the
+adenoids. The mother is made nervous. Of course this makes the child
+more nervous and adds to the evil effects of adenoids. If the mother
+had the good fortune to be very poor, she could not sit up nights, and
+would long ago have decided either to let the child alone or else to
+have the trouble removed.
+
+Adenoids are not a city specialty. Country earache is largely due to
+adenoids or to inflammation that quickly leads to adenoids. In 415
+villages of New York state twelve per cent were found to be mouth
+breathers. For two summers I have known a lad named Fred. He lives at
+the seashore. Throughout his twelve years he has lived in a veritable
+El Dorado of health and nature beauty. Groves and dunes and flora vie
+with the blues of ocean and sky in resting the eye and in filling the
+soul with that harmony which is said to make for sound living. Yet to a
+child, Fred's schoolmates are experts on patent medicines and on the
+heredity that is alleged to be responsible for bad temper, running
+sores, tuberculosis, anæmia, and weak eyes. Freddie is particularly
+favored. His well-to-do parents have supplied him with ponies, games,
+and bicycles. Nothing prevents his breathing salt air fresh from the
+north pole but hermetically sealed windows. The father thinks it absurd
+to make a fuss over adenoids. Didn't he have them when a boy, and
+doesn't he weigh two hundred pounds and "make good money"? The mother
+never knew of operations for such trifles when she taught school; she
+supposes her boy needs an operation, but "just can't bear to see the
+dear child hurt." As for Fred, he breathes through his mouth, talks
+through his nose, grows indifferent to boy's fun, fails to earn
+promotion at school, and fears that "I won't be strong in spite of all
+the patent medicine I've taken." Father, mother, and Fred feel profound
+pity for the city child living so far from nature.
+
+Adenoids are not monopolized by children whose parents are ignorant of
+the importance of them and of physical examination. Last summer I was
+asked by a small boy to buy some chocolate. A glance at his cigar box
+with its two or three uninviting things for sale showed that the boy
+was really begging. He had thick lips, open mouth, "misty" eyes, and a
+nasal twang. I asked him if his teacher had not told him he had lumps
+back of his nose and could not breathe right. He said, "No." I
+explained then that he could make a great deal more money if he talked
+like other boys, stepped livelier, and breathed as other people
+breathe. He said he had "been by a doctor onct but didn't want to be
+op'rated." I turned to my companion and asked, "Have you never noted
+those same lines on your boy's face?" Although he had been lecturing on
+mouth breathers, he had never noticed his own boy's trouble. He
+hastened home and found the infallible signs. The mother declared it
+could not be true of her boy. About five months before, their family
+physician had said of the child's earache, "The same inflammation of
+the nasal passages that causes earache causes adenoids; you must be on
+the lookout." Although in the country, the boy's appetite was not good
+and his zest for play had flagged. They had looked for the trouble to
+back generations and in psychology books,--everywhere but at the boy's
+face, in his mouth, and in his nose. After the operation, which took
+less than two minutes, the appetite was ravenous, the eyes cleared,
+and the spirit rebounded to its old buoyancy that craved worlds to
+conquer.
+
+The new personal experience made a deep impression upon my friend's
+mind. He wanted everybody to know how easy it was to overlook a child's
+distress. One person after another had a story to tell him; even the
+janitor said: "You'd ought to have seen our John at sixteen. He spent a
+week by the hospital." The only people who do not seem to know more
+than the new convert are the mouth breathers whom he religiously stops
+on the street.
+
+The indexes to adenoids and large tonsils for the teacher to read at
+school are:
+
+  1. Inability to breathe through the nose.
+
+  2. A chronically running nose, accompanied by frequent nose-bleeds
+  and a cough to clear the throat.
+
+  3. Stuffy speech and delayed learning to talk. "Common" is
+  pronounced "cobbéd"; "nose," "dose"; and "song," "sogg."
+
+  4. A narrow upper jaw and irregular crowding of the teeth.
+
+  5. Deafness.
+
+  6. Chorea or nervousness.
+
+  7. Inflamed eyes and conjunctivitis.
+
+The adenoids and large tonsils discovered at school are an index:
+
+  1. To children needlessly handicapped in school work.
+
+  2. To teachers needlessly burdened.
+
+  3. To whole classes held back by afflicted children.
+
+  4. To breeding grounds for disease.
+
+  5. To homes where children's diseases and tuberculosis are most
+  likely to break out and flourish.
+
+  6. To parents who need instruction in their duty to their
+  children, to themselves, and to their neighbors, and who are
+  ignorant of the way in which "catching" diseases originate and
+  spread.
+
+The riot that occurred when the adenoids of children in a school on the
+"East Side" in New York City were removed without the preliminary of
+convincing the parents as to the advantages of the operation was merely
+a demand for the "right to knowledge," which is never overlooked with
+impunity. Reluctance to permit operation on a young child, and the
+natural shrinking of a parent at seeing a child under the surgeon's
+knife, require the teacher or school physician or nurse to answer fully
+the usual questions of the hesitant mother and father.
+
+1. Is the operation necessary? Will the child not outgrow its adenoids?
+Usually the adenoid growths atrophy or dry up after the age of puberty.
+Adenoids are not uncommon in adults, however. The surgeon general of
+the army reports that during the year 1905, out of 3004 operations on
+officers and enlisted men in service, there were 225 operations on the
+nose, mouth, and pharynx, 103 of which were operations for adenoids and
+enlarged or hypertrophied tonsils. Allowing the child to "outgrow"
+adenoids may mean not only that he is being subjected to infection
+chronically but that his body is allowed to be permanently deformed and
+his health endangered. Beginning at the age of the second dentition,
+the bones of jaw, nose, throat, and chest are undergoing important
+changes--nasal occlusion. Adenoids left to atrophy--if large enough to
+cause mouth breathing--may mean atrophy of this developing process,
+permanent disfiguration of face, and permanent deformity of chest and
+lungs.
+
+2. Will the growth recur? In a few cases it does recur; frequently
+either because it was not desirable to make a complete removal of the
+adenoid tissue or because the surgeon was careless. If the growths do
+recur, then they must be removed again.
+
+3. Is the operation a dangerous one?
+
+4. Is an anæsthetic necessary?
+
+5. Will the operation cure the child of all its troubles? These
+questions are best answered by the process and results of an "adenoid
+party," which was given especially for the benefit of this book, every
+step and symptom of which were carefully studied.
+
+The seven children pictured here were discovered by their school
+physician to have moderately large adenoid growths,--one boy having
+enlarged tonsils also.
+
+    [Illustration: MOUTH BREATHERS IMMEDIATELY AFTER "ADENOID
+    PARTY"]
+
+The picture on page 46 was taken by flash light at 2.30 P.M., January
+15, 1908. At 3 P.M. the principal escorted these children into the
+operating room at Vanderbilt Clinic. The doctor examined the throat and
+nose of each child, entered the name and age of each, together with his
+diagnosis, on a clinic card, sending each child into the next room
+after examination. He then called the first boy and explained that it
+would hurt, but that it would be over in a minute. The principal stood
+by and told him to be brave and remember the five cents he could have
+for ice cream afterwards. The clinic nurse tied a large towel about him
+and put him in her lap; with one hand she held his clasped hands, while
+the other held his head back. The doctor then took the little
+instrument--the curette--and pushed it up back of the soft palate, and
+with one twist brought out the offending spongy lump. The boy's head
+was immediately held over a basin of running water. He was so occupied
+with spitting out the blood that rushed down to choke him that he
+hadn't time to cry before the acute pain had ceased. The rush of cool
+air through his nostrils was such a pleasurable sensation that he
+smiled as the school nurse escorted him out into the hall to wait for
+his companions. At 3.30 P.M. all seven children were out in the hall,
+all seven mouths were closed, and all seven faces were clothed with the
+sleepy, peaceful expression that comes with rest from the prolonged
+labor of trying to get enough air. At 3.45 P.M. they had been all
+reëxamined by the doctor, and a few tag ends were picked out of the
+nasopharynx of one child. At 4 P.M. the "party" had returned to the
+Children's Aid Society's school and to the ice cream that follows each
+adenoid party.
+
+It is worth while to tell mothers stories of the "marvelous improvement
+in school progress of those children whose brains have been poisoned
+and starved by the accursed adenoid growths, and how their bodies
+fairly bloom when the mysterious and awful incubus is removed," to use
+the words of one school principal. It is worth while to show them
+"before" and "after" pictures, and "before" and "after" children, and
+"before" and "after" school marks.
+
+
+
+
+CHAPTER VI
+
+CATCHING DISEASES, COLDS, DISEASED GLANDS
+
+
+Deadly fevers, the plague, black death, cholera, malaria, smallpox,
+taught mankind invaluable lessons. Millions of human beings died before
+the mind of man devoted itself to preventing the diseases for which no
+sure cure had been found. Efforts to conquer these diseases were tardy
+because men were taught that some unseen power was punishing men and
+governments for their sins. The difference between the old and the new
+way is shown powerfully by a painting in the Liverpool Gallery entitled
+"The Plague." A mediæval village is strewn with the dead and dying.
+Bloated, spotted faces look into the eyes of ghouls as laces and
+jewelry are torn from bodies not yet cold. In the foreground a muscular
+giant, paragon of conscious virtue, clad like John the Baptist and
+Bible in hand, finds his way among his plague-stricken fellow-townsmen,
+urging them to turn from their sins. Modern efficiency learns of the
+first outbreak of the plague, isolates the patient, kills rats and
+their fleas which spread the disease, thoroughly cleanses or destroys,
+if necessary, all infected clothing, bedding, floors, and walls, and
+makes it possible for us to go on living for each other with a better
+chance of "bringing forth fruits worthy for repentance."
+
+Where boards of health make it compulsory to report cases of sickness
+due to contagion, health records are a reliable index to "catching"
+diseases. But now that the chief infection is the kind that afflicts
+children, we can read the index before the outbreak that calls in a
+physician to diagnose the case. School examination shows which
+children have defects that welcome and encourage disease germs. It
+points to homes that cultivate germs, and consequently menace other
+homes. To locate children who have enlarged tonsils may prevent a
+diphtheria epidemic. To detect in September those who are
+undernourished, who have bad teeth, and who breathe through the mouth
+will help forecast winter's outbreaks of scarlet fever and measles. One
+dollar spent at this season in examination for soil hospitable to
+disease germs may save fifty dollars otherwise necessary for inspection
+and cure of contagious diseases.
+
+It is harder at first to interest a community in medical examination
+than in medical inspection, because we are all afraid of "catching"
+diseases, while few of us know how they originate and how they can be
+prevented by correcting the unfavorable conditions which physical
+examination of school children will bring to light.
+
+Courses in germ sociology are therefore of prime necessity. How do
+germs act? On what do they live? Why do they move from place to place?
+What causes them to become extinct? With few exceptions, germs migrate
+for the same reason as man,--search for food, love of conquest, and
+love of adventure. When there is plenty of food they multiply rapidly.
+Full of life, overflowing with vitality, they move out for new worlds
+to conquer. Like human beings, they will do their best to get away from
+a country that provides a scanty food supply. Like men and women, they
+starve if they cannot eat. Like boys and girls, they avoid enemies; the
+weak give way to the strong, the slow to the swift, the devitalized to
+the vitalized.
+
+Human sociology imprisons, puts to death, deprives of opportunity to do
+evil, or reforms those who murder, steal, or slander. Germ sociology
+teaches us to do the same with injurious germs. We imprison them, we
+take away their food supply, we kill them outright, or we starve them
+slowly. They have a peculiar diet, being especially partial to
+decomposing vegetable and animal matter and to what human beings call
+dirt. By putting this diet out of their reach we make it impossible for
+them to propagate their kind. By placing poison within their reach or
+by forcing it upon them we can successfully eliminate them as enemies.
+As the president of Mexico restored order "by setting a thief to catch
+a thief," so modern science is setting germs to kill germs that harm
+crops and human stock. Of utmost consequence is it that the body's germ
+consumer--its pretorian guard--be always armed with vitality ready to
+vanquish every intruding hostile germ. If we are false to our guard, it
+will turn traitor and join invaders in attacking us. But here, as in
+dealing with evils that originate with human beings, an ounce of
+prevention is worth a ton of cure. The most effectual way to eliminate
+germ diseases is to remove the cause--the food supply of disease germs.
+The fact that many germs are plants, not animals, does not weaken the
+analogy, for weeds do not get a chance in well-tilled soil.
+
+Perhaps the most notable recent example of government germ
+extermination is the triumph over the yellow-fever and malaria mosquito
+in Panama. When the French started to build a canal in Panama, the
+first thing they did was to build a hospital. The hospital was always
+full and the canal was given up. At the time the United States proposed
+to re-attempt the work, it was thought that it could not be done
+without great loss of life and without great labor difficulties.
+Instead of taking the sickness for granted and enlarging the French
+hospital, the chief medical inspector, Gorgas, took for granted that
+there need be no unusual sickness if proper preventive measures were
+taken. He knew what the French had not known, that the yellow-fever
+scourge depends for its terrors upon mosquitoes. Accordingly, with the
+aid of six thousand men and five million dollars he set about to
+starve out the few infected and infectious kinds of mosquito,--the
+yellow-fever or house mosquito and the malaria or meadow mosquito. He
+introduced waterworks and hydrants, paved the streets, drained the
+swamps and pools in which they breed, and instituted a weekly
+house-to-house inspection to prevent even so much as a pail of stagnant
+water offering harbor to these enemies. The grass of the meadows where
+the malaria mosquito breeds was cut short and kept short within three
+hundred feet of dwellers,--as far as the mosquito can fly. All ditches
+were disinfected with paraffin, and the natives were forced to observe
+sanitary laws. President Roosevelt, in his special message to Congress
+on the Panama Canal in 1906, stated that in the weekly house-to-house
+visit of the inspectors at the time he was in Panama but two mosquitoes
+were found. These were not of the dangerous type. As a consequence of
+this sanitary engineering there is very little sickness in Panama, the
+hospital is seldom one third full, and the canal is progressing very
+much faster than was expected. Panama, like Havana, is now safer than
+many American cities, because cleaner and less hospitable to disease
+germs.
+
+Any place where numbers of people are accustomed to assemble favors the
+propagation of germs,--whether it be the meetinghouse, the townhall,
+the theater, or the school. Every teacher can be the sanitary engineer
+of her own schoolroom, school, or community by coöperating with the
+school doctor, the town board of health, family physicians, and
+mothers. Every teacher can exterminate disease by applying the very
+same principles to her schoolroom as Chief Medical Inspector Gorgas
+applied to Panama. Knowledge, disinfection, absolute cleanliness,
+education, and inspection are the essential steps. First she must know
+that "children's diseases" are not necessary. She should discountenance
+the old superstition that every child must run the gamut of children's
+diseases, that every child must sooner or later have whooping cough,
+measles, chicken pox, mumps, scarlet fever, just as they used to think
+yellow fever and cholera inevitable. The price of this terrible
+ignorance has been not only expense, loss of time, acquisition of
+permanent physical defects, and loss of vitality, but, for the majority
+of children, death before reaching five years of age. All these
+"catching" diseases are germ diseases, which disinfection can
+eliminate. The free use of strong yellow soap and disinfectants on the
+school floor, windows, benches, desks, blackboards, pencils, in the
+coat closets and toilets, plus the natural disinfectants, hot sun and
+oxygen, will prevent the schoolroom from being a source of danger. One
+or more of these germ-killing remedies must be constantly applied;
+cleansing deserves a larger part in every school budget.
+
+Often country towns are as ignorant of the existence of germs and of
+the means of preventing the spread of disease as the woman in a small
+country town who used daily to astound the neighbors by the "shower of
+snow" she produced by shaking the bedding of her sick child out of the
+window. Their astonishment was soon changed to panic when that shower
+of snow resulted in a deadly epidemic of scarlet fever. Medical
+inspection of New York City's schools was begun after an epidemic of
+scarlet fever was traced to a popular boy who passed around among his
+schoolmates long rolls of skin from his fingers.
+
+Much of the care exercised at school to prevent children's diseases is
+counteracted because children are exposed at home and in public places
+to contagion, where ignorance more often than carelessness is the cause
+of uncleanliness. By hygiene lessons, illustrating practically the
+proper methods of cleaning a room, much may be done to enlist school
+children in the battle against germs. Through the enthusiasm of the
+children as well as through visits to the homes parents may be
+instructed as to the danger of letting well children sleep with sick
+children; the wisdom of vaccination to prevent smallpox, of antitoxin
+to prevent serious diphtheria, of tuberculin tests to settle the
+question whether tuberculosis is present; why anything that gathers
+dust is dangerous unless cleansed and aired properly; and why bedding,
+furniture, floor coverings, and curtains that can be cleansed and aired
+are more beautiful and more safe than carpets, feather beds,
+upholstery, and curtains that are spoiled by water and sunshine; how to
+care for the tuberculous member of the family, etc. Anti-social acts
+may be prevented, such as carrying an infected child to the doctor in a
+public conveyance, thereby infecting numberless other people; sending
+infected linen to a common laundry; mailing a letter written by an
+infected person without first disinfecting it; sending a child with
+diphtheria to the store; returning to the dairy unscalded milk bottles
+from a sick room.
+
+The daily inspection of school children for contagious diseases by the
+school physician has, where tried, been found to reduce considerably
+the amount of sickness in a town. Such inspection should be universally
+adopted. Moreover, the teacher should be conversant with the early
+symptoms of these diseases so that on the slightest suspicion the child
+may be sent home without waiting for the physician's call. Like the
+little girl who never stuttered except when she talked, school children
+and school-teachers are rarely frightened until too late to prevent
+trouble. The "easy" diseases such as measles, whooping cough, etc.,
+cost our communities more than the more terrible diseases like typhoid
+and smallpox. During one typical week ending May 18, 630 new cases of
+measles were reported to one department of health. Obviously the
+nineteen deaths reported give no conception of the suffering, the cost,
+the anxiety caused by this preventable disease. The same may be said
+of diphtheria and croup, of which only thirty-two deaths are reported,
+but 306 cases of sickness. Yet no one to-day will send a child to sleep
+with a playmate so as to catch diphtheria and "be done with it."
+
+The most strategic point of attack is almost universally unrecognized.
+That is the child's mouth. Here the germs find lodgment, here they find
+a culture medium--at the gateway of the human system. The mouth is
+never out of service and is almost never in a state of true
+cleanliness. Solid particles from the breath, saliva, food between the
+teeth, and other débris form a deposit on the teeth and decompose in a
+constant temperature of ninety-eight degrees Fahrenheit. In the normal
+mouth from eight to twenty years of age the teeth present from twenty
+to thirty square inches of dentate surface, constantly exposed to
+ever-changing, often inimical, conditions. This bacterially infected
+surface makes a fairly large garden plot. Every cavity adds to the
+germ-nourishing soil. Dental caries--tooth decay--is a disease hitherto
+almost universal from birth to death. Thus the air taken in through the
+mouth becomes a purveyor of its poisonous emanations and affects the
+lung tissues and the blood. Food and water carry hostile germs down
+into the stomach. Thence they may be carried into any organ or tissue,
+just as nourishment or poison is carried.
+
+Moreover, the child with an unclean mouth not only infects and
+reinfects himself but scatters germs in the air whenever he sneezes or
+coughs. In a cold apartment where there is no appreciable current of
+air a person can scatter germs for a distance of more than twenty-two
+feet. Germs are also scattered through the air by means of salivary or
+mucous droplets. It is this fact that makes colds so dangerous.
+
+
+TABLE VIII
+
+=City of Manchester Education Committee=
+
+=INFECTIOUS OR CONTAGIOUS DISEASES IN SCHOOLS INFORMATION FOR TEACHERS=
+
+  Four columns are omitted: (1) Interval between Exposure to
+  Infection and the First Signs of the Disease; (2) Day from Onset
+  of Illness on which Rash appears; (3) Period of Exclusion from
+  School after Exposure to Infection; (4) Period of Exclusion from
+  School of Person suffering from the Disease
+
+-----------+------------------------------+------------+------------------
+DISEASE    | PRINCIPAL SIGNS AND SYMPTOMS | Method of  | REMARKS
+           |                              | Infection  |
+-----------+------------------------------+------------+------------------
+Measles    |_Begins like cold in the      |            |After effects
+           |head_, with _feverishness,    |            |often severe.
+           |running nose, inflamed and    |            |Period of greatest
+           |watery eyes, and sneezing_;   |            |risk of infection
+           |small crescentic groups of    | Breath and |first three or
+           |_mulberry-tinted spots_ appear| discharges |four days, before
+           |about the third day; _rash    | from nose  |the rash appears.
+           |first seen on forehead and    | and mouth. |May have repeated
+           |face_. The rash varies with   |            |attacks. Great
+           |heat; may almost disappear if |            |variation in type
+           |the air is cold, and come out |            |of disease.
+           |again with warmth.            |            |
+-----------+------------------------------+------------+------------------
+German     |Illness usually slight. Onset |            |
+Measles    |sudden. _Rash often first     |            |
+           |thing noticed;_ no cold in    | Breath and |
+           |head. Usually have            | discharges |After effects
+           |_feverishness_ and _sore      | from nose  |slight.
+           |throat_, and the _eyes may    | and mouth  |
+           |be inflamed. Rash_ something  |            |
+           |between Measles and Scarlet   |            |
+           |Fever, variable.              |            |
+-----------+------------------------------+------------+------------------
+Chicken    |Sometimes begins with         |            |When children
+Pox        |feverishness, but is _usually |            |return, examine
+           |very mild_ and without sign   |            |head for
+           |of fever. _Rash_ appears on   |            |overlooked spots.
+           |second day as _small pimples_,|            |All spots should
+           |which in about a day become   |            |have disappeared
+           |filled with _clear fluid_.    | Breath and |before child
+           |This fluid then becomes       | crust of   |returns. A mild
+           |_matter_, and then the _spot  | spots.     |disease and
+           |dries up_and _the crust falls |            |seldom any after
+           |off_.                         |            |effects.
+           |                              |            |
+           |May have _successive crops of |            |
+           |of rash_ until tenth day.     |            |
+-----------+------------------------------+------------+------------------
+Whooping   |_Begins like cold in the      |            |After effects
+Cough      |head_, with _bronchitis_ and  |            |often very severe
+           |_sore throat_, and a _cough_  |            |and the disease
+           |which is _worse at night_.    | Breath and |causes great
+           |Symptoms may at first be very | discharges |debility. Relapses
+           |mild. Characteristic          | from nose  |are apt to occur.
+           |_"whooping" cough_ develops   | and mouth. |Second attack
+           |in about a fortnight, and the |            |rare. Specially
+           |spasm of coughing often ends  |            |infectious for
+           |with _vomiting_.              |            |first week or two.
+           |                              |            |If a child is sick
+           |                              |            |after a bout of
+           |                              |            |coughing, it is
+           |                              |            |most probably
+           |                              |            |suffering from
+           |                              |            |whooping cough.
+           |                              |            |
+           |                              |            |Great variation in
+           |                              |            |type of disease.
+-----------+------------------------------+------------+------------------
+Mumps      |Onset may be sudden, beginning|            |
+           |with sickness and fever, and  |            |
+           |_pain about the angle of the  | Breath and |Seldom leaves
+           |jaw_. The _glands become      | discharges |after effects.
+           |swollen and tender_, and the  | from nose  |Very infectious.
+           |_jaws stiff_, and the _saliva | and mouth. |
+           |sticky_.                      |            |
+-----------+------------------------------+------------+------------------
+Scarlet    |The _onset is usually sudden_,| Breath,    |Dangerous both
+Fever or   |with _headache, languor,      | discharges |during attack and
+Scarlatina |feverishness, sore throat_,   | from nose  |from after effects.
+           |and often the child is _sick_.| and mouth, |Great variation
+           |Usually within twenty-four    | particles  |in type of disease.
+           |hours the _rash_ appears, and | of skin,   |Slight attacks
+           |is _finely spotted, evenly    | and        |as infectious as
+           |diffused_, and _bright red_.  | discharges |severe ones. Many
+           |The _rash_ is seen first on   | from       |mild cases not
+           |the _neck and upper part of   | suppuratory|diagnosed and many
+           |chest_, and lasts three to    | glands or  |concealed. The
+           |ten days, when it fades and   | ears. Milk |peeling may last
+           |the _skin peels in scales,    | specially  |six to eight weeks.
+           |flakes_, or even _large       | apt to     |A second attack is
+           |pieces_. The _tongue_ becomes | convey     |rare. When scarlet
+           |whitish, with bright red      | infection. |fever is occurring
+           |spots. The eyes are not watery|            |in a school, all
+           |or congested.                 |            |cases of sore
+           |                              |            |throat should be
+           |                              |            |sent home.
+-----------+------------------------------+------------+-------------------
+Diphtheria |Onset insidious, may be rapid | Breath and |Very dangerous
+           |or gradual. Typically _sore   | discharges |both during attack
+           |throat_, great weakness, and  | from nose, |and from after
+           |swelling of glands in the     | mouth, and |effects. When
+           |neck, about the angle of the  | ears.      |diphtheria is
+           |jaw. The back of the throat,  |            |occurring in a
+           |tonsils, or palate may show   |            |school all children
+           |_patches_ like pieces of      |            |suffering from sore
+           |yellowish-white kid. The most |            |throat should be
+           |pronounced symptom is great   |            |excluded. There is
+           |debility and lassitude, and   |            |great variation of
+           |there may be little else      |            |type, and mild
+           |noticeable. There may be      |            |cases are often not
+           |hardly any symptoms at all.   |            |recognized but are
+           |                              |            |as infectious as
+           |                              |            |severe cases. There
+           |                              |            |is no immunity from
+           |                              |            |further attacks.
+           |                              |            |Fact of existence
+           |                              |            |of disease
+           |                              |            |sometimes
+           |                              |            |concealed.
+-----------+------------------------------+------------+-------------------
+Influenza  |_Begins with feverishness,    | Breath and |Excessively
+           |pain in head, back_, and      | discharges |infectious. After
+           |_limbs_, and usually _cold in | from nose  |effects often very
+           |the head_.                    | and mouth. |serious and
+           |                              |            |accompanied with
+           |                              |            |great prostration
+           |                              |            |and nervous
+           |                              |            |debility.
+-----------+------------------------------+------------+--------------
+Smallpox   |The illness is usually well   | Breath,    |Peculiarly
+           |marked and the onset rather   | all        |infectious. When
+           |sudden, with _feverishness,   | discharges,|smallpox occurs in
+           |severe backache, and          | and        |connection with a
+           |sickness_. About third day    | particles  |school or with any
+           |a _red rash_ of _shotlike     | of skin    |of the children's
+           |pimples_, felt below the skin,| or scabs.  |homes, an endeavor
+           |and seen first about the      |            |should be made to
+           |_face_ and _wrists. Spots     |            |have all persons
+           |develop_ in _two days_, then  |            |over seven years
+           |form _little blisters_, and   |            |of age
+           |in other two days become      |            |revaccinated.
+           |_yellowish_ and filled with   |            |
+           |matter. _Scabs_ then form,    |            |Cases of modified
+           |and these fall off about      |            |smallpox--in
+           |the fourteenth day.           |            |vaccinated
+           |                              |            |persons--may be,
+           |                              |            |and often are, so
+           |                              |            |slight as to
+           |                              |            |escape detection.
+           |                              |            |Fact of existence
+           |                              |            |of disease may be
+           |                              |            |concealed. Mild
+           |                              |            |or modified
+           |                              |            |smallpox as
+           |                              |            |infectious as
+           |                              |            |severe type.
+-----------+------------------------------+------------+-----------------
+=In the following diseases only the affected child is excluded=
+
+=Erysipelas.= Child should not      | =Ringworm on Scalp.= Child should
+ return till all swelling and       |  be excluded till cured. Very
+ peeling of skin has disappeared.   |  difficult to cure and often takes
+                                    |  a very long time.
+=Ophthalmia.= Child should not      |
+ return till all traces have        | =Phthisis= (=Consumption=). If in
+ disappeared.                       |  advanced stage and coughing much
+                                    |  _or spitting_, child should be
+=Scabies or Itch.= Child should be  |  excluded. (Infection from breath
+ excluded until cured.              |  and dried spit floating in the air
+                                    |  as dust.)
+=Ringworm on Skin.= Child should be |
+ excluded till cured. This takes    | =Impetigo= (=Contagious Sore=).
+ only a few days if properly        |  Child should be excluded until
+ treated.                           |  cured. A week or ten days should
+                                    |  suffice.
+
+=A. BROWN RITCHIE=, _Medical Officer to Education Committee_.
+
+Most people still think that colds are due to cold air or draughts
+rather than to a cold germ, which finds a body unequipped with
+resisting power, with its germ police off guard, exhausted from
+overwork, or disaffected and ready to turn traitor if the enemy seems
+stronger than our vitality. Sometimes it seems as if we contracted it
+from a sneezing fellow-passenger, sometimes from a draught from an open
+car window. An uninformed opponent of the theory that colds are a germ
+disease wrote the following letter last winter to a New York newspaper:
+
+  In addition to the Society for the Suppression of Noises there
+  should be in this town a Society for the Suppression of
+  "Fresh-Air" Fiends. The newspapers report an epidemic of
+  pneumonia, grippe, and colds. It is almost entirely due to the
+  fact that the average New Yorker is compelled to live, move, and
+  have his being from daylight to midnight in a succession of
+  draughts of cold air caused by the insanity of overfed male and
+  female hogs, who, with blood almost bursting through their skins,
+  demand "fresh air" in order to keep from suffocating. Everywhere a
+  man goes, day or night, he is in a draught caused by the crazy
+  ideas about fresh air.
+
+  Our wise ancestors, who as a rule lived much longer than we do,
+  and had much better health, said:
+
+    "If the wind should blow through a hole,
+    God have mercy on your soul."
+
+After the correspondent has learned that our ancestors had more colds
+than we, had poorer health, and died twenty years younger, perhaps he
+will listen to proof that his unclean warm air weakens the body and
+makes it an easy prey to cold germs.
+
+Many physicians preach and practice this fallacy as to fresh air and
+colds, but few physicians now deny that influenza is a germ disease or
+that a nose so irritated and so neglected as to secrete large
+quantities of mucus is a better place for breeding disease germs than a
+nose whose membranes are clean and not thus irritated.
+
+Until medical specialists are agreed, and until they have definitely
+located the cold germ, we laymen must choose for ourselves a working
+theory. The weight of opinion at the present time declares that colds
+are due to germs. Strong membranes with good circulation and drainage
+provide poor food for germs. Congested membranes furnish proper
+conditions for propagation. The germ theory explains the spread of
+germs from the nose to the passages of the head, and from head to
+arteries and lungs.
+
+A cold can always be charged to some one else. How many can be laid to
+our account? There is one right that is universally not recognized, and
+that is the right of protection from the germs showered in the air we
+breathe, over the food we eat, by the sneezes of our unfortunate
+neighbor at school, in the street car, at the restaurant. The chief
+danger of a cold is to our neighbor, not to ourselves. A cold which a
+strong person may throw off in a day or two may mean death to his
+tuberculous neighbor. Though for our own health "lying up for a mere
+cold" is an unnecessary bore, the failure to do so may deprive our
+neighbor of a right greater than the right to protection against
+scarlet fever or smallpox. Though formerly this statement would not
+have been true, rights change with conditions, and the fact that to-day
+the three most deadly diseases are pneumonia, tuberculosis, and
+diphtheria,--all diseases of the respiratory organs,--justifies the
+assertion that we have a right to protection against colds. The
+prevalence of colds, sore throats, irritated vocal cords, bad voices,
+catarrh, bronchitis, laryngitis, and asthma in America to-day demands
+summary measures. One can learn to sneeze into a handkerchief, not into
+a companion's face or into a room. School children can be taught to
+avoid handkerchiefs on which mucus has dried. In the far distant future
+we may be willing to use cheesecloth, and boil it or throw it away, or,
+like the Japanese, use soft paper handkerchiefs and burn them after
+using.
+
+
+TABLE IX
+
+DEATH RATE PER 10,000 POPULATION, PNEUMONIA AND BRONCHITIS FIVE-YEAR
+PERIOD, 1896-1900
+
+  England and Wales       22.70
+  Scotland                27.40
+  Stockholm               26.70
+  London                  31.20
+  Berlin                  16.10
+  Vienna                  39.70
+  Christiania             21.30
+  Boston                  30.60
+  Chicago                 24.20
+  Philadelphia            25.10
+  New York City           36.60
+
+One child with a cold can infect a whole class or family, thus
+depriving the class and family of the top of their vitality and
+efficiency without their consent. Because a person is thought a
+weakling who lies up for a "mere cold," one is inclined to wish that
+colds were as prostrating as typhoid, in which case there would be some
+hope of their extermination.
+
+The exclusion of children with colds from school deserves trial as a
+check to children's diseases. Many of these "catching" diseases start
+with a cold in the head, as, for instance, measles, influenza, and
+whooping cough. The first symptom of mumps, diphtheria, and scarlet
+fever is a sore throat or swollen glands, which, because they commonly
+accompany a cold, are not at first distinguished from it.
+
+The first step for the teacher or mother in reading the index for colds
+is to look into the coat closet for evidence of warm clothing and
+overshoes, then to note whether the children put them on when they go
+out for lunch or recess. Whether "cold" settles in the nasal passages,
+ear, or stomach depends upon which is the weak spot. Draughts, thin
+soles, wet soles, exposure when perspiring, may be the immediate cause
+of the nutritional or respiratory disturbances that give cold germs a
+foothold. Adenoids, diseased teeth, inflamed ears, may furnish the food
+supply. "There is no use treating children and sending them on
+fresh-air trips as long as they have nutritional and digestive
+disturbances due to bad teeth, or colds due to adenoids," said a
+physician when examining a party of children for a summer outing. The
+great preventive measure to be taken for catching diseases, colds,
+diseased glands,--in fact all germ diseases,--is the repeated cleansing
+of those portions of the human body in which germs may find
+lodgment,--the mouth, the nose, the eyes, and the ears.
+
+In caring for young infants great pains is taken to cleanse all the
+orifices daily, but as soon as the child washes himself this practice
+is usually abandoned. Washing these gateways is far more important than
+washing the surface of the body through which germs could not possibly
+gain entrance into the system except through wounds. Oftentimes the
+douching of the nostrils with salt water will stop a cold at once. The
+mouth is the most important place of all, and the teacher should take
+care of her pupils' mouths first and foremost. As bad teeth, enlarged
+tonsils, and adenoids harbor germs and putrescent matter that vitiate
+every incoming and outgoing breath, these defects should be immediately
+corrected. Are we coming to a time when a thorough house-cleaning in
+the mouth of every child will take place before he enters the
+schoolroom, preferably in the presence of the teacher?
+
+Two other "catching" diseases cause city schools a great deal of
+trouble,--trachoma and pediculosis (head lice). There are probably no
+two diseases more quickly transmitted from one person to another.
+Almost before their presence is known, all children of a school or all
+persons of a group have contracted them. When at college twenty men of
+my fraternity discovered almost at the same time that they had an
+infectious eye trouble; yet we thought we were using different towels
+and otherwise taking sanitary precautions. Last summer a Vassar
+graduate took a party of tenement children for a country picnic. She
+returned with head lice that required constant attention for weeks.
+What then may we expect of children who live in homes where there is
+neither water, time, nor privacy for bathing, where one towel must
+serve a family of six, where mothers work for wages away from home and
+see their children only before seven and after six?
+
+Unfortunately for thousands of children, many parents still believe
+these troubles will be outgrown. Last summer a fresh-air agency in New
+York City arranged for several hundred school girls to go to a certain
+camp for ten days each. The only condition was that the heads should be
+free from lice and nits (eggs). From the list furnished by
+school-teachers--girls supposed to have been cured by school
+nurses--not one in five was accepted. A baby two weeks old, brought to
+Caroline Rest, had already begun to suffer from this easily preventable
+scourge. Of 1219 children examined in Edinburgh, Scotland, 909, or 69
+per cent, had some skin disease, and 60 per cent had sores due to head
+lice. Even when neglect has caused the loss of hair and ugly sores on
+the head, mothers deceive themselves into believing that some other
+cause is responsible.
+
+Trachoma, if neglected, not only impairs the health of the eye, but may
+cause blindness. Tears carry the germs from the eye to the face, where
+they are taken up on handkerchiefs, towels, and fingers and infect
+other eyes. Of late, thanks to school nurses and physicians and hygiene
+instruction, American cities have found relatively little trachoma
+except among recent immigrants. So dangerous is the germ and so
+insidious its methods of propagation, that a physician should be
+summoned at once at the first sign of inflammation. Conjunctivitis is
+due to a germ, and will spread unless checked. Since the board of
+health of New York City has instituted the systematic examination of
+the eyes of the children in the public schools, it has found fully one
+third affected with some form of conjunctivitis. Many of these cases
+are out-and-out trachoma, others acute conjunctivitis, and a larger
+proportion are "mild trachoma." This last form of the disease is found
+to a great extent among children who have adenoids. The adenoids should
+be regarded as a predisposing factor rather than a direct cause.
+Therefore sore eyes are given as one of the indexes of adenoids. When
+we consider that adenoids are made up of lymphoid material, and that
+trachoma follicles are made up of the same sort of tissue, it is not
+surprising that the two conditions are found in the same child. The
+catarrhal inflammation produced by adenoids in the nasal mucous
+membrane travels up the lachrymal duct and thus infects the conjunctiva
+by contiguity.
+
+In preventing pediculosis and infection of the eye vigilance and
+cleanliness are indispensable. After the diseases are advanced, after
+the germ colonies have taken title, some antiseptic or germ killer more
+violent than water is needed,--kerosene for the hair or strong green
+oil soap; for the eye, only what a physician prescribes.
+
+
+
+
+CHAPTER VII
+
+EYE STRAIN
+
+
+Wherever school children's eyes have been examined, from six to nine
+out of thirty are found to be nearsighted, farsighted, or otherwise in
+need of attention. A child is dismissed from school for obstinately
+declaring that the letter between _c_ and _t_ in "cat" is an _o_; "a
+pupil in her fourth school year was recently brought to me by her
+teacher with the statement that she did unreasonably poor work in
+reading for an intelligent and willing child;" a boy is punished for
+being backward. These three cases are typical. Examinations showed that
+the first child was astigmatic and not obstinate; the boy had run a pin
+into one eye ten years before and destroyed its sight; while the second
+girl was found to be afflicted with diplopia, and in a friendly chat
+told the following story: "I very often see two words where there is
+only one. When I was a very little girl I used to write every word
+twice. Then I was scolded for being careless. _So I learned that I must
+not say two words even when I saw them._" As Miss Alida S. Williams,
+principal of Public School 33 in New York City, has in many articles
+and addresses freely illustrated from school experience, the art of
+seeing is acquired, not congenital, and every human being who possesses
+it has learned it.
+
+The large proportion of children suffering more or less seriously from
+eye trouble has led many persons to suggest physical deterioration as
+the cause. Eye specialists, however, assure us that eye troubles are
+probably as old as man. Our tardiness in learning the facts regarding
+these troubles is due in part to the lack, until recently, of
+instruments for examining the eye and for manufacturing glasses to
+correct eye defects; in part, also, to the tendency of the medical
+profession, which I shall repeatedly mention, to explain disorders by
+causes remote and hard to find rather than by those near at hand.
+
+About 1870 Dr. S. Weir Mitchell's attention was called "to the marked
+relief of headache, insomnia, and other reflex symptoms following the
+correction of optical defects by glasses." In 1874 and 1876 he wrote
+two articles that "impressed upon the general profession the grave
+significance of eye strain." Since that time, "in Philadelphia at
+least, no study of the rebellious cause of headache or of the obscure
+nervous diseases has ever been considered complete until a careful
+examination of the eyes has included them as a possible cause of the
+disturbance."
+
+The new fact, therefore, is not weak eyes or strained eyes, but rather
+(1) an increase in the regular misuse of eyes by school children,
+seamstresses, stenographers, lawyers, etc.; and (2) the incipient
+propaganda growing out of school tests that show the relation of eye
+strain to headache, nervous diseases, stomach disorder, truancy,
+backwardness.
+
+Every school, private and parochial as well as public, should supply
+itself with the Snellen card for testing eyes. Employers would do well
+to have these cards in evidence also, for they may greatly increase
+profits by decreasing inefficiency and risks. If there is no expert
+optician near, apply for cards to your health board or school board;
+failing there, write to your state health and school boards. In many
+states rural teachers are already supplied with these cards by state
+boards. In October, 1907, the New York state board of health sent out
+cards, with instructions for their use, to 446 incorporated towns. The
+state commissioner of education also sent a letter giving school
+reasons for using the cards. Results from 415 schools having shown
+that nearly half the children had optical defects, it is proposed to
+secure state legislation that will make eye tests obligatory in all
+schools. Such a test in Massachusetts recently discovered twenty-two
+per cent of the school children with defective vision, and from forty
+to fifty thousand in need of immediate care by specialists.
+
+    [Illustration: POSITIONS OFTEN SUGGEST EYE STRAIN]
+
+Of course eye specialists,--oculists,--if skillful, know more about
+eyes and eye troubles than general medical practitioners or teachers.
+Preliminary eye tests, however, may be made by any accurate person who
+can read. The Massachusetts state board of health reports that tests
+made by teachers were "not less efficient" than tests made by
+specialists. In June, 1907, a group of eminent oculists recommended to
+the school board of New York City that teachers make this first test
+after being instructed by oculists. Persons interested in the schools
+nearest them can quickly interest teachers and pupils by starting tests
+with this card. In cities oculists can be found who will be glad to
+explain to teachers, individually or in groups, how the cards should be
+used and what dangers to avoid.
+
+Nature intended the human eye to read the last line of this card at a
+distance of ten feet. This conclusion is not a guess, but is based upon
+the examination of thousands of eyes. In making the test, the number of
+feet the eye ought to see is written as the denominator of the
+fraction; the distance the eye can see clearly is the numerator. If the
+child's card reads, "Right eye 10/10, left eye 10/20," it means that
+the right eye sees without conscious strain the distance it is intended
+to see, while the left eye must be within ten feet to see what it ought
+to see twenty feet away.
+
+The practical steps for a teacher to take in making eye tests are:
+
+  1. Scrutinize the faces for a strained or worried expression while
+  reading or writing, for squint eyes, for unnatural positions, and
+  for improper distances (more or less than nine inches) from eye to
+  book.
+
+  2. Select for first tests the children who obviously need
+  attention and will be obviously benefited. Use the eye test to
+  help trace the cause of headaches, nervousness, inattention.
+
+  3. Let the children mark off the distances with a foot rule and
+  chalk, going as high as twenty. Be sure to get the best light in
+  the room.
+
+  4. Start all children on the ten-foot line. If a child cannot read
+  at ten feet the letter which should be seen at that distance, move
+  the child forward, have it step forward and backward, and note the
+  result carefully. It is better to have ten separate letters of
+  exactly the right size and the same size than a row of letters on
+  one card, as in the Snellen test, otherwise memory will aid the
+  eye, or, as happened recently, a whole class may agree to feign
+  remarkable nearsightedness or farsightedness by confusing letters
+  learned in advance from the card. If the Snellen card is used, and
+  if it is more convenient to have both child and card stationary,
+  satisfactory results will be obtained by having the child read
+  from large letters down as far as he can see.
+
+  5. Have the child read from right to left, from left to right, or
+  skip about so that memory cannot aid the eye.
+
+  6. Test each eye separately. I was twenty-five years old before I
+  learned that my left eye did practically all of the close sight
+  work. A grown woman discovered just a few days ago that she was
+  almost blind in the left eye; when she rubbed the right one while
+  reading she was shocked to find that she could see nothing with
+  the left eye.
+
+  7. If the card is stationary and the child moved, and if only one
+  size of the letter is used, put in the denominator the number of
+  feet at which the normal eye should see clearly, and in the
+  numerator the distance at which each eye and both together can
+  easily see. If the regular Snellen card is used containing letters
+  of different size, place in the denominator the number of the
+  lowest line each eye and both eyes together can read easily, and
+  in the numerator the number of feet from card to eye.
+
+  8. Explain the result to the child, to his fellows, to his
+  parents. If the left eye reads 10/20 and the right eye 10/30, it
+  means that neither eye is normal, and that reading small type is a
+  constant strain, even though unnoticed. The right eye must be
+  within ten feet to read what it should read at twenty feet. The
+  left eye must be within ten feet to read what it should read at
+  thirty feet. If the two eyes read at ten, it means that in working
+  together they successfully strain for a result that is not worth
+  what it is costing. When eyes thus unconsciously see what they are
+  not intended to see, it is only a matter of time when stomach and
+  nervous system will announce that the strain can no longer be
+  borne. Indigestion, dislike of study, restlessness follow. If,
+  however, the eyes are so near the normal that their story reads
+  12/10 or 8/10, the strain will be negligible _for the present_.
+  If, on the other hand, the only difficulty is a confusion of _x_
+  and _z_ with _c_ and _g_, it means that there is a strain due to
+  astigmatism, and that the child should be sent to an oculist.
+
+  9. Teach children and parents (and practice what you preach) the
+  urgent importance of periodic reëxamination, just as you would
+  teach them to visit a dentist twice a year. This is needed by
+  those who wear eyeglasses, and more particularly by those who have
+  recently put them on. Moreover, as shown below, it is needed by
+  children able to pass satisfactorily the Snellen test.
+
+  10. Acquire the habit of reading the eye for evidence of temperate
+  or intemperate living, sleeping, eating, dancing, drinking, and
+  smoking. Inflamed eyes are _results_,--signals of danger. "The
+  organ may be faultless in construction and in its work poor,
+  because of nerve exhaustion, or, in a less and more easily
+  recoverable degree, nerve fatigue." If unusual eye conditions are
+  not readily explained by mode of living or by eye tests, an
+  oculist should be consulted.
+
+The limits of the card test must be constantly kept in mind: (1) it
+does not register eye sickness due to dust, smoke, or disease germs;
+(2) it does not show unconscious eye strain due to successful
+accommodation. But it will discover a great part of the children who
+most need care. Sooner or later, too, inflammation of the eyelids, due
+to external causes, will affect the nerves of the eye and their power
+to conceal by accommodation the eye's defects. Just as we unconsciously
+open the mouth when a cold stops up the nose, the eye adapts itself to
+our needs without our realizing it. We expect it to see. It sees. If
+our eyes are not made alike, they do their best to work together. Like
+a good team of horses, the slow one hurries, the fast one holds back a
+little. But if one eye is 10/15 and the other 10/10, they will both be
+unnatural and strained if both read the same type. The effects of this
+strain frequently upset the stomach before the eyes rebel. I learned
+that I needed eyeglasses after a case of protracted indigestion, first
+diagnosed as "nervous" and later traced to eyes. Thousands of
+upper-grade children and college students are dieting for stomach
+trouble that will last until the eyes are relieved of the undue and
+unrecognized strain. To prove the influence of eye strain on
+indigestion, persuade some obstinate parent to wear improperly focused
+glasses for a day; she will then be willing to have her child's eyes
+attended to.
+
+It is unfortunate that the eyes will overwork without protesting. For
+years many persons suffer without learning that their eyes are unlike,
+or, as often happens, that one eye does all the close range work. Even
+when being tested, eyes will seem to see easily what requires a great
+effort of "accommodation." To prevent this self-deception skilled
+oculists do not trust the eye card, but put a drug in the eye that
+benumbs the muscles of accommodation. They cannot contract or expand if
+they want to. The oculist then studies the length of the eye and the
+muscle of accommodation. With this absolute knowledge of how each eye
+is made he knows what is wrong, exactly at what angle light enters the
+eye, whether objects are focused too soon or too late, exactly what
+kind of eyeglasses or what operation upon the eye is needed to enable
+it to do its work without undue straining or accommodation. So
+unconsciously do the eyes accommodate themselves to the work expected
+of them that not infrequently a child with seemingly perfect sight may
+be more in need of glasses than the child with imperfect sight.
+Practically, however, it is out of the question at the present time to
+have the majority of children given a more thorough test than that
+provided by the Snellen card. Where eye strains escape this test
+teachers will find evidence in complaints of headache, nervousness,
+sick stomach, chorea, or even epilepsy. The constant strain may also
+cause red or inflamed lids. Parents and teachers must be on the
+constant lookout for these symptoms of good sight persisting in spite
+of imperfect eyes.
+
+An epidemic of eyeglasses is usually the consequence of eye tests. So
+naturally do we associate eyeglasses with eye defects that some people
+assert that the eye tests at school originate with opticians more
+intent upon selling spectacles than upon helping children. In fact,
+even among educators who proclaim the need for eye tests there has been
+far more talk of eyeglasses than of removable conditions that cause eye
+strain. The women principals of New York City have sounded an alarm,
+and urge more attention to light and to reading position, more rest,
+more play, more hand work, less home study and less eye work at school,
+rather than more eyeglasses to conceal temporarily the effect of
+abusing children's eyes. Putting glasses on children without changing
+causal conditions is like giving alcohol to consumptives. The feeling
+of relief is deceptive. The trouble grows worse.
+
+For some time to come eye tests will find eye troubles by the wholesale
+in every industrial and social class, in country as well as city
+schools. In 415 New York villages 48.7 per cent of school children had
+defects of vision,--this without testing children under seven,--while
+11.3 per cent had sore eyes.
+
+There are three possible ways of remedying defects: (1) changing the
+eye by operation; (2) changing the light as it enters the eye by
+eyeglasses; (3) decreasing the demands made upon the eye. To change
+eyes or light requires a technical skill which few physicians as yet
+possess. It will be remembered that it is but thirty years since the
+medical profession in America first began to understand the relation of
+eye defects to other defects. Until a generation of physicians has been
+trained by medical colleges to learn the facts about the eye and to
+apply scientific remedies, it is especially necessary that teachers and
+parents reduce the demands made upon children's eyes; oral can be
+substituted for written work, manual for optical work, relaxed and
+natural movement for discipline, outdoor exercise for less home study.
+Other requirements are suitable light and proper position, and
+abolition of shiny paper, shiny blackboard, and fine print. Even after
+it is easy to obtain the correction of eye defects it will still be
+necessary to adapt the demands upon children's eyes to the strength and
+shape of those eyes. Because we are born farsighted, nearsighted, and
+astigmatic, we must be watchful to eradicate conditions that aggravate
+these troubles. Finally, there is no excuse whatever for permitting the
+parent of any school child in the United States to remain ignorant of
+the fact that it is just as absurd to go to the druggist or jeweler for
+eyeglasses as to the hardware store for false teeth.
+
+The education of physician, oculist, and optician can be expedited by
+eye tests in school and by the follow-up work of schools in removing
+the prejudice of parents against glasses when needed. Because knowledge
+of chemistry preceded knowledge of the human body, the teaching of
+medicine still shows the effect of predilection for the remote, the
+problematical, the impossible. This predilection has influenced many
+specialists as well as many general practitioners, both overlooking too
+frequently obvious causes that even intelligent laymen can be taught to
+detect. Very naturally the man who makes money out of attention to
+simple troubles has stepped into the field not as yet occupied by the
+general practitioner and the specialist. Thus we have the optician, the
+painless tooth extractor, and quack cures for consumption. Opticians
+are placing before hundreds of thousands simple truths about the eye
+not otherwise taught as yet. Because they make their money by selling
+eyeglasses and because their special knowledge pertains to glasses
+rather than to eyes they frequently fail to recognize their
+limitations.
+
+Physicians feel very strongly that it is as unethical for an optician
+to fit eyeglasses without a physician's prescription as for a
+pharmacist to give drugs without a physician's prescription. The
+justification for this feeling should be based not upon the commercial
+motive of the optician but upon his ignorance. A physician uninformed
+as to eye troubles is just as unsafe as an optician determined to sell
+glasses. It must be made unethical and unprofessional for physician and
+optician alike to prescribe in the dark. Laymen and physicians must be
+taught that it is just as unethical and unprofessional for oculists and
+physicians to fail to bring their knowledge within the practical reach
+of the masses as for the optician to advertise his wares. School tests
+will not have been used to their utmost possibilities until optician
+and physician alike take the ethical position that the first
+consideration is the patient's welfare, not their own profits. It must
+soon be recognized as unethical and unprofessional for an optician who
+is also a skilled physician to refer patients to a medical practitioner
+ignorant as to optical science.
+
+Whether opticians and physicians are unprofessional or unethical may be
+told by reëxamination if the _examiner_ is himself competent and
+ethical. There is no better judge of their efficiency than the patient
+himself, who can tell whether the results promised have been effected.
+Whether the work of a country oculist is efficient and ethical can be
+learned: (1) by teaching country school children to recognize eye
+strain; (2) by comparing his results with those of other physicians. As
+soon as one or two states have tested eyes, we shall have an average by
+which to compare each class, school, and city with others of their size
+under similar conditions. If a particular physician finds half as many
+more or only half the average number, the presumption will be that his
+results are inaccurate and warrant an investigation. The interested
+teacher or parent can render an inestimable service to her local school
+and to the children of her state by taking steps to secure state laws
+compelling eye tests in all schools.
+
+Finally, it must be remembered by teachers, employers, parents, and all
+eye users that eyes are constantly changing; that eyes may need glasses
+six months after they are examined and found sound; that glasses change
+or develop the eye, so that they may be unnecessary and harmful six
+months after they are prescribed, or the eye may require a stronger
+glass; that eyeglasses become bent and scratched, so that they worry
+and strain the eye; that a periodic examination is essential to the
+health of the eye.
+
+In caring for the health of the eye, we should also remember that our
+eyes are our chief interpreters of the world that gives us problems,
+profits, and pleasures. Out of gratitude, if not out of enlightened
+self-interest, we owe our eyes protection, attention, and training, so
+that without straining we shall always be able to see truth and
+beauty.
+
+
+
+
+CHAPTER VIII
+
+EAR TROUBLE, MALNUTRITION, DEFORMITIES
+
+
+The presence of adenoids is a frequent cause of both slight and
+aggravated deafness. Of 156 deaf mutes examined 59 per cent had
+adenoids, while only 6 per cent of the general run of the children in
+the neighborhood had this trouble. In mouth breathing, the current of
+air entering the mouth draws out some of the air from the Eustachian
+tube which ventilates the middle ear and unequalizes the atmospheric
+pressure on the eardrum, causing it to sink in and to blunt the
+hearing. An examination of the eardrums of school children in New York
+who are mouth breathers showed a high percentage of deafness, incipient
+or pronounced, accompanying adenoids. For example, of 9 mouth breathers
+selected from one class (average age 7-8 years), 6 were well-marked
+cases of deafness. Of 8 mouth breathers (average age 8-9 years), and of
+5 mouth breathers (average age 5-6 years), all had noticeable defects
+of hearing. Many adults that suffer from deafness maintain that they
+never had any trouble in childhood. Yet the evidences of nose and
+throat trouble in childhood persist and disprove such statements. _The
+foundations of deafness in later life are, in most instances, laid in
+childhood._ Since the majority of cases of ear trouble occurring in
+school children accompany diseased conditions of the nose and throat,
+the proper care of nose and throat will, in large measure, balance the
+shortcomings of the aural examinations. Since the examination of the
+drum itself is not practicable, especial care should be given to the
+examination of the nose and throat.
+
+The figures published by New York City's department of health show that
+of 274,641 children examined from March, 1905, to January, 1908, 3540,
+or 1.2 per cent, gave evidence of defective hearing. Ear specialists
+suggest that this small percentage results from employing the whisper
+test at twenty feet. The whisper test at sixty feet has been set by
+experts as a test of normal hearing. But preciseness with this test is
+well-nigh impossible when we consider that the acoustics, the quality
+of the examiner's voice, the weather, the vowel or consonant sounds,
+all are variable quantities. The watch test is frequently used, but
+since a young teacher in her enthusiasm used an alarm clock to make the
+test, specialists have decided that the volume of sound differs in
+watches to such a degree as to make the watch test unreliable. The
+examination of the eye has been reduced to mathematical precision, due
+altogether to the anatomy of that organ. As yet there is no instrument
+for the ear comparable to the ophthalmoscope. The acoumeter is largely
+used by aurists and can be obtained from the optician. This instrument
+has an advantage over the whisper or watch tests in that its tick is
+uniform.
+
+Each ear should be tested separately. Let the child place his finger
+against the flap of one ear while the other is being tested. Then
+compare the farthest distance from the ear at which the tick can be
+heard with the normal, standard distance. During the test all sound
+should be eliminated as far as possible and the eyes should be closed.
+At a demonstration of ear testing at Teachers College, one student
+stated that she could not hear the tick of the watch at a distance
+greater than twenty inches. Then the tester walked noisily toward her,
+leaving the watch on the desk, five feet away from the patient. She
+heard it now. When the class burst out laughing she opened her eyes,
+and, seeing the watch so far away, exclaimed, "Why, I thought I
+imagined it." Be careful in testing a child to distinguish between what
+he "thinks he imagines" and what he really hears. Because of the
+difficulties of this test a doubt should be sufficient to warn the
+teacher to send the child to be tested by an expert. Detection of
+slight deafness may lead to the discovery of serious defects of nose or
+throat. Inflammation from cold or catarrh may cause deafness, which if
+neglected may permanently injure the ear. Often deafness is due to an
+accumulation of wax. A running ear should receive immediate attention,
+as it is an indication of inflammation which may imperil the integrity
+of the eardrum, and, if neglected, may eat its way through the thin
+partition between the ear and the brain and cause death.
+
+It should never be assumed that deafness is incurable. Stupidity,
+inattention, and slowness to grasp a situation accompany difficulty of
+hearing and should cause the teacher to examine the ears. No ear
+trouble is negligible. Children and parents should be taught that the
+normal ear is intended to hear for us, not to divert our attention to
+itself. When the ear aches or "runs" or rumbles there is something
+wrong, and it should be examined together with the throat and nose.
+
+
+NERVOUSNESS
+
+In New York City one child in ninety-one already examined has had the
+form of nervous disease known as St. Vitus's Dance, or chorea. So prone
+are we to overlook moderate evils and moderate needs that the child
+with aggravated St. Vitus's Dance is apt to be cured sooner than the
+child who is just "nervous." Teachers cannot know whether twitching
+eyes, emotional storms, constant motion of the fingers or feet are due
+to chorea, to malnutrition, to eye strain, or to habits acquired in
+babyhood or early childhood and continued for the advantage that
+accrues when discipline impends. Many a child treasures as his chief
+asset in time of trouble the ability to lose his temper, to have a
+"fit," to exhibit nervousness that frightens parent, teacher, or
+playmate, incites their pity, and wards off punishment. The school
+examination will settle once for all whether the trouble can be cured.
+The family physician will explain what steps to take.
+
+
+TESTS OF MALNUTRITION
+
+We Americans were first interested in the physical examination of
+school children by exaggerated estimates of the number of children who
+are underfed. As fast as figures were obtained for eye defects,
+breathing defects, bad teeth, some one was ready to declare that these
+were results of underfeeding. Hence the conclusion: give children at
+least one meal a day at school. Scientific men began to set us straight
+and to give undernourishment a technical meaning,--soft bones, flabby
+tissue, under size, anæmia. While too little food might cause this
+condition, it was also explained that too much food of the wrong sort,
+or even food of the right sort eaten irregularly or hurriedly or
+poisoned by bad teeth, might also cause undernourishment, including the
+extreme type known as malnutrition. In extreme instances the symptoms
+enable an observant teacher who has learned to distinguish between the
+pretty hair ribbon and clean collar and the sunken, pale, or hectic
+cheek and lusterless eyes to detect the cause. But as with eyes and
+nose, an unhealthy condition of nourishment may exist long before
+outward symptoms are noticeable. Therefore the value of the periodic
+searching examination by the school physician.
+
+    [Illustration: SAME AGE, SAME SCHOOL, DIFFERENT NUTRITION]
+
+
+BONE TUBERCULOSIS; ORTHOPEDIC TESTS
+
+Only recently have we laymen learned that knee trouble, clubfoot, ankle
+sores, spine and hip troubles, scrofula, running sores at joints, etc.,
+are not hereditary and inevitable, but are rather the direct result of
+carelessness on the part of adult consumptives. These conditions in
+school are indices of homes and houses where tuberculosis is or has
+been active, and of health boards that are or have been inactive in
+checking the white plague. Early examination may disclose the small
+lump on the child's spine,--which one mother diagnosed as inherited
+"round shoulders,"--and save a child from being a humpback for life.
+Moreover, the examination of the crippled child's brothers and sisters
+will often show the beginnings of pulmonary tuberculosis.
+
+    [Illustration: A GRIEVOUS PENALTY FOR NEGLECT BY ADULT
+    CONSUMPTIVES]
+
+
+ENLARGED GLANDS--TUBERCULOSIS
+
+In almost every class are one or more children who are proud of small
+or big lumps under one or more jaws. Only physicians can find very
+small lumps. Many family doctors will say, "Oh, he will outgrow those,"
+or "Those lumps will be absorbed." Like most other evils that we
+"outgrow" or that pass away, these lumps shriek not to be neglected.
+They mean interference with nourishment and prevent proper action of
+the lymphatic system, as adenoids prevent free breathing. Even when not
+actually infected with tubercle bacilli, they are fertile soil for the
+production of these germs. If detected early, they point to home
+conditions and personal habits that can be easily corrected. In New
+York one child in four has these enlarged glands. If the same
+proportion prevails in other parts of the United States, there are
+5,400,000 children whose strength is being needlessly drained, many of
+whom, if neglected, will need repeated operations.
+
+    [Illustration: MODEL OF AMERICA'S FIRST HOSPITAL FOR SEASHORE
+    FRESH-AIR TREATMENT OF NONPULMONARY TUBERCULOSIS IN CHILDREN
+    To be erected at Rockaway Beach, New York City]
+
+
+
+
+CHAPTER IX
+
+DENTAL SANITATION
+
+
+"Have their teeth attended to first, and many of the eye defects will
+disappear." This was an unexpected contribution to the debate upon free
+eyeglasses for the school children of New York City. So little do most
+of us realize the importance of sound, clean teeth, and the
+interrelation of stomach and sense nerves, that even the school
+principals thought the eye specialist was exaggerating when he declared
+that bad teeth cause indigestion and indigestion causes eye strain.
+
+"Bad" teeth mean to most people dirty teeth and offensive odors, loose,
+crooked, or isolated teeth, or black stumps. Even among dentists a
+great many, probably the majority, do not appreciate that "bad" teeth
+mean indigestion, lowered vitality, plague spots for contaminating
+sound teeth and for breeding disease germs. Until recently the only
+rule about the teeth of new recruits in the United States army was:
+"There must be two opposing molars on each side of the mouth. It
+doesn't matter how rotten these molars may be." The surgeon general was
+persuaded to change to "four opposing molars on each side"; still
+nothing as to the condition of the two additional molars! In the German
+army there is a regular morning inspection of teeth and toothbrushes.
+Several German insurance companies give free dental treatment to policy
+holders, not to bestow charity but to increase profits.
+
+Neglecting "baby teeth" and adenoids may mean crooked second teeth that
+will cause: (1) hundreds of dollars for straightening; (2) permanent
+business handicap because crooked teeth are disagreeable to others,
+because mastication is less perfect, and because a disfigured mouth
+means dis-arranged nerves; or perhaps (3) large dental bills because it
+is difficult to clean between cramped, crooked teeth.
+
+Unfortunately the great majority of parents rarely think of their
+children's teeth until too late to preserve them intact. Even among
+families where the rule of brushing the teeth twice daily prevails,
+regular dental examination is often not required. Doctors and dentists
+themselves have not been trained to realize that the teeth are a most
+dangerous source of infection when unclean. Does your dentist insist
+upon removing tartar and food particles beyond your reach, upon
+polishing and cleansing, or does he regard these as vanity touches, to
+be omitted if you are in a hurry?
+
+    [Illustration: INDUSTRIAL HANDICAPS DISCOVERED AT SCHOOL]
+
+Physicians send tuberculosis patients to hospitals or camps without
+correcting the mouth conditions that make it impossible for the patient
+to eat or swallow without infecting himself. Tonics are given to women
+whose teeth are breeding and harboring disease germs that tear down
+vitality. Nurses watch their suffering patients and do the heavier
+tasks heroically, but are not trained to teach the simple truths about
+dental hygiene. The far-reaching results of neglect of teeth will not
+be understood until greater emphasis is placed on the bacteriology, the
+economics, the sociology, and the æsthetics of clean, sound teeth.
+Whether or not there is at present a tendency to exaggerate the
+importance of sound teeth, there is no difference of opinion as to the
+fact that the teeth harbor virulent germs, that the high temperature of
+the mouth favors germ propagation, that the twenty to thirty square
+inches of surface constantly open to bacterial infection offer an
+extensive breeding ground, and that the formation of the teeth invites
+the lodgment of germs and of particles of food injurious both to teeth
+and to other organs.
+
+By scraping the teeth with the finger nail and noticing the odor you
+can convince yourself of the presence of decomposing organic matter not
+healthful to be carried into the stomach. By applying a little iodine
+and then washing it off with water, your teeth may show stains. These
+stains are called gelatinous plaques, which are transparent and
+invisible to the naked eye except when colored by iodine. These plaques
+protect the germs, which ferment and create the acid which destroys
+tooth structure. Their formation can be prevented by vigorous brushing
+and by eating hard food.
+
+The individual with decayed teeth, even with unclean teeth, is open to
+infection of the lungs, tonsils, stomach, glands, ears, nose, and
+adenoid tissues. Every time food is taken, and at every act of
+swallowing, germs flow over the tonsils into the stomach. Mouth
+breathers with teeth in this condition cannot get one breath of
+uncontaminated air, for every breath becomes infected with poisonous
+emanations from the teeth. Bad teeth are frequently the sole cause of
+bad breath and dyspepsia, and can convey to the system tuberculosis of
+the lungs, glands, stomach, or nose, and many other transmissible
+diseases. They may also cause enlarged tonsils and ear trouble.
+
+Apart from decomposing food and stagnant septic matter from saliva
+injured by indigestion, and by sputum which collects in the healthy
+mouth, there are in many infected mouths pus, exudations from the
+irritated and inflamed gum margins, gaseous emanations from decaying
+teeth, putrescent pulp tissue, tartar, and chemical poisons. Every
+spray from such a mouth in coughing, sneezing, or even talking or
+reading, is laden with microbes which vitiate the air to be breathed by
+others. Indigestion from imperfect mastication and imperfect salivation
+(themselves often due solely to bad teeth) is far less serious than
+indigestion from germ infection. Germs taken into the stomach can so
+change the composition of saliva (a natural disinfectant when healthy)
+as to render it no longer able to kill germs. Indigestion may result in
+excess of uric acid and toxic material, so that the individual becomes
+subject to gout and rheumatism, which in turn frequently destroy the
+bony support of the teeth and bring about Riggs's Disease. The last
+named is a prevalent and disfiguring disease, whose symptom is receding
+gums. The irritating toxins deposited on the teeth cause inflammation
+of the tissues at the gum margins. The gums withdraw more and more from
+sections of the teeth; the poisons get underneath and work back toward
+the roots; the infection increases and hastens the loosening of the
+teeth. I know of a man who had all of his teeth extracted at twenty-one
+years of age, because he was told that this was the only treatment for
+this disease, which was formerly thought to be incurable. Yet thorough
+cleansing and removal of this matter from under the edges of the gums,
+disinfection, a few visits to the dentist, will stop the recession but
+cannot regain lost ground.
+
+Among those who regularly use the toothbrush, instinct, comfort, or
+display is the ruling motive, while a small percentage have evolved to
+the anti-nuisance stage, where the æsthetic standard of their group
+forbids any member to neglect his teeth. The anti-slum and pro-slum
+motives for mouth cleanliness and dental sanitation have been awakened
+in but one or two places. A significant pro-slum activity is the dental
+clinic organized by forty volunteer dentists, acting for an industrial
+school maintained by the New York Children's Aid Society.
+
+    [Illustration: NEW YORK CHILDREN'S AID SOCIETY'S DENTAL CLINIC
+    FOR SCHOOL CHILDREN]
+
+Here 550 children have been examined, 447 teeth extracted, 284 teeth
+filled, 200 teeth treated for diseased pulp (and only 24 sets cleaned),
+40 dentists taking turns in giving time to this work. The equipment
+cost but $239; cards and stationery, $72; incidentals, $33. The
+principal attends the clinic, because in her presence no child is
+willing to confess fear or unwillingness. To supplement this work, the
+dentists have prepared for free distribution a leaflet which tells in
+short, clear sentences how to care for the teeth.
+
+    [Illustration: (leaflet)]
+
+ +----------------------------------------------------------------------+
+ | A DENTAL CATECHISM                 =When should they be cleansed?=   |
+ |                                                                      |
+ | =What are the teeth for?=          Immediately after the morning and |
+ |                                    noonday meals and before going to |
+ | To masticate food; that is,        bed.                              |
+ | grind it into fine particles,                                        |
+ | mix it with saliva, and so         =By what means should they be     |
+ | begin its digestion; also to       cleansed?=                        |
+ | aid in speaking and singing.                                         |
+ |                                    By a moderately stiff brush,      |
+ | =How long should they last?=       water, and floss silk.            |
+ |                                                                      |
+ | To the very end of life.           =How should these be used?=       |
+ |                                                                      |
+ | =How do we lose them?=             The brush should be first used in |
+ |                                    a general way, high up on the     |
+ | By decay, by loosening, and by     gums length-wise of the jaws, to  |
+ | accident.                          remove large particles and        |
+ |                                    stimulate the gums, then the      |
+ | =What causes teeth to decay?=      brush and the teeth should be     |
+ |                                    carefully rinsed with water. The  |
+ | Particles of food decaying in      brush should next be used with a  |
+ | contact with them.                 rolling or circular motion, so    |
+ |                                    that the bristles will follow the |
+ | =Where does food lodge?=           lines of all the grooves and      |
+ |                                    spaces in which the particles of  |
+ | All along the edges of the gums,   food have lodged, and so brush    |
+ | in the spaces between the teeth,   them out. Then again the mouth    |
+ | and in the crevices of their       should be rinsed with water.      |
+ | grinding surfaces.                                                   |
+ |                                    =Should the gums be brushed?=     |
+ | =Can we prevent this loss?=                                          |
+ |                                    Yes, moderate friction helps to   |
+ | Yes, to a large extent.            keep them healthy.                |
+ |                                                                      |
+ | =How can we do it?=                =How can the spaces between the   |
+ |                                    teeth be reached?=                |
+ | By using the teeth properly and                                      |
+ | by keeping them clean and the      By dental floss silk passed       |
+ | gums healthy.                      between the teeth, drawn          |
+ |                                    carefully back and forth till it  |
+ | =What does using them properly     reaches the gum, pressed firmly   |
+ | mean?=                             against the side of each tooth in |
+ |                                    turn and drawn out towards the    |
+ | 1. Using sufficient hard or        grinding end of the tooth, and    |
+ | fibrous food to give the teeth     this repeated several times in    |
+ | and gums full exercise.            each space.                       |
+ |                                                                      |
+ | 2. Taking time enough to           =Should tooth powder or paste be  |
+ | masticate food thoroughly before   used?=                            |
+ | swallowing.                                                          |
+ |                                    Usually once a day.               |
+ | =How often should teeth be                                           |
+ | cleansed?=                                                           |
+ |                                                                      |
+ | As often as they are used.                                           |
+ +----------------------------------------------------------------------+
+
+Such a leaflet should be given out at dispensaries, hospitals, dental
+offices, schools, and from many Sunday schools and missions.[5]
+
+The time for the schools to begin is when the child is first
+registered. Examination and reëxamination must be accompanied by
+explanation of the serious disadvantages of neglected teeth, and the
+physical, social, and economic advantages of clean, sound teeth.
+Instruction at school must be followed by education of parents. The
+school or health authorities should examine the teeth of all children
+before issuing work certificates. Finally, the dental, medical, and
+nursing professions and the press must be enlisted in the school's
+campaign for dental hygiene. The Dental Hygiene Council of
+Massachusetts should be copied in all states.
+
+A preliminary examination of teeth can be made by parent or teacher.
+Crooked, loose, dirty, or black teeth or receding gums can be detected
+by a layman's naked eye. In fact, children can be interested in finding
+the most obvious defects in their own or their brothers' teeth. There
+could be no better first lesson than to ask each pupil to look in a
+hand mirror and to count each tooth obviously needing a cleaning or a
+filling. The most urgent need can thus be ascertained without expert
+aid. But because parent, teacher, or child cannot discover defects does
+not prove that dental care is not imperative; hence the importance of
+examination by a dentist or by a physician competent to discover dental
+needs. If a private, public, or parochial school has no paid visiting
+dentist, a zealous school officer can, at least in large towns,
+persuade one or more dentists or physicians to make a few first tests
+to confirm the teacher's findings, and to persuade the community that
+regular examination and reëxamination are necessary and a saving of
+pain, beauty, and money.
+
+Reëxamination is necessary because decay _may_ start the day after a
+dentist has pronounced a tooth sound. For most of us twice a year is
+often enough. A reëxamination should be made upon the slightest
+suspicion of decay, breaking, or loosening.
+
+Educational use should be made by the teacher of the results of school
+examination. Children cannot be made self-conscious and cleanly by
+telling them that their teeth will ache three or five years from now.
+They can be made to brush or wash their teeth every morning and every
+night if they once realize that cavities can be caused only by _mouth
+garbage_. All decay of human teeth starts from the outside through the
+enamel that covers the soft bone of the tooth. This enamel can be
+destroyed by accidentally cracking or breaking it, or by acids eating
+into it. These acids come from (1) particles of food allowed to remain
+in the teeth; (2) tartar, etc., that adheres to the teeth and can be
+removed only by a dentist; (3) saliva brought up from an
+ill-conditioned stomach. Even where the enamel is destroyed, absolute
+cleanliness will prevent serious decay of the tooth. A perfectly clean
+tooth will not decay. Generally speaking, unless particles of food or
+removable acids remain on or between the teeth long enough to
+decompose, teeth cannot decay. Decay always means, therefore,
+uncleanliness. To unclean teeth is due in large part the offensive odor
+of many schoolrooms.
+
+Uncleanliness becomes noticeable to our neighbors sooner or later.
+There is no offense we are so reluctant to commit as that of having
+uncleanliness of our bodies disagreeable to those about us. Very young
+children will make every effort in their power to live up to the
+school's standard of cleanliness. The other side to this reason for
+having clean teeth is vanity. Because all cleanliness is beautiful to
+us, clean teeth are one attribute of beauty that all of us can possess.
+
+Habits of cleanliness are easily fixed. In the most crowded, most
+overworked section of large cities visitors from "uptown" are surprised
+by the children's bright hair ribbons, clean aprons, clean faces, and
+smoothly combed hair. It will be easy to add clean teeth to the list of
+things necessary to personal and family standing. Armenian children
+are taught to clean their teeth after eating, even if only an apple
+between meals. They covet "beautiful teeth." American standards will
+soon prevent these Armenians from cleaning their teeth in public, but
+desire for beautiful teeth will stay, and will remind them to care for
+their teeth in private. As coarse food gives way to sugars and soft
+foods, stiff toothbrushes must supplement tongue and toothpicks.
+
+    [Illustration: AN ARMENIAN SCHOOL GIRL]
+
+Strong as are the instinct and display motives in cleaning teeth, both
+parents and children need to be reached through the commerce motive.
+Instinct makes children afraid of the dentist, or content when the
+tooth stops aching. Display may be satisfied with cleaning the front
+teeth, as many boys comb only the front hair or as girls hide dirty
+scalps under pompadours and pretty ribbons. Desire to save money may
+give stronger reasons for not going to the dentist than instinct and
+comfort can urge for going. But parents can be made to see, as can
+children after they begin to picture themselves as wage earners, that a
+dentist in time saves nine, and that no regular family investment will
+earn more money than the price of prompt and regular dental care. A
+problem in arithmetic would be convincing, if, by questions such as
+those on page 98, we could compare the family cost of neglecting teeth
+with the cost of toothbrushes, bicarbonate of soda, pulverized chalk or
+tooth powder, early and repeated examination by a dentist, and
+treatment when needed.
+
+ How many members in your family?     What does a toothbrush cost?
+
+ How many teeth have they?            How many do you need in one
+                                      year?
+ How many teeth have they lost?
+                                      How much does tooth powder
+ How many false teeth have they?      cost?
+
+ How many teeth have been filled?     How much is needed for one
+                                      year?
+ What is the total cost to date?
+                                      How much would two examinations
+ How many days have been lost         a year by a dentist cost?
+ from work because of toothache?
+
+ How many teeth are now decayed?
+
+ What will it cost to have them
+ attended to?
+
+The result will show that the money spent for one good "house cleaning"
+of one child at fourteen or eighteen exceeds the cost of keeping clean
+and in repair the teeth of the entire family. How effective and
+economical is thorough cleaning is confessed by an eminent dentist, who
+taught an assistant to clean his patients' teeth. "Do you know," he
+said, "I had to stop it, so perceptibly did my work decrease." The
+total time required to examine school children for teeth needing
+attention is much less than the time now lost by absence from school or
+wasted at school on account of toothache.
+
+To remind school children regularly of dental hygiene is not more
+important than for the school to remind parents repeatedly of the many
+reasons for attending to their children's teeth. It is not enough,
+however, to send one message to parents. Illustrated lectures, mothers'
+meetings, demonstrations at hospitals and fresh-air homes are all very
+serviceable, but listening is a poor substitute for understanding.
+Schools should see that parents understand the æsthetics, the
+economics, the humanity of dental hygiene. The best test of whether
+the parent has understood is the child's tooth.
+
+Dental examination of children applying for work certificates gives the
+health and school authorities a means of enforcing their precepts. When
+no child is allowed to go to work whose teeth cause malnutrition or
+disgust, the news will spread, and both child and parent will see
+clearly the grave need for dental care.
+
+    [Illustration: WON BY THE ECONOMIC ARGUMENT]
+
+Finally, local papers can be interested. They will print almost
+anything the teacher sends about the need for dental care. They like
+particularly facts about the number of cavities found, the number of
+children needing care, efforts made to procure care, and new facts
+about diseases that can be caused by bad teeth or about diseases that
+can injure teeth. Teachers can persuade dentists and physicians to
+write stories. No newspaper will refuse to print such statements as
+this: "A tuberculous patient in six weeks lost ground steadily. I
+persuaded him to go to a dentist to clean the vestibule to his
+digestive system, and to have a set of false teeth. He enjoys his
+meals, and has gained twelve pounds in six weeks." Popular magazines
+and newspapers mention teeth seldom, because those who best know the
+interesting vital things are making money, not writing articles or
+otherwise concerning themselves with dental education. It is said that
+of forty thousand American dentists not over eleven thousand are
+readers of dental journals, and probably not three hundred contribute
+to professional literature. One dentist who is working for the
+children's clinic described above, when asked by the board of education
+to lecture to the people on the care of the teeth and to recommend
+simple, readable books, told me that he knew no good books to suggest.
+
+Five obstacles exist to practicing what is here preached:
+
+  1. The expensiveness of proper dentistry.
+
+  2. The untrustworthiness of cheap dental service and "painless"
+  dental parlors; the domination of the supply houses wishing to
+  sell instruments and other supplies.
+
+  3. The ethical objection to any kind of advertising or to work by
+  wholesale.
+
+  4. The lack of dispensaries.
+
+  5. The profit-making basis of dental education.
+
+Additional reasons these for cleanliness that will make the dentist
+serviceable for his knowledge rather than for his time and gold.
+
+Good dentists really "come too high" for both the poor and the
+comfortably situated. Families in New York City that have four or five
+thousand dollars a year hesitate to go to a dentist whom they
+thoroughly trust, because his time is worth more than they feel they
+can afford to pay.
+
+The "free-extraction" dental parlors undoubtedly are doing a vast
+amount of harm. In every city are dental quacks that injure
+wage-earning adults as much as soothing-sirup quacks injure babies.
+Instead of teaching people to preserve their teeth, they extract, and
+then, by dint of overpersuading by a pretty cashier hired for the
+purpose, make a contract for a gold crown or a false set at an
+exorbitant price. A reputable dentist has said that a dental parlor can
+do more damage to the welfare of the race in a few months than a
+well-intentioned man in the profession can repair in a lifetime. Its
+question is not, What can I do for this patient? but What is there in
+this mouth for me? Many "parlors" never expect to see the same person
+twice, because they do not make him comfortable or gain his confidence;
+they put a filling in on top of decayed matter or even diseased pulp;
+put in plates and bridges that do not fit; charge more than the
+examination at first leads one to expect; refuse to correct mistakes;
+deny having ever seen the patient before. Yet true and severe as this
+arraignment is, many of these parlors, with their liveried "runners
+in," are doing an educational service not otherwise provided; it is
+conceivable that in many cities they are doing less harm by their
+malpractice than well-intentioned men in the profession by neglect of
+public needs or by failure to organize facilities for meeting those
+needs.
+
+I realize that advertising is "unethical" among dentists as among
+physicians. Humbug and imposition are supposed to go inevitably with
+self-advertising by the methods used in selling shoes or automobiles.
+Therefore such advertising is prohibited. But what seems to be
+forgotten in this definition of ethics is that the need and the
+opportunity for dental care must be advertised in some way, if we are
+ever to control diseases and evils due to bad teeth. The rich that one
+dentist can help are able to pay for his good taste, his neat
+attendants, his automobile, his club dues, his vacations at fashionable
+resorts, his hours without work, his standard of living. All of these
+things advertise him, just as hospital appointments and social position
+may and do advertise successful physicians. The patients of moderate
+means that one dentist can treat cannot afford to pay for rent, time
+disengaged, and indirect advertising. Either they must have free
+treatment, must go without treatment, or must go to a dental parlor
+where dental needs are organized so that a very large number will
+contribute to rent and display. It is out of the question to have both
+dentists and patients so distributed and prices so adjusted that
+dentists can make a good living by charging what the patient can
+afford, and at the same time admit of every patient being properly
+treated when necessary. Judging from every other branch of work, the
+solution of the problem lies partly in free care for those who can pay
+nothing or very little, and partly in coöperative treatment through the
+heretofore objectionable dental parlors. If instead of inveighing
+against advertisers, honorable and capable dentists worked through
+dental and medical societies to secure adequate public supervision of
+dental practice, more progress would be made against dental
+malpractice.
+
+Dental clinics will quickly follow the publication of facts that
+schools should gather. In some places these should be separate; but at
+first the best thing is to make every hospital, every children's home,
+every settlement a clinic, and every school an examining center. A
+skilled dentist informs me: "The demand that will follow examination of
+school children's teeth will make it profitable for young dentists to
+adopt a coöperative scheme, where several young men hire a parlor in a
+cheap district, and, under the supervision of some experienced dentist,
+give good advice at reasonable rates. This is the best antidote to the
+dental parlor which exploits the public so shamelessly." Bellevue
+Hospital in New York is the first general hospital to establish regular
+dental examination; others will undoubtedly soon follow.
+
+Dental education for profit rather than for instruction and for health
+has been the rule. Even where universities have put in dental courses,
+they have demanded a net profit from tuition. Instead of protecting
+society against men incapable of caring for teeth, the schools have
+marketed certificates to as large numbers as slowly enlightened
+self-interest would permit. Much progress has been made toward uniform
+standards of admission and graduation, but dental colleges sadly need
+the light and the inspiration of school facts about teeth.
+
+Of fourteen dental journals in America, only one has the advancement of
+dental science as its first reason for existence. Thirteen are trade
+journals. Not one of these would print articles proving that the
+supplies advertised by their backers were inimical to dental hygiene.
+Many dental colleges still retain on their faculties agents or editors
+in the pay of supply houses, Harvard's new dental school being a
+notable exception. This trade motive tolerates and encourages the
+disreputable practices of existing dental parlors. Largely because of
+this prostitution of the dental profession, patients generally neglect
+the repairing and cleansing of the teeth and the sterilizing of the
+mouth from which germs are carried to all parts of the body. Dental
+journalism for the sale of supplies cannot outlive the dentist's
+reading of the school's index.
+
+Many dentists will say that they must learn dentistry before they learn
+the economics and sociology of clean teeth. Being a young profession,
+it is natural that dentistry should first devote itself to learning its
+own mechanics,--the tricks of the trade--how to fill teeth. But the
+fact that it took the medical profession centuries to begin to feel
+responsibility for community health is no reason why the social sense
+of the dentist should be dormant for centuries or decades. We need
+training and exercise to determine what kind of filling will be most
+comfortable and most serviceable; whether the pulp of the teeth needs
+treating or removing before the filling is inserted; whether it is
+worth while to fill a deciduous or baby tooth. Sociology will never
+take the place of dental technic. The few dentists who have studied the
+social significance and social responsibility of their profession
+declare, however, that careless workmanship and indifferent education
+of patients continue chiefly because dentists themselves do not see the
+community's interest in dental hygiene. The school can socialize or
+humanize the dental profession if teachers themselves possess the
+social sense and make known the facts about the need for dental care
+among school children.
+
+FOOTNOTES:
+
+[5] _The Teeth and Their Care_, by Thaddeus P. Hyatt, D.D.S., is a
+short, concise treatment of the principles of dental sanitation.
+
+
+
+
+CHAPTER X
+
+ABNORMALLY BRIGHT CHILDREN
+
+
+What is commonly considered abnormal brightness in a school child is
+often a tendency to live an abnormal physical life. Being a child
+bookworm means that time is spent indoors that should be spent playing
+games with one's fellows. Excellence in the activities of children, not
+ability to imitate the activities of adults, should be the test of
+child brightness. To be able to hit a bull's-eye, to throw a ball
+accurately, to calculate the swing of a curve or the bound of a
+"grounder," these are tests of brightness quite as indicative of mental
+power as the ability to win highest marks in school, while less
+injurious to physical power. The child who is abnormally bright
+requires special treatment just as much as the child who is abnormally
+dull. The former as well as the latter must have his abnormal condition
+corrected if he is to grow into a normally bright man.
+
+The college man who sacrifices health to "marks" is thus described by
+the director of physical training at Harvard University:
+
+  A drooping head, a pale face, dull, sunken eyes, flat chest and
+  rounded shoulders, with emaciated limbs, soft flabby muscles, and
+  general lack of good physical, mental, and moral tone.
+
+For the protection of these physical defective grinds it is suggested
+to put a physical qualification upon the candidates of Phi Beta Kappa
+and their awards of scholarship. If scholarship men cannot be induced
+to take time to improve their physique for fear of lowering their
+college standing, then give them credit for standing in physical work.
+
+The abnormally bright, at whatever age, is as much a subject for
+examination and treatment as the child with adenoids and pulmonary
+tuberculosis. Such attention will increase the percentage of abnormally
+bright schoolmates who figure in active business in later life.
+Moreover, it will decrease the number of high school superintendents
+who declare that their honor pupils are physical wrecks.
+
+There are children who develop very rapidly, both physically and
+mentally, and whose mental superiority is not at the expense of their
+bodies. Protection of such children requires that their minds be
+permitted to progress as rapidly as bodily health justifies. It is as
+cruel to keep back a physically and mentally superior child, as to push
+the physically or mentally defective beyond his powers. Worry and
+fatigue can be produced by lack of interest as well as by overwork.
+"Normal" should not be confused with "average." To keep a bright child
+back with the average child--marking time till the dull ones catch
+up--is to make him abnormal. The tests that we have employed for
+grading pupils are either the tests of age in years or of mental
+capacity. The first takes no account of slowness or rapidity of
+physiological development,--of physiological age. The second encourages
+mental activity at the expense of physique. The entrance of a child
+into school, the promotion from one class to another, the entrance into
+college, are thus determined either by the purely artificial test of
+age or by the individual teacher's discretion. There is nothing to
+prevent the ambitious teacher or the ambitious parent from pushing a
+child into kindergarten at four, high school at twelve, college at
+fifteen. If this cannot be done at the public school, a private school
+is resorted to. A community of college professors once started a school
+for faculty children. A tremendous pressure was put upon these scions
+of intellectual aristocracy to enter the high school at twelve. No
+thought was given to the ventilation of the school. The windows were
+so arranged that they could not be opened without the air blowing on
+some child's back. "You could cut the air with a knife" was a
+description given by one sensible professor who had taken his sturdy
+girl of seven away from the school, because he feared that in this
+environment she would become like the other little puny, pale,
+undersized children of that school.
+
+The University of Pennsylvania has instituted a psychological clinic.
+Parents and teachers are invited to bring any deviation from the usual
+or the expected to the attention of this clinic. Every month a bulletin
+is published called the _Psychological Clinic_, which will be found of
+great service in dealing with the abnormally bright as well as with the
+abnormally dull. Naturally the well-to-do and the rich are the first to
+take advantage of these special facilities for ascertaining just what
+work should be done by a precocious child or by the mentally and
+morally retarded.
+
+Abnormal brightness means power to be happy and to be serviceable that
+is above the average. Every school can be a miniature psychological
+clinic. While every teacher cannot be an expert, national and state
+superintendents can constantly remind teachers that the abnormally
+bright are also abnormally apt to neglect physical welfare and to
+endanger future mental power.
+
+
+
+
+CHAPTER XI
+
+NERVOUSNESS OF TEACHER AND PUPIL
+
+
+Nervousness of teacher and pupil deserves special mention. So universal
+is this physical defect that we take it for granted, especially for
+teachers. Teachers themselves feel that they need not even apologize
+for nervousness, in fact they too frequently use it as an excuse for
+impatience, ugly temper, discourtesy, and unfairness. Children, slates,
+papers, parents, blackboards "get on their nerves." Nervousness of
+teacher causes nervousness of pupils and adds to the evil results of
+mouth breathing, bad teeth, eye strain, and malnutrition. These
+conditions, added to bad ventilation, bad light, and an overcrowded
+schoolroom, render the atmosphere thoroughly charged with
+electricity--nerves--toward the end of the day. Lack of oxygen to
+breathe as well as inability to breathe it; lack of well-printed books
+and good light, as well as lack of the power to use them; toothache,
+earache, headache, deplete the vitality of both teacher and pupil.
+
+Most of the disturbances at school are but outward signs of unwholesome
+physical conditions. If the teacher attempts to treat these causes by
+crushing the child, she makes confession of her own nervousness and
+inadequacy and visits her own suffering upon her pupils. A transfixing
+glance prolonged into an overbearing stare, a loud, sharp voice, a
+rough manner, are successful only so far as they work on the
+nervousness of her pupil. She finds that it is temporarily effective,
+and so by her example and practice sets the child an example in losing
+control of himself. The position often assumed by school children when
+before authority, of hands held stiffly at the side, head drooped, and
+roving eye, does not mean control: it means a crushed spirit,
+hypocrisy, or brooding anarchy. The mother or teacher who obtains
+obedience by clapping her hands, pointing her finger, distorting her
+face, is copying in her own home the attitudes of caste in India, of
+serfdom in Russia, the discipline of the prison the world over, a
+modern reminder of the power of life and death or of physical torture.
+
+A young college girl unfamiliar with the ways of the public school was
+substituting in the highest grammar grade. The time for civics arrived.
+Here, she thought, is a subject in which I can interest them. The boys
+showed a vast amount of press information, as well as decided opinions
+on the politics of the day. The candidates which they elected for the
+position of ideal American patriot were Rockefeller, Lincoln, and
+Sharkey the prize fighter. During the ensuing debate, which gave back
+to Lincoln his proper rank, the boys in the back of the room had moved
+forward and were sharing seats with the boys in the front. Every boy
+was engrossed in the discussion. The room was in perfect order,--not,
+however, according to the ideas of the principal, who entered at that
+moment to see how the new substitute was managing the class, famed for
+its bad boys. With the stern look of a Simon Legree she demanded, "How
+dare you leave your seats!" When one child started to explain she
+shouted: "How dare you speak without permission! Don't you know your
+teacher never permits it? Every boy take his own seat at his own desk."
+This principal was far more to be pitied than the boys, for they had
+before them the prospect of "work papers" and a grind less monotonous
+and more productive than the principal's discipline. She was a victim
+of a nerve-racking system, more sinned against than sinning.
+
+There is nothing in school life _per se_ to cause nervousness. Given a
+well-aired, sunny room, where every child has enough fresh air to
+breathe, where he can see without strain, where he has a desk fitted to
+his body and work fitted to his maximum abilities, a teacher who is
+physically strong and mentally inspiring, and plenty of play space and
+play time, there will be no nervousness. One who visits vacation
+schools is struck with the difference in the atmosphere from that of
+the winter day schools. Here are the same rooms, the same children, and
+in many cases the same teachers, but different work. Each child is busy
+with a bright, interested, happy expression and easy attitude. Some are
+at nature study, some are weaving baskets, making dresses, trimming
+hats, knitting bright worsted sacks and mittens for the winter. Boys
+are at carpentering, raffia, or wrought-iron work. In none of the rooms
+is the absolute unity or the methodical order of the winter schoolroom,
+but rather the hum of the workroom and the order that comes from a
+roomful of children interested in the progress of their work. This
+condition only illustrates what a winter schoolroom might be were
+physical defects corrected or segregated, windows open, light good, and
+work adapted to the child.
+
+    [Illustration: VACATION SCHOOL INTEREST: AN ANTIDOTE TO
+    NERVOUSNESS]
+
+Nervousness is not a monopoly of city teachers and city pupils. In
+country schools that I have happened to know, nervous children were the
+chief problem. Nervousness led in scholarship, in disorder, in
+absences, in truancy, and in backwardness. After reading MacDonald's
+_Annals of a Quiet Neighborhood_, I became interested in one or two
+particularly nervous children, just to see if I could overcome my
+strong dislike for them. To one boy I gave permission to leave the room
+or to go to the library whenever he began to lose his self-control. My
+predecessors had not been able to control him by the rod. A few weeks
+after Willie's emancipation from rules, the county superintendent was
+astonished to see that the county terror led my school in history,
+reading, and geography.
+
+Had I known what every teacher should be taught in preparation,--the
+relation of eye strain, bad teeth, adenoids, "overattention," and
+malnutrition to nervousness and bad behavior,--I could have restored
+many "incorrigibles" to nerve control. Had I been led at college to
+study child psychology and child physiology, I should not have expected
+a control that was possible only in a normal adult.[6] In its primary
+aspect the question of nervousness in the schoolroom is purely
+physiological, and the majority of principals and teachers are not
+trained by professional schools how to deal with it. Normal schools
+should teach the physical laws which govern the child's development;
+should show that the pupil's mental, moral, and physical nature are one
+and inseparable; that children cannot at one time be docile, sickly,
+and intelligent,--perfect mentally and imperfect physically. Until
+teachers are so taught, the condition cannot be changed that makes of
+our schools manufactories of nervous teachers and pupils.
+
+Country nervousness, like city nervousness, is of three kinds: (1) that
+caused by defective nervous systems; (2) that resulting from physical
+defects other than defects of the nervous system, but reacting upon it;
+(3) that due to habit or to lack of self-control. Children who suffer
+from a defective nervous system should, in city schools, be segregated
+where they can have special care under constant medical supervision.
+Such children in schools too small for special classes should be given
+special treatment. Their parents should know that they have chorea,
+which is the same trouble as St. Vitus's Dance, although often existing
+in a degree too mild to attract attention. Special treatment does not
+mean that such children should be permitted to interfere with the
+school progress of other children. In many rural schools, where special
+privileges cannot be given children suffering with chorea without
+injury to other children, it would be a kindness to the unfortunates,
+to their parents, and to all other children, were the parents requested
+to keep such children at home.
+
+Nervousness that results from removable physical defects--eye strain,
+adenoids, indigestion, earache--will be easily detected by physical
+examination, and easily corrected by removing the physical defect.
+
+Preventable nervousness due to "habit" can be quite as serious in its
+effects upon the mind and health as the other two forms of nervousness.
+Twitching the face, biting the nails, wetting the lips, blinking the
+eyelids, continually toying with something, being in perpetual motion
+and never relaxing, always changing from one thing to the next, being
+forever on the rush, never accomplishing anything, are common faults of
+both teacher and pupil. We call them mannerisms or tricks of
+personality. They are readily imitated by children. I once knew a young
+lawyer who had started life as an oyster dealer, whose power of
+imitation helped to make him responsive to both helpful and harmful
+influences. After being at the same table for two weeks with a
+talented man whom he admired, he acquired the latter's habit of
+constantly twitching his shoulder and making certain gestures. These
+habits in turn quickly produced a nervousness that interfered with his
+power to reason straight.
+
+Nervousness is often confused with aggressiveness, initiative,
+confidence. "Think twice before you jump, and perhaps you won't want to
+jump" is a very difficult rule to follow for any one whose bodily
+movements are not under perfect control.
+
+It is said that the confusion of city life causes habits of
+nervousness. Unfortunately no one knows whether the city children or
+the country children have the highest percentage of nervousness. There
+is a general feeling that city life causes an unwholesome degree of
+activity, yet one finds that those people in the city who least notice
+the elevated railway are those whose windows it passes. City noises
+irritate those who come from the country, or the city man on returning
+to the city from the country, but a similar irritation is felt by the
+city-bred man on coming to the country. Mr. Dooley's description of a
+night in the country with the crickets and the mosquitoes and the early
+birds shows that it is the unusual noise rather than the volume or
+variety of noises that wreck nerves. At the time of the opening of the
+New York schools in 1907 a newspaper published an editorial on "Where
+can the city child study?" showing that in New York the curriculum, the
+schoolhouse, and the tenements are so crowded and so noisy that study
+is practically impossible. Lack of sleep, lack of a quiet place in
+which to study at school and at home, are causes for nervousness,
+whether these conditions are in the city or in the country. What
+evidence is there that the country curriculum is less crowded or
+country work better adjusted to the psychological and physiological age
+of the country pupil? The index is there; it should be read.
+
+In breaking habits of nervousness the first step is to explain how
+easily habits are formed, why their effects may be serious, and how a
+little attention will correct them. When a habit loses its mystery it
+becomes unattractive. Children will take an interest in coöperating
+with each other and with the teacher in curing habits acquired either
+at home or at school. My pupils greatly enjoyed overcoming the habit of
+jumping or screaming after some sudden noise. I told them how, when a
+boy, my imagination had been very much impressed by one of Thackeray's
+characters, the last remnant of aristocratic traditions, almost a
+pauper, but possessing one attribute of nobility,--absolute
+self-control. When his house burned he stood with his ankles crossed,
+leaning on his cane, the only onlooker who was not excited. For months
+I imitated that pose, using sticks and rakes and fork handles. The
+result was that when I taught school, a scream, a broken desk, or
+unusual noise outside reminded me of my old aristocrat in time to
+prevent my muscles from jumping. In a very short time several fidgety
+and nervous girls and boys had learned to think twice and to relax
+before jumping.
+
+One test of thorough relaxation in a dentist's chair proves the folly
+of tightening one's muscles. When in school or out the remedy for
+nervousness is relaxation. The discipline that prohibits a pupil from
+stretching or changing his posture or seat is as much to be condemned
+as that which flourishes the rod. It has been said of our schools that
+children are not worked to death but bored to death. Wherever a room
+must be stripped of all beauty and interest to induce concentration,
+wherever the greater part of the teacher's time must be spent in
+keeping order, there is confession either of inappropriateness of the
+present curriculum or of the failure of teacher and text-book to
+present subjects attractive to the pupils. Nervous habits will be
+inevitable until the pupil's attention is obtained through interest.
+Sustained interest will be impossible until teacher and pupil alike
+practice relaxation, not once a morning or twice a day, not during
+recess or lunch hour, but whenever relaxation is needed.
+
+In overcoming nervousness of teacher and pupil, both must be interested
+in home causes as well as school causes of that nervousness. Time must
+be found to ask questions about those causes and to discuss means for
+removing them. Naturally it will be embarrassing for a very nervous
+teacher to discuss nervousness with children,--until after she has
+overcome her own lack of nerve stability. To help her or to compel her
+to learn the art of relaxation of bodily and of mental control is the
+duty and the privilege of the school physician, of her doctor, and of
+superintendent and trustees. The outside point of view is necessary,
+because of the peculiar fact that almost every nervous person believes
+that he has unusually good control over his nerves, just as a man in
+the midst of his anger will declare that he is cool and
+self-controlled. Had Robert Burns been thinking of the habit of
+nervousness he could not have thought of a better cure than when he
+wrote:
+
+    Oh wad some power the giftie gie us
+    To see oursel's as ithers see us;
+    It wad frae mony a blunder free us,
+      And foolish notion.
+
+FOOTNOTES:
+
+[6] _The Unconscious Mind_ by Schofield, _The Study of Children and
+their School Training_ by Dr. Frances Warner, and _The Development of
+the Child_ by Nathan Oppenheimer show clearly the physical and mental
+limitations and possibilities of children.
+
+
+
+
+CHAPTER XII
+
+HEALTH VALUE OF "UNBOSSED" PLAY AND PHYSICAL TRAINING
+
+
+_A boy without play means a father without a job. A boy without
+physical training means a father who drinks. When people have
+wholesome, well-disciplined bodies there will be less demand for
+narcotics as well as for medicines._ On these three propositions
+enthusiasm has built arguments for city parks and playgrounds, for
+school gymnastics, and for temperance instruction. We have tried the
+remedies and now realize that too much was expected of them. Neither
+movement appreciated the mental and physical education of spontaneous
+games and play.
+
+Like hygiene instruction, physical training was made compulsory by law
+in many states, and, like hygiene instruction, physical training had to
+yield to the pressure of subjects in which children are examined. At
+the outset both were based upon distorted psychology and physiology. Of
+late physical training has been revived "to correct defects of the
+school desk and to relieve the strain of too prolonged study periods."
+In New York grammar schools ten minutes a day for the lower grades, and
+thirty minutes a week for the higher grades, are set aside for physical
+training. With the exception of eighteen schools where apparatus is
+used, the exercise has been in the class rooms. It consists of what are
+known as "setting-up exercises,"--deep breathing and arm movements for
+two minutes between each study period, often forgotten until it is time
+to go home, when the children are tired and need it least. Many
+teachers so conduct these exercises that children keenly enjoy them.
+
+    [Illustration: SERVICEABLE RELIEF FROM SCHOOL STRAIN, BUT A POOR
+    SUBSTITUTE FOR OUTDOOR PLAY]
+
+Like hygiene instruction, physical training preceded physical
+examination. Generally speaking, it has not yet, either in schools or
+in colleges, been related to physical needs of the individual pupil. In
+fact, there is no guarantee that it is not in many schools working a
+positive injury on defective children or imposing a defective
+environment on healthy children. Formal exercises in cramped space, in
+ill-ventilated rooms, with tight belts and heavy shoes, are conceded to
+be pernicious. Formal exercises should never be given to any child
+without examination and prescription by a physician. Children with
+heart weakness, enlarged tonsils, adenoid growths, spinal curvature,
+uneven shoulders, are frequently seen doing exercises for which they
+are physically unfit, and which but serve to deplete further their
+already low vitality. Attention might be called to many a class engaged
+in breathing exercises when by actual count over half the boys were
+holding their mouths open. Special exercises are needed by children who
+show some marked defect like flat foot, flat chest, weak abdominal
+muscles, habitual constipation, uneven shoulders, spinal trouble, etc.
+
+That no physical training should be provided for normal children is the
+belief of many leading trainers. This special training is useful to
+develop athletes or to correct defects. Like massage, osteopathy, or
+medicine, it should follow careful diagnosis. The time is coming when
+formal indoor gymnasium exercises for normal pupils or normal students
+will be considered an anomaly. There is all the difference in the world
+between physical development and what is called physical training. The
+test of physical development is not the hours spent upon a prescribed
+course of training, but the physical condition determined by
+examination. To be refused permission to substitute an hour's walk for
+an hour's indoor apparatus work is often an outrage upon health laws.
+Given a normal healthy body, plenty of space, and plenty of playtime,
+the spontaneous exercise which a child naturally chooses is what is
+really health sustaining and health giving.
+
+Mere muscular development artificially obtained through the devices of
+a gymnasium is inferior to the mental and moral development produced by
+games and play in the open air. Eustace Miles, M.D., amateur tennis
+player of England, says:
+
+  I do not consider a mere athlete to be a really healthy man. He
+  has no more right to be called a really healthy man than the
+  foundations or scaffolding of a house have a right to be called a
+  house. They become a good house, and, indeed, they are
+  indispensable to a good house, but at present the good house
+  exists only in potentiality.
+
+The "healthy-mindedness" and "physical morality" which play and games
+foster rarely result from physical training as a business, at stated
+times, indoors, under class direction. It is too much like taking
+medicine. A certain breakfast food is said to have lost much of its
+popularity since advertised as a health food. When the National
+Playground Association was organized President Roosevelt cautioned its
+officers against too frequent use of the word "supervision" on the
+ground that supervision and direction were apt to defeat the very
+purpose of games and to stultify the play spirit. Is the little girl on
+the street who springs into a hornpipe or a jig to the tune of a
+hurdy-gurdy, or even the boy who runs before automobiles or trolley
+cars or under horses' noses, getting less physical education than those
+who play a round game in silence under the supervision of a teacher in
+the school basement, or who stretch their arms up and down to the tune
+of one, two, three, four, five, six? Who can doubt that the much-pitied
+child of the tenement playing with the contents of the ash can in the
+clothes yard or with baby brother on the fire escape is developing more
+originality, more lung power, and better arteries than the child of
+fortune who is led by the hand of a governess up and down Fifth Avenue.
+
+Children have not forgotten how to play, but adults have forgotten to
+leave space in cities, and time out of school, home work, and factory
+work in which children may play. Again, the child--whether a city child
+or a country child--rarely needs to be taught how to play. Teaching him
+games will not produce vitality. Games are the spontaneous product of a
+healthy body, active mind, and a joy in living. Give the children parks
+and piers, roof gardens and playgrounds in which they may play, and
+leave the rest to them. Give them time away from school and housework,
+and leave the rest to them. Instead of lamenting the necessity for
+playing in the streets, let us reserve more streets for children's
+play. There are too many students of child welfare whose reasoning
+about play and games is like that of a lady of Cincinnati, who, upon
+reading the notice of a child-labor meeting, said: "Well, I am glad to
+see there is going to be a meeting here for child labor. It is high
+time some measure was taken to keep the children off the streets."
+Physical examinations would prove that streets are safer and better
+than indoor gymnasiums for growing children. Intelligent physical
+training will train children to go out of doors during recess; will
+train pupils and teachers not to use recess for study, discipline, or
+eating lunch.
+
+    [Illustration: SPONTANEOUS PLAY ON ONE OF NEW YORK CITY'S SCHOOL
+    ROOF PLAYGROUNDS]
+
+"After-school" conditions are quite as important as physical training
+and gymnastics at school. Not long ago a nurse was visiting a sick
+tenement mother with a young baby. She found a little girl of twelve
+standing on a stool over a washtub. This child did all the housework,
+took care of the mother and two younger children, got all the meals
+except supper, which her father got on his return from work. As the
+nurse removed the infant's clothes to give it a bath, the little girl
+seized them and dashed them into the tub. "Yes, I am pretty tired when
+night comes," she confessed. This child has prototypes in the country
+as well as the city, and she did not need physical training. She did
+not lack initiative or originality. She did need playmates, open air, a
+run in the park, and "fun."
+
+The educational value of games and outdoor play should be weighed
+against the advantages of lowering the compulsory school age, and of
+bridging over the period from four to seven with indoor kindergarten
+training. Neither physical training nor education is synonymous with
+confinement in school. The whole tendency of Nature's processes in
+children is nutritional; it is not until adolescence that she makes
+much effort to develop the brain. Overuse of the young mind results,
+therefore, in diverting natural energy from nutritive processes to
+hurried growth of the overstimulated brain. The result is a type of
+child with a puny body and an excitable brain,--the neurotic. The young
+eye, for example, is too flat (hypermetropic)--made to focus only on
+objects at a distance. Close application to print, or even to weaving
+mats or folding bits of paper accurately, causes an overstrain on the
+eye, which not only results in the chronic condition known as
+myopia,--short-sightedness,--so common to school children, but which
+acts unfavorably on the constitution and on the whole development of
+the child. At the recent International Congress of School Hygiene in
+London, Dr. Arthur Newsholme, medical officer of health of Brighton,
+made a plea for the exclusion of children under five years of age from
+schools. "During the time the child is in the infant department it has
+chiefly to grow. Nutrition and sleep are its chief functions. Paints,
+pencils, paper, pins, and needles should not be handled in school by
+children below six." Luther Burbank, in an article on "The Training of
+the Human Plant," says:
+
+  The curse of modern child life in America is overeducation,
+  overconfinement, overrestraint. The injury wrought to the race by
+  keeping too young children in school is beyond the power of any
+  one to estimate. The work of breaking down the nervous systems of
+  the children of the United States is now well under way. Every
+  child should have mud pies, grasshoppers, and tad-poles, wild
+  strawberries, acorns, and pine cones, trees to climb and brooks
+  to wade in, sand, snakes, huckleberries, and hornets, and any
+  child who has been deprived of these has been deprived of the best
+  part of his education.
+
+Not every child can have these blessings of the country, but every
+child can be protected from the stifling of the nature instinct of play
+by formal indoor "bossed" exercises, whether called games, physical
+training, gymnastics, or Delsarte.
+
+    [Illustration: NEW YORK CITY'S SCHOOL FARM DOES NOT STIFLE
+    NATURE INSTINCT]
+
+The answer to the protest against too early and too constant
+confinement in school has always been: "Where will the child be if out
+of school? Will its environment at home not work a worse injury to its
+health? Will not the street injure its morals?" Because we have not yet
+worked out a method of supervising the health of those children who are
+not in school, it does not follow that such supervision is impossible.
+Perhaps the time will come when there will be state supervision over
+the health of children from birth, parents being expected to present
+them once a year at school for examination by the school physician. In
+this way defects can be corrected and health measures devised to build
+up a physique that should not break down under the strain of school
+life. For children whose mothers work during the day, and for those
+whose home environment is worse than school, it might be cheaper in the
+long run to assign teachers to protect them from injury while they play
+in a park, roof garden, or out-of-door gymnasium. If parks and
+playgrounds come too slowly, why not adopt the plan advocated by Alida
+S. Williams, a New York principal, of reserving certain streets for
+children between the hours of three and five, and of diverting traffic
+to other streets less suitable for children's play? So great is the
+value--mentally, morally, and physically--of out-of-door play that it
+has even been suggested that the substitution of such play for school
+for all children up to the age of ten would insure better minds and
+sounder physiques at fifteen. It is generally admitted that the child
+who enters school at eight rather than at six will be the gainer at
+twelve. What a travesty upon education to insist upon schooling for
+children because they are apt to be run over on the street, or to be
+neglected at home, to shoot craps, or belong to a gang and develop bad
+morals.
+
+Educators will some day be ashamed to have made the schools the
+catch-all or the court-plaster for the evils of modern industry.
+Instead of pupils and mothers going to the school, enough hygiene
+teachers, and play teachers, and district physicians could be employed
+with the money now spent on indoor instruction to do the house-to-house
+visiting urged in many chapters of this book. Such a course of action
+would have an incalculable effect on the reduction of tuberculosis, not
+only in making healthier physiques but by inculcating habits of outdoor
+life and love of fresh air. The danger of those contagious diseases
+which ravish childhood would be greatly reduced. An ambition for
+physical integrity would make unnatural living unpopular. Competition
+in games with children _of the same physical class_ develops accuracy,
+concentration, dispatch, resourcefulness, as much as does instruction
+in arithmetic. Smoking can easily be discredited among boys trying to
+hit the bull's-eye. A boy would sooner give up a glass of beer than the
+championship in rifle shooting or a "home run."
+
+The influence of the "spirit of the game" on practical life has been
+described thus by New York's director of physical training, Dr. Luther
+H. Gulick:
+
+  Play is the spontaneous enlistment of the entire personality in
+  the pursuit of some coveted end. We do not have to pursue the
+  goal; we wish to--it is our main desire. This is the way in which
+  greatest discoveries, fortunes, and poems are made. It is the way
+  in which we take the responsibilities and problems of life that
+  makes it either a deadly bore--a mere dull round of routine and
+  drudgery--or the most interesting and absorbing game, capable of
+  enlisting all the energy and enthusiasm we have to put into it.
+  The people who accomplish things are the people who play the game.
+  They let themselves go; they are not afraid. Under the stimulus
+  and enthusiasm of play muscles contract more powerfully and longer
+  than under other conditions. Blood pressure is higher in play. It
+  is far more interesting to play the game than to work at it. When
+  you work you are being driven, when you play you are doing the
+  driving yourself. We play not by jumping the traces of life's
+  responsibilities, but by going so far beyond life's compulsions as
+  to lose sight of the compulsion element. Play up, play up, and
+  play the game.
+
+
+
+
+CHAPTER XIII
+
+VITALITY TESTS AND VITAL STATISTICS
+
+
+Two things will disclose the strength or weakness of a bank and the
+soundness or unsoundness of a nation's banking policy, namely, a
+financial crisis or an expert audit. A searching audit that analyzes
+each debit and each credit frequently shows that a bank is solvent only
+because it is not asked to pay its debts. It continues to do business
+so long as no obvious weaknesses appear, analogous to measles,
+adenoids, or paralysis. A frequent disorder of banking results from
+doing too big a business on too little capital, in making too many
+loans for the amount of cash held ready to pay depositors upon demand.
+This disorder always comes to light in a crisis--too late. It can be
+discovered if looked for in advance of a crisis. Many individuals and
+communities are likewise physically solvent only because their physical
+resources are not put to the test. Weaknesses that lie near the surface
+can be discovered before a crisis by physical examination for
+individuals and sanitary supervision for communities. Whether
+individuals or communities are trying to do too much business for their
+health capital, whether the health reserves will pay debts that arise
+in a crisis, whether we are ill or well prepared to stand a run on our
+vitality, can be learned only by carefully analyzing our health
+reserves. Health debits are compared with health credits for
+individuals by vitality tests, for communities by vital statistics.
+
+Of the many vitality tests none is practicable for use in the ordinary
+class room. Scientific training is just as necessary for such tests as
+for discovering the quality of the blood, the presence or absence of
+tubercle bacilli in the sputum, diphtheria germs in throat mucus, or
+typhoid germs in milk. But scientific truth, the results of scientific
+tests, can be made of everyday use in all class rooms. State and
+national headquarters for educators, and all large cities, can afford
+to engage scientists to apply vitality tests to school children for the
+sake of discovering, in advance of physical breakdown and before
+outward symptoms are obvious, what curriculum, what exercise, what
+study, recreation, and play periods are best suited to child
+development. It will cost infinitely less to proceed this way than to
+neglect children or to fit school methods to the loudest, most
+persistent theory.
+
+The ergograph is an interesting strength tester. It takes a picture (1)
+of the energy exerted, and (2) of the regularity or fitfulness of the
+manner in which energy is exerted. Perhaps the time will come when
+science and commerce will supply every tintype photographer with an
+ergograph and the knowledge to use it. Then we shall hear at summer
+resorts and fairs, "Your ergograph on a postal card, three for a
+quarter." We can step inside, harness our middle finger to the
+ergograph, lift it up and down forty-five times in ninety seconds, and
+lo! a photograph of our vitality! If we have strong muscles or good
+control, the picture will be like this:
+
+    [Illustration: FIG. 1. Ergogram of T.R., a strong, healthy girl,
+    before taking 40 minutes' work in the gymnasium. Weight used,
+    3.5 kg. Distance lifted, 151 cm. Work done, 528.5 kg.-cm.]
+
+If weak and nervous, we shall look like this before taking exercise:
+
+    [Illustration: FIG. 2. Ergogram of C.E., a weak and somewhat
+    nervous girl, before taking 40 minutes' work in the gymnasium.
+    Weight used, 3.5 kg. Distance lifted, 89 cm. Work done, 311.5
+    kg.-cm.]
+
+And like this after gymnasium exercise:
+
+    [Illustration: FIG. 3. Ergogram of C.E. after taking 40 minutes'
+    work in the gymnasium, showing that the exercise proved very
+    exhausting. Weight used, 3.5 kg. Distance lifted, 55 cm.]
+
+In Chicago, two of whose girls are above photographed, the physician
+was surprised to have four pupils show more strength late in the day
+than in the morning. "Upon investigation it was found that the teacher
+of the four pupils had been called from school, and that they had no
+regular work, but had been sent to another room and employed
+themselves, as they said, in having a good time." The chart on page 127
+shows the effect of the noon recess and of the good time after three
+o'clock.
+
+Chicago's child-study experts concluded after examining a large number
+of children:
+
+  1. In general there is a distinct relationship in children between
+  physical condition and intellectual capacity, the latter varying
+  directly as the former.
+
+  2. The endurance (ergographic work) of boys is greater than that
+  of girls at all ages, and the difference seems to increase after
+  the age of nine.
+
+  3. There are certain anthropometric (body measurements)
+  indications which warrant a careful and thorough investigation
+  into the subject of coeducation in the upper grammar grades.
+
+  4. Physical condition should be made a factor in the grading of
+  children for school work, and especially for entrance into the
+  first grade.
+
+  5. The great extremes in the physical condition of pupils in the
+  upper grammar grades make it desirable to introduce great
+  elasticity into the work of these grades.
+
+  6. The classes in physical culture should be graded on a physical
+  instead of an intellectual basis.
+
+    [Illustration: FIG. 4]
+
+To these conclusions certain others should be added, not as settled
+beyond any possibility of modification, but as being fairly indicated
+by these tests.
+
+  1. The pubescent period is characterized by great and rapid
+  changes in height, weight, strength of grip, vital capacity, and
+  endurance. There seems to accompany this physical activity a
+  corresponding intellectual and emotional activity. It therefore is
+  a period when broad educational influences are most needed. From
+  the pedagogic standpoint it is preëminently a time for character
+  building.
+
+  2. The pubescent period is characterized by extensive range of all
+  physical features of the individuals in it. Hence, although a
+  period fit for great activity of the mass of children, it is also
+  one of numerous individual exceptions to this general law. During
+  this period a greater per cent of individuals than usual pass
+  beyond the range of normal limits set by the mass. It is a time,
+  therefore, when the weak fail and the able forge to the front, and
+  hence calls for a higher degree than usual of individualization of
+  educational work and influence.
+
+  3. Unidexterity is a normal condition. Rapid and marked
+  accentuation of unidexterity is a pubescent change. On the whole,
+  there is a direct relationship between the degree of unidexterity
+  and the intellectual progress of the pupil. At any given age of
+  school life bright or advanced pupils tend toward accentuated
+  unidexterity, and dull or backward pupils tend toward
+  ambidexterity.... Training in ambidexterity is training contrary
+  to a law of child life.
+
+  4. Boys of school age at the Bridewell (reform school) are
+  inferior in all physical measurements to boys in the ordinary
+  schools, and this inferiority seems to increase with age.
+
+  5. Defects of sight and hearing are more numerous among the dull
+  and backward pupils. These defects should be taken into
+  consideration in the seating of pupils. Only by removing the
+  defects can the best advancement be secured.
+
+  6. The number of eye and ear defects increases during the first
+  years of school life. The causes of this increase should be
+  investigated, and, as far as possible, removed.
+
+  7. There are certain parts of the school day when pupils, on the
+  average, have a higher storage of energy than at other periods.
+  These periods should be utilized for the highest forms of
+  educational work.
+
+  8. The stature of boys is greater than that of girls up to the age
+  of eleven, when the girls surpass the boys and remain greater in
+  stature up to the age of fourteen. After fourteen, girls increase
+  in stature very slowly and very slightly, while boys continue to
+  increase rapidly until eighteen.
+
+  9. The weight of the girl surpasses that of the boy about a year
+  later than her stature surpasses his, and she maintains her
+  superiority in weight to a later period of time than she maintains
+  her superiority in height.
+
+  10. In height, sitting, girls surpass boys at the same age as in
+  stature, namely, eleven years, but they maintain their superiority
+  in this measurement for one year longer than they do in stature,
+  which indicates that the more rapid growth of the boy at this age
+  is in the lower extremities rather than in the trunk.
+
+  11. Commencing at the age of thirteen, strength of grip in boys
+  shows a marked accentuation in its rate of increase, and this
+  increase continues as far as our observations extend, namely, to
+  the age of twenty. In girls no such great acceleration in muscular
+  strength at puberty occurs, and after sixteen there is little
+  increase in strength of grip. The well-known muscular
+  differentiation of the sexes practically begins at thirteen.
+
+  12. As with strength of grip, so with endurance as measured by the
+  ergograph; boys surpass girls at all ages, and this
+  differentiation becomes very marked after the age of fourteen,
+  after which age girls increase in strength and endurance but very
+  slightly, while after fourteen boys acquire almost exactly half of
+  the total power in these two features which they acquire in the
+  first twenty years of life.
+
+  13. The development of vital capacity bears a striking resemblance
+  to that of endurance, the curves representing the two being almost
+  identical.
+
+Physiological age, according to studies made in New York City, should
+be considered in grading, not only for physical culture classes but for
+all high school or continuation classes. Dr. C. Ward Crampton,
+assistant physical director, while examining boys in the first grade of
+the High School of Commerce, noticed a greater variation in physical
+advancement than in years. He kept careful watch of the educational
+progress and discovered three clear divisions: (1) boys arrived at
+puberty,--postpubescent; (2) boys approaching maturity,--pubescent; (3)
+boys not yet approaching maturity,--prepubescent.
+
+The work in lower grades they had all passed satisfactorily, but in
+high school only the most advanced class did well. Practically none of
+the not-yet-maturing boys survived and few of the almost mature. In
+other words, the high school course was fitted to only one of the three
+classes of boys turned out of the grammar schools. The others succumbed
+like hothouse azaleas at Christmas time, forced beyond their season.
+Physiological age, not calendar years or grammar school months, should
+determine the studies and the companions of children after the tenth
+year. Physiological strength and vitality, not ability to spell or to
+remember dates, should be the basis of grading for play and study and
+companionship among younger children. Vitality, power to endure
+physically, should be the test of work and recreation for adults.
+Physicians may be so trained to follow directions issued by experts
+that physical examinations will disclose the chief enemies of vitality
+and the approximate limits of endurance.
+
+Teachers may train themselves to recognize signs of fatigue in school
+children and to adapt each day's, each hour's work to the endurance of
+each pupil. One woman principal has written:
+
+  School programmes, after they have been based upon the laws of a
+  child's development, should provide for frequent change of
+  subject, alternating studies requiring mental concentration with
+  studies permitting motor activity, and arranging for very short
+  periods of the former. Anæmic children should be relieved of all
+  anxiety as to the results of their efforts, and only short hours
+  of daylight work required of them. The disastrous consequences of
+  eye strain should be understood by all in charge of children who
+  are naturally hypermetropic. The ventilation of a class room is
+  far more important than its decoration or even than a high average
+  percentage in mathematics, and the lack of pure air is one of the
+  auxiliary causes of nervous exhaustion in both pupils and
+  teachers. Deficient motor control is a most trustworthy indication
+  of fatigue in children, and teachers may safely use it as a rough
+  index of the amount of effort to be reasonably expected of their
+  pupils. Facial pallor or feverish flushes are both evidences of
+  overtasking, and either hints that fatigue has already begun. As
+  to unfavorable atmospheric conditions, the teacher herself will
+  undoubtedly realize them as soon as the children, but she should
+  remember that effort carried to the point of exhaustion, injurious
+  as it is in an adult, is yet less harmful than it is to the
+  developing nerve centers of the child.
+
+Because adults at work and at play reluctantly submit themselves to
+vitality tests, because few scientists are beseeching individuals to be
+tested, because almost no one yearns to be tested, the promotion of
+adult vitality and of community vitality can best be hastened by
+demanding complete vital statistics. Industrial insurance companies and
+mutual benefit societies are doing much to educate laborers regarding
+the effect upon vitality of certain dangerous and unsanitary trades,
+and of certain unhygienic habits, such as alcoholism and nicotinism.
+Progress is slower than it need be because state boards of health are
+not gathering sufficiently complete information about causes of
+sickness and death. American health and factory inspection is not even
+profiting, as it should, from British, German, and French statistics.
+Statistics are in ill repute because the truth is not generally known
+that our boasted sanitary improvements are due chiefly to the efficient
+use of vital statistics by statesmen sanitarians.[7]
+
+The vital statistics of greatest consequence are not the number of
+deaths or the number of births, not even the number of deaths from
+preventable diseases, but rather the number of cases of sickness from
+transmissible diseases. The cost and danger to society from preventable
+diseases, such as typhoid, diphtheria, scarlet fever, measles, are
+imperfectly represented by the number of deaths. Medical skill could
+gradually reduce death rates in the face of increasing prevalence of
+infectious disease. With few exceptions, only those patients who refuse
+to follow instructions will die of measles, diphtheria, or smallpox.
+The scarlet-fever patient who recovers and goes to church or school
+while "peeling" can cause vastly more sickness from scarlet fever than
+a patient who dies. Dr. W. Leslie Mackenzie, who has recently written
+_The Health of the School Child_, said ten years ago, while health
+officer of Leith:
+
+  Death is the ultimate and most severe injury that any disease can
+  inflict, but short of death there may be disablement, permanent or
+  temporary, loss of wages, loss of employment, loss of education,
+  increase of home labor, increase of sickness outlays, increase of
+  worry, anxiety and annoyance, disorganization of the household,
+  general impairment of social efficiency.
+
+The best guarantee against such loss, the best protection of health,
+and the most essential element of vital statistics is prompt, complete
+record of cases of sickness. Statistics of sickness are confined to
+sickness from transmissible diseases, because we have not yet arrived
+at the point where we recognize the state's right to require
+information, except when the sick person is a menace to the health of
+other persons.
+
+The annual report of a board of health should give as clear a picture
+of a community's health during the past week or past quarter as the
+ergograph gives of the pupils mentioned on page 126. As ragged, rapidly
+shortening lines show nervousness and depleted vitality, so charts and
+diagrams can be made to show the needless waste of infant life during
+the summer months, the price paid for bad ventilation in winter time,
+when closed windows cause the sickness-and-death line from diphtheria
+and scarlet fever to shoot up from the summer level. In cities it is
+now customary for health boards to report weekly the number of deaths
+from transmissible diseases. Health officers will gladly furnish facts
+as to cases of sickness, if citizens request them. Newspapers will
+gladly publish such information if any one will take the pains to
+supply it. Wherever newspapers have published this information, it
+quickly takes its place with the weather reports among the news
+necessities. Marked changes are commented on editorially. Children can
+easily be interested, as can adults, in filling out week by week a
+table that will show increases and decreases in preventable sickness
+due to transmissible diseases.
+
+
+TABLE X
+
+CASES OF INFECTIOUS AND CONTAGIOUS DISEASES REPORTED
+
+=================+================================================
+                 |                         WEEK ENDING
+                 +------+------+------+------+------+------+------
+                 | Oct. | Nov. | Nov. | Nov. | Nov. | Nov. | Dec.
+                 |  26  |  2   |  9   |  16  |  23  |  30  |  7
+-----------------+------+------+------+------+------+------+------
+Tuberculosis     |      |      |      |      |      |      |
+  pulmonalis     | 350  | 350  | 317  | 364  | 345  | 337  | 422
+Diphtheria and   |      |      |      |      |      |      |
+  croup          | 313  | 264  | 283  | 331  | 282  | 343  | 326
+Measles          | 142  | 212  | 203  | 261  | 293  | 323  | 472
+Scarlet fever    | 208  | 228  | 231  | 252  | 278  | 323  | 372
+Smallpox         |  --  |   1  |  --  |   1  |  --  |  --  |   2
+Varicella        |  40  |  83  |  91  | 162  | 136  | 115  | 167
+Typhoid fever    | 106  | 105  | 107  | 123  |  86  |  77  |  71
+Whooping cough   |   6  |  13  |  15  |  14  |  27  |   9  |   8
+Cerebro-spinal   |      |      |      |      |      |      |
+  meningitis     |   6  |  11  |   3  |   4  |   4  |   8  |  15
+-----------------+------+------+------+------+------+------+------
+Total            | 1171 | 1267 | 1250 | 1512 | 1451 | 1535 | 1855
+=================+======+======+======+======+======+======+======
+
+=================+=========================================
+                 |             WEEK ENDING
+                 +------+------+------+------+------+------
+                 | Dec. | Dec. | Dec. | Jan. | Jan. | Jan.
+                 |  14  |  21  |  28  |  4   |  11  |  18
+-----------------+------+------+------+------+------+------
+Tuberculosis     |      |      |      |      |      |
+  pulmonalis     | 360  | 354  | 308  | 344  | 432  | 402
+Diphtheria and   |      |      |      |      |      |
+  croup          | 369  | 338  | 347  | 308  | 370  | 406
+Measles          | 471  | 517  | 346  | 581  | 691  | 803
+Scarlet fever    | 397  | 417  | 426  | 478  | 562  | 585
+Smallpox         |   4  |   3  |   2  |  --  |   2  |  --
+Varicella        | 160  | 198  | 123  |  98  | 199  | 169
+Typhoid fever    |  62  |  35  |  42  |  37  |  55  |  36
+Whooping cough   |  12  |  19  |   3  |  25  |  24  |  14
+Cerebro-spinal   |      |      |      |      |      |
+  meningitis     |  13  |   7  |   6  |  11  |  16  |  13
+-----------------+------+------+------+------+------+------
+Total            | 1844 | 1888 | 1603 | 1882 | 2351 | 2428
+=================+======+======+======+======+======+======
+
+In cities where physicians are not compelled to notify the health board
+of danger centers,--that is, of patients sick from measles, smallpox,
+or diphtheria,--and in smaller communities where notices are sent only
+to state boards of health, parents will find it difficult to take a
+keen interest in vital statistics. But if teachers would start at the
+beginning of the year to record in such a table the days of absence
+from school because of transmissible disease, both they and their
+pupils would discover a new interest in efficient health
+administration. After a national board of health is organized we may
+reasonably expect that either state boards of education or state boards
+of health will regularly supply teachers with reports that will lead
+them to compare the vitality photographs of their own schools and
+communities with the vitality photographs of other schools and other
+communities working under similar conditions. Then children old enough
+to study physiology and hygiene will be made to see the
+happiness-giving possibilities of vitality tests and vital statistics.
+
+    [Illustration: VITAL STATISTICS CAN MAKE DISEASE CENTERS AS
+    OBVIOUS AND AS OFFENSIVE AS THE SMOKE NUISANCE]
+
+Instead of discussing the theory of vital statistics, or the extent to
+which statistics are now satisfactory, it would be better for us at
+this point to make clear the significance of the movement for a
+national fact center for matters pertaining to personal, industrial,
+and community vitality. Five economic reasons are assigned for
+establishing a national department of health:
+
+  1. To enable society to increase the percentage of exceptional men
+  of each degree, many of whom are now lost through preventable
+  accidents, and also to increase the total population.
+
+  2. To lessen the burden of unproductive years by increasing the
+  average age at death.
+
+  3. To decrease the burden of death on the productive years by
+  increasing the age at death.
+
+  4. To lessen the cost of sickness. It is estimated that if illness
+  in the United States could be reduced one third, nearly
+  $500,000,000 would be saved annually.
+
+  5. To decrease the amounts spent on criminality that can be traced
+  to overcrowded, unwholesome, and unhygienic environment.
+
+  In addition to the economic gain, the establishment of a national
+  department of health would gradually but surely diminish much of
+  the misery and suffering that cannot be measured by statistics.
+  Sickness is a radiating center of anxiety; and often death in the
+  prime of life closes the gates of happiness on more than one life.
+  Let us not forget that the "bitter cry of the children" still goes
+  up to heaven, and that civilization must hear, until at last it
+  heeds, the imprecations of forever wasted years of millions of
+  lives.
+
+  If progress is to be real and lasting, it must provide whatever
+  bulwarks it can against death, sickness, misery, and ignorance;
+  and in an organization such as a national department of health,
+  adequately equipped,--a vast preventive machine working
+  ceaselessly,--an attempt at least would be made to stanch those
+  prodigal wastes of an old yet wastrel world.
+
+Among the branches of the work proposed for the national bureau are the
+following: infant hygiene; health education in schools; sanitation;
+pure food; registration of physicians and surgeons; registration of
+drugs, druggists, and drug manufacturers; registration of institutions
+of public and private relief, correction, detention and residence;
+organic diseases; quarantine; immigration; labor conditions;
+disseminating health information; research libraries and equipment;
+statistical clearing house for information.
+
+Given such a national center for health facts or vital statistics,
+there will be a continuing pressure upon state, county, and city health
+officers, upon physicians, hospitals, schools, and industries to report
+promptly facts of birth, sickness, and death to national and state
+centers able and eager to interpret the meaning of these facts in such
+simple language, and with such convincing illustrations, that the
+reading public will demand the prompt correction of preventable evils.
+
+Our tardiness in establishing a national board of health that shall do
+this great educational work is due in part to the fact that American
+sanitarians have frequently chosen to _do things_ when they should have
+chosen to _get things done_. Almost every state has its board of
+health, with authority to require registration of births, deaths, and
+sickness due to transmissible disease; with few exceptions the heads of
+these state boards have spent their energies in abating nuisances. In a
+short time they have degenerated into local scavengers, because they
+have shown the public neither the meaning of the vital statistics
+gathered nor its duty to support efficient health administration.
+
+The state reports of vital statistics have not been accurate; therefore
+in many states we have the anomalous situation of an aggressive
+veterinary board arousing the farmer and the consumer of milk to the
+necessity of protecting the health of cattle, and an inactive,
+uninformed state board of health failing to protect the health of the
+farmer and the consumer.
+
+Vital statistics presume efficient health administration. An
+inefficient health officer will not take the initiative in gathering
+health statistics. If some one else compels him to collect vital
+statistics, or furnishes him with statistics, they are as a lantern to
+a blind man. Unless some one also compels him to make use of them,
+unless we remove the causes of transmissible or infectious diseases and
+check an epidemic when we first hear of it, the collection of
+information is of little social value. "Statistics" is of the same
+derivation as "states" and "statesmen." Statistics have always been
+distinguished from mere facts, in that statistics are instruments in
+the hands of the statesman. Wherever the term "statistics" is applied
+to social facts it suggests action, social control of future
+contingencies, mastery of the facts whose action they chronicle. The
+object of gathering social facts for analysis is not to furnish
+material for future historians. They are to be used in shaping future
+history. They are facts collected with a view to improving social
+vitality, to raising the standard of life, and to eliminating
+permanently those forces known to be destructive to health. Unless they
+are to be used this way, they are of interest only to the historical
+grub. No city or state can afford to erect a statistical office to
+serve as a curiosity shop. Unless something is to be done to prevent
+the recurrence of preventable diseases annually experienced by your
+community or your school, it is not reasonable to ask the public
+printer to make tables which indicate the great cost of this
+preventable sickness. A tax collector cannot discharge his duties
+unless he knows the address of every debtor. The police bureau cannot
+protect society unless it knows the character and haunts of offenders.
+A health officer cannot execute the law for the protection of society's
+health unless he knows the haunts and habits of diseases. For this he
+must look to vital statistics.
+
+But the greatest service of vital statistics is the educational
+influence. Health administration cannot rise far above the hygienic
+standards of those who provide the means for administering sanitary
+law. The taxpaying public must believe in the economy, utility, and
+necessity of efficient health administration. Power and funds come
+from town councils and state legislatures. To convince and move these
+keepers of the purse, trustworthy vital statistics are indispensable.
+Information will be used for the benefit of all as soon as it is
+possessed by all.
+
+Fortunately the gathering of vital statistics is not beyond the power
+of the kind of health officer that is found in small cities and in
+rural communities. If years of study of mathematics and of the
+statistical method were required, we should despair of obtaining light
+within a century. But the facts we want are, for the most part, common,
+everyday facts, easily recognizable even by laymen; for example,
+births, deaths, age at death, causes of death, cases of transmissible
+diseases, conditions found upon examination of children applying for
+work certificates, etc. Where expert skill is required, as at state and
+national headquarters, it can be found. Every layman can train himself
+to use skillfully the seven ingredients of the statistical method which
+it is his duty to employ, and to know when to pay for expert analysis
+and advice. We can all learn to base judgment of health needs upon the
+seven pillars,--desire to know, unit of inquiry, count, comparison,
+percentages, classification, and summary.
+
+FOOTNOTES:
+
+[7] Dr. Arthur Newsholme's _Vital Statistics_ should be in public
+libraries and on the shelves of health officers, public-spirited
+physicians, and school superintendents.
+
+
+
+
+CHAPTER XIV
+
+IS YOUR SCHOOL MANUFACTURING PHYSICAL DEFECTS?
+
+
+Last year a conference on the physical welfare of school children was
+told by a woman principal: "Of course we need physicians to examine our
+children and to teach the parents, but many of us principals believe
+that our school curriculum and our school environment manufacture more
+physical defects in a month than all your physicians and nurses will
+correct in a year." At the same meeting the physical director of
+schools of New York City appealed eloquently for "biological engineers"
+at school, who would test the child's strength as building engineers
+are employed to test the strength of beams and foundations.[8] As
+explanation for the need of the then recently organized National School
+Hygiene Association, he elaborated the proposition that school
+requirements and school environment damage child health. "Ocular
+defects are in direct ratio to the length of time the pupil has
+attended school.... A desk that is too high may easily be the indirect
+agent for causing scoliosis, producing myopia or astigmatism....
+Physically examine school children by all means, but do not fail to
+examine school desks."
+
+Fifty schools in different parts of New York City were examined last
+year with especial reference to the factors likely to cause or to
+aggravate physical defects.[9] The results, tabulated and analyzed,
+prove that the woman principal was right; many schools are so built or
+so conducted, many school courses are so devised or so executed, that
+children are inevitably injured by the environment in which the
+compulsory education law forces them to spend their formative years.
+
+    [Illustration: ONE OF NEW YORK CITY'S ROOF PLAYGROUNDS]
+
+Recently I noticed that our little office girl, so anæmic and nervous
+when she left school that we hesitated to employ her, was becoming rosy
+and spirited. The child herself explained the change: "I like it
+better. I have more money to spend. I get more outdoor exercise, and
+then, oh, the room is so much sunnier and there is more air and the
+people are all so nice!" And these were just the necessities which were
+lacking in the school from which she came. Moreover, it is a fair
+commentary on the school work and the school hygiene in too many of our
+towns and cities to-day. "I like it better" means that school work is
+not adapted to the dominant interests of the child, that the curriculum
+includes subjects remote from the needs and ambitions of the modern
+school child, and fails to include certain other subjects which it
+recognizes as useful and necessary, and therefore finds interesting.
+"I have more money to spend" means that this little girl was able to
+have certain things, like a warm, pretty dress, rubbers, or an
+occasional trolley ride, which she longed for and needed. "I get more
+outdoor exercise" means that there was no open-air playground for her
+school, that "setting up" exercises were forgotten, that recess was
+taken up in rushing home, eating lunch, and rushing back again, and
+that "after school" was filled up with "helping mother with the
+housework." "The office is so much sunnier and I get more air" accounts
+for the increase in vitality; and "the people are all so nice," for the
+happy expression and initiative which the undiscriminating discipline
+at school had crushed out.
+
+    [Illustration: BONE TUBERCULOSIS IS ONE OF THE PENALTIES FOR DRY
+    SWEEPING AND FEATHER DUSTERS]
+
+For such unsanitary conditions crowded sections of great cities have no
+apologies to make to rural districts. A wealthy suburb recently learned
+that there was overcrowding in every class room, and that one school
+building was so unsanitary as to be a menace to the community.
+Unadjustable desks, dry sweeping, feather dusters, shiny blackboards,
+harassing discipline that wrecks nerves, excessive home study and
+subjects that bore, are not peculiar to great cities. In a little
+western town a competition between two self-governing brigades for
+merit points was determined by the amount of home study; looking back
+fifteen years, I can see that I was encouraging anæmic and
+overambitious children to rob themselves of play, sleep, and vitality.
+Many a rural school violates with impunity more laws of health than
+city factories are now permitted to transgress.
+
+After child labor is stopped, national and state child labor committees
+will learn that their real interest all the time has been child
+welfare, not child age, and will be able to use much of the old
+literature, simply substituting for "factory" the word "school" when
+condemning "hazardous occupations likely to sap [children's] nervous
+energy, stunt their physical growth, blight their minds, destroy their
+moral fiber, and fit them for the moral scrap heap."
+
+Many of the evils of school environment the teacher can avert, others
+the school trustee should be expected to correct. So far as unsanitary
+conditions are permitted, the school accentuates home evils, whereas it
+should counteract them by instilling proper health habits that will be
+taken home and practiced. Questions such as were asked in Miss North's
+study will prove serviceable to any one desiring to know the probable
+effect of a particular school environment upon children subject to it.
+Especially should principals, superintendents, directors, and volunteer
+committeemen apply such tests to the public, parochial, or private
+school, orphanage or reformatory for which they may be responsible.
+
+
+I. NEIGHBORHOOD HEALTH RESOURCES
+
+ 1. Is the district congested?
+
+ 2. Is congestion growing?
+
+ 3. How far away is the nearest public park?
+
+    a. Is it large enough?
+    b. Has it a playground or beauty spot?
+    c. Has it swings and games?
+    d. Is play supervised?
+    e. Have children of different ages equal opportunities, or do
+       the large children monopolize the ground?
+    f. Are children encouraged by teachers and parents to use this
+       park?
+
+ 4. Are the streets suitable for play?
+
+    a. Does the sun reach them?
+    b. Are they broad?
+    c. Are they crowded with traffic?
+
+ 5. How far away is the nearest public bath?
+
+    a. Has it a swimming pool?
+    b. Has it showers?
+    c. Is it used as an annex to the school?
+
+    [Illustration: VACATION-SCHOOL PLAY CLINIC ON A "VACANT" CITY
+    LOT OWNED BY THE ROCKEFELLER INSTITUTE FOR MEDICAL RESEARCH]
+
+
+II. EFFECT OF SCHOOL EQUIPMENT UPON HEALTH
+
+ 1. Is there an indoor yard?
+
+    a. Is the area adequate or inadequate?
+    b. Is the floor wood, cement, or dirt?
+    c. Is the heat adequate or deficient?
+    d. Is the ventilation adequate or deficient?
+    e. Is the daylight adequate, deficient, or almost lacking?
+    f. Is there equipment for light gymnastics and games?
+    g. Is it used out of school hours; by special classes, athletic
+       teams, etc., or by pupils generally?
+
+ 2. Is there an outdoor yard?
+
+    a. Is the area ample or inadequate?
+    b. Is the area mainly occupied by toilets?
+    c. Is the daylight sufficient or deficient?
+    d. For how many hours does the sun reach it?
+    e. Is it equipped for games?
+    f. How much larger ought it to be?
+    g. Is it used out of school hours; by special classes, athletic
+       teams, etc., or by pupils generally?
+
+ 3. Is there a gymnasium?
+
+    a. Is it large enough?
+    b. Is it used for a gymnasium?
+    c. Is it cut up into class rooms?
+    d. Is it used out of school hours; by special classes, athletic
+       teams, etc., or by pupils generally?
+
+ 4. Is there a roof playground?
+
+    a. Is there open ventilation?
+    b. Is it used in the daytime?
+    c. Is it used at night?
+    d. Is it used during the summer?
+    e. Is it monopolized by the larger children?
+    f. Is it used out of school hours; by special classes, athletic
+       teams, etc., or by pupils generally?
+
+ 5. Are washing facilities adequate?
+
+    a. How many pupils per washbasin?
+    b. Are there individual towels?
+    c. Have eye troubles been spread by roller towels?
+    d. Are only clean towels permitted?
+    e. Are there bathing facilities; are these adequate?
+    f. Are swimming pools used for games, contests, etc.?
+    g. Are bathing facilities used out of school hours?
+    h. Who is responsible for cleanliness of towels, washbasins, and
+       swimming pools?
+    i. How often is water changed in swimming pool, or is it
+       constantly changing?
+
+ 6. Is adequate provision made for clean drinking water?
+
+    a. Are sanitary fountains used that prevent contamination of
+       faucet or water?
+    b. How often are cups or faucets cleaned?
+
+ 7. Is provision made for airing outer clothing?
+
+    a. Are children permitted to pile their clothing in the class
+       room?
+    b. Are there hooks for each child?
+    c. Are lockers provided with wire netting to permit
+       ventilation?
+    d. Are lockers or hooks in the halls or in the basement?
+    e. Have you ever thought of the disciplinary and social value of
+       cheap coat hangers to prevent wrinkling and tearing?
+
+    [Illustration: AN ATTEMPT TO OVERCOME THE DISADVANTAGES OF
+    CONGESTION--A BOYS' HIGH SCHOOL, NEW YORK CITY]
+
+
+III. THE CLASS ROOM AS A PLACE OF CONFINEMENT
+
+ 1. How many sittings are provided?
+
+    a. How many pupils are there?
+
+ 2. What is the total floor area?
+
+    a. What proportion is not occupied by desks?
+
+ 3. Are the seats adjustable?
+
+    a. Are the seats adjusted to pupils?
+    b. Where desks are adjustable, are short children seated in low
+       desks, or are children seated according to class or according
+       to discipline exigencies without regard to size of desk?
+    c. Are seats placed properly with reference to light?
+
+ 4. Is the light ample and proper?
+
+    a. For how many hours must artificial light be used in the
+       daytime?
+    b. Is artificial light adequate for night work?
+    c. Does the reflection of light from blackboard and walls injure
+       the eye?
+    d. Are the blackboards black enough?
+    e. Are the walls too dark?
+    f. Is the woodwork too dark?
+    g. Are window panes kept clean?
+
+ 5. Is the air always fresh?
+
+    a. Is ventilation by open windows?
+    b. Is ventilation artificial?
+    c. Does the ventilating apparatus work satisfactorily?
+    d. Are the windows thrown open during recess, and after and
+       before school?
+    e. Do unclean clothes vitiate the atmosphere?
+    f. Do unclean persons vitiate the atmosphere?
+    g. Does bad breath vitiate the atmosphere?
+    h. Are pupils and parents taught that unclean clothes, unclean
+       persons, and bad breath may decrease the benefits of
+       otherwise adequate ventilation and seriously aggravate the
+       evils of inadequate ventilation?
+
+ 6. Is the temperature properly regulated?
+
+    a. Has every class room a thermometer?
+    b. Are teachers required to record the thermometer's story
+       three or more times daily?
+    c. Is excess or deficiency at once reported to the janitor?
+
+ 7. Are the floors, walls, desks, and windows always clean?
+
+    a. How often are they washed?
+    b. Is twice a year often enough?
+    c. Do the floors and walls contain the dust of years?
+    d. Is dry sweeping prohibited?
+    e. Has wet sawdust or even wet sand been tried?
+    f. Has oil ever been used to keep down surface dust on floors?
+    g. Are feather dusters prohibited?
+    h. Are dust rags moist or dry?
+    i. Is an odorless disinfectant used?
+
+ 8. Does overheating prevail?
+
+    a. Do you know teachers and principals who protest against
+       insufficient ventilation, particularly against mechanical
+       ventilation, while they themselves are "in heavy winter
+       clothing in a small room closely sealed, the thermometer at
+       80 degrees"?
+
+
+IV. EXERCISE AND RECREATION
+
+ 1. How much time and at what periods is exercise provided for in the
+    school schedule?
+
+    a. Indoors?
+    b. Outdoors?
+
+ 2. How much exercise indoors and outdoors is actually given?
+
+ 3. Are the windows open during exercise?
+
+ 4. Is exercise suited to each child by the school physician after
+    physical examination, or are all children compelled to take the
+    same exercise?
+
+ 5. Whose business is it to see that rules regarding exercise are
+    strictly enforced?
+
+ 6. Do clouds of dust rise from the floor during exercise and play?
+
+ 7. Are children deprived of exercise as a penalty?
+
+ 8. Should hygiene talks be considered as exercise?
+
+    [Illustration: HOME WORKSHOPS NEED FRESH AIR]
+
+
+V. THE SCHOOL JANITOR AND CLEANERS
+
+ 1. Do they understand the relation of cleanliness to vitality?
+
+ 2. Is their aim to do the least possible amount of work, or to attain
+    the highest possible standard of cleanliness?
+
+ 3. Will the teacher's complaint of uncleanliness be heeded by
+    trustees? If so, is the teacher not responsible for uncleanliness?
+
+ 4. Have you ever tried to stimulate the pride of janitors and
+    cleaners for social service?
+
+    a. Have you ever tried to show them how much work they save
+       themselves by thorough cleansing?
+    b. Have you ever shown them the danger, to their own health, of
+       dust and dirt that may harbor infection and reduce their own
+       vitality?
+
+ 5. What effort is made to instruct janitors and cleaners by your
+    school trustees or by your community?
+
+ 6. Have you explained to pupils the important responsibility of
+    janitors for the health of those in the tenements, office
+    buildings, or schools?
+
+    a. Do you see in this an opportunity to emphasize indirectly
+       the mother's responsibility for cleanliness of home?
+
+    [Illustration: SCHOOL WORKSHOPS ALSO NEED FRESH AIR]
+
+
+VI. REQUIREMENTS OF CURRICULUM
+
+ 1. How much home study is there?
+
+    a. How much is required?
+    b. What steps are taken to prevent excessive home study?
+    c. Are light and ventilation conditions at home considered when
+       deciding upon amount of home study?
+
+ 2. Is the child fitted to the curriculum, or is the curriculum
+    fitted to the child?
+
+    a. Does failure or backwardness in studies lead to additional
+       study hours or to regrading?
+    b. Are there too many subjects?
+    c. Are the recitation periods too long?
+    d. Are the exercise periods too short and too few?
+    e. Is there too much close-range work?
+    f. Is it possible to give individual attention to individual
+       needs so as to awaken individual interest?
+
+ 3. Is follow-up work organized to enlist interest of parents, or, if
+    necessary, of outside agencies in fitting a child to do that for
+    which, if normal, he would be physically adapted?
+
+By reducing the harm done by old buildings and by the traditions of
+curriculum and discipline, teachers can do a great deal. Perhaps they
+cannot move the windows or the desks, but they can move the children.
+If they cannot insure sanitary conditions for home study, they can cut
+down the home study. If the directors do not provide proper
+blackboards, they can do less blackboard work. They can make children
+as conscious, as afraid, and as resentful of dirty air as of dirty
+teeth. They can make janitors believe that "dry sweeping" or "feather
+dusting" may give them consumption, and leave most of the dirt in the
+room to make work for the next day; that adjustable desks are made to
+fit the child's legs and back, not the monkey wrench; that the
+thermometer in the schoolroom is a safer guide to heat needed than a
+boiler gauge in the basement; that fresh air heated by coal is cheaper
+for the school fund than stale air heated by bodies and by bad breath.
+Finally, they can make known to pupils, to parents, to principals and
+superintendents, to health officials and to the public, the extent to
+which school environment violates the precepts of school hygiene.
+
+If the state requires the attendance of all children between the ages
+of five and fourteen at school for five hours a day, for five days in
+the week, for ten months in the year, then it should undertake to see
+that the machinery it provides for the education of those children for
+the greater part of the time for nine years of their lives--the
+formative years of their lives--is neither injuring their health nor
+retarding their full development.
+
+If the amount of "close-range" work is rapidly manufacturing myopic
+eyes; if bad ventilation, whether due to faulty construction or to
+faulty management, is preparing soil for the tubercle bacillus; if
+children with contagious diseases are not found and segregated; if
+desks are so ill adapted to children's sizes and physical needs that
+they are forming crooked spines; if too many children are crowded into
+one room; if lack of air and light is producing strained eyes and
+malnutrition; if neither open air, space, nor time is provided for
+exercise, games, and physical training; if school discipline is adapted
+neither to the psychology nor the physiology of child or teacher, then
+the state is depriving the child of a greater right than the compulsory
+education law forces it to endure. Not only is the right to health
+sacrificed to the right to education, but education and health are both
+sacrificed.
+
+In undertaking to enforce the compulsory education law, to put all
+truants and child laborers in school, the state should be very sure for
+its own sake that it is not depriving the child of the health on which
+depends his future usefulness to the state as well as to himself.
+
+
+TABLE XI
+
+EFFECTS OF A CHILD LABOR LAW
+
+Increase in Chicago Attendance
+
+                            Grades 4-9
+
+########                                                1901-1902
+
+#############                                           1902-1903
+
+######################################################  1903-1904
+
+                            Grades 9-15
+
+#######################                                 1901-1902
+
+####################                                    1902-1903
+
+######################################################  1903-1904
+
+FOOTNOTES:
+
+[8] _The Sanitation of Public Buildings_, by William Paul Gerhard,
+contains a valuable discussion of how the school may avoid manufacturing
+physical defects.
+
+[9] By Professor Lila V. North, Baltimore College for Women, for the New
+York Committee on the Physical Welfare of School Children, 105 East 22d
+Street, New York City.
+
+
+
+
+CHAPTER XV
+
+THE TEACHER'S HEALTH
+
+
+"Teachers, gentlemen, no less than pupils, have a heaven-ordained right
+to work so adjusted that the highest possible physical condition shall
+be maintained automatically." This declaration thundered out by an
+indignant physician startled a well-meaning board of school directors.
+The teacher's right to health was, of course, obvious when once
+mentioned, and the directors concluded:
+
+  1. School conditions that injure child health also injure teacher
+  health.
+
+  2. Poor health of teacher causes poor health of pupil.
+
+  3. Poor health of pupil often causes poor health of teacher.
+
+  4. Adequate protection of children requires adequate protection of
+  their teachers.
+
+  5. Teachers have a right to health protection for their own sake
+  as well as for their children's sake.
+
+Too little concern has hitherto been shown for the vitality of teachers
+in private or public schools and colleges. Without protest, and without
+notice until too late, teachers often neglect their own health at home
+and at school,--recklessly overwork, undersleep, and undernourish; ruin
+their eyes, their digestion, and their nerves. School-teachers are
+frequently "sweated" as mercilessly as factory operatives. The time has
+come to admit that a school environment which destroys the health of
+the teacher is as unnecessary and reprehensible as an army camp that
+spreads typhoid among a nation's defenders. A school curriculum or a
+college tradition that breaks down teachers is as inexcusable as a gun
+that kills the gunner when discharged. Experience everywhere else
+proves that periodic physical examinations and health precautions, not
+essays about "happy teachers--happy pupils," are indispensable if
+teachers' health rights are to be protected.
+
+Physical tests are imposed upon applicants for teachers' licenses by
+many boards of education. In New York City about three per cent of
+those examined are excluded for defects of vision, of hearing, of
+probable endurance. Once a teacher, however, there is no further
+physical examination,--no way of discovering physical incapacity,
+nothing to prevent a teacher from exposing class after class to
+pulmonary tuberculosis contracted because of overwork and
+underventilation. The certainty of salary increase year by year and of
+a pension after the twentieth year will bribe many a teacher to overtax
+her own strength and to jeopardize her pupils' health.
+
+Seldom do training schools apply physical tests to students who intend
+to become teachers. One young girl says that before starting her normal
+course she is going to the physician of the board of education for
+examination, so as to avoid the experience of one of her friends, who,
+after preparing to be a teacher, was rejected because of pulmonary
+tuberculosis. During her normal course no examination will be
+necessary. Overwork during the first year may cause pulmonary
+tuberculosis, and in spite of her foresight she, too, may be rejected
+four years hence.
+
+The advantages of physical examination upon beginning and during the
+courses that prepare one for a teacher are so obvious that but little
+opposition will be given by prospective teachers. The disadvantages to
+teacher and pupil alike of suffering from physical defects are so
+obvious that every school which prepares men and women for teachers
+should make registration and certification dependent upon passing a
+satisfactory physical test. No school should engage a teacher who has
+not good proof that she can do the required work without injury to her
+own or her pupils' health. Long before physicians can discover
+pulmonary tuberculosis they can find depleted vitality which invites
+this disease. Headaches due to eye trouble, undernourishment due to
+mouth breathing, preventable indigestion, are insidious enemies that
+cannot escape the physical test.
+
+Three objections to physical tests for teachers will be urged, but each
+loses its force when considered in the light of general experience.
+
+1. _A sickly teacher is often the most efficient teacher in a school or
+a county._ It is true that some sickly teachers exert a powerful
+influence over their pupils, but in most instances their influence and
+their efficiency are due to powers that exist in spite of devitalizing
+elements. Rarely does sickness itself bring power. It must be admitted
+that many a man is teaching who would be practicing law had his health
+permitted it. Many a woman's soul is shorn of its self-consciousness by
+suffering. But even in these exceptional instances it is probable that
+children are paying too dearly for benefits directly or indirectly
+traceable to defects that physical tests would exclude.
+
+2. _There are not enough healthy candidates to supply our schools._
+This is begging the question. In fact, no one knows it is true. On the
+contrary, it is probable that the teacher's opportunity will make even
+a stronger appeal to competent men and women after physical soundness
+and vitality are made conditions of teaching,--after we all believe
+what leading educators now believe, that the highest fulfillment of
+human possibilities requires a normal, sound body, abounding in
+vitality.
+
+3. _Examination by a physician, especially if a social acquaintance, is
+an unnecessary embarrassment._ The false modesty that makes physical
+examination unwelcome to many adults, men as well as women, is easily
+overcome when the advantages of such examination are understood. It is
+likewise easy to prove to a teacher that the loss of time required in
+having the examination is infinitesimal compared with the loss of time
+due to ignoring physical needs. The programme for school hygiene
+outlined in Chapter XXVII, Part IV, assumes that state and county
+superintendents will provide for the examination of teachers as well as
+of pupils.
+
+    [Illustration: TEACHERS WILL PREFER PHYSICAL EXAMINATIONS TO
+    FORCED VACATIONS
+    Boston Society for Relief and Study of Tuberculosis]
+
+Because the health of others furnishes a stronger motive for preventive
+hygiene than our own health, it is probable that the general
+examination of teachers will come first as the result of a general
+conviction that unhealthy teachers positively injure the health of
+pupils and retard their mental development. Children at school age are
+so susceptible and imitative that their future habits of body and mind,
+their dispositions, their very voices and expressions, are influenced
+by those of their teachers. Experts in child study say that a child's
+vocal chords respond to the voices and noise about him before he is
+able to speak, so that the tones of his voice are determined before he
+is able to express them. This influence is also marked when the child
+begins to talk. Babies and young children instinctively do what adults
+learn not to do only by study,--follow the pitch of others' voices. Can
+we then overestimate the effect upon pupils' character of teachers who
+radiate vitality?
+
+The character and fitness, aside from scholarship, of applicants for
+teachers' licenses are now subjected by the board of examiners of New
+York City to the following tests:
+
+  1. Moral character as indicated in the record of the applicant as
+  a student or teacher or in other occupation, or as a participant
+  in an examination.
+
+  2. Physical fitness for the position sought, reference being had
+  here to all questions of physical fitness other than those covered
+  in a physician's report as to "sound health."
+
+  3. Satisfactory quality and use of voice.
+
+  4. Personal bearing, cleanliness, appearance, manners.
+
+  5. Self-command and power to win and hold the respect of teachers,
+  school authorities, and the community.
+
+  6. Capacity for school discipline, power to maintain order and to
+  secure the willing obedience and the friendship of pupils.
+
+  7. Business or executive ability,--power to comprehend and carry
+  out and to accomplish prescribed work, school management as
+  relating to adjustment of desks, lighting, heating, ventilation,
+  cleanliness, and attractiveness of schoolroom.
+
+  8. Capacity for supervision, for organization and administration
+  of a school, and for the instructing, assisting, and inspiring of
+  teachers.
+
+These tests probably exclude few applicants who should be admitted.
+Experience proves that they include many who, for their own sake and
+for children's sake, should be rejected. The moral character, physical
+fitness, quality of voice, personal bearing, self-command, executive
+ability, capacity for supervision, are qualities that are modified by
+conditions. The voice that is satisfactory in conference with an
+examiner may be strident and irritating when the teacher is impatient
+or is trying to overcome street noises. On parade applicants are
+equally cleanly; this cannot be said of teachers in the service, coming
+from different home environments. Self-command is much easier in one
+school than in another. Physical fitness in a girl of twenty may,
+during one short year of teaching, give way to physical unfitness.
+Therefore the need for _periodic tests_ by principal, superintendent,
+and school board, _to determine the continuing fitness_ of a teacher to
+do the special task assigned to her, based upon physical evidence of
+her own vitality and of her favorable influence upon her pupils' health
+and enjoyment of school life. Shattered nerves due to overwork may
+explain a teacher's shouting: "You are a dirty boy. Your mother is a
+dirty woman and keeps a dirty store where no decent people will go to
+buy." A physical examination of that unfortunate teacher would probably
+show that she ought to be on leave of absence, rather than, by her
+overwork and loss of control, to cause the boys of her class to feel
+what one of them expressed: "Grandmother, if she spoke so of my mother
+I would strike her."
+
+Just as there should be a central bureau to count and correct the open
+mouths and closed minds that clog the little old red schoolhouse of the
+country, so a central bureau should discover in the city teacher as
+well as in the country teacher the ailments more serious than
+tuberculosis that pass from teacher to pupil; slovenliness, ugly
+temper, frowning, crossness, lack of ambition, cynicism,--these should
+be blackballed as well as consumption, contagious morphine habit, and
+contagious skin disease. Crooked thinking by teacher leads to crooked
+thinking by pupil. Disregard of health laws by teacher encourages
+unhygienic living by pupils. A man whose fingers are yellow, nerves
+shaky, eyes unsteady, and mind alternately sleepy and hilarious from
+cigarettes, cannot convey pictures of normal, healthy physical living,
+nor can he successfully teach the moral and social evils of nicotinism.
+Both teacher and pupil have a right to the periodic physical
+examination of teachers that will give timely warning of attention
+needed. Until there is some system for giving this right to all
+teachers in private, parochial, charitable, and public schools, we
+shall produce many nervous, acrid, and physically threadbare teachers,
+where we should have only teachers who inspire their pupils with a
+passion for health by the example of a good complexion, sprightly step,
+bounding vitality, and forceful personality born of hygienic living.
+
+
+
+
+PART III. COÖPERATION IN MEETING HEALTH OBLIGATIONS
+
+
+
+
+CHAPTER XVI
+
+EUROPEAN REMEDIES: DOING THINGS AT SCHOOL
+
+
+Recently I traveled five hundred miles to address an audience on
+methods of fitting health remedies to local health needs. I told of
+certain dangers to be avoided, of results that had always followed
+certain remedies, of motives to be sought and used, of community ends
+to seek. Not knowing the local situation, I could not tell them exactly
+what to do next, or how or with whom to do it; not seeing the patient
+or his symptoms, I did not diagnose the disease or prescribe medicine.
+Several members of the audience who were particularly anxious to start
+a new organization on a metropolitan model were disappointed because
+they were told, not just how to organize, but rather how to find out
+what sort of organization their town needed. They were right in
+believing that it was easier to copy on paper a plan tried somewhere
+else, than to think out a plan for themselves. They had forgotten for
+the time being their many previous disappointments due to copying
+without question some plan of social work, just as they copy Paris or
+New York fashions. They had not expected to leave this meeting with the
+conviction that while the _ends_ of sanitary administration may be the
+same in ten communities, health _machinery_ should fit a particular
+community like a tailor-made suit.
+
+American-like, they had a mania for organization. I once heard an aged
+kindergartner--the savant of an isolated German village--describe my
+fellow-Americans as follows: "Every American belongs to some
+organization. The total abstainers are organized, the brewers are
+organized, the teachers are organized, the parents are organized, the
+young people and even the juniors are organized. Finally, those who
+belong to no organization go off by themselves and organize a society
+of the unorganized." Love of organization and love of copying have
+given us Americans a feverish desire for what we see or read about in
+Europe. When we talk about our European remedies we try to make
+ourselves believe that we are broad-minded and want to learn from
+others' experience. In a large number of cases our impatient demand for
+European remedies is similar to the schoolboy's desire to show off the
+manners, the slang, or the clothes picked up on his first visit away
+from home. With many travelers and readers European remedies or
+European ways are souvenirs of a pleasant visit, to be described like a
+collection of postal cards, a curious umbrella, a cane associated with
+Alpine climbing, or a stolen hymnal from an historic cathedral.
+
+Experience proves, however, that just as Roman walls and Norman castles
+look out of place in New York and Kansas, so European laws and European
+remedies are too frequently misfits when tried by American schools,
+hospitals, or city governments. Yesterday a Canadian clergyman, after
+preaching an eloquent sermon, met a professional beggar on the street
+in New York City and emptied his purse--of Canadian money! Quite like
+this is the enthusiastic demand of the tourist who has seen or read
+about "the way it's done in Germany." The trouble is that European
+remedies are valued like ruins, by their power to interest, by their
+antiquity or picturesqueness, or, like the beggar, by their power to
+stimulate temporary emotion. But we do not sleep in ruins, go to
+church regularly in thirteenth-century abbeys, or live under the
+remedies that fire our imagination. We do not therefore see their
+everyday, practical-result side.
+
+The souvenir value of European remedies is due to the assumption that
+no better way was open to the European, and that the remedy actually
+does what it is intended to do. Because free meals are given at school
+to cure and prevent undernourishment, it is taken for granted that
+undernourishment stops when free meals are introduced; therefore
+America must have free meals. Because it is made compulsory in a
+charming Italian village for every child to eat the free school meal,
+it is taken for granted that the children of that village have no
+physical defects; therefore let Kansas City, Seattle, and Boston
+introduce compulsory free meals. But when one goes to Europe to see
+exactly how those much-advertised, eulogized remedies operate from day
+to day, it is often necessary to write, as did a great American
+sanitarian recently, of health administration in foreign cities
+continually held up as models to American cities: "In spite of the
+rules and theories over here, the patient has better care in New York
+City."
+
+We have been asked of late to copy several very attractive European
+remedies for the physiological ills of school children, and for the
+physical deficiencies of the next generation of adults: breakfasts or
+lunches, or both, at school for all children, rich as well as poor,
+whether they want school nourishment or not; school meals for the poor
+only; school meals to be given the poor, but to be bought by those who
+can afford the small sum required; free eyeglasses for the poor, for
+poor and well-to-do, for those who wish them, for those who need them
+whether they want to wear eyeglasses or not; free dental care; free
+surgical treatment; free rides and outings during summer and winter;
+country children to visit the metropolis, city children to visit
+country and village; free treatment in the country of all children
+whose parents are consumptives; free rides on street cars to and from
+school; city-owned street railways that will prevent congestion by
+making the country accessible; city-built tenements to prevent
+overcrowding, dark rooms, insufficient air and light; free coal, free
+clothes, free rent for those whose parents are unable to protect them
+properly against hunger and cold. Every one of these remedies is
+attractive. Every one is being tried somewhere, and can be justified on
+emotional, economic, and educational grounds, if we think only of its
+purpose. Let us view them with the eyes of their advocates.
+
+Would it not be nice for country children to know that toward the end
+of the school year they would be given an excursion to the largest city
+of their state, to its slums, its factories, parks, and art galleries?
+They would grow up more intelligent about geography. They would read
+history, politics, sociology, and civil government with greater
+interest. They would have less contracted sympathies. They might even
+decide that they would rather live their life in the spacious country
+than in the crowded, rushing city.
+
+City children, on the other hand, would reap worlds of physical benefit
+and untold inspiration from periods of recreation and study in the
+country, with its quiet, its greens and bronzes and yellows, its birds
+and animals, its sky that sits like a dome on the earth, its
+hopefulness. Winter sleigh rides and coasting would give new vigor and
+ambition. Why spend so much on teaching physiology, geography, and
+nature study, if in the end we fail to send the child where alone
+nature and hygiene tell their story? Why tax ourselves to teach history
+and sociology and commercial geography out of books when excursions to
+the city and country will paint pictures on the mind that can never be
+erased? What more attractive or more reasonable than appetizing, warm
+meals, or cool salads and drinks for the boys and girls who carry
+their little dinner pails and baskets down the long road where
+everything runs together in summer and everything freezes in winter?
+One needs little imagination to see the "smile that won't come off,"
+health, punctuality, and school interest resulting from the school
+meal.
+
+Again, if children must have teeth filled and pulled, eyes tested and
+fitted for glasses, adenoids and enlarged tonsils removed, surely the
+school environment offers the least affrighting spot for the tragedy.
+Thence goblins long ago fled. There courage, real or feigned, is
+brought to the surface by the anxious, critical, competitive interest
+of one's peers.
+
+    [Illustration: A SOUTH IRELAND ARGUMENT FOR "DOING THINGS"]
+
+The economic defense of these remedies is many-sided. An English
+drummer once instructed me during a railroad journey from southern to
+northern Ireland. As we entered the fertile fields of Lord Dunraven's
+estate near Athlone, I expressed sympathy for other countries
+impoverished of soil, of wealth, and of thrift. My instructor replied:
+"It would pay the government to bring them all to this land free once a
+year, just to show them what they are missing." That his idea of an
+investment is sound has been proved by railroads and land companies and
+even by states, who give away excursions to entice settlers and buyers.
+Ambition at almost any cost is cheaper than indifference to
+opportunity. It would be cheaper for our American taxpayer to send
+school children to city and country than to pay the penalty for having
+a large number of citizens with narrow interests, unconscious of the
+struggles and joys of their co-citizens. Free meals, free books, free
+rides, free eyeglasses, are cheaper than free instruction for the
+second, third, and sixth terms in studies not passed because of
+physical defects,--infinitely cheaper than jails and almshouses, truant
+officers and courthouses.
+
+The demoralizing results of giving "something for nothing" did not
+follow free schooling or free text-books. Perhaps they would not follow
+the free remedies that we are asked to copy from Europe. In fact, the
+word "free" is the wrong word. These remedies rather require
+coöperation of parent with parent. It has demoralized nobody because
+the streets are cleaned by all of us, country roads made by the
+township, police paid for by taxes and not by volunteer subscription.
+
+The man whose children do not need glasses or nourishment or operation
+for adenoids would find it cheaper to pay for European remedies than
+for the useless schooling of boys unable to get along in school because
+of removable defects. An unruly, uninterested boy sitting beside your
+boy in public school, a pampered, overfed, undisciplined child sitting
+beside yours at private school, is taxing you without your consent and
+doing your child injury that may prove irreparable.
+
+It costs $2.50 to furnish a child with eyeglasses. It costs $25 to $50
+to give that child a year's schooling. If the child cannot see right
+and fails in his studies, we have lost a good investment and, after one
+year so lost, we are out $22.50. In two years we have lost $47.50. But,
+what is more serious, we have discouraged that boy. Used to failure in
+school, his mind turns to other things. He is made to think that it is
+useless for him to try for first place. Perhaps he can play ball, and
+excels. He chooses a career of ball playing. Valuable years are lost.
+
+Initiative and competition are not interrupted any more by free
+eyeglasses and free operation for adenoids than by free schooling.
+There is only one place in the world where there is less competition or
+less struggle than among the ignorant, and that is among the ignorant
+and unwell. The boy who can't see the blackboard, who can't learn to
+spell, who can't breathe through his nose, and can't be interested,
+doesn't compete at all with the bright, healthy boy. Remove the
+adenoids, give glasses, make interest possible, and fitness to survive
+takes a higher level because larger numbers become fit to survive.
+
+Professor Patten says that it is easier to support in the almshouse
+than in competitive industry a man who cannot earn more than $1.50 a
+day. The question, therefore, regarding European remedies is not, To
+what general theory do they belong? but, What will they accomplish? How
+do they compare with other remedies of which we know?
+
+
+
+
+CHAPTER XVII
+
+AMERICAN REMEDIES: GETTING THINGS DONE
+
+
+In New York City there is a committee called the Committee on the
+Physical Welfare of School Children. The word "welfare" was used rather
+than "condition" because the committee proposed to use whatever facts
+it could gather for the improvement of home and school conditions
+prejudicial to child welfare. The following programme was adopted:
+
+ 1. _Study of the physical welfare of school children._
+
+    a. Examination of board of health records of children needing
+       medical, dental, or ocular care, and better nourishment.
+
+    b. Home visitation of such children, in order to ascertain
+       whether their need arises from deficient income or from other
+       causes.
+
+    c. Effort to secure proper treatment, either from parents or
+       from free clinics or other established agencies.
+
+    d. Effort to secure proper physical surroundings of children
+       while at school--playgrounds, baths, etc.
+
+
+ 2. _Effort to secure establishment of such a system of school
+    records and reports_ as will disclose automatically significant
+    school facts,--e.g. regarding backward pupils, truancy,
+    regularity of attendance, registered children not attending,
+    sickness, physical defects, etc.
+
+ 3. _Effort to utilize available information regarding school needs_
+    so as to stimulate public interest and thus aid in securing
+    adequate appropriations to meet school needs.
+
+The committee grew out of the discussion, in the year 1905, of the
+following proposition: _To insure a race physically able to receive our
+vaunted free education, we must provide at school free meals, free
+eyeglasses, free medical and dental care._ Thanks to the
+superintendent of schools of New York City, to Robert Hunter's
+_Poverty_, to John Spargo's _Bitter Cry of the Children_, hundreds of
+thousands of American citizens were made to realize for the first time
+that a large proportion of our school children are in serious need of
+medical, dental, or ocular attention, or of better nourishment.
+
+Because physicians, dentists, oculists, hospitals, dispensaries, relief
+agencies, had seemingly been unconscious of this serious state of
+affairs, they had no definite, constructive remedy to propose. Their
+unpreparedness served to strengthen the arguments for the European
+method of _doing things_. France, Germany, Italy, England, had found it
+necessary to do things at school. Arguing from their experience, it was
+only a matter of time when American cities must follow their example.
+Why not, therefore, begin at once to deal radically with the situation
+and give school meals, school eyeglasses, etc.? Those who organized the
+Committee on the Physical Welfare of School Children realized the
+danger of trying to settle so great a question with the little definite
+information then available. If _doing things at school_ were to be
+adopted as a principle and logically carried out, vast sums must be
+added to the present cost of the public school system. Complications
+would arise with private and parochial schools, whose children might
+have quite as serious physical defects, even though not educated by
+public funds. It would be difficult to obtain proper rooms for medical
+and dental treatment and meals, and perhaps still more difficult to
+insure proper food, skilled oculists, dentists, surgeons, and
+physicians. No one was clear as to how the problem was to be solved by
+small cities and rural districts, whose needy children are no less
+entitled to public aid simply because their numbers are smaller. Great
+as were the difficulties, however, the committee saw that difficulties
+are in themselves no reason for not doing the right thing. On the
+other hand, if doing things at school is wrong, if school meals fail to
+correct and remove physical defects, great social and educational wrong
+would result from New York's setting an example that would not only
+misdirect funds and attention in that city, but would undoubtedly lead
+other cities to move in the wrong direction. Right could be hastened,
+wrong could be prevented more effectually by facts than by any amount
+of theory. School meals had been made a political issue in England. The
+arguments supporting them were stronger than any possible arguments
+against them, except proof that they would be less effective in helping
+children than other means that might be proposed. If the American
+people must choose between sickly, unteachable, dull children without
+school meals, on the one hand, and bright, teachable, healthy children
+plus school meals, on the other hand, they will not hesitate because of
+expense or eighteenth-century objections to "socialism."
+
+During one year of investigation and of _getting things done_ the
+committee has prepared three studies for publication: (1) a report on
+the home conditions of fourteen hundred school children of different
+nationalities, found by school physicians to have defects of vision,
+breathing, hearing, teeth, and nourishment; (2) an examination of fifty
+schools--curriculum, buildings, home-study requirements, play space and
+playtime, physical culture--in an attempt to answer the question, How
+far does school environment directly cause or aggravate physical
+defects of school children; (3) a comparative study of methods now
+employed in a hundred cities to record, classify, and make public
+significant school facts.
+
+The results of the first year's work prove conclusively that physical
+defects are not caused solely by the inability of parents to pay for
+proper food. Among the twenty significant facts reported by the
+committee are the following:
+
+  1. Physical defects found in public schools are, for the most
+  part, such as frequently occur in wealthy families and do not of
+  themselves presume as the cause insufficient income. Of 145
+  reported for malnutrition, 44 were from families having over $20
+  weekly.
+
+  2. Few of the defects can be corrected by nourishment alone;
+  plenty of fresh air, outside nourishment at school, or extra
+  nourishment at home will not entirely counteract the influences of
+  bad ventilation and bad light in school buildings. Country
+  children have adenoids, bad teeth, and malnutrition. Plenty of
+  food will not prevent bad teeth and bad ventilation from causing
+  adenoids, enlarged tonsils, and malnutrition.
+
+  3. Children whose parents have long lived in the United States
+  need attention quite as much as the recent immigrant.
+
+  4. A large part of the defects reported could be produced by
+  conditions due directly to neglect of teeth.
+
+From twenty such statements of fact and from its experience in _getting
+things done_ for one year, the committee drew fifteen practical
+conclusions, among which the following deserve emphasis here:
+
+  1. The only new thing about the physical defects of school
+  children is not their existence, but our recent awakening to their
+  existence, their prevalence, their seriousness if neglected, and
+  their cost to individual children, to school progress, to
+  industry, and to social welfare.
+
+  2. _Physical deterioration_, applied to America's school children,
+  is a misnomer. No evidence whatever has been given that the
+  percentage of children suffering from physical defects in 1907 is
+  greater than the percentage of children suffering from such
+  defects in 1857. On the contrary, the small proportion of defects
+  that are not easily removable, as well as a vast amount of
+  evidence from medical experience and vital statistics, indicates
+  that, if a comparison were possible, the children of 1907 would be
+  found to have sounder bodies and fewer defects than their
+  predecessors of fifty years ago. If there is an exception to this
+  statement, it is probably defects of vision, with regard to which
+  school authorities and oculists seem to agree that confinement in
+  school for longer hours and more constant application under
+  unfavorable lighting conditions have caused a marked increase.
+  Positive evidence as to tendencies will be easily obtained after
+  thorough physical examination has been carried on for a
+  generation.
+
+  3. The effect of massing facts as to physical defects of school
+  children should not be to cause alarm, but to stimulate remedial
+  and preventive measures, to invoke congratulations and aggressive
+  optimism, not doleful pessimism and palliative measures born of
+  despair.
+
+  4. The causes of physical defects are not confined to "marginal"
+  incomes, but, while more apt to be present in families having
+  small incomes, are found among all incomes wherever there exist
+  bad ventilation, insufficient outdoor exercise, improper light,
+  irregular eating, overeating, improper as well as insufficient
+  food, lack of medical, dental, and ocular attention.
+
+  5. Whatever may be said of free meals at school as a means of
+  insuring punctual attendance or better attention, they are
+  inadequate to correct physical conditions that home and street
+  environment produce.
+
+  6. _To remove physical defects, causal conditions among all income
+  classes should be treated, and not merely symptoms revealed at
+  school by children of the so-called poor._
+
+  7. Parents can and will correct the greater part of the defects
+  discovered by the physical examination of school children, if
+  shown what steps to take. Where parents refuse to do what can be
+  proved to be within their power, and where existing laws are
+  nonenforced or inadequate, the segregation of children having
+  physical defects in special classes might prove an effective
+  stimulus to obstinate parents.
+
+  8. Where parents are unable to pay for medical, dental, and ocular
+  care and proper nourishment, private philanthropy must either
+  provide adequately or expect the state to step in and assume the
+  duty.
+
+  9. Private dispensaries and hospitals must either arrange
+  themselves to treat cases and to educate communities as to the
+  importance of detecting and correcting physical defects, or must
+  expect the state to provide hospital and dispensary care. Until
+  private hospitals and dispensaries take steps to prevent people
+  with adequate incomes from imposing upon them for free treatment,
+  it is difficult to make out a case against free eyeglasses and
+  free meals for school children.
+
+  10. Either private philanthropy or the state must take steps to
+  procure more dental clinics and an educational policy on the part
+  of the dental profession that will prevent the exploitation of the
+  poor when dental care is needed.
+
+  11. The United States Bureau of Education is the only agency with
+  authority and equipment adequate to secure from all sections of
+  the country proper attention to the subject. Nothing in the world
+  can prevent free meals, free eyeglasses, free medical care, free
+  material relief at school, unless educational use is made by each
+  community of the facts learned through physical examination to
+  correct home, school, and street conditions that produce and
+  aggravate physical defects. The national bureau can mass
+  information in such a way as to convince budget makers in city,
+  county, and state to vote gladly the funds necessary to promote
+  the physical welfare of school children.
+
+    [Illustration: THE DARK-HALL EVIL IS HERE INDEXED BY ADENOIDS.]
+
+How the committee got things done is often referred to. There is
+something about a request for coöperation, whether by schools or by any
+other agency, that enlists the interest of those whose help is asked.
+The reason is not that people are flattered by requests to serve on
+committees, or that human nature finds it difficult to be unfriendly or
+unkind. On the contrary, men and women are by nature social; there is
+more joy in giving than in withholding, in working with others than in
+working alone. Men and women, official and volunteer agencies, will
+coöperate with school-teachers when invited, for the same reason and
+with the same readiness that ninety-nine farmers out of a hundred, on
+the prairie or in the mountain, will welcome a request for food and
+lodging.
+
+    [Illustration: WHERE "GETTING THINGS DONE" IS POSSIBLE BUT
+    "DOING THINGS" INEFFECTIVE]
+
+Mothers will naturally take a greater interest in the welfare of their
+children if held responsible for proper food and proper home
+surroundings than if not reminded of their responsibility. In New York
+City a woman district superintendent of schools, Miss Julia Richman,
+has organized a unique "social settlement." She and several
+school-teachers occupy a house, known as "The Teachers' House." This is
+their residence. Here they are subject to neither intrusion nor
+importunity; no clubs or classes are held here; visitors are treated as
+guests, not as beneficiaries. The purpose these teachers have in living
+together is to work out the methods of interesting private and official
+leaders in community needs disclosed at school.
+
+Where clubs and social gatherings are held in school buildings, it is
+not unusual for a thousand mothers, recent immigrants, to meet together
+in one hall to hear talks on the care of children. Thus, instead of
+principals, teachers, and physicians taking the place of mothers (which
+they nowhere have succeeded in doing), they do succeed in harnessing
+mothers to the school programme. It may take two, three, or ten visits
+to get a particular mother to do the necessary thing for her child, but
+when once convinced and once inspired to do that thing, she will go on
+day in and day out doing the right thing for that child and for all
+others in her home. It may take a year to convert a police magistrate
+whose sympathy for delinquent parents and truant children is an active
+promoter of disorder; but a magistrate convinced, efficient, and
+interested is worth a hundred volunteer visitors. To get things done in
+this way for a hundred thousand children costs less in time and money
+than to do the necessary things for one thousand children.
+
+
+
+
+CHAPTER XVIII
+
+COÖPERATION WITH DISPENSARIES AND CHILD-SAVING AGENCIES
+
+
+Scientists agree that the human brain is superior to the animal brain,
+not because it is heavier, but because it is finer and better supplied
+with nerves. As one writer has said, the human brain is better "wired,"
+has better organized "centrals." A poor system of centrals will spoil a
+telephone service, no matter how many wires it provides. An independent
+wire is of little use, because it will not reach the person desired at
+the other end. The ideal system is that which almost instantly connects
+two persons, no matter how far away or how many other people are
+talking at the same time on other wires.
+
+The school that tries to do everything for its pupils without using
+other existing agencies for helping children[10] will be like the man
+who refuses to connect his telephone with a central switch board, or
+like a bank that will not use the central clearing house. As one
+telephone center can enable scores of people to talk at once, and as
+one clearing house can make one check pay fifty debts, so hospital and
+relief agencies enable a teacher who employs "central" to help several
+times as many children as she alone can help.
+
+    [Illustration: ADEQUATE RELIEF RECOGNIZES THE FAMILY AS THE
+    UNIT]
+
+It seems easier for a teacher to give twenty-five cents to a child in
+distress than to see that the cause of the misery is removed. In New
+York City there are over five hundred school principals, under them are
+over fifteen thousand teachers, and the average attendance of children
+is about six hundred thousand, representing one hundred and fifty
+thousand homes. If teachers give only to those children who ask for
+help, many will be neglected. In certain sections of the city
+principals have combined to establish a relief fund to be given out to
+children who need food, clothes, shoes, etc. One principal had to stop
+replacing stolen overcoats because, when it was known that he had a
+fund, an astonishingly large number of overcoats disappeared. At
+Poughkeepsie school children get up parties, amateur vaudeville,
+minstrel shows, basket picnics, to obtain food and clothing for
+children in distress. They are, of course, unable to help parents or
+children not in school. Of this method a district superintendent in New
+York said to his teachers and principals: "For thirty-two years I have
+been working in the schools of this district. I have given food and
+shoes to thousands of children. I know that however great our interest
+in a particular child when it comes to us with trouble at home, our
+duty as teachers prevents us from following our gift into the home and
+learning the cause of the child's trouble. This last winter we have
+made an experiment in using a central society, which makes it a
+business to find out what the family needs, to supply necessaries,
+country board, medicine, etc. We now know that we can put a slip of
+paper with the name and address of the child into a general hopper and
+it will come out eyeglasses, food, rent, vacation parties, as the need
+may be."
+
+Relief at home through existing agencies was brought about by the
+distribution of cards like those on opposite page, which offer winter
+and summer coöperation.
+
+    [Illustration: FRESH-AIR AGENCIES LIKE SEA BREEZE PREFER TO AID
+    CHILDREN IN ORDER OF NEED]
+
+    [Illustration: (Facsimile of flyer for the New York Association
+    for Improving the Condition of the Poor.)]
+
+ +--------------------------------------------------------------------+
+ | =For School Children=                                              |
+ |                                                                    |
+ | Compulsory education implies the ability of all families, even the |
+ | poorest, to take advantage of school benefits. This means that     |
+ | children should be fed properly, clad comfortably, and healthfully |
+ | housed.                                                            |
+ |                                                                    |
+ | The New York Association for Improving the Condition of the Poor   |
+ | aims to coöperate with school-teachers in every part of Manhattan  |
+ | and The Bronx to insure comfort and prevent suffering among school |
+ | children, their parents, and younger brothers and sisters. On one  |
+ | day last winter we received appeals from school principals and     |
+ | teachers in behalf of twenty-nine families. Within six hours every |
+ | family was visited, emergent aid in food and coal provided for     |
+ | many, and orders given for shoes and dresses and coats required by |
+ | the children of school age. During the winter we gave not only     |
+ | clothing, groceries, food, and rent, but found work for older boys |
+ | and parents, taught mothers to prepare food properly, and sent a   |
+ | visiting cleaner to make sick mothers comfortable and to get the   |
+ | children ready for school.                                         |
+ |                                                                    |
+ | In a word, we followed that need, the surface evidence of which    |
+ | comes to the attention of the teacher, back into the home and its  |
+ | conditions, aiding throughout the period when the family was       |
+ | unable to do justice by the school child.                          |
+ |                                                                    |
+ | In many instances the home income was sufficient, but the home     |
+ | management inefficient. Probably such homes could be more          |
+ | effectively benefited through educational work emanating directly  |
+ | from the school.                                                   |
+ |                                                                    |
+ | We can be reached by telephone (348, 349, and 1873 Gramercy) from  |
+ | 9 A.M. to 12 M. Letters or postal cards should be addressed to     |
+ | Mrs. H. Ingram, Superintendent, 105 East 22d Street. Reference     |
+ | slips will be gladly furnished upon application.                   |
+ |                                                                    |
+ |           The New York Association for Improving                   |
+ |           1843  *  the Condition of the Poor  *  1905              |
+ |                                                                    |
+ |     =Teachers of Manhattan and The Bronx=                          |
+ |                                                                    |
+ |     _Do you know of such children as these:_                       |
+ |                                                                    |
+ |     1. Convalescent children now out of school, who would be       |
+ |     benefited by a stay at the seashore in May or June?            |
+ |                                                                    |
+ |     2. Children in school whose anæmic condition would be          |
+ |     greatly improved by a week at Sea Breeze during July or        |
+ |     August?                                                        |
+ |                                                                    |
+ |     3. Small brothers and sisters (and tired mothers) who may      |
+ |     need outings or special help?                                  |
+ |                                                                    |
+ |     The New York Association for Improving the Condition of the    |
+ |     Poor will act promptly. Write or telephone (348 Gramercy).     |
+ +--------------------------------------------------------------------+
+
+When these cards were first distributed several teachers went from room
+to room, asking children who needed help to raise the hand. In many
+cases parents were very angry that their children should have asked for
+help. But help given in instances like the following soon proved to
+teachers that they could afford the time necessary to notice children
+who appeared neglected, when so much good would ensue:
+
+  The father is sick and unable to work. They cannot get clothes for
+  the children, who are not attending school on that account.
+  Children were provided with shoes and clothes.
+
+  November 30, 1907, a school principal reported that six children
+  in one family needed underwear. A visitor discovered that one of
+  the boys who had the reputation of being unruly and light-fingered
+  also had adenoids. He was taken to a hospital for operation, and
+  was later interested in his school work.
+
+  A little girl was unruly and truant. No attempt was made to keep
+  her at school, but she was reported to the Committee on the
+  Physical Welfare of School Children. The parents could not control
+  her. The girl was taken for examination by a specialist and found
+  to be feeble-minded. Later she was sent to a custodial institute.
+
+  Another little girl was nine years old, but could not talk. A
+  University Extension Society worker found that she was not kept at
+  school because it was too much trouble. The child was taken to a
+  physician who operated and corrected the tongue-tie.
+
+  A girl of twelve said she must stay home to "help mother." The
+  mother was found to be a janitress, temporarily incapacitated by
+  rheumatism. A substitute was provided until the mother was well,
+  and all the children were properly clad for school.
+
+  After the adenoid operations in a New York school that occasioned
+  the East Side riots of 1906, the physicians and principals who had
+  persuaded parents to permit the operations were fearful lest the
+  summer in unsanitary surroundings might make the demonstration
+  less complete. Over forty children in three parties were sent away
+  for the summer, where they had wholesome food and all the milk
+  they could drink and fresh air day and night. When they returned
+  in the fall the principal wrote: "The improvement in each
+  individual is simply marvelous. We shall try to continue this
+  condition and shall constantly urge the parents to keep up the
+  good work by means of proper food and fresh air."
+
+In none of these instances could the teachers have accomplished equal
+results for the individual children or for the families without
+neglecting school duties. By informing other agencies as to children's
+needs, teachers started movements that have since helped practically
+every school child in New York City. Dispensaries are setting aside
+separate hours for school children; fresh-air agencies are giving
+preference to children found by teachers or school physicians to be in
+physical need; relief agencies are making "rush orders" of every note
+from teachers; the health board is more active because volunteer
+agencies have added their voice to that of teacher and health officer
+in demanding adequate funds for physical examination of school
+children.
+
+    [Illustration: "CENTRAL" FOUND THE MOTHER SICK IN A HOSPITAL,
+    THE FATHER KILLED--THE CHILDREN WERE BOARDED IN THE COUNTRY
+    UNTIL THE MOTHER RECOVERED]
+
+Coöperation is at present easier in New York than in any other city.
+Charitable societies, hospitals, dispensaries, are probably more keenly
+alive to their responsibilities and are at least more apt to have
+acquired the habit of coöperation when asked. Yet even here I have been
+told repeatedly by teachers: "If we have to wait for that hospital or
+that charitable society, our children will go barefoot." In small
+communities where hospital and relief agencies are for emergencies only
+and generally inactive, it seems that the first thing to do is to ask
+some friends to establish a small relief fund, just as it is easier to
+give a child a five-cent meal than to teach its mother how to prepare
+its food. But the school-teacher will find that it takes very much less
+energy to arouse the relief society than to maintain her own relief
+work. In fact, in many cities nothing could do more to strengthen
+hospitals and charitable societies than to put them in touch with the
+needs of school children. For a principal to make known the fact that
+school children are neglected will help the charitable society and
+hospital to get the funds necessary to do their part better than they
+are now doing it and better than the school could ever do it. Finally,
+one reason for a breakdown of charitable societies is not their own
+inadequacy, but rather the failure of the school and church to make
+use of an agency better equipped than themselves to give material
+relief. The teacher sees the child every day, while the relief society
+will never see it and has no reason to see it until some one calls
+attention to it. The very first step, and an indispensable one in
+relief policy, is for teachers to be on the lookout for children not
+adequately provided for, and then have the physical evidence discovered
+at school followed to the home for the cause of the child's distress.
+
+    [Illustration: HOME-TO-HOME INSTRUCTION IN COOKING
+    Anæmic condition of child due to bad cooking, not to lack of
+    income]
+
+_Coöperation_ removes the cause of distress; _doing_ may aggravate it.
+Teachers would do well to draw up for themselves a chart which will
+show exactly what part of the community's work can be best done by
+their school. On the following page is charted the social work now
+being conducted at the Massachusetts General Hospital, Boston. So far
+as agencies exist to deal with any individual or family problem coming
+into the social-work square, the hospital aims to utilize that agency.
+Its own direct dealing with neurasthenics, with hygiene education, with
+sexual deviates, is primarily for the purpose of giving adequate
+treatment to the needy, and secondarily to demonstrate how adequate
+treatment should be organized for the community. Please to note that
+governmental agencies are not mentioned in Dr. Cabot's chart. This does
+not mean that he would not emphasize the importance of those agencies,
+but that up to the present time, for the particular cases dealt with in
+his clinics, governmental agencies can be reached most effectively
+through the private charitable agencies in the reference square. So the
+teacher will frequently find that the relief bureau, children's
+society, public education association, or church can get better results
+for her pupils from public health and correctional agencies than can
+she by writing directly.
+
+  [Illustration: CHART OF SOCIAL WORK, MASSACHUSETTS GENERAL HOSPITAL]
+
+                   +-----------------------------------+
+                   | _Work for the Tuberculous_        |
+                   |                                   |
+                   | 1. Tuberculosis classes           |
+                   | 2. Reference to other agencies    |
+                   | 3. Examination of children        |
+                   | 4. Stimulation of suburbs         |
+                   +-----------------------------------+
+                                     |
+                                     |
+                                     |
++--------------------------------+   |   +--------------------------------+
+| _Psychiatric Work_             |   |   | _Work for Hygienic Conditions_ |
+|                                |   |   |                                |
+| 1. For neurasthenics and       |   |   | 1. Individual instruction      |
+|    hysterics                   |   |   | 2. Convalescent homes          |
+| 2. For defectives              |   |   | 3. Industrial hygiene          |
+| 3. For stammerers              |   |   | 4. Home hygiene                |
+| 4. For epileptics              |   |   |                                |
++--------------------------------+   |   +--------------------------------+
+                        \            |            /
+                         \           |           /
+                          \          |          /
+                           \         |         /
+                            \        |        /
+                             \       |       /
+                              \      |      /
+                               +-----|-----+
+                               |           |
+                               /SOCIAL WORK\
+                              /|   M.G.H.  |\
+                             / +---/|\-----+ \
+                            /     / | \       \
+                           /     /  |  \       \
+                          /     /   |   \       \
+                         /     /    |    \       \
+                      +-------/-----|-----\-------\---+
+                      | _References to Other Agencies_|
+                      |                               |
+                     /|1. Hospitals and sanatoriums   |
+                    / |2. Associated charities        |\
+                   /  |3. Societies for children      | \
+                  /   |4. District and visiting nurses|  \
+                 /    |5. Settlements                 |   \
+                /     |6. Homes--temporary or not     |    \
+               /     /|7. Employment agencies         |     \
+              /     / +-------------|-----------------+      \
++------------/-----/----+           |              +--\-------\----------+
+| _Ward Work_           |           |              |                     |
+|                       |           |              | _Work for           |
+| 1. With cases soon to |           |              |  Cases of           |
+|    be discharged      |           |              |  Varicose Ulcer_    |
+| 2. Cases needing      |           |              |                     |
+|    friendly offices   |           |              |                     |
++-------------/---------+           |              +---------\-----------+
+             /                      |                         \
++-----------/-----------+           |           +--------------\----------+
+| _Work for             |           |           | _Assistance to M.G.H._  |
+|  Sexual Deviates_     | +---------|---------+ | Financial investigation |
+|                       | |  _Assistance to   | |                         |
+| 1. Unmarried but      | |   Other Agencies_ | |(a) of Cases asking free |
+|    pregnant           | |                   | | treatment               |
+| 2. Diseased           | | 1. Steering cases | |(b) of Cases presumably  |
+| 3. Exposed            | | 2. Coöperation    | | able to pay a physician |
++-----------------------+ +-------------------+ +-------------------------+
+
+In country districts no plan has yet been worked out for adequate
+relief. Fortunately, however, the distress is generally of such a kind,
+and the teacher so well acquainted with all the parents of her
+district, that it will not be difficult to procure such attention as is
+necessary. Country schools should be furnished by county and state
+superintendents with clear directions for getting the treatment
+afforded in the immediate vicinity. Where teachers are alone in seeing
+the need for coöperation they can quickly interest young and old,
+physicians, dentists, pastors, health officers, in home visiting,
+street cleaning, nursing, helping truants, needed changes of
+curriculum, etc. _Getting things done_ is easy because it is human to
+love the _doing_; getting things done is _doing_ of the highest order.
+
+FOOTNOTES:
+
+[10] The importance of recognizing the family as the unit of social
+treatment is presented in Edward T. Devine's _Principles of Relief_, and
+in Homer Folks's _Care of Dependent, Defective, and Delinquent
+Children_.
+
+
+
+
+CHAPTER XIX
+
+SCHOOL SURGERY AND RELIEF OBJECTIONABLE, IF AVOIDABLE
+
+
+The popular arguments for free meals, free relief, free medical
+treatment at school, are based upon the assumption that there are but
+two ways to travel, one leading to a physically sound, moral, teachable
+child, the other to an undernourished, subnormal, backward child. They
+tell us we must choose either school meals or malnutrition, school
+eyeglasses or defective vision, free coal or freezing poor, free rent
+or people sleeping on the streets, free dental clinics at school or
+indigestion and undernourishment, free operation at school for adenoids
+or backward, discouraged pupils. If there is no other alternative than
+neglect of the child, if we must either waste fifty dollars in giving a
+child education that he is physically unable to take, or pay two,
+three, four, or even fifty dollars to fit him for that education, the
+American people will not hesitate. Whether there are other roads to
+healthy children, whether it is cheaper and better for the school to
+see that outside agencies prepare the child for education rather than
+itself to take the place of those outside agencies, is a question of
+fact, not of theory.
+
+Facts prove, as we have seen, that there is more than one way to
+prevent malnutrition. Parents can be taught to attend to their
+children; hospitals and dispensaries will furnish eyeglasses where
+parents are unable to pay for them; charitable societies will go back
+of the need for eyeglasses to the conditions that produce that need and
+will do vastly more for the child than can eyeglasses alone. If
+parents, hospitals, dispensaries, and charitable societies will attend
+to children's needs, then relief at school is unnecessary, even though
+it may seem desirable.
+
+The objection to school surgery should be clearly before us, so that we
+can judge of the two methods that are open to us,--_treatment at
+school_ vs. _treatment away from school_.
+
+Society is so organized that the treatment of serious physical defects
+and social needs at school would upset the machinery a very great deal.
+For the school to do for its children whatever they may need during
+their school years will require the setting up of a miniature society
+in every school building or under every school board. Unless schools
+are to equip themselves to take the place of all existing facilities
+for relief and surgery, children would not be so well taken care of as
+at present. It should not be forgotten that the physical welfare of the
+school child is the most accurate index to the physical needs of the
+community. After all, the child lives for six important years before
+coming to the school and leaves at the early age of fourteen or
+fifteen; even while attending school it sleeps at home and is
+influenced more by home and street standards of ventilation,
+cleanliness, and morality than by conditions at school. It would seem,
+therefore, the wider use of the school's influence to use the child's
+appeal to strengthen every agency having to do with community health,
+rather than to concentrate upon the child himself. If babies were
+properly cared for up to the sixth year, the protection of the school
+child's health would be infinitely easier. To take our eyes from the
+child not yet in school and from the child just out of school is to
+make the mistake that so many advocates of the child labor movement
+have made of going whither and only so far as our interest leads us and
+of not continuing until our work is accomplished.
+
+    [Illustration: "DOING THINGS" THROUGH MODEL TENEMENTS]
+
+Do we want to make of our schools miniature hospitals, dispensaries,
+relief bureaus, parks? Or shall we use the momentum of society's
+interest in the school child to put within the reach of every school
+building adequate hospitals, dispensaries, relief centers, and parks
+for school child and adult? Shall every little school have its library,
+or shall the child be taught at school how to use the same library
+that is available to his parents and older brothers and sisters? If
+the library is to be under the school roof, if dispensary and relief
+hospital are to be conducted on the same site as the school, shall they
+be known as dispensary, library, relief bureau, each under separate
+management, or shall they be known as school under the management of
+school principal and superintendent? So complicated and many-sided is
+the problem of working together with one's neighbor for mutual benefit
+that it is a safe rule for the schools to adopt: _We shall do nothing
+that is unnecessary or extravagant. We shall have done our part if we
+do well what no one else can do. Whatever any agency can do better than
+we, we shall leave to that agency. Work that another agency ought to
+have done and has left undone, we shall try to have done by that
+agency._
+
+    [Illustration: IMMEDIATELY OPPOSITE THE MODEL TENEMENTS, BUT
+    UNINFLUENCED
+    "Getting things done" by the Tenement House Department their
+    special need]
+
+I know a hospital where a welfare nurse was recently employed. Within a
+few blocks were three different relief agencies and two
+visiting-nurse's associations, having among them over one hundred
+visitors and nurses going to all sections of Manhattan. This nurse had
+the choice of telephoning to one of these agencies and asking it to
+call at the needy home of one of her hospital patients, or of going to
+the home herself. Had she chosen to use another agency, she could have
+been the means of furnishing the kind of help needed in every needy
+home discovered in her hospital rounds, but she chose to do the running
+about herself and thus of helping ten families where she ought to have
+helped five hundred. Much the same condition confronts the school that
+tries to do all extra work for its child instead of seeing that the
+work is done. Illustration is afforded by the New York tenement
+department. Whereas European cities have built a few model tenements,
+New York City secured a law declaring that everybody who built a
+tenement and everybody who owned a tenement should provide sanitary
+surroundings. At the present time a philanthropist, by spending two
+million dollars, could give sanitary surroundings to thirty-five
+families; by spending each year the interest on one tenth that sum he
+could insure the enforcement of the tenement laws affecting every
+tenement resident in New York City.
+
+If schools are to perform surgical operations, they are in danger of
+being sued for malpractice; discipline will be interfered with.
+Finally, let us not forget that we are dealing with buildings,
+teachers, and school institutions as they exist. Where education is
+made compulsory, the unpleasant and the controversial should be kept
+out of school. Because a democratic institution, the American school
+should represent at all times a maximum of general agreement.
+
+To take _palliative measures to public schools_ not only _leaves undone
+remedial_ work necessary for the health of public school children but
+_neglects entirely the still large numbers who go to parochial, private
+pay, and private free schools_; no one has had the temerity to suggest
+that the public shall force upon nonpublic schools a system of free
+operations, free eyeglasses, free meals.
+
+Civilization has painstakingly developed a large number of agencies for
+the education and protection of mankind. Of these agencies the school
+is but one. Its first and peculiar function is _to teach and to train_.
+This it can do better than any other agency or combination of agencies.
+In attempting to "bring all life under the school roof," we use but a
+small part of our resources. Instead of persuading each of the agencies
+for the promotion of health to do its part for school children, we set
+up the school in competition with them. Thus in trying to _do things_
+for school children we are in danger of crippling agencies equipped to
+do things for both school children and their parents, for babies before
+they come to school, and for wage earners after they leave school.
+
+_Getting things done_ will lead schools to study underlying causes;
+_doing things_ has heretofore caused schools to confine themselves to
+symptoms. _Getting things done_ will leave the school free to
+concentrate its attention upon school problems; _doing things_ will
+lead it afield into the problem of medicine, surgery, restaurant
+keeping, and practical charity.
+
+
+
+
+CHAPTER XX
+
+PHYSICAL EXAMINATION FOR WORKING PAPERS
+
+
+There is no sacred right to work when our work involves injury to
+ourselves and to our neighbor. Work at the expense of health is an
+unjustifiable tax upon the state. It is the duty of society to protect
+itself against such depletion of national efficiency.
+
+Three classes of workmen need special attention: (1) those who are
+physically unfit to work; (2) those who are physically unfitted for the
+work they are doing; (3) those who are subjected to unhealthful
+surroundings while at work. Viewing these three classes from the
+standpoint of their neighbors, we have three social rights that should
+be enforced by law: (1) the right to freedom from unhealthy work; (2)
+the right to work fitted to the body; (3) the right to healthy
+surroundings at work.
+
+It is undoubtedly true that just as the sick child may be found at the
+head of his class, so unhealthy men and women are often good business
+managers, good salesmen, good typewriters, successful capitalists. They
+excel, however, not because of their ill health, but in spite of it,
+excepting of course those instances where men and women, because of ill
+health, have devoted to business an attention that would have been
+given to recreation if bad health had not deprived recreation of its
+pleasure. As statistics in school have proved that the majority of
+mentally superior children are also physically superior, so statistics
+will probably prove that the number of the "sick superior" among the
+working classes is very small, while the danger of inefficiency that
+comes from physical defect is very great.
+
+There is one time in the individual's working life when the state may
+properly step in and demand an inventory of physical resources, and
+that is when the child asks the state for permission to go to work.
+Strategically, this is probably the most important of all contact as
+yet provided between society and the future wage earner. Here at the
+threshold of his industrial career the boy may be told for what work he
+is physically fitted, what physical defects need to be remedied, what
+physical precautions he needs to take, in order to do justice to
+himself and his opportunity.
+
+Every year from two to three million children leave the public schools
+of this country to join the army of workers. The percentage of those
+recruits who have physical defects needing attention is undoubtedly
+great; how great we shall never know until the benefits of physical
+examination are given to all of them. What steps is your state taking
+to ascertain the physical fitness of the children who present
+themselves each year for working papers? How does it insure itself
+against the risk of their defective eyesight, chorea, deafness, or
+general debility? Does it inform children of their defects, or tell
+them how they may increase their earning power by correcting these
+defects? What effort does it make to induce children to avoid dangerous
+trades, or trades that are particularly dangerous for their physiques?
+
+At the close of school last spring I had my secretary look in upon the
+New York board of health and see what demands that city makes upon its
+boys and girls before allowing them to drive its machinery, to run its
+elevators, to match its colors, to sew on its buttons, to set its type,
+to carry its checks to the bank. The officer at the door of the room
+where the children were being examined, greeted her as follows: "You
+must bring your child with you; bring his birth certificate or swear
+that he is fourteen years old, and bring a signed statement from his
+teacher that he has been in school for one hundred and thirty
+consecutive days within twelve months." "Is there no physical
+examination or test?" she asked. "No, no," he answered impatiently. Yet
+the board of health certifies that "said child has in our opinion
+reached the normal development of a child of its age, and is in sound
+health and is physically able to perform the work which it intends to
+do." In addition the blank calls for place and date of birth, color of
+hair and of eyes, height, weight, and facial marks. Volunteer societies
+in practically every state in the Union have been working for years to
+have it made a criminal offense to employ a child who has not been in
+school a minimum of days after a stated age (12, 13, 14, 15). Even in
+New York, however, the center of this agitation, no strong demand was
+made upon the board of health to apply a physical-fitness test as well
+as an age test until 1908 when examination for working papers was added
+to the programme for child hygiene. Yet who does not know girls and
+boys of sixteen less fit for factory or shop work than other boys and
+girls of twelve? It is the fetich of age which has made possible the
+"democracy" that permits a child of fourteen to work all day on
+condition that he go to school at night!
+
+    [Illustration: CHILDREN ENLISTING IN THE INDUSTRIAL ARMY]
+
+    [Illustration: WAITING TO BE EXAMINED FOR WORKING PAPERS
+    An excellent opportunity for physical-fitness tests]
+
+So great is the risk of defective, sickly, or intemperate employees,
+that in some trades employers take every precaution to exclude them.
+One man with defective eyesight or unsteady nerves may cost a railroad
+thousands of dollars. As insurance companies rank trades as first-,
+second-, or third-class risks, so many factories, from long experience,
+debar men with certain characteristics which have been found
+detrimental to business. The Interborough Rapid Transit Company of New
+York City examines all applicants for employment, as to age, weight,
+height, keenness of vision, hearing, color perception, lungs, hearts,
+arteries, alcoholism, and nicotinism. Those who fall below the standard
+are rejected, but in each case the physical condition is explained to
+the applicant. Where defects are removable or correctable, the
+applicant is told what to do and invited to take another test after
+treatment. Moreover, accepted employees are periodically reëxamined.
+While designed to increase company profits and to reduce company
+losses, this examination obviously decreases the employees' losses
+also, and increases the certainty of work and prospect of promotion.
+
+Our states, and many of our industries, still have the attitude of a
+certain manufacturer who employs several hundred boys and girls. I
+asked him what tests he employed. "I look over a long line of the
+applicants and say," pointing his finger, "I want you, and you, and
+you; the rest may go." I asked him if he made a point of picking out
+those who looked strong. "No. The work is easy, sitting down all day
+long and picking over things. I select those whose faces I like. Yes,
+there is one question we now ask of all the girls. One day a girl in
+the workroom had an epileptic fit and it frightened everybody and upset
+the work so that the foreman always asks, 'Do you have fits? Because if
+you do, you can't work here.'" He makes no attempt to determine the
+physical fitness and endurance of the children employed, because when
+the strength of one is spent there is always another to step into her
+place.
+
+Because the apprentice's future is of no value to the manufacturer, the
+state must restrict the manufacturer's freedom to spend like water
+society's capital,--the health of the coming generation. Could there be
+a grosser mis-management of society's business than to permit trade to
+waste children on whose education society spends so many millions
+yearly? The most effective and most timely remedy is physical
+examination as a condition of the work certificate. A simple, easily
+applied, inexpensive measure that imposes only a legitimate restriction
+upon individual freedom, it is absolutely necessary in order to get to
+the bottom of the child labor problem. If thoroughly applied, children
+of the nation will no longer be exploited by unscrupulous or
+indifferent employers, nor will their health be hazarded by lack of
+discriminating examination that rejects the obviously sick and favors
+the apparently robust. Furthermore, knowledge that this test will be
+applied when work certificates are required, will be an incentive to
+the school boy and girl to keep well. Tell a boy that adenoids or weak
+lungs will keep him from getting a job, and you will make him a strong
+advocate of operation and of fresh air. Show him that his employers
+will not wish his services when his week is out if he is physically
+below par, and he will gladly submit to a board of health examination
+and ask to be told what his defects are and how to correct them.
+
+    [Illustration: CHILDREN AT WORK BELOW BOTH AGE LIMIT AND
+    VITALITY LIMIT
+    National Child Labor Committee]
+
+Some there are who will object to this appeal to the child's economic
+instinct. This objection does not remove the instinct. The normal child
+is greedy for a job. His greed, as well as that of the manufacturer and
+parent, is responsible for much of the child labor; his greed for
+activity, for association, for money, and so for work. A little boy
+came into my office and wanted to hire as an office boy. I looked at
+him and said: "My little fellow, you ought to be in school. What do you
+want to hire out here for?" He said, "I am tired of school; nothing
+doing." He doesn't care about work for its own sake; he doesn't care
+about wealth for its own sake; he wants to get into life; to be where
+there is "something doing." In this lies one potent argument for
+vocational training. To tell a boy of his physical needs just before he
+has taken his first business step is to put him everlastingly in our
+debt. Then he is responsive, and, fortunately for the extreme cases,
+necessarily dependent, for he knows that his refusal would stand
+between himself and his ambition.
+
+When boys and girls go for work certificates to Dr. Goler, medical
+officer of health at Rochester, he requires not merely evidence of age
+and of schooling, but examines their eyes for defective vision and for
+disease, their teeth for cavities and unhealthy gums, and their noses
+and throats for adenoids and enlarged tonsils. If a boy has sixteen
+decayed teeth, Dr. Goler explains to him that teeth are meant to be not
+only ornaments and conveniences, but money getters as well. The boy
+learns that decayed teeth breed disease, contaminate food, interfere
+with digestion, make him a disagreeable companion and a less efficient
+worker. If he will go and have them put into proper condition he will
+enjoy life better and earn good wages sooner. After the teeth are
+attended to the boy secures his work certificate. If the boy's mother
+protests in tears or in anger that her boy does not work with his
+teeth, she learns what she never learned at school, that sound teeth
+help pay the rent. If a girl applicant for working papers has adenoids,
+she is asked to look in the mirror and to notice how her lips fail to
+meet, how the lower jaw drops, how much better she looks with her jaws
+and lips together. She is told that other people breathe through the
+nose, and that perhaps the reason she dislikes school and does not feel
+as she used to about play is that she cannot breathe through her nose
+as she used to. She is shown that her nose is stopped up by a spongy
+substance, as big as the end of her little finger, which obstruction
+can be easily removed. She is shown adenoids and enlarged tonsils that
+have been removed from some other girl, and is so impressed with the
+before-operation and after-operation contrast and by the story of the
+other girl's rapid increase in wages, that she and her mother both
+decide not to wait for the adenoids to disappear by absorption. After
+the operation they come back with proof that the trouble is gone, and
+get the "papers." Similar instruction is given when defects of vision
+seriously interfere with a child's prospects of getting ahead in his
+work, or when evidence of incipient tuberculosis makes it criminal to
+put a child in a store or factory.
+
+    [Illustration: THE GRENFELL ASSOCIATION FINDS MOUTH BREATHERS AT
+    WORK IN LABRADOR]
+
+No law as yet authorizes the health officer of Rochester to refuse work
+certificates to children physically unfit to become wage earners. A
+higher law than that which any legislature can pass or revoke, has
+given Dr. Goler power over children and parents, namely, interest in
+children and knowledge of the industrial handicap that results from
+physical defects. This higher law authorizes every health officer in
+the United States to examine the school child before issuing a work
+certificate, to tell the child and his parents what defects need to be
+removed, for what trades he is physically unfitted, what trades will
+not increase his physical weakness, and to what trade he is physically
+adapted.
+
+We should not forget that a large proportion of our children never
+apply for work certificates; some because they never intend to work;
+some because they expect to remain in school until sixteen or later;
+some because they live on farms, in small towns, or in cities and
+states where prohibition of child labor is not enforced. Because there
+is no reason for this large proportion of children to visit a board of
+health, some substitute must be found. This substitute has been already
+suggested by principals and district superintendents in New York City,
+who claim that the natural place for the examination of children is the
+school and not health headquarters. Developing the idea that the school
+should pronounce the child's fitness to leave school and to engage in
+work, we are led to the suggestion that the state, which compels
+evidence that every child, rich or poor, is being taught during the
+compulsory school age, shall also at the age of fourteen or sixteen
+require evidence that the child is physically fit to use his education,
+and that it shall not, because of preventable ill health, prove a
+losing investment.
+
+Parochial and private schools, the ultra-religious and ultra-rich, may
+resent for a time public supervision of the physical condition of
+children who do not ask for work certificates. This position will be
+short-lived, because however much we may disagree about society's right
+to control a child's act after his physical defects are discovered, few
+of us will question the state's duty to tell that child and his
+parents the truth about his physical needs before it accepts his labor
+or permits him to go to college, to "come out," to "enter society," or
+to live on an income provided by others. Thus an invaluable
+commencement present can be given by the state to children in country
+schools and to those compelled to drop out of fourth or fifth grades of
+city schools.
+
+    [Illustration: THE HEALTH DEPARTMENT'S CLINICAL CARE AND HOME
+    INSTRUCTION COME AFTER WAGE LOSSES, WHILE WORK CERTIFICATES
+    PRECEDE BREAKDOWNS FROM TUBERCULOSIS]
+
+A brief test of this method of helping children, such as is now being
+made by several boards of health at the instance of the National Bureau
+of Labor, will prove conclusively that parents are grateful for the
+timely discovery of these defects which handicap because of their
+existence, not because of their discovery. Of the cadets preparing for
+war at West Point, it has recently been decided that those "who in the
+physical examinations are found to have deteriorated below the
+prescribed physical standard will be dropped from the rolls of the
+academy." Shall not cadets preparing for an industrial life and
+citizenship be given at least a knowledge of an adequate physical
+standard? To allow the school child to deteriorate whether before or
+after going to work is only to waste potential citizenship. Citizens
+who use themselves up in the mere getting of a living have no surplus
+strength or interest for overcoming incompetence in civic business, or
+for achieving the highest aim of citizenship,--the art of
+self-government for the benefit of all the governed.
+
+
+
+
+CHAPTER XXI
+
+PERIODICAL PHYSICAL EXAMINATION AFTER SCHOOL AGE
+
+
+Governor Hughes, in his address to the students in Gettysburg College,
+pleaded for such lives that strength would be left for the years of
+achievement. How many men and women can you count who are squandering
+their health bank account? How many do you know who are now physically
+bankrupt? The man who is prodigal of his health may work along all
+right for years, never realizing until the test comes that he is
+running behind in his vitality. The test may be hard times, promotion,
+exposure to cold, heat, fever, or a sudden call for all his control in
+avoiding accident. If his vitality fails to stand the test, his career
+may be ruined, "all for the want of a horseshoe nail": because of no
+health bank account to draw upon in time of need,--failure; because of
+vitality depleted by alcohol, tobacco, overeating, underexercise, or
+too little sleep,--no power to resist contagious diseases; because of
+ignorance of existing lung trouble,--a year or more of idleness,
+perhaps poverty for his family; or there is neglected ear or eye
+trouble,--and thousands of lives may be lost because the engineer
+failed to read the signals.
+
+Adults are now examined when applying for insurance or accident
+policies, for work on railroads, for service in the army and on the
+police and fire forces of cities that provide pensions. It is somewhat
+surprising that the hundreds of thousands who carry life insurance
+policies have not realized that a test which is rigorously imposed for
+business reasons by insurance companies can be applied by individuals
+for business reasons. Generations hence the state will probably
+require of every person periodic physical examination after school age.
+Decades hence business enterprises will undoubtedly require evidence of
+health and vitality from employees before and during employment, just
+as schools will require such evidence from teachers. It is, after all,
+but a step from the police passport to the health passport. Why should
+we not protect ourselves against enemies to health and efficiency as
+well as against enemies to order? But for the present we must rely upon
+the intelligence of individuals to recognize the advantage to
+themselves, their families, and their employers, of knowing that their
+bodies do not harbor hidden enemies of vitality and efficiency. From a
+semi-annual examination of teeth to a semi-annual physical examination
+is but a short step when once its effectiveness is seen by a few in
+each community.
+
+    [Illustration: THE OLD SOUTHFIELD, NOW ANCHORED AT BELLEVUE
+    HOSPITAL'S DOCK, NEW YORK CITY, GIVES DAILY LESSONS IN THE
+    PREVENTABLE TAX LEVIED BY TUBERCULOSIS]
+
+Ignorance of one's physical condition is a luxury no one can afford. No
+society is rich enough to afford members ignorant of physical
+weaknesses prejudicial to others' health and efficiency. Every one of
+us, even though to all appearances physically normal, needs the
+biological engineer. New conditions come upon us with terrific
+rapidity. The rush of work, noise, dust, heat, and overcrowding of
+modern industry make it important to have positive evidence that we
+have successfully adapted ourselves to these new conditions. Only by
+measuring the effects of these environmental forces upon our bodies can
+we prevent some trifling physical flaw from developing into a chronic
+or acute condition. As labor becomes more and more highly specialized,
+the body of the laborer is forced to readapt itself. The kind of work a
+man does determines which organs shall claim more than their share of
+blood and energy. The man who sets type develops keenness of vision and
+manual dexterity. The stoker develops the muscles of his arms and back,
+the engineer alertness of eye and ear. All sorts of devices have been
+invented to aid this specialization of particular organs, as well as to
+correct their imperfections: the magnifying glass, the telescope, the
+microscope, extend the powers of the eye; the spectacle or an operation
+on the eye muscles enables the defective eye to do normal work. A man
+with astigmatism might be a policeman all his life, win promotion, and
+die ignorant of his defect; whereas if the same man had become a
+chauffeur, he might have killed himself and his employer the first
+year, or, if an accountant, he might have been a chronic dyspeptic from
+long-continued eye strain. It is a soul tragedy for a man to attempt a
+career for which he is physically unadapted.[11] It is a social tragedy
+when men and women squander their health. A great deal of the success
+attributed to luck and opportunity, or unusual mental endowment, is in
+reality due to a chance compatibility of work with physique. To secure
+such compatibility is the purpose of physical examination after school
+age.
+
+If the periodic visit to the doctor is the first law of adult health,
+still more imperative is the law that competent physicians should be
+seen at the first indication of ill health. Even when competent
+physicians are at hand, parents and teachers should be taught what
+warning signs may mean and what steps should be taken. In Germany
+insurance companies find that it saves money to provide free medical
+and dental care for the insured. Department stores, many factories and
+railroads, have learned from experience that they save money by
+inducing their employees to consult skilled physicians at the first
+sign of physical disorder. Many colleges, schools, and "homes" have a
+resident physician. Wherever any large number of people are assembled
+together,--in a hotel, factory, store, ship, college, or school,--there
+should be an efficient consulting physician at hand. If people are
+needlessly alarmed, it is of the utmost importance to show them that
+there is nothing seriously wrong. Therefore visits to the consulting
+physician should be encouraged.
+
+The reader's observation will suggest numerous illustrations of pain,
+prolonged sickness, loss of life, that could have been prevented had
+the physician been semi-annually visited. A strong man, well educated,
+with large income, personally acquainted with several of the foremost
+physicians of New York City, after suffering two weeks from pains "that
+would pass away," was hurriedly taken to a hospital at three o'clock in
+the morning, operated upon immediately, and died at nine. A business
+man of means put off going to a physician for fifteen years, for fear
+he would be told that his throat trouble was tobacco cancer, or
+incipient tuberculosis, or asthma; a physical examination showed that a
+difficulty of breathing and chronic throat trouble were due to a
+growth in the nose, corrected in a few minutes by operation.
+
+A celebrated economist was forced to give up academic work, and
+consecrated his life to painful and chronic dyspepsia because of eye
+trouble detected upon the first physical examination. A woman secretary
+suffered from alleged heart trouble; paralysis threatened, continuous
+headache and blurred vision forced her to give up work and income; a
+physical examination found the cause in nasal growths, whose removal
+restored normal conditions. A woman lecturer on children's health heard
+described last summer a friend's experience with receding gums: "'Why,
+I never heard of that disease.' she said. 'Don't you know you have it
+yourself'? I asked. She had never noticed that her gums were growing
+away in little points on her front teeth. I touched the uncovered
+portion and she winced. That ignorance has meant intense pain and ugly
+fillings. If it had gone longer, it might have meant the loss of her
+front teeth." A teacher lost a month from nervous prostration; physical
+examination would have discovered the eye trouble that deranged the
+stomach and produced the nerve-racking shingles which forced him to
+take a month's vacation. A journalist lost weeks each year because of
+strained ankles; since being told that he had flat foot, and that the
+arch of his foot could be strengthened by braces and specially made
+shoes, he has not lost a minute. A relief visitor, ardent advocate of
+the fresh-air, pure-milk treatment for tuberculosis, had a "little
+cough" and an occasional "cold sweat"; medical friends knew this, but
+humored her aversion to examination; when too late, she submitted to an
+examination and to the treatment which, if taken earlier, would most
+certainly have cured her. A mother's sickness cost a wage-earning
+daughter nearly $3000; softening of the brain was feared; after six
+years of suffering and unnecessary expense, physical examination
+disclosed an easily removable cause, and for two years she has
+contributed to the family income instead of exhausting it. Untold
+suffering is saved many a mother by knowledge of her special physical
+need in advance of her baby's birth. Untold suffering might be saved
+many a woman in business if she could be told in what respects she was
+transgressing Nature's law.
+
+    [Illustration: NEW YORK CITY'S TUBERCULOSIS SANATORIUM AT
+    OTISVILLE IS SENDING HOME APOSTLES OF SEMI-ANNUAL EXAMINATIONS]
+
+    [Illustration: BOSTON'S PICTURESQUE DAY CAMP FOR TUBERCULOSIS
+    PATIENTS IS TEACHING THE NEED FOR A PERIODIC INVENTORY OF
+    PHYSICAL RESOURCES]
+
+To encourage periodic physical examination is not to encourage morbid
+thinking of disease. One reason for our tardiness in recognizing the
+need for thorough physical examination is the doctor's tradition of
+treating symptoms. After men and women are intelligent enough to demand
+an inventory of their physical resources,--a balance sheet of their
+physical assets and liabilities,--physicians will study the whole man
+and not the fraction of a man in which they happen to be specializing
+or about which the patient worries. By removing the mystery of bodily
+ailments and by familiarizing ourselves with the essentials to healthy
+living, we find protection against charlatans, quacks, faddists, and
+experimenters. By taking a periodic inventory of our physical resources
+we discharge a sacred obligation of citizenship.
+
+FOOTNOTES:
+
+[11] See _Dangerous Trades_, compiled by Thomas Oliver; also list of
+reports by the United States Bureau of Labor.
+
+
+
+
+CHAPTER XXII
+
+HABITS OF HEALTH PROMOTE INDUSTRIAL EFFICIENCY
+
+
+Education's highest aim is to train us to do the right thing at the
+right moment without having to think. The technic of musician,
+stenographer, artist, electrician, surgeon, orator, is gained only from
+patient training of the body's reflex muscles to do brain work.[12] The
+lower nerve centers are storehouses for the brain energy, just as
+central power houses are used for storing electric energy to be spent
+upon demand. From habit, not from mental effort, we turn to the right,
+say "I beg pardon" when we step on another's foot, give our seats to
+ladies or to elderly persons, use acceptable table manners. No person
+seems "to the manner born" who has to think out each act necessary to
+"company manners." How numerous are the mental and physical processes
+essential to good manners no one ever recognizes but the very bashful
+or the uncouth person trying to cultivate habits of unconsciousness in
+polite society. The habit of living ethically enables us to go through
+life without being tempted to steal or lie or do physical violence. No
+person's morals can be relied upon who is tempted constantly to do
+immoral acts; ethical training seeks to incapacitate us for committing
+unethical deeds and to habituate us to ethical acts alone.
+
+Eight different elements of industrial efficiency are concerned with
+the individual's health habits,--the industrial worker, his industrial
+product, his employer, his employer's profit, his trade or profession,
+its product, his nation, national product. Obviously few men have so
+little to do that they have time to think out in detail how this act or
+that indulgence will affect each of these eight factors of industrial
+efficiency. Once convinced, however, that all of these elements are
+either helped or injured by the individual's method of living, each one
+of us has a strong reason for imposing habits of health upon all
+industries, upon employees and operatives, upon all who are a part of
+industrial efficiency. When these eight relations are seen, parents and
+teachers have particularly strong reasons for inculcating habits of
+health in their children.
+
+That industrial inefficiency results from chronic habits of unhealthy
+living is generally recognized. The alcoholic furnishes the most vivid
+illustration. The penalties suffered by him and his family are grave
+enough, but because he has not full possession of his faculties he is
+unpunctual, wastes material, disobeys instructions, endangers others'
+lives, decreases the product of his trade and of his employer, lessens
+the profits of both, depresses wages, increases insurance and business
+risks. Because no one can foresee when the "drop too much" will be
+taken, industry finds it important to know that the habit of drinking
+alcoholics moderately has not been acquired by train dispatcher,
+engineer, switchman, chauffeur. Because the habit of drinking
+moderately is apt, among lower incomes, to go hand in hand with other
+habits injurious to business and fatal to integrity, positions of trust
+in industry seek men and women who have the habit of declining drink.
+
+In the aggregate, milder forms of unhealthy living interfere with
+industrial efficiency even more than alcoholism. Many capable men and
+women, even those who have had thorough technical training, fail to win
+promotion because their persons are not clean, their breath offensive,
+their clothes suggestive of disorderly, uncleanly habits. Persons of
+extraordinary capacity not infrequently achieve only mediocre results
+because they fail to cultivate habits of cleanliness and health. An
+employer can easily protect his business from loss due to alcoholism
+among his own employees; but loss through employees' constipation,
+headache, bad ventilation at home, irregular meals, improper diet, too
+many night parties, nicotinism, personal uncleanliness, is loss much
+harder to anticipate and avoid. Because evil results are less vivid, it
+is also hard to convince a clerk that intemperance in eating, sleeping,
+and playing will interfere with his earning capacity and his enjoyment
+capacity quite as surely as intemperance in the use of alcohol and
+nicotine. Where employees are paid by the piece, instead of by the
+hour, day, or week, the employer partially protects himself against
+uneven, sluggish, slipshod workmen; but, other things being equal, he
+awards promotion to those who are most regular and who are most often
+at their best, for he finds that the man who does not "slump" earns
+best profits and deserves highest pay.
+
+    [Illustration: THESE PATIENTS ON THE OLD SOUTHFIELD ARE TAXING
+    THEIR UNIONS AND THEIR TRADES AS WELL AS THEIR FAMILIES AND THE
+    TUBERCULOSIS COMMITTEE]
+
+There are exceptions, it is true, where both industrial promotion and
+industrial efficiency are won by people who violate laws of
+health,--but at what cost to their efficiency? Your efficiency should
+be measured not by some other person's advancement, but by what you
+yourself ought to accomplish; while the effect of abusing your physical
+strength is shown not only in the shortening of your industrial life
+and in the diminishing returns from your labor, but by the decrease of
+national and trade efficiency. "Sweating" injures those who buy and
+those in the same trade who are not "sweated" just as truly as it
+injures the "sweated."
+
+    [Illustration: HABITS OF HEALTH AMONG DAIRYMEN MEAN SAFE MILK
+    FOR BABIES]
+
+What are the health habits that should become instinctive and
+effortless for every worker? What acts can we make our lower nerve
+centers--our subconscious selves--do for us or remind us to do? The
+following constitutes a daily routine that should be as involuntary as
+the process of digestion:
+
+  1. Throw the bedding over the foot of the bed.
+
+  2. Close the window that has been open during the night.
+
+  3. Drink a glass of water.
+
+  4. Bathe the face, neck, crotch, chest, armpits (finishing if not
+  beginning with cold water), and particularly the eyes, ears, and
+  nose. If time and conveniences permit, bathe all over.
+
+  5. Cleanse the finger nails.
+
+  6. Cleanse the teeth, especially the places that are out of sight
+  and hard to reach.
+
+  7. Breakfast punctually at a regular hour. Eat lightly and only
+  what agrees with you. If you read a morning paper, be interested
+  in news items that have to do with personal and community
+  vitality.
+
+  8. Visit the toilet; if impracticable at home, have a regular time
+  at business.
+
+  9. Have several minutes in the open air, preferably walking.
+
+  10. Be punctual at work.
+
+  11. As your right by contract, insist upon a supply of fresh air
+  for your workroom with the same emphasis you use in demanding
+  sufficient heat in zero weather.
+
+  12. Eat punctually at noon intermission; enjoy your meal and its
+  after effects.
+
+  13. Breathe air out of doors a few minutes, preferably walking.
+
+  14. Resume business punctually.
+
+  15. Stop work regularly.
+
+  16. Take out-of-door exercise--indoor only when fresh air is
+  possible--that you enjoy and that agrees with you.
+
+  17. Be regular, temperate, and leisurely in eating the evening
+  meal; eat nothing that disagrees with you.
+
+  18. Spend the evening profitably and pleasantly and in ways
+  compatible with the foregoing habits.
+
+  19. Retire regularly at a fixed hour, making up for irregularity
+  by an earlier hour next night.
+
+  20, 21, 22. Repeat 4, 6, 8.
+
+  23. Turn underclothes wrong side out for ventilation.
+
+  24. Open windows.
+
+  25. Relax mind and body and go to sleep.
+
+No man chronically neglects any one of the above rules without reducing
+his industrial efficiency. No man chronically neglects all of them
+without becoming, sooner or later, a health bankrupt.
+
+In addition to this daily routine, there are certain other acts that
+should become habitual:
+
+  1. Bathing less frequently than once a week is almost as dangerous
+  to health as it is to attractiveness.
+
+  2. Distaste for unclean linen or undergarments and for acts or
+  foods that interfere with vitality should become instinctive.
+
+  3. Excesses in eating or playing should be automatically corrected
+  the next day and the next. Parties we shall continue to have. It
+  will be some time before reasonable hours and reasonable
+  refreshments will prevail. Meanwhile it is probably better for an
+  individual to sacrifice somewhat his own vitality for the sake of
+  the union, the class, or the church. While trying to improve group
+  habits, one can acquire the habit of not eating three meals in
+  one, of eating less next day, of sleeping longer next night, of
+  being particularly careful to have plenty of outdoor air.
+
+  4. Visits to the dentist twice a year at least, and whenever a
+  cavity appears, even if only a week after the dentist has failed
+  to find one; whenever the gums begin to recede; and whenever
+  anything seems to be wrong with the teeth.
+
+  5. Periodic physical examination by a physician.
+
+  6. Examination by a competent physician whenever any disorder
+  cannot be satisfactorily explained by violation of the daily
+  routine or by interruption of business or domestic routine.
+
+Health habits do not become instinctive until a continued, conscious
+effort is made to accustom the body to them. When this is once done,
+however, the body not only attends to its primary health needs
+automatically, but it rebels at their omission, as surely as does the
+stomach at the omission of dinner. Witness the discomfort of the
+consumptive, trained to fresh air at a sanatorium, when he returns to
+his overheated and underventilated home, or the actual pain experienced
+in readjusting our own healthy bodies to the stuffy workroom or
+schoolroom after a summer vacation out of doors. I heard a consumptive
+say that he left a sanatorium for a day class after trying for three
+nights to sleep in an unventilated ward. For many people the regular
+morning bath is at first a trial, then a pleasure, and finally a need;
+if omitted, the body feels thirsty and dissatisfied, the eyes sleepy,
+and the spirit flags early in the day.
+
+    [Illustration: IMPROVISED SEASIDE HOSPITAL FOR NONPULMONARY
+    TUBERCULOSIS AT SEA BREEZE TEACHES PASSERS-BY THE FRESH-AIR
+    GOSPEL]
+
+Cold baths are not essential or even good for everybody. The same diet
+or the same amount of food or time for eating is not of equal value for
+all. The temperature of bath water, the kind and quality of food, are
+influenced by one's work and one's cook. Set rules about these things
+do more harm than good. Such questions must be decided for each
+individual,--by his experience or by the advice of a physician,--but
+they must be decided and the decisions converted into health habits if
+he would attain the highest efficiency of which he is capable. Here
+again our old contrast between "doing things" and "getting things done"
+applies. Get your body to attend to the essential needs for you, and
+get it to remind you when you let the exigencies of life interfere.
+Don't burden your mind every day with work that your body will do for
+you if properly trained.
+
+    [Illustration: CRIPPLED CHILDREN LEAVING SEA BREEZE HOSPITAL FOR
+    BONE TUBERCULOSIS FIND STALE AIR OFFENSIVE BY NIGHT OR BY DAY]
+
+Obstacles to habits of health are numerous; therefore the importance of
+correcting those habits of factory, family, trade, city, or nation that
+make health habits impracticable. We must change others' prejudices
+before we can breathe clean air on street cars without riding outside.
+When one's co-workers are afraid of fresh air, ventilation of shop,
+store, and office is impossible. So long as parents fear night air,
+children cannot follow advice to sleep with windows open. Unless the
+family coöperates in making definite plans for the use of toilet and
+bath for each member, constipation and bad circulation are sure to
+result. Indigestion is inevitable if employees are not given lunch
+periods and closing hours that permit of regular, unhurried meals.
+Cleanliness of person costs more than it seems to be worth where cities
+fail either to compel bath tubs in rented apartments or to erect public
+baths. A temperate subsistence on adulterated, poisonous, or drugged
+foods might be better for one's health than gormandizing on pure foods.
+No recipe has ever been found for bringing up a healthy baby on
+unclean, infected milk; for avoiding tuberculosis among people who are
+compelled to work with careless consumptives in unclean air; or for
+making a five-story leap as safe as a fire escape. Perfect habits of
+health on the part of an individual will not protect him against
+enervation or infection resulting from inefficient enforcement of
+sanitary codes by city, county, state, and national authorities.
+
+    [Illustration: AT JUNIOR SEA BREEZE, TEACHING MOTHERS THE HEALTH
+    ROUTINE FOR BABIES]
+
+The "municipalization" or "public subsidy" of health habits is
+indispensable to protecting industrial efficiency. Public lavatories,
+above or below ground, have done much to reduce inefficiency due to
+alcoholism, constipation of the bowels, and congestion of the kidneys.
+Theaters, churches, and assembly rooms could be built so as to drill
+audiences in habits of health instead of fixing habits of uncleanly
+breathing. Street flushing, drinking fountains, parks and breathing
+spaces, playgrounds and outdoor gymnasiums, milk, food, and drug
+inspection, tenement, factory, and shop supervision, enforcement of
+anti-spitting penalties, restriction of hours of labor, prohibition of
+child labor,--these inculcate community habits of health that promote
+community efficiency. It is the duty of health boards to compel all
+citizens under their jurisdiction to cultivate habits of health and to
+punish all who persistently refuse to acquire these habits, so far as
+the evils of neglect become apparent to health authorities. The
+unlimited educational opportunity of health boards consists in their
+privilege to point out repeatedly and cumulatively the industrial and
+community benefits that result from habits of health, and the
+industrial and community losses that result from habits of unhealthy
+living.
+
+FOOTNOTES:
+
+[12] Serviceable guides to personal habits of health are _Aristocracy of
+Health_ by Mary Foote Henderson, and _Efficient Life_ by Dr. Luther H.
+Gulick.
+
+
+
+
+CHAPTER XXIII
+
+INDUSTRIAL HYGIENE
+
+
+To call the movement for better factory conditions the "humanizing of
+industry" implies that modern industry not influenced by that movement
+is brutalized. The brutalizing of industry was due chiefly to a general
+ignorance of health laws,--an ignorance that registers itself clearly
+and promptly in factory and mine. It is not that a man is expected to
+do too much, but that too little is expected of the human body. The
+present recognition of the body's right to vitality is not because the
+employer's heart is growing warmer, or because competition is less
+vicious, but because the precepts of hygiene are found to be practical.
+Where better ventilation used to mean more windows and repair bills, it
+now means greater output. Where formerly a comfortable place in which
+to eat lunch meant giving up a workroom and its profits, it now means
+25 per cent more work done in all workrooms during the afternoon. The
+general enlightenment as to industrial hygiene has been accelerated by
+the awakening that always follows industrial catastrophes, by the
+splendid crusade against tuberculosis, and by compulsory notification
+and treatment of communicable diseases.
+
+Catastrophes, however, have dominated the vocabulary that describes
+factory "welfare work." Because accidents such as gas in mines, fire in
+factories, fever in towns, and epidemics of diseases incident to
+certain trades were beyond the power of the workers themselves to
+control or prevent, wage earners have come to be looked upon as
+helpless victims of the cupidity and inhumanity of their employers.
+This attitude has weakened the usefulness of many bodies organized to
+promote industrial hygiene. Although the term "industrial hygiene" is
+broad enough to include all sanitary and hygienic conditions that
+surround the worker while at work, it is restricted by some to the
+efforts made by altruistic or farsighted employers in the interest of
+employees; others think of prohibitions and mandates, in the name of
+the state, that either prevent certain evils or compel certain
+benefits; for too few it refers to what the wage earner does for
+himself.
+
+Pity for the employee has caused the motive power of the employee to be
+wastefully allowed to atrophy. Yet when a man becomes an employee, he
+does not forfeit any right of citizenship, nor does being an employee
+relieve him from the duties of citizenship. In too many cases it has
+been overlooked that a worker's carelessness about habits of health, as
+well as about his machinery, causes accidents and increases industrial
+diseases. Too often the worker himself is responsible for uncleanliness
+and lack of ventilation and his own consequent lack of vitality. A
+study into the conditions of ventilation and cleanliness of workers'
+homes will prove this.
+
+Knowing that a light, well-aired, clean, safe factory would not of
+itself insure healthy men, many employers have built and supplied
+houses for their workmen at low rents. Just as these employers failed
+to see that they could reach more people and secure more permanent
+results if they demanded that tenement laws and the sanitary code be
+enforced as well as the laws for the instruction of children in
+hygiene, so the employee has failed to see that he is a part of the
+public that passes laws and determines the efficiency of factory
+inspection. The enforcement of state legislation for working hours,
+proper water and milk supply, proper teaching of children, proper
+tenement conditions, efficient health administration, is dependent upon
+the interest and activity of the public, of which the working class is
+no small or uninfluential part.
+
+    [Illustration: COUNTRY CLUB HOUSE FOR NEW YORK SOCIAL WORKERS
+    Given by the founder of Caroline Rest Educational Fund]
+
+The first and most important step in securing hygienic rights for
+workingmen is to make sure that they know the rights that the law
+already gives them. Men still throw out their chests when talking of
+their rights. The posting of the game laws in a club last summer, and
+the instruction of all the natives of the countryside in regard to
+their rights as against those of outsiders, meant that for the first
+time in their history the game laws were enforced. All the natives,
+instead of poaching as has been their wont, joined together in
+protecting club property from intruding outside sportsmen. Poachers
+were caught and served with the full penalties of the law. Over winter
+fires these people's heroism will grow, but their respect for law will
+grow also, and it is doubtful if the game laws can be violated in that
+section so long as the tradition of this summer's work lives. And so
+it would be in a factory, if employees once realized that by uniting
+they could, as citizens, enforce health rights in the factory.
+
+The hygiene of the workshop is not the same problem as the hygiene of
+the home and schoolhouse, because there are by-products of factory work
+that contaminate the air, overheat the room, and complicate the
+ordinary problems of ventilation. Certain trades are recognized as
+"dangerous trades." The problem of adequate government control of
+factories is one for a sanitary engineer. It has to do with
+disease-bearing raw material that comes to a factory, disease-producing
+processes of manufacture. There is need for revision of the
+dangerous-trade list. Many of the industries not so classed should be;
+many of the so-called dangerous trades can be made comparatively
+harmless by devices for exhausting harmful by-products. Industrial
+diseases should be made "notifiable," so that they can be controlled by
+the factory or health department. It is those trades that are dangerous
+because of remediable unsanitary and unhygienic conditions which demand
+the employer's attention. Complaints should be made by individuals when
+carelessness or danger becomes commonplace.
+
+The manner in which many organizations have tried to better working
+conditions is similar to the manner in which Europeans are trying to
+help defective school children. Here, as there, is the difference
+between _doing things_ and _getting things done_. Here more than there
+is the tendency to exaggerate legislation and to neglect enforcement of
+law. Instead of harnessing the whole army of workingmen to the crusade
+and strengthening civic agencies such as factory, health, and tenement
+departments, houses are built and given to men, clubs are formed to
+amuse factory girls, amateur theatricals are organized. All this is
+called "welfare work." "What is welfare work?" reads the pamphlet of a
+large national association. "It is especial consideration on the part
+of the employer for the welfare of his employees." In the words of this
+pamphlet, the aim of this association "is to organize the best brains
+of the nation in an educational movement toward the solution of some of
+the great problems related to social and industrial progress." The
+membership is drawn from "practical men of affairs, whose acknowledged
+leadership in thought and business makes them typical representatives
+of business elements that voluntarily work together for the general
+good." As defined by this organization, welfare work is something given
+to the employee by the employer for the welfare of both. It is not
+something the employee himself does to improve his own working
+conditions.
+
+  We are told that employees should assume the management of welfare
+  work.
+
+  Should they install sanitary conveniences? Of course not.
+
+  Would they know the need of a wash room in a factory if they never
+  had had one? No.
+
+  Should they manage lunch rooms? A few employers have attempted
+  unsuccessfully to turn over the management of the lunch rooms to
+  the employees, the result being that one self-sacrificing
+  subofficial in each concern would find the burden entirely on his
+  shoulders before working hours, during working hours, and after
+  working hours. Employees cannot attend committee meetings during
+  working hours, and they are unwilling to do so afterwards, for
+  they generally have outside engagements. Furthermore, the
+  employees know nothing about the restaurant business. If they did,
+  they would probably be engaged in it instead of in their different
+  trades. All experiments along this line of which we have heard
+  have failed. The so-called "democratic idea," purely a fad, never
+  has been successfully operated.
+
+  Many employers would introduce welfare work into their
+  establishments were it not for the time and trouble needed for its
+  organization. The employment of a welfare director removes this
+  obstacle. Successful prosecution of welfare work requires
+  concentration of responsibility. All of its branches must be under
+  the supervision of one person, or efforts in different directions
+  may conflict, or special and perhaps pressing needs may escape
+  attention. Pressure of daily business routine usually relegates
+  welfare work to the last consideration, but the average employer
+  is interested in his men and is willing to improve their condition
+  if only their needs are brought to his attention.
+
+    [Illustration: FIRST LESSONS IN INDUSTRIAL HYGIENE]
+
+ +--------------------------------------------------------------------+
+ | =Consumption=                                                      |
+ |                                                                    |
+ | Is chiefly caused by the Filthy Habit of                           |
+ |                                                                    |
+ | =SPITTING=                                                         |
+ |                                                                    |
+ | TAKE THIS CARD HOME                                                |
+ |                                                                    |
+ | And show it to your family, friends, and neighbors                 |
+ |                                                                    |
+ | Consumption is a disease of the lungs, which is taken from others, |
+ | and is not simply caused by colds, although a cold may make it     |
+ | easier to take the disease.                                        |
+ |                                                                    |
+ | The matter coughed up and sneezed out by consumptives is full of   |
+ | living germs or "tubercle bacilli" too small to be seen. These     |
+ | germs are the cause of consumption, and when they are breathed     |
+ | into the lungs they set up the disease.                            |
+ |                                                                    |
+ | DON'T GET CONSUMPTION YOURSELF                                     |
+ |                                                                    |
+ | Keep as well as possible, for the healthier your body, the harder  |
+ | for the germs of consumption to gain a foothold. Every person      |
+ | should observe the following rules:                                |
+ |                                                                    |
+ |                                                                    |
+ |     =DON'T= live, study, or sleep in rooms where there is no       |
+ |        fresh air. Fresh air and sunlight kill the consumption      |
+ |        germs and other germs causing other diseases; therefore     |
+ |        have as much of both in your room as possible.              |
+ |                                                                    |
+ |     =DON'T= live in dusty air; keep rooms clean; get rid of dust   |
+ |        by cleaning with damp cloths and mops. =DON'T= sweep with   |
+ |        a dry broom.                                                |
+ |                                                                    |
+ |     =KEEP= one window partly open in your bedroom at night, and    |
+ |        air the room two or three times a day.                      |
+ |                                                                    |
+ |     =DON'T= eat with soiled hands. Wash them first.                |
+ |                                                                    |
+ |     =DON'T= put hands or pencils in the mouth, or any candy or     |
+ |        chewing gum other persons have used.                        |
+ |                                                                    |
+ |     =DON'T= keep soiled handkerchiefs in your pockets.             |
+ |                                                                    |
+ |     =TAKE= a warm bath at least once a week.                       |
+ |                                                                    |
+ |     =DON'T= neglect a cold or a cough, but go to a doctor or       |
+ |        dispensary.                                                 |
+ +--------------------------------------------------------------------+
+
+    [Illustration: WELFARE WORK THAT COUNTS]
+
+ +-------------------------------------------------------------------+
+ | =HOW TO GET WELL IF YOU HAVE CONSUMPTION=                         |
+ |                                                                   |
+ | If you or any one in your family have consumption, you must obey  |
+ | the following rules if you wish to get well:                      |
+ |                                                                   |
+ |      =DON'T= waste your money on patent medicines or advertised   |
+ |         cures for consumption, but go to a doctor or dispensary   |
+ |         (see last page). If you go in time, you can be cured; if  |
+ |         you wait, it may be too late.                             |
+ |                                                                   |
+ |      =DON'T= drink whisky or other forms of liquor.               |
+ |                                                                   |
+ |      =DON'T= sleep in the same bed with any one else, and, if     |
+ |         possible, not in the same room.                           |
+ |                                                                   |
+ |   =Good food, fresh air, and rest are the best cures. Keep out    |
+ |   in the fresh air and in the sunlight as much as possible.=      |
+ |                                                                   |
+ |      =KEEP= your windows open winter and summer, day and night.   |
+ |                                                                   |
+ |      =IF= properly wrapped up you will not catch cold.            |
+ |                                                                   |
+ |      =GO= to a sanatorium while you can and before it is too      |
+ |         late.                                                     |
+ |                                                                   |
+ |  =The careful and clean consumptive is not dangerous to those     |
+ |  with whom he lives and works.=                                   |
+ |                                                                   |
+ |  =Don't give consumption to others.=                              |
+ |                                                                   |
+ |  Many grown people and children have consumption without knowing  |
+ |  it, and can give it to others. Therefore every person, even if   |
+ |  healthy, should observe the following rules:                     |
+ |                                                                   |
+ |      =DON'T SPIT= on the sidewalks, playgrounds, or on the        |
+ |         floors or hallways of your home or school. It spreads     |
+ |         disease, and is dangerous, indecent, and unlawful.        |
+ |                                                                   |
+ |      =WHEN YOU MUST SPIT=, spit in the gutters or into a spittoon |
+ |         half filled with water.                                   |
+ |                                                                   |
+ |      =DON'T COUGH OR SNEEZE= without holding a handkerchief or    |
+ |         your hand over your mouth or nose.                        |
+ +-------------------------------------------------------------------+
+ $/
+
+This method of promoting the welfare of the worker may have been a
+necessary step in the development of industrial hygiene. Undoubtedly it
+has succeeded, in many cases, in bringing to an employer's
+consciousness the needs of his workmen, in accustoming employees to
+higher sanitary standards, and in teaching them to demand health rights
+from their employers. In many cases, however, "welfare work" has
+miseducated both employer and employee. The fact that "the so-called
+democratic idea, purely a fad, has never been successfully operated,"
+is due to the interpretation given to "democratic idea." The two
+alternatives in the paragraph above quoted are lunch rooms, wash rooms,
+as gifts from employers to employees, or lunch rooms and wash rooms to
+be furnished by employees at their own expense. The true democratic
+idea, however, is that factory conditions detrimental to health shall
+be prohibited by factory legislation, and this legislation enforced by
+efficient factory inspectors, regardless of what may be given to
+employees above the requirement of hygiene.
+
+Until employees are more active as citizens and more sensitive to
+hygienic rights, it is desirable that welfare directors be employed in
+factories to arbitrate between employer and employee, to raise the
+moral standard of a factory settlement, to organize amusements.
+
+Welfare work at its best is a method of dividing business profits among
+all who participate in making these profits. Too often welfare
+secretaries teach employees how to be happy in the director's way,
+rather than in their own way. This adventitious position increases
+suspicion on both sides, disturbs the discipline of the foreman,
+weakens rather than strengthens the worker's efficiency, because it
+depends upon other things than work well done and the relation of
+health to efficiency. In a small factory town the owner of a large
+cotton mill has recognized the financial benefit of physically strong
+workers, and is trying the experiment of a welfare director. The man
+himself works "with his sleeves up." The social worker has an office in
+the factory. A clubhouse is fitted up for the mill hands to make merry
+in. A room in the factory is reserved for a lunch room, with plants,
+tables, and chairs for the comfort of the women. Parties are given by
+the employer to the employees, which he himself attends. He has thrown
+himself into whatever schemes his director has suggested. The director
+complained that the reason the new lunch room was not more popular was
+because a piano was needed. A second-hand one would not do, for that
+would cultivate bad taste in music. This showed the employer that soon
+everything would be expected from the "big house on the hill." An event
+which happened at the time when the pressure was greatest on him for
+the piano, convinced him that his employees could supply their real
+needs without any trouble or delay. The assistant manager was about to
+leave, and in less than a week five hundred dollars was raised among
+the workers for his farewell gift. Walking home that night late from
+his office the owner was attracted by the sound of jollity, and saw a
+little room jammed full of mill people enjoying the improvised music of
+a mouth organ played to the accompaniment of heels. He resolved
+henceforth to train his employees to do his work well and to earn more
+pay,--and to let them amuse themselves. From that time on he refused to
+be looked upon as the _deus ex machina_ of the town. He decided that
+the best way to give English lessons to foreigners was to improve the
+school. His beneficence in supplying them with pure water at the mill
+did not prevent a ravaging typhoid epidemic because the town water was
+not watched. He saw that the best way to improve health was to
+strengthen the health board and to make his co-workers realize that
+they were citizens responsible for their own privileges and rights.
+
+Emergency hospitals and Y.M.C.A. buildings are sad substitutes for
+safety devices and automatic couplers. Christmas shopping in November
+is less kind than prevention of overwork in December. Night school and
+gymnastic classes are a poor penance for child labor and for work
+unsuited to the body. The left hand cannot dole favors enough to offset
+the evils of underpay, of unsanitary conditions, of inefficient
+enforcement of health laws tolerated by the right hand.
+
+Just because a man is taking wages for work done, is no reason why he
+should forfeit his rights as a citizen, or allow his children, sisters,
+neighbors, to work in conditions which decrease their efficiency and
+earning power. What the employee can do for himself as a citizen,
+having equal health rights with employers, he has never been taught to
+see. Factory legislation is state direction of industries so far as
+relates to the safety, health, and moral condition of the people,--and
+which embraces to-day, more than in any other epoch, the opinion of the
+workers themselves. No government, however strong, can hope
+successfully to introduce social legislation largely affecting personal
+interests until public opinion has been educated to the belief that the
+remedies proposed are really necessary. Until schools insist upon a
+better ventilation than the worst factories, how can we expect to find
+children of working age sensitive to impure air? Where work benches are
+more comfortable than school desks, where drinking water is cleaner and
+towels more sanitary, however unsanitary they may be, than those found
+in the schoolhouse, the worker does not realize that they menace his
+right to earn a living wage as much as does a temporary shut-down.
+
+Employers are by no means solely to blame for unhealthy working
+conditions. A shortsighted employee is as anxious to work overtime for
+double pay as a shortsighted employer is to have him. Among those who
+are agitating for an eight-hour day are many who, from self-interest or
+interest in the cause, work regularly from ten to sixteen hours.
+
+Would it help to punish employees for working in unhealthy places? The
+highest service that can be rendered industrial hygiene is to educate
+the industrial classes to recognize hygienic evils and to coöperate
+with other citizens in securing the enforcement of health rights.
+
+
+
+
+CHAPTER XXIV
+
+THE LAST DAYS OF TUBERCULOSIS
+
+
+If the historian Lecky was right in saying that the greatest triumphs of
+the nineteenth century were its sanitary achievements, the Lecky of the
+twenty-first century will probably honor our generation not for its
+electricity, its trusts, and its scientific research, but for its
+crusade against the white plague and for its recognition of health
+rights. Thanks to committees for the prevention of tuberculosis,--local,
+state, national, international,--we are fast approaching the time when
+every parent, teacher, employer, landlord, worker, will see in
+tuberculosis a personal enemy,--a menace to his fireside, his income,
+and his freedom. Just as this nation could not exist half slave, half
+free, we of one mind now affirm that equal opportunity cannot exist
+where one death in ten is from a single preventable disease.[13]
+
+Of no obstacle to efficient living is it more true than of
+tuberculosis, that the remedy depends upon enforcing rather than upon
+making law, upon practice rather than upon precept, upon health habits
+rather than upon medical remedies, upon coöperation of lay citizens
+rather than upon medical science or isolated individual effort. Without
+learning another fact about tuberculosis, we can stamp it out if we
+will but apply, and see that officers of health apply, lessons of
+cleanliness and natural living already known to us.
+
+    [Illustration: DR. TRUDEAU'S "LITTLE RED COTTAGE" AT
+    SARANAC--BIRTHPLACE OF OUT-OF-DOOR TREATMENT IN AMERICA]
+
+Perhaps the most striking results yet obtained in combating
+tuberculosis are those of the Massachusetts General Hospital in Boston.
+To visit its tuberculosis classes reminds one more of the sociable than
+the clinic. In fact, one wonders whether the milk diet and the rest
+cure or the effervescing optimism and good cheer of the physicians and
+nurses should be credited with the marvelous cures. The first part of
+the hour is given to writing on the blackboard the number of hours that
+the class members spent out of doors the preceding week. So great was
+the rivalry for first place that the nurse protested that a certain boy
+in the front row gave himself indigestion by trying to eat his meals in
+ten or fifteen minutes. It was then suggested that twenty hours a day
+would be enough for any one to stay out of doors, and that plenty of
+time should be taken for meals with the family and for cold baths,
+keeping clean, etc. Interesting facts gathered by personal interviews
+of two physicians with individual patients are explained to the whole
+class. Next to the number of hours out of doors, the most interesting
+fact is the number of hours of exercise permitted. A man of forty, the
+head of a family, beamed like a school child when told that, after
+nearly a year of absolute rest, he might during the next week exercise
+ten minutes a day. A graduate drops in, the very picture of health,
+weighing two hundred pounds. An apparently hopeless case would brighten
+up and have confidence when told that this strong, handsome man has
+gained fifty pounds by rest, good cheer, fresh air, all on his own
+porch. One young man, just back from a California sanatorium where he
+progressively lost strength in spite of change of climate, is now
+returning to work and is back at normal weight.
+
+
+    [Illustration: OUTDOOR LIFE CHART.]
+
+    [Illustration: FIGHTING TUBERCULOSIS IN THE MOUNTAINS--SARANAC]
+
+Every patient keeps a daily record, called for by the following
+instructions:
+
+  Make notes of temperature and pulse at 8, 12, 4, and 8 o'clock,
+  daily; movements of bowels; hours in open air; all food taken;
+  total amount of milk; total amount of oil and butter; appetite;
+  digestion; spirits; cough (amount, chief time); expectoration
+  (amount in 24 hours, color, nature); exercise (if allowed), with
+  temperature and pulse 15 minutes after exercise; sweats; visitors.
+
+The following simple instructions can be followed in any home, even
+where open windows must take the place of porches:
+
+  Rest out of doors is the medicine that cures consumption. Absolute
+  rest for mind and body brings speedy improvement. It stops the
+  cough and promotes the appetite. The lungs heal more quickly when
+  the body is at rest. Lie with the chest low, so the blood flow in
+  the lungs will aid to the uttermost the work of healing. The rest
+  habit is soon acquired. Each day of rest makes the next day of
+  rest easier, and shortens the time necessary to regain health. The
+  more time spent in bed out of doors the better. Do not dress if
+  the temperature is above 99 degrees, or if there is blood in the
+  sputum. It is life in the open air, not exercise, that brings
+  health and strength. Just a few minutes daily exercise during the
+  active stage of the disease may delay recovery weeks or months.
+  Rest favors digestion, exercise frequently disturbs digestion.
+  When possible have meals served in bed. Never think the rest
+  treatment can be taken in a rocking-chair. If tired of the cot,
+  shift to the reclining chair, but sit with head low and feet
+  elevated. Do not write letters. Dictate to a friend. Do not read
+  much and do not hold heavy books. While reading remain in the
+  recumbent posture.
+
+    [Illustration: FIGHTING TUBERCULOSIS IN DAY CAMPS--BOSTON]
+
+Once having learned the simple facts that must be noted and the simple
+laws that must be followed, once having placed oneself in a position
+to secure the rest, the fresh air, and the health diet, no better next
+steps can be taken than to observe the closing injunction in the rules
+for rest:
+
+  There are few medicines better than clouds, and you have not to
+  swallow them or wear them as plasters,--only to watch them.
+  Keeping your eyes aloft, your thoughts will shortly clamber after
+  them, or, if they don't do that, the sun gets into them, and the
+  bad ones go a-dozing like bats and owls.
+
+    [Illustration: THE BACK OF A STREET-CAR TRANSFER, SUNDAYS, NEW
+    YORK CITY]
+
+ +--------------------------------------------------------------------+
+ |  CONSUMPTION IN EARLY STAGES CAN BE CURED                          |
+ |                                                                    |
+ |  Take your case in time to a good physician or to a dispensary and |
+ |  you may be cured--DO NOT WAIT.                                    |
+ |                                                                    |
+ |  Consumption is "caught" mainly through the spit of consumptives.  |
+ |                                                                    |
+ |  Friends of Consumption--Dampness, Dirt, Darkness, Drink.          |
+ |                                                                    |
+ |  Enemies of Consumption--Sun, Air, Good Food, Cleanliness.         |
+ |                                                                    |
+ |  If you have tuberculosis do not give it to others by spitting;    |
+ |  even if you have not, set a good example by refraining from a     |
+ |  habit always dirty and often dangerous.                           |
+ |                                                                    |
+ |  _The Committee on the Prevention of Tuberculosis_                 |
+ |  _Of the Charity Organization Society_                             |
+ |                                                                    |
+ |  (By Courtesy of Siegel Cooper Co.)                                |
+ +--------------------------------------------------------------------+
+
+Important as are sanatoriums in mountain and desert, day or night camps
+within and near cities, milk and egg clinics, home visiting, change of
+air and rest for those who are known to be tuberculous, their
+importance is infinitesimal compared with the protection that comes
+from clean, healthy environment and natural living for those not known
+to be tuberculous. This great fact has been recognized by the various
+bodies now engaged in popularizing the truth about tuberculosis by
+means of stationary and traveling exhibits, illustrated lectures,
+street-car transfers, advertisements, farmers' institutes,
+anti-spitting signs in public vehicles and public buildings, board of
+health instructions in many languages, magazine stories, and press
+reports of conferences. This brilliant campaign of education shows what
+can be done by national, state, and county superintendents of schools,
+if they will make the most of school hygiene and civics.
+
+
+    [Illustration: AN EXAMPLE IN COÖPERATION THAT ANTI-TUBERCULOSIS
+    CRUSADERS SHOULD FOLLOW]
+
+ +-------------------------------------------------------------------+
+ | CIRCULAR ISSUED BY                                                |
+ |                                                                   |
+ | The Committee of Sanitation of the Central Federated Union of     |
+ | New York                                                          |
+ |                                                                   |
+ | The Committee on the Prevention of Tuberculosis of the Charity    |
+ | Organization Society                                              |
+ |                                                                   |
+ | 105 East 22d Street, New York City                                |
+ |                                                                   |
+ |        *       *       *       *       *                          |
+ |                                                                   |
+ | Don't Give Consumption to Others                                  |
+ |                                                                   |
+ | Don't Let Others Give It to You                                   |
+ |                                                                   |
+ |        *       *       *       *       *                          |
+ |                                                                   |
+ | =How to Prevent Consumption=                                      |
+ |                                                                   |
+ | =The spit and the small particles coughed up and sneezed out by   |
+ | consumptives, and by many who do not know that they have          |
+ | consumption, are full of living germs too small to be seen. THESE |
+ | GERMS ARE THE CAUSE OF CONSUMPTION.=                              |
+ |                                                                   |
+ |                                                                   |
+ |     =DON'T SPIT on the sidewalks--it spreads disease, and it is   |
+ |     against the law.=                                             |
+ |                                                                   |
+ |     =DON'T SPIT on the floors of your rooms or hallways.=         |
+ |                                                                   |
+ |     =DON'T SPIT on the floors of your shop.=                      |
+ |                                                                   |
+ |     =WHEN YOU SPIT, spit in the gutters or into a spittoon.=      |
+ |                                                                   |
+ |     =Have your own spittoons half full of water, and clean them   |
+ |     out at least once a day with hot water.=                      |
+ |                                                                   |
+ |     =DON'T cough without holding a handkerchief or your hand      |
+ |     over your mouth.=                                             |
+ |                                                                   |
+ |     =DON'T live in rooms where there is no fresh air.=            |
+ |                                                                   |
+ |     =DON'T work in rooms where there is no fresh air.=            |
+ |                                                                   |
+ |     =DON'T sleep in rooms where there is no fresh air.=           |
+ |                                                                   |
+ |     =Keep at least one window open in your bedroom day and        |
+ |     night.=                                                       |
+ |                                                                   |
+ |     =Fresh air helps to kill the consumption germ.=               |
+ |                                                                   |
+ |     =Fresh air helps to keep you strong and healthy.=             |
+ |                                                                   |
+ |     =DON'T eat with soiled hands--wash them first.=               |
+ |                                                                   |
+ |     =DON'T NEGLECT A COLD or a cough.=                            |
+ |                                                                   |
+ |                                                                   |
+ |   =How to Cure Consumption=                                       |
+ |                                                                   |
+ |     =DON'T WASTE YOUR MONEY on patent medicines or advertised     |
+ |       cures for consumption, but go to a doctor or a              |
+ |       dispensary. If you go in time YOU CAN BE CURED; if you      |
+ |       wait until you are so sick that you cannot work any         |
+ |       longer, or until you are very weak, it may be too late;     |
+ |       at any rate it will in the end mean more time out of work   |
+ |       and more wages lost than if you had taken care of           |
+ |       yourself at the start.=                                     |
+ |                                                                   |
+ |     =DON'T DRINK WHISKY, beer, or other intoxicating drinks;      |
+ |       they will do you no good, but will make it harder for you   |
+ |       to get well.=                                               |
+ |                                                                   |
+ |     =DON'T SLEEP IN THE SAME BED with any one else, and, if       |
+ |       possible, not in the same room.=                            |
+ |                                                                   |
+ |     =GOOD FOOD, FRESH AIR, AND REST are the best cures. Keep in   |
+ |       the sunshine as much as possible, and KEEP YOUR WINDOWS     |
+ |       OPEN, winter and summer, night and day. Fresh air, night    |
+ |       and day, is good for you.=                                  |
+ |                                                                   |
+ |     =GO TO A HOSPITAL WHILE YOU CAN AND BEFORE IT IS TOO LATE.    |
+ |       There you can get the best treatment, all the rest, all     |
+ |       the fresh air, and all the food which you need.=            |
+ |                                                                   |
+ |     =THE CAREFUL AND CLEAN CONSUMPTIVE IS NOT DANGEROUS TO THOSE  |
+ |       WITH WHOM HE LIVES AND WORKS=                               |
+ +-------------------------------------------------------------------+
+
+Is it not significant that America's national movement is due primarily
+to the organizing capacity of laymen in the New York Charity
+Organization Society rather than to schools or hospitals? Most of the
+local secretaries are men whose inspiration came from contact with the
+non-medical relief of the poor in city tenements. The secretary of the
+national association is a university professor of anthropology, who has
+also a medical degree. The child victim's plea--Little Jo's Smile--was
+nationalized by an association of laymen, aided by the advertising
+managers of forty magazines. The smaller cities of New York state are
+being aroused by a state voluntary association that for years has
+visited almshouses, insane asylums, and hospitals. These facts I
+emphasize, for they illustrate the opportunity and the duty of the lay
+educator, whether parent, teacher, labor leader, or trustee of
+hospital, orphanage, or relief society.
+
+Three fundamental rules of action should be established as firmly as
+religious principles:
+
+  1. The public health authorities should be told of every known and
+  every suspected case of tuberculosis.
+
+  2. For each case proved by examination of sputum to be
+  tuberculous, the public-health officers should know that the germs
+  are destroyed before being allowed to contaminate air or food.
+
+  3. Sick and not yet sick should practice habits of health that
+  build up vitality to resist the tubercle bacilli and that abhor
+  uncleanliness as nature abhors a vacuum.
+
+    [Illustration: FIGHTING TUBERCULOSIS WITH A NATIONAL
+    ORGANIZATION]
+
+All laws, customs, and environmental conditions opposed to the
+enforcement of these three principles must be modified or abolished. If
+the teachers of America will list for educational use in their own
+communities the local obstacles to these rules of action, they will see
+exactly where their local problem lies. The illustrations that are
+given in this book show in how many ways these rules of action are now
+being universalized. Three or four important steps deserve especial
+comment:
+
+  1. Compulsory notification of all tuberculous cases.
+
+  2. Compulsory removal to hospital of those not able at home to
+  destroy the bacilli, or compulsory supervision of home care.
+
+  3. Examination of all members of a family where one member is
+  discovered to be tuberculous.
+
+  4. Special provision for tuberculous teachers.
+
+  5. Protection of children about to enter industry but predisposed
+  to tuberculosis.
+
+  6. Prohibition of dry cleaning of schools, offices, and streets.
+
+  7. Tax provision for educational and preventive work.
+
+Compulsory notification was introduced first in New York City by
+Hermann M. Biggs, M.D., chief medical officer: 1893, partially
+voluntary, partially compulsory; 1897, compulsory for all. Physicians
+who now hail Dr. Biggs as a statesman called him persecutor, autocrat,
+and violator of personal freedom fifteen years ago. Foreign sanitarians
+vied with American colleagues in upbraiding him for his exaggeration of
+the transmissibility of consumption and for his injustice to its
+victims. As late as 1899 one British expert particularly resented the
+rejection of tuberculous immigrants at Ellis Island, and said to me,
+"Perhaps if you should open a man's mouth and pour in tubercle bacilli
+he might get phthisis, but compulsory notification is preposterous." In
+1906 the International Congress on Tuberculosis met in Paris and
+congratulated New York upon its leadership in securing at health
+headquarters a list of the known disease centers within its borders; in
+1906 more than twenty thousand individual cases were reported, ten
+thousand of these being reported more than once. To know the nature and
+location of twenty thousand germ factories is a long step toward
+judging their strength and their probable product. To compulsory
+notification in New York City is largely due the educational movements
+of the last decade against the white plague, more particularly the
+growing ability among physicians to recognize and to treat conditions
+predisposing to the disease. As in New York City, the public should
+provide free of cost bacteriological analysis of sputum to learn
+positively whether tuberculosis is present. Simpler still is the
+tuberculin test of the eyes, with which experiments are now being made
+on a large scale in New York City, and which bids fair to become cheap
+enough to be generally used wherever physical examinations are made.
+This test is known as Calmette's Eye Test. Inside the eyelid is placed
+a drop of a solution--95 per cent alcohol and tuberculin. If
+conjunctivitis develops in twenty-four hours, the patient is proved to
+have tuberculosis. Some physicians still fear to use this test. Others
+question its proof. The "skin test" is also being thoroughly tried in
+several American cities and, if finally found trustworthy, will
+greatly simplify examination for tuberculosis. Dr. John W. Brannan,
+president of Bellevue and Allied Hospitals, New York City, is to report
+on skin and eye tuberculin tests for children at the International
+Congress on Tuberculosis, mentioned later.
+
+    [Illustration: FIGHTING TUBERCULOSIS BY ORGANIZED COÖPERATIVE
+    DISPENSARY WORK]
+
+    [Illustration: FIGHTING BONE TUBERCULOSIS AT SEA BREEZE, WHERE
+    EYE AND SKIN TUBERCULIN TESTS ARE BEING MADE]
+
+Compulsory removal of careless consumptives is yet rare. One obstacle
+is the lack of hospitals. In New York ten thousand die annually from
+tuberculosis and fifty thousand are known to have it, yet there are
+only about two thousand beds available. So long as the patients anxious
+for hospital care exceed the number of beds, it does not seem fair to
+give a bed to some one who does not want it. On the other hand, it
+should not be forgotten that patients are taken forcibly to smallpox
+and scarlet-fever hospitals, not for their own good, but for the
+protection of others. The last person who should be permitted to stay
+at home is the tuberculous person who is unable, unwilling, or too
+ignorant to take the necessary precautions for others' protection. A
+rigid educational test should be applied as a condition of remaining at
+home without supervision.
+
+The objections to compulsory removal are two: (1) it is desired to make
+sanatorium care so attractive that patients will go at the earliest
+stage of the disease; (2) an unwilling patient can defeat the
+sanitarian's effort to help him and others. The alternative for
+compulsory removal is gratuitous, and, if need be, compulsory,
+supervision of home care, such as is now given in New York City. In
+Brighton, England, Dr. Newsholme treats his municipal sanatorium as a
+vacation school, giving each patient one month only. Thus one bed helps
+twelve patients each year. Almost any worker can spare one month and in
+that time can be made into a missionary of healthy living.
+
+Family examining parties were begun in New York by Dr. Linsly R.
+Williams, for the relief agency that started the seaside treatment of
+bone tuberculosis. Many of the crippled children at Sea Breeze were
+found to have consumptive fathers or mothers. In one instance the
+father had died before Charlie had "hip trouble." Long after we had
+known Charlie his mother began to fail. She too had consumption. Family
+parties were planned for 290 families. Weights were taken and careful
+examination made, the physician explaining that predisposition means
+defective lung capacity or deficient vitality. Of 379 members,
+supposedly free from tuberculosis, sixteen were found to have
+well-marked cases. (Of twenty Boston children whose parents were in a
+tuberculosis class, four had tuberculosis.) In one instance the father
+was astonished to learn not only that he was tuberculous, but that he
+had probably given the disease to the mother, for whom he was tenderly
+concerned. Of special benefit were the talks about teeth and
+nourishment, and about fresh air and water as germ killers. One
+examination of this kind will organize a family crusade against
+carelessness.
+
+    [Illustration: FIGHTING TUBERCULOSIS IN SMALL CITIES
+    New York State Charities Aid Association]
+
+Tuberculous teachers ought to be excluded from schoolrooms not merely
+because they may spread tuberculosis, but because they cannot do
+justice to school work without sacrifices that society ought not to
+accept. A tuberculous teacher ought to be generous enough to permit
+public hospitals to restore her strength or enterprising enough to
+join tuberculosis classes. It is selfish to demand independence at the
+price which is paid by schools that employ tuberculous teachers.
+
+    [Illustration: FIGHTING BONE TUBERCULOSIS WITH SALT WATER AND
+    SALT AIR]
+
+Predisposition to tuberculosis should be understood by every child
+before he is accepted as an industrial soldier. Many trades now
+dangerous would be made safe if workers knew the risk they run, and if
+society forbade such trades needlessly to exhaust their employees. A
+perfectly sound man is predisposed to tuberculosis if he elects to work
+in stale, dust-laden air. Ill-ventilated rooms, cramped positions, lack
+of exercise in the open air, prepare lungs to give a cordial reception
+to tubercle bacilli. Rooms as well as persons become infected.
+Fortunately, opportunities to work are so varied in most localities
+that workers predisposed to tuberculosis may be sure of a livelihood in
+an occupation suited to their vitality. Destruction of germs in the
+air, in carpets, on walls, on streets, is quite as important as
+destruction of germs in lungs. Why should not tenants and workers
+require health certificates stating that neither house nor working
+place is infected with tubercle bacilli? Some cities now compel the
+disinfection of premises occupied by tuberculous persons _after_ their
+removal. Landlords, employers, tenants, and employees can easily be
+taught to see the advantage of disinfecting premises occupied by
+tuberculous cases _before_ detection.
+
+    [Illustration: FIGHTING FEATHER DUSTERS IS ONE OBJECT OF SEA-AIR
+    HOSPITALS FOR BONE TUBERCULOSIS]
+
+Dry cleaning, feather dusters, dust-laden air, will disappear from
+schoolrooms within twenty-four hours after school-teachers declare that
+they shall disappear. We have no right to expect street cleaners,
+tenement and shop janitors, or overworked mothers to be more careful
+than school-teachers. Last year I said to a janitress, "Don't you
+realize that you may get consumption if you use that feather duster?"
+Her reply caused us to realize our carelessness: "I don't want any more
+than I've got now." Shall we some day have compulsory examination and
+instruction of all cleaners, starting with school cleaners?
+
+    [Illustration: FIGHTING TUBERCULOSIS IN OPEN TENTS]
+
+Taxing is swift to follow teaching in matters of health. Teachers can
+easily compute what their community loses from tuberculosis. The totals
+will for some time prove a convincing argument for cleanliness of air,
+of body, and of building wherever the community is responsible for air,
+building, and body. The annual cost of tuberculosis to New York City is
+estimated at $23,000,000 and to the United States at $330,000,000. The
+cost of exterminating it will be but a drop in the bucket if
+school-teachers do their part this next generation with the twenty
+million children whose day environment they control for three fourths
+of the year, and whose habits they can determine.
+
+The first meeting in America of the International Congress on
+Tuberculosis was held at Washington, D.C., September 21 to October 12,
+1908. For many years the proceedings of this congress will undoubtedly
+be the chief reference book on the conquest of tuberculosis.[14]
+
+How many aspects there are to this problem, and how many kinds of
+people may be enlisted, may be seen from the seven section names: I.
+Pathology and Bacteriology; II. Sanatoriums, Hospitals, and
+Dispensaries; III. Surgery and Orthopedics; IV. Tuberculosis in
+Children--Etiology, Prevention, and Treatment; V. Hygienic, Social,
+Industrial, and Economic Aspects; VI. State and Municipal Control of
+Tuberculosis; VII. Tuberculosis in Animals and Its Relation to Man.
+
+    [Illustration: FIGHTING TUBERCULOSIS IN CHEAP SHACKS, $125 PER
+    BED, OTISVILLE, NEW YORK]
+
+How many-sided is the responsibility of each of us for stamping out
+tuberculosis is shown by the preliminary programme of the eight
+sessions of Section V. These topics suggest an interesting and
+instructive year's study for clubs of women, mothers, or teachers, or
+for advanced pupils.
+
+
+I. ECONOMIC ASPECTS OF TUBERCULOSIS
+
+1. The burdens entailed by tuberculosis:
+
+    a. On individuals and families.
+    b. On the medical profession.
+    c. On industry.
+    d. On relief agencies.
+    e. On the community.
+    f. On social progress.
+
+ 2. The cost of securing effective control of tuberculosis:
+
+    a. In large cities.
+    b. In smaller towns.
+    c. In rural communities.
+
+
+II. ADVERSE INDUSTRIAL CONDITIONS
+
+ 1. Incidence of tuberculosis according to occupation.
+
+ 2. Overwork and nervous strain as factors in tuberculosis.
+
+ 3. Effect of improvements in factory conditions on the health of
+    employees.
+
+ 4. Legitimate exercise of police power in protecting the life and
+    health of employees.
+
+
+III. THE SOCIAL CONTROL OF TUBERCULOSIS
+
+ 1. Outline of a comprehensive programme for:
+
+    a. National, state, and municipal governments.
+    b. Departments of health and departments of public relief.
+    c. Private endowments.
+    d. Voluntary associations for educational propaganda.
+    e. Institutions, such as schools and relief agencies, which
+       exist primarily for other purposes.
+
+ 2. A symposium on the relative value of each of the features in an
+    aggressive campaign against tuberculosis:
+
+    a. Compulsory registration.
+    b. Free sputum examination.
+    c. Compulsory removal of unteachable and dangerous cases.
+    d. Laboratory research.
+    e. Hospital.
+    f. Sanatorium.
+    g. Dispensary.
+    h. The tuberculosis class.
+    i. Day camp.
+    j. Private physician.
+    k. Visiting nurse.
+    l. After-care of arrested cases.
+    m. Relief fund.
+    n. Climate.
+    o. Hygienic instruction,--personal and in class.
+    p. Inspection of schools and factories.
+    q. Educational propaganda.
+
+
+IV. EARLY RECOGNITION AND PREVENTION
+
+ 1. Importance of discovering the persons who have tuberculosis
+    before the disease has passed the incipient stage.
+
+ 2. Examination of persons known to have been exposed or presumably
+    predisposed.
+
+ 3. Systematic examination of school children during their course
+    and on leaving school to go to work.
+
+ 4. Professional advice as to choice of occupation in cases where
+    there is apparent predisposition to disease.
+
+
+V. AFTER-CARE OF ARRESTED CASES
+
+ 1. Instruction in healthful trades in the sanatorium.
+
+ 2. Training for professional nursing in institutions for the care
+    of tuberculous patients.
+
+ 3. Farm colonies.
+
+ 4. Convalescent homes or cottages.
+
+ 5. Aid in securing suitable employment on leaving the sanatorium.
+
+ 6. How to deal with the danger of a return to unfavorable home
+    conditions.
+
+
+VI. EDUCATIONAL METHODS AND AGENCIES
+
+ 1. Special literature for general distribution.
+
+ 2. Exhibits and lectures.
+
+ 3. The press.
+
+ 4. Educational work of the nurse.
+
+ 5. Labor organizations.
+
+ 6. Instruction in schools of all grades.
+
+ 7. Presentation and discussion of leaflets awarded prizes by the
+    congress.
+
+
+VII. PROMOTION OF IMMUNITY
+
+ 1. Development of the conception of physical well-being.
+
+ 2. Measures for increasing resistance to disease:
+
+    a. Parks and playgrounds.
+    b. Outdoor sports.
+    c. Physical education.
+    d. Raising the standards of living: housing, diet,
+       cleanliness.
+
+ 3. Individual immunity and social conditions favorable to general
+    immunity.
+
+
+VIII. RESPONSIBILITY OF SOCIETY FOR TUBERCULOSIS
+
+ 1. A symposium of representative
+
+    a. Citizens.
+    b. Social workers.
+    c. Employers.
+    d. Employees.
+    e. Physicians.
+    f. Nurses.
+    g. Educators.
+    h. Others.
+
+Cash prizes of one thousand dollars each are offered: (1) for the best
+evidence of effective work in the prevention or relief of tuberculosis
+by any voluntary association since 1905; (2) for the best exhibit of a
+sanatorium for working classes; (3) for the best exhibit of a furnished
+home for the poor, designed primarily to prevent, but also to permit
+the cure of tuberculosis.
+
+    [Illustration: BOSTON FIGHTS TUBERCULOSIS WITH A COMPREHENSIVE PLAN
+    _A-D, F, H-J_, private hospitals and agencies reporting cases to
+    the official center; _E_, home care; _K, L, M_, day camp and
+    hospitals for incipient and advanced cases]
+
+A white-plague scrapbook containing news items, articles, and
+photographs will prove an interesting aid to self-education or to
+instruction of children, working girls' clubs, or mothers' meetings.
+Everybody ought to enlist in this war, for the fight against
+tuberculosis is a fight for cleanliness and for vitality, for a fair
+chance against environmental conditions prejudicial to efficient
+citizenship.
+
+So sure is the result and so immediate the duty of every citizen that
+Dr. Biggs wrote in 1907: _In no other direction can such large results
+be achieved so certainly and at such relatively small cost. The time is
+not far distant when those states and municipalities which have not
+adopted a comprehensive plan for dealing with tuberculosis will be
+regarded as almost criminally negligent in their administration of
+sanitary affairs and inexcusably blind to their own best economic
+interests._
+
+FOOTNOTES:
+
+[13] The best literature on tuberculosis is in current magazines and
+reports of anti-tuberculosis crusaders. For a scientific, comprehensive
+treatment, libraries and students should have _The Prevention of
+Tuberculosis_ (1908) by Arthur Newsholme, M.D. A popular book is _The
+Crusade against Tuberculosis_, by Lawrence F. Flick, of the Henry Phipps
+Institute for the Study, Treatment, and Prevention of Tuberculosis.
+
+[14] Those desiring copies this year or hereafter will do well to write
+to The National Association for the Study and Prevention of
+Tuberculosis, 105 East 22d St., New York City. The congress is under the
+control of the National Association and is managed by a special
+committee appointed by it. Even after a national board of health is
+established, the National Association for the Study and Prevention of
+Tuberculosis will continue to be a center for private interest in public
+protection against tuberculosis. One of its chief functions is the
+preparation and distribution of literature to those who desire it.
+
+
+
+
+CHAPTER XXV
+
+THE FIGHT FOR CLEAN MILK
+
+
+"With the approval of the President and with the coöperation of the
+Department of Agriculture,[15] the [national quarantine] service has
+undertaken to prepare a complete report upon the milk industry from
+farm to the consumer in its relation to the public health." This
+promise of the United States Treasury insures national attention to the
+evils of unclean milk and to the sanitary standards of farmer and
+consumer. Nothing less than a national campaign can make the vivid
+impression necessary to wean dairymen of uncleanly habits and mothers
+of the ignorant superstition that babies die in summer just because
+they are babies. When two national bureaus study, learn, and report,
+newspapers will print their stories on the first page, magazines will
+herald the conclusions, physicians will open their minds to new truths,
+state health secretaries will carry on the propaganda, demagogues and
+quacks will become less certain of their short-cut remedies, and
+_everybody will be made to think_.
+
+The evolution of this newly awakened national interest in clean milk
+follows the seven stages and illustrates the seven health motives
+presented in Chapter II. I give the story of Robert M. Hartley because
+he began and prosecuted his pure-milk crusade in a way that can be
+duplicated in any country town or small city.
+
+Robert M. Hartley was a strong-bodied, strong-minded, country-bred man,
+who started church work in New York City almost as soon as he arrived.
+He distributed religious tracts among the alleys and hovels that
+characterized lower New York in 1825. Meeting drunken men and women one
+after another, he first wondered whether they were helped by tracts,
+and then decided that the mind befogged with alcohol was unfit to
+receive the gospel message. Then for fifteen years he threw himself
+into a total-abstinence crusade, distributing thousands of pamphlets,
+calling in one year at over four thousand homes to teach the industrial
+and moral reasons for total abstinence. Finally, he began to wonder
+whether back of alcoholism there was not still a dark closet that must
+be explored before men could receive the message of religion and
+self-control. So in 1843 he organized the New York Association for
+Improving the Condition of the Poor, which ever since has remembered
+how Hartley found alcoholism back of irreligion, and how back of
+alcoholism and poverty and ignorant indifference he found indecent
+housing, unsanitary streets, unwholesome working conditions, and impure
+food.
+
+    [Illustration: FIGHTING INFANT MORTALITY BY A SCHOOL FOR MOTHERS
+    IN THE HEART OF NEW YORK CITY,--JUNIOR SEA BREEZE]
+
+    [Illustration: PROVIDING AGAINST GERM GROWTH AND ADAPTING MILK
+    TO THE INDIVIDUAL BABY'S NEED,--ROCHESTER'S MODEL DAIRY]
+
+Hartley's instinct started the first great pure-milk agitation in this
+country. While visiting a distillery for the purpose of trying to
+persuade the owner to invest his money in another business, he noticed
+that "slops smoking hot from the stills" were being carried to cow
+stables. He followed and was nauseated by the sights and odors. Several
+hundred uncleaned cows in low, suffocating, filthy stables were being
+fed on "this disgusting, unnatural food." Similar disgust has in many
+other American cities caused the first effort to better dairy
+conditions. Hartley could never again enjoy milk from distillery cows.
+Furthermore, his story of 1841 made it impossible for any readers of
+newspapers in New York to enjoy milk until assured that it was not
+produced by distillery slops. The instinctive loathing and the
+discomfort of buyers awakened the commerce motives of milk dealers, who
+covered their wagons with signs declaring that they "no longer" or
+"never" fed cows on distillery refuse. But Hartley could not stop when
+the anti-nuisance stage was reached. He did not let up on his fight
+against impure or adulterated milk until the state legislature declared
+in 1864 that _every baby, city born or country born, no matter how
+humble its home, has the right to pure milk_.
+
+ +-------------------------------------------------------------------+
+ |  =Clean Milk for New York City=                                   |
+ |                                                                   |
+ |  =CONFERENCE=                                                     |
+ |                                                                   |
+ |  =ROOM 44, N.Y. ACADEMY OF MEDICINE=                              |
+ |  =No. 17 WEST 43D STREET=                                         |
+ |                                                                   |
+ |  =November 20th, 1906, Tuesday 3 p.m. and 8 p.m.=                 |
+ |                                                                   |
+ |                                                                   |
+ |  =ESSENTIAL FACTS AS TO NEW YORK CITY=                            |
+ |                                                                   |
+ |  =Manhattan's Infant Mortality=                                   |
+ |  (=UNDER 5 YRS.=)                                                 |
+ |                                                                   |
+ |    June to September, 1904, 4428                                  |
+ |    June to September, 1905, 4687                                  |
+ |    June to September, 1906, 4428                                  |
+ |                                                                   |
+ |  =Daily Consumption of Milk=                                      |
+ |                                                                   |
+ |    1,600,000 qts.                                                 |
+ |    ¼ in quart bottles                                             |
+ |    ¾ in 40-quart cans                                             |
+ |    "Certified," 10,000 quarts                                     |
+ |    "Inspected," 3,000 quarts                                      |
+ |    24 to 48 hours old on arrival                                  |
+ |                                                                   |
+ |  =Comes from=                                                     |
+ |                                                                   |
+ |    30,000 dairies, 40 to 400 miles distant                        |
+ |    600 creameries--105 proprietors                                |
+ |    10 city railroad depots                                        |
+ |                                                                   |
+ |  =Sold in=                                                        |
+ |                                                                   |
+ |    12,000 places, mostly from cans                                |
+ |    Sale of skim milk prohibited                                   |
+ |                                                                   |
+ |  =Milk Law Violations, 1905=                                      |
+ |                                                                   |
+ |    Destroyed, 39,618 quarts                                       |
+ |    Arrests, 806                                                   |
+ |    Fines, $16,435                                                 |
+ |                                                                   |
+ |  =New York City Inspectors=                                       |
+ |                                                                   |
+ |    14 in country since July; might make rounds not oftener than   |
+ |      once a year                                                  |
+ |        (For 3 yrs. before, only 2; previously none)               |
+ |    16 in city, might make rounds in 30 to 40 days                 |
+ |        (Before July, 14)                                          |
+ |                                                                   |
+ |                                                                   |
+ |  =POINTS OF AGREEMENT=                                            |
+ |                                                                   |
+ |  =Cleanliness is the supreme requisite, from cow to consumer=     |
+ |                                                                   |
+ |    Cows must be healthy, persons free from contagious diseases,   |
+ |     premises clean, water pure, utensils clean, cans and bottles  |
+ |     sterile, shops sanitary                                       |
+ |                                                                   |
+ |  =Temperature is second essential=                                |
+ |                                                                   |
+ |    50° F. or lower at dairy                                       |
+ |    45° F. at creamery                                             |
+ |    45° F. or less during transportation                           |
+ |    Not above 50° when sold to the consumer                        |
+ |                                                                   |
+ |  =As to Pasteurization=                                           |
+ |                                                                   |
+ |    Not necessary for absolutely clean milk                        |
+ |    Destroys benign as well as harmful germs                       |
+ |    Disease germs develop more rapidly than in pure raw milk       |
+ |    True, 155° for 30 minutes to 167° for 20 minutes               |
+ |       Cost per quart, estimated, ¼ to ½ ct.                       |
+ |    Commercial, 165° for 15 seconds                                |
+ |      Cost per quart, negligible                                   |
+ |                                                                   |
+ |  =As to Inspection=                                               |
+ |                                                                   |
+ |    _Some_ inspection needed within the city                       |
+ |    _Some_ inspection needed of dairy and creamery                 |
+ |                                                                   |
+ |                                                                   |
+ |  =WHAT NEXT STEPS SHOULD NEW YORK TAKE?=                          |
+ |                                                                   |
+ |  =Skim Milk=                                                      |
+ |                                                                   |
+ |    Should its sale be permitted?                                  |
+ |    Under what conditions?                                         |
+ |    How would this affect price of whole milk?                     |
+ |                                                                   |
+ |  =Pasteurization=                                                 |
+ |                                                                   |
+ |    Should pasteurization be made compulsory?                      |
+ |      For what portion of the supply?                              |
+ |      At whose expense?                                            |
+ |    Would it increase price of milk?                               |
+ |    Does it render inspection unnecessary?                         |
+ |    Does it reduce need for inspection?                            |
+ |    Should sale of repasteurized milk or cream be permitted?       |
+ |    Should bottles show whether true or commercial pasteurization  |
+ |      is used?                                                     |
+ |                                                                   |
+ |  =Infants' Milk Depots=                                           |
+ |                                                                   |
+ |    Should they use pasteurized or clean milk?                     |
+ |    Are municipal depots desirable?                                |
+ |    Should private philanthropy support depots?                    |
+ |    How many depots would be required in New York City?            |
+ |    Is Rochester experience applicable to New York City?           |
+ |    What educational work is possible in connection with milk      |
+ |      depots?                                                      |
+ |                                                                   |
+ |                                                                   |
+ |  =Model Milk Shops=                                               |
+ |                                                                   |
+ |    What may safely be sold in connection with milk?               |
+ |    Should law discourage other than model shops?                  |
+ |    Are present sanitary laws rigid enough?                        |
+ |    Should private capital be encouraged to establish shops?       |
+ |    Is it practicable to prohibit use of cans?                     |
+ |    What provision can be demanded for proper refrigeration?       |
+ |    What for receiving milk before business hours when delivered   |
+ |      from stations?                                               |
+ |    What for sterilization of utensils and bottles?                |
+ |    What for attendants' dress and care of person?                 |
+ |    Would such restrictions increase price?                        |
+ |                                                                   |
+ |  =Inspection=                                                     |
+ |                                                                   |
+ |    Is it practicable by inspection alone to secure a clean milk   |
+ |      supply?                                                      |
+ |    Will it protect against more dangerous forms of infection?     |
+ |    How many inspectors does New York City need?                   |
+ |      Within the city?                                             |
+ |      Among country dairies and creameries?                        |
+ |    How many inspectors should the state employ?                   |
+ |                                                                   |
+ |  =Legislation=                                                    |
+ |                                                                   |
+ |    What needed as to diseased cattle?                             |
+ |    What as to diseases of persons producing or handling milk?     |
+ |    Is present sanitary code sufficient?                           |
+ |    Shall law require sterilization of all milk cans and bottles   |
+ |      by milk company or creamery before returned to farms or      |
+ |      refilled?                                                    |
+ |    Shall sealing cans at creameries be required?                  |
+ |    Shall transferring from one can to another or from can to      |
+ |      bottle in open street be made a misdemeanor?                 |
+ |    Shall pollution of milk cans and bottles be made a             |
+ |      misdemeanor?                                                 |
+ |    Shall bacterial standard be established?                       |
+ |    Is state supervision now adequate?                             |
+ |    What further legislation is needed?                            |
+ |    Does present law prescribe adequate penalties?                 |
+ |                                                                   |
+ |  =Education=                                                      |
+ |                                                                   |
+ |    Should state system of lectures before agricultural institutes |
+ |      be extended?                                                 |
+ |    Should Maryland plan of traveling school be adopted as means   |
+ |      of reaching producer?                                        |
+ |    What can be done to assist Teachers College in its plan for    |
+ |      milk exhibit?                                                |
+ |    What can be done to teach mothers to detect unclean milk and   |
+ |      to care properly for milk purchased?                         |
+ |    How can tenement mothers keep milk at proper temperature?      |
+ |    Can nothing be done to increase the supply and cheapen the     |
+ |      price of ice?                                                |
+ |    Is it desirable that a local committee be formed to coöperate  |
+ |      with the Department of Health and County Medical Society?    |
+ +-------------------------------------------------------------------+
+
+Unfortunately Hartley and his contemporaries had never heard of disease
+germs that are carried by unclean milk into the human stomach. Science
+had not yet proved that many forms of barnyard filth could do quite as
+much harm as distillery refuse. Commerce had not invented milk bottles
+of glass or paper. The law of 1864 failed in two particulars: (1) it
+did not demand cleanliness from cow to consumer; (2) it did not provide
+means for its own enforcement, for learning whether everything and
+everybody that had to do with milk was clean. Not knowing of germs and
+their love for a warm climate and warm food, they naturally did not
+prohibit a temperature above fifty degrees from the time of milking to
+the time of sale. How much has been left for our generation to do to
+secure pure milk is illustrated by the opening sentence of this
+chapter, and more specifically by the programme of a milk conference
+held in New York in November, 1906, the board of health joining in the
+call. The four-page folder is reproduced in facsimile (excepting the
+names on the fourth page), because it states the universal problem, and
+also because it suggests an effective way to stimulate relevant
+discussion and to discourage the long speeches that spoil many
+conferences.
+
+This conference led to the formation of a milk committee under the
+auspices of the association founded by Hartley. Business men,
+children's specialists, journalists, clergymen, consented to serve
+because they realized the need for a continuing public interest and a
+persisting watchfulness. Such committees are needed in other cities and
+in states, either as independent committees or as subcommittees of
+general organizations, such as women's clubs, sanitary leagues, county
+and state medical societies. Teachers' associations might well be
+added, especially for rural and suburban districts where they are more
+apt than any other organized body to see the evils that result from
+unclean milk. The New York Milk Committee set a good example in paying
+a secretary to give his entire time to its educational programme,--a
+paid secretary can keep more volunteers and consultants busy than could
+a dozen volunteers giving "what time they can spare." Thanks chiefly to
+the conference and the Milk Committee's work, several important results
+have been effected. The general public has realized as never before
+that two indispensable adjectives belong to safe milk,--_clean_ and
+_cool_. Additional inspectors have been sent to country dairies;
+refrigeration, cans, and milk have been inspected upon arrival at
+night; score cards have been introduced, thanks to the convincing
+explanations of their effectiveness by the representatives of the
+Bureau of Animal Industry of the national Department of Agriculture;
+8640 milch cows were inspected by veterinary practitioners (1905-1907),
+to learn the prevalence of bovine tuberculosis (of these thirty-six per
+cent reacted to the tuberculin test); state societies and state
+departments have been aroused to demand an efficient live-stock
+sanitary board; magistrates have fined and imprisoned offenders against
+the milk laws, where formerly they "warned"; popular illustrated milk
+lectures were added to the public school courses; illustrated cards
+were distributed by the thousand, telling how to keep the baby well;
+finally, private educational and relief societies, dispensaries,
+settlements, have been increasingly active in teaching mothers at home
+how to prepare baby's milk. In 1908 a Conference on Summer Care of
+Babies was organized representing the departments of health and
+education, and fifty private agencies for the care of sick babies and
+the instruction of mothers. The superintendent of schools instructed
+teachers to begin the campaign by talks to children and by giving out
+illustrated cards. Similar instructions were sent to parochial schools
+by the archbishop.
+
+    [Illustration: NIGHT INSPECTION OF COUNTRY MILK UPON ARRIVAL IN
+    NEW YORK CITY]
+
+As elsewhere, there are two schools of pure-milk crusaders: (1) those
+who want cities to _do things_, to pasteurize all milk, start milk
+farms, milk shops, or pure-milk dispensaries; and (2) those who want
+cities and states to _get things done_. So far the New York Milk
+Committee has led the second school and has opposed efforts to
+municipalize the milk business. The leader of the other school is the
+noted philanthropist, Nathan Strauss, who has established
+pasteurization plants in several American and European cities. The
+discussion of the two schools, similar in aim but different in method,
+is made more difficult, because to question philanthropy's method
+always seems to philanthropy itself and to most bystanders an
+ungracious, ungrateful act. As the issue, however, is clean milk, not
+personal motive, it is important that educators and parents in all
+communities benefit from the effective propaganda of both schools,
+using what is agreed upon as the basis for local pure-milk crusades,
+reserving that which is controversial for final settlement by research
+over large fields that involve hundreds of thousands of tests.
+
+    [Illustration: A NEW YORK MILK COMMITTEE'S INFANT DEPOT AND
+    SCHOOL FOR MOTHERS]
+
+Pasteurization, municipal dairies, municipal milk shops, municipal
+infant-milk depots, are the four chief remedies of the _doing things_
+school. European experience is cited in support of each. We are told
+that cow's milk, intended by nature for an infant cow with four
+stomachs, is not suited, even when absolutely pure, to the human
+infant's single stomach. Cow's milk should be modified, weakened,
+diluted, to fit the digestive powers of the individual infant; hence
+the municipal depot or milk dispensary that provides exactly the right
+milk for each baby, prescribed by municipal physicians and nurses who
+know. That the well-to-do and the just-past-infancy may have milk as
+safe as babies receive at the depot, municipalization of farm and milk
+shop is advocated. Some want the city to run only enough farms and milk
+shops to set a standard for private farmers, as has been done in
+Rochester. This is city ownership and operation for educational
+purposes only. Finally, because raw milk even from clean dairies may
+contain germs of typhoid, scarlet fever, or tuberculosis,
+pasteurization is demanded to kill every germ. There are advocates of
+pasteurization that deprecate the practice and deny that raw milk is
+necessarily dangerous; they favor it for the time being until farms and
+shops have acquired habits of cleanliness. Likewise many would prefer
+private pasteurization or laws compelling pasteurization of all milk
+offered for sale; but they despair of obtaining safe milk unless city
+officials are held responsible for safety. Why wait to discuss
+political theories about the proper sphere for government, when, by
+acting, hundreds of thousands of lives can be saved annually? These
+methods of _doing things_ will not add to the price of milk; it is, in
+fact, probable that the reduction in the cost of caring for the sick
+and for inspecting farms and shops will offset the net cost of depots,
+farms, and dairies.
+
+    [Illustration: ONE OF ROCHESTER'S SCHOOLS IN CLEANLINESS]
+
+    [Illustration: ROCHESTER'S MODEL DAIRY FARM]
+
+As to pasteurization, its cost is negligible, while the cost of
+cleanliness is two, four, or ten cents a quart. Whether ideally clean
+milk is safe or not, raw milk that is not clean is unfit for human
+consumption. All cities should compel evidence of pasteurization as a
+condition of sale. Large cities should have their own pasteurizing
+plants, just as many cities now have their own vaccine farms and
+antitoxin laboratories. Parents in small towns and in the country
+should be taught to pasteurize all milk.
+
+The _getting things done_ school admits the need for modified milk of
+strength suited to the infant's stomach; affirms the danger of milk
+that contains harmful germs; demands educational work by city, state,
+and nation; confesses that talk about cleanliness will not make milk
+safe. On the other hand, it denies that raw milk is necessarily
+dangerous; that properly modified, clean, raw milk is any safer when
+pasteurized; that talking about germ-proof milk insures germ
+extinction. It maintains that pasteurization kills benign germs
+essential to the life of milk, and that after benign germs are killed,
+pasteurized milk, if exposed to infection, is more dangerous than raw
+milk, for the rapid growth of harmful germs is no longer contested by
+benign germs fighting for supremacy. While it is admitted that raw milk
+produced under ideal conditions may become infected by some person
+ignorant of his condition, and before detection may cause typhoid,
+scarlet fever, or consumption, it has not been proved that such
+instances are frequent or that the aggregate of harm done equals that
+which pasteurized milk may do. Pasteurization does not remove chemical
+impurities; boiling dirt does not render it harmless. The remedy for
+germ-infected milk is to keep germs out of milk. The remedy for unclean
+milk is cleanliness of cow, cow barn, cowyard, milker, milk can,
+creamery, milk shop, bottle, nipple. If the sale of unclean milk is
+prevented, farmers will, as a matter of course, supply clean milk. By
+teaching farmers and milk retailers the economic advantages of
+cleanliness they will cultivate habits that guarantee a clean milk
+supply. By punishing railroads and milk companies that transport milk
+at a temperature which encourages germ growth, and by dumping in the
+gutter milk that is offered for sale above 50 degrees, the
+refrigerating of milk will be made the rule. Purging magistrates'
+courts of their leniency toward dealers in impure, dangerous milk is
+better than purging milk of germs. Boiling milk receptacles will save
+more babies than boiling milk. Teaching mothers about the care of
+babies will bring better results than giving them a false sense of
+safety, because only one of many dangers has been removed by
+pasteurization. Educating consumers to demand clean milk and to
+support aggressive work by health departments leaves fewer evils
+unchecked than covering up uncleanliness by pasteurization.
+
+    [Illustration: NEW YORK MILK COMMITTEE'S GRAPHIC METHOD OF
+    SHOWING BABIES' PROGRESS]
+
+    [Illustration: PRODUCING WINTER CONDITIONS IN MIDSUMMER BY
+    PROPER REFRIGERATION FOR MILK IN FREIGHT CARS]
+
+When doctors disagree what are we laymen to do? We can take an
+intelligent interest in the inquiries that are now being made by city,
+state, and national governments. Because everybody believes that clean
+milk is safer than unclean milk, that milk at 50 degrees will not breed
+harmful germs, we can demand milk inspection that will tell our health
+officers and ourselves which dealers sell only clean milk at 50 degrees
+and never more than 60 degrees, that never shows over 100,000 colonies
+to the cubic centimeter. We can get our health departments to publish
+the results of their scoring of dairies and milk shops in the papers,
+as has been done in Montclair. We can tell our health officers that the
+best results in fighting infant mortality are at Rochester, which city,
+winter and summer, by inspection, correspondence, and punishment,
+educates farmers and dealers in cleanliness, not only censuring when
+dirty or careless, but explaining how to make more money by being
+clean. Finally, mothers can be taught at home how to cleanse the
+bottles, the nipples, all milk receptacles, and all things in rooms
+where milk is kept. Absolutely clean milk of proper temperature _at the
+shop_ may not safely be given to a baby in a dirty bottle. Infant milk
+depots, pasteurization, the best medical and hospital care, breast
+feeding itself, cannot prevent high baby mortality if mothers are not
+clean. The most effective volunteer effort for pure milk is that which
+first makes the health machinery do its part and then teaches, teaches,
+teaches mothers and all who have to do with babies.
+
+    [Illustration: NEITHER PASTEURIZATION NOR INSPECTION CAN MAKE IT
+    SAFE TO SELL "DIP MILK" UNDER SUCH UNCLEAN CONDITIONS]
+
+"Clean air, clean babies, clean milk," has been the slogan of Junior
+Sea Breeze,--a school for mothers right in the heart of New York's
+upper East Side. In the summer of 1907 twenty nurses went from house to
+house telling 102,000 mothers how to keep the baby well. This was the
+only district that had fewer baby deaths than for 1906. Had other parts
+of the city shown the same gain, there would have been a saving of 1100
+babies. The following winter a similar work was conducted by nurses
+from the recently founded Caroline Rest, which has an educational fund
+for instruction of mothers in the care of babies, especially babies not
+yet born and just born. Heretofore the baby has been expected to cry
+and to have summer complaint before anybody worried about the treatment
+it received. If the baby lived through its second summer, it was
+considered great good fortune. Junior Sea Breeze and Caroline Rest
+start their educational work before the baby is sick, in fact, before
+it is born. Their results have been so notable that several well-to-do
+mothers declare that they wish they too might have a school.
+Dispensaries and diet kitchens and more particularly maternity wards of
+hospitals, family physicians, nurses, and midwives, should be required
+to know how to teach mothers to feed babies regularly, the right
+quantities, under conditions that insure cleanliness whether the breast
+or the bottle is used. Perhaps some day no girl will be given a
+graduating certificate, or a license for work, teaching, or marriage,
+until she has demonstrated her ability to give some mother's baby
+"clean air, clean body, clean milk."
+
+FOOTNOTES:
+
+[15] Libraries should obtain all reports on milk, Bureau of Animal
+Industry, Washington, D.C.
+
+
+
+
+CHAPTER XXVI
+
+PREVENTIVE "HUMANIZED" MEDICINE: PHYSICIAN AND TEACHER
+
+
+No profession, excepting possibly the ministry, is regarded with
+greater deference than the medical profession. Our ancestors listened
+with awe and obedience to the warnings and behests of the medicine man,
+bloodletter, bonesetter, family doctor. In modern times doctors have
+disagreed with each other often enough to warrant laymen in questioning
+the infallibility of any individual healer or any sect, whether
+homeopath, allopath, eclectic, osteopath, or scientist. Yet to this day
+most of us surround the medical profession or the healing art with an
+atmosphere of necromancy. Even after we have given up faith in drugs or
+after belief is denied in the reality of disease and pain, we revere
+the calling that concerns itself, whether gratuitously or for pay, with
+conquering bodily ills.
+
+Self-laudation continues this hold of the medical profession upon the
+lay imagination. One physician may challenge another's faults, ridicule
+his remedies, call his antitoxin dangerous poison, but their common
+profession he proudly styles "the most exalted form of altruism." Young
+men and women beginning the study or the practice of medicine are
+exhorted to continue its traditions of self-denial, and in their very
+souls to place human welfare before personal or pecuniary advancement.
+Newspapers repeat exhortation and laudation. We laymen pass on the
+story that we know is not universally true,--physicians know,
+physicians apply what they know without consciousness of error,
+physicians must be implicitly trusted.
+
+For a physician to give poison when he means to give food is worse, not
+better, than for a layman to make the same mistake. Neither the moral
+code nor the law of self-preservation enjoins a tuberculous mother to
+take alcohol or to sleep in an unventilated room, even if an uninformed
+physician prescribes it. Instruction in physiology and hygiene would be
+futile if those who are educated as to the elementary facts of hygiene
+and physiology must blindly follow blind physicians. A family doctor
+who gives cod-liver oil for anæmia due to adenoids may do a child as
+much harm as a nurse who drugs the baby to make it sleep. The physician
+who refuses to tell the board of health when smallpox or typhoid fever
+first breaks out takes human life just as truly as if he tore up the
+tracks in front of an express train. This is another way of saying that
+parents and teachers must fit themselves to know whether the family
+physician and their community's physicians are efficient practitioners
+and teachers. Every one can learn enough about the preventable causes
+of sickness and depleted vitality to insist upon the ounce of education
+and prevention that is better than a pound of cure.
+
+For its sins of omission, as for its sins of commission, the medical
+profession shares responsibility with laymen. For years leading
+educators, business men, hospital directors, public officials, have
+known that communicable diseases could be stamped out. The methods have
+been demonstrated. There is absolutely no excuse to-day for epidemics
+of typhoid in Trenton, Pittsburg, or Scranton, for epidemics of scarlet
+fever in the small towns of Minnesota, for uninterrupted epidemics of
+tuberculosis everywhere. Had either laymen, physicians, or
+school-teachers made proper use of the knowledge that has been in
+text-books for a generation, this country would be saving thousands of
+lives and millions of dollars every year. Our _doing_ and _getting
+done_ have lagged behind our _knowing_.
+
+The failure of physicians to "socialize" or "humanize" their knowledge
+is due to two causes: (1) no one has been applying _result tests_ to
+the profession as a whole and to the state in its capacity as doctor,
+testing carefully the sickness rate, the death rate, and the expense
+rate of preventable diseases; (2) physicians themselves have not needed
+to know, either at college or in practice, the tax levied upon their
+communities by preventable sickness. Public schools can do much to
+secure result tests for individual physicians, for the profession as a
+whole, and for boards of health. Schooling in preventive medicine, or,
+better named, schooling in preventive hygiene, will fit physicians to
+do their part in eradicating preventable disease.
+
+Preventive hygiene is not an essential part of the training of American
+physicians or nurses to-day. Not only are there no colleges of
+preventive hygiene, but medical schools have not provided individual
+courses. It is possible for a man to graduate with honors from our
+leading medical colleges without knowing what "vital statistics" means.
+Even boards of health, their duties and their educational
+opportunities, are not understood by graduates; it is an accident if
+the "social and economic aspects of medical practice," "statistical
+fallacies," "hospital administration," "infant mortality," are familiar
+terms. It is for this reason, rather than because physicians are
+selfish, that indispensable and beneficent legislation is so generally
+opposed by them when the prerogatives of their profession seem in
+danger. Practically every important sanitary advance of the past
+century has been fought at the outset by those whose life work should
+have made them see the need. Physicians bitterly attacked compulsory
+vaccination, medical inspection of schools, compulsory notification of
+communicable diseases. What is perhaps more significant of the
+physician's indifference to preventive hygiene is the fact that most of
+the sanitary movements that have revolutionized hygienic conditions in
+America owe their inception and their success to laymen, for example,
+tenement-house reform, anti-child labor and anti-tuberculosis crusades,
+welfare work in factories, campaigns for safety appliances, movement
+for a national board of health, prison, almshouse, and insane-asylum
+reform, schools for mothers, and milk committees. The first hospital
+for infectious diseases, the first board of health, the first
+out-of-door sea-air treatment of bone tuberculosis in the United
+States, were the result of lay initiative.
+
+Dr. Hermann M. Biggs says that in America the greatest need of the
+medical profession and of health administration is training that will
+enable physicians and lay inspectors to use their knowledge of
+preventive hygiene for the removal of living and working conditions
+that cause preventable sickness. A physician without knowledge of
+preventive hygiene is simply doing a "general repair" business.
+
+For a few months in 1907 New York City had a highly efficient
+commissioner of street cleaning, who, in spite of the unanimous
+protests and appeals of the press, refused to give up the practice of
+medicine. Hitherto the board of health of that city has been unable to
+obtain the full time of its physicians because professional standards
+give greater credit to the retail application of remedies than to the
+wholesale application of preventives.
+
+Statesmanship as well as professional ability is expected of physicians
+in the leading European cities, more particularly of those connected
+with health departments. There it is not felt that a medical degree is
+of itself a qualification for sanitary or health work. After the
+professional course, physicians must take courses in preventive hygiene
+and in health administration. Medical courses include such subjects as
+vital statistics, duties of medical officers of health, sanitary
+legislation, state medicine.
+
+The needless cost for one year of "catching" diseases in New York City
+would endow in perpetuity all the schools and lectureships and journals
+necessary to teach preventive hygiene in every section of this great
+country. That city alone sacrifices twenty-eight thousand lives
+annually to diseases that are officially called preventable. The yearly
+burial cost of these victims of professional and community neglect is
+more than a million dollars. When to the doctor bills, wages lost,
+burial cost of those who die are added the total doctor bills, wages
+lost, and other expenses of the sick who do not die, we find that one
+city loses in dollars and cents more every year from communicable
+diseases than is spent by the whole United States for hospitals and
+boards of health.
+
+Many diseases and much sickness are preventable that are not
+communicable. Indigestion due to bad teeth is not itself communicable,
+but it can be prevented. One's vitality may be sapped by irregular
+eating or too little sleep; others will not catch the trouble, although
+too often they imitate the harmful habits. Adenoids and defective
+vision are preventable, but not contagious. Spinal curvature and flat
+foot are unnecessary, but others cannot catch them. Preventive hygiene,
+however, should teach the physician's duty to educate his patient and
+his community regarding all controllable conditions that injure or
+promote the health.
+
+In the absence of special attention to preventive medicine new truth is
+forced to fight its way, sometimes for generations, before it is
+accepted by the medical profession. So strong are the traditions of
+that profession and so difficult is it for the unconventional or
+heterodox individual to retain the confidence of conservative patients,
+that the forces of honorable medical practice tend to discourage
+research and invention. The man who discovers a surgical appliance is
+forced by the ethics of his profession either to commercialize it and
+lose his professional standing, or to abide the convenience of his
+colleagues and their learned organizations in testing it. Rather than
+be branded a quack, charlatan, or crank, the physician keeps silent as
+to convictions which do not conform to the text-books. Many a
+life-saving, health-promoting discovery which ought to be taken up and
+incorporated into general practice from one end of the country to the
+other, and which should be made a part of the minimum standard of
+medical practice and medical agreement, must wait twenty-five or fifty
+years for recognition.
+
+    [Illustration: THE DISCIPLE OF FRESH AIR AND HOME INSTRUCTION IS
+    STILL AN OUTCAST IN SCORES OF HOSPITALS]
+
+For want of a school of preventive medicine to emphasize universally
+every new truth, the medical colleges are permitted to remain
+twenty-five or fifty years behind absolutely demonstrated facts as to
+medical truth and medical practice. In 1761 a German physician,
+Avenbruger, after discovering that different sounds revealed diseased
+tissue, used "chest tapping" in the diagnosis of lung trouble. In 1815
+Lëannec discovered that sound from the chest was more distinct through
+a paper horn. On that principle the modern stethoscope is built. He
+made an accurate diagnosis of tuberculosis, and while suffering from
+that disease treated himself as a living clinical study. In 1857
+Pasteur proved the presence of germs "without which no putrefaction, no
+fermentation, no decay of tissue takes place." In 1884 Trudeau started
+the first out-of-door care of pulmonary tuberculosis in America. In
+1892 Biggs secured the compulsory notification of pulmonary
+tuberculosis. In 1904 began our first out-of-door sea-air treatment for
+bone tuberculosis. Yet there are thousands of physicians to-day who
+sincerely believe that they are earning their fees, who, from houses
+shut up like ovens, give advice to patients for treatment of
+tuberculosis, who prescribe alcohol and drugs, who diagnose the disease
+as malaria for fear patients will be scared, who oppose compulsory
+registration, and who never look for the tuberculous origin of crippled
+children. Just think of its being possible, in 1908, for a tuberculous
+young man of thirty to pay five dollars a day to a sanatorium whose
+chief reliance is six doses of drugs a day!
+
+In 1766 America's first dentist came to the United States. By 1785
+itinerant dentists had built up a lucrative practice. In 1825 a course
+of lectures on dentistry was delivered before the medical class at the
+University of Maryland. As early as 1742 treatises were written "Upon
+Dentition and the Breeding of Teeth in Children." In 1803 the
+possibility of correcting irregularities was pointed out, as was the
+pernicious effect of tartar on the teeth in 1827. In 1838 attempts were
+made to abolish, "in all common cases, the pernicious habit of tooth
+drawing." In 1841 treatises were written on the importance of
+regulating the teeth of children before the fourteenth year and on the
+importance of preserving the first teeth. Yet in 1908 it is necessary
+to write the chapter on Dental Sanitation. Few physicians, whether in
+private practice or hospitals or just out of medical college, consider
+it necessary to know the conditions of the mouth before prescribing
+drugs for physical illness.
+
+Osteopathy furnishes an up-to-date illustration. Discredited by the
+medical profession, by medical journals and medical schools, it has in
+fifteen years built up a practice of eight thousand men, having from
+one to three years' training, including over one hundred physicians
+with full medical training plus a course in osteopathy. There were
+means of learning fifteen years ago what was truth and what was
+quackery about the practice of osteopathy. By refusing to look for its
+truth and by concentrating attention upon its quackery the medical
+profession has lost fifteen years. Whereas the truth of osteopathy
+should have been adopted by the medical colleges and a knowledge of its
+possibilities and limitations required of every practicing physician, a
+position has been reached where alleged quackery seems in several
+important points to be discrediting the sincerity, the intelligence,
+and the efficiency of orthodox medicine. No appeal to the natural can
+be stronger, no justification of schools of preventive medicine more
+complete, than the following paragraph from an osteopathic physician
+who is among the small number who, having both the medical and
+osteopathic degrees, see both the possibilities and limitations of
+manual surgery and demand the inclusion of this new science in the
+medical curriculum.
+
+  The physical method of treating disease presents a tremendous and
+  significant departure from the empiricism of medicine and the
+  experimentation of dietetics, the restricted fields of
+  electricity, suggestion, water cures, and massage. The patient as
+  an individual is not treated; the disease as a disease is not
+  treated; the symptoms are not treated; but the entire physical
+  organism, with its many parts and diverse functions, is
+  exhaustively examined until each and every abnormal condition,
+  whether of structure or of function, causing disease and
+  maintaining symptoms, is found and administered to with the skill
+  of a definite art, based upon the data of an exact science.
+
+Likewise the truths underlying Christian Science have been disdained by
+medical schools and medical experts, just as its spiritual truth has
+been disdained by religious leaders, until it has grown to such
+strength that laymen are almost forced to question the sincerity and
+the efficacy of the conventional in religion as well as medicine. In
+May, 1907, the Emmanuel Church in Boston organized a clinic for the
+purpose of utilizing for neurasthenics particularly both the spiritual
+and the physical truths underlying religion and the various branches of
+medical science. Daily papers and magazines are giving a great deal of
+space to this experiment in "psychotherapy," which is discussed in the
+chapter on Mental Hygiene. Schools and chairs in preventive hygiene
+would soon give to the medical profession a point of view that would
+welcome every new truth, such as the alliance of religion and medicine,
+and estimate its full worth promptly. Truth seeking would be not only
+encouraged but made a condition of professional standing.
+
+Just what attitude any particular physician takes can be learned by the
+teacher or parents whose children he treats. If he pooh-poohs or
+resents board of health regulations as to isolation of scarlet-fever
+patients, he is a dangerous man, no matter how noble his personal
+character. If he says cross-eyes will straighten, weak eyes will
+strengthen, or nose-stopping adenoids "absorb," he is bound to do harm.
+If he says tuberculosis is incurable, noncommunicable, hereditary, or
+curable by drugs, or if he tries to cure cancer by osteopathy, he can
+do more injury than an insane criminal. If he fails to teach a mother
+how to bathe, feed, and clothe the baby, how to ventilate a room for
+the sick or the well, he is an expensive luxury for family or for
+school, and belongs to an age that knew neither school nor preventive
+hygiene. If he takes no interest in health administration; if he
+overlooks unclean milk or unclean streets, open sewers, and unsanitary
+school buildings, street cars, churches, and theaters; if he does not
+help the health board, the public hospitals, the schools, the factory,
+and tenement departments enforce sanitary laws, he is derelict as a
+citizen and as a member of an "exalted profession." If he sees only
+the patients he himself treats or one particular malady, he is derelict
+as a teacher, no matter how charming his personality or how skilled in
+his specialty. If a school physician is slovenly in his work, if he
+spends fifteen minutes when he is paid for an hour, should the
+efficient school-teacher conceal the fact from her superiors because he
+is a physician? If private hospitals misrepresent facts or compromise
+with political evils for the sake of a gift of public money, their
+offense is more heinous because of their exalted purpose. The test of a
+physician's worth to his patients and to his community is not what he
+is or what he has learned, and not what his profession might be, but
+what happens to patient and to community. Human welfare demands that
+the medical profession be judged by what it does, not by what it might
+do if it made the best possible use of its knowledge or its
+opportunity.
+
+    [Illustration: TOO MANY PHYSICIANS AND EVEN MATERNITY HOSPITALS
+    FAIL TO TEACH MOTHERS, EITHER BEFORE OR AFTER BABIES ARE BORN
+    Caroline Rest Educational Fund was given to show the value of
+    such teaching]
+
+A dispensary that treats more patients than it can care for properly is
+no better than a street-car company that chronically provides too few
+seats and too many straps. Unless physicians test themselves and their
+profession by results, we shall be compelled to "municipalize the
+medical man." Preventable sickness costs too much, causes too much
+wretchedness, and hampers too many modern educational and industrial
+activities to be neglected. If the medical profession does not fit
+itself to serve general interests, then cities, counties, and states
+will take to themselves the cure as well as the prevention of
+communicable and other preventable sickness. Human life and public
+health are more precious than the medical profession, more important
+even than theories and traditions against public interference in
+private matters. The unreasoning opposition of medical men to
+government protection of health, their concentration on cure, and their
+tardy emphasis on prevention have forced many communities to stumble
+into the evil practices mentioned in Chapter XVI. Incidentally, the
+best physicians have learned that the prosperity of their profession
+increases with every increase in the general standard of living. It is
+the man in the ten-room house not the man in one room who supports
+physicians in luxury. It is the healthy man and the healthy community
+that value efficient medical service.
+
+Many American cities maintain dispensaries and hospitals for the poor.
+Whether they will go to the logical conclusion of engaging physicians
+to give free treatment to all regardless of income depends largely upon
+what the next generation of private physicians do. The state already
+says when a physician's training fits him to practice. It will soon
+expect him to pass rigid examinations in the social and economic
+aspects of his profession,--its educational opportunity, vital
+statistics, sick and death rates. Will it need to municipalize him in
+order to protect itself?
+
+Obviously the teacher or parent should not begin cooperation with
+physicians by lecturing them or by assuming that they are selfish and
+unwilling to teach. The best first step is to ask questions that they
+should be able to answer:
+
+  What causes cholera morbus or summer complaint? When does milk
+  harm the baby? How can unclean milk be made safe? Whose fault is
+  it that the milk is sold unclean and too warm? What agencies help
+  sick babies? What is the health board doing to teach mothers?
+
+Or, if a school physician, the teacher can ask:
+
+  Why not remove these adenoids? What causes them? When will they
+  disappear by absorption? What harm can they do in the meantime?
+  How long would an operation take? Would it hurt very much? What
+  would be the immediate effects? Why not act at once? What
+  provisions are there in town for such operations? Why have the
+  physicians paid so little attention to breathing troubles? What
+  could your state do to interest physicians in school hygiene? Will
+  the school physician talk to a mothers' meeting? What agencies
+  will give outings to sick children? What dispensaries are
+  accessible? Who is the proper person to organize a public health
+  league?
+
+Physicians love to teach. If teachers and parents will love to learn
+and will ask the right questions, all physicians can be converted into
+hygiene missionaries, heralds of a statesmanship that guarantees health
+rights to all.
+
+
+LICENSING THE PRACTITIONER
+
+Three parties are interested in setting a high standard for physicians,
+dentists, druggists, nurses, and veterinary surgeons--the profession
+itself, the schools that educate, and the general public on whom the
+arts are practiced. The schools and the practitioners are, for the most
+part, primarily interested in protecting a monopoly of skill. Their
+interest in restrictive legislation is analogous to that of the labor
+union which limits the number of apprentices. This trade unionism among
+professional colleges and professional graduates of these colleges has
+gradually developed a higher and higher standard that results in
+greater protection to the public. The first step is generally to demand
+that all persons entering a profession after a given date shall prove
+to the state their ability to "practice" without injury to clients. It
+is almost impossible to get such laws through unless the original law
+exempts all persons by whatever name, who are practicing the art in
+question at the time the law is passed. Whether we are speaking of
+medicine, law, dentistry, accountancy, osteopathy, or barbering, this
+has been the history of compulsory restriction and of state
+examinations.
+
+As with regard to most other legislation, the enforcement of the law
+lags behind its definition. Moreover nothing is done after a man has
+passed a certain examination to see that he remains fit and safe to
+treat the public. Because no supervision is provided except on the day
+of examination, it is possible for men and women to fill their brains
+for a week or two weeks with the information necessary to pass what
+coaches and tutors have learned will, in all probability, be asked.
+Forever after, the public is left to protect itself. Out of this
+condition have arisen the evil, unethical, and unprofessional practices
+represented particularly by painless dentists, by ignorant or dishonest
+physicians, and by osteopaths and careless nurses.
+
+The machinery for preventing these evils is discussed in Chapter XXIX.
+Suffice it here to present to parents and teachers the need for
+examination in advance of certification that will show whether or not
+those who make a livelihood by caring for others' health are equipped
+to mitigate rather than aggravate evils, and for further tests by which
+the public can learn from time to time which, among those professional
+men who are protected by the public against competition, continue to be
+safe. Finally, if, as will be clearly seen, it is desirable that what
+we call professional ethics persist and that self-advertisement be
+discouraged, society must, for its own protection, adopt some other
+means than epithets to correct the evils of self-advertisement and
+quackery. Even though we admit the responsibility of each citizen when
+he goes to the house of a private practitioner who has made no other
+effort to lure him thither than to place a card in the window, it must
+be seen that we cannot hold responsible for their choice men and women
+who receive through newspapers, magazines, or circulars convincing
+notices that Dr. So-and-So or the Integrity Company or the Peerless
+Dental Parlor will place at their disposal, at prices within their
+reach, skill and devotion absolutely beyond their reach at the office
+of an efficient private practitioner. Some way must be found by which
+departments of health will currently impose tests of methods and
+results upon physicians, opticians, pharmacists, manufacturers of
+medicine, and dentists.
+
+As laymen become more intelligent regarding their own bodies and
+healthy living, it grows harder and harder for quacks and incompetents
+to mislead and exploit them. Better than any possible outside safeguard
+is hygienic living. Fortunately, we can all learn the simple tests of
+environment and of living necessary to the selection of physicians,
+dentists, and opticians, or other "architects of health" whose
+efficiency and integrity are beyond question.
+
+
+
+
+PART IV. OFFICIAL MACHINERY FOR ENFORCING HEALTH RIGHTS
+
+
+
+
+CHAPTER XXVII
+
+DEPARTMENTS OF SCHOOL HYGIENE
+
+
+The term "school hygiene" generally suggests no other school than the
+public school. State laws say nothing about compulsory hygiene in
+military academies, ladies' seminaries, or other preparatory and
+finishing schools. Yet when one thinks of it, one must conclude that
+the right to health and to healthful school environment cannot
+equitably be confined to the children whose tuition is given at public
+expense. There is a better way to check "swollen" fortunes than by
+ruining the health of "fortune's children." The waste and danger of
+slow-minded, noticeably inefficient children are no less when parents
+are rich than when parents are poor. There is no justification for
+neglecting the health of children in parochial schools, in private
+schools for the well-to-do or rich, or in commercial schools for the
+ambitious youth of lower income strata. Nor has the commercial,
+parochial, private school, or college, any clearer right than the
+public school to injure or to fail to promote pupils' health. So far as
+school hygiene is advisable, so far as it is right to make hygiene
+compulsory, its personal and social benefits should be shared by
+children of school age without regard to income, and its laws should be
+enforced by all teachers, principals, and officers that have to do
+with school. In presenting a programme for school hygiene this chapter
+refers to the hygiene taught, the hygiene practiced, the hygiene not
+taught, and the hygiene not practiced in buildings and on grounds where
+children and youth are at school, whether these children are in
+kindergarten or high school, in reformatory or military academy, in
+charitable school, or in finishing and preparing center for society's
+juniors.
+
+The question of the local, state, and national machinery by which
+proper standards of school hygiene shall be made effective will be
+taken up after we have considered individual steps in a comprehensive
+programme for school hygiene.
+
+1. _Thorough physical examination of all candidates for teachers'
+positions and periodic reëxamination of accepted teachers._
+
+Teachers would be grateful to be told in time their own physical needs
+and the relations of their vitality to the vitality of their pupils.
+Are your teachers examined? Do they know the laws of health and the
+signs of child health? Are they permitted to continue in schoolrooms
+after tuberculosis is discovered? Are normal graduates given physical
+tests before being permitted to teach and before being permitted to
+give four years to preparation for teaching?
+
+2. _Thorough physical examination of every single child in every single
+school upon entering and periodically during school life._
+
+We believe a vast number of things that "ain't so" about the health of
+country children as compared with city children, of private-school
+children as compared with public-school children. Where do we find more
+degenerate men, physically and morally, than in so-called "American
+settlements," where, for generations, children have had all outdoors to
+play in, except when in homes and schoolhouses that are seldom cleansed
+and seldom ventilated? Open mouths and closed minds clog the "little
+red schoolhouse"; there headaches do not suggest eye strain; there
+deafness and running ears are frankly attributed to scarlet fever which
+everybody must have with all the other "catching" diseases, the earlier
+the better; there colds begin in December and run until March, to the
+serious injury of attendance and promotion records; there bone
+tuberculosis is called "knee trouble" or "spine trouble in the family";
+there boys like my little friend Fred count the bottles of cod-liver
+oil they take to cure adenoids that could be removed in two minutes.
+
+The index to community life and community living conditions should be
+read in the country, not only for the country's sake, but also for the
+sake of the city whose milk and water, poisoned in the country, cause
+thousands of deaths annually, besides annual sick bills exceeding many
+times over the Russell Sage and Carnegie Foundations, which we rightly
+call munificent. Reading the index of private schools and colleges is
+important for their children and youth, but still more important for
+the community upon which unbridled passion, inability to work or to
+spend properly, inconsequential thinking, mediæval ideals of caste,
+etc., can inflict greater injuries than can typhoid fever or cholera.
+
+The physical record of each child should be kept from date of entrance
+to date of leaving school, showing condition at successive
+examinations, absence because of illness, etc.
+
+3. _Thorough physical examination of children when leaving school, or
+when passing compulsory school age, as a condition to "working papers"
+and to "coming out."_
+
+To give working papers to children seriously handicapped by physical
+defects is to buy future industrial trouble, hospital and poorhouse
+bills. A boy with adenoids, a girl with eye trouble, should not be
+permitted to begin the fight for self-support without at least being
+clearly shown that the correction of these defects will increase their
+earning power. At present a schoolgirl with incipient tuberculosis, or
+predisposed to that disease, can get working papers, go to a hammock or
+tobacco factory, work long hours, breathe bushels of dust, deplete her
+vitality, spread tuberculosis among her co-workers and home associates,
+infect a tenement,--and all this without any help or advice or any
+protection from society until she is too sick to work and her physician
+notifies the health department that she is a danger center. We may
+disagree about society's right to control a child's act after the
+defects are discovered, but who will question society's duty to tell
+that child and her parents the truth about her physical needs before it
+accepts her labor or permits her to "enter society"?
+
+4. _Supervision by physicians of hygiene practiced in schoolrooms and
+on playgrounds._
+
+Superintendent Maxwell, of New York City, and other educational leaders
+urge teachers to do their utmost to learn the physical conditions and
+home environment of the individual child, and to fit school treatment
+to the individual possibilities and handicaps. But experience proves
+conclusively that try as they will, teachers and principals have
+neither the special knowledge nor the time to acquire the special
+knowledge requisite to use the facts disclosed by the physical
+examination of school children. Physicians and nurses are needed, not
+so much for treating children, as for teaching children, parents,
+teachers, family and dispensary physicians.
+
+Private schools have visiting physicians who may be consulted; they
+need physicians to supervise, with power to examine or to require
+certificates of examination. The Committee on the Physical Welfare of
+School Children found that when a visitor was detailed for that purpose
+it was easy to secure the coöperation of parents, teachers, family
+physicians, dispensaries, school boards, and charitable societies. The
+Hawthorne Club's school secretary has been similarly successful in
+Boston, as have those of Hartley House, Greenwich House, and the Public
+Education Association in New York.
+
+5. _Restriction of study hours at school and at home to limits
+compatible with health._
+
+Whether the hours of study at school and at home are excessive cannot
+be learned from treatises on pedagogics or physiology. Because children
+differ in vitality as in ability to learn, the maximum limit for study
+hours should be determined by the individual child's physical
+condition. When the Japanese went to war with Russia the highest
+authority in the field was the army surgeon. To this fact was largely
+due the astonishingly small amount of sickness and the high fighting
+capacity and endurance of the Japanese, working under unfavorable
+conditions. No board of school superintendents or board of directors,
+no state superintendent of schools or college professor, has the right
+to compel or to allow study hours beyond the maximum compatible with
+the individual student's physical condition and endurance. The
+physician responsible for school hygiene should have an absolute veto
+upon any educational policy, method, or environment demonstrably
+detrimental to children's vitality.
+
+6. _Establishment of a "follow-up" plan to insure action by parents to
+correct physical defects and to attend to physical needs._
+
+The advantages of _getting things done_ over _doing things_ have been
+repeatedly emphasized. In smaller cities and in rural districts it is
+particularly important for schools to get things done better by
+existing local agencies, such as churches, health and street-cleaning
+departments, hospitals, clinics, medical and sanitary societies, trade
+unions, young people's societies, and women's clubs. Where parents who
+have been followed up and taught, obstinately or ignorantly refuse to
+attend to their children's needs, the segregation of the physically
+defective or needy will encourage the coöperation of children
+themselves in persuading parents to act intelligently for the child's
+sake. No child wants to remain "queer" or "dopey" or behind his peers.
+The city superintendent of schools for New York City has asked for laws
+compelling parents to permit operations and punishing them for
+neglecting to take steps, within their power, to remove physical
+defects discovered at school.
+
+    [Illustration: TEACHING A MOTHER TO CARE FOR ONE CHILD INSURES
+    BETTER CARE FOR ALL HER CHILDREN]
+
+7. _Physiological age should influence school classification and school
+curriculum._ On this subject the studies of Dr. C. Ward Crampton,
+referred to in the chapter on Vitality Tests, are invaluable and as
+convincing as they are revolutionary. Scientists accept his proof that
+our present high school curriculum is ill adapted to a large proportion
+of children; the "physiologically too young" drop out; only the
+physiologically mature succeed. The two physiological ages should be
+given different work. Children whose bodies yearn for pictures,
+muscular and sense expression, should be given a chance in school for
+normal development. Analysis should wait for action. Organized play and
+physical training antedated physical examination in our schools. Like
+the curriculum they often disregard physiological age, doing harm
+instead of good. Facts as to physical condition and physiological
+development would enable us to utilize the momentum of these two to
+broaden school hygiene and to insure proper physical supervision. Only
+good would result from adopting Leipsic's plan of having school
+children examined without clothing, in the presence of parents if
+parents desire. Expensive? Not so expensive as high school "mortality"
+due to maladjusted curriculums that force the great majority of boys
+and girls to drop out before graduation and ruin the health of a large
+fraction of those who remain.
+
+8. _Construction of school building and of curriculum so that, when
+properly conducted, they shall neither produce nor aggravate physical
+defects._
+
+When the state for its own protection compels a child to go to school,
+it pledges itself not to injure itself by injuring the child. Thousands
+of children are now being subjected to conditions in school far more
+injurious than the factory and shop conditions against which the
+national and state child labor committees have aroused universal
+indignation. Two illuminating studies of school buildings in New York
+City were made last year by the Committee on the Physical Welfare of
+School Children, and later by the Board of Education. Similar studies
+should be made of every schoolroom. Whereas our discussions of
+buildings and curriculum have hitherto proceeded largely from abstract
+principles of light, ventilation, heating, and pedagogics, these two
+reports deal with rooms, equipment, courses of study, and school habits
+as they are, with obvious detrimental effects on child victims.
+Numerous questions that it is practicable to answer are given in
+Chapter XIV.
+
+What and when to build can be better determined after we have learned
+the what and the where of present equipment.
+
+In passing it is worth while to note that in large cities teachers are
+frequently forced to choose between bad ventilation and street noises.
+From Boston comes the suggestion that we avoid noises and evils of
+congestion by building schoolhouses for city children on the outskirts
+in the midst of fields, transporting, and, if necessary, feeding
+children at public expense. While it is true that the public funds now
+spent in attempting to cure physical and moral ills would purchase
+ample country reservations, the practical next step seems to be to
+provide ample play space and breathing space within the city for every
+school building already erected, and without fail for all buildings to
+be erected hereafter.
+
+9. _Hygiene should be so taught that children will cultivate habits of
+health and see clearly the relation of health and vitality to present
+happiness and future efficiency._ Social rather than personal, public
+rather than private, health needs emphasis. Children can be shown how
+their health affects their neighbor; why money spent for health boards
+is a better investment than money given to corrupt politicians; that
+the cost of accepting Thanksgiving turkey or a park picnic from a
+political leader who encourages inefficient government is sickness,
+misery, deficient schooling, lifelong handicap; that children and
+adults have health rights in school and factory, on street and
+playground, which the law will protect if only they know when these
+rights are infringed.
+
+10. _Central supervision of school hygiene._ In private and public,
+boarding and day, country and city, reformatory and military,
+commercial and high schools, the index--physical welfare of school
+children--should be read and interpreted. Headquarters should learn
+whether or not physical examinations are made and whether harmful
+conditions are corrected. So far as public schools are concerned,
+"headquarters" means for cities the fact center that informs city
+superintendent or school board; for rural schools, it means the county
+superintendent's office. Whether city or county headquarters have the
+facts and act accordingly should be known by state superintendents.
+Whether state superintendents are demanding the facts and educating the
+county and city headquarters of their states should be known to the
+national commissioner of education and by him published for all the
+world. Some people think the state health board should be responsible,
+others the state educational authority. The important thing is to make
+some one officer responsible. Methods can be easily worked out if the
+need is conceded. Legislatures will gladly confer the powers necessary
+to reading the index of all public schools.
+
+As for parochial and private schools, they may resent for a time public
+supervision of their hygiene teaching and practice. However, the case
+could be so presented that they would ask for it, because it would help
+not only their pupils and society but the schools themselves. No
+religious belief or private investment can afford to admit that it
+disregards child health; state supervision would require nothing more
+than evidence of adequate school hygiene.
+
+11. _Information gained at school regarding conditions prejudicial to
+community health should be published and made the basis of an
+aggressive campaign for the enforcement of sanitary laws._ Ten thousand
+uses can be made of the information gained at school, ten thousand
+forces can be made to do educational work, but only a few kinds of work
+can be done effectively at school. Franklin Ford has said: "You can
+relate school to all life, but you cannot bring all life under the
+school roof." As Chapters XVI-XVIII make clear, to socialize the point
+of view of dispensaries and hospitals is more effective than to put
+clinics in school buildings. To _do for_ or _give to_ people who can
+help themselves is to _give up_ and _do up_ power of self-help.
+
+Machinery that must some day exist for the execution of this programme
+will be approximately the following:
+
+  I. NATIONAL MACHINERY
+
+  1. Clearing house for facts regarding school hygiene as taught and
+  practiced in all schools under the Stars and Stripes; this to be a
+  part of the National Bureau of Education.
+
+  2. Scientific research to be conducted by the National Bureau of
+  Education or by the future National Board of Health.
+
+
+  II. STATE MACHINERY
+
+  1. Clearing house for facts regarding school hygiene taught and
+  practiced in all schools within state limits; this to be
+  maintained by the state educational authorities.
+
+  2. Agents to make special inquiries as to practice and teaching of
+  school hygiene.
+
+  3. Agents to inspect and to instruct county superintendents,
+  county physicians, teachers, normal schools, etc.
+
+  4. A bureau of experts--architect, sanitarian, teacher--whose
+  approval must be obtained before any school building can be
+  erected. (A plan which brought excellent results when applied by
+  state boards to charitable institutions, hospitals for the insane,
+  etc.)
+
+  5. Standard making by normal schools, state universities,
+  hospitals, or other educational and correctional institutes under
+  direct state management.
+
+
+  III. COUNTY MACHINERY
+
+  1. Clearing house for facts regarding school hygiene taught and
+  practiced in all schools within county limits; this to be
+  maintained by the county superintendent of schools.
+
+  2. Physician and nurse to organize inspection and instruction for
+  rural schools, to give lessons and make demonstrations at county
+  institutes, to show teachers how to interest physicians, dentists,
+  health officers, and parents in the physical welfare of school
+  children.
+
+
+  IV. TOWN AND TOWNSHIP MACHINERY
+
+  1. Teachers intelligent as to physical needs, as to sanitation of
+  buildings, etc.
+
+  2. An examining physician, to be salaried where the population
+  justifies; elsewhere to work as a volunteer in coöperation with
+  teacher and with county physician.
+
+  3. Physical history of each child from date of entrance to date of
+  leaving school, to be kept up to date by teacher.
+
+
+  V. CITY MACHINERY
+
+  1. A division to be known as the Department of School Hygiene,
+  headed by an officer who gives his entire time to that department.
+
+  2. A subcommittee of the Board of Education.
+
+  3. Clearing house for facts regarding school hygiene taught and
+  practiced in all schools within city limits.
+
+  4. Specialists to examine applicants for teaching positions, and
+  to reëxamine teachers to determine fitness for continuance, for
+  promotion, and for special assignments.
+
+  5. A bureau for inspection and control of all hygiene of school
+  buildings, old and new, with power to compel repairs or to reject
+  plans that do not make adequate sanitary provision.
+
+  6. Similar supervision of curriculum and of study hours
+  prescribed.
+
+  7. A bureau for the inspection and control of curriculum, required
+  home study, exercise, physical training, etc., so far as relates
+  to the health of pupils, and to the physical ability of children
+  to be in certain grades or to be promoted. This will decide the
+  duration of lessons, frequency of intermissions, sequence of
+  subjects, time and method of recess throughout the various grades.
+
+  8. Supervision of indoor and outdoor playgrounds, roof gardens,
+  indoor and outdoor gymnasiums, swimming pools, etc.
+
+  9. Supervision of instruction in school hygiene.
+
+  10. A staff of inspectors for communicable diseases of pupils and
+  teachers, to be subject to the board of education or the board of
+  health.
+
+  11. A staff of examiners adequate to examine all children and
+  teachers at least once a year for defects of eye, ear, teeth,
+  nose, throat, lungs, spine, bones, glands, etc., and for weight
+  and height to be under the control of the board of education or
+  the board of health. The expense would not be as great as the
+  penalty paid for omitting such examination.
+
+  12. A staff of nurses to assist medical examiners to give children
+  practical demonstrations in cleanliness, to teach mothers the care
+  of children both at their homes and in mothers' meetings, to
+  enlist the coöperation of family physician and neighborhood
+  facilities, such as hospitals, dispensaries and relief agencies,
+  magistrates' courts and probation officers,--all to be under the
+  control of the board of education or the board of health.
+
+Whether inspectors, examiners, and nurses shall be directed by the
+board of education or the board of health is a question that it is
+impossible to decide without knowledge of local conditions. So far as
+state and county organizations are concerned, it is clear that whatever
+the boards of health may do, it will be necessary for state and county
+superintendents of education to equip themselves with the machinery
+above recommended. In cities it is quite clear that a board of
+education should be responsible for all of the machinery suggested,
+excepting the three divisions that have to do with work hitherto
+considered as protection against transmissible diseases, namely,
+inspection, examination, district visiting. In Cleveland these are
+school duties. In New York they are duties of the health department.
+Boston has school nurses and health department physicians. The state
+law of Massachusetts provides that where health boards do not examine
+school children, school boards may spend money for the purpose.
+
+As to inspection for transmissible diseases, it seems quite clear that
+health boards should not delegate their authority or responsibility to
+any other body, for they alone are accountable to their communities for
+protection against contagion. It is clear, too, that in the interest of
+community health, departments of health are justified in pointing out
+in advance of contagion those children most likely to become a menace.
+Similar grounds of public interest justify the health boards in sending
+nurses and physicians to the home as a means of getting things done.
+
+Dr. Biggs feels that responsibility for the physical welfare of school
+children will strengthen health work in all cities, and, given proper
+interest on the part of school officials, should make possible
+universal coöperation in a constructive programme. On the other hand,
+he believes that division of responsibility between school and health
+boards will weaken both in their appeals for funds and for support of a
+constructive programme. I have heard principals and superintendents
+maintain also that the moral effect of a visit to the school by a
+representative of the health board vested with powers of that board was
+much greater than a visit by a representative of the school board. They
+further allege that a physician coming from the outside is more apt to
+see things that need correction and less apt to accept excuses than an
+inspector who feels that he belongs to the same working group as the
+school-teacher. Because the follow-up work in the homes incident to
+successful use of knowledge gained at school involves so many sanitary
+remedies, it is theoretically better organization to hold the health
+authority responsible.
+
+
+
+
+CHAPTER XXVIII
+
+PRESENT ORGANIZATION OF SCHOOL HYGIENE IN NEW YORK CITY
+
+
+Many of the elements of the machinery outlined in the preceding chapter
+already exist in New York City. All of them brought together, either by
+amalgamation or by proper coördination, would present a very strong
+front. Unfortunately, however, there is not only unsatisfactory team
+work, but the efficiency of individual parts is seriously questioned by
+the heads of the health and school departments.
+
+The inspection for contagious diseases, the examination for physical
+defects, the follow-up work by nurses and physicians, are in charge of
+the department of health. Physical training and athletics for
+elementary and high schools, winter recreation centers, and vacation
+playgrounds are under directors and assistants employed by the board of
+education. Heretofore inadequate powers and inadequate assistance for
+training or for research have been given to the physical director.
+
+The city superintendent of schools, in his report for the year 1907,
+presented to the board of education in January, 1908, declares that the
+"present arrangements have been inadequate.... In only 248
+schools--less than half the total number--were any examinations for
+possible diseases made. In these 248 schools not more than one third of
+the pupils were examined. It is only a few months since any
+examinations for physical defects were made outside of the boroughs of
+Manhattan and The Bronx, and then only on account of the New York
+Committee on the Physical Welfare of School Children."
+
+As is so often the case, it is difficult to decide the merits of a
+method that has not been efficiently executed. The department of health
+has not hitherto done its best in its school relations. The
+commissioner of health, in a public interview, expresses resentment at
+the strictures by the school authorities. Yet in 1907 he permitted to
+accumulate an unexpended balance of $33,000 specifically voted for
+school inspectors, and repeatedly tried to have this amount transferred
+to other purposes. The interest of the Bureau of Municipal Research in
+municipal budgets that tell for what purposes money is voted and then
+prevent transfers without full publicity, preserved this particular
+fund. Moreover, the discussion that prevented its diversion from
+physical examinations strengthened the health department's interest in
+this important responsibility. Neither physicians nor nurses have been
+adequately supervised. Instead of seeing that defects were removed, the
+department of health sent out postal cards like the following:
+
+    [Illustration: (Notice Example)]
+
+ +-----------------------------------------------------------------------+
+ |         "This Notice Does NOT Exclude This Child From School"         |
+ |                                                                       |
+ |                          DEPARTMENT OF HEALTH                         |
+ |                          THE CITY OF NEW YORK                         |
+ |                                                                       |
+ |                            _Oct. 2, 190_6_                            |
+ |                                                                       |
+ | The parent or guardian of ___________________________________________ |
+ |  of____________________________________attending P.S.__51___________  |
+ | is hereby informed that a physical examination of this child seems to |
+ | show an abnormal condition of the ___________________________________ |
+ | ___Eyes, Nose, Throat and Teeth______________________________________ |
+ | _____________________________________________________________________ |
+ | Remarks__Is Anaemic__________________________________________________ |
+ | _____________________________________________________________________ |
+ |                                                                       |
+ | Take this child to your family physician for treatment and advice.    |
+ | Take this card with you to the family physician.                      |
+ |                                                                       |
+ |                                       THOMAS DARLINGTON, M.D.,        |
+ |                                               Commissioner of Health. |
+ |                                                                       |
+ | HERMANN M. BIGGS, M.D.,                                               |
+ |          General Medical Officer                                      |
+ +-----------------------------------------------------------------------+
+
+From 118,000 such notices sent out only 9600 replies were received, of
+which only one in twenty stated that attention had actually been given
+the needy child. The department had been satisfied with evidence that
+family physicians had advised parents properly, as in the case of the
+child above reported:
+
+    [Illustration: (Card example)]
+
+ +----------------------------------------------------------------------+
+ |                   TAKE THIS CARD TO YOUR PHYSICIAN                   |
+ |                                                                      |
+ |         The Physician in charge is requested to fill out and         |
+ |        forward this postal after he has examined this child.         |
+ |                                                                      |
+ | I have this day examined ___________________________________________ |
+ | of P.S. __51______________ and find the following condition:         |
+ |                                                                      |
+ | __As reported, Also enlarged (unclear) glands_______________________ |
+ | and advised as follows:__operation for adenoids and tonsils_________ |
+ | _____Dental treatment at Cornell. Fresh air ________________________ |
+ | _____outing at Sea Breeze Eyes wait.________________________________ |
+ |                                                                      |
+ |                                             Respectfully yours,      |
+ |                                          _______P.L. OB___________   |
+ | Date __Oct. 9, 1906______                _________________________   |
+ |                                                                      |
+ +----------------------------------------------------------------------+
+
+For a candid, complete criticism of the medical examination work up to
+June, 1908, consult the report of the Bureau of Municipal Research,
+presented to the Washington Congress of Public Education Associations
+in October, 1908, by Commissioner of Health, Dr. Darlington. The
+bureau's study is entitled _A Bureau of Child Hygiene_, and, in
+addition to the story of medical examination in New York City schools,
+gives the blank forms adopted for use in September, 1908. Important as
+are the facts given in this study, its greatest value, its authors
+declare, is in its account of "the method of intelligent self-criticism
+and experiment which alone enables a public department to keep its
+service abreast of public needs."
+
+The Bureau of Municipal Research made its study for the purpose of
+learning whether the disappointing results emphasized by the school
+authorities were due to "dual responsibility in the school--that of the
+board of education and that of the department of health"--and to "lack
+of power or inclination to compel parents to remedy defects," or to
+_deficient administration_ of power and inclination by health
+officials. Coöperating with school physicians and nurses in three
+schools, 1442 children were examined, of whom 1345, or 93.2 per cent,
+had 3458 defects that needed treatment. The postal-card notice was
+followed by an interview with the parent either at school or at home.
+Only 4.2 per cent of the total number of parents refused to act, 81 per
+cent secured or permitted treatment for one or more defects, while 15
+per cent promised to take the proper steps at the earliest possible
+date. Three fourths of the parents acted after one personal interview.
+"The net average result of a day's work by a nurse was the actual
+treatment of over five children, three of them completely, and two of
+them for one or more defects,"--sixty cents per child!
+
+    [Illustration: A PHOTOGRAPH OF MOUTH BREATHING MAY MAKE
+    COMPULSION UNNECESSARY]
+
+Having established the willingness--even eagerness--of parents to do
+all in their power to remove defects that handicapped their children,
+it was obviously the duty of the health department so to organize its
+work that it could insure the education of parents. The new Bureau of
+Child Hygiene gives foremost place to instruction of parents in care of
+babies, in needs of school children, and in the importance of physical
+examination when enlisting in the industrial army. Whether this work is
+well done is learned by result tests applied at headquarters, where
+work done and results are reported daily and summarized weekly. No
+longer will it be possible, without detection, for one physician to
+find only eye trouble and to neglect all other defects; for two
+inspectors examining different children in the same school to report
+results differing by 100 per cent; for physicians in different schools
+to find one 18 per cent, another 100 per cent with defects; for two
+inspectors examining identical children to agree on 51 out of 101 cases
+of vision, on 49 out of 96 cases of adenoids, or 3 out of 10 cases of
+skin disease.
+
+So conclusive were the results of follow-up work efficiently supervised
+by the department of health, that school officials are, for the
+present, inclined to waive the demand for the transfer of physicians
+and nurses to the board of education, and to substitute education for
+compulsion with parents who obstinately refuse to take proper remedial
+measures for their children when reported defective.
+
+This present plan requires the entire working time of inspectors and
+nurses for school work. Thus New York has for the present definitely
+abandoned the plan of having the district inspection for contagious
+diseases done by school physicians. The purpose of the change is not to
+reduce danger of infection, which was negligible, but to increase the
+probability of scientific attention to school children.
+
+Before a final settlement is made for New York City there should be
+tests showing what the school authorities would do if physicians and
+nurses were subordinate to them. It is conceivable that one physician
+working from nine to five would accomplish more than six physicians
+working the alleged three hours a day. So imperative are the demands of
+school hygiene that it seems probable that in New York and in other
+large cities school physicians, whether paid by the board of health or
+the board of education, must be expected to be at the service of school
+children, subject to the call of school officers, during as many hours
+of the day as teachers themselves must give. It is even conceivable
+that effective use of the knowledge gained by physical examinations of
+school children, and by those responsible for school hygiene, will
+require evening office hours or evening visits to homes, and regular
+Saturday office hours and Saturday visits by school physicians and
+nurses. Finally, it must be expected that the programme for school
+hygiene will need the special attention of physicians and nurses during
+the summer months, and other vacation periods when children and parents
+alike have time to receive and to carry out their instructions.
+
+One danger in New York City is that the board of education, like the
+board of health, when compelled to choose between so-called standard,
+necessary, traditional duty and school hygiene, will sacrifice the
+latter. The school authorities, without any more funds and without
+physicians and nurses, could already have made, had they desired, eye
+tests and breathing tests sufficiently accurate to detect the majority
+of children needing attention. The outcome of the discussion as to the
+jurisdiction of the two boards will undoubtedly be to interest both in
+their joint responsibility for children's welfare, and to increase the
+attention given by both to the physical condition of the child when he
+presents himself for registration as a wage earner.
+
+
+
+
+CHAPTER XXIX
+
+OFFICIAL MACHINERY FOR ENFORCING HEALTH RIGHTS
+
+
+The argument for _getting things done_ presumes adequate active
+machinery, official and private, for _doing things_ that schools are
+being urged to do. The chapter on Departments of School Hygiene
+suggests local, county, state, and national machinery necessary (1) to
+protect the child from injuries due to school environment, school
+methods, and school curriculum; (2) to getting those things done for
+the child at home and on the street, need for which is disclosed by
+physical and vitality tests at school. It is unreasonable to confine
+the school to the activities above outlined unless health machinery,
+adequate to the demands placed upon it by school and other community
+needs, is devised and kept in order.
+
+Generally speaking, adequate health machinery is already provided for
+by city charters and by the state laws under which villages, townships,
+and counties are organized. Quite as generally, however, machinery and
+methods of adequate administration are undeveloped. How much machinery
+has already been set to work by New York City is shown by the
+accompanying chart. A useful exercise for individuals or school classes
+wishing to study health administration would be to chart in this way
+the machinery actually at work in their locality, county, and state.
+Even for New York it should be remembered that this chart does not
+include national quarantine, the state protection of the port, the
+state dairy and health commissions, or the state and national food
+inspection. To get an idea of the vast amount of attention given
+to health in New York City there should be added to this chart the work
+of many departments other than the department of health. The building
+bureau, tenement-house department, board of water supply, sewage
+commission, street cleaning, public baths and comfort stations, the
+department of water, gas, and electricity, and finally the department
+of hygiene and physical training in the public schools.
+
+    [Illustration: CHART SHOWING HOW NEW YORK CITY'S DEPARTMENT OF
+    HEALTH EXERCISES IT'S AUTHORITY
+    Courtesy of Bureau of Municipal Research]
+
+Five elements of adequate machinery are generally lost sight of:
+
+  1. The voter.
+
+  2. The nonvoter, subject to health laws and often apt to violate
+  them.
+
+  3. The mayor, governor, or president who appoints health officers.
+
+  4. The council, board of aldermen, legislature, or congress that
+  enacts health laws.
+
+  5. The police courts and the judiciary--police, circuit and
+  supreme--that decide whether society has suffered from violation
+  of law and what penalties should be inflicted for such violation.
+
+Legislative bodies have hitherto slighted their responsibilities toward
+public health. The chairman of a committee on public health of a state
+legislature was heard to remark, "I asked for that committee because
+there isn't a blooming thing to do." If voters, nonvoters, and health
+officials will follow the suggestion of this book to secure school and
+health reports that will disclose community and health needs, it will
+be increasingly difficult for legislators to refuse funds necessary to
+efficient health administration.
+
+To the courts tradition has required such deference that one hesitates
+to find out in how far they have been responsible in the past for the
+nonenforcement of health laws. Yet nothing is more obstructive of
+sanitary progress than the failure of magistrates to enforce adequate
+penalties for truancy, adulteration of milk, maintaining a public
+nuisance, defiling the air with black smoke, offering putrid meats for
+sale, running an unclean lodging house, defying tenement-house or
+factory regulations, working children under age and overtime, spitting
+in public places, or failing to register transmissible diseases.[16]
+
+The appointing officer cannot, of course, be held responsible unless
+voters and nonvoters know in how far his appointees are inefficient,
+and in how far he himself has failed to do his utmost to secure funds
+necessary to efficiency. Too frequently appointments to health
+positions have been made on political grounds, and catastrophes have
+been met by blundering incapacity. The political appointee has been
+made the scapegoat, and the appointing officer, whether mayor,
+governor, or president, has regained public confidence by replacing an
+old with a new incompetent.
+
+In order to have health machinery work properly, the appointing officer
+should not be allowed to shift responsibility for failure to his
+subordinates. For example, it was recently found in New York City that
+while the tenement-house commissioner was being condemned for failing
+to enforce the law, he had turned over to the corporation counsel, also
+appointed by the mayor, for prosecution ten thousand "violations" to
+which no attention whatever had been paid!
+
+The voter, nonvoter, appointing officer, legislative officer, and
+judicial officer determine the character and purpose of machinery and
+are analogous to the surveyors, stock-holders, directors, and
+constructors who provide railroads with tracks and with running stock.
+The actual running force of health department or railroad is what is
+meant by its official machinery. What this machinery should be depends,
+of course, upon the amount of business to be done, and differs with
+the size of the district and the character of population to be served.
+
+    [Illustration: FOR PUSH-CART FOOD, INSPECTION IS PARTICULARLY
+    NEEDFUL]
+
+Local health machinery should guarantee protection against the evils
+mentioned in preceding chapters. In general, one man is better than
+three to execute, although three may be better than one to legislate.
+Where small communities do not wish to have the entire state sanitary
+code rigidly administered, they can adopt New York's method of a
+legislative board of three members, headed by an executive, whose
+business it is to act, not talk; to watch subordinates, and to enforce
+rigidly and continuously ordinances passed by the board. The National
+Bureau of Census places under the general heading Health and Sanitation
+the following activities: health administration, street cleaning and
+refuse disposal, sewers and sewage disposal. Sanitarians generally
+emphasize also the health significance of efficient water service.
+
+A community's health programme should be clearly outlined in the annual
+budget. Where health work is given funds without specification of the
+kinds of work to be done, serious evils may be overlooked and lesser
+evils permitted to monopolize the energies of health officers. Again,
+after money has been voted to prevent an evil, records should be made
+of work done when done, and of money spent when spent, so that any
+diversion will be promptly made known. The best present guides to
+budget making, to educational health reports, and to records that show
+efficiency or inefficiency of health administrators are the budget and
+report of the department of health for New York City, and the story of
+their evolution told in _Making a Municipal Budget_, by the Bureau of
+Municipal Research.
+
+To find out whether local machinery is adequate, the reader must
+enumerate the things that need to be done in his community, remembering
+that in all parts of the United States to-day there are sanitary laws
+offering protection against dangers to health, excepting some dangers
+not understood until recently, such as child labor, dangerous trades,
+lack of safety devices. Adequate local protection, however, will not
+become permanent until adequate state machinery is secured.
+
+State health machinery should be of two kinds,--fact-gathering and
+executive supervision through inspection. The greatest service of state
+boards of health is to educate localities as to their own needs, using
+the experience of all communities to teach each community in how far
+its health administration menaces itself and its neighbors. In addition
+to registration of contagious diseases, facts as to deaths and births
+should be registered. State health boards should "score" communities as
+dairies and milk shops are now being scored by the National Bureau of
+Animal Industries and several boards of health. When communities
+persist in maintaining a public nuisance and in failing to enforce
+health laws, state health machinery should be made to accomplish by
+force what it has failed to accomplish by education.
+
+    [Illustration: NATIONAL MACHINERY HAS STIMULATED LOCAL MILK
+    INSPECTION AND STATE DAIRY INSPECTION]
+
+States alone can cope adequately with dangers to milk and water sources
+and to food. The economic motive of farmers has developed strong
+veterinary boards for the protection of cattle. Similar executive
+precaution must soon be taken by cities for the protection of babies
+and adults of the human species. It is far more economical to insure
+clean dairies, clean water sources, and wholesome manufactured foods by
+state inspectors than by local inspectors. At present the task of
+obtaining clean milk and clean water falls upon the few cities
+enlightened enough and rich enough to finance the inspection of
+community foods. Once tested, it would be very easy to prove that
+properly supported state health authorities will save many times the
+cost of their health work in addition to thousands of lives.
+
+County or district machinery is little known in America. For that
+reason rural sanitary administration is neglected and rural hospitals
+are lacking. In the British Isles rural districts are given almost as
+careful inspection as are cities. Houses may not be built below a
+certain standard of lighting, ventilation, and conveniences.
+Outbuildings must be a safe distance from wells. Dairies must be kept
+clean. Patients suffering from transmissible diseases may be removed by
+force to hospitals. What is more to the point, rural hospitals have
+proved that patients cared for by them are far more apt to recover than
+patients cared for much more expensively and less satisfactorily at
+home, while less likely to pollute water and milk sources or otherwise
+to endanger health.
+
+With national machinery the chapter on Vital Statistics has already
+dealt. We shall undoubtedly soon have a national board of health. Like
+the state boards, its first function should be educative. In addition,
+however, there are certain administrative functions where inefficiency
+may result in serious losses to nation, state, and locality. National
+quarantine, national inspection of meats, foods, and drugs are
+administrative functions of vital consequence to every citizen.
+Authorities are acquainted at the present time with the fact that the
+sanitary administration of the army and navy is unnecessarily and
+without excuse wasteful of human energy and human life. In the Spanish
+American War 14 soldiers died of disease for 1 killed in battle; in the
+Civil War 2 died of disease to 1 killed in battle; during the wars of
+the last 200 years 4 have died of disease for 1 killed in battle. Yet
+Japan in her war with Russia, by using means known to the United States
+Army in 1860, gave health precedence over everything else and lost but
+1 man to disease for 4 killed in battle. Diseases are still permitted
+to make havoc with American commerce because the national government
+does not apply to its own limits the standards which it has
+successfully applied to Cuba and Panama.
+
+"The Japanese invented nothing and had no peculiar knowledge or skill;
+they merely took occidental science and used it. The remarkable thing
+is not what they did, but that they were allowed to do it. It is a
+terrible thing that Congress should choose to make one of its rare
+displays of economy in a matter where a few thousand dollars saved
+means, in case our army should have anything to do, not only the
+utterly needless and useless loss of thousands of lives, but an
+enormous decrease of military efficiency, and might, conceivably, make
+all the difference between victory and defeat."
+
+FOOTNOTES:
+
+[16] The technic and principles of municipal engineering have been
+treated in detail in _Principles of Sanitary Science and the Public
+Health_, by William T. Sedgwick, and in _Municipal Sanitation in the
+United States_, by Charles N. Chapin, M.D.
+
+
+
+
+CHAPTER XXX
+
+SCHOOL AND HEALTH REPORTS
+
+
+For every school-teacher or school physician responsible for the
+welfare of children at school, there are fifty or more parents
+responsible for the physical welfare of children at home. Therefore it
+is all important for parents to know how to read the index for their
+own children, for their children's associates, and for their community.
+School reports and health reports should tell clearly and completely
+the story of the school child's physical needs.
+
+    [Illustration: NECESSARY TO EFFICIENT DEMOCRACY]
+
+It is impracticable at the present time to expect a large number of men
+and women to be interested in the reports published by school and
+health boards, for, with few exceptions, little effort is made to write
+these reports so that they will interest the parent. Fortunately, a
+small number of persons wishing to be intelligent can compel public
+officials to ascertain the necessary facts and to give them to the
+public. So backward is the reporting of public business that at the
+present time there is probably no service that a citizen can render his
+community which would prove of greater importance than to secure proper
+publicity from health and school boards.
+
+Generally speaking, these published reports fail to interest the
+citizen, not because officials wish to conceal, but because officials
+do not believe that the public is interested. A mayor of Philadelphia
+once furnished a notable exception. He called at the department of
+health and complained against publishing the number of cases of typhoid
+and smallpox lest stories in the newspapers "frighten the city and
+injure business." A sanitary inspector who was in the room asked if
+Philadelphia's business was more important than the health of
+Philadelphia's citizens. As a result of her "impertinence" the
+inspector was removed. That same year an epidemic of smallpox spread
+through all the rural districts and cities of Pennsylvania, because
+physicians thought it would be kinder to the patients not to make known
+to their neighbors the presence of so disagreeable a disease. Almost
+all health and school authorities, however, can be made to see the
+advantage of taking the public into their confidence, because public
+confidence means both public recognition and greater success in
+obtaining funds. With more funds comes the power to do more work.
+
+Other details with regard to health reports will be found in the
+chapter on Vital Statistics. As to school reports, little thought has
+been given in the past to their educational possibilities. A book was
+recently published--_School Reports and School Efficiency_--by the
+Committee on the Physical Welfare of School Children, which tells the
+origins of school reports; contains samples of reports from one hundred
+cities; gives lists of questions frequently answered, occasionally
+answered, and never answered; and shows how to study a particular
+report so as to learn whether or not important questions are answered.
+The United States commissioner of education has organized among state
+and city superintendents special committees on uniform and adequate
+reporting. His aggressive leadership is welcomed by school men
+generally, and promises vast benefits.
+
+Just because the physical welfare of the school child is an index to
+health needs, the school report can put into one statement for a city
+or a state the story told by the index. The accompanying card tells
+facts that the individual teacher and individual parent want to know
+about a child, what a superintendent wants to know about all children,
+and what a community wants to know about all children. A modification
+of this card will soon be adopted in New York City. It is both a card
+index and a card biography of the individual boy or girl. It is
+expected to follow the child from class to class, each teacher telling
+the story of his physical welfare and his progress. When the boy goes
+to a new school or new grade, his new teacher can see at a glance not
+only what subjects have given him trouble, but what diseases or
+physical defects have kept him out of school or otherwise retarded his
+progress. With this card it is easy to take a hundred children of the
+same age and the same grade, to put down in one column those who have
+eye defects, and in another those who have no eye defects, for every
+school, every district, and for the schools as a whole. Schools that
+use these record cards are enabled, by thus classifying the total, to
+learn where the defects of children are, how serious the problem is,
+how many days children lose from school because of preventable defects,
+and in what section of the city the defects are most prevalent.
+
+The mere reporting of facts will stimulate teachers, principals, and
+parents to give attention. For example, assume a table:
+
+           FIELD OF INSPECTION
+
+ Total number of public schools              7
+ Public schools under inspection             3
+ Public schools not under inspection         4
+
+The reader wonders why four schools are neglected and which particular
+schools they are. Let the next table read:
+
+           EXAMINATION
+
+ Total registration in all schools        1500
+ Number of children examined               500
+ Number of children not examined          1000
+
+Parents begin to wonder whether or not their children were examined,
+and why the taxes spent for school examination of all children go to
+one third of the children. The next table arrests attention:
+
+           TREATMENT
+
+ Number needing treatment                  200
+ Number known to have been treated          50
+ Number not known to have been treated     150
+
+We ask, at once, if examination is worth while, and if treatment really
+corrects the defects, saves the pupil's time and teacher's time,
+discovers many defects; and we want to find out whether the one hundred
+and fifty reported not treated have since been attended to.
+
+    [Illustration: PUPIL'S RECORD]
+
+    [Illustration: DEPARTMENT OF HEALTH CITY OF NEW YORK REPORT]
+
+Again, if three out of five of those examined need treatment, people
+will wonder whether among the thousand not examined there is the same
+proportion--three out of five, or six hundred--who have some trouble
+that needs attention. Having begun to wonder, they will ask questions,
+and will expect the board of health or the school physicians to see
+that the questions are answered. As has been proved in New York,
+taxpayers and the press will go farther and will demand that the annual
+budget provide for making general next year the benefits found to
+result last year from a test of health policies.
+
+The story of the prevalence of contagious diseases in school children
+could be told by a table such as is now in use by New York's department
+of health:
+
+
+TABLE XII
+
+PREVALENCE OF CONTAGIOUS DISEASES IN SCHOOL CHILDREN
+
+(Case rate schools)
+
+KEY:
+A: In School
+B: Among Absentee
+=========+========================================+======================
+         |                                        |  COMMUNICABLE
+         |    GENERAL COMMUNICABLE DISEASES[1]    | DISEASES OF EYE
+ SCHOOL  |                                        |   AND SKIN[2]
+         +----------------------------------------+----------+-----------
+         |           NUMBER           |           |          |
+         +----------+-----------+-----+ Number per|          |Number
+         |Found by  | Reported  |     | 1000      |Number    |per 1000
+         |Inspectors|     by    |     | Registered|found by  |Registered
+         +-----+----+ Attending +     + in Schools+Inspectors|in Schools
+         | A   |  B | Physician |Total| Inspected |and Nurses|Inspected
+---------+-----+----+-----------+-----+-----------+----------+-----------
+A        |     |    |           |     |           |          |
+B        |     |    |           |     |           |          |
+C        |     |    |           |     |           |          |
+=========+=====+====+===========+=====+===========+==========+===========
+  [1] Smallpox, diphtheria, scarlet fever, measles, chicken pox, mumps,
+      and whooping cough; excluded when found.
+  [2] Trachoma and other contagious eye diseases, ringworm, impetigo,
+      scabies, favus, and pediculosis; excluded only for persistent
+      nontreatment.
+
+Another table shows the following facts for each disease:
+
+
+TABLE XIII
+
+CONTAGIOUS DISEASES FOUND IN SCHOOLS BY INSPECTORS AND NURSES
+
+(Number and disposition of cases)
+
+
+KEY:
+A: Diphtheria          J: Other
+B: Scarlet fever       K: Ringworm
+C: Measles             L: Impetigo
+D: Smallpox            M: Scabies
+E: Chicken pox         N: Favus
+F: Whooping cough      O: Pediculosis
+G: Mumps               P: Miscellaneous
+H: Total               Q: Total
+I: Trachoma
+
+===================+=======================+===========================
+                   |     GENERAL           | COMMUNICABLE DISEASES
+                   |  COMMUNICABLE         |   OF EYE AND SKIN
+                   |    DISEASES           |-----+---------------------
+                   |                       | EYE |        SKIN
+                   +--+--+--+--+--+--+--+--+--+--+--+--+--+--+--+--+---
+                   | A| B| C| D| E| F| G| H| I| J| K| L| M| N| O| P| Q
+-------------------+--+--+--+--+--+--+--+--+--+--+--+--+--+--+--+--+---
+Cases found in     |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
+ school            |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
+Cases excluded     |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
+ from school       |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
+Cases treated in   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
+ school            |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
+Cases instructed   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
+ in school or      |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
+ evidence of       |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
+ treatment         |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
+ furnished         |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
+Number of          |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
+ treatments        |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
+Number of          |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
+ instructions      |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
+===================+==+==+==+==+==+==+==+==+==+==+==+==+==+==+==+==+===
+
+The story of noncontagious physical defects found and treated is set
+forth in the following table:
+
+
+TABLE XIV
+
+MEDICAL EXAMINATION OF SCHOOL CHILDREN: NONCONTAGIOUS PHYSICAL DEFECTS
+FOUND AND TREATED, 1906
+
+==============+=============================+=============================+
+              |           SCHOOL A          |           SCHOOL B          |
+              |--------------+--------------+--------------+--------------|
+              |   Found      |   Reported   |   Found      |   Reported   |
+              |              |   Treated    |              |   Treated    |
+              |-----+--------+-----+--------+-----+--------+-----+--------|
+  DEFECTS     | No. |  % of  | No. |  % of  | No. |  % of  | No. |  % of  |
+              |     | Total  |     |Defects |     | Total  |     |Defects |
+              |     |Defects |     | Found  |     |Defects |     | Found  |
+              |     | Found  |     |        |     | Found  |     |        |
+--------------+-----+--------+-----+--------+-----+--------+-----+--------+
+Adenoids      |     |        |     |        |     |        |     |        |
+              |     |        |     |        |     |        |     |        |
+Nasal         |     |        |     |        |     |        |     |        |
+ breathing    |     |        |     |        |     |        |     |        |
+Hyper-trophied|     |        |     |        |     |        |     |        |
+ tonsils      |     |        |     |        |     |        |     |        |
+Defective     |     |        |     |        |     |        |     |        |
+ palate       |     |        |     |        |     |        |     |        |
+Defective     |     |        |     |        |     |        |     |        |
+ hearing      |     |        |     |        |     |        |     |        |
+Defective     |     |        |     |        |     |        |     |        |
+ vision       |     |        |     |        |     |        |     |        |
+Defective     |     |        |     |        |     |        |     |        |
+ teeth        |     |        |     |        |     |        |     |        |
+Bad nutrition |     |        |     |        |     |        |     |        |
+Diseased      |     |        |     |        |     |        |     |        |
+ anterior     |     |        |     |        |     |        |     |        |
+ cervical     |     |        |     |        |     |        |     |        |
+ glands       |     |        |     |        |     |        |     |        |
+Diseased      |     |        |     |        |     |        |     |        |
+ posterior    |     |        |     |        |     |        |     |        |
+ cervical     |     |        |     |        |     |        |     |        |
+ glands       |     |        |     |        |     |        |     |        |
+Heart disease |     |        |     |        |     |        |     |        |
+Chorea        |     |        |     |        |     |        |     |        |
+Pulmonary     |     |        |     |        |     |        |     |        |
+ disease      |     |        |     |        |     |        |     |        |
+Skin disease  |     |        |     |        |     |        |     |        |
+Deformity     |     |        |     |        |     |        |     |        |
+ of spine     |     |        |     |        |     |        |     |        |
+Deformity     |     |        |     |        |     |        |     |        |
+ of chest     |     |        |     |        |     |        |     |        |
+Deformity of  |     |        |     |        |     |        |     |        |
+ extremities  |     |        |     |        |     |        |     |        |
+Defective     |     |        |     |        |     |        |     |        |
+ mentality    |     |        |     |        |     |        |     |        |
+  Total       |     |        |     |        |     |        |     |        |
+==============+=====+========+=====+========+=====+========+=====+========+
+
+==============+=============================+
+              |           SCHOOL C          |
+              |--------------+--------------|
+              |   Found      |   Reported   |
+              |              |   Treated    |
+              |-----+--------+-----+--------|
+  DEFECTS     | No. |  % of  | No. |  % of  |
+              |     | Total  |     |Defects |
+              |     |Defects |     | Found  |
+              |     | Found  |     |        |
+--------------+-----+--------+-----+--------+
+Adenoids      |     |        |     |        |
+              |     |        |     |        |
+Nasal         |     |        |     |        |
+ breathing    |     |        |     |        |
+Hyper-trophied|     |        |     |        |
+ tonsils      |     |        |     |        |
+Defective     |     |        |     |        |
+ palate       |     |        |     |        |
+Defective     |     |        |     |        |
+ hearing      |     |        |     |        |
+Defective     |     |        |     |        |
+ vision       |     |        |     |        |
+Defective     |     |        |     |        |
+ teeth        |     |        |     |        |
+Bad nutrition |     |        |     |        |
+Diseased      |     |        |     |        |
+ anterior     |     |        |     |        |
+ cervical     |     |        |     |        |
+ glands       |     |        |     |        |
+Diseased      |     |        |     |        |
+ posterior    |     |        |     |        |
+ cervical     |     |        |     |        |
+ glands       |     |        |     |        |
+Heart disease |     |        |     |        |
+Chorea        |     |        |     |        |
+Pulmonary     |     |        |     |        |
+ disease      |     |        |     |        |
+Skin disease  |     |        |     |        |
+Deformity     |     |        |     |        |
+ of spine     |     |        |     |        |
+Deformity     |     |        |     |        |
+ of chest     |     |        |     |        |
+Deformity of  |     |        |     |        |
+ extremities  |     |        |     |        |
+Defective     |     |        |     |        |
+ mentality    |     |        |     |        |
+  Total       |     |        |     |        |
+==============+=====+========+=====+========+
+
+The effect of a report telling what schools have enough seats, proper
+ventilation, adequate medical inspection, safe drinking water, ample
+play space, and what schools are without these necessities is to cause
+the reader to rank the particular school that he happens to know; i.e.
+he says, "School A is better equipped than School B; or, School C is
+neglected." County and state superintendents in many states have
+acquired the habit of ranking schools according to the number of
+children who pass in arithmetic, algebra, etc. It would greatly further
+the cause of public health and, at the same time, advance the interest
+of education if state superintendents would rank individual schools,
+and if county superintendents would rank individual schools, _according
+to the number of children found to have physical defects, the number
+afflicted with contagious diseases, and the number properly treated_.
+
+It is difficult to compare one school with another, because it is
+necessary to make subtractions and divisions and to reduce to
+percentages. It would not be so serious for a school of a thousand
+pupils as for a school of two hundred, to report 100 for adenoids. To
+make it possible to compare school with school without judging either
+unfairly, the state superintendent of schools for Connecticut has made
+tables in which cities are ranked according to the number of pupils,
+average attendance, per capita cost, etc. As to each of these headings,
+cities are grouped in a manner corresponding to the line up of a
+battalion, "according to height." A general table is then shown, which
+gives the ranking of each city with respect to each important item.
+Applied to schools, this would work out as follows:
+
+
+TABLE XV
+
+TABLE OF RANKING-SCHOOLS ARRANGED ALPHABETICALLY
+
+=============================================================
+       |
+SCHOOL |               RANK IN
+-------+----------+----------+----------+----------+---------
+       | Register | Defects  | Children | Children | Children
+       |          |  Found   | Needing  | Treated  |   not
+       |          |          | Treatment|          | Treated
+-------+----------+----------+----------+----------+---------
+   A   |    10    |    11    |    11    |    12    |    6
+   B   |    20    |    22    |    22    |    24    |   12
+   C   |    30    |    33    |    30    |    36    |   18
+=======+==========+==========+==========+==========+=========
+
+Such a table fails to convey its significance unless the reader is
+reminded that rank 18 in children not treated is as good a record for a
+school that ranks 30 in register as is rank 6 for a school that ranks
+10 in register.
+
+The Connecticut report makes a serious mistake in failing to arrange
+schools according to population. If this were done, schools of a size
+would be side by side and comparison would be fair. When, as in the
+above table, schools are arranged alphabetically, a school with four
+thousand pupils may follow or precede a school with four hundred
+pupils, and comparison will be unfair and futile.
+
+Where, on the other hand, schools are arranged in order of register, a
+table will show whether schools confronted with practically the same
+problems, the same number of defects, the same number of children
+needing treatment, are equally successful, or perhaps equally inactive,
+in correcting these defects. The following table brings out clearly
+marked unequal achievement in the face of relatively equal need.
+
+
+TABLE XVI
+
+TABLE OF RANKING-SCHOOLS ARRANGED ACCORDING TO REGISTER, NOT
+ALPHABETICALLY
+
+=============================================================
+       |
+       |                       RANK IN
+SCHOOL +----------+----------+----------+----------+---------
+       | Register | Defects  | Children | Children | Children
+       |          |  Found   | Needing  | Treated  |   not
+       |          |          | Treatment|          | Treated
+-------+----------+----------+----------+----------+---------
+   A   |     9    |     9    |     9    |     9    |    9
+   X   |    10    |    10    |    10    |    14    |    6
+   H   |    11    |    11    |    11    |    17    |    3
+=======+==========+==========+==========+==========+=========
+
+If the number of schools in a state is so large that it is unlikely
+that people will read the table of ranking because of the difficulty of
+finding their own school, an alphabetical table might be given that
+would show where to look in the general ranking table for the school or
+schools in which the reader is interested.
+
+Experience will demonstrate to public school superintendents the
+strategic advantage of putting together all the things they need and of
+telling the community over and over again just what needs there are,
+what penalties are paid for want of them, and what benefits would
+result from obtaining them. If health needs of school children were
+placed side by side with mental results, the relation would come out so
+clearly that parents, school boards, and taxpayers would realize how
+inextricably they are bound together and would see that health needs
+are satisfied. To this end superintendents should require teachers to
+keep daily reports of school conditions.
+
+
+TABLE XVII
+
+WEEKLY CLASS-ROOM SCHEDULE
+
+===========+================+========================+==============
+          |    Temperature  |          Cleaning      |  Exercise
+          +-----+-----+-----+-----+-----+------------+------+-------
+          |     |     |     |     |     |            |  In  |Out of
+          |10.30|12.00| 2.00| Dry | Wet |Disinfecting| Room | Room
+----------+-----+-----+-----+-----+-----+------------+------+-------
+Monday    |     |     |     |     |     |            |      |
+Tuesday   |     |     |     |     |     |            |      |
+Wednesday |     |     |     |     |     |            |      |
+Thursday  |     |     |     |     |     |            |      |
+Friday    |     |     |     |     |     |            |      |
+==========+=====+=====+=====+=====+=====+============+======+=======
+
+The teacher's daily report of the temperature of a schoolroom, taken
+three times a day, tells the parent exactly what is the efficiency of
+the ventilating and heating apparatus in the particular school in which
+he is interested; whereas the report of the department of buildings
+gives only the number of schools which have an approved system of
+ventilation and steam heat. School authorities may or may not know that
+this system of ventilation is out of order, that the thermometer in the
+indoor playground of School A stood at forty degrees for many days in
+winter. But they must know it when the principal of School A sends in a
+daily record; the school board, the parents, or the press will then
+see that the condition is remedied. If the condition is due to lack of
+funds, funds will never be forthcoming so long as the condition is
+concealed.
+
+Similar results will follow publicity of overcrowding, too little play
+space, dry cleaning of school buildings, etc. The intent of such
+reporting is not to "keep tabs" on the school-teacher, the school
+child, the janitor, the principal, superintendent, or board, but to
+insure favorable conditions and to correct bad conditions. This is done
+best by giving everybody the facts. The objective test of the
+efficiency of a method throws emphasis on the method, not on the motive
+of those operating it. The blackboard method of publishing facts
+concentrates attention upon the importance of those facts and enlists
+aid in the attainment of the end sought.
+
+
+
+
+CHAPTER XXXI
+
+THE PRESS
+
+
+The president of Princeton University declares that for several decades
+we have given education that does not instruct and instruction that
+does not educate. Others tell us that because we read daily papers and
+magazines our minds become superficial, that our power to concentrate
+or memorize is weakened,--that we read so much of everything that we
+learn little of anything. As the habit of reading magazines and
+newspapers is constantly increasing, I think we must assume that it has
+come to stay. If we cannot check it, we can at least turn it to good
+advantage, systematize it, and discipline ourselves.
+
+Among the subjects continually described in newspapers and magazines,
+and even on billboards and in street-car advertising, is the subject of
+hygiene. No greater service can be rendered the community than for
+those who are conducting discussions of health to teach people how to
+read correctly this mass of information regarding health, to separate
+misinformation from information, and to apply the lessons learned to
+personal and public hygiene. There is no better way of doing this than
+to teach a class or a child to clip out of magazines and newspapers all
+important references to health, and then to classify these under the
+subject-matter treated. A teacher, parent, or club leader might
+practice by using the classification of subjects outlined in the
+Contents of this book. It is surprising how rapidly one builds up a
+valuable collection serviceable for talks or papers, but more
+particularly for giving one a vital and intelligent interest in
+practical health topics.
+
+Interested in comparing the emphasis placed on health topics in a
+three-cent paper having a small circulation with a penny paper having
+twenty times the circulation, I made during one week thirty-eight
+clippings from the three-cent paper and ninety-five from the penny
+paper. The high-priced paper had no editorial comment within the field
+of health, whereas the penny paper had three columns, in which were
+discussed among other things: _The Economics of Bad Teeth_; _Need for
+Individual Efficiency_; _"Good Fellows" Lower Standard of Living by
+Neglecting their Families_. The penny paper advertised fifty-two foods,
+garments, whiskies, patent medicines, or beautifiers urged upon health
+grounds. In the three-cent paper twenty-six out of thirty-eight items
+advertised food, clothing, patent medicine, or whisky. One issue of a
+monthly magazine devoted to woman's interests contained twenty-eight
+articles and editorials and fifty-five advertisements that concern
+health,--thirty-seven per cent of total reading matter and thirty-seven
+per cent of total advertisement.
+
+Excellent discipline is afforded by this clipping work. It is
+astonishing how few men and women, even from our better colleges, know
+how to organize notes, clippings, or other data, so that they can be
+used a few weeks later. There is a satisfaction in seeing one's material
+grow, as is remembered by all of us, in making picture scrapbooks or
+collections of picture postal cards and stamps. "Collections" have
+generally failed for want of classification,--putting things of a kind
+together. Chronological arrangement is uninteresting because
+unprofitable. One never knows where to find a picture, or a stamp, or a
+health clipping. Clippings, like libraries, will be little used if not
+properly catalogued so that use is easy. If a health-clipping collection
+is attempted, there are four essentials: (1) arrangement by topic; (2)
+inclusion of advertisements; (3) inclusion of items from magazines; (4)
+cross references.
+
+For classification, envelopes can be used or manila cards 10×12 inches.
+The teacher, parent, or advanced student will probably think the
+envelope most useful because most easily carried and filed,--most
+likely to be used. But clippings should be bound together in orderly
+appearance, or else it will be disagreeable working with them.
+Children, however, will like the pasting on sheets, which show clearly
+the growth of each topic. Envelopes or cards should not have clippings
+that deal with only one health topic. Unless a test is made to see how
+many health references there are in a given period, it should be made a
+rule not to clip any item that does not contain something new,--some
+addition to the knowledge already collected.
+
+Advertisements will prove interesting and educative. When newspapers
+and magazines announce some new truth, the commercial motive of
+manufacturer or dealer sees profit in telling over and over again how
+certain goods will meet the new need. Children will soon notice that
+the worst advertisements appear in the papers that talk most of
+"popular rights," "justice," and "morality." They will be shocked to
+see that the popular papers accept money to tell falsehoods about fake
+cures. They will be pleased that the best monthly magazines contain no
+such advertisements. They will challenge paper or magazine, and thus
+will be enlisted while young in the fight against health advertisements
+that injure health.
+
+To clip articles from magazines will seem almost irreverent at first.
+But the reverence for magazines and books is less valuable to education
+than the knowledge concealed in them. Except where families preserve
+all magazines, clippings will add greatly to their serviceability.
+
+The art of cross-referencing is invaluable to the organized mind. The
+purpose of classifying one's information is not to show how much there
+is, but to answer questions quickly and to guide constructive thinking.
+A clipping that deals with _alcoholism_, _patent medicine_, and
+_tuberculosis_ must be posted in three places, or cross-referenced;
+otherwise it will be used to answer but one question when it might
+answer three. If magazines may not be cut, it will be easy to record
+the fact of a useful article by writing the title, page, and date on
+the appropriate index card, or inclosing a slip so marked in the proper
+envelope.
+
+While it is true that the most important bibliography one can have in
+his private library is a classification of the material of which he
+himself has become a part while reading it, there are a number of
+health journals that one can profitably subscribe for. In fact, it is
+often true that the significant discoveries in scientific fields, or
+the latest public improvements, such as parks, bridges, model
+tenements, will not be appreciated until one has read in health
+journals how these improvements affect the sickness rate and the
+enjoyment rate of those least able to control their living conditions.
+The physician and nurse in their educational work for hospitals are
+distributors of health propaganda.
+
+Wherever there is a local journal devoted to health, parents, teachers,
+educators, and club leaders would do well to subscribe and to hold this
+journal up to a high standard by quoting, thanking, criticising it. In
+New Jersey, for example, is a monthly called the _New Jersey Review of
+Charities and Corrections_ that deals with every manner of subject
+having to do with public health as well as with private and public
+morality and education.
+
+A similar journal, intended for national instruction, is _The Survey_,
+whose topical index for last year enumerates two hundred and thirty-two
+articles dealing with subjects directly connected with public hygiene,
+e.g.:
+
+  Schools, 6; school inspection, 3; eyes,--school children, 1; sex
+  instruction in the schools, 2; psychiatric clinic, special
+  children, 2; industrial education, 5; child labor, 18;
+  playgrounds, 26; alley, crap, playing in streets, 3; labor
+  conditions, 18; industrial accidents, 10; wage-earner's
+  insurance, 4; factory inspection, 1; consumer's league, 3; women's
+  work, 6; tuberculosis, 23; hospitals, dispensaries (social), 5;
+  tenement reform, 10; living conditions, 2; baths, 1; public
+  comfort stations, 2; lodging houses, 1; clean streets, 6; clean
+  milk, 6; smoke, 1; noises, 1; parks, 1; patent medicines, 2;
+  sanitary code, 1; mortality statistics, 2; social settlements and
+  public health, 1; midwives, 1; children's bureau, 1; juvenile and
+  adult delinquent, 25; dependent, defective, and insane, 7; blind,
+  5; cripples, 1; homes for aged, 1; inebriates, 3; Traveler's Aid
+  Committee, 1; infant mortality, 2; social diseases, 2.
+
+       *       *       *       *       *
+
+_The National Hospital Record_, the _Dietetic and Hygienic Gazette_,
+the _Journal of Nursing_, are three other magazines primarily intended
+for nurses and physicians, but full of suggestive material for
+unprofessional readers. National magazines concerned with health, but
+seeking popular circulation, are _Good Health_ and _Physical Culture_.
+In England there is a special magazine called _Children's Diseases_,
+which could be of great help to a school library for special reference.
+The same can be said of the _Psychological Clinic_, _Pediatrics_, and
+other technical journals published in this country. For many persons,
+to make the best use of any one copy of these magazines, clipping is of
+course impossible, but noting on a card or envelope is practicable.
+
+Of late many of the national popular magazines have several columns
+devoted to health. We have not appreciated the educational
+possibilities of these columns. In most large cities there are monthly
+book reviews which may be profitably consulted in learning the new
+thought in the health field. If teachers would either write their
+experience or ask questions, if children knew that in a certain
+magazine or newspaper questions as to ventilation, bathing, exercise,
+would be answered, they would take a keen interest in the progress of
+discussions. The large daily papers make a great feature of their
+health hints. It is not their fault if questioners care more about
+cosmetics and hair bleaches than about the fresh-air cure of headaches.
+They will coöperate with teachers and parents in securing more general
+discussion of other problems than beauty doctoring.
+
+Finally, persons wanting not only to have intelligence as to matters
+promoting health, but actually to exert a helpful influence in their
+community, ought to want the published reports of the mayor, health
+department, the public schools, and other institutions, noting
+carefully all that is said about conditions relating to health and
+about efforts made to correct all unfavorable conditions. The best
+literature of our day, with regard to social needs, appears in the
+reports of our public and private institutions and societies. Of
+increasing value are the publications of the national government
+printing office. Because it is no one's business to find out what
+valuable material is contained in such reports, and because no
+educational museum is comparing report with report, those who live
+nearest to our health problems and who see most clearly the health
+remedies, are not stimulated to give to the public their special
+knowledge in an interesting, convincing way.
+
+Teaching children how to find health lessons in public documents will
+advance the cause of public ethics as well as of public health. At the
+New York State Conference of Charities, of 1907, one official
+complained that the physicians made no educational use of their
+valuable experience for public education. He stated that a study of
+medical journals and health articles in popular magazines revealed the
+fact that the number of papers prepared by physicians in state
+hospitals averaged one to a doctor for every five or six years of
+service. This state of affairs is even more exaggerated in strictly
+educational institutions. Columbia University has recently instituted a
+series of lectures to be given by its professors to its professors, so
+that they may have a general knowledge of the work being done in other
+fields besides their own at their own university. This is equally
+important for teachers and heads of departments in elementary schools.
+It is now admitted by most educators that elementary schools and young
+children present more pedagogical difficulties and pressing biological
+problems than higher schools. If teachers and parents would realize
+that their method of solving the health problems that arise daily in
+the schoolroom and in the home would interest other mothers and
+teachers, their spirit of coöperation would soon be reflected in school
+journals, popular magazines, and daily newspapers.
+
+
+
+
+PART V. ALLIANCE OF HYGIENE, PATRIOTISM, AND RELIGION
+
+
+
+
+CHAPTER XXXII
+
+DO-NOTHING AILMENTS
+
+
+"Men have died, from time to time, and worms have eaten them, but not
+for love"--_nor for work_. Work of itself never killed anybody nor made
+anybody sick. Work has caused worry, mental strain, and physical
+breakdown, only when men while working have been deprived of air, sun,
+light, exercise, sleep, proper food at the proper time, opportunity to
+live and work hygienically. Fortunately for human progress, doing
+nothing brings ailments of its own and has none of the compensations of
+work. As the stomach deprived of substantial food craves unnatural
+food,--sweets, stimulants,--so the mind deprived of substantial,
+regular diet of wholesome work turns to unwholesome, petty, fantastic,
+suspicious, unhappy thoughts. This state of mind, combined with the
+lack of bodily exercise that generally accompanies it, reacts
+unfavorably on physical health. An editor has aptly termed the
+do-nothing condition as a self-inflicted confinement:
+
+  A great deal of the misery and wretchedness among young men that
+  inherit great fortunes is caused by the fact that they are
+  practically in jail. They have nothing to do but eat, drink, and
+  enjoy themselves, and they cannot understand why their lives are
+  dull.
+
+  We have had the owner of a great railroad system pathetically
+  telling the public that he is unhappy. That is undoubtedly true,
+  because with all his race horses, and his yachts, and all the
+  things that he imagines to be pleasures, he is not really doing
+  anything.
+
+  If he were running one little railroad station up the road,
+  handling the freight, fussing about dispatches, living above the
+  railroad station in two rooms, and buying shoes in a neighboring
+  village for fifteen children he would be busy and happy.
+
+  But he cannot be happy because he is in prison,--in a prison of
+  money, a prison that is honorable because it gives him everything
+  that he wants, and he wants nothing.
+
+A New York newspaper that circulates among the working classes where
+young men and women are inclined to associate health and happiness with
+doing nothing recently gave two columns to "Dandy Jim," the richest dog
+in the world. Dandy Jim's mistress left him a ten-thousand-dollar
+legacy. During his lifetime he wore diamonds. Every day he ate candy
+that cost eighty cents a pound. The coachman took him driving in the
+park sunny afternoons. He had no cares and nothing to work for. His
+food came without effort. He had fatty degeneration of the vital
+organs. He was pampered, coddled, and killed thereby. Thousands of men
+and women drag out lives of unhappiness for themselves and others
+because, like Dandy Jim, they have nothing to work for, are pampered,
+coddled victims of fatty degeneration. When President Butler of
+Columbia University finds it necessary to censure "the folly and
+indifference of the fathers, vanity and thoughtless pride of the
+mothers" who encourage do-nothing ailments; and when the editor of the
+_Psychological Clinic_ protests that the fashionable private schools
+and the private tutor share with rich fathers and mothers
+responsibility for life failures,--it is time that educators teach
+children themselves the physical and moral ailments and disillusions
+that come from doing nothing.
+
+Ten years ago a stenographer inherited two hundred and fifty thousand
+dollars. Her dream of nothing to do was realized. She gave up her
+strenuous business life. Possessions formerly coveted soon clogged her
+powers of enjoyment. She imagined herself suffering from various
+diseases, shut herself up in her house, and refused to see any one. She
+grew morbid and was sure that every person who approached her had some
+sneaking, personal, hostile motive. Though always busy, she
+accomplished little. Desultory work, procrastination, and
+self-indulgence destroyed her power of concentration. She could not
+think long enough on one subject to think it out straight, therefore
+she was constantly deceived in her friends and interests. She first
+trusted everybody, then mistrusted everybody. Infatuation with every
+new acquaintance was quickly followed by suspicion. For years she was a
+very sick woman, a victim of do-nothing ailments.
+
+Doing nothing has of late been seriously recommended to American
+business men. They are advised to retire from active work as soon as
+their savings produce reasonable income. It is true, this suggestion
+has been made as an antidote to greed rather than for the happiness of
+the business man. What retiring from business is apt to mean, is
+indicated by a gentleman who at the age of sixty decided to sell his
+seat on the New York Stock Exchange and to enjoy life. He became
+restless and very miserable. He threw himself violently into one thing
+after another; in less than a year he became an ill, broken old man,
+after trying vainly to buy back his business.
+
+Both mind and body were made to work. The function of the brain is to
+think to a purpose, just as the function of the heart is to pump blood.
+The habit of doing nothing is very easily formed. The "out-of-work"
+soon become "the work-shy." Having too little to do is worse for the
+body and mind than having too little to eat. Social reformers emphasize
+the bad effect on society of vagrancy. Evils of indiscriminate relief
+to the poor are vividly described year after year. The philanthropist
+is condemned, who, by his gifts, encourages an employee's family to
+spend what they do not earn, and to shun work. Yet the idleness of the
+tramp, street loafer, and professional mendicant is a negligible evil
+compared with the hindrance to human progress caused by the idleness of
+the well-to-do, the rich, the educated, the refined, the "best" people.
+It is as much a wrong to bring up children in an atmosphere of
+do-nothingism, as to refuse to have their teeth attended to or to have
+glasses fitted to weak eyes.
+
+From the point of view of community welfare it is far more serious for
+the rich child to be brought up in idleness or without a purpose than
+for the poor child to become a public charge. Not only has society a
+right to expect more from rich children in return for the greater
+benefits they enjoy, but so long as rich children control the
+expenditure of money, they control also the health and happiness of
+other human beings. Unless taught the value and joy of wholesome work
+they cannot themselves think straight, nor are they likely to want to
+understand how they can use their wealth for the benefit of mankind. To
+quote President Butler again:
+
+  The rich boy who receives a good education and is trained to be a
+  self-respecting member of the body politic might in time share on
+  equal terms the chance of the poor boy to become a man of genuine
+  influence and importance on his own account, just as now by the
+  neglect, or worse, of his parents the very rich boy is apt to be
+  relegated to the limbo of curiosities, and too often of decadence.
+
+Nervous invalids make life miserable for themselves and for others,
+when often their sole malady is lack of the right kind of work to do.
+
+Suiting work to interest and interest to work is an economy that should
+not be overlooked. The energy spent in forcing oneself to do a
+distasteful task can be turned to productive channels when work is made
+pleasurable. The fact is frequently deplored that whereas formerly a
+man became a full-fledged craftsman, able to perform any branch of his
+trade, he is now confined to doing special acts because neither his
+interest nor his mind is called into play. Work seems to react
+unfavorably on his health. He has not the pride of the artisan in the
+finished product, for he seldom sees it. He does a task. His employer
+is a taskmaster. He decides that work is not good for him as easily as
+when a school-boy he grasped the meaning of escape from his lessons. By
+failing to fit studies to a student's interest, or by failing to insure
+a student's interest in his studies, schools and colleges miseducate
+young men and young women to look upon all work as tasks, as
+discipline, necessary but irksome, and to be avoided if possible. Just
+as there is a way of turning all the energy of the play instinct into
+school work, so there is a way of interesting the factory and office
+worker in his job. However mechanical work may be, there is always the
+interest in becoming the most efficient worker in a room or a trade.
+Routine--accurate and detailed work--does not mean the stultification
+of the imagination. It takes more imagination to see the interesting
+things in statistical or record work than to write a novel. Therefore
+employers should make it a point to help their employees to realize the
+significance of the perfection of each detail and the importance of
+each man's part. The other day a father said to me, "I want my boys to
+be as ashamed to do work in which they are not interested as to accept
+graft." When interest in work and efficiency in work are regarded as of
+more importance than the immediate returns for work, when it is as
+natural for boys and girls to demand enjoyment and complete living in
+work as it is to thrill at the sight of the Stars and Stripes,
+do-nothing ailments will be less frequent and less costly.
+
+Work--that one enjoys--is an invaluable unpatented medicine. It can
+make the sick well and keep the well from getting sick. It is the chief
+reliance of mental hygiene. "I should have the grippe if I had time,"
+said a business woman to me the other day; but she did not have time,
+hence she did not have the grippe.
+
+    If you're sick with something chronic,
+    And you think you need a tonic,
+            Do something.
+    There is life and health in doing,
+    There is pleasure in pursuing;
+    Doing, then, is health accruing--
+            Do something.
+
+    And if you're seeking pleasure,
+    Or enjoyment in full measure,
+            Do something.
+    Idleness, there's nothing in it;
+    'Twill not pay you for a minute--
+            Do something.
+
+
+
+
+CHAPTER XXXIII
+
+HEREDITY BUGABOOS AND HEREDITY TRUTHS
+
+
+One of the red-letter days of my life was that on which I learned that
+I could not have inherited tuberculosis from two uncles who died of
+consumption. For years I had known that I was a marked victim. Silently
+I carried my tragedy, suspecting each cold and headache to be the
+telltale messenger that should let others into my secret. He was a
+veritable emancipator who informed me that heredity did not work from
+uncle to nephew; that not more than a predisposition to consumption
+could pass even from parent to child; that a predisposition to
+consumption would come to nothing without the germ of the disease and
+the environmental conditions which favor its development; and that if
+those so predisposed avoid gross infection, lead a healthy life, and
+breathe fresh air they are as safe as though no tuberculous lungs had
+ever existed in the world. Some years later I learned to understand the
+other side of the case; I realized how I had been in real danger of
+contracting consumption in the darkened, ill-ventilated sick room of
+the uncle who taught me my letters and gave me my ideal of God's
+purpose in sending uncles to small boys.
+
+There are two distinct things which make each individual life: the
+living stuff, the physical basis of life, handed down from parent to
+child; and the environmental conditions which surround it and play upon
+it and rouse its reactions and its latent possibilities. It is like the
+seed and the cultivation. You cannot grow corn from wheat, but you can
+grow the best wheat, or you may let your crop fail through careless
+handling.
+
+It is well that we should think seriously about the part played by
+heredity, for the living stuff of the future depends upon our sense of
+responsibility in this regard. The intelligent citizen would do well to
+read such a book as J. Arthur Thompson's _Heredity_ (1908), in which
+the latest conclusions of science are clearly and soundly set forth.
+
+The main problem of to-day, however, is to use well the talents that we
+have. Here two things should always be kept in mind: First, the
+inherited elements which make up our minds and bodies are complex and
+diverse. Health and strength are inherited as well as disease and
+weakness; they have indeed a better chance of survival. In the most
+unpromising ancestry there are latent potentialities which may be made
+fruitful by effort. No limit whatever can be set to the possibilities
+of improvement in any individual.
+
+In the second place, if science has shown anything more clearly than
+the importance of heredity, it is the importance of environment. This
+influence upon human lives is within our control, and it is a grave
+error to neglect what lies clearly within our power and to bemoan what
+does not. Science has wrought no benefits greater than those which
+result from drawing a clear line between heredity bugaboos and heredity
+truths. An overemphasis on the hereditary factor in development at the
+expense of the environmental factor, I call a heredity bugaboo; and it
+is a tendency which cannot be too strongly condemned. To fight against
+the sins and penalties of one's grandfather is a forlorn task that
+quickly discourages. To overcome diseases of environment, of shop and
+street, of house and school, seems, on the contrary, an easy task.
+Heredity bugaboos dishearten, enervate, encourage excesses and neglect.
+Heredity truths stimulate remedial and preventive measures.
+
+We may well watch with interest the progress of eugenics, that new
+science which biologists and sociologists hope will some day remake the
+very living stuff of the human race. But meanwhile let us take up with
+hope and courage and enthusiasm the great hemisphere of human fate
+which lies within our grasp. Good food and fresh air, well-built
+cities, enlightened schools and well-ordered industries, stable and
+free and expert government,--given these things, we can transform the
+world with the means now at our disposal. We can reap, if we will,
+splendid possibilities now going to waste, and by intelligent
+biological and sociological engineering we can hand on to the next
+generation an environmental inheritance which will make their task far
+easier than ours.
+
+"Physical deterioration" is a bugaboo that is discovered by some in
+heredity and by others in modern industrial evils. The British director
+general called attention a few years ago to the fact that from forty to
+sixty per cent of the men who were being examined for military service
+were physically unfit. A Commission on Physical Deterioration was
+appointed to investigate the cause, and to learn whether the low
+physical standard of the would-be Tommy Atkins was due to inherited
+defects. The results of this study were published in a large volume
+called _Report on Physical Deterioration, 1904_, in which is set forth
+a positive programme for obtaining periodically facts as to the
+physique of the nation. In the course of the commission's exhaustive
+investigation there was found no evidence that any progressive
+deterioration was going on in any function of the body except the
+teeth. "There are happily no grounds for associating dental degeneracy
+with progressive physical deterioration." The increase in optical
+defects is attributed not to the deterioration of the eye, but to
+greater knowledge, more treatment, and better understanding of the
+connection between optical defects and headache.
+
+    [Illustration: Testing Environment--House Score]
+
+ +--------------------------------------------------------------------+
+ |           DEFINITIONS OF TERMS USED IN HOUSE SCORE CARD            |
+ |                                                                    |
+ | LIGHT--Light enough to read easily in every part.                  |
+ |                                                                    |
+ | GLOOMY--Not light enough to read easily in every part, but enough  |
+ | readily to see one's way about when doors are closed.              |
+ |                                                                    |
+ | DARK--Too dark to see one's way about easily when doors are        |
+ | closed.                                                            |
+ |                                                                    |
+ | WELL VENTILATED--With window on street or fair-sized yard (not     |
+ | less than 12 ft. deep for a five-story tenement house not on a     |
+ | corner), or on a "large," "well-ventilated" court open to the sky  |
+ | at the top: "large" being for a court entirely open on one side to |
+ | the street or yard in a five-story tenement, not less than 6 ft.   |
+ | wide from the wall of the building to the lot line; for a court    |
+ | inclosed on three sides and the other on the lot line in a         |
+ | five-story tenement, not less than 12×24 ft., "well ventilated"    |
+ | meaning either entirely open on one side to the street or yard, or |
+ | else having a tunnel at the bottom connecting with the street or   |
+ | yard.                                                              |
+ |                                                                    |
+ | FAIRLY VENTILATED--With window opening on a shallow yard or on a   |
+ | narrow court, open to the sky at the top, or else with 5×3 inside  |
+ | window (15 ft. square) opening on a well-ventilated room in same   |
+ | apartment.                                                         |
+ |                                                                    |
+ | BADLY VENTILATED--With no window on the street, or on a yard, or   |
+ | on a court open to the sky, and with no window, or a very small    |
+ | window, opening on an adjoining room.                              |
+ |                                                                    |
+ | IN GOOD REPAIR--No torn wall paper, broken plaster, broken         |
+ | woodwork or flooring, nor badly shrunk or warped floor boards or   |
+ | wainscoting, leaving large cracks.                                 |
+ |                                                                    |
+ | IN FAIR REPAIR--Slightly torn or loose wall paper, slightly broken |
+ | plaster, warped floor boards and wainscoting.                      |
+ |                                                                    |
+ | IN BAD REPAIR--Very badly torn wall paper or broken plaster over a |
+ | considerable area, or badly broken woodwork or flooring.           |
+ |                                                                    |
+ | (Rooms not exactly coinciding with any of the three classes are to |
+ | be included in the one the description of which comes nearest to   |
+ | the condition.)                                                    |
+ |                                                                    |
+ | SINKS: GOOD--Iron, on iron supports with iron back above to        |
+ | prevent splashing of water on wall surface, in light location,     |
+ | used for one family. Water direct from city water mains or from a  |
+ | CLEAN roof tank.                                                   |
+ |                                                                    |
+ | BAD--Surrounded by wood rims with or without metal flushings,      |
+ | space beneath inclosed with wood risers; dark location, used by    |
+ | more than one family; water from dirty roof tank.                  |
+ |                                                                    |
+ | FAIR--Midway between above two extremes. (Sinks not exactly        |
+ | coinciding with any of the three classes are to be included in the |
+ | one the description of which comes nearest to the condition.)      |
+ |                                                                    |
+ | WATER-CLOSET: GOOD--Indoor closet. In well lighted and ventilated  |
+ | location, closet fixture entirely open underneath, abundant water  |
+ | flush.                                                             |
+ |                                                                    |
+ | FAIR--Indoor closet, poor condition--badly lighted and ventilated  |
+ | location, fixture inclosed with wood risers, or poor flush.        |
+ |                                                                    |
+ | POOR--Yard closet--separate water-closet in individual compartment |
+ | in the yard.                                                       |
+ |                                                                    |
+ | BAD--School sink--sewer-connected privy, having one continuous     |
+ | vault beneath the row of individual toilet compartments.           |
+ +--------------------------------------------------------------------+
+
+The commission hoped "that the facts and opinions they have collected
+will have some effect in allaying the apprehensions of those who, as it
+appears, on insufficient grounds, have made up their minds that
+progressive deterioration is to be found among people generally." In
+regard to the facts which started the fear, the report says: (1) the
+evidence adduced in the director general's memorandum was inadequate to
+prove that physical deterioration had affected the classes referred to;
+(2) no sufficient material (statistical or other) is at present
+available to warrant any definite conclusions on the question of the
+physique of the people by comparison with data obtained in past times.
+
+    [Illustration: THE BEST INHERITANCE IS A MOTHER WHO KNOWS HOW TO
+    KEEP HER BABY WELL]
+
+The topics dealt with in the report refer to only a partial list of
+conditions that need to be carefully studied before we can know what
+environment heredity we are preparing for those who follow us:
+
+
+  I. AS TO BABIES
+
+  Training of mothers, provident societies and maternity funds,
+  feeding of infants, milk supply, milk depots, sterilization and
+  refrigeration of milk, effect of mother's employment upon infant
+  mortality, still births, cookery, hygiene and domestic economy,
+  public nurseries, crèches.
+
+
+  II. AS TO CHILDREN
+
+  Anthropometric measurements, sickness and open spaces, medical
+  examination of school children, teeth, eyes, and ears, games and
+  exercises for school children, open spaces and gymnastic
+  apparatus, physical exercise for growing girls and growing boys,
+  clubs and cadet corps, feeding of elementary school children,
+  partial exemption from school, special schools for "retarded"
+  children, special magistrate for juvenile cases, juvenile smoking,
+  organization of existing agencies for the welfare of lads and
+  girls, education, school attendance in rural districts, defective
+  children.
+
+
+  III. AS TO LIVING AND WORKING CONDITIONS
+
+  Register of sickness, medical certificates as to causes of death,
+  overcrowding, building and open spaces, register of owners of
+  buildings, unsanitary and overcrowded house property, rural
+  housing, workshops, coal mines, etc., medical inspection of
+  factories, employment of women in factories, labor colonies,
+  overfatigue, food and cooking, cooking grates, adulteration, smoke
+  pollution, alcohol, syphilis, insanity.
+
+
+  IV. AS TO HEALTH MACHINERY
+
+  Medical officers of health, local, district, and national boards,
+  health associations.
+
+Scientists of the next generation will continue to differ as to
+heredity truths and heredity bugaboos unless records are kept now,
+showing the physical condition of school children and of applicants for
+work certificates and for civil service and army positions. The British
+investigators declared that "anthropometric records are the only
+accredited tests available, and, if collected on a sufficient scale,
+they would constitute the supreme criterion of physical deterioration,
+or the reverse.... The school population and the classes coming under
+the administration of the Factory Acts offer ready material for the
+immediate application of such tests." In addition to the physical tests
+proposed in other chapters, there is great educational opportunity in
+the records of private and public hospitals. Every nation, every state,
+and every city should enlist all its educational and scientific forces
+to ascertain in what respects social efficiency is endangered by
+physical deficiencies that can be avoided only by restricting
+parenthood, and the environmental deficiencies that can be avoided by
+efficient health machinery.
+
+The greatest of all heredity truths are these: (1) the deficiencies of
+infants are infinitesimal compared with the deficiencies of the world
+with which we surround them; (2) each of us can have a part in
+begetting for posterity an environment of health and of opportunity.
+
+
+
+
+CHAPTER XXXIV
+
+INEFFECTIVE AND EFFECTIVE WAYS OF COMBATING ALCOHOLISM
+
+
+Wherever the Stars and Stripes fly over school buildings it is made
+compulsory to teach the evils of alcoholism. For nearly a generation
+the great majority of school children of the United States have been
+taught that alcohol, in however small quantities, is a poison and a
+menace to personal and national health and prosperity. Yet during this
+very period the per capita consumption of every kind of alcoholic
+beverage has increased. Whereas 16.49 gallons of spirituous liquors
+were consumed per capita of population in 1896, 22.27 gallons were used
+in 1906. Obviously the results of methods hitherto in vogue for
+combating alcoholism are disappointing.
+
+Why this paradoxical relation of precept to practice? Why is this, the
+most hygiene-instructed country in the world, the Elysium of the
+patent-medicine and cocaine traffic? If we have only the expected
+divergence of achievement from ideal, then there is nothing for us to
+do but to congratulate ourselves and posterity upon the part played by
+compulsory legislation in committing all states and territories to
+hygiene instruction in all public schools. If, on the other hand, our
+disappointment is due to ineffective method, then the next step is to
+change our method.
+
+The chief purpose of school hygiene has hitherto been not to promote
+personal and community health, but to lessen the use of alcohol and
+tobacco. Arguments were required against whisky, beer, cigars, and
+cigarettes. As the strongest arguments would probably make the most
+lasting impression upon the school child and the best profits for
+author and bookseller, writers vied with one another in the rhetoric
+and hyperbole of platform agitation. What effect would it have upon you
+if you were exhorted frequently during the next eight years to avoid
+tobacco because a mother once killed a child by washing its head in
+tobacco water? What is the effect on the mind of a boy or a girl who
+sees that the family doctor, the minister, the teacher, the judge, the
+governor, the President, and the philanthropist use tobacco and
+alcoholic beverages, when taught that "boys who use tobacco and
+alcoholic beverages will find closed in their faces the doors to
+strength, good health, skill in athletics, good scholarship, long life,
+best companions, many business positions, highest success"? It is
+probably true that "a boy once drank some whisky from a flask and died
+within a few hours." But that story is about as typical of boys and of
+whisky as that a boy once drank whisky from a flask and did not die for
+ninety years afterwards, or that George Washington drank whisky and
+became the Father of his Country.
+
+How special pleading has dominated the teaching of school hygiene is
+illustrated by a recent book which, for the most part, successfully
+breaks away from the narrow point of view and the crude methods
+hitherto prevailing. It presents the following facts concerning New
+York City:
+
+ Saloons                                                 10,821
+ Arrests                                                133,749
+ Expense of police department                       $10,199,206
+ Police courts, jails, workhouses, reformatories      1,310,411
+ Hospitals, asylums, and other charities              4,754,380
+
+It is fair to the author to state that she does not declare in so many
+words that the shutting up of the saloons would obviate all the arrests
+and all the hospital, jail, and charity bills. Instead of _wipe out_
+she says _shrivel_. No truth would have been lost by avoiding all
+misrepresentation.
+
+The author probably felt as I did when I took my total abstainer's
+protest to a celebrated scientist who had exposed certain misstatements
+regarding the effect of small quantities of alcohol: "Is not the
+untruth of these exaggerated statements less dangerous than the untruth
+of dispassionate, scientific statement? So long as the child mind takes
+in only an impression, is it not better to write this impression
+indelibly?" He sadly but indulgently replied, "And in what other
+studies would you substitute exaggeration for truth?"
+
+The reaction has already begun against exaggeration in hygiene
+text-books, against drawing lessons from accidental or exceptional
+cases of excessive use of alcohol, against classing moderate drinking
+and smoking with drunkenness as sins of equal magnitude, and against
+overlooking grave social and industrial evils that threaten children
+far earlier and more frequently than do tobacco and alcohol. Instead of
+adding an ell to the truth, text-book writers are now adding only an
+inch or two at a time. No longer do we favor highly colored charts that
+picture in purple, green, and black the effect of stimulants and
+narcotics upon the heart and brain, the stomach, the liver, the knee,
+and the eardrum, _assuming that all resultant evils are concentrated in
+one organ_. Menacing habits, such as overeating and indulgence in
+self-pity, are beginning to receive attention. It is also true that
+physiology and anatomy are progressively made more interesting.
+Publishers are looking for the utmost originality compatible with the
+purpose of the present laws and with the only effective public
+sentiment that has hitherto been interested in the interpretation of
+those laws.
+
+A score of improvements in the method of carrying out a small ideal
+will not take the place of enlarging that ideal. If existing laws stand
+in the way of broadening the purpose of school hygiene, let the laws be
+changed. If text-book publishers stand in the way, let us induce or
+compel them to get out of the way. If we fear rumsellers, their money,
+and the insidious political methods that they might employ to bring in
+undertruth if overtruth is once sacrificed, let us go to our
+communities and locate the rumseller's guns, draw their fire, tell the
+truth about their opposition, and educate the public to overcome it.
+If, on the other hand, misguided teetotalism stands in the way, then,
+as one teetotaler, I suggest that we prove, as we can, in our
+respective communities that there is a better way of inculcating habits
+of temperance and self-restraint than by telling untruths, overtruths,
+or half truths about alcohol and tobacco. Let us prove, as we can, that
+a subject vital to every individual, to every industry, and to every
+government is now prevented from fulfilling its mission not by its
+enemies but by its friends. We can learn the character of hygiene
+instruction in our schools and the interest taken in it by teachers,
+principals, and superintendents. We can learn how teachers practice
+hygiene at school, and how the children of our communities are affected
+by the hygiene instruction now given. Finally, we can compel a public
+discussion of the facts, and action in accordance with facts. Without
+questioning anybody's avowed motive, we can learn how big that motive
+is and how adequate or inadequate is the method of executing it.
+
+Alcohol and tobacco really occupy but a very small share of the
+interest and attention of even those men and women by whom they are
+habitually used. Hygiene, on the other hand, is of constant,
+uninterrupted concern. Why, therefore, should it be planned to have
+alcohol and tobacco displace the broader subject of personal and public
+hygiene in the attention and interest of children throughout the school
+life? Beyond the text-book and schoolroom a thousand influences are at
+work to teach the social evils, the waste of energy, and the
+unhappiness that always accompany the excessive use--and frequently
+result from a moderate use--of stimulants and narcotics. Of the many
+reasons for not drinking and smoking, physiology gives those that
+least interest and impress the child. The secondary effects, rather
+than the immediate effects, are those that determine a child's action.
+Most of the direct physiological effects are, in the majority of
+instances, less serious in themselves than the effects of overeating,
+of combining milk with acids, of eating irregularly, of neglecting
+constipation. Were it not for the social and industrial consequences of
+drunkenness and nicotinism, it is doubtful if the most lurid picture of
+fatty degeneration, alcoholic consumption, hardened liver, inactive
+stomach lining, would outweigh the pleasing--and deceiving--sensations
+of alcoholic beverages and cigarettes.
+
+The strong appeal to the child or man is the effect these habits have
+upon his mother, his employer, his wife, his children. The vast
+majority of us will avoid or stop using anything that makes us
+offensive to those with whom we are most intimately associated, and to
+those upon whom our professional and industrial promotion depends.
+Children will profit from drill in and out of school in the science of
+avoiding offense and of giving happiness, but unless the
+categories--_acts that give offense_ and _acts that give
+happiness_--are wide enough to include the main acts committed in the
+normal relations of son, companion, employer, husband, father, and
+citizen, those who set out to avoid alcohol and tobacco find themselves
+ill equipped to carry the obligations of a temperate, law-abiding
+citizen.
+
+Things do not happen as described in the early text-book. Other things
+not mentioned hinder progress and happiness. The child at work resents
+the mis-education received at school and suspects that he has been
+following false gods. The enemies that cause him trouble come from
+unexpected sources. He finds it infinitely easier to eschew alcohol and
+tobacco than to avoid living conditions that insidiously undermine his
+aversion to stimulants and narcotics. The reasons for avoiding
+stimulants in the interest of others are more numerous and more cogent
+than the reasons for avoiding stimulants and narcotics for one's own
+sake. The altruistic reasons for shunning stimulants and narcotics
+cannot be implanted in the child unless he sees the evil of excess _per
+se_ in anything and everything, and unless he becomes thoroughly
+grounded in the life relations and health relations to which he must
+adapt himself.
+
+Unclean streets, unclean milk, congested tenements, can do more harm
+than alcohol and tobacco, because they breed a physique that craves
+stimulants and drugs. Adenoids and defective vision will injure a
+larger proportion of the afflicted than will alcohol and tobacco,
+because they earlier and more certainly substitute discouragement for
+hope, handicap for equal chance. Failure to enforce health laws is a
+more serious menace to health and morals than drunkenness or tobacco
+cancer.
+
+If it is true that we must attack the problem of alcohol from the
+standpoint of its social and industrial effects, we are forced at once
+to consider the machinery by which cities and governments control the
+manufacture and sale of alcohol. It is not an exaggeration to say that
+courses in regulating the traffic in alcohol are more necessary than
+courses in the effects of alcohol upon digestion and respiration.
+
+If Sunday closing of saloons, local option, high license, and
+prohibition have failed, there is no evidence that the failure is due
+to the principles underlying any one of these methods. Until more
+earnest effort is made to study the effects of these methods, the
+results of their enforcement and the causes of their nonenforcement, no
+one is justified in declaring that either policy is successful or
+unsuccessful. It is very easy to select from the meager facts now
+available convincing proofs both that prohibition does not prohibit and
+that high license leads to increased drunkenness. The consequence is
+that the movements to control, restrict, or prohibit the use of alcohol
+are emotional, not rational.
+
+It is impossible to keep emotion, sensation, sentiment, at white heat.
+Most extremists worship legislation and do not try to keep interest
+alive by telling every week or every month new facts about the week or
+the month before. No new fuel is added to the anti-saloon fire, which
+gradually cools and dies down. Not so, however, with those who make
+money by the sale of intoxicants. The greater the opposition, the more
+brains, the more effort, the more money they put into overcoming or
+circumventing that opposition. Fuel is piled on and the bonfire is fed
+freely. Every day the anti-restriction bonfire becomes larger and
+larger, and the anti-saloon bonfire becomes smaller and smaller. By
+carefully selecting their facts, by counting the number of arrests for
+drunkenness and the number of saloons open on Sunday, by reiteration of
+their story the pro-saloonists gradually win recruits from the
+opposition, and, when the next election comes, their friends outnumber
+their enemies and the "dry" policy of a city, county, or state is
+reversed.
+
+The failures attributed to prohibitive or restrictive measures are
+probably no more numerous than the failures of government in other
+respects. The present ambassador from England, James Bryce, writing his
+_American Commonwealth_, declared that municipal government was
+America's "most conspicuous failure." The mayor of Toledo, writing in
+1907, says, "There has been a pessimism, almost enthusiastic, about the
+city." These failures are due not to any lack of desire for good
+government, not to any fundamental evils of cities, but to the fact
+that municipal reform, like the crusade against alcohol, has been based
+upon emotionalism, not upon definite proof. Reformers have been unable
+to lead in the right direction, because they have looked at their
+lantern instead of their road. Not having cumulative information as to
+government acts, they have been unable to keep their fires burning. To
+illustrate: in November, 1907, the governor of New York state, the
+mayor of New York City, and reformers of national reputation eulogized
+the tenement-house department; yet this department, whose founding was
+regarded as a national benefaction, was the only department of the city
+government that did not receive an increase for 1908. It is in the
+position of temperance legislation, the facts of whose enforcement or
+nonenforcement are not promptly and continuously made public.
+
+Fear of the negro victim of alcoholism, social evils of intemperance,
+whether among white or black, industrial uncertainty and waste due to
+alcoholism, are the three chief motives that have swept alcohol traffic
+out of the greater part of the South. Knowledge of physiological evils
+has had little influence, except as it may have rendered more
+acceptable the claim that alcoholism is a disease against which there
+is no insurance except abolition of alcohol as a beverage. Religious
+revivals, street parades by day and by night, illustrated banners,
+personal intercession, lines of women and children at the polls, made
+it necessary for voters to make known their intention, and made it
+extremely difficult for respectable men, engaged in respectable
+business, to vote for saloons. Some states have gone so far as to
+prohibit the manufacture of alcoholic stimulants, even though not
+offered for sale within state limits. In Georgia wine cannot be used at
+the communion service, nor can druggists sell any form of liquor except
+pure alcohol. In Louisiana it is illegal for representatives of "wet
+districts" to solicit orders for liquor in any of the "dry districts."
+In Texas the sale of liquor in dining cars is forbidden, and the
+traveler may not even drink from his own flask. Congress is being urged
+by senators and congressmen, as well as by anti-saloon advocates, to
+pass laws prohibiting common carriers from delivering alcoholics to any
+"dry" community. The more optimistic anti-saloon workers believe it is
+but a matter of a short time when Congress will pass laws prohibiting
+the manufacture or sale of alcoholic beverages within any limits
+protected by the United States Constitution.
+
+Southern states have been warned that they could not afford the
+depreciation of real estate values, of rents, and of business that
+would surely follow the "confiscation of capital" and "interference
+with personal liberty." This warning has been met by plausible
+arguments that the buyers of legitimate and nonpoisonous commodities
+could pay better rents, better profits on business and on real estate,
+if freed from the uneven fight against temptation to drink. The
+argument that schools and streets and health must suffer if the license
+money was withdrawn, has been met by the plausible argument that the
+ultimate taxpayer--the family that wants clothing, food, and
+shelter--will save enough money to be able to spend still larger sums
+than heretofore upon education, health, and public safety.
+
+For the first time dealers in alcohol recognize the possibility of a
+great national movement and of national prohibition. Both the defects
+in methods hitherto used to oppose saloon legislation and the reasons
+for meeting the present situation by new methods are presented in the
+May issue (1907) of the _Transactions of the American Brewing
+Institute_. Under the title, "Social Order and the Saloon--the Measure
+of the Brewer's Responsibility," Mr. Hugh F. Fox, known throughout the
+Union as a defender of child rights, advocate of probation and
+children's courts, promoter of health and education, outlined a plan
+for research that is indispensable to the proper settling of this great
+question. Whether brewer or anti-saloon leaguist, total abstainer or
+moderate drinker, employer or trade unionist, it is necessary to the
+intelligent control of alcohol that each of us approach this momentous
+question of control or abolition of the saloon in the spirit expressed
+in this paper, whose thoroughness and whose social point of view would
+do credit to a church conference. The address is quoted and its
+questions copied because both show how much depends upon knowing
+whether laws are enforced and how much greater is the difficulty of
+coping with a conciliatory antagonist who professes willingness to
+submit to tests of evidence.
+
+  The regulation of the liquor business involves fundamental
+  questions of the function and scope of government, and there is
+  hardly any department of organized human activity that has been
+  the subject of so much experiment and futile tinkering.... The
+  only people who are perfectly consistent are the prohibitionists,
+  whose policy is abolition. Let us, however, try to detach
+  ourselves from any personal interest that we may have in the
+  subject, and consider it impartially as a matter of public
+  concern.
+
+  What the brewer as an individual cannot do, the brewers as an
+  organization have done successfully in many places in spite
+  sometimes of official negligence, corruption, or incapacity. The
+  Texas Brewers' Association is reported as having successfully
+  prosecuted two thousand cases against keepers of disreputable
+  resorts during the past three years. The object of their campaign
+  was to purify the retail liquor trade from unclean and law-defying
+  elements.
+
+  The greatest gain that has come to society, as distinguished from
+  the individual, through the temperance movement is its effect in
+  unconsciously informing the public that the regulation and
+  administration of licensing is in itself a great and vital
+  problem; and as a secondary result of such agitation, I should
+  cite the growing sensitiveness of all persons in the business to
+  the power of public opinion.
+
+  The recognition by brewers of the force of public opinion is a
+  recent affair. In former years they were totally indifferent to
+  it, if indeed they did not openly flout it. Even now their appeal
+  to public sentiment is mainly a special plea for defensive
+  purposes, and has little or no educational value. Brewers have
+  opposed practically every effort to effect a change in excise
+  laws, often without any convincing reason, but simply because the
+  proposed change involved temporary inconvenience and uncertainty,
+  and perhaps a temporary loss. The brewing trade has utterly failed
+  to develop a constructive programme in connection with the public
+  regulation of its affairs. It does not seem to have any fixed
+  principles or positive convictions as to excise methods and liquor
+  laws. Its policy has been that of an opportunist, at the best,--or
+  an obstructionist, at the worst. As in all other industries which
+  affect the welfare of the people, reforms have been forced from
+  the outside, with no help from within. Of course this is equally
+  true of insurance and railroad corporations, of food purveyors,
+  mine owners, cotton merchants, and a score of other interests. It
+  is due not merely to human selfishness but to shortsightedness; in
+  other words, to a lack of statesmanship.
+
+  To call your opponents hypocrites, cranks, fakirs, and fanatics
+  may relieve your feelings, but it doesn't convince anybody, and
+  only hurts a just cause. It is foolish to question the motives of
+  men who, without thought of personal gain, are trying to remedy
+  the evils of inebriety.
+
+  The church is perfectly right in urging total abstinence upon the
+  individual. The only path of safety lies in abstinence for some
+  individuals....
+
+  The recognition of the right of a community to establish its own
+  licensing conditions carries with it the right of the community to
+  determine whether there shall be any licenses at all!
+
+  To make the discussion of this subject as fruitful as possible, I
+  venture to submit the following questions for your consideration.
+  None of them involve any direct moral issue, but there is an
+  honest difference of opinion about each one of them, and they are
+  certainly of vital importance in determining the course of wise
+  and just administration.
+
+  What has been the effect of high license?
+
+  How much public revenue should the traffic yield?
+
+  Does high license stimulate unlawful trade?
+
+  How much license tax should be imposed upon local bottlers and
+  grocers? Should they be allowed to peddle beer or to sell it in
+  single bottles?
+
+  Should the place or the individual be licensed?
+
+  Should the licensing authorities be appointive or elective? By
+  whom should they be appointed, and for what term of office?
+
+  Have the courts made good or bad licensing authorities? Where the
+  courts issue licenses, what has been the effect on the court?
+
+  Should the licensing authority alone have the power to revoke a
+  license, and discretion to withhold a license?
+
+  How can the licensing authority enforce the law? Should it not be
+  independent of the police?
+
+  What should be the penalty for breach of the law? Do not severe
+  penalties miscarry?
+
+  On what plea, and under what conditions, should licenses be
+  transferred?
+
+  What has been the effect of limiting the number of saloons?
+
+  Should limitation be according to area or to population?
+
+  Is there any relation between the number of saloons and the volume
+  of consumption?
+
+  What should be the limit to the hours of selling?
+
+  Should saloons be allowed to become places of entertainment?
+
+  How can the sale of liquor by druggists be controlled?
+
+  How can spurious drinking clubs be prevented or controlled?
+
+  How can the operation of disreputable hotels be prevented? What
+  should be the definition of a hotel? Who should define it? By whom
+  should it be licensed? What special privileges should be given to
+  it?
+
+  How can the "back-room" evil be stopped? Is it legal (i.e.
+  constitutional) to prohibit the sale or serving of liquor to
+  women?
+
+  Has the removal of screens reduced the volume of consumption? Has
+  it improved the character of saloons? Has it solved the problem of
+  Sunday prohibition for any length of time? What has been the
+  general effect of it in the tenement districts?
+
+  Should the state undertake to regulate the liquor business or to
+  enforce liquor laws?
+
+  Is it possible to devise any working plan which will apply with
+  equal effectiveness and equity in communities of compact and of
+  scattered population?
+
+  Should, or should not, the principle of self-government be
+  carefully preserved in the whole scheme of legislation to regulate
+  the liquor business?
+
+Whether the present prohibition wave shall wash away the legalized
+saloon, as ocean waves have from time to time engulfed peninsulas,
+islands, and whole continents, depends upon the power of American
+educators and American officials to answer right such questions as the
+foregoing. The great danger is that we shall, as usual, over-emphasize
+lawmaking, underemphasize lawbreaking, and go to sleep during the next
+two or three years when we should be wide-awake and constantly active
+in seeing that the law is enforced. Unless exactly the same principles
+of law enforcement are applied in "dry districts" as we have urged for
+eradication of smallpox, typhoid, scarlet fever, and adenoids, local
+and city prohibition are doomed to failure. There must be:
+
+  1. Inspection to discover disease centers--"blind pigs," "blind
+  tigers," etc.
+
+  2. Compulsory notification by parents and landlords, and by police
+  and other officials.
+
+  3. Prompt investigation upon complaint from private citizens.
+
+  4. Prompt removal of the disease and disinfection of the center.
+
+  5. Segregation of individual units that disseminate disease,
+  whether bartender, saloon keeper, owner of premises, or
+  respectable wholesaler, none of whom should be permitted to shift
+  to another the responsibility for violating liquor laws.
+
+  6. Persistent publicity as to the facts regarding enforcement and
+  violation, so that no one, whether saloon leaguist or anti-saloon
+  leaguist, shall be uninformed as to the current results of "dry"
+  laws.
+
+It is perfectly safe to assume that none of these things will be done
+consistently unless funds are provided to pay one or more persons in
+each populous locality to give their entire time to the enforcement of
+laws, just as the improvement of other ills of municipal government
+require the constant attention of trained investigators. Cogent
+arguments for such funds have recently appeared in the _New York
+Evening Post's_ symposium on "How to Give Wisely," by Mrs. Emma Garrett
+Boyd, of Atlanta, and Miss Salmon, of Vassar College.
+
+If the saloon is here to stay, we must all agree that it is a frightful
+waste of human energy and of educational momentum to be appealing for
+its abolition when we might be hastening its proper control. On the
+other hand, if the saloon is destined to be abolished as a public
+nuisance and a private wrong, as a menace to industry and social order,
+is it not a frightful, unforgivable waste of energy to permit
+prohibition laws to fail, and thus to discredit the principle of
+prohibition? Philanthropists have provided millions for scientific
+research, for medical research, for the study of tuberculosis, and for
+the study of living conditions. It is to be hoped that a large
+benefaction, or that an aggregation of small benefactions, will apply
+to governmental attempts to regulate the sale of alcohol those methods
+of scientific research which have released men from the thraldom of
+ignorance and diseases less easily preventable than alcoholism.
+
+
+
+
+CHAPTER XXXV
+
+IS IT PRACTICABLE IN PRESENTING TO CHILDREN THE EVILS OF ALCOHOLISM TO
+TELL THE TRUTH, THE WHOLE TRUTH, AND NOTHING BUT THE TRUTH?
+
+
+If children are taught that the most effective way of combating
+alcoholism is to insure the enforcement of existing laws and to profit
+from lessons taught by such enforcement; if children are taught that
+the strongest reasons for total abstinence are social, economic, and
+industrial rather than individual and physiological,--there is much to
+be gained and little to lose from telling them the truth, the whole
+truth, and nothing but the truth about alcohol. To stimulate a child's
+imagination by untruths about alcohol is as vicious as to stimulate his
+body with alcohol. Whisky drinking does not always lead to drunkenness,
+to physical incapacity, to short life, or to obvious loss of vitality.
+Beer drinking is not always objected to by employers. Neither crime,
+poverty, immorality, lack of ambition, nor ignorance can always be
+traced to alcohol. On the contrary, it is unquestionably true that the
+majority of the nation's heroes have used alcoholics moderately or
+excessively for the greater part of their lives. It is probably true
+that among the hundred most eminent officials, pastors, merchants,
+professors, and scientists of to-day, the great majority of each class
+are moderate users of one or more forms of alcoholics. Overeating of
+potatoes or cake or meat, sleeping or working in ill-ventilated rooms,
+neglect of constipation, may occasion physiological and industrial
+injuries that are not only as grave in themselves as the evils of
+moderate drinking, but, in addition, actually tempt to moderate
+drinking.
+
+All of this can be safely admitted, because whether parents and
+teachers admit it or deny it, children by observation and by reading
+will become convinced that up to the year 1908 the noblest and the most
+successful men of America, as well as the most depraved and least
+successful, have used alcoholics. To be candid enough to admit this
+enables us to gain a hold upon the confidence and the intelligence of
+children and youth that will strengthen our arguments, based upon
+social and industrial as well as physiological grounds, against running
+the risks that are inevitably incurred by even the moderate use of
+alcohol.
+
+Other things being equal, the same man will do better work without
+alcohol than with alcohol; the same athlete will be stronger and more
+alert without alcohol than with alcohol; the clerk or lawyer or teacher
+will win promotion earlier without alcohol than with alcohol; man or
+woman will grow old quicker with than without alcohol. Other things
+being equal, a man of fifty will have greater confidence in a total
+abstainer than in a man of identical capacity who uses alcohol
+moderately; a mother will give better vitality and better care to her
+children without than with alcohol; a policeman or fireman or
+stenographer is more apt to win promotion without than with alcohol.
+Whatever the physical ailment, there is in every instance a better
+remedy for an acute trouble, and infinitely better remedies for
+deep-seated troubles, than alcoholics.
+
+The percentage of failure to use alcoholics moderately is so high, the
+uncertainty as to a particular individual's ability to drink moderately
+is so great, as to lead certain insurance companies, first, to give
+preference to men who never use alcoholics, and later, to refuse to
+insure moderate drinkers. Life insurance companies have the general
+rule that habitual drinkers are bad risks, as the alcohol habit is
+prejudicial to health and longevity; but they have no means of studying
+the risk of moderate drinkers, because, except where alcohol has
+already left a permanent impression upon the system, the indications
+are by no means such as to enable the medical examiner to trace its
+existence with certainty. For this reason the life insurance companies
+have little effect in _preventing_ alcoholism. Though they are agreed
+that habitual drinkers ought to be declined altogether, only a few
+companies have taken the decided stand of declining them. "Habitual
+drinkers, if not too excessive, are admitted into the general class
+where the expected mortality, according to the experience of the
+Pennsylvania Mutual Life Insurance Company, is 80 per cent, as against
+56 per cent for the temperate class. Though it is only necessary to
+look over the death losses presented each day to see that intemperance
+in the use of liquors, as shown by cirrhosis of the liver, Bright's
+disease, diseases of the heart, brain, and nervous system, is the cause
+of a large proportion of the deaths, these companies prefer to grade
+the premiums accordingly rather than to decline habitual drinkers
+altogether. While this is partly due to the difficulty and expense of
+diagnosis, it is more probably due to an objection to take a definite
+stand on the temperance question."
+
+Thus the insurance companies' rules touch only the confirmed drinker,
+whose physique is often irreparably injured. One company writes: "Men
+who have been intemperate and taken the Keeley or other cures are never
+accepted until five years have elapsed from the date of taking the
+cure, and only when it can be conclusively shown that during the whole
+period they have refrained entirely from the use of alcoholic liquor,
+and that their former excesses have not in any way impaired the
+physical risk."
+
+Thus far American insurance companies are doing little preventive and
+educational work on the alcohol question, though they have the very
+best means at their command for so doing. According to the Metropolitan
+Life Insurance Company nine tenths of the school children in New York
+City are insured by them, and an even greater proportion of workingmen.
+Even though this is done "at twice the normal cost," the most cursory
+medical examination is given and no attempt is made to instruct them in
+the relation of their physical condition to their working power, or in
+the evils of the alcohol and the smoking habits.
+
+Naturally the moderate drinker is first rejected for positions where an
+occasional overindulgence would be most noticeable and most serious.
+The manager of a large factory tells his men: "You cannot work here
+unless you are sober. If you must drink at parties, stay at home if
+necessary until 12 o'clock the next day and sleep it off, but don't
+come here till you are straight. We cannot afford it." Occasionally his
+men stay at home and not a word is said, but the minute they are found
+at work in an unsteady condition they are summarily discharged. From
+this position it is but a step to that of an upholsterer in New York
+City, who prints on his order blanks, "No drinking man employed." His
+company recently discharged a man after twenty years of service because
+a customer for whom this man was working detected a whisky breath. Men
+reported to trade unions for frequent intoxication are blacklisted. A
+certain financial corporation permits no liquor on its grounds or in
+its lunch rooms. The head of one of its large branches was heard to say
+recently that he would discharge on the spot a man who showed evidences
+of drinking, even though he had previously worked faithfully for years.
+
+Rejection of moderate drinkers by business houses is not done on moral
+grounds alone, but because experience has proved the danger of
+employing men who have not their faculties fully under control _all_
+the time they are at work. The rules are especially strict for men
+working for a railroad or street railway company. The Pennsylvania
+Railroad Company replied to my inquiry as to their custom of
+discriminating against drinking men in these words: "We have no printed
+rules in regard to this except in a general way,--that no employee is
+allowed to go into a saloon during his hours of work or wearing the
+company's uniform. Of course the men are promptly discharged or
+disciplined if they show the effects of liquor while on duty, and the
+whole tendency of the administration of the rules is to get rid of any
+men who are habitual drinkers, but the administration of the rules and
+discipline is left to the superintendent of each division." The
+Interborough Rapid Transit Company of New York has these printed rules
+for the physical standard required for applicants for employment:
+
+  1. _Examination of heart and arteries._ Rejection of candidates
+  showing excessive or long-continued use of tobacco and alcohol,
+  with explanation of condition, causes, and dangers of continued
+  use. Warning to chiefs of departments regarding those accepted who
+  show tendency to drink at times, but whose physical examination
+  does not disclose sufficient evidence to warrant their
+  disqualifications. Foremen and chiefs of departments to be
+  notified and to carry out the policy of employing only men who are
+  at all times sober and not under the influence of alcohol at all.
+
+  2. _On reëxamination of employees._ Warning to or rejection of
+  those showing, on physical examination, indulgence to excess of
+  alcohol, tobacco, or drugs. Warning to chief of department of
+  evidence of such habits on part of any employee examined for any
+  reason, but retained in service of the company with injunction to
+  chief of department to speak with such employee and have him under
+  proper supervision.
+
+The blacklisting of habitual drinkers by their union, and the growing
+tendency on the part of large corporations, factories, and business
+houses to take a decided stand against drinking, are having a marked
+effect in reducing drunkenness where it does most harm. This practice
+has been declared by John Bach McMasters, the noted American historian,
+to have exerted a stronger influence in promoting temperance and total
+abstinence than all the temperance crusades from Hartley's time to the
+prohibition wave of 1907. The school, by instructing children how the
+alcohol habit will affect their chances of business success, future
+usefulness as citizens, and enjoyment of life, will inevitably reduce
+the evils of alcohol. By teaching based on facts that intimately
+concern the life of the child, as well as by caring for his health and
+his environment, the schools can help supplant the desire for alcohol
+with other more healthy desires.
+
+No truth about alcohol is more important than that the craving for
+alcohol or something just as bad will exist side by side with imperfect
+sanitation, too long hours of work, food that fails to nourish, lack of
+exercise, rest, and fresh air. Conditions that produce bounding
+vitality and offer freedom for its expression at work and at play will
+supplant the craving for stimulants. Finally, the great truth contained
+in the last chapter must be taught, that success in coping with
+alcoholism is a community task requiring efficient government above all
+else.
+
+
+
+
+CHAPTER XXXVI
+
+FIGHTING TOBACCO EVILS
+
+
+"It is not necessarily vicious or harmful to soothe excited nerves."
+This editorial comment explains, even if it condemns while trying to
+justify, the tobacco habit. To soothe excited nerves by lying to them
+about their condition and by weakening where we promise to nourish, is
+vicious and harmful just as other lying and robbery are vicious and
+harmful. Yet two essential facts in dealing with tobacco evils must be
+considered: tobacco does soothe excited nerves, and the harm done to
+the majority of smokers seems to them to be negligible. For these two
+reasons the tobacco user, unless frightened by effects already visible,
+refuses to listen to physiological arguments against his amiable
+self-indulgence. Cheerfully he admits the theoretical possibility that
+by its method of soothing nerves tobacco kills nerve energy. But in all
+sincerity he points to men who have found the right stopping point up
+to which tobacco hurts less perhaps than coffee or tea, candy or
+lobster, overeating or undersleeping. Therefore the physician, the
+bishop, the school superintendent, candidly run the necessary risk for
+the sake of nerve soothing and sociability.
+
+Less harm would be done by tobacco if it were more harmful. Like so
+many other food poisons, its use in small quantities does not produce
+the prompt, vivid, unequivocal results that remove all doubt as to the
+user's injuries and intemperance. As inability to see the physiological
+effect upon himself encourages the tobacco user to continue smoking or
+chewing, so failure to identify evil physiological effects upon the
+smoker encourages the nonuser to begin smoking or chewing. A very few
+smokers give up the habit because they fear its results, but too often
+the man who can see the evil results would rather give up almost
+anything else. The one motive that most frequently stops inveterate
+smoking--fear--is the least effective motive in dissuading those who
+have not yet acquired the habit; every young man, unless already
+suffering from known heart trouble, thinks he will smoke moderately and
+without harm. Unfortunately, every boy who begins to smoke succeeds in
+picturing to himself the adult who shows no surface sign of injury from
+tobacco, rather than some other boy who has been stunted physically,
+mentally, and morally by cigarettes.
+
+For adult and child, therefore, it behooves us to find some other
+weapons against tobacco evils in addition to fear of physiological
+injuries. Among these weapons are:
+
+1. Enforcement of existing laws that make it an offense against society
+for dealer, parent, or other person to furnish children under sixteen
+with tobacco in any form; and raising the age limit to twenty-one, or
+at least to eighteen.
+
+2. Enforcement of restrictions as to place and time when smoking is
+permitted.
+
+3. Agitation against tobacco as a private and public nuisance.
+
+4. Explanation of commercial advantages of abstinence.
+
+Because the childish body quickly shows the injurious effects of what
+in adults would be called moderate smoking, the proper physical
+examination of school children will reveal injuries which in turn will
+show where and to what extent the cigarette evil exists among the
+children of a community. Even the scientists who claim that "in some
+cases tobacco aids digestion," or that "tobacco may be used without bad
+effects when used moderately by people who are in condition to use it,"
+declare emphatically that tobacco "must not be used in any form by
+growing children or youths." Prohibitive laws can be rigidly enforced
+if a small amount of attention is given to organizing the strong
+public sentiment that exists against demoralizing children by tobacco.
+Thus children and youths will not need to make a decision regarding
+their own use of tobacco until after other arguments than physiological
+fear have been used for many years by parent, teacher, and society.
+
+One effective weapon is the sign on a ferryboat or street car: "No
+smoking allowed on this side," or "Smoking allowed on three rear seats
+only." Public halls and vehicles in increasing numbers either prohibit
+smoking altogether or put smokers to some considerable inconvenience.
+The trouble involved in going to places where smoking is permitted
+tends gradually to irritate the nerves beyond the power of tobacco to
+soothe. Again, many men would rather not soothe their excited nerves
+after five, than have their nerves excited all day waiting for freedom
+to smoke. Restrictions as to time or place make possible and expedite
+still further restrictions. Thus gradually the army of occasional
+smokers or nonsmokers is being recruited from the army of regular
+smokers.
+
+The anti-nuisance motive follows closely upon the drawing of sharp
+lines of time and place for the use of tobacco. Like treason, smoking
+in the presence of nonsmokers can be considered respectable only when
+the numbers who profess and practice it are numerous. If the two
+first-mentioned weapons are effectively used, there will be an
+increasing proportion of nonsmokers and not-yet-smokers who will give
+attentive ear to proof that nicotinism is a nuisance. The physical
+evidences of the cigarette habit can easily be made distasteful to all
+nonsmokers if frankly pointed out,--the yellow fingers, the yellow
+teeth, the nasty breath, the offensive excretions from the pores that
+saturate the garments of all who cannot afford a daily change of
+underwear. The anti-nuisance argument is always insidious and abiding.
+In the presence of nonsmokers accustomed to regard tobacco using as a
+nuisance, smokers become self-conscious and sensitive. Men and women
+alike would prefer a reputation for cleanliness to the pleasures of
+tobacco. The educational possibility of fighting tobacco with the name
+"nuisance" was recognized the other day by an editorial that protested
+against a law to prevent women from using cigarettes in restaurants.
+"The way for any man who has the desire to reform some woman addicted
+to the cigarette habit is insidiously and gently to point out the
+injurious effects on her appearance. Cigarette smoking stains a woman's
+fingers and discolors her teeth. It also tends to make her complexion
+sallow and to detract from the rubiness of her lips. It bedims the
+sparkle of her eyes. It makes her less attractive mornings." Chewing
+has practically disappeared, not because it ceased to soothe excited
+nerves but because it was seen to be a nasty nuisance.
+
+Finally, the selfishness of the smoker is a nuisance that continues
+only because it has not been called by its right name. "Do you mind if
+I smoke?" was a polite question two hundred years ago when tobacco was
+rare enough to make smoking a distinction, or fifty years ago when
+everybody smoked at home and in public. But it is effrontery to-day
+when people do mind, when smoking pollutes the air of drawing room and
+office, and while soothing the excited nerves of the smoker lowers the
+vitality of nonsmokers compelled to breathe smoke-laden air. It is
+selfish to intrude upon others a personal weakness or a personal
+appetite. It is selfish to divert from family purposes to "soothing
+excited nerves" even the small amounts necessary to maintain the cigar
+or cigarette habit. It is selfish to run the risk of shortening one's
+life, of reducing one's earning capacity. Because the tobacco habit is
+selfish it is anti-social and a nuisance, and should be fought by
+social as well as personal weapons, as are other recognized nuisances,
+such as spitting in public or offensive manners.
+
+The economic motive for avoiding and for eliminating tobacco is gaining
+in strength. The soothing qualities of all drugs are found to be
+expensive to physical and business energy if enjoyed during business
+hours. Strangely enough, employers who smoke are quite as apt as are
+nonsmokers, to forbid the use of tobacco by employees at work. Some of
+this seeming inconsistency is due to a dislike for cheaper tobacco or
+for mixed brands in one atmosphere; some of it is due to the smoker's
+knowledge that "soothing nerves" and sustained attention do not go hand
+in hand, while "pipe dreams" and unproductive meditation are fast
+companions; finally no little of the opposition to tobacco in business
+is due to fear of fire. These various motives, combining with the
+anti-nuisance motive among nonsmokers, have led many business
+enterprises to prohibit the use of tobacco in any form on their
+premises or during business hours, even when on the premises of others.
+Notable examples are railroads that permit no passenger trainman to use
+tobacco while on duty. (Freight trainmen are restricted more tardily
+because the risk of damages is less and the anti-nuisance objection is
+wanting.)
+
+From penalizing excessive use and prohibiting moderate use in business
+hours, it is a short cut to choosing men who never use tobacco and thus
+never suffer any of its effects and never exhibit any of its offensive
+evidences. No young man expects to obtain a favorable hearing if he
+offers himself for employment while smoking or chewing tobacco.
+Business men dislike to receive tobacco-scented messengers. Cars and
+elevators contain signs prohibiting lighted cigars or cigarettes.
+Insurance companies reject men who show signs of excessive use of
+tobacco. Why? Because they are apt to die before their time. The
+Interborough Rapid Transit Company of New York City rejects applicants
+for motormen and conductors "for excessive or long-continued use of
+tobacco." Why? Because, other things being equal, such men are more
+apt to lose their nerve in an emergency and to fail to read signals or
+instructions correctly.
+
+Armed with these weapons against tobacco, parents and teachers can
+effectively introduce physiological arguments against excessive use,
+against use by those who suffer from nervous or heart trouble, and
+against any use whatever by those who have not reached physical
+maturity. By avoiding physiological arguments that children will
+not--cannot--believe contrary to their own eyes, parents and teachers
+are able to speak dogmatically of that which children will
+believe,--injuries to children, evils of excess, restrictions as to
+time and place, and offensiveness to nonsmokers. But even here it is
+wrong, as it is inexpedient, to leave the physical strength of the next
+generation to the persuasive power of parents and teachers or to the
+faith and knowledge of minors. Society should protect all minors
+against their own ignorance, their own desires, the ignorance of
+parents and associates, and against the economic motive of tobacco
+sellers by machinery that enforces the law.
+
+
+
+
+CHAPTER XXXVII
+
+THE PATENT-MEDICINE EVIL
+
+
+  "Dhrugs," says Dock O'Leary, "are a little iv a pizen that a
+  little more iv wud kill ye. Ye can't stop people fr'm takin'
+  dhrugs, an' ye might as well give thim somethin' that will look
+  important enough to be inthrojuced to their important and fatal
+  cold in th' head. If ye don't, they'll leap f'r th' patent
+  medicines. Mind ye, I haven't got annything to say agin' patent
+  medicines. If a man wud rather take them thin dhrink at a bar or
+  go down to Hop Lung's f'r a long dhraw, he's within his rights.
+  Manny a man have I known who was a victim iv th' tortures iv a
+  cigareet cough who is now livin' comfortable an' happy as an opeem
+  fiend be takin' Dr. Wheezo's Consumption Cure." The Dock says th'
+  more he practices medicine th' more he becomes a janitor with a
+  knowledge iv cookin'. He says if people wud on'y call him in
+  befure they got sick he'd abolish ivry disease in th' ward except
+  old age and pollyticks.
+
+Thus Mr. Dooley with his usual wit and insight tells the American
+people why they spend over two hundred million dollars annually on
+patent medicines. Americans consume more drugs and use more patent
+medicines than the people of any other country on the civilized globe.
+Self-medication has grown to tremendous proportions. Everywhere--in
+cars, on transfers, on billboards, in magazines, in newspapers, in the
+mails--are advertised medicines to cure disease and devices to promote
+health. When we consider that electric cars contain from thirty-two to
+fifty-two advertisements each, three fourths of which are directly or
+indirectly concerned with health; when we multiply these by the number
+of cars actually in use in American cities; when we consider the number
+of advertisements in magazines and daily papers, and the enormous
+circulation of these papers and magazines; when we consider that an
+increasingly large proportion of advertising space is devoted to
+health,--we begin to realize the cumulative power for good or for evil
+that health advertisements must have.
+
+To illustrate advertisements devoted to health to-day, I have kept
+clippings for one week of news items, editorials, and advertisements in
+a penny and a three-cent paper, and had them classified according to
+the subjects treated:
+
+===================+=========================+========================
+                   |     PENNY PAPER         |  THREE-CENT PAPER
+                   +------+---------+--------+-----+---------+--------
+                   | News |Editorial| Adver- | News|Editorial| Adver-
+                   | Item |         |tisement| Item|         |tisement
+-------------------+------+---------+--------+-----+---------+--------
+Milk               |  3   |   --    |   2    |  3  |   --    |   2
+Teeth              |  --  |    1    |   2    |  -- |   --    |   1
+Shoes              |  --  |   --    |   4    |  -- |   --    |   1
+Food               |  1   |   --    |   --   |  1  |   --    |   4
+Alcohol            |  1   |   --    |   5    |  3  |   --    |   7
+Tuberculosis       |  --  |   --    |   1    |  1  |   --    |   --
+Patent medicine    |  --  |   --    |  17    |  -- |   --    |   --
+Constipation cures |  --  |   --    |   4    |  -- |   --    |   5
+Eyes               |  3   |   --    |   5    |  1  |   --    |   --
+Beauty             |  2   |   5     |   8    |  -- |   --    |   6
+General            |  8   |   3     |   3    |  5  |   --    |   --
+-------------------+------+---------+--------+-----+---------+--------
+  Total            | 18   |   9     |  51    | 14  |   --    |  26
+===================+======+=========+========+=====+=========+========
+
+The following list of health topics was treated in the advertisements,
+editorials, and articles of a popular monthly periodical devoted to
+women:
+
+=========================+=========+===========+===============
+                         | ARTICLE | EDITORIAL | ADVERTISEMENT
+-------------------------+---------+-----------+---------------
+Babies                   |   1     |   --      |    11
+Soaps and powders        |  --     |   --      |     5
+Beauty                   |   3     |   --      |     6
+Quack cures              |  --     |    2      |    --
+Tooth powders            |  --     |   --      |     4
+Household                |   1     |   --      |     5
+Food and cooking         |   1     |   --      |    14
+Clothes                  |  13     |   --      |     5
+Teaching sex laws        |   1     |    2      |    --
+Medicine                 |   4     |    1      |    --
+-------------------------+---------+-----------+---------------
+  Total                  |  24     |    5      |    50
+=========================+=========+===========+===============
+
+Besides the classic patent medicines, such as Lydia Pinkham's Vegetable
+Compound, Castoria, Cod Liver Oil, etc., there are "Colds Cured in One
+Day," "Appendixine," health foods, massage vibrators, violet rays,
+Porosknit underwear, sanitary tooth washes, soaps, vitopathic,
+naturopathic, and faith cures. New ones appear every day,--enough to
+make a really sick person dizzy, let alone a person suffering from
+imaginary ailments. All seem to outline my particular symptoms. After
+they have flamed at me in red letters in the surface cars, pursued me
+in the elevated and underground, accompanied me out into the country
+and back again to the city, greeted me each morning in the daily paper
+and in my daily mail, each week or each month in the periodical, the
+coincidence of a familiar package on a drug-store counter seems to be
+providential and therefore irresistible. I know that I ought to be
+examined by a physician, but I am busy and not unwilling to gamble for
+my health; it cannot kill me and there is a chance that it will cure
+me. If there is nothing the matter with us, we may be cured by our
+faith. If we are taking a cure for consumption, the morphine in it may
+lull us into thinking we feel better. If we are taking a tonic for
+spring fever, the cheap alcohol may excite us into thinking our
+vitality has been heightened. Soothing sirup soothes the baby, often
+doping its spirit for life, or soothing it into a sleep from which it
+never wakes.
+
+In spite of the fact that the "Great American Fraud" has been exposed
+repeatedly in newspapers and magazines of wide circulation, the appeal
+of the quack still catches men and women of intelligence. The other
+night a friend went out to a dinner and conference with a lawyer in the
+employ of the national government. Annoyed by a nagging headache, he
+made for the nearest drug store and ordered a "headache powder." He
+admitted that it was an awful dose, but he had been told that it always
+"did the business." He knew the principle was bad, confessed to a
+scorn for friends of his whom he knew to be bromo-seltzer fiends, but
+he had the headache and the work to do--a sure cure and a quick one
+seemed imperative. The headache was due to overwork, indigestion,
+constipation. Plain food and quiet sleep was what he needed most. But
+the dinner conference plus the headache was the unanswerable argument
+for a dose with an immediate result.
+
+Last winter an Irish maid slowly lost her rosy cheeks and grew
+hollow-eyed and thin. She was taken to a specialist who discovered a
+rapidly advancing case of consumption. He said that owing to the girl's
+ignorance, stupidity, and homesickness, her only chance of recovery was
+to return to the "auld countrie" at once. The girl agreed to go, but
+insisted on a few days "to talk it over with her cousins in New York."
+After two weeks had elapsed she was found in a stuffy, overcrowded New
+York tenement. She had found a doctor who had given her a little bottle
+of medicine for two dollars, which would cure her in the city. It was
+futile to protest. Days in the unventilated tenement and nights in a
+"dark room" meant that she would never live to finish the bottle.
+
+For a year Miss H. took a patent preparation for chronic catarrh. It
+seemed to "set her up"; but it so undermined her strength, through its
+artificial nerve spur, that chronic catarrh was followed by
+consumption. It later transpired that the cure's chief ingredient was
+whisky, and cheap whisky. A good grandmother, herself a vigorous
+temperance agitator and teetotaler, offered to pay for it as long as my
+friend would take it faithfully. The irony of it makes one wonder how
+many earnest advocates of total abstinence are in reality addicted to
+the liquor habit.
+
+Last summer a district nurse of the summer corps who visited city
+babies under two years of age encountered in the hallway of a tenement
+a bevy of frenzied women. A baby lay on the bed gasping and "rolling
+its eyes up into the top of its head." The nurse asked the frightened
+mother what she had been giving it. "Nothing at all," said the woman.
+But a telltale bottle of soothing sirup showed that the child was dying
+from morphine poisoning. Happily the nurse came in time to save it.
+
+Is it not pitiful, this grasping for a poison in an extremity; this
+seizing of a defective rope to escape the fire?
+
+    [Illustration: LEARNING HOW TO KEEP BABY WELL WITHOUT PATENT
+    MEDICINES
+    Recreation Pier, New York City, Summer, 1908]
+
+The patent-medicine evil cannot be cured by occasional exposure or by
+overexposure. Nor can it be cured by legislation, legislation,
+legislation, unless laws are rigidly enforced.
+
+Occasional exposure is no better than occasional advertising of good
+things. The patent-medicine business thrives on constant, not
+occasional, advertising. Leading advertisers expect so little from the
+first notice that they would not take the trouble to write out a single
+advertisement. That is the reason merchants charge advertising in the
+programmes of church, festival, and glee-club concert to charity, not
+to business. Warning people once does no more lasting good than sending
+a child to school once a month. The exposure of patent-medicine evils
+must be as constant as efforts to sell the medicines.
+
+Overexposure is ineffective. It is the evils of patent medicines that
+do harm, not their name and not their patents. The medical profession
+has in vain protested against proprietary medicines. Ethical barriers
+cannot be erected by resolution. Calling things unethical does not make
+them unethical. The mere patenting of medicines for profit does not
+make the medicine injurious any more than the mere mixing of unpatented
+drugs makes a physician safe. Physicians who would not themselves
+patent a drug will use certain patented drugs whose ingredients are
+known to be safe and uniform. True exposure of patent-medicine evils
+will enable the average physician and the average layman to distinguish
+the dangerous from the safe, the fraud from the genuine, lies from
+truths.
+
+Legislation is needed to crystallize modern knowledge and to establish
+in courts the right to protection against the evils of patent
+medicines. The national Pure Food Law, passed January 1, 1907, and now
+in force throughout the country, requires on the "labels of all
+proprietary medicines entering into interstate commerce, a statement of
+the quantity or proportion of any alcohol, morphine, opium, heroin,
+chloroform, cannabis indica, chloral hydrate, or acetanilid, or any
+derivative or preparation of any such substance contained therein; this
+information must be in type not smaller than eight-point capital
+letters; also _the label shall embody no statement which shall be false
+or misleading in any particular_." This law does not forbid patent
+medicines nor the use of alcohol and narcotics in patent medicines; it
+merely says, "Let the label tell, that all who _buy_ may read." It does
+not require that all who _run_ may read, for _it does not say that
+advertisements of a patent medicine shall tell the truth about its
+ingredients or its action on the human body_; only that the label on
+the bottle shall tell. The object of this law is to explain to the
+consumer the exact nature of the medicine. But to the majority of
+people the word "acetphenitidin" on the label of a headache medicine
+does not explain. The new order that requires manufacturers to
+substitute acetanilid for acetphenitidin does no more than replace fog
+with mist. Protection requires legislation that cannot be evaded by
+technical terms. The present law requires that packages must be
+properly labeled _on entering the state_. To carry out the national
+law, state laws should make it an offense for dealers to have in their
+possession proprietary medicines without explanatory labels that
+explain. Where state laws to this effect do not exist, the packages
+once in the state may be deprived of their labels and sold as secret
+remedies, thus nullifying the whole effect of the national law.
+
+Enforcement must be insured. Impure drugs may do as much harm as patent
+medicines containing harmful drugs. In New York a vigorous campaign was
+recently inaugurated by the department of health to drive out impure
+drugs. Drugs are dangerous enough at their best. When they are not what
+they pretend to be, whether patented or not, they may take life. One
+extreme case where a patient's heart was weakened when it ought to have
+been strengthened, led to the discovery that practically all of one
+particular drug offered for sale in New York City was unfit to use and
+calculated to kill in the emergency where alone it would be used.
+Yesterday four lives and several million dollars were lost in a New
+York fire because the hose was rotten or weak. As inspection and
+testing were needed to insure hose equal to emergency pressure, so
+inspection and testing of patent medicines and drugs are needed to make
+legislation effectual.
+
+Legislation and enforcement should reach the newspaper, magazine,
+billboard, street car, that advertises a falsehood or less than the
+essential truth regarding drugs, foods, and patent medicines. Public
+sentiment condemns the advertising of many opportunities to commit
+crime or to be disorderly or indecent or to injure one's neighbor. The
+facts about hundreds of nostrums can be absolutely determined. The
+advertising agency, whether secular or religious, that carries
+misrepresentation of drugs and foods should be forbidden circulation
+through the mails. The existence of such advertisements should be made
+evidence of complicity in a public offense and punished accordingly.
+Treat them as we treated the Louisiana lottery. Boards of health,
+instead of furnishing names to druggists and manufacturers who want to
+sell patent foods and medicines, should print circulars exposing
+frauds, and punish so far as the law permits.
+
+While trying to secure adequate legislation and efficient
+administration of the above-mentioned standards, there is much that can
+be done by individuals and clubs. We can give preference to those
+journals that refuse drug and food advertisements unless evidence is
+produced that the truth is told and that the goods are not harmful. We
+can refuse to have in the house a paper or journal which prints notices
+that lie or that conceal the truth. If this drastic measure would cut
+us off entirely from daily papers, we could choose the least offensive
+and petition it to exclude specific lying methods. When it preaches
+health, honesty, and philanthropy, we can cut out of one issue the
+noble editorial and the exploiting advertisements and send them to the
+editor with our protest. Knowledge of the ingredients and dangers of
+patent medicines should be a prerequisite for the practice of medicine
+or pharmacy. We can help bring about such conditions, and we can
+patronize physicians who send patients to drug stores that cater to
+intelligence rather than to ignorance.
+
+Fighting patent-medicine evils is a civic duty to be accomplished by
+civic coöperation, not private effort. It is impossible to organize
+unofficial educational agencies that can offset the cumulative, lying
+advertisement. Personal opposition is but the beginning. Official
+machinery must be set running and kept running so as to protect the
+public health against the commercial motive that preys upon ignorance
+and easily inspired faith.
+
+
+
+
+CHAPTER XXXVIII
+
+HEALTH ADVERTISEMENTS THAT PROMOTE HEALTH
+
+
+It is usually considered futile to attempt to defeat the devil with his
+own methods, because he knows so much better how to use them. But abuse
+does not do away with use, and the success of quacks in reaching the
+people demands our respect. There is no reason why their methods, based
+on a knowledge of human nature and human psychology, should not be
+employed to appeal to needs rather than to weaknesses. A good thing may
+lie unused because of lack of advertisement. Vitality is coming to be
+the passion of the American people. It is on this sincere passion that
+fakirs have so long traded.
+
+There can be no doubt that advertisements of health-promoting goods are
+quite as profitable as health advertisements that injure health, when
+equally effective methods are used to make them reach the public. The
+tradition has been repeatedly mentioned in this book that the better
+the doctor, the less he advertises himself, except in medical and
+scientific journals that notoriously fail to reach the people. The same
+is too often true of reputable remedies and goods. The theory that
+these things stand or fall on their merits is not borne out by
+practical experience,--conspicuously in the case of "fake" remedies.
+Purely philanthropic undertakings for the advancement of health fail,
+if not placed before the people whom they aim to help in an attractive,
+convincing form. Failure to advertise a worthy cause limits its
+usefulness, and is therefore unjustifiable, whether we speak of
+medicine, legal aid, or dental clinics.
+
+An intensive study of the methods used to advertise patent medicines
+will suggest means of extending the usefulness of health-promoting
+goods. Aside from clever methods of suggestion that lead many people to
+take medicine for imaginary ailments, especially seasonal ailments,
+patent-remedy advertisers have employed (as an argument for the
+efficiency of their cures) scientific theory, bacterial origin of
+diseases, recent medical or physiological discoveries, and state and
+national movements for promoting health. In fact, they have turned to
+their own uses the very law that seeks to control them and the
+exposures that seek to exterminate them. Whatever may be the merits of
+Castoria, the "Don't Poison Baby" advertisement on the following page,
+printed just after the accompanying "Babies Killed by Patent
+Medicines," which appeared in a home journal, was surely a clever bit
+of advertising. Upon an editorial in a daily paper on the relation of
+eyeglasses to headache and indigestion, an optician based a promise of
+immediate relief for these ailments if he himself were patronized. The
+recent investigations of the Department of Agriculture, and of
+Professors Chittenden and Fisher, in regard to foodstuffs, are proving
+helpful to food quacks and advertisers of pills for constipation and
+indigestion. Since the passage of the Pure Food Law one health food is
+advertised in a column headed "Pure Food."
+
+When the season for pneumonia comes around numerous medicines are "sure
+cures" for grippe and pneumonia. "Rosy teachers look better in the
+schoolroom than the sallow sort," is surely a good introduction to a
+new food. Woman's vanity sells many a remedy advertised to counteract
+the "vandal hand of disease, which robs her of her beauty, yellows and
+muddies her complexion, lines her face, pales cheek and lip, dulls the
+brilliancy of her eye, which it disfigures with dark circles, aging her
+before her time." Who in your town is as good a friend to "owners of
+bad breath" as the advertiser who tells them that they "whiff out odor
+which makes those standing near them turn their heads away in
+disgust"? The climax of effective educational advertising as well as of
+consummate presumption and villainy is reached in the notice of an
+alcoholic concoction that uses the headline, "Medical Supervision
+Needed to Prevent the Spread of Consumption in the Schools." Thus
+grafting itself on the successful results of the medical examination in
+the Massachusetts schools, it enlists the aid of teachers, trades on
+the fear of tuberculosis, even indorses the fresh-air treatment. So
+convincing was this appeal that it was reprinted in the news columns
+of a daily paper in New York as official advice to school children.
+
+    [Illustration: Don't Poison Baby.]
+
+So clever are these methods of advertising and so successful are they
+in reaching great numbers of people, that if reputable physicians would
+take lessons of them, they might conduct a health crusade that would
+exterminate tuberculosis, diminish the use of alcohol and tobacco, and
+save thousands of babies that die unnecessarily. The theory of
+patent-medicine advertising is sound. It emphasizes the joys of health,
+the beauty of health, the earning power of health. It adapts its
+message to season, event, and need. It offers testimonials of real
+persons cured. It is all-appealing, promising, convincing,--a fearful
+menace to health when the remedies offered are dishonest, a universal
+opportunity for promoting health if the cure is genuine.
+
+A classic example of health advertising that promotes health is
+Sapolio. The various hygiene lessons that have promoted Sapolio have
+done much to raise the standard of living in the United States. Few
+eminent physicians have done so much for public health as the "Poor
+M.D. of Spotless Town who scoured the country for miles around, but the
+only case he could find was a case of Sapolio."
+
+Recent press discussions about furnishing free eyeglasses to the
+children in the public schools have so enlightened people as to the
+need for expert examination of their eyes that opticians will be forced
+to employ competent oculists to make the preliminary examination and to
+see that the glasses are properly adjusted. In spite of the long
+mis-education by makers of corsets, the persistent advertising of "good
+health" and "common-sense" waists has gained an increasing number of
+recruits from the ranks of the self-persecuting. It is only a matter of
+time when the term "stylish" will be transferred to the advocates of
+health, because advertisers who tell the truth will, if persistent,
+gain a larger patronage than advertisers of falsehoods; there is
+profit in retaining old customers. The advertisement of a window device
+for "Fresh air while you sleep" will make prevention of tuberculosis
+more profitable than "sure cures" that lie and kill.
+
+A man deserves profit who sends this message to millions of readers:
+
+  There are three kinds of cleanliness:
+
+  First, the ordinary soap-and-water cleanliness.
+
+  Second, the so-called "beauty" cleanliness.
+
+  Third, prophylactic cleanliness, or the cleanliness that "guards
+  against disease."
+
+But the man who sells soap ought to be the one to use this
+advertisement, not a man who sells toothwash that, when pure, is little
+better than water, that is seldom pure, and that always hurts the
+teeth. Many children and adults are being cured of flat foot by men who
+make money by selling shoes designed to strengthen the arch of the
+foot. Millions would never know how to discover the evil effects upon
+themselves of coffee and alcohol except for money-making
+advertisements. Little Jo's Smile taught a nation that the majority of
+crippled children are victims of neglect on the part of adult
+consumptives.
+
+Certain it is that advertising is an art promoted by the severest
+competition of the cleverest brains. It is a force which we cannot
+afford to ignore. If we can harness it to the promotion of aids to
+health, it will do more good than all the hygiene books ever written.
+To this end we must educate ourselves to distinguish between goods
+which do what they profess to do and those which do not. A good eye
+opener would be to keep for a week clippings from a high-priced daily
+paper, a penny daily paper, and one or two representative magazines,
+including a religious paper. Teachers and parents can very easily
+interest children in such clippings. Moreover, they can use the
+bulletin method, the stereopticon exhibit, the _cumulative
+illustration_ of a fact, which is the essence of successful
+advertising. Boards of health can use all the typographical aids to
+clear understanding,--cuts, diagrams, interesting anecdotes. In New
+York both the health board and the school board have issued circulars
+and given illustrated lectures, some of them being in school and some
+on public squares. Medical and sanitary societies and other educators
+can be induced to follow what a successful business man has called the
+three cardinal rules of advertising:
+
+  First, put your advertisement where it will be seen. (Tell your
+  story where it will be heard.)
+
+  Second, write it so that people will read it. (Tell it so that
+  people will understand it.)
+
+  Third, tell the truth, so that people will believe it.
+
+
+
+
+CHAPTER XXXIX
+
+IS CLASS INSTRUCTION IN SEX HYGIENE PRACTICABLE?
+
+
+Among remedies for preventable disease and preventable poverty, the
+following was urged at a national conference for the betterment of
+social conditions: "We have been too prudish. Because we have been
+unwilling to teach school children the evils of violating sex hygiene,
+we have been unsuccessful in combating evils justly attributable to
+ignorance on the part of girls as to the duties and dangers of
+motherhood." This point of view is shared by so many men and women that
+a national body was organized in 1905 to promote the teaching of sex
+hygiene,--the Society for Sanitary and Moral Prophylaxis. This society
+has its headquarters in New York, and distributes at cost lectures and
+essays. The second of its educational pamphlets is addressed to
+teachers, and is entitled "Instruction in the Physiology and Hygiene of
+Sex." The introduction asks eleven questions of the teachers as
+follows:
+
+  1. Do you wish a pamphlet on sex subjects to hand to your pupils?
+  Why?
+
+  2. Do you wish separate pamphlets for boys and girls?
+
+  3. For what age limits and social conditions do you wish them?
+
+  4. What topics do you wish the pamphlets for boys to "handle"?
+
+  5. What topic do you wish the pamphlet for girls to "handle"?
+
+  6. If you think one pamphlet sufficient for both sexes, what
+  should it consider?
+
+  7. How far do you go in teaching sexual hygiene or reproduction?
+  By what method?
+
+  8. What special difficulties do you find in teaching it?
+
+  9. What special need of teaching it have you found?
+
+  10. What special benefits (or otherwise) have you noticed from
+  teaching it?
+
+  11. What criticisms (favorable or otherwise) do you encounter?
+
+The difficulty of introducing formal instruction in sex hygiene, even
+in the upper grades of public and private schools, is hinted at in the
+pamphlet. The purpose of the publishing society as given in its
+constitution is "to eliminate the spread of diseases which have their
+origin in the social evil." Although sex hygiene does not begin with
+sex immorality, almost every text-book on sex hygiene, and almost every
+pamphlet urging class instruction in sex hygiene, begins with sex
+immorality. Yet only the exceptional school child is in danger of
+violating sex morals, while every school child needs instruction in sex
+hygiene.
+
+Instruction in sex hygiene, whether at school or at home, should deal
+with sex normality, sex health, sex temperance. Instruction in sex
+immorality is objectionable, not merely because it offends prudists,
+not because it is difficult, but because it can be shown by experience
+to be less efficacious than training in sex health.
+
+To expect fear to prompt sex hygiene is to make a mistake that has
+retarded the development of sound measures in the treatment of
+offenders against criminal law. For centuries man failed in attempts to
+fit the punishment to the crime. To deter men from committing crime by
+holding up a threat of prolonged and dreadful punishment has been found
+futile. Individuals take the risk because they think they will escape
+detection. It is an axiom of criminal procedure that a would-be
+offender is deterred by the certainty, not by the severity, of
+punishment. The modern theory of probation is, that children and adults
+may be best led away from evil practices by crowding out old influences
+with newer and stronger interests. Occupations that are wholesome are
+made to rival diversions or occupations that are harmful and criminal.
+
+    [Illustration: OBJECT LESSONS FOR INSTRUCTION IN SEX HEALTH
+    Note the uncomfortable, unhealthy overdressing]
+
+Abnormal conditions of mind and body in regard to sex can almost always
+be traced to general physical ill health or to an unhealthy moral
+environment. Cure and prevention require two kinds of treatment within
+reach of parents and teachers: (1) build up the child's physical
+condition; and (2) give him other interests. Proper physical care, and
+work adjusted to body and mind, may be relied upon to do infinitely
+more to promote sex hygiene than instruction, either at home or at
+school, in immoral sex diseases. That sex morality is weak and
+untrustworthy which is based upon fear of sex diseases. Like alcoholism
+and nicotinism, the saddest results of sex diseases are social and
+economic. The strongest reasons against such diseases are economic and
+social, not physiological.
+
+    [Illustration: THE STUDY OF INFANT HEALTH IS CONDUCIVE TO
+    PURE-MINDEDNESS
+    Note the simple, comfortable, hygienic dress]
+
+Once having made up our minds to concentrate the teaching of sex
+hygiene upon sex health rather than upon sex immorality, upon sex
+functions rather than upon sex diseases, the chief objection to school
+instruction and to instruction in class will disappear. Our school
+text-books in history, literature, and biology abound in references to
+sex distinctions, sex functions, and sex health. In enumerating the
+daily routine of health habits I mentioned daily bathing of the armpits
+and crotch. There is nothing in this injunction to offend or injure a
+boy or girl. If studies and physical training are to be adapted to
+physiological age, and if children are to know why they are graded
+according to physiological age as well as mental brightness, we shall
+soon be talking of mature, maturing and not-yet-maturing girls and
+boys, so that everybody will be instructed in sex hygiene without
+offense. Any teacher who can explain the family troubles of King Henry
+VIII without becoming self-conscious can easily learn to look a class
+of girls and boys in the face and explain how a mother's health will
+injure her baby before its birth, why breast-fed babies are more apt to
+live than bottle-fed babies, why it is as important for the mother to
+keep a nursing breast absolutely clean as to clean the nipple of a
+nursing bottle. Words whispered by children, or marked in dictionaries,
+to be stealthily and repeatedly looked upon and talked over with other
+children, lose all their glamour when pronounced by a teacher.
+
+In these days of state subsidy of school libraries the child is hard to
+find who has not free access to books of fiction full of voluptuous
+allusions that make undesirable impressions which only blunt, candid
+discussion of sex facts can make harmless. Children now learn, whether
+in fashionable private schools or crowded slums, practically all that
+is lascivious and unwholesome about sex. For teachers to explain that
+which is wholesome and pure will disinfect the minds of most children
+and protect them against miseducation.
+
+Class instruction in hygiene is practicable for all matters pertaining
+to normal sex health. Girls of thirteen should be taught in classes the
+fact and meaning of menstruation, and its grave importance to the
+health, in order that they may care for themselves not only before,
+during, and immediately after the menstrual period, but throughout the
+month, in order that menstruation itself shall not be unnecessarily
+painful, enervating, and harmful to efficiency. It is not yet advisable
+to discuss dangers peculiar to girls or dangers peculiar to boys in
+mixed classes. Generally speaking, it is undesirable that men teachers
+discuss girls' troubles with girl pupils. But why should it not become
+possible for women teachers to explain health dangers peculiar to girls
+to classes of boys?
+
+Individual instruction in sex matters should be reserved for the
+diseased mind, for the boy or girl who has already been morbidly
+instructed. Discussion of immoral sex diseases should be confined to
+individual talk. This field teachers have already entered. Repeated
+physical examination of children will detect symptoms of sex
+abnormality. When detected, the fact and the meaning should be
+explained to the individual by school physician, school nurse, or
+school-teacher. While much can be done through mothers' meetings and
+through individual instruction of parents, the most effective means of
+improving the general attitude towards sex health is to give the simple
+truth to the millions of children who have not yet left school. Armed
+with the A B C's of sex hygiene at school, boys and girls will be
+prepared to select employment, associates, and newspapers that will
+permit normal, healthy sex development. Men and women who are leading
+normal lives, who have plenty of work, sleep, fresh air, nourishing
+food, amusement, and exercise are unlikely to be sexually abnormal.
+
+After all, the question of instruction in sex hygiene will quickly
+settle itself when it is made a condition of a teacher's certificate
+that the applicant shall himself or herself know the personal and
+social reasons for sex health. The woman who does not know how to take
+care of her own sex health, the man who is ignorant of a woman's
+special needs, cannot do justice to the requirements of arithmetic,
+language, and discipline. Whether men and women teachers are mentally,
+physically, and morally equipped to be sexually normal and to teach the
+law of sex health will be disclosed as soon as trustees and
+superintendent dare to ask the necessary questions. Whether an
+instructor's personality will enable him to fill the minds of children
+with interests more wholesome, more absorbing than obscene stories or
+morbid sex curiosity can also be learned. When school-teachers are
+prepared to teach the social and economic aspects of general health
+they will quickly solve the problem of instruction in sex health.
+
+Just one word about country morality. It is customary to deplore the
+influence of large cities on the young. Of late, however, there has
+been a tendency to question whether, after all, sex morality is apt to
+be higher in the country than in the city. Parents and teachers in
+small towns and in rural districts will do well to take an inventory of
+the influences surrounding their children. It will always be impossible
+to give country children city diversions. One great disadvantage of
+country children frequently counter-acts the beneficial influence of
+out-of-door living; namely, isolation. The city child is practically
+always in or about to be in the sight of, if not in the presence of,
+other people. Numbers and close contact with people, though they be
+strangers, mean restraint and pervading social conscience. City
+children find it difficult to have good times in pairs. No amount of
+instruction of rural pupils in sex hygiene will take the place of
+amusements and entertainments for groups of children, forming thus a
+special antidote for "two's company, three's a crowd." Liberating and
+standardizing normal intersex relations and discouraging cramped social
+intersex relations are more urgent needs than instruction in sex
+diseases. A working environment that permits pure-mindedness will do
+more to inculcate a reverence for sex cleanliness and for parenthood
+than lectures and essays on moral prophylaxis.
+
+
+
+
+CHAPTER XL
+
+THE ELEMENT OF TRUTH IN QUACKERY; HYGIENE OF THE MIND
+
+
+Patent medicines and other forms of quackery could not pay such
+enormous dividends unless there was some truth in their claims; unless
+their victim found some beneficial return for his money. They win
+confidence because they raise hopes and combat fear. They do cure
+thousands of people of fear and of "ingrowing thoughts." In so doing
+they remove the sole cause of much disability.[17] In so doing they are
+merely applying by wholesale principles of mental hygiene that are
+legitimately used by physicians, tradesmen, teachers, and parents who
+deal successfully with nervousness.
+
+Quackery makes cures and makes money because of the undoubted influence
+of mind in causing and in removing those ailments that originate in
+fear, imagination, or morbid introspection. A few years ago a little
+out-of-the-way town in southern Minnesota was visited by train loads of
+the sick and crippled from miles around. Miraculous cures were heralded
+broadcast. Life-long cripples left wagon loads of crutches and braces
+to decorate the little church with the enchanted transom. People who
+had not walked for years returned to their homes cured. The marvels of
+famous shrines were fast being duplicated when the church authorities
+at St. Paul issued an explanation of the alleged miraculous appearance
+of biblical figures in the transom of the new church. The outlines of a
+mother carrying a baby had been vaguely impressed in the transom glass
+when molten. When the mystery was explained the excursions and the
+cures stopped.
+
+Nearly every physician and practically every medical charlatan can
+count scores of cures of ailments that had previously defied the skill
+of eminent physicians. A child's bumps actually stop aching after the
+mother or nurse kisses the abused spot. Invalids forget their
+limitations under stress of some great excitement or some intense
+desire for pleasures incompatible with invalidism. Many a physician of
+reputation owes his success in great part to the discriminating use of
+the _placebo_,--a bread pill designed to supplant the patient's fear
+with confidence. Hypnotism and "suggestion" have been successfully used
+to cure alcoholism and to fill patients' minds with conviction stronger
+than the fear that produced the sickness. A well-known writer and
+preacher cures insomnia by auto-suggestion, telling himself he is
+sleepy, is very sleepy, is going to sleep, is almost asleep, is fast
+asleep. Treatment by osteopathy has been followed by disappearance of
+diseases that cannot possibly be cured by osteopathy. Christian Science
+has restored to health and happy usefulness hundreds of thousands of
+chronic invalids. Verily is hygiene of the mind an important factor in
+the civics of health.
+
+Fear can originate with mind. Fear produces fear. Fear disarranges
+circulation of the blood and the nourishment of muscle and nerve. Fear
+can produce many bodily disorders which in turn feed fear. Fear cannot
+last unless bodily symptoms exist or arise to justify and feed it. Fear
+can be cured and removed in two ways: (1) by driving away fear and
+releasing bodily disorders from its thraldom; (2) by removing the
+disorders and making fear impossible to the logical mind. An enforced
+sea voyage begins with the disorder; a clever, buoyant physician begins
+with the fear. Patent-medicine proprietors, quacks, and fakes of every
+kind begin by displacing the fear with hope or cheer; the physical
+disorders frequently vanish by the same window as fear. For _fear_
+write _self-pity_, _morbid self-consciousness_, _hypertrophied
+submission_; to _hope_ and _cheer_ add _smile_, _relaxation_, and
+_zest_; and we have the chief elements of mental hygiene and the reason
+why intelligent as well as unintelligent men like to be swindled by
+medical or other quacks.
+
+The social aspects of mental hygiene are particularly important. Once
+admitting the power of the mind to decrease vitality, we recognize the
+duty of seeming happy, buoyant, cheerful, vital, at least when with
+others, for the sake of others' minds and bodies. Secondly, we find the
+duty to refrain from commenting on others' appearance in a way that
+will start "ingrowing thoughts." A "grouchy" foreman can give blues and
+indigestion to a roomful of factory girls. A self-pitying teacher can
+check the heart beats of her class, cause arteries and lungs to
+contract, and deprive the brain of fresh blood. An oversympathetic
+neighbor can put a strong man to bed by discovering signs of nervous
+disintegration. Shall we gradually work out a code of mental hygiene
+rights and nuisances that will require compulsory notification of the
+"blues" and compulsory segregation of every person unable to "smile
+dull care away"? Is the time coming when boards of health will
+accompany infection leaflets with messages such as this from James
+Whitcomb Riley:
+
+    Talk health. The dreary, never-changing tale
+    Of mortal maladies is worn and stale.
+    You cannot charm or interest or please
+    By harping on that minor chord, disease.
+
+    "Whatever the weather may be," says he,
+    "Whatever the weather may be,
+    It's the songs ye sing, and the smiles ye wear,
+    That's a-making the sun shine everywhere."
+
+Mental hygiene has hitherto enjoyed an evil reputation and has been
+condemned to generally evil associations, because the rank and file
+have been ignorant of hygiene of every kind. Medical science has so
+long enveloped itself in mystery that it is in danger now of becoming
+discredited and of falling heir to the mantle of quackery.
+
+Quacks often get social and economic results more agreeable to the
+patient and more helpful to society than orthodox medicine. "When
+traitors become numerous enough treason becomes respectable." So when
+mental hygiene succeeds, it becomes science for the case in question,
+and for that case orthodox medicine loses its respectability. For the
+layman there is no safety except in having intelligence enough to know
+whether his trouble has defied the sincere application of mental
+treatment, auto-suggestion, and loyalty to the health ideal.
+
+Mental hygiene admits the existence of dental cavities, scarlet fever
+germs, adenoids, cross-eyes, uncleanliness, broken legs, inflamed eyes,
+overeating. The organic, structural defects which are to be sought by
+physical examination are all admitted by mental hygienists. They work
+for an orderly, daily routine and affirm the penalties of its
+violation. They would even favor going periodically to a physician,
+provided that we never go to him except when organic or structural
+disorders may safely be assumed from the fact that cheer and relaxation
+treatment does not give relief. Unhygienic living and mind cure cannot
+go together. The mind that tries to deceive itself cannot cure either
+mind or body. The man who violates the habits of health cannot patch
+his injuries or conceal the ravages of dissipation by mental hygiene.
+Here is the great advantage of knowing how to live hygienically, of
+observing habits of health, and then concerning ourselves not with
+ourselves, but with conditions of living for all those whose health can
+be affected by our health, or can affect our health and efficiency.
+
+The most recent practical application of mental hygiene for moral and
+physical uplifting is the "moral clinic" or "psychotherapeutic" clinic
+established by Emmanuel Church in Boston. This clinic represents the
+union of three forces,--religion, medical diagnosis, mental hygiene. As
+a result of this alliance it is anticipated that both religion and
+medicine will be humanized, socialized, vitalized, made to express more
+accurately and more consistently that community consciousness and that
+yearning for equal opportunity and equal happiness which constitute the
+profoundest religious impulse. No person is treated at this moral
+clinic whose trouble is organic or structural. In determining whether
+the case belongs to this clinic, expert medical diagnosis is relied
+upon rather than the credulity of the patient or the zeal of the
+clergyman. Medical scientists of highest repute can consistently
+coöperate, because they recognize two scientific facts: first, that
+many troubles are due primarily to mental disorder; and, second, the
+greatest asset of the human mind is that something called religion,
+which is no less real and potent because peculiar to each individual.
+Whatever may be that deepest current of thought and feeling, whatever
+that synthetic philosophy, that explanation of being, which guides my
+life, it can be of inestimable aid if enlisted in an effort to secure
+normal vitality of mind and body.
+
+The controlling motive of the moral clinic has proved infectious. There
+is reason to believe that the alliance of medicine and religion has
+come to stay, and that the present excitement over psychotherapeutics
+will settle down into a scientific utilization of religious motive and
+medical knowledge to prevent mental and moral disease. Unwholesome,
+morbid, self-centered thought is driven out. A recognition of others'
+claims takes its place. Hypnotism, suggestion, and group enthusiasm are
+used to their utmost possibilities. The success of the Boston moral
+clinic is due to establishing in the mind of the neurasthenic, the
+alcoholic, the world-weary, and the purposeless a truer conception of
+the pleasures that result from vitality and from altruistic effort.
+
+It is too early to classify by kind of functional disorder the patients
+treated. Results from one patient have been described in newspapers as
+follows:
+
+  A school-teacher, as a result of nervous collapse, had lost
+  control, began to fear the children under her care, and thought of
+  relinquishing her profession. She was instructed in the art of
+  self-control and the control of others; the notion of fear was
+  dislodged and a sentiment of love for her little charges took its
+  place. In the course of a few weeks this conscientious and
+  experienced teacher regained her poise and found herself
+  performing her duties better than ever before.
+
+Many alcoholics have for months given evidences of complete cure.
+Stories almost incredible are quickening pastor and physician alike
+throughout the country. After individual treatments are given, after
+religious motive is appealed to, and the soul stirred to heed the
+lessons of religion, medicine, and sociology, patients are given the
+work cure. Thus a branch of social service is established, where
+after-treatment is given to the patient whose thoughts have been turned
+from himself to others. All of a sudden the church finds itself in need
+of definite knowledge as to opportunities for altruistic work, as to
+definite community needs not met, as to people in distress who can be
+relieved by volunteers, as to agencies which can be called upon to
+coöperate both in treating the individual and in utilizing his energies
+for others' benefits.
+
+Because a relatively small percentage of men and women are
+neurasthenic, melancholy, morbid, alcoholic, the lesson of the moral
+clinic is most serviceable when extended for the benefit of the "not
+yet alcoholic" and the "not quite neurasthenic." In other words,
+individuals in thinking of themselves must learn the health value and
+soul value of purpose that centers in others' happiness. That thing
+which we have called tact in personality, and which in the past was
+discovered by induction, namely, the law of mental hygiene and the
+control it gives over others' health, must be taught in schools to
+children by wholesale, must be taught in medical and theological
+schools, to all physicians and all pastors. This alliance of medicine
+and religion, which is at present confined to one or two moral clinics,
+should be incorporated into education, into social work, into church
+work, becoming thus a part of civilization's normal point of view.
+
+Mental hygiene cannot survive conscious violation of the fundamental
+laws of medicine and religion. The alliance of medicine and religion
+will prove utterly futile unless habits of living and of thinking are
+inculcated that conform to nature's law of self-preservation and to
+God's law of brotherly love. Self-centered religion, like self-centered
+medicine, destroys both body and soul.
+
+FOOTNOTES:
+
+[17] The alliance of mental hygiene, medicine, and religion is discussed
+in the Emmanuel Church book, _Religion and Medicine; the Moral Control
+of Nervous Disorders_; also in its bulletins, _Religion and Medicine_.
+
+
+
+
+CHAPTER XLI
+
+"A NATURAL LAW IS AS SACRED AS A MORAL PRINCIPLE"
+
+
+When a grammar-school boy I learned from the game "Quotations" that
+Louis Agassiz, scientist, had written the sentence with which I
+introduce a final appeal for living that will permit physical and civic
+efficiency. Agassiz has been called "America's greatest educator," and
+again "the finest specimen yet discovered of the genus _homo_, of the
+species _intelligens_." The story of his long life as teacher of
+teachers reads like a romance. But among his gifts to education and
+citizenship none can be made to mean more than the simple proposition
+that natural law is as sacred as a moral principle. All who remember
+this "beatitude" will be helped to solve many perplexing problems of
+dress, diet, play, education, philanthropy, morals, and civics.
+
+Reverence for the natural carries with it a distaste for the unnatural.
+Those who obey natural law soon come to regard its violation as a
+nuisance when not immoral. On the other hand, compromise with the
+unnatural, like compromise with vice, quickly leads first to toleration
+and thence to interest and practice. Therefore the importance of giving
+children Agassiz's conception of the sacredness of the laws that govern
+the human body. A passion for the natural is a strong foundation for
+habits of health and a priceless possession for one who wishes to know
+morality in its highest sense.
+
+"Natural" is less attractive to us than it would be had Agassiz first
+interpreted it for us rather than Rousseau or present-day exponents of
+"the simple life," "back to nature," and "back to the land." It is too
+often forgotten that no one sins against natural law more grievously
+than the primitive man or the isolated man in daily contact with
+non-human nature. Communing with nature seems not only to require
+communing with man but to give joys in proportion as the nature lover
+is concerned for the human society of which he is a part. Natural law
+does not become a moral principle until man is benefited or injured by
+man's use of nature's resources within and about him. Natural living
+according to natural law must be something sounder, more beautiful, and
+more progressive than can be read into or out of mountains, trees,
+brooks, and sky, or primitive society.
+
+Natural law points to a Nature Fore as well as a Nature Back, to a
+Nature Up and Beyond as well as a Nature Down and Behind. The Nature
+that was yesterday will not do for to-morrow, any more than a man is
+willing to give up his nature aspirations for the careless, animal ways
+of romping childhood. Civilization is constantly urged at each step to
+repeat the prayer of Holmes's old man who dreams for the Autocrat of
+the Breakfast Table:
+
+    Oh for one hour of youthful joy!
+      Give back my twentieth spring!
+    I'd rather laugh a bright-haired boy
+      Than reign a gray-beard king!
+
+    Off with the wrinkled spoils of age!
+      Away with learning's crown!
+    Tear out life's wisdom-written page,
+      And dash its trophies down!
+
+    One moment let my life blood stream
+      From boyhood's fount of flame!
+    Give me one giddy, reeling dream
+      Of life all love and fame!
+
+But every experiment in turning back exalts the present and the future.
+Gifts as well as problems are seen to come with complexity, and
+civilization flatly refuses to relinquish these gifts. Sound maturity
+is better than youth or age:
+
+    The smiling angel dropped his pen,--
+      "Why, this will never do;
+    The man would be a boy again,
+      And be a father too!"
+
+Problems of health and of civics can never be solved by appealing to
+Nature Back, when only the few could be healthy, when one baby in three
+died in infancy, when old age was toothless and childish, when
+infection ravished nations, when the average life was twenty years
+shorter than now, and when unspeakable filth was tolerated in air,
+street, and house. They can all be solved by appeals to Nature Fore,
+which holds up an ideal of mankind physically able to enjoy all the
+benefits and to conquer all the dangers of civilization. It is not
+looking back, but looking in and forward that reveals what natural law
+promises to those who obey it.
+
+By using numerous tests which have been suggested in preceding chapters
+we can learn how far we and our communities obey natural law when
+working and playing. Health for health's sake has nowhere been urged.
+On the contrary, healthful living has been frankly valued for its aid
+to efficient living by individual and by community; wherefore the
+emphasis upon others' health and upon the civic aspects of our own
+health. Tests furnish us with the technic necessary to efficient
+living; civics, with the larger reason; natural law, with the "pillar
+of fire by night" to help us choose our path among habits and pleasures
+whose immediate results upon efficient living cannot easily be
+determined.
+
+Fashions, tastes, mannerisms, personal indulgences, have been left for
+Agassiz to deal with. Generally speaking, we all know of numerous acts
+committed and numerous acts omitted in our daily routine that convict
+us of not living up to our knowledge of physiology and hygiene,--wearing
+tight shoes or tight corsets, drinking strong coffee, smoking, reading
+while reclining, failing to insure clean air and clean bodies. Then
+there are other acts whose omission or commission violate no physical
+law so far as we can see, but whose unnaturalness we concede,--putting
+chalk on the eyebrows, wearing false hair or curious puffs, putting
+perfumery in the bath or on handkerchiefs, assuming artificial poses of
+body or mouth. These violations of natural law are forced upon us by
+"style" or "custom" or family convenience. When we come to choose
+between following fashions and disobeying them, we generally decide that
+it is better to do a foolish or slightly harmful thing than to occasion
+criticism, mirth, or even special notice by our dress or our
+abstemiousness.
+
+Last night I went to a dinner party at eight. I ate and ate a great
+variety of palatable foods that Nature Back never knew. After two hours
+of eating I imbibed for two hours the tobacco smoke of the gentlemen
+who made up the party. I knew that eight o'clock was too late for me to
+begin eating, that two hours was too long to eat, that the tobacco of
+others was bad for my health and for to-day's efficiency. All this I
+knew when I accepted the invitation to dinner. I went with no intention
+of preventing others from smoking or of lecturing my host or his chef
+or his guests for the unhygienic practices of our day. Yet the physical
+ills were more than offset by certain definite gains to the school
+children of New York that will result from last night's meeting.
+Natural law was abated in part. But I declined certain dishes that
+would not agree with me, helped myself sparingly of many dishes,
+avoided tobacco and wines, and by a three-mile walk in the open air, a
+bath, and a good long night's sleep have almost recovered my right to
+talk of the sacredness of natural law.
+
+Nature Back says I should not have gone to this dinner. But I was
+compelled to go. I know I am going to others. I cannot do my work
+unless I overdraw my current health account. Nature Fore tells me that
+effective coöperation with others will frequently require me to eat at
+the dinner hour of others, to retire at others' sleeping time, to wear
+what others will approve, to violate natural law. But Nature Fore also
+tells me how to build up a health reserve so that I can meet these
+emergencies without endangering my health credit.
+
+Nature Back demands "dress reform." Nature Fore tells me that I can
+march in step with my contemporaries without either attracting
+attention or discrediting and affronting natural law. Passion for the
+natural has effected numerous reforms in dress, diet, and social
+habits, until commerce provides a natural adaptation of practically
+every fashion. With regard to few things is it necessary to-day for any
+one who reads magazines to do violence to bodily health for fashion's
+sake. We may wear what we will, eat what we prefer, decline what is
+unnatural for us, without inviting censure. The debauches of those
+unfortunate people who live an unnatural, purposeless existence, affect
+such a small number that their laws need not be considered here.
+Natural law makes obedience to itself attractive; hence commerce is
+rapidly learning to cater to distaste for the unnatural. With few
+exceptions, only temporary concessions to unnatural living are required
+in order to dress and act conventionally.
+
+Nature Back throws little light upon conditions necessary for modern
+labor. It can do nothing but demand the abolition of the factory, the
+big store, the tenement, the school. Nature Fore says we cannot abolish
+the means of working out the highest forms of coöperation. But we can
+make them compatible with natural living. We can modify conditions so
+that earning a livelihood will not compel workers to violate natural
+law at any or all times. The greatest need of factory and tenement
+reform is for parents and teachers to make a religion of Nature Fore
+and to instill its principles in the minds of children. Parents and
+teachers must live the natural before they can make children love the
+natural. Parents and teachers cannot possibly be natural in this day,
+cannot live or love natural law unless they know the machinery by which
+their communities are combating conditions prejudicial to health,
+morals, and civic efficiency.
+
+
+
+
+INDEX
+
+
+Adenoids. See _Mouth breathing_
+
+Administration, health:
+  steps in evolution, 11-22;
+  knowledge of needs, 220;
+  machinery, 302-309;
+  in combating alcoholism, 362;
+  departments of health:
+    (1) New York City, 26, 27, 47, 48, 61, 71, 84, 296-298, 302;
+    (2) general, 265, 281
+
+Advertisements:
+  motives for, 8;
+  for dental parlors, 100;
+  for consumptives, 234;
+  by physicians, 281;
+  educational, in newspapers and magazines, 323;
+  "no smoking" signs, 365;
+  of patent medicines, 369;
+  that promote health, 378-383
+
+Agassiz, Louis, 398, 400
+
+Air, night, 216.
+  See _Fresh air_
+
+Alcoholism, 343-362;
+  compulsory instruction in, 3;
+  insurance companies against, 7;
+  disqualifies for railroad service, 193;
+  depletes vitality, 201;
+  results, 209;
+  Hartley's fight against, 253;
+  injures the tuberculous, 274;
+  ineffective ways of combating, 343;
+  incited by bad living conditions, 348;
+  injury to negroes, 350;
+  so-called moderate use, 358;
+  labor unions blacklist drunkards, 361;
+  social dangers, 386;
+  mental hygiene, 392, 396
+
+Animal sanitation, 252, 260, 307
+
+Association for Improving the Condition of the Poor, New York, 177,
+    236, 253
+
+
+Babies. See _Milk_
+
+Bathing:
+  motives for, 8, 13;
+  a social requirement, 14;
+  cold-water, 214
+
+Beauty, reason for health, 15
+
+Bibliography:
+  A Bureau of Child Hygiene (Bureau of Municipal Research), 298;
+  Annals of a Quiet Neighborhood (MacDonald), 110;
+  Aristocracy of Health (Henderson), 208;
+  Bitter Cry of the Children (Spargo), 33, 167;
+  Bulletins of Emmanuel Church, 391;
+  Bureau of Municipal Research, publications, 298;
+  Care of Dependent, Defective, and Delinquent Children (Folks), 174;
+  Charities and the Commons, 325;
+  Child Growth (Newsholme), 120;
+  Children of the Nation (Gorst), 33;
+  Children's Diseases, 326;
+  Clean Milk for New York City, 255;
+    clippings, 370, 382;
+    white-plague scrapbook, 250;
+  Committee on Physical Welfare of School Children, programme, 166,
+    three studies, 168;
+  Crusade against Tuberculosis (Flick), 229;
+  Dangerous Trades (Oliver), 203;
+  Dental Catechism, 94;
+  Dentistry, lectures and treatises, 274;
+  Deterioration, Physical, report on, 339;
+  Development of the Child (Oppenheimer), 110;
+  Dietetic and Hygienic Gazette, 326;
+  Efficient Life (Gulick), 208;
+  Environment of Child at School (North), 142;
+    Pure Food (U.S. Department of Agriculture), 379;
+  Good Health, 326;
+  Health of the School Child (Mackenzie), 132;
+  Heredity (Thompson), 336;
+  How to Give Wisely, 355;
+  International Congress, Tuberculosis, programme, 246-249;
+  Journal of Nursing, 326;
+  Making a Municipal Budget (Bureau of Municipal Research), 306;
+  Milk Industry, 252;
+  Municipal Sanitation in the United States (Chapin), 304;
+  National Hospital Record, 326;
+  New Basis of Civilization (Patten), 33;
+  New Jersey Review of Charities and Corrections, 325;
+  Pediatrics, 326;
+  Physical Culture, 326;
+  Poverty (Hunter), 167;
+    press and magazines, 322-328;
+  Prevention of Tuberculosis (Newsholme), 229;
+  Principles of Relief (Devine), 174;
+  Principles of Sanitary Science and the Public Health (Sedgwick), 304;
+  Psychological Clinic, 106, 326, 330;
+  Real Triumph of Japan (Seaman), 23;
+  Religion and Medicine (Emmanuel Church), 391;
+  reports of schools, 166;
+  reports of schools and health, 310-321;
+  reports of institutions and societies, 327;
+  reports of state and national conferences of charities and
+    corrections, 327;
+  reports of United States bureau of labor, 203;
+  Sanitation of Public Buildings (Gerhard), 139;
+  School Reports and School Efficiency (Snedden and Allen), 311;
+  Social Order and the Saloon (Fox), 351;
+  Study of Children and their School Training (Warner), 110;
+  Study of School Buildings in New York City, 289;
+  Teeth and their Care (Hyatt), 94;
+  Training of the Human Plant (Burbank), 120;
+  Typhoid Fever (Whipple), 13, 16;
+  Uncommercial Traveller (Dickens), 46;
+  Unconscious Mind (Schofield), 110;
+  Vital Statistics (Newsholme), 131
+
+Biggs, Hermann M., M.D., 237, 251, 271, 274, 295
+
+Boston, 34, 155, 161, 241, 250, 290, 395
+
+Boston Society for the Relief and Study of Tuberculosis, 155
+
+Boyd, Emma Garrett, 355
+
+Brannan, John Winters, M.D., 240
+
+Breath, bad, 360, 379
+
+Brightness, abnormal, 104-106
+
+Bronchitis, 67
+
+Brookline, 34
+
+Budget:
+  should provide for cleansing, 61;
+  and tuberculosis, 237;
+  annual health programme, 306;
+  reforms in New York City, 350
+
+Burbank, Luther, 120
+
+Bureau of Municipal Research, 298, 306
+
+Butler, Nicholas Murray, LL.D., 330, 332
+
+
+Cabot, Richard C., M.D., 181
+
+Calmette's Eye Test, 238
+
+Carnegie Foundation, 285
+
+Caroline Rest, 70, 267
+
+Catching diseases:
+  cost of, 16;
+  unenforced laws, 30;
+  steps in eradicating, 31;
+  germ sociology, 57, 71;
+  favorable soil at school, 58;
+  instruction concerning, 62;
+  mouth a breeding ground for, 63;
+  information for bathers, 64;
+  dangers of, 131;
+  reasons for national board of health, 135;
+  cost of, in New York City, 272;
+  remedies urged, 384
+
+Charity Organization Society, New York, 236, 239
+
+Chicago, 34
+
+Chicken-pox, 64
+
+Child Hygiene, Bureau of:
+  working-paper tests, 192;
+  established, New York City, 298;
+  programme, 299
+
+Child labor:
+  compulsory school attendance, 140;
+  welfare or age test, 142;
+  movement's limitations, 185;
+  national and local committees, 33, 192;
+  physical-fitness tests, 194
+
+Children's Aid Society, New York, 56, 93
+
+Child-saving agencies:
+  coöperation with schools, 174-183;
+  do-nothingism in, 332
+
+Chorea. See _Nervousness_
+
+Christian Science, 276, 392
+
+Christmas shopping, 227
+
+Cigarettes. See _Tobacco_
+
+Cincinnati, 118
+
+Cleanliness:
+  acquired taste, 14;
+  beauty of, 96;
+  personal uncleanliness, 210;
+  cost of, 216;
+  dry cleaning dangerous, 244;
+  in fighting tuberculosis, 250
+
+Cleveland, Ohio, 294
+
+Clippings:
+  scrapbook, 250;
+  envelope method, 324;
+  advertisements, 382
+
+Coffee, strong, 401
+
+Colds, 63-69
+
+College, physical tests, 39
+
+Committee on Physical Welfare of School Children, New York, 39-41, 166,
+    168, 178, 286, 290, 311
+
+Compulsory laws:
+  school hygiene, 3;
+  purpose of, 33;
+  registration of catching diseases, 57;
+  removal of tuberculosis cases, 237;
+  notification of tuberculosis, 237, 274;
+  hygiene, for private schools, 283;
+  to remove physical defects, 288;
+  restricting alcoholism, 343
+
+Conference on Summer Care of Babies, New York, 260
+
+Congestion:
+  evils avoided, 290;
+  and alcoholism, 348
+
+Conjunctivitis, 71. See _Eyes_
+
+Connecticut's school reports, 318
+
+Constipation, 210, 216, 347, 357
+
+Consumption. See _Tuberculosis_
+
+Corsets, 381, 401
+
+Cost:
+  of preventable diseases, 16;
+  of bad breath, 98;
+  of diseases to nation, 135;
+  of tuberculosis, 245
+
+Crampton, C. Ward, M.D., 129, 289
+
+
+Dangerous trades, 191
+
+Darlington, Thomas, M.D., 297
+
+Death rates:
+  of bronchitis, 67;
+  of pneumonia, 67;
+  how to reduce, 131
+
+Defects, physical:
+  index of community needs, 33-44;
+  removable, of children, 22;
+  schools manufacture, 139;
+  income distribution, 169
+
+Delinquency, and mouth breathing, 47
+
+Dental Hygiene Council, 95
+
+Dental sanitation, 89-103;
+  surface for breeding germs, 63;
+  dentists, 93;
+  state organizations, 95;
+  clinics needed, 171;
+  insurance companies treat teeth, 204;
+  family instruction, 245;
+  indigestion, 272;
+  early treatises, 274;
+  advertising parlors, 281
+
+Devine, Professor Edward T., 174
+
+Diet:
+  cooking lessons at home, 180;
+  overeating, 201, 347;
+  improper, 210;
+  proper and regular, 212;
+  adapted to need, 214, 401;
+  kitchens, 267;
+  irregular eating, 272, 347
+
+Diet kitchens, 267
+
+Diphtheria, 18, 65
+
+Dispensaries and hospitals:
+  dental supervision, 102;
+  coöperate with schools, 174-183, 185;
+  welfare nurse, 188;
+  emergency, 227;
+  to prevent duplication, 239;
+  lack of, 240;
+  teach baby feeding, 261;
+  inefficient, 278;
+  social interest of, 292
+
+Doing things at school, 159-165;
+  free meals, 44, 161, 171;
+  may hurt, 181;
+  cripple social agencies, 185, 189;
+  danger of malpractice, 184, 189;
+  analogous to model tenements, 186
+
+Do-nothing ailments, 329-334
+
+
+Ear trouble, 83-85;
+  periodic tests for, 201, 207
+
+Edinburgh, 70
+
+Ellis Island, 238
+
+Environment:
+  health problem, 9;
+  tests, 120, 320;
+  injurious school, 139-150;
+  effect on physique, 203;
+  and tuberculosis, 229-251;
+  do-nothing ailments, 329;
+  within our control, 336;
+  in combating liquor, 362
+
+Epidemics, 18, 38
+
+Epilepsy, 47, 49
+
+Ergograph, 125-127
+
+Erysipelas, 65
+
+Ethics, professional, 81, 101, 281
+
+Eugenics, and heredity, 336
+
+European remedies, 159-165
+
+Eye trouble, 72-82;
+  in high school, 40;
+  catching diseases, 69-71;
+  caused by bad teeth, 89;
+  eyeglasses, free, 161, 164, 171, 184;
+  in business, 193;
+  examination for adults, 201;
+  tuberculin test, 238;
+  inefficient inspection of, 300;
+  teachers' test, 301
+
+Examination, physical:
+  of school children, 33-138;
+  best test of health needs, 33-44;
+  individual record of, 35, 312;
+  Snellen test, 73, 77;
+  of teachers, 153;
+  for work certificates, 190-200, 237, 301;
+  by railroads, 193;
+  at West Point, 199;
+  periodic after school, 201-207, 218, 228;
+  semi-annual, 202;
+  tuberculin tests, 240;
+  stripped, at Leipsic, 289;
+  follow-up work, 295-300;
+  of teachers and sex hygiene, 389
+
+
+Family:
+  unit of social treatment, 174;
+  examining parties, 237, 241;
+  tuberculosis histories, 241
+
+Fear and bodily disorders, 392
+
+Flick, Lawrence F., M.D., 229
+
+Follow-up work, 295-301
+
+Fox, Hugh F., 351
+
+Fresh air:
+  others' standards of, 9;
+  fiends, 66;
+  outings, 176, 178;
+  economic value of, 195;
+  ventilation at school, 142;
+  ventilation at home, 210;
+  ventilation at work, 212;
+  ventilation at sanatoriums, 214;
+  ventilation at churches and theaters, 217.
+  See _Air_
+
+
+Georgia, 350
+
+Germany, 160, 204
+
+Germs, disease:
+  in milk bottles, 14;
+  isolation, 31;
+  germ sociology, 57-71;
+  dental sanitation, 89-103;
+  locating germ factories, 238;
+  tuberculosis, 234
+
+Getting things done, 166-173;
+  doing of highest kind, 183;
+  study underlying causes, 189;
+  by local agencies, 287
+
+Glands, 88
+
+Goler, George W., M.D., 196
+
+Gorgas, William C., M.D., 59
+
+Government. See _Administration_
+
+Greenwich House, 287
+
+Grenfell Association, 197
+
+Grippe, 379
+
+Gulick, Luther H., M.D., 123, 208
+
+
+Habits of health, 208-217;
+  combat tobacco, 364;
+  mental hygiene, 394;
+  and Nature Fore, 400
+
+Hartley House, 287
+
+Hartley, Robert M., 252
+
+Havana, 60
+
+Hawthorne Club, 287
+
+Headache, 210
+
+Heredity, 335-342
+
+High schools need physical tests, 39
+
+Hip trouble. See _Tuberculosis_
+
+Home conditions:
+  indexed by epidemics, 32;
+  indexed at school, 33;
+  among different incomes, 39;
+  cooking instructions, 180;
+  weighing parties, 241;
+  score card, 337;
+  promote alcoholism, 348
+
+Hughes, Governor Charles E., 201
+
+Hunter, Robert, 167
+
+Hyatt, Thaddeus P., D.D.S., 94
+
+
+Impetigo, 65
+
+Income, 34, 38, 39
+
+India, 108
+
+Indigestion:
+  anti-social, 10;
+  due to teeth, 272
+
+Individual record card, 35, 312-314
+
+Industrial hygiene:
+  educates laborers, 131;
+  factory conditions, 221, 227;
+  factory reforms, 403;
+  employers, 3, 210, 218, 360, 367;
+  employees, 202, 211, 219, 228, 360
+
+Influenza, 65-68
+
+Ingram, Helene, 177
+
+Insomnia, 392
+
+Inspection:
+  of milk, 26, 259;
+  score cards, 27, 29, 337;
+  of school children, 43, 61, 296;
+  of factories, 131;
+  of milch cows, 260;
+  of transmissible diseases, 295;
+  of foods, 307
+
+Instinct, motive to health, 12, 14, 94
+
+International Congress on tuberculosis, 238, 245
+
+Itch, 65
+
+
+Japan, 23, 287, 309
+
+Junior Sea Breeze, 267
+
+
+Kansas City, 161
+
+Kidney trouble, 217
+
+
+Labrador, 197
+
+Lavatories, public, 217
+
+Laws:
+  nonenforcement demoralizing, 4;
+  define rights, 23;
+  when not enforced, 25;
+  should not injure health, 151;
+  enforcement better than character, 219;
+  regarding milk, 258;
+  licensing practitioners, 280;
+  need machinery, 303, 348;
+  to control liquor, 343, 355;
+  test of prohibition, 353;
+  on patent medicine, 373;
+  on pure foods, 379
+
+Leipsic, 289
+
+Louisiana, 350, 376
+
+Lung trouble. See _Tuberculosis_
+
+
+Machinery, health:
+  unsatisfactory coordination, 296;
+  necessary, 302-309;
+  five elements, 303
+
+Mackenzie, W. Leslie, M.D., 132
+
+Magistrates:
+  promote disorder, 173;
+  enforce health laws, 303
+
+Malnutrition, 35;
+  income distribution, 39;
+  signs and tests, 86;
+  prevention of, 184;
+  education of family, 241
+
+Massachusetts, 74
+
+Maxwell, Superintendent William H., 286, 288
+
+Measles, 64
+
+Mental hygiene, 391-397;
+  blues, anti-social, 10;
+  hospital welfare work, 182;
+  moral clinics, 276, 291, 295;
+  and insomnia, 392
+
+Meyer, William, M.D., 47
+
+Milk:
+  unclean dairies, 10;
+  scalding receptacles of, 17;
+  carries typhoid, 18;
+  inspector's outfit, 24;
+  tests of protection, 25;
+  score cards, 26, 259, 337;
+  public should know, 219;
+  fight for pure, 252-267;
+  New York conferences, 255, 260;
+  breast feeding, 266
+
+Milk committee, New York, 258, 260
+
+Minnesota, 45, 269
+
+Misgovernment causes sickness, 10
+
+Mitchell, S. Weir, M.D., 73
+
+Montclair, 265
+
+Mosquitoes, 59, 307
+
+Motives, seven health, 11-22, 377
+
+Mouth breathing, 45-56;
+  and delinquency, 47;
+  adenoid parties, 55;
+  causes deafness, 83;
+  injures baby teeth, 89;
+  industrial disadvantage of, 195;
+  in Labrador, 197;
+  preventable defect, 272;
+  inefficient inspection of, 300
+
+
+National Association for the Study and Prevention of Tuberculosis, 236, 246
+
+National Board of Health, 133, 292, 308
+
+National Bureau of Labor, 199
+
+National Bureau of Census, 305
+
+National Bureau of Animal Industry, 306
+
+National Bureau of Education, 171, 292
+
+National Playground Association, 118
+
+National School Hygiene Association, 139
+
+Nature Fore and Nature Back, 398-403
+
+Negroes and alcoholism, 350
+
+Nervousness, 85;
+  and school life, 108;
+  physical defects, 110;
+  preventable, 111;
+  causes of, 112;
+  habit, 111, 113;
+  from tobacco, 363
+
+Neurasthenia. See _Mental Hygiene_
+
+New Jersey, 12
+
+Newsholme, Arthur, M.D., 120, 131, 229, 241
+
+New York City, 16, 25, 34
+
+New York Juvenile Asylum, 47
+
+New York state, 12, 24
+
+New York State Charities Aid Association, 236, 242
+
+Nicotinism. See _Tobacco_
+
+Normal schools, 110
+
+North, Professor Lila V., 142
+
+Notification of diseases, 31, 41
+
+Nuisances, 17, 18, 23, 366
+
+Nurses at school, 230, 286, 293, 300.
+  See _Milk_
+
+
+Oliver, Thomas, 203
+
+Orthopedics. See _Tuberculosis_
+
+Ophthalmia, 65
+
+Oppenheimer, Nathan, M.D., 110
+
+Osteopathy, 275
+
+
+Panama, 59
+
+Parents:
+  and school hygiene, 3;
+  interested by examinations, 41;
+  should coöperate with physician, 279;
+  interested in school examinations, 297;
+  need health reports, 310;
+  heredity, 335-342;
+  nicotinism, 368
+
+Parks and playgrounds, 7, 32, 118, 122, 142, 186, 290, 294
+
+Parochial schools, 189, 198
+
+Patent medicines:
+  evils of, 369-377;
+  advertisements, 380
+
+Patten, Professor Simon N., 9, 14, 33, 165
+
+Pediculosis, 69-71
+
+Pennsylvania, 311
+
+Philadelphia, 34
+
+Phthisis. See _Tuberculosis_
+
+Physical training, 115-117;
+  in New York City, 296;
+  and sex hygiene, 387
+
+Physician:
+  preventive medicine, 268-282;
+  and eyes, 81;
+  semi-annual visit to, 204;
+  self-advertisement, 378;
+  school, 173, 286, 293, 315
+
+Physiological age, 105, 289, 387
+
+Pittsburgh, 269
+
+Plague, 15, 57
+
+Pneumonia, 67, 379
+
+Preventable diseases:
+  those not communicable, 272.
+  See _Catching Diseases_
+
+Private schools, 189, 198, 283, 291, 330
+
+Prohibition laws, 348, 350, 355
+
+Pro-slum motive, 19-20
+
+Public Education Association, New York, 287, 298
+
+Publicity, 45, 81, 99, 292, 310-321, 382
+
+
+Quarantine, first, 15;
+  national, 308
+
+
+Records:
+  of disease centers, 31;
+  defective, 32;
+  individual, 35, 312-314
+
+Reform's failure, 349
+
+Registration:
+  of diseases, 31
+
+Relief, material:
+  sound principles of, 174;
+  at school, 175, 179, 184;
+  indiscriminate, harmful, 332
+
+Richman, Julia, 172
+
+Riggs disease, 92
+
+Rights:
+  political, 21;
+  not enforced, 23-32;
+  of workmen at work, 190;
+  machinery for enforcing, 283-322
+
+Riis, Jacob, 18
+
+Ringworm, 65
+
+Rochester, N.Y., 262, 266
+
+Rome, 15
+
+Roosevelt, Theodore, 60, 118
+
+Rural districts:
+  encourage disease, 13;
+  compared, 32;
+  physical defects, 74;
+  schools unsanitary, 141;
+  hygiene in Great Britain, 308
+
+Russia, 108
+
+
+Sage Foundation, 285
+
+St. Vitus's dance, 111
+
+Salmon, Professor Lucy M., 355
+
+Scabies, 65.
+  See _Itch_
+
+Scarlatina, 65
+
+Scarlet fever:
+  thrives in slums, 18;
+  signs and method of infection, 65;
+  "peeling," 132;
+  compulsory removal of cases, 240;
+  germ carried in milk, 264
+
+School hygiene:
+  and employers, 3;
+  instruction compulsory, 3-10;
+  practice of, 5, 18;
+  biological engineering, 139, 203, 339;
+  departments of, 283-293;
+  in New York City, 294, 296-301
+
+Score cards, 27, 29, 259, 337
+
+Scranton, 269
+
+Sea Breeze fresh-air home, 176
+
+Sea Breeze seaside hospital, 9, 240
+
+Seaman, L.L., M.D., 23
+
+Seattle, 161
+
+Sedgwick, Professor William T., 304
+
+Sex hygiene, 384-389
+
+Sexual deviates, 182
+
+Shoes, tight, 401
+
+Sickness, preventable, cost of, 278
+
+Sleep and vitality, 201, 272
+
+Slum, a menace, 13, 20
+
+Smallpox:
+  epidemics great teachers, 6;
+  conquered by vaccination, 7;
+  neglected in rural Pennsylvania, 18;
+  comes rarely to cities, 31;
+  compulsory removal of cases, 240
+
+Snedden, Professor David S., 33, 165, 311
+
+Snellen eye test, 73, 77
+
+Society for Sanitary and Moral Prophylaxis, 384
+
+Southern states, 351
+
+Spargo, John, 33, 167
+
+Spitting, 223, 235
+
+State activity, 4, 73, 121, 236, 292, 306
+
+Statistics, object of, 131, 134, 333
+
+Strauss, Nathan, 260
+
+Streets, 15, 122, 217, 254, 348
+
+Study hours, too long, 287
+
+Sweating, 152, 211
+
+
+Taxes, taxpayers. See _Budget_
+
+Teacher's health:
+  tests of, 152-158
+
+Teachers:
+  social work, 172;
+  health passport, 202;
+  for tuberculous pupils, 237;
+  excluded when tuberculous, 242;
+  and physicians, 279;
+  physical examination of, 284;
+  use of alcohol, 358;
+  cigarettes, 368;
+  use clippings, 382
+
+Teeth. See _Dental Sanitation_
+
+Temperance. See _Alcoholism_
+
+Tenement reforms, 20, 186, 209, 304, 403
+
+Thompson, J. Arthur, 336
+
+Tobacco:
+  instruction at school, 3;
+  economic injuries of, 201;
+  forbidden to employees, 210;
+  evils of nicotinism, 363-368, 386
+
+Tonsils, hypertrophied, 44
+
+Trachoma, 69-71
+
+Trudeau, E.L., M.D., 274
+
+Tuberculosis:
+  pupils excluded from school because of, 65;
+  aggravated by colds, 68;
+  bone tuberculosis, 87, 88, 236;
+  and bad teeth, 90, 99;
+  in teachers, 153;
+  examination for working papers, 191;
+  periodical examination for, 201;
+  last days of, 229-251;
+  eye and skin tests for, 240;
+  tests of cows, 260;
+  carried in milk, 264;
+  out-of-door treatment, 274;
+  only predisposition to, inherited, 335
+
+Typhoid:
+  a rural disease, 13;
+  carried in milk, 264
+
+
+University Extension Society, 178
+
+
+Vacation schools, playgrounds, 109, 296
+
+Veiller, Lawrence, 9
+
+Vitality tests and statistics, 124-138
+
+
+Water, drinking:
+  reason for works, 15;
+  factories pollute, 17;
+  fountains, 217;
+  public responsibility for, 226;
+  protecting sources, 307
+
+Welfare work, 7, 221-225
+
+West Point, 199
+
+Wheeler, Herbert L., D.D.S., 93
+
+Whipple, George C., Ph. D., 13, 16
+
+White plague. See _Tuberculosis_
+
+Whooping cough, 64
+
+Williams, Alida S., 72, 122
+
+Williams, Linsly R., M.D., 241
+
+Work:
+  physical examination for working papers, 190-200, 285;
+  healthful habits, 208-217;
+  unpatented medicine, 334.
+  See _Industrial Hygiene_
+
+
+Young Men's Christian Association, 227
+
+       *       *       *       *       *
+
+    +-----------------------------------------------------------+
+    | 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. Allen
+
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+<pre>
+
+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: ISO-8859-1
+
+*** 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
+
+
+
+
+
+
+</pre>
+
+
+<br />
+<hr />
+<br />
+
+<div class="tr">
+<p class="cen" style="font-weight: bold;">Transcriber's Note:</p>
+<br />
+<p class="noin">Inconsistent hyphenation in the original document has been preserved.</p>
+<p class="noin">Some text in this document has been moved to avoid multi-page tables being inserted mid-paragraph.</p>
+<p class="noin" style="text-align: left;">Obvious typographical errors have been corrected in this text.
+For a complete list, please see the <span style="white-space: nowrap;"><a href="#TN">end of this document</a>.</span></p>
+<p class="noin">Click on the images to see a larger version.</p>
+</div>
+
+<br />
+<hr />
+<br />
+
+<div class="img">
+<a href="images/frontis.jpg">
+<img border="0" src="images/frontis.jpg" width="50%" alt="Louis Agassiz" /></a><br />
+<p class="cen" style="margin-top: .2em;">LOUIS AGASSIZ <br />"A natural law is as sacred as a moral principle"</p>
+</div>
+
+<br />
+<hr />
+<br />
+
+<h1>CIVICS AND HEALTH</h1>
+
+<br />
+<br />
+
+<h4>BY</h4>
+<h2 style="margin-bottom: 2px;">WILLIAM H. ALLEN</h2>
+
+<h5 class="sc2" style="margin-top: 2px; margin-bottom: 2px;">Secretary, Bureau of Municipal Research</h5>
+
+<h5 class="sc2" style="margin-top: 6px;">Former Secretary of the New York Committee on Physical Welfare of<br />
+School Children, Author of "Efficient Democracy" and "Rural<br />
+Sanitary Administration in Pennsylvania," Joint Author<br />
+of "School Reports and School Efficiency"</h5>
+
+<br />
+<br />
+<br />
+
+<h4>WITH AN INTRODUCTION</h4>
+
+<h4>BY</h4>
+
+<h3 style="margin-bottom: 2px;">WILLIAM T. SEDGWICK</h3>
+<h5 class="sc2" style="margin-top: 6px;">Professor of Biology in the Massachusetts Institute of Technology</h5>
+
+<br />
+<br />
+<br />
+
+<h5>GINN AND COMPANY<br />
+BOSTON &middot;&nbsp; NEW YORK &middot;&nbsp; CHICAGO &middot;&nbsp; LONDON</h5>
+
+<br />
+<hr />
+<br />
+<br />
+<br />
+<br />
+
+<h5><span class="sc2">Entered at Stationers' Hall</span><br />
+<br />
+<span class="sc2">Copyright, 1909</span><br />
+<span class="sc2">By</span> WILLIAM H. ALLEN</h5>
+<br />
+<h5>ALL RIGHTS RESERVED</h5>
+<h6>910.4</h6>
+<br />
+<br />
+<br />
+<h5>The Athen&aelig;um Press<br />
+GINN AND COMPANY &middot;&nbsp; PROPRIETORS &middot;&nbsp; BOSTON &middot;&nbsp; U.S.A.</h5>
+
+<br />
+<br />
+<br />
+<br />
+<hr />
+<span class='pagenum'><a name="Page_v" id="Page_v">[v]</a></span><br />
+
+<h3>INTRODUCTION</h3>
+<br />
+
+<p>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.</p>
+
+<p>With our forefathers the phrase <i>mens sana in corpore sano</i> 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."</p>
+
+<p>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 <span class='pagenum'><a name="Page_vi" id="Page_vi">[vi]</a></span>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.</p>
+
+<p>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 <i>mens sana in corpore sano</i> 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,&mdash;not in education of the brain. If lack of
+initiative or energy proceeds from defective a&euml;ration 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.</p>
+
+<p>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&mdash;like this of Dr. Allen's&mdash;in
+striving to teach mankind how to become happier, and healthier, and
+more useful members of society.</p>
+
+<p>Dr. Allen is undoubtedly a reformer, but of the modern, not the
+ancient, type. He is a prophet crying in our present <span class='pagenum'><a name="Page_vii" id="Page_vii">[vii]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p class="right">WILLIAM T. SEDGWICK</p>
+
+<p class="sc">Massachusetts Institute of Technology</p>
+
+<br />
+<br />
+<br />
+<span class='pagenum'><a name="Page_viii" id="Page_viii">[viii]</a></span><br />
+<a name="toc" id="toc"></a><hr />
+<span class='pagenum'><a name="Page_ix" id="Page_ix">[ix]</a></span><br />
+
+<h3>CONTENTS</h3>
+<br />
+
+<div class="centered">
+<table border="0" cellpadding="2" cellspacing="0" width="90%" summary="Table of Contents">
+  <tr>
+  <td class="tdc" colspan="3"><a href="#PART_I_HEALTH_RIGHTS">PART I. HEALTH RIGHTS</a></td>
+  </tr>
+  <tr>
+  <td class="tdrt" width="10%"><span style="font-size: 80%;">CHAPTER</span></td>
+  <td class="tdl" width="70%">&nbsp;</td>
+  <td class="tdrb" width="20%"><span style="font-size: 80%;">PAGE</span></td>
+  </tr>
+  <tr>
+  <td class="tdrt">I.</td>
+  <td class="tdlsc"><a href="#CHAPTER_I">Health a Civic Obligation</a></td>
+  <td class="tdrb">3</td>
+  </tr>
+  <tr>
+  <td class="tdrt">II.</td>
+  <td class="tdlsc"><a href="#CHAPTER_II">Seven Health Motives and Seven Catchwords</a></td>
+  <td class="tdrb">11</td>
+  </tr>
+  <tr>
+  <td class="tdrt">III.</td>
+  <td class="tdlsc"><a href="#CHAPTER_III">What Health Rights are not enforced in your Community?</a></td>
+  <td class="tdrb">23</td>
+  </tr>
+  <tr>
+  <td class="tdrt">IV.</td>
+  <td class="tdlsc"><a href="#CHAPTER_IV">The Best Index to Community Health is the Physical
+         Welfare of School Children</a></td>
+  <td class="tdrb">33</td>
+  </tr>
+  <tr>
+  <td class="tdc" colspan="3" style="padding-top: 1em; padding-bottom: 1em;"><a href="#PART_II_READING_THE_INDEX_TO_HEALTH_RIGHTS">PART II. READING THE INDEX TO HEALTH RIGHTS</a></td>
+  </tr>
+  <tr>
+  <td class="tdrt">V.</td>
+  <td class="tdlsc"><a href="#CHAPTER_V">Mouth Breathing</a></td>
+  <td class="tdrb">45</td>
+  </tr>
+  <tr>
+  <td class="tdrt">VI.</td>
+  <td class="tdlsc"><a href="#CHAPTER_VI">Catching Diseases, Colds, Diseased Glands</a></td>
+  <td class="tdrb">57</td>
+  </tr>
+  <tr>
+  <td class="tdrt">VII.</td>
+  <td class="tdlsc"><a href="#CHAPTER_VII">Eye Strain</a></td>
+  <td class="tdrb">72</td>
+  </tr>
+  <tr>
+  <td class="tdrt">VIII.</td>
+  <td class="tdlsc"><a href="#CHAPTER_VIII">Ear Trouble, Malnutrition, Deformities</a></td>
+  <td class="tdrb">83</td>
+  </tr>
+  <tr>
+  <td class="tdrt">IX.</td>
+  <td class="tdlsc"><a href="#CHAPTER_IX">Dental Sanitation</a></td>
+  <td class="tdrb">89</td>
+  </tr>
+  <tr>
+  <td class="tdrt">X.</td>
+  <td class="tdlsc"><a href="#CHAPTER_X">Abnormally Bright Children</a></td>
+  <td class="tdrb">104</td>
+  </tr>
+  <tr>
+  <td class="tdrt">XI.</td>
+  <td class="tdlsc"><a href="#CHAPTER_XI">Nervousness of Teacher and Pupil</a></td>
+  <td class="tdrb">107</td>
+  </tr>
+  <tr>
+  <td class="tdrt">XII.</td>
+  <td class="tdlsc"><a href="#CHAPTER_XII">Health Value of "Unbossed" Play and Physical Training</a></td>
+  <td class="tdrb">115</td>
+  </tr>
+  <tr>
+  <td class="tdrt">XIII.</td>
+  <td class="tdlsc"><a href="#CHAPTER_XIII">Vitality Tests and Vital Statistics</a></td>
+  <td class="tdrb">124</td>
+  </tr>
+  <tr>
+  <td class="tdrt">XIV.</td>
+  <td class="tdlsc"><a href="#CHAPTER_XIV">Is your School Manufacturing Physical Defects?</a></td>
+  <td class="tdrb">139</td>
+  </tr>
+  <tr>
+  <td class="tdrt">XV.</td>
+  <td class="tdlsc"><a href="#CHAPTER_XV">The Teacher's Health</a></td>
+  <td class="tdrb">152</td>
+  </tr>
+  <tr>
+  <td class="tdc" colspan="3" style="padding-top: 1em; padding-bottom: 1em;"><a href="#PART_III_COOPERATION_IN_MEETING_HEALTH_OBLIGATIONS">PART III. CO&Ouml;PERATION IN MEETING HEALTH OBLIGATIONS</a></td>
+  </tr>
+  <tr>
+  <td class="tdrt">XVI.</td>
+  <td class="tdlsc"><a href="#CHAPTER_XVI">European Remedies: Doing Things at School</a></td>
+  <td class="tdrb">159</td>
+  </tr>
+  <tr>
+  <td class="tdrt">XVII.</td>
+  <td class="tdlsc"><a href="#CHAPTER_XVII">American Remedies: Getting Things Done</a></td>
+  <td class="tdrb">166</td>
+  </tr>
+  <tr>
+  <td class="tdrt">XVIII.</td>
+  <td class="tdlsc"><a href="#CHAPTER_XVIII">Co&ouml;peration with Dispensaries and Child-Saving Agencies</a></td>
+  <td class="tdrb">174</td>
+  </tr>
+  <tr>
+  <td class="tdrt">XIX.</td>
+  <td class="tdlsc"><a href="#CHAPTER_XIX">School Surgery and Relief Objectionable, if Avoidable</a></td>
+  <td class="tdrb">184<span class='pagenum'><a name="Page_x" id="Page_x">[x]</a></span></td>
+  </tr>
+  <tr>
+  <td class="tdrt">XX.</td>
+  <td class="tdlsc"><a href="#CHAPTER_XX">Physical Examination for Working Papers</a></td>
+  <td class="tdrb">190</td>
+  </tr>
+  <tr>
+  <td class="tdrt">XXI.</td>
+  <td class="tdlsc"><a href="#CHAPTER_XXI">Periodical Physical Examination after School Age</a></td>
+  <td class="tdrb">201</td>
+  </tr>
+  <tr>
+  <td class="tdrt">XXII.</td>
+  <td class="tdlsc"><a href="#CHAPTER_XXII">Habits of Health promote Industrial Efficiency</a></td>
+  <td class="tdrb">208</td>
+  </tr>
+  <tr>
+  <td class="tdrt">XXIII.</td>
+  <td class="tdlsc"><a href="#CHAPTER_XXIII">Industrial Hygiene</a></td>
+  <td class="tdrb">218</td>
+  </tr>
+  <tr>
+  <td class="tdrt">XXIV.</td>
+  <td class="tdlsc"><a href="#CHAPTER_XXIV">The Last Days of Tuberculosis</a></td>
+  <td class="tdrb">229</td>
+  </tr>
+  <tr>
+  <td class="tdrt">XXV.</td>
+  <td class="tdlsc"><a href="#CHAPTER_XXV">The Fight for Clean Milk</a></td>
+  <td class="tdrb">252</td>
+  </tr>
+  <tr>
+  <td class="tdrt">XXVI.</td>
+  <td class="tdlsc"><a href="#CHAPTER_XXVI">Preventive "Humanized" Medicine: Physician and Teacher</a></td>
+  <td class="tdrb">268</td>
+  </tr>
+  <tr>
+  <td class="tdc" colspan="3" style="padding-top: 1em; padding-bottom: 1em;"><a href="#PART_IV_OFFICIAL_MACHINERY_FOR_ENFORCING_HEALTH_RIGHTS">PART IV. OFFICIAL MACHINERY FOR ENFORCING HEALTH RIGHTS</a></td>
+  </tr>
+  <tr>
+  <td class="tdrt">XXVII.</td>
+  <td class="tdlsc"><a href="#CHAPTER_XXVII">Departments of School Hygiene</a></td>
+  <td class="tdrb">283</td>
+  </tr>
+  <tr>
+  <td class="tdrt">XXVIII.</td>
+  <td class="tdlsc"><a href="#CHAPTER_XXVIII">Present Organization of School Hygiene in New York City</a></td>
+  <td class="tdrb">296</td>
+  </tr>
+  <tr>
+  <td class="tdrt">XXIX.</td>
+  <td class="tdlsc"><a href="#CHAPTER_XXIX">Official Machinery for enforcing Health Rights</a></td>
+  <td class="tdrb">302</td>
+  </tr>
+  <tr>
+  <td class="tdrt">XXX.</td>
+  <td class="tdlsc"><a href="#CHAPTER_XXX">School and Health Reports</a></td>
+  <td class="tdrb">310</td>
+  </tr>
+  <tr>
+  <td class="tdrt">XXXI.</td>
+  <td class="tdlsc"><a href="#CHAPTER_XXXI">The Press</a></td>
+  <td class="tdrb">322</td>
+  </tr>
+  <tr>
+  <td class="tdc" colspan="3" style="padding-top: 1em; padding-bottom: 1em;"><a href="#PART_V_ALLIANCE_OF_HYGIENE_PATRIOTISM_AND_RELIGION">PART V. ALLIANCE OF HYGIENE, PATRIOTISM, AND RELIGION</a></td>
+  </tr>
+  <tr>
+  <td class="tdrt">XXXII.</td>
+  <td class="tdlsc"><a href="#CHAPTER_XXXII">Do-Nothing Ailments</a></td>
+  <td class="tdrb">329</td>
+  </tr>
+  <tr>
+  <td class="tdrt">XXXIII.</td>
+  <td class="tdlsc"><a href="#CHAPTER_XXXIII">Heredity Bugaboos and Heredity Truths</a></td>
+  <td class="tdrb">335</td>
+  </tr>
+  <tr>
+  <td class="tdrt">XXXIV.</td>
+  <td class="tdlsc"><a href="#CHAPTER_XXXIV">Ineffective and Effective Ways of Combating Alcoholism</a></td>
+  <td class="tdrb">343</td>
+  </tr>
+  <tr>
+  <td class="tdrt">XXXV.</td>
+  <td class="tdlsc"><a href="#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?</a></td>
+  <td class="tdrb">357</td>
+  </tr>
+  <tr>
+  <td class="tdrt">XXXVI.</td>
+  <td class="tdlsc"><a href="#CHAPTER_XXXVI">Fighting Tobacco Evils</a></td>
+  <td class="tdrb">363</td>
+  </tr>
+  <tr>
+  <td class="tdrt">XXXVII.</td>
+  <td class="tdlsc"><a href="#CHAPTER_XXVII">The Patent-Medicine Evil</a></td>
+  <td class="tdrb">369</td>
+  </tr>
+  <tr>
+  <td class="tdrt">XXXVIII.</td>
+  <td class="tdlsc"><a href="#CHAPTER_XXXVIII">Health Advertisements that Promote Health</a></td>
+  <td class="tdrb">378<span class='pagenum'><a name="Page_xi" id="Page_xi">[xi]</a></span></td>
+  </tr>
+  <tr>
+  <td class="tdrt">XXXIX.</td>
+  <td class="tdlsc"><a href="#CHAPTER_XXXIX">Is Class Instruction in Sex Hygiene Practicable?</a></td>
+  <td class="tdrb">384</td>
+  </tr>
+  <tr>
+  <td class="tdrt">XL.</td>
+  <td class="tdlsc"><a href="#CHAPTER_XL">The Element of Truth in Quackery; Hygiene of the Mind</a></td>
+  <td class="tdrb">391</td>
+  </tr>
+  <tr>
+  <td class="tdrt">XLI.</td>
+  <td class="tdlsc"><a href="#CHAPTER_XLI">"A Natural Law is as Sacred as a Moral Principle"</a></td>
+  <td class="tdrb">398</td>
+  </tr>
+  <tr>
+  <td class="tdl">&nbsp;</td>
+  <td class="tdl"><a href="#INDEX">INDEX</a></td>
+  <td class="tdrb">405</td>
+  </tr>
+</table>
+</div>
+
+<br />
+<br />
+<br />
+<br />
+<hr />
+<br />
+<br />
+<br />
+<br />
+
+<h1>CIVICS AND HEALTH</h1>
+
+<br />
+<br />
+<br />
+<br />
+<a name="PART_I_HEALTH_RIGHTS" id="PART_I_HEALTH_RIGHTS"></a><a name="CHAPTER_I" id="CHAPTER_I"></a><hr />
+<span class='pagenum'><a name="Page_3" id="Page_3">[3]</a></span><br />
+<br />
+<br />
+<br />
+
+<h2 class="wrap">PART I. HEALTH RIGHTS</h2>
+
+<br />
+
+<h3>CHAPTER I<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>HEALTH A CIVIC OBLIGATION</h4>
+<br />
+
+<p>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.</p>
+
+<p>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,&mdash;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.</p>
+
+<p>Interviews with teachers and principals regarding the present apathy
+to formal hygiene instruction have brought <span class='pagenum'><a name="Page_4" id="Page_4">[4]</a></span>out the following points
+that merit the serious consideration of those who are struggling for
+higher health standards.</p>
+
+<p>1. <i>There is many a slip 'twixt the making of a law and its
+enforcement.</i> 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 <i>Legislation</i>, the advocates
+of anti-alcohol and anti-tobacco instruction failed to see the truth
+that experienced political reformers are but slowly coming to
+see&mdash;<i>Legislation which does not provide machinery for its own
+enforcement is apt to do little good and frequently will do much
+harm.</i> 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.</p>
+
+<p>2. <i>Teachers give as one reason for neglecting hygiene, that they are
+often compelled to struggle with a curriculum which <span class='pagenum'><a name="Page_5" id="Page_5">[5]</a></span>requires more
+than they are able to teach and more than pupils are able to learn in
+the time allowed.</i> 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?</p>
+
+<p>3. <i>Teachers are made to feel that while arithmetic and reading are
+essential, hygiene is not essential.</i> 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 <span class='pagenum'><a name="Page_6" id="Page_6">[6]</a></span>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."</p>
+
+<p>4. <i>Teachers believe that they get better results for their children
+from teaching hygiene informally and indirectly than from stated
+formal lessons.</i> 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.</p>
+
+<p>If one illustration is better than ten lessons, if an open window is
+worth more than all that text-books have to say <span class='pagenum'><a name="Page_7" id="Page_7">[7]</a></span>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.</p>
+
+<p>5. <i>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.</i> 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 <span class='pagenum'><a name="Page_8" id="Page_8">[8]</a></span>refuse
+to take risks upon the lives of men or women addicted to the excessive
+use of alcohol or tobacco.</p>
+
+<p>Other people's interests&mdash;tenement conditions, factory rules&mdash;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&mdash;" will always arrest attention
+more quickly than "The human frame consists&mdash;." What others think of
+me helps me to obey law&mdash;statutory, moral, or hygienic&mdash;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 <span class="fakesc">A.M.</span> to 9 <span class="fakesc">P.M.</span> 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.</p>
+
+<p>6. <i>Other people's habits of health influence our well-being quite as
+much, if not more, than our own.</i> Because we are social beings,
+ability to get along with our families, our friends, our employers,
+is&mdash;at least so it seems to most of us&mdash;quite as important as
+individual health. For too <span class='pagenum'><a name="Page_9" id="Page_9">[9]</a></span>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,&mdash;a fresh-air fiend,&mdash;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."</p>
+
+<p>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."</p>
+
+<p>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 <span class='pagenum'><a name="Page_10" id="Page_10">[10]</a></span>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?"</p>
+
+<p>7. <i>Because the problems of health have to do principally with
+environment,&mdash;home, street, school, business,&mdash;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.</i> Since healthful
+living requires the co&ouml;peration 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.</p>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_II" id="CHAPTER_II"></a><hr />
+<span class='pagenum'><a name="Page_11" id="Page_11">[11]</a></span><br />
+
+<h3>CHAPTER II<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>SEVEN HEALTH MOTIVES AND SEVEN CATCHWORDS</h4>
+<br />
+
+<p>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.</p>
+
+<p>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, <span class='pagenum'><a name="Page_12" id="Page_12">[12]</a></span>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.</p>
+
+<p>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:
+<i>Instinct</i>, <i>Display</i>, <i>Commerce</i>, <i>Anti-nuisance</i>, <i>Anti-slum</i>,
+<i>Pro-slum</i>, <i>Rights</i>. 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.</p>
+
+<p><i>Instinct</i> 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, <span class='pagenum'><a name="Page_13" id="Page_13">[13]</a></span>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.</p>
+
+<br />
+
+<p class="cen sc">Table I</p>
+
+<p class="cen sc">Typhoid a Rural Disease<a name="FNanchor_1_1" id="FNanchor_1_1"></a><a href="#Footnote_1_1" class="fnanchor">[1]</a></p>
+
+<br />
+
+<div class="centered">
+<table border="0" cellpadding="2" cellspacing="0" width="80%" summary="Table 1: Typhoid a Rural Disease">
+  <tr>
+  <td width="70%" class="tdctrb">&nbsp;</td>
+  <td width="15%" class="tdctrlb">Average Per Cent of Rural Population</td>
+  <td width="15%" class="tdctlb">Average Typhoid Fever Death Rate per 100,000</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; border-top: 1px solid black; padding-top: .5em;">Five states in which the urban population was more than 60% of the total</td>
+  <td class="tdcrl" style="border-top: 1px solid black; padding-top: .5em;">30</td>
+  <td class="tdcl" style="border-top: 1px solid black; padding-top: .5em;">25</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black;">Six states in which the urban population was between 40% and 60%</td>
+  <td class="tdcrl">49</td>
+  <td class="tdcl">42</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black;">Seven states in which the urban population was between 30% and 40%</td>
+  <td class="tdcrl">67</td>
+  <td class="tdcl">38</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black;">Eight states in which the urban population was between 20% and 30%</td>
+  <td class="tdcrl">75</td>
+  <td class="tdcl">46</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black;">Twelve states in which the urban population was between 10% and 20%</td>
+  <td class="tdcrl">87</td>
+  <td class="tdcl">62</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; border-bottom: 2pt solid black; padding-bottom: .5em;">Twelve states in which the urban population was between 0 and 10%</td>
+  <td class="tdcrl" style="border-bottom: 2pt solid black; padding-bottom: .5em;">95</td>
+  <td class="tdcl" style="border-bottom: 2pt solid black; padding-bottom: .5em;">67</td>
+  </tr>
+</table>
+</div>
+
+<br />
+
+<p>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 <span class='pagenum'><a name="Page_14" id="Page_14">[14]</a></span>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.</p>
+
+<p><i>Display</i> 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."</p>
+
+<p>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
+<span class='pagenum'><a name="Page_15" id="Page_15">[15]</a></span>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.</p>
+
+<p>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.</p>
+
+<p><i>Commerce</i> 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&mdash;maritime quarantine&mdash;date from the same
+year, 1348 <span class="sc">A.D.</span>; the former in the foremost German <span class='pagenum'><a name="Page_16" id="Page_16">[16]</a></span>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.</p>
+
+<br />
+
+<p class="cen sc">Table II</p>
+
+<p class="cen sc">Cost in Life Capital of Preventable Diseases<a name="FNanchor_2_2" id="FNanchor_2_2"></a><a href="#Footnote_2_2" class="fnanchor">[2]</a></p>
+
+<br />
+
+<div class="centered">
+<table border="0" cellpadding="2" cellspacing="0" width="80%" summary="Table 2: Cost in Life Capital of Preventable Diseases">
+  <tr>
+  <td width="15%" class="tdctrb">Age</td>
+  <td width="15%" class="tdctrlb">Estimated Value of Human Life</td>
+  <td width="70%" class="tdctlb" style="padding-right: .5em; padding-left: .5em;">Multiply by the number of deaths for each age group to learn the cost in life
+    capital to your community in loss of life from one or all preventable diseases.</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; border-top: 1px solid black; padding-top: .5em;"> &nbsp;&nbsp;0-&nbsp;&nbsp;5 years</td>
+  <td class="tdcrl" style="border-top: 1px solid black; padding-top: .5em;">$1,500</td>
+  <td class="tdcl" style="border-top: 1px solid black; padding-top: .5em;">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black;"> &nbsp;&nbsp;5-10 years</td>
+  <td class="tdcrl">&nbsp;&nbsp;2,300</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; white-space: nowrap;">10-15 years</td>
+  <td class="tdcrl">&nbsp;&nbsp;2,500</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black;">15-20 years</td>
+  <td class="tdcrl">&nbsp;&nbsp;3,000</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black;">20-25 years</td>
+  <td class="tdcrl">&nbsp;&nbsp;5,000</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black;">25-30 years</td>
+  <td class="tdcrl">&nbsp;&nbsp;7,500</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black;">30-35 years</td>
+  <td class="tdcrl">&nbsp;&nbsp;7,000</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black;">35-40 years</td>
+  <td class="tdcrl">&nbsp;&nbsp;6,000</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black;">40-45 years</td>
+  <td class="tdcrl">&nbsp;&nbsp;5,500</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black;">45-50 years</td>
+  <td class="tdcrl">&nbsp;&nbsp;5,000</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black;">50-55 years</td>
+  <td class="tdcrl">&nbsp;&nbsp;4,500</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black;">55-60 years</td>
+  <td class="tdcrl">&nbsp;&nbsp;4,500</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black;">60-65 years</td>
+  <td class="tdcrl">&nbsp;&nbsp;2,000</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black;">65-70 years</td>
+  <td class="tdcrl">&nbsp;&nbsp;1,000</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; border-bottom: 2pt solid black; padding-bottom: .5em; white-space: nowrap;">70- &nbsp;&nbsp;&nbsp;&nbsp;years</td>
+  <td class="tdcrl" style="border-bottom: 2pt solid black; padding-bottom: .5em;">&nbsp;&nbsp;1,000</td>
+  <td class="tdcl" style="border-bottom: 2pt solid black; padding-bottom: .5em;">&nbsp;</td>
+  </tr>
+</table>
+</div>
+
+<br />
+
+<p><span class='pagenum'><a name="Page_17" id="Page_17">[17]</a></span><i>Anti-nuisance</i> 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 <span class='pagenum'><a name="Page_18" id="Page_18">[18]</a></span>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.</p>
+
+<p><i>Anti-slum</i> 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 <span class='pagenum'><a name="Page_19" id="Page_19">[19]</a></span>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.</p>
+
+<div class="img">
+<a href="images/imagep019.jpg">
+<img border="0" src="images/imagep019.jpg" width="80%" alt="A Country Menace To City Health" /></a><br />
+<p class="cen" style="margin-top: .2em;">A COUNTRY MENACE TO CITY HEALTH</p>
+</div>
+
+<p><i>Pro-slum</i> 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 <span class='pagenum'><a name="Page_20" id="Page_20">[20]</a></span>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.</p>
+
+<p><i>Rights</i> 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; <span class='pagenum'><a name="Page_21" id="Page_21">[21]</a></span>a probation law takes the place of the friendly
+visitor to the county jail.</p>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_22" id="Page_22">[22]</a></span>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.</p>
+
+<p>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.</p>
+
+<br />
+<hr style="width: 15%;" />
+<br />
+
+<h4>FOOTNOTES:</h4>
+
+<div class="footnote"><p class="noin"><a name="Footnote_1_1" id="Footnote_1_1"></a><a href="#FNanchor_1_1"><span class="label">[1]</span></a> Prepared by Dr. John S. Fulton, secretary of the state
+board of health, Maryland, and quoted by Dr. George C. Whipple in
+<i>Typhoid Fever</i>.</p></div>
+
+<div class="footnote"><p class="noin"><a name="Footnote_2_2" id="Footnote_2_2"></a><a href="#FNanchor_2_2"><span class="label">[2]</span></a> Marshall O. Leighton, quoted in Whipple's <i>Typhoid
+Fever</i>.</p></div>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_III" id="CHAPTER_III"></a><hr />
+<span class='pagenum'><a name="Page_23" id="Page_23">[23]</a></span><br />
+
+<h3>CHAPTER III<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>WHAT HEALTH RIGHTS ARE NOT ENFORCED IN YOUR COMMUNITY?</h4>
+<br />
+
+<p>Laws define rights. Men enforce them. For definitions we go to books.
+For record of enforcement we go to acts and to conditions.<a name="FNanchor_3_3" id="FNanchor_3_3"></a><a href="#Footnote_3_3" class="fnanchor">[3]</a> 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.</p>
+
+<p>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.</p>
+
+<div class="img"><span class='pagenum'><a name="Page_24" id="Page_24">[24]</a></span>
+<a href="images/imagep024.jpg">
+<img border="0" src="images/imagep024.jpg" width="80%" alt="A Dairy Inspector's Outfit" /></a><br />
+<p class="cen" style="margin-top: .2em;">A DAIRY INSPECTOR'S OUTFIT</p>
+</div>
+
+<p>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 <span class='pagenum'><a name="Page_25" id="Page_25">[25]</a></span>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.</p>
+
+<p>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).</p>
+
+
+<br />
+
+<p class="cen sc">Table III<span class='pagenum'><a name="Page_26" id="Page_26">[26]</a></span></p>
+
+<p class="cen fakesc">MILK INSPECTION WITHIN NEW YORK CITY, 1906</p>
+
+<br />
+
+<div class="centered">
+<table border="0" cellpadding="0" cellspacing="0" width="80%" summary="Table 3: Milk Inspection within New York City, 1906">
+  <tr>
+  <td width="60%" class="tdctrb" rowspan="2">&nbsp;</td>
+  <td colspan="2" class="tdctrlb">New York</td>
+  <td colspan="2" class="tdctlb">Each borough</td>
+  </tr>
+  <tr>
+  <td width="10%" class="tdctrlb" style="border-top: 1px solid black;">Stores</td>
+  <td width="10%" class="tdctrlb" style="border-top: 1px solid black;">Wagons</td>
+  <td width="10%" class="tdctrlb" style="border-top: 1px solid black;">Stores</td>
+  <td width="10%" class="tdctlb" style="border-top: 1px solid black;">Wagons</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; border-top: 1px solid black; padding-top: .5em;">FIELD</td>
+  <td class="tdcrl" style="border-top: 1px solid black; padding-top: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="border-top: 1px solid black; padding-top: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="border-top: 1px solid black; padding-top: .5em;">&nbsp;</td>
+  <td class="tdcl" style="border-top: 1px solid black; padding-top: .5em;">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Permits issued during 1906</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Permits revoked during 1906</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 2em;">For discontinuance of selling</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 2em;">For violation of law</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Average permits in force in 1906</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-top: 1em;">INSPECTION</td>
+  <td class="tdcrl" style="padding-top: 1em;">&nbsp;</td>
+  <td class="tdcrl" style="padding-top: 1em;">&nbsp;</td>
+  <td class="tdcrl" style="padding-top: 1em;">&nbsp;</td>
+  <td class="tdcl" style="padding-top: 1em;">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Regular inspections</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Inspections at receiving stations</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Total</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; font-weight: bold; padding-left: 1.5em;">Average inspections per permit per year</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Specimens examined</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Samples taken</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-top: 1em;">CONDITIONS FOUND</td>
+  <td class="tdcrl" style="padding-top: 1em;">&nbsp;</td>
+  <td class="tdcrl" style="padding-top: 1em;">&nbsp;</td>
+  <td class="tdcrl" style="padding-top: 1em;">&nbsp;</td>
+  <td class="tdcl" style="padding-top: 1em;">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; font-weight: bold; padding-left: 1.5em;">Inspections finding milk above 50&deg;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; font-weight: bold; padding-left: 1.5em;">% of such discoveries to total inspections</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; font-weight: bold; padding-left: 1.5em;">Inspections finding adulteration</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 2em;">Warning given</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 2em;">Prosecuted</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; font-weight: bold; padding-left: 1.5em;">% of adulterations found to inspections</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-top: .25em; padding-left: 1.5em;">Rooms connected contrary to sanitary code</td>
+  <td class="tdcrl" style="padding-top: .25em;">&nbsp;</td>
+  <td class="tdcrl" style="padding-top: .25em;">&nbsp;</td>
+  <td class="tdcrl" style="padding-top: .25em;">&nbsp;</td>
+  <td class="tdcl" style="padding-top: .25em;">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Ice box badly drained</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Ice box unclean</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Store unclean</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Utensils unclean</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Milk not properly cooled</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Infectious disease</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-top: .25em; padding-left: 1.5em;">Persons found selling without permit</td>
+  <td class="tdcrl" style="padding-top: .25em;">&nbsp;</td>
+  <td class="tdcrl" style="padding-top: .25em;">&nbsp;</td>
+  <td class="tdcrl" style="padding-top: .25em;">&nbsp;</td>
+  <td class="tdcl" style="padding-top: .25em;">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-top: 1em;">ACTION TAKEN</td>
+  <td class="tdcrl" style="padding-top: 1em;">&nbsp;</td>
+  <td class="tdcrl" style="padding-top: 1em;">&nbsp;</td>
+  <td class="tdcrl" style="padding-top: 1em;">&nbsp;</td>
+  <td class="tdcl" style="padding-top: 1em;">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-top: .5em; font-size: 80%; padding-left: 1em;">DESTRUCTION OF MILK</td>
+  <td class="tdcrl" style="padding-top: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="padding-top: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="padding-top: .5em;">&nbsp;</td>
+  <td class="tdcl" style="padding-top: .5em;">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Lots of milk destroyed for being over 50&deg;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Quarts so destroyed</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em; font-weight: bold;">Lots of milk destroyed for being sour</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Quarts so destroyed</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em; font-weight: bold;">Lots of milk destroyed for being otherwise adulterated</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Quarts so destroyed</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Total quarts destroyed</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-top: .5em; font-size: 80%; padding-left: 1em;">NOTICES ISSUED</td>
+  <td class="tdcrl" style="padding-top: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="padding-top: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="padding-top: .5em;">&nbsp;</td>
+  <td class="tdcl" style="padding-top: .5em;">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">To drain and clean ice box</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">To clean store</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-top: .5em; font-size: 80%; padding-left: 1em;">CRIMINAL ACTIONS BEGUN</td>
+  <td class="tdcrl" style="padding-top: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="padding-top: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="padding-top: .5em;">&nbsp;</td>
+  <td class="tdcl" style="padding-top: .5em;">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">For selling adulterated milk</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">For selling without permit</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">For interference with inspector</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; border-bottom: 2px solid black; padding-bottom: .5em; padding-left: 1.5em;">Total</td>
+  <td class="tdcrl" style="border-bottom: 2px solid black; padding-bottom: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="border-bottom: 2px solid black; padding-bottom: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="border-bottom: 2px solid black; padding-bottom: .5em;">&nbsp;</td>
+  <td class="tdcl" style="border-bottom: 2px solid black; padding-bottom: .5em;">&nbsp;</td>
+  </tr>
+</table>
+</div>
+
+<br />
+<span class='pagenum'><a name="Page_27" id="Page_27">[27]</a></span><br />
+
+<p class="cen sc">Table IV</p>
+
+<br />
+
+<div class="block2">
+
+<p class="right">Perfect Score 100%<br />
+Score allowed ...%</p>
+
+<p class="noin">File No............</p>
+
+<h2>DEPARTMENT OF HEALTH</h2>
+<h5>(Thirteen items are here omitted)</h5>
+
+<p><span class="ltext"><b>Dairy Inspection</b></span> <span class="rtext"><b>Division of Inspections</b></span></p>
+
+<div class="block">
+<p class="hang">1 &nbsp;Inspection No. <span style="white-space: nowrap;">.........</span> &nbsp;&nbsp;&nbsp;&nbsp;Time <span style="white-space: nowrap;">.........</span> A. P. M. &nbsp;&nbsp;&nbsp;&nbsp;Date <span style="white-space: nowrap;">......</span> 190</p>
+<p class="hang">2 &nbsp;All persons in the households of those engaged in producing or handling
+   milk are <span style="white-space: nowrap;">.........</span> free from all infectious disease <span style="white-space: nowrap;">.........</span></p>
+<p class="hang">3 &nbsp;Date and nature of last case on farm <span style="white-space: nowrap;">.........</span></p>
+<p class="hang">4 &nbsp;A sample of the water supply on this farm taken for analysis <span style="white-space: nowrap;">.........</span>
+   190... and found to be <span style="white-space: nowrap;">.........</span></p>
+</div>
+</div>
+
+<br />
+
+<div class="centered">
+<table border="0" cellpadding="2" cellspacing="0" width="90%" summary="Table 4: Dairy Inspection Tally card">
+  <tr>
+  <td width="80%" class="tdctrb" style="font-size: 110%; font-weight: bold;">STABLE</td>
+  <td width="10%" class="tdctrlb">Perfect</td>
+  <td width="10%" class="tdctlb">Allow</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black; border-top: 1px solid black; padding-top: .5em;">&nbsp;&nbsp;5
+  &nbsp;<span style="font-weight: bold;">COW STABLE</span> is <span style="white-space: nowrap;">......</span> located on
+  elevated ground with no stagnant water, hog pen, or privy within 100 feet</td>
+  <td class="tdcrl vab" style="border-top: 1px solid black; padding-top: .5em;">1</td>
+  <td class="tdcl vab" style="border-top: 1px solid black; padding-top: .5em;">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">&nbsp;&nbsp;6 &nbsp;<span style="font-weight: bold;">FLOORS</span>
+  are <span style="white-space: nowrap;">......</span> constructed of concrete or some nonabsorbent material</td>
+  <td class="tdcrl vab">1</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">&nbsp;&nbsp;7 &nbsp;Floors are
+  <span style="white-space: nowrap;">......</span> properly graded and water-tight</td>
+  <td class="tdcrl vab">2</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">&nbsp;&nbsp;8
+  &nbsp;<span style="font-weight: bold;">DROPS</span> are <span style="white-space: nowrap;">......</span>
+  constructed of concrete, stone, or some nonabsorbent material</td>
+  <td class="tdcrl vab">2</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">&nbsp;&nbsp;9 &nbsp;Drops are
+  <span style="white-space: nowrap;">......</span> water-tight</td>
+  <td class="tdcrl vab">2</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">10
+  &nbsp;<span style="font-weight: bold;">FEEDING TROUGHS</span>, platforms, or cribs are ...
+   well lighted and clean</td>
+  <td class="tdcrl vab">1</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">11
+   &nbsp;<span style="font-weight: bold;">CEILING</span> is constructed of
+  <span style="white-space: nowrap;">......</span> and is <span style="white-space: nowrap;">......</span>
+   tight and dust proof</td>
+  <td class="tdcrl vab">2</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">12 &nbsp;Ceiling is
+   <span style="white-space: nowrap;">......</span> free from hanging straw, dirt, or cobwebs</td>
+  <td class="tdcrl vab">1</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">13
+   &nbsp;<span style="font-weight: bold;">NUMBER OF WINDOWS</span>
+   <span style="white-space: nowrap;">......</span> total square feet ... which is
+   <span style="white-space: nowrap;">......</span> sufficient</td>
+  <td class="tdcrl vab">2</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">14 &nbsp;Window panes are
+  <span style="white-space: nowrap;">......</span> washed and kept clean</td>
+  <td class="tdcrl vab">1</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">15
+   &nbsp;<span style="font-weight: bold;">VENTILATION</span> consists of
+   <span style="white-space: nowrap;">......</span> which is sufficient 3, fair 1, insufficient 0</td>
+  <td class="tdcrl vab">3</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">16
+   &nbsp;<span style="font-weight: bold;">AIR SPACE</span> is
+   <span style="white-space: nowrap;">......</span> cubic feet per cow which is
+   <span style="white-space: nowrap;">......</span> sufficient (600 and over&mdash;3) (500 to
+   600&mdash;2) (400 to 500&mdash;1) (under 400&mdash;0)</td>
+  <td class="tdcrl vab">3</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">17
+   &nbsp;<span style="font-weight: bold;">INTERIOR</span> of stable painted or whitewashed on
+   <span style="white-space: nowrap;">......</span> which is satisfactory 2, fair 1, never 0</td>
+  <td class="tdcrl vab">2</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">18 &nbsp;<span style="font-weight: bold;">WALLS
+   AND LEDGES</span> are <span style="white-space: nowrap;">......</span> free from dirt, dust, manure, or cobwebs</td>
+  <td class="tdcrl vab">2</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">19 &nbsp;<span style="font-weight: bold;">FLOORS
+   AND PREMISES</span> are <span style="white-space: nowrap;">......</span> free from dirt,
+   rubbish, or decayed animal or vegetable matter</td>
+  <td class="tdcrl vab">1</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">20 &nbsp;<span style="font-weight: bold;">COW BEDS</span> are
+   <span style="white-space: nowrap;">......</span> clean</td>
+  <td class="tdcrl vab">1</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">21 &nbsp;<span style="font-weight: bold;">LIVE
+   STOCK</span>, other than cows, are <span style="white-space: nowrap;">......</span> excluded
+   from rooms in which milch cows are kept</td>
+  <td class="tdcrl vab">2</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">22 &nbsp;There is
+   <span style="white-space: nowrap;">......</span> direct opening from barn into
+   silo or grain pit</td>
+  <td class="tdcrl vab">1</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">23
+  &nbsp;<span style="font-weight: bold;">BEDDING</span> used is
+  <span style="white-space: nowrap;">......</span> clean, dry, and absorbent</td>
+  <td class="tdcrl vab">1</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">24 &nbsp;<span style="font-weight: bold;">SEPARATE BUILDING</span> is <span style="white-space: nowrap;">......</span> provided for cows
+   when sick</td>
+  <td class="tdcrl vab">1</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">25 &nbsp;Separate quarters are <span style="white-space: nowrap;">......</span> provided for cows
+   when calving</td>
+  <td class="tdcrl vab">1</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">26 &nbsp;<span style="font-weight: bold;">MANURE</span> is <span style="white-space: nowrap;">......</span> removed daily to at least 200
+   feet from the barn ( ... ft.)</td>
+  <td class="tdcrl vab">2</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">27 &nbsp;Manure pile is <span style="white-space: nowrap;">......</span> so located that the cows
+   cannot get at it</td>
+  <td class="tdcrl vab">1</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">28 &nbsp;<span style="font-weight: bold;">LIQUID MATTER</span> is <span style="white-space: nowrap;">......</span> absorbed and removed
+   daily and <span style="white-space: nowrap;">......</span> allowed to overflow and saturate ground under or around cow barn</td>
+  <td class="tdcrl vab">2</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">29 &nbsp;<span style="font-weight: bold;">RUNNING WATER</span> supply for washing stables is
+   <span style="white-space: nowrap;">......</span> located within building</td>
+  <td class="tdcrl vab">1</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">30 &nbsp;<span style="font-weight: bold;">DAIRY RULES</span> of the Department of Health are
+   <span style="white-space: nowrap;">......</span> posted</td>
+  <td class="tdcrl vab">1</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdc" style="border-right: 1px solid black; padding-top: 1em; font-size: 110%; font-weight: bold;">COW YARD</td>
+  <td class="tdcrl vab" style="padding-top: 1em;">&nbsp;</td>
+  <td class="tdcl vab" style="padding-top: 1em;">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">31 &nbsp;<span style="font-weight: bold;">COW YARD</span> is <span style="white-space: nowrap;">......</span> properly graded and drained</td>
+  <td class="tdcrl vab">1</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">32 &nbsp;Cow yard is <span style="white-space: nowrap;">......</span> clean, dry, and free from
+   manure</td>
+  <td class="tdcrl vab">2</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdc" style="border-right: 1px solid black; padding-top: 1em; font-size: 110%; font-weight: bold;"><span class='pagenum'><a name="Page_28" id="Page_28">[28]</a></span>COWS</td>
+  <td class="tdcrl vab" style="padding-top: 1em;">&nbsp;</td>
+  <td class="tdcl vab" style="padding-top: 1em;">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">33 &nbsp;<span style="font-weight: bold;">COWS</span> have <span style="white-space: nowrap;">......</span> been examined by veterinarian ...
+   Date  <span style="white-space: nowrap;">......</span> 190  Report was</td>
+  <td class="tdcrl vab">3</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">34 &nbsp;Cows have <span style="white-space: nowrap;">......</span> been tested by tuberculin, and
+   all tuberculous cows removed</td>
+  <td class="tdcrl vab">5</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">35 &nbsp;Cows are <span style="white-space: nowrap;">......</span> all in good flesh and condition
+   at time of inspection</td>
+  <td class="tdcrl vab">2</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">36 &nbsp;Cows are <span style="white-space: nowrap;">......</span> all free from clinging manure and
+   dirt. (No. dirty ... )</td>
+  <td class="tdcrl vab">4</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">37 &nbsp;<span style="font-weight: bold;">LONG HAIRS</span> are <span style="white-space: nowrap;">......</span> kept short on belly, flanks,
+   udder, and tail</td>
+  <td class="tdcrl vab">1</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">38 &nbsp;<span style="font-weight: bold;">UDDER AND TEATS</span> of cows are <span style="white-space: nowrap;">......</span> thoroughly
+   cleaned before milking</td>
+  <td class="tdcrl vab">2</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">39 &nbsp;<span style="font-weight: bold;">ALL FEED</span> is <span style="white-space: nowrap;">......</span> of good quality and all grain
+   and coarse fodders are <span style="white-space: nowrap;">......</span> free from dirt and mold</td>
+  <td class="tdcrl vab">1</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">40 &nbsp;<span style="font-weight: bold;">DISTILLERY</span> waste or any substance in a state
+   of fermentation or putrefaction is <span style="white-space: nowrap;">......</span> fed</td>
+  <td class="tdcrl vab">1</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">41 &nbsp;<span style="font-weight: bold;">WATER SUPPLY</span> for cows is <span style="white-space: nowrap;">......</span> unpolluted and
+   plentiful</td>
+  <td class="tdcrl vab">2</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdc" style="border-right: 1px solid black; padding-top: 1em; font-size: 110%; font-weight: bold;">MILKERS AND MILKING</td>
+  <td class="tdcrl vab" style="padding-top: 1em;">&nbsp;</td>
+  <td class="tdcl vab" style="padding-top: 1em;">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">42 &nbsp;<span style="font-weight: bold;">ATTENDANTS</span> are <span style="white-space: nowrap;">......</span> in good physical condition</td>
+  <td class="tdcrl vab">1</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">43 &nbsp;Special Milking Suits are <span style="white-space: nowrap;">......</span> used</td>
+  <td class="tdcrl vab">1</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">44 &nbsp;Clothing of milkers is <span style="white-space: nowrap;">......</span> clean</td>
+  <td class="tdcrl vab">1</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">45 &nbsp;Hands of milkers are <span style="white-space: nowrap;">......</span> washed clean before
+   milking</td>
+  <td class="tdcrl vab">1</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">46 &nbsp;<span style="font-weight: bold;">MILKING</span> is <span style="white-space: nowrap;">......</span> done with dry hands</td>
+  <td class="tdcrl vab">2</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">47 &nbsp;<span style="font-weight: bold;">FORE MILK</span> or first few streams from each teat
+   is <span style="white-space: nowrap;">......</span> discarded</td>
+  <td class="tdcrl vab">2</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">48 &nbsp;Milk is strained at <span style="white-space: nowrap;">......</span> and <span style="white-space: nowrap;">......</span> in clean
+   atmosphere</td>
+  <td class="tdcrl vab">1</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">49 &nbsp;Milk strainer is <span style="white-space: nowrap;">......</span> clean</td>
+  <td class="tdcrl vab">1</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">50 &nbsp;<span style="font-weight: bold;">MILK</span> is <span style="white-space: nowrap;">......</span> cooled to below 50&deg; F. within two
+   hours after milking and kept below 50&deg; F. until delivered to the creamery <span style="white-space: nowrap;">......</span> &deg;</td>
+  <td class="tdcrl vab">2</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">51 &nbsp;Milk from cows within 15 days before or 5 days
+   after parturition is <span style="white-space: nowrap;">......</span> discarded</td>
+  <td class="tdcrl vab">1</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdc" style="border-right: 1px solid black; padding-top: 1em; font-size: 110%; font-weight: bold;">UTENSILS</td>
+  <td class="tdcrl vab" style="padding-top: 1em;">&nbsp;</td>
+  <td class="tdcl vab" style="padding-top: 1em;">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">52 &nbsp;<span style="font-weight: bold;">MILK PAILS</span> have <span style="white-space: nowrap;">......</span> all seams soldered flush</td>
+  <td class="tdcrl vab">1</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">53 &nbsp;Milk pails are <span style="white-space: nowrap;">......</span> of the small-mouthed design,
+   top opening not exceeding 8 inches in diameter. Diameter <span style="white-space: nowrap;">......</span> </td>
+  <td class="tdcrl vab">2</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">54 &nbsp;Milk pails are <span style="white-space: nowrap;">......</span> rinsed with cold water
+   immediately after using and washed clean with hot water and washing solution</td>
+  <td class="tdcrl vab">2</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">55 &nbsp;Drying racks are <span style="white-space: nowrap;">......</span> provided to expose milk
+   pails to the sun</td>
+  <td class="tdcrl vab">1</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdc" style="border-right: 1px solid black; padding-top: 1em; font-size: 110%; font-weight: bold;">MILK HOUSE</td>
+  <td class="tdcrl vab" style="padding-top: 1em;">&nbsp;</td>
+  <td class="tdcl vab" style="padding-top: 1em;">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">56 &nbsp;<span style="font-weight: bold;">MILK HOUSE</span> is <span style="white-space: nowrap;">......</span> located on elevated ground
+   with no hog pen, manure pile, or privy within 100 feet</td>
+  <td class="tdcrl vab">1</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">57 &nbsp;Milk house has <span style="white-space: nowrap;">......</span> direct communication with
+    <span style="white-space: nowrap;">......</span> building</td>
+  <td class="tdcrl vab">1</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">58 &nbsp;Milk house has <span style="white-space: nowrap;">......</span> sufficient light and
+   ventilation</td>
+  <td class="tdcrl vab">1</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">59 &nbsp;Floor is <span style="white-space: nowrap;">......</span> properly graded and water-tight</td>
+  <td class="tdcrl vab">1</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">60 &nbsp;Milk house is <span style="white-space: nowrap;">......</span> free from dirt, rubbish, and all material not used in the handling and storage of milk</td>
+  <td class="tdcrl vab">1</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">61 &nbsp;Milk house has <span style="white-space: nowrap;">......</span> running or still supply of
+   pure clean water</td>
+  <td class="tdcrl vab">1</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">62 &nbsp;Ice is <span style="white-space: nowrap;">......</span> used for cooling milk and is cut from ...</td>
+  <td class="tdcrl vab">1</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdc" style="border-right: 1px solid black; padding-top: 1em; font-size: 110%; font-weight: bold;">WATER</td>
+  <td class="tdcrl vab" style="padding-top: 1em;">&nbsp;</td>
+  <td class="tdcl vab" style="padding-top: 1em;">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">63 &nbsp;<span style="font-weight: bold;">WATER SUPPLY</span> for utensils is from a <span style="white-space: nowrap;">......</span> located
+    <span style="white-space: nowrap;">......</span> feet deep and apparently is <span style="white-space: nowrap;">......</span> pure, wholesome, and uncontaminated</td>
+  <td class="tdcrl vab">5</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">64 &nbsp;Is <span style="white-space: nowrap;">......</span> protected against flood or surface
+   drainage</td>
+  <td class="tdcrl vab">2</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">65 &nbsp;There is <span style="white-space: nowrap;">......</span> privy or cesspool within 250 feet
+   ( ... feet) of source of water supply</td>
+  <td class="tdcrl vab">2</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black;">66 &nbsp;There is <span style="white-space: nowrap;">......</span> stable, barnyard, or pile of
+   manure or other source of contamination within 200 feet <span style="white-space: nowrap;">( ... feet)</span> of source of water supply</td>
+  <td class="tdcrl vab" style="border-bottom: 1px black solid;">1</td>
+  <td class="tdcl vab">...</td>
+  </tr>
+  <tr>
+  <td class="tdlhang" style="border-right: 1px solid black; border-bottom: 2px black solid;">&nbsp;</td>
+  <td class="tdcrl vab" style="border-bottom: 2px black solid;">100</td>
+  <td class="tdcl vab" style="border-bottom: 2px black solid;">&nbsp;</td>
+  </tr>
+</table>
+</div>
+
+<br />
+<br />
+
+<p><span class='pagenum'><a name="Page_29" id="Page_29">[29]</a></span>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&mdash;unpicturesque, unexciting efficiency&mdash;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:</p>
+
+<br />
+
+<p class="cen sc">Table V</p>
+
+<p class="cen sc">Score Card for Citizen Use</p>
+
+<br />
+
+<div class="centered">
+<table border="0" cellpadding="1" cellspacing="0" width="70%" summary="Table 5: Score Card for Citizen Use">
+  <tr>
+  <td width="80%" class="tdctrb">&nbsp;</td>
+  <td width="10%" class="tdctrlb">Perfect</td>
+  <td width="10%" class="tdctlb">Allow</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; border-top: 1px solid black; padding-top: .5em;"><i>Schoolhouse</i></td>
+  <td class="tdcrl" style="border-top: 1px solid black; padding-top: .5em;">&nbsp;</td>
+  <td class="tdcl" style="border-top: 1px solid black; padding-top: .5em;">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Well ventilated, 20; badly, 0-10</td>
+  <td class="tdcrl">&nbsp;&nbsp;20</td>
+  <td class="tdcl">...</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Cleaned regularly, 20; irregularly, 0-10</td>
+  <td class="tdcrl">&nbsp;&nbsp;20</td>
+  <td class="tdcl">...</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Feather duster prohibited, 10</td>
+  <td class="tdcrl">&nbsp;&nbsp;10</td>
+  <td class="tdcl">...</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">No dry sweeping, 10</td>
+  <td class="tdcrl">&nbsp;&nbsp;10</td>
+  <td class="tdcl">...</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Has adequate play space, 10; inadequate, 0-5</td>
+  <td class="tdcrl">&nbsp;&nbsp;10</td>
+  <td class="tdcl">...</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Has clean drinking water, 10</td>
+  <td class="tdcrl">&nbsp;&nbsp;10</td>
+  <td class="tdcl">...</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Has clean outbuildings and toilet, 20: unclean, 0-10</td>
+  <td class="tdcrl" style="border-bottom: 1px solid black;">&nbsp;&nbsp;20</td>
+  <td class="tdcl">...</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">&nbsp;</td>
+  <td class="tdcrl">100</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black;"><i>Church and Sunday School</i></td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Well ventilated, 20; badly, 0-10</td>
+  <td class="tdcrl">&nbsp;&nbsp;20</td>
+  <td class="tdcl">...</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Heat evenly distributed, 20; unevenly, 0-10</td>
+  <td class="tdcrl">&nbsp;&nbsp;20</td>
+  <td class="tdcl">...</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Cleaned regularly, 20; irregularly, 0-10</td>
+  <td class="tdcrl">&nbsp;&nbsp;20</td>
+  <td class="tdcl">...</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Without carpets, 20</td>
+  <td class="tdcrl">&nbsp;&nbsp;20</td>
+  <td class="tdcl">...</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Without plush seats, 20</td>
+  <td class="tdcrl" style="border-bottom: 1px solid black;">&nbsp;&nbsp;20</td>
+  <td class="tdcl">...</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">&nbsp;</td>
+  <td class="tdcrl">100</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black;"><i>Streets</i></td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Sewerage underground, 20; surface, 0-10</td>
+  <td class="tdcrl">&nbsp;&nbsp;20</td>
+  <td class="tdcl">...</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">No pools neglected, 10</td>
+  <td class="tdcrl">&nbsp;&nbsp;10</td>
+  <td class="tdcl">...</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">No garbage piled up, 10</td>
+  <td class="tdcrl">&nbsp;&nbsp;10</td>
+  <td class="tdcl">...</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Swept regularly, 20; irregularly, 0-10</td>
+  <td class="tdcrl">&nbsp;&nbsp;20</td>
+  <td class="tdcl">...</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Sprinkled and flushed, 10</td>
+  <td class="tdcrl">&nbsp;&nbsp;10</td>
+  <td class="tdcl">...</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Has baskets for refuse, 10</td>
+  <td class="tdcrl">&nbsp;&nbsp;10</td>
+  <td class="tdcl">...</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">All districts equally cleaned, 20; unequally, 0-10</td>
+  <td class="tdcrl" style="border-bottom: 1px solid black;">&nbsp;&nbsp;20</td>
+  <td class="tdcl">...</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em; border-bottom: 2px solid black; padding-bottom: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="border-bottom: 2px solid black; padding-bottom: .5em;">100</td>
+  <td class="tdcl" style="border-bottom: 2px solid black; padding-bottom: .5em;">&nbsp;</td>
+  </tr>
+</table>
+</div>
+
+<br />
+<br />
+
+<p><span class='pagenum'><a name="Page_30" id="Page_30">[30]</a></span>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_31" id="Page_31">[31]</a></span>found that conditions that produced the
+disease have been overlooked and neglected.</p>
+
+<p>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?</p>
+
+<br />
+
+<div class="block"><p>1. Notification of danger when it is first recognized.</p>
+
+<p>2. Registration at a central office of facts as to each dangerous
+thing or person.</p>
+
+<p>3. Examination of the seat of danger to discover its extent, its
+cost, and new seats of danger created by it.</p>
+
+<p>4. Isolation of the dangerous thing or person.</p>
+
+<p>5. Constant attention to prevent extension to other persons or
+things.</p>
+
+<p>6. Destruction or removal of disease germs or other causes of
+danger.</p>
+
+<p>7. Analysis and record, for future use, of lessons learned by
+experience.</p>
+
+<p>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.</p></div>
+
+<br />
+
+<p><span class='pagenum'><a name="Page_32" id="Page_32">[32]</a></span>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.</p>
+
+<div class="img">
+<a href="images/imagep032.jpg">
+<img border="0" src="images/imagep032.jpg" width="80%" alt="The Baby, Not The Law, Is The Test Of Infant Protection In Country And In City" /></a><br />
+<p class="cen" style="margin-top: .2em;">THE BABY, NOT THE LAW, IS THE TEST OF INFANT PROTECTION IN COUNTRY AND IN CITY</p>
+</div>
+
+<p>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.</p>
+
+<br />
+<hr style="width: 15%;" />
+<br />
+
+<h4>FOOTNOTES:</h4>
+
+<div class="footnote"><p class="noin"><a name="Footnote_3_3" id="Footnote_3_3"></a><a href="#FNanchor_3_3"><span class="label">[3]</span></a> A striking demonstration of law enforcement that followed
+lawmaking is given in <i>The Real Triumph of Japan</i>, L.L. Seaman, M.D.</p></div>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_IV" id="CHAPTER_IV"></a><hr />
+<span class='pagenum'><a name="Page_33" id="Page_33">[33]</a></span><br />
+
+<h3>CHAPTER IV<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>THE BEST INDEX TO COMMUNITY HEALTH IS THE PHYSICAL WELFARE OF SCHOOL CHILDREN</h4>
+<br />
+
+<p>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.<a name="FNanchor_4_4" id="FNanchor_4_4"></a><a href="#Footnote_4_4" class="fnanchor">[4]</a></p>
+
+<div class="img"><span class='pagenum'><a name="Page_34" id="Page_34">[34]</a></span>
+<a href="images/imagep034.jpg">
+<img style="border: 1px black solid;" src="images/imagep034.jpg" width="80%" alt="(Facsimile) PHYSICAL RECORD." /></a><br />
+</div>
+
+<p>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 re&euml;xamined for
+<span class='pagenum'><a name="Page_35" id="Page_35">[35]</a></span>the physical signs called for by the card on page 34. Weight, height,
+and measurements are needed to tell the whole story.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_36" id="Page_36">[36]</a></span>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 an&aelig;mic. 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,&mdash;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.</p>
+
+<div class="img">
+<a href="images/imagep036.jpg">
+<img border="0" src="images/imagep036.jpg" width="80%" alt="Looking for Enlarged Tonsils and Bad Teeth" /></a><br />
+<p class="cen" style="margin-top: .2em;">LOOKING FOR ENLARGED TONSILS AND BAD TEETH<br />Note the mouth breather waiting</p>
+</div>
+
+<p>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.</p>
+
+<br />
+
+<p class="cen sc">Table VI<span class='pagenum'><a name="Page_37" id="Page_37">[37]</a></span></p>
+
+<p class="cen sc">Physical Examination of School Children&mdash;performed by the<br />
+Department of Health in the Borough of Manhattan, 1905-1907</p>
+
+<br />
+
+<div class="centered">
+<table border="0" cellpadding="1" cellspacing="0" width="70%" summary="Table 6: Physical Examination of School Children">
+  <tr>
+  <td width="70%" class="tdctrb">&nbsp;</td>
+  <td width="15%" class="tdctrlb">Total</td>
+  <td width="15%" class="tdctlb">Percentage</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; border-top: 1px solid black; padding-top: .5em;">Number of children examined</td>
+  <td class="tdrprl" style="border-top: 1px solid black; padding-top: .5em;">275,641</td>
+  <td class="tdrpl" style="border-top: 1px solid black; padding-top: .5em;">100</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black;">Number of children needing treatment</td>
+  <td class="tdrprl">198,139</td>
+  <td class="tdrpl">71.9</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;"><i>Defects found:</i></td>
+  <td class="tdrprl">&nbsp;</td>
+  <td class="tdrpl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 2em;">Malnutrition</td>
+  <td class="tdrprl">16,021</td>
+  <td class="tdrpl">5.8</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 2em;">Diseased anterior or posterior cervical
+    glands</td>
+  <td class="tdrprl">125,555</td>
+  <td class="tdrpl">45.5</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 2em;">Chorea</td>
+  <td class="tdrprl">3,776</td>
+  <td class="tdrpl">1.3</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 2em;">Cardiac disease</td>
+  <td class="tdrprl">3,385</td>
+  <td class="tdrpl">1.2</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 2em;">Pulmonary disease</td>
+  <td class="tdrprl">2,841</td>
+  <td class="tdrpl">1.0</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 2em;">Skin disease</td>
+  <td class="tdrprl">4,557</td>
+  <td class="tdrpl">1.6</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 2em;">Deformity of spine, chest, or extremities</td>
+  <td class="tdrprl">4,892</td>
+  <td class="tdrpl">1.7</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 2em;">Defective vision</td>
+  <td class="tdrprl">58,494</td>
+  <td class="tdrpl">21.2</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 2em;">Defective hearing</td>
+  <td class="tdrprl">3,540</td>
+  <td class="tdrpl">1.2</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 2em;">Obstructed nasal breathing</td>
+  <td class="tdrprl">43,613</td>
+  <td class="tdrpl">15.8</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 2em;">Defective teeth</td>
+  <td class="tdrprl">136,146</td>
+  <td class="tdrpl">49.0</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 2em;">Deformed palate</td>
+  <td class="tdrprl">3,625</td>
+  <td class="tdrpl">1.3</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 2em;">Hypertrophied tonsils</td>
+  <td class="tdrprl">75,431</td>
+  <td class="tdrpl">27.4</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 2em;">Posterior nasal growths</td>
+  <td class="tdrprl">46,631</td>
+  <td class="tdrpl">16.9</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; border-bottom: 2px solid black; padding-bottom: .5em; padding-left: 2em;">Defective mentality</td>
+  <td class="tdrprl" style="border-bottom: 2px solid black; padding-bottom: .5em;">7,090</td>
+  <td class="tdrpl" style="border-bottom: 2px solid black; padding-bottom: .5em;">2.5</td>
+  </tr>
+</table>
+</div>
+
+<br />
+<br />
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_38" id="Page_38">[38]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_39" id="Page_39">[39]</a></span>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.</p>
+
+<br />
+
+<p class="cen sc">Table VII</p>
+
+<p class="cen sc">Showing Per Cent Share of Physical Defects of Children,<br />
+Unfavorable Housing Conditions, and Child Mortality<br />
+found among each Family-income Group</p>
+
+<br />
+
+<div class="centered">
+<table border="0" cellpadding="2" cellspacing="0" width="95%" summary="Table 7: Showing Per Cent Share of Physical Defects of Children">
+  <tr>
+  <td width="44%" rowspan="3" class="tdctrb">&nbsp;</td>
+  <td class="tdctlb" colspan="7"><span class="sc">Weekly Family Income</span></td>
+  </tr>
+  <tr>
+  <td width="8%" class="tdctrlb" style="border-top: 1px black solid;">$0-10</td>
+  <td width="8%" class="tdctrlb" style="border-top: 1px black solid;">$10-15</td>
+  <td width="8%" class="tdctrlb" style="border-top: 1px black solid;">$16-19</td>
+  <td width="8%" class="tdctrlb" style="border-top: 1px black solid;">$20-25</td>
+  <td width="8%" class="tdctrlb" style="border-top: 1px black solid;">$25-29</td>
+  <td width="8%" class="tdctrlb" style="border-top: 1px black solid;">$30 and over</td>
+  <td width="8%" class="tdctlb" style="border-top: 1px black solid;">$100</td>
+  </tr>
+  <tr>
+  <td class="tdctrlb" style="border-top: 1px black solid;">%</td>
+  <td class="tdctrlb" style="border-top: 1px black solid;">%</td>
+  <td class="tdctrlb" style="border-top: 1px black solid;">%</td>
+  <td class="tdctrlb" style="border-top: 1px black solid;">%</td>
+  <td class="tdctrlb" style="border-top: 1px black solid;">%</td>
+  <td class="tdctrlb" style="border-top: 1px black solid;">%</td>
+  <td class="tdctlb" style="border-top: 1px black solid;">%</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; border-top: 1px solid black; padding-top: .5em;">Proportion to total families</td>
+  <td class="tdcrl" style="border-top: 1px solid black; padding-top: .5em;">&nbsp;&nbsp;8.4</td>
+  <td class="tdcrl" style="border-top: 1px solid black; padding-top: .5em;">32.7</td>
+  <td class="tdcrl" style="border-top: 1px solid black; padding-top: .5em;">15.2</td>
+  <td class="tdcrl" style="border-top: 1px solid black; padding-top: .5em;">23.8</td>
+  <td class="tdcrl" style="border-top: 1px solid black; padding-top: .5em;">&nbsp;&nbsp;3.9</td>
+  <td class="tdcrl" style="border-top: 1px solid black; padding-top: .5em;">15.6</td>
+  <td class="tdcl" style="border-top: 1px solid black; padding-top: .5em;">100</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black;"><i>Physical defects</i>:</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Malnutrition</td>
+  <td class="tdcrl">13.8</td>
+  <td class="tdcrl">43.4</td>
+  <td class="tdcrl">12.4</td>
+  <td class="tdcrl">17.9</td>
+  <td class="tdcrl">&nbsp;&nbsp;3.4</td>
+  <td class="tdcrl">&nbsp;&nbsp;9.&nbsp;&nbsp;</td>
+  <td class="tdcl">"</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Enlarged glands</td>
+  <td class="tdcrl">&nbsp;&nbsp;8.6</td>
+  <td class="tdcrl">37.4</td>
+  <td class="tdcrl">14.6</td>
+  <td class="tdcrl">22.6</td>
+  <td class="tdcrl">&nbsp;&nbsp;3.6</td>
+  <td class="tdcrl">13.2</td>
+  <td class="tdcl">"</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Defective breathing</td>
+  <td class="tdcrl">&nbsp;&nbsp;9.6</td>
+  <td class="tdcrl">32.3</td>
+  <td class="tdcrl">15.5</td>
+  <td class="tdcrl">24.4</td>
+  <td class="tdcrl">&nbsp;&nbsp;2.8</td>
+  <td class="tdcrl">15.4</td>
+  <td class="tdcl">"</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Bad teeth</td>
+  <td class="tdcrl">&nbsp;&nbsp;8.1</td>
+  <td class="tdcrl">32.2</td>
+  <td class="tdcrl">15.3</td>
+  <td class="tdcrl">24.5</td>
+  <td class="tdcrl">&nbsp;&nbsp;4.8</td>
+  <td class="tdcrl">15.1</td>
+  <td class="tdcl">"</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Defective vision</td>
+  <td class="tdcrl">&nbsp;&nbsp;8.2</td>
+  <td class="tdcrl">34.6</td>
+  <td class="tdcrl">16.5</td>
+  <td class="tdcrl">22.1</td>
+  <td class="tdcrl">&nbsp;&nbsp;1.4</td>
+  <td class="tdcrl">17.3</td>
+  <td class="tdcl">"</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black;"><i>Unfavorable housing conditions</i>:</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Dark rooms</td>
+  <td class="tdcrl">&nbsp;&nbsp;8.2</td>
+  <td class="tdcrl">35.4</td>
+  <td class="tdcrl">18.1</td>
+  <td class="tdcrl">18.4</td>
+  <td class="tdcrl">&nbsp;&nbsp;3.8</td>
+  <td class="tdcrl">15.9</td>
+  <td class="tdcl">"</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Closed air shaft</td>
+  <td class="tdcrl">&nbsp;&nbsp;6.9</td>
+  <td class="tdcrl">30.2</td>
+  <td class="tdcrl">18.9</td>
+  <td class="tdcrl">26.4</td>
+  <td class="tdcrl">&nbsp;&nbsp;3.2</td>
+  <td class="tdcrl">19.6</td>
+  <td class="tdcl">"</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">No baths</td>
+  <td class="tdcrl">10.1</td>
+  <td class="tdcrl">38.5</td>
+  <td class="tdcrl">16.5</td>
+  <td class="tdcrl">19.7</td>
+  <td class="tdcrl">&nbsp;&nbsp;4.4</td>
+  <td class="tdcrl">10.8</td>
+  <td class="tdcl">"</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Paying over 25% rent</td>
+  <td class="tdcrl">&nbsp;&nbsp;8.6</td>
+  <td class="tdcrl">27.6</td>
+  <td class="tdcrl">21.7</td>
+  <td class="tdcrl">14.7</td>
+  <td class="tdcrl">...</td>
+  <td class="tdcrl">27.6</td>
+  <td class="tdcl">"</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black;"><i>Child Mortality</i>:</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Families losing children</td>
+  <td class="tdcrl">10.3</td>
+  <td class="tdcrl">35.5</td>
+  <td class="tdcrl">14.7</td>
+  <td class="tdcrl">20.5</td>
+  <td class="tdcrl">&nbsp;&nbsp;5.4</td>
+  <td class="tdcrl">13.6</td>
+  <td class="tdcl">"</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Families losing no children</td>
+  <td class="tdcrl">&nbsp;&nbsp;6.4</td>
+  <td class="tdcrl">30.1</td>
+  <td class="tdcrl">15.7</td>
+  <td class="tdcrl">26.9</td>
+  <td class="tdcrl">&nbsp;&nbsp;2.4</td>
+  <td class="tdcrl">18.6</td>
+  <td class="tdcl">"</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Children dead</td>
+  <td class="tdcrl">11.7</td>
+  <td class="tdcrl">36.2</td>
+  <td class="tdcrl">13.1</td>
+  <td class="tdcrl">20.8</td>
+  <td class="tdcrl">&nbsp;&nbsp;6.1</td>
+  <td class="tdcrl">12.1</td>
+  <td class="tdcl">"</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; padding-left: 1.5em;">Infants dying from intestinal diseases</td>
+  <td class="tdcrl">&nbsp;&nbsp;8.9</td>
+  <td class="tdcrl">37.6</td>
+  <td class="tdcrl">18.3</td>
+  <td class="tdcrl">18.8</td>
+  <td class="tdcrl">&nbsp;&nbsp;4.&nbsp;&nbsp;</td>
+  <td class="tdcrl">12.4</td>
+  <td class="tdcl">"</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border-right: 1px solid black; border-bottom: 2px black solid; padding-bottom: .5em; padding-left: 1.5em;">Children working</td>
+  <td class="tdcrl" style="border-bottom: 2px black solid; padding-bottom: .5em;">&nbsp;&nbsp;4.2</td>
+  <td class="tdcrl" style="border-bottom: 2px black solid; padding-bottom: .5em;">19.5</td>
+  <td class="tdcrl" style="border-bottom: 2px black solid; padding-bottom: .5em;">13.2</td>
+  <td class="tdcrl" style="border-bottom: 2px black solid; padding-bottom: .5em;">30.3</td>
+  <td class="tdcrl" style="border-bottom: 2px black solid; padding-bottom: .5em;">11.5</td>
+  <td class="tdcrl" style="border-bottom: 2px black solid; padding-bottom: .5em;">21.3</td>
+  <td class="tdcl" style="border-bottom: 2px black solid; padding-bottom: .5em;">"</td>
+  </tr>
+</table>
+</div>
+
+<br />
+<br />
+
+<p>The index should be read in all grades from kindergarten to high
+school and college.</p>
+
+<p><span class='pagenum'><a name="Page_40" id="Page_40">[40]</a></span>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&mdash;one of his own daughter, another of his honor girls, a third of
+his honor boys&mdash;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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_41" id="Page_41">[41]</a></span>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.</p>
+
+<p>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,&mdash;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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_42" id="Page_42">[42]</a></span>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,&mdash;the advantage
+of instituting corrective work through democratic machinery such as
+the public school,&mdash;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
+co&ouml;perate 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.</p>
+
+<p>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
+<span class='pagenum'><a name="Page_43" id="Page_43">[43]</a></span>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.</p>
+
+<p>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,&mdash;private, parochial,
+reformatory, public, high, college.</p>
+
+<p>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 <span class='pagenum'><a name="Page_44" id="Page_44">[44]</a></span>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.</p>
+
+<br />
+<hr style="width: 15%;" />
+<br />
+
+<h4>FOOTNOTES:</h4>
+
+<div class="footnote"><p class="noin"><a name="Footnote_4_4" id="Footnote_4_4"></a><a href="#FNanchor_4_4"><span class="label">[4]</span></a> Sir John E. Gorst in <i>The Children of the Nation</i> reads
+the index of the health of school children in the United Kingdom; John
+Spargo, in <i>The Bitter Cry of the Children</i>, and Simon N. Patten in
+<i>The New Basis of Civilization</i>, suggest the necessity for reading the
+index in the United States and for heeding it.</p></div>
+
+<br />
+<br />
+<br />
+<br />
+<a name="PART_II_READING_THE_INDEX_TO_HEALTH_RIGHTS" id="PART_II_READING_THE_INDEX_TO_HEALTH_RIGHTS"></a><a name="CHAPTER_V" id="CHAPTER_V"></a><hr />
+<span class='pagenum'><a name="Page_45" id="Page_45">[45]</a></span><br />
+<br />
+<br />
+<br />
+
+<h2 class="wrap">PART II. READING THE INDEX TO HEALTH RIGHTS</h2>
+
+<br />
+
+<h3>CHAPTER V<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>MOUTH BREATHING</h4>
+<br />
+
+<p>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.</p>
+
+<div class="img"><span class='pagenum'><a name="Page_46" id="Page_46">[46]</a></span>
+<a href="images/imagep046.jpg">
+<img border="0" src="images/imagep046.jpg" width="80%" alt="Mouth Breathers Before &quot;Adenoid Party&quot;" /></a><br />
+<p class="cen" style="margin-top: .2em;">MOUTH BREATHERS BEFORE "ADENOID PARTY"</p>
+</div>
+
+<p>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
+<i>Uncommercial Traveller</i> 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 <span class='pagenum'><a name="Page_47" id="Page_47">[47]</a></span>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."</p>
+
+<p>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?</p>
+
+<div class="img">
+<a href="images/imagep048.jpg">
+<img border="0" src="images/imagep048.jpg" width="80%" alt="A &quot;Degenerate&quot; Made Normal By Removal Of Adenoids" /></a><br />
+<p class="cen" style="margin-top: .2em;">A "DEGENERATE" MADE NORMAL BY REMOVAL OF ADENOIDS</p>
+</div>
+
+<p>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,&mdash;will bump against something, <span class='pagenum'><a name="Page_48" id="Page_48">[48]</a></span>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,&mdash;he looked intelligent, was
+alert and interested. When <span class='pagenum'><a name="Page_49" id="Page_49">[49]</a></span>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."</p>
+
+<div class="img">
+<a href="images/imagep049.jpg">
+<img border="0" src="images/imagep049.jpg" width="80%" alt="Reason Enough for Mouth Breathing: Adenoid and tonsils reduced one third" /></a><br />
+<p class="cen" style="margin-top: .2em;">REASON ENOUGH FOR MOUTH BREATHING<br />Adenoid and tonsils reduced one third</p>
+</div>
+
+<p>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 <span class='pagenum'><a name="Page_50" id="Page_50">[50]</a></span>because their parents did, not because the human race is
+deteriorating, but because their noses are stopped up,&mdash;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.</p>
+
+<p>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.</p>
+
+<p>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 an&aelig;mic. 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 <span class='pagenum'><a name="Page_51" id="Page_51">[51]</a></span>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.</p>
+
+<p>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, an&aelig;mia, 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 <span class='pagenum'><a name="Page_52" id="Page_52">[52]</a></span>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.</p>
+
+<p>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,&mdash;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 <span class='pagenum'><a name="Page_53" id="Page_53">[53]</a></span>ravenous, the eyes cleared,
+and the spirit rebounded to its old buoyancy that craved worlds to
+conquer.</p>
+
+<p>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.</p>
+
+<p>The indexes to adenoids and large tonsils for the teacher to read at
+school are:</p>
+
+<br />
+
+<div class="block"><p>1. Inability to breathe through the nose.</p>
+
+<p>2. A chronically running nose, accompanied by frequent nose-bleeds
+and a cough to clear the throat.</p>
+
+<p>3. Stuffy speech and delayed learning to talk. "Common" is
+pronounced "cobb&eacute;d"; "nose," "dose"; and "song," "sogg."</p>
+
+<p>4. A narrow upper jaw and irregular crowding of the teeth.</p>
+
+<p>5. Deafness.</p>
+
+<p>6. Chorea or nervousness.</p>
+
+<p>7. Inflamed eyes and conjunctivitis.</p></div>
+
+<br />
+
+<p>The adenoids and large tonsils discovered at school are an index:</p>
+
+<br />
+
+<div class="block"><p>1. To children needlessly handicapped in school work.</p>
+
+<p>2. To teachers needlessly burdened.</p>
+
+<p>3. To whole classes held back by afflicted children.</p>
+
+<p>4. To breeding grounds for disease.</p>
+
+<p>5. To homes where children's diseases and tuberculosis are most
+likely to break out and flourish.</p>
+
+<p>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.</p></div>
+
+<br />
+
+<p>The riot that occurred when the adenoids of children in a school on
+the "East Side" in New York City were <span class='pagenum'><a name="Page_54" id="Page_54">[54]</a></span>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.</p>
+
+<p>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&mdash;nasal occlusion. Adenoids left to
+atrophy&mdash;if large enough to cause mouth breathing&mdash;may mean atrophy of
+this developing process, permanent disfiguration of face, and
+permanent deformity of chest and lungs.</p>
+
+<p>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.</p>
+
+<p>3. Is the operation a dangerous one?</p>
+
+<p>4. Is an an&aelig;sthetic necessary?</p>
+
+<p>5. Will the operation cure the child of all its troubles? These
+questions are best answered by the process and <span class='pagenum'><a name="Page_55" id="Page_55">[55]</a></span>results of an "adenoid
+party," which was given especially for the benefit of this book, every
+step and symptom of which were carefully studied.</p>
+
+<p>The seven children pictured here were discovered by their school
+physician to have moderately large adenoid growths,&mdash;one boy having
+enlarged tonsils also.</p>
+
+<div class="img">
+<a href="images/imagep055.jpg">
+<img border="0" src="images/imagep055.jpg" width="80%" alt="Mouth Breathers Immediately After &quot;Adenoid Party&quot;" /></a><br />
+<p class="cen" style="margin-top: .2em;">MOUTH BREATHERS IMMEDIATELY AFTER "ADENOID PARTY"</p>
+</div>
+
+<p>The picture on page 46 was taken by flash light at 2.30 <span class="fakesc">P.M.</span>,
+January 15, 1908. At 3 <span class="fakesc">P.M.</span> 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&mdash;the curette&mdash;and pushed it
+up back of the soft palate, and with one twist <span class='pagenum'><a name="Page_56" id="Page_56">[56]</a></span>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
+<span class="fakesc">P.M.</span> 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 <span class="fakesc">P.M.</span> they had been all
+re&euml;xamined by the doctor, and a few tag ends were picked out of the
+nasopharynx of one child. At 4 <span class="fakesc">P.M.</span> the "party" had returned
+to the Children's Aid Society's school and to the ice cream that
+follows each adenoid party.</p>
+
+<p>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.</p>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_VI" id="CHAPTER_VI"></a><hr />
+<span class='pagenum'><a name="Page_57" id="Page_57">[57]</a></span><br />
+
+<h3>CHAPTER VI<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>CATCHING DISEASES, COLDS, DISEASED GLANDS</h4>
+<br />
+
+<p>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 medi&aelig;val 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."</p>
+
+<p>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
+<span class='pagenum'><a name="Page_58" id="Page_58">[58]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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,&mdash;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.</p>
+
+<p>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
+<span class='pagenum'><a name="Page_59" id="Page_59">[59]</a></span>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&mdash;its pretorian guard&mdash;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&mdash;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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_60" id="Page_60">[60]</a></span>out the few infected and infectious kinds of
+mosquito,&mdash;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,&mdash;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.</p>
+
+<p>Any place where numbers of people are accustomed to assemble favors
+the propagation of germs,&mdash;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
+co&ouml;perating 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 <span class='pagenum'><a name="Page_61" id="Page_61">[61]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_62" id="Page_62">[62]</a></span>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_63" id="Page_63">[63]</a></span>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."</p>
+
+<p>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&mdash;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 d&eacute;bris 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&mdash;tooth decay&mdash;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.</p>
+
+<p>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.</p>
+
+<span class='pagenum'><a name="Page_64" id="Page_64">[64]</a></span><br />
+
+<p class="cen sc">Table VIII</p>
+
+<p class="cen"><b>City of Manchester Education Committee</b></p>
+
+<h3>INFECTIOUS OR CONTAGIOUS DISEASES IN SCHOOLS INFORMATION FOR
+TEACHERS</h3>
+
+<div class="block"><p>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</p></div>
+
+<br />
+
+<div class="centered">
+<table border="0" cellpadding="2" cellspacing="0" width="95%" summary="Table 8: Infectious or Contagious Diseases in Schools Information For Teachers">
+  <tr>
+  <td width="10%" class="tdctrb"><i>DISEASE</i></td>
+  <td width="35%" class="tdctrlb"><i>PRINCIPAL SIGNS AND SYMPTOMS</i></td>
+  <td width="20%" class="tdctrlb"><i>Method of Infection</i></td>
+  <td width="35%" class="tdctlb"><i>REMARKS</i></td>
+  </tr>
+  <tr>
+  <td class="tdl vat" style="border-right: 1px solid black; border-top: 1px solid black; border-bottom: 1px solid black; padding: .5em;">Measles</td>
+  <td class="tdlrlb vat" style="border-top: 1px solid black; padding-top: .5em;"><i>Begins like cold in the head</i>, with
+    <i>feverishness, running nose, inflamed and watery eyes, and sneezing</i>; small crescentic groups of
+    <i>mulberry-tinted spots</i> appear about the third day; <i>rash first seen on forehead and face</i>.
+    The rash varies with heat; may almost disappear if the air is cold, and come out again with warmth.</td>
+  <td class="tdlrlb vat" style="border-top: 1px solid black; padding-top: .5em;">Breath and discharges from nose and mouth.</td>
+  <td class="tdllb vat" style="border-top: 1px solid black; padding-top: .5em;">After effects often severe. Period of greatest
+    risk of infection first three or four days, before the rash appears. May have repeated attacks. Great
+    variation in type of disease.</td>
+  </tr>
+  <tr>
+  <td class="tdl vat" style="border-right: 1px solid black; border-top: 1px solid black; border-bottom: 1px solid black; padding: .5em;">German Measles</td>
+  <td class="tdlrlb vat" style="border-top: 1px solid black; padding-top: .5em;">Illness usually slight. Onset
+    sudden. <i>Rash often first thing noticed;</i> no cold in head. Usually have <i>feverishness</i> and
+    <i>sore throat</i>, and the <i>eyes may be inflamed. Rash</i> something between Measles and Scarlet
+    Fever, variable.</td>
+  <td class="tdlrlb vat" style="border-top: 1px solid black; padding-top: .5em;">Breath and discharges from nose
+    and mouth</td>
+  <td class="tdllb vat" style="border-top: 1px solid black; padding-top: .5em;">After effects slight.</td>
+  </tr>
+  <tr>
+  <td class="tdl vat" style="border-right: 1px solid black; border-top: 1px solid black; border-bottom: 1px solid black; padding: .5em;">Chicken Pox</td>
+  <td class="tdlrlb vat" style="border-top: 1px solid black; padding-top: .5em;">Sometimes begins with feverishness,
+    but is <i>usually very mild</i> and without sign of fever. <i>Rash</i> appears on second day as <i>small pimples</i>,
+    which in about a day become filled with <i>clear fluid</i>. This fluid then becomes <i>matter</i>, and then the <i>spot
+    dries up</i>and <i>the crust falls off</i>.<br /><br />
+    May have <i>successive crops of of rash</i> until tenth day.</td>
+  <td class="tdlrlb vat" style="border-top: 1px solid black; padding-top: .5em;">Breath and crust of spots.</td>
+  <td class="tdllb vat" style="border-top: 1px solid black; padding-top: .5em;">When children return, examine head for
+    overlooked spots. All spots should have disappeared before child returns. A mild disease and seldom any after
+    effects.</td>
+  </tr>
+  <tr>
+  <td class="tdl vat" style="border-right: 1px solid black; border-top: 1px solid black; border-bottom: 1px solid black; padding: .5em;">Whooping Cough</td>
+  <td class="tdlrlb vat" style="border-top: 1px solid black; padding-top: .5em;"><i>Begins like cold in the
+    head</i>, with <i>bronchitis</i> and <i>sore throat</i>, and a <i>cough</i> which is <i>worse at night</i>.
+    Symptoms may at first be very mild. Characteristic <i>"whooping" cough</i> develops in about a fortnight,
+    and the spasm of coughing often ends with <i>vomiting</i>.</td>
+  <td class="tdlrlb vat" style="border-top: 1px solid black; padding-top: .5em;">Breath and discharges
+    from nose and mouth.</td>
+  <td class="tdllb vat" style="border-top: 1px solid black; padding-top: .5em;">After effects often very severe
+    and the disease causes great debility. Relapses are apt to occur. Second attack rare. Specially infectious for
+    first week or two. If a child is sick after a bout of coughing, it is most probably suffering from whooping cough.
+    <br /><br />Great variation in type of disease.</td>
+  </tr>
+  <tr>
+  <td class="tdl vat" style="border-right: 1px solid black; border-top: 1px solid black; border-bottom: 1px solid black; padding: .5em;">Mumps</td>
+  <td class="tdlrlb vat" style="border-top: 1px solid black; padding-top: .5em;">Onset may be sudden, beginning
+    with sickness and fever, and <i>pain about the angle of the jaw</i>. The <i>glands become swollen and
+    tender</i>, and the <i>jaws stiff</i>, and the <i>saliva sticky</i>.</td>
+  <td class="tdlrlb vat" style="border-top: 1px solid black; padding-top: .5em;">Breath and discharges from nose
+    and mouth.</td>
+  <td class="tdllb vat" style="border-top: 1px solid black; padding-top: .5em;">Seldom leaves after effects.
+    Very infectious.</td>
+  </tr>
+  <tr>
+  <td class="tdl vat" style="border-right: 1px solid black; border-top: 1px solid black; border-bottom: 1px solid black; padding: .5em;">Scarlet
+    Fever or Scarlatina<span class='pagenum'><a name="Page_65" id="Page_65">[65]</a></span></td>
+  <td class="tdlrlb vat" style="border-top: 1px solid black; padding-top: .5em;">The <i>onset is usually
+    sudden</i>, with <i>headache, languor, feverishness, sore throat</i>, and often the child is <i>sick</i>.
+    Usually within twenty-four hours the <i>rash</i> appears, and is <i>finely spotted, evenly diffused</i>,
+    and <i>bright red</i>. The <i>rash</i> is seen first on the <i>neck and upper part of chest</i>, and
+    lasts three to ten days, when it fades and the <i>skin peels in scales, flakes</i>, or even <i>large
+    pieces</i>. The <i>tongue</i> becomes whitish, with bright red spots. The eyes are not watery or congested.</td>
+  <td class="tdlrlb vat" style="border-top: 1px solid black; padding-top: .5em;">Breath, discharges from nose
+    and mouth, particles of skin, and discharges from suppuratory glands or ears. Milk specially apt to
+    convey infection.</td>
+  <td class="tdllb vat" style="border-top: 1px solid black; padding-top: .5em;">Dangerous both during attack
+    and from after effects. Great variation in type of disease. Slight attacks as infectious as severe ones.
+    Many mild cases not diagnosed and many concealed. The peeling may last six to eight weeks. A second attack
+    is rare. When scarlet fever is occurring in a school, all cases of sore throat should be sent home.</td>
+  </tr>
+  <tr>
+  <td class="tdl vat" style="border-right: 1px solid black; border-top: 1px solid black; border-bottom: 1px solid black; padding: .5em;">Diphtheria</td>
+  <td class="tdlrlb vat" style="border-top: 1px solid black; padding-top: .5em;">Onset insidious, may be rapid
+    or gradual. Typically <i>sore throat</i>, great weakness, and swelling of glands in the neck, about the
+    angle of the jaw. The back of the throat, tonsils, or palate may show <i>patches</i> like pieces of
+    yellowish-white kid. The most pronounced symptom is great debility and lassitude, and there may be little
+    else noticeable. There may be hardly any symptoms at all.</td>
+  <td class="tdlrlb vat" style="border-top: 1px solid black; padding-top: .5em;">Breath and discharges
+    from nose, mouth, and ears.</td>
+  <td class="tdllb vat" style="border-top: 1px solid black; padding-top: .5em;">Very dangerous both during
+    attack and from after effects. When diphtheria is occurring in a school all children suffering from sore
+    throat should be excluded. There is great variation of type, and mild cases are often not recognized
+    but are as infectious as severe cases. There is no immunity from further attacks. Fact of existence
+    of disease sometimes concealed.</td>
+  </tr>
+  <tr>
+  <td class="tdl vat" style="border-right: 1px solid black; border-top: 1px solid black; border-bottom: 1px solid black; padding: .5em;">Influenza</td>
+  <td class="tdlrlb vat" style="border-top: 1px solid black; padding-top: .5em;"><i>Begins with feverishness,
+    pain in head, back</i>, and <i>limbs</i>, and usually <i>cold in the head</i>.</td>
+  <td class="tdlrlb vat" style="border-top: 1px solid black; padding-top: .5em;">Breath and discharges
+    from nose and mouth.</td>
+  <td class="tdllb vat" style="border-top: 1px solid black; padding-top: .5em;">Excessively infectious. After
+    effects often very serious and accompanied with great prostration and nervous debility.</td>
+  </tr>
+  <tr>
+  <td class="tdl vat" style="border-right: 1px solid black; border-top: 1px solid black; border-bottom: 1px solid black; padding: .5em; border-bottom: 2px solid black;">Smallpox</td>
+  <td class="tdlrlb vat" style="border-top: 1px solid black; padding-top: .5em; border-bottom: 2px solid black;">The illness is usually well
+    marked and the onset rather sudden, with <i>feverishness, severe backache, and sickness</i>. About third
+    day a <i>red rash</i> of <i>shotlike pimples</i>, felt below the skin, and seen first about the <i>face</i>
+    and <i>wrists. Spots develop</i> in <i>two days</i>, then form <i>little blisters</i>, and in other two
+    days become <i>yellowish</i> and filled with matter. <i>Scabs</i> then form, and these fall off about
+    the fourteenth day.</td>
+  <td class="tdlrlb vat" style="border-top: 1px solid black; padding-top: .5em; border-bottom: 2px solid black;">Breath, all discharges,
+    and particles of skin or scabs.</td>
+  <td class="tdllb vat" style="border-top: 1px solid black; padding-top: .5em; border-bottom: 2px solid black;">Peculiarly infectious. When
+    smallpox occurs in connection with a school or with any of the children's homes, an endeavor
+    should be made to have all persons over seven years of age revaccinated. <br /><br /> Cases of modified
+    smallpox&mdash;in vaccinated persons&mdash;may be, and often are, so slight as to escape detection.
+    Fact of existence of disease may be concealed. Mild or modified infectious as severe type.</td>
+  </tr>
+</table>
+</div>
+
+<h4>In the following diseases only the affected child is excluded</h4>
+
+<div class="centered">
+<table border="0" cellpadding="2" cellspacing="0" width="80%" summary="In the following diseases only the affected child is excluded">
+  <tr>
+  <td width="50%" class="tdlr"><b>Erysipelas.</b> Child should not return till all swelling and
+     peeling of skin has disappeared.</td>
+  <td width="50%" class="tdll" style="padding-left: 1em;"><b>Ringworm on Scalp.</b> Child should be excluded till cured. Very
+    difficult to cure and often takes a very long time.</td>
+  </tr>
+  <tr>
+  <td class="tdlr"><b>Ophthalmia.</b> Child should not return till all traces have disappeared.</td>
+  <td class="tdll" rowspan="2" style="padding-left: 1em;"><b>Phthisis</b> (<b>Consumption</b>). If in advanced stage and coughing much
+    <i>or spitting</i>, child should be excluded. (Infection from breath and dried spit floating in the
+    air as dust.)</td>
+  </tr>
+  <tr>
+  <td class="tdlr"><b>Scabies or Itch.</b> Child should be excluded until cured.</td>
+  </tr>
+  <tr>
+  <td class="tdlr"><b>Ringworm on Skin.</b> Child should be excluded till cured. This takes
+    only a few days if properly treated.</td>
+  <td class="tdll" style="padding-left: 1em;"><b>Impetigo</b> (<b>Contagious Sore</b>). Child should be excluded until
+    cured. A week or ten days should suffice.</td>
+  </tr>
+  <tr>
+  <td colspan="2" class="tdr" style="padding-top: 1em;"><b>A. BROWN RITCHIE</b>, <i>Medical Officer to Education Committee</i>.</td>
+  </tr>
+</table>
+</div>
+
+<br />
+<br />
+
+<p><span class='pagenum'><a name="Page_66" id="Page_66">[66]</a></span>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:</p>
+
+<div class="block"><p>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.</p>
+
+<p>Our wise ancestors, who as a rule lived much longer than we do,
+and had much better health, said:</p></div>
+
+<div class="poem"><div class="stanza">
+<span class="i0">"If the wind should blow through a hole,<br /></span>
+<span class="i0">God have mercy on your soul."<br /></span>
+</div></div>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_67" id="Page_67">[67]</a></span>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_68" id="Page_68">[68]</a></span>not
+have been true, rights change with conditions, and the fact that
+to-day the three most deadly diseases are pneumonia, tuberculosis, and
+diphtheria,&mdash;all diseases of the respiratory organs,&mdash;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.</p>
+
+<br />
+
+<p class="cen sc">Table IX</p>
+
+<p class="cen sc">Death Rate per 10,000 Population, Pneumonia and Bronchitis<br />
+Five-Year Period, 1896-1900</p>
+
+<br />
+
+<div class="centered">
+<table border="0" cellpadding="2" cellspacing="0" width="50%" summary="Death Rate per 10,000 Population">
+  <tr>
+  <td width="50%" class="tdl">England and Wales</td>
+  <td width="50%" class="tdr">22.70</td>
+  </tr>
+  <tr>
+  <td class="tdl">Scotland</td>
+  <td class="tdr">27.40</td>
+  </tr>
+  <tr>
+  <td class="tdl">Stockholm</td>
+  <td class="tdr">26.70</td>
+  </tr>
+  <tr>
+  <td class="tdl">London</td>
+  <td class="tdr">31.20</td>
+  </tr>
+  <tr>
+  <td class="tdl">Berlin</td>
+  <td class="tdr">16.10</td>
+  </tr>
+  <tr>
+  <td class="tdl">Vienna</td>
+  <td class="tdr">39.70</td>
+  </tr>
+  <tr>
+  <td class="tdl">Christiania</td>
+  <td class="tdr">21.30</td>
+  </tr>
+  <tr>
+  <td class="tdl">Boston</td>
+  <td class="tdr">30.60</td>
+  </tr>
+  <tr>
+  <td class="tdl">Chicago</td>
+  <td class="tdr">24.20</td>
+  </tr>
+  <tr>
+  <td class="tdl">Philadelphia</td>
+  <td class="tdr">25.10</td>
+  </tr>
+  <tr>
+  <td class="tdl">New York City</td>
+  <td class="tdr">36.60</td>
+  </tr>
+</table>
+</div>
+
+<br />
+<br />
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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, <span class='pagenum'><a name="Page_69" id="Page_69">[69]</a></span>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,&mdash;in fact all germ diseases,&mdash;is the
+repeated cleansing of those portions of the human body in which germs
+may find lodgment,&mdash;the mouth, the nose, the eyes, and the ears.</p>
+
+<p>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?</p>
+
+<p>Two other "catching" diseases cause city schools a great deal of
+trouble,&mdash;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 <span class='pagenum'><a name="Page_70" id="Page_70">[70]</a></span>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?</p>
+
+<p>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&mdash;girls supposed to have been cured by school
+nurses&mdash;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.</p>
+
+<p>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, <span class='pagenum'><a name="Page_71" id="Page_71">[71]</a></span>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.</p>
+
+<p>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,&mdash;kerosene for the hair or strong
+green oil soap; for the eye, only what a physician prescribes.</p>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_VII" id="CHAPTER_VII"></a><hr />
+<span class='pagenum'><a name="Page_72" id="Page_72">[72]</a></span><br />
+
+<h3>CHAPTER VII<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>EYE STRAIN</h4>
+<br />
+
+<p>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 <i>c</i> and <i>t</i> in "cat" is an <i>o</i>; "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. <i>So I learned that I
+must not say two words even when I saw them.</i>" 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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_73" id="Page_73">[73]</a></span>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.</p>
+
+<p>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."</p>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_74" id="Page_74">[74]</a></span>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.</p>
+
+<div class="img">
+<a href="images/imagep074.jpg">
+<img border="0" src="images/imagep074.jpg" width="75%" alt="Positions Often Suggest Eye Strain" /></a><br />
+<p class="cen" style="margin-top: .2em;">POSITIONS OFTEN SUGGEST EYE STRAIN</p>
+</div>
+
+<p>Of course eye specialists,&mdash;oculists,&mdash;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 <span class='pagenum'><a name="Page_75" id="Page_75">[75]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>The practical steps for a teacher to take in making eye tests are:</p>
+
+<div class="block"><p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_76" id="Page_76">[76]</a></span>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.</p>
+
+<p>5. Have the child read from right to left, from left to right, or
+skip about so that memory cannot aid the eye.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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 <i>for the present</i>.
+If, on the other hand, the only difficulty is a confusion of <i>x</i>
+and <i>z</i> with <i>c</i> and <i>g</i>, it means that there is a strain due to
+astigmatism, and that the child should be sent to an oculist.</p>
+
+<p><span class='pagenum'><a name="Page_77" id="Page_77">[77]</a></span>9. Teach children and parents (and practice what you preach) the
+urgent importance of periodic re&euml;xamination, 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.</p>
+
+<p>10. Acquire the habit of reading the eye for evidence of temperate
+or intemperate living, sleeping, eating, dancing, drinking, and
+smoking. Inflamed eyes are <i>results</i>,&mdash;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.</p></div>
+
+<p>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. <span class='pagenum'><a name="Page_78" id="Page_78">[78]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>An epidemic of eyeglasses is usually the consequence of eye tests. So
+naturally do we associate eyeglasses with <span class='pagenum'><a name="Page_79" id="Page_79">[79]</a></span>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.</p>
+
+<p>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,&mdash;this without testing children under
+seven,&mdash;while 11.3 per cent had sore eyes.</p>
+
+<p>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 <span class='pagenum'><a name="Page_80" id="Page_80">[80]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_81" id="Page_81">[81]</a></span>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.</p>
+
+<p>Whether opticians and physicians are unprofessional or unethical may
+be told by re&euml;xamination if the <i>examiner</i> 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.</p>
+
+<p><span class='pagenum'><a name="Page_82" id="Page_82">[82]</a></span>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.</p>
+
+<p>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.</p>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_VIII" id="CHAPTER_VIII"></a><hr />
+<span class='pagenum'><a name="Page_83" id="Page_83">[83]</a></span><br />
+
+<h3>CHAPTER VIII<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>EAR TROUBLE, MALNUTRITION, DEFORMITIES</h4>
+<br />
+
+<p>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. <i>The foundations of deafness in later life are, in
+most instances, laid in childhood.</i> 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.</p>
+
+<p><span class='pagenum'><a name="Page_84" id="Page_84">[84]</a></span>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.</p>
+
+<p>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, <span class='pagenum'><a name="Page_85" id="Page_85">[85]</a></span>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.</p>
+
+<p>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.</p>
+
+<br />
+
+<h4 class="sc">Nervousness</h4>
+
+<p>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 <span class='pagenum'><a name="Page_86" id="Page_86">[86]</a></span>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.</p>
+
+<br />
+
+<h4 class="sc">Tests of Malnutrition</h4>
+
+<p>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,&mdash;soft
+bones, flabby tissue, under size, an&aelig;mia. 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 <span class='pagenum'><a name="Page_87" id="Page_87">[87]</a></span>of nourishment may
+exist long before outward symptoms are noticeable. Therefore the value
+of the periodic searching examination by the school physician.</p>
+
+<div class="img">
+<a href="images/imagep086.jpg">
+<img border="0" src="images/imagep086.jpg" width="50%" alt="Same Age, Same School, Different Nutrition" /></a><br />
+<p class="cen" style="margin-top: .2em;">SAME AGE, SAME SCHOOL, DIFFERENT NUTRITION</p>
+</div>
+
+
+<br />
+
+<h4 class="sc">Bone Tuberculosis; Orthopedic Tests</h4>
+
+<p>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,&mdash;which one mother
+diagnosed as inherited "round shoulders,"&mdash;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.</p>
+
+<div class="img">
+<a href="images/imagep087.jpg">
+<img border="0" src="images/imagep087.jpg" width="80%" alt="A Grievous Penalty For Neglect By Adult Consumptives" /></a><br />
+<p class="cen" style="margin-top: .2em;">A GRIEVOUS PENALTY FOR NEGLECT BY ADULT CONSUMPTIVES</p>
+</div>
+
+<span class='pagenum'><a name="Page_88" id="Page_88">[88]</a></span><br />
+
+<h4 class="sc">Enlarged Glands&mdash;Tuberculosis</h4>
+
+<p>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.</p>
+
+<div class="img">
+<a href="images/imagep088.jpg">
+<img border="0" src="images/imagep088.jpg" width="80%" alt="Model Of America's First Hospital For Seashore Fresh-air Treatment of Nonpulmonary Tuberculosis in Children" /></a><br />
+<p class="cen" style="margin-top: .2em;">MODEL OF AMERICA'S FIRST HOSPITAL FOR SEASHORE FRESH-AIR<br /> TREATMENT OF NONPULMONARY TUBERCULOSIS IN CHILDREN<br />
+To be erected at Rockaway Beach, New York City</p>
+</div>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_IX" id="CHAPTER_IX"></a><hr />
+<span class='pagenum'><a name="Page_89" id="Page_89">[89]</a></span><br />
+
+<h3>CHAPTER IX<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>DENTAL SANITATION</h4>
+<br />
+
+<p>"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.</p>
+
+<p>"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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_90" id="Page_90">[90]</a></span>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.</p>
+
+<p>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?</p>
+
+<div class="img">
+<a href="images/imagep090.jpg">
+<img border="0" src="images/imagep090.jpg" width="80%" alt="Industrial Handicaps Discovered At School" /></a><br />
+<p class="cen" style="margin-top: .2em;">INDUSTRIAL HANDICAPS DISCOVERED AT SCHOOL</p>
+</div>
+
+<p>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 <span class='pagenum'><a name="Page_91" id="Page_91">[91]</a></span>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 &aelig;sthetics 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.</p>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_92" id="Page_92">[92]</a></span>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_93" id="Page_93">[93]</a></span>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 &aelig;sthetic 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.</p>
+
+<div class="img">
+<a href="images/imagep093.jpg">
+<img border="0" src="images/imagep093.jpg" width="80%" alt="New York Children's Aid Society's Dental Clinic For School Children" /></a><br />
+<p class="cen" style="margin-top: .2em;">NEW YORK CHILDREN'S AID SOCIETY'S DENTAL CLINIC FOR SCHOOL CHILDREN</p>
+</div>
+
+<p>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.</p>
+
+<span class='pagenum'><a name="Page_94" id="Page_94">[94]</a></span><br />
+
+<div class="img">
+<a href="images/imagep094.png">
+<img border="0" style="border: 1px black solid;" src="images/imagep094.png" width="60%" alt="(leaflet) A DENTAL CATECHISM" /></a><br />
+</div>
+
+<p>Such a leaflet should be given out at dispensaries, hospitals, dental
+offices, schools, and from many Sunday schools and missions.<a name="FNanchor_5_5" id="FNanchor_5_5"></a><a href="#Footnote_5_5" class="fnanchor">[5]</a></p>
+
+<p><span class='pagenum'><a name="Page_95" id="Page_95">[95]</a></span>The time for the schools to begin is when the child is first
+registered. Examination and re&euml;xamination 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.</p>
+
+<p>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 re&euml;xamination are
+necessary and a saving of pain, beauty, and money.</p>
+
+<p>Re&euml;xamination is necessary because decay <i>may</i> start the day after a
+dentist has pronounced a tooth sound. For most of us twice a year is
+often enough. A re&euml;xamination should be made upon the slightest
+suspicion of decay, breaking, or loosening.</p>
+
+<p><span class='pagenum'><a name="Page_96" id="Page_96">[96]</a></span>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 <i>mouth
+garbage</i>. 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.</p>
+
+<div class="imgr" style="width: 30%;">
+<a href="images/imagep097.jpg">
+<img border="0" src="images/imagep097.jpg" width="90%" alt="An Armenian School Girl" /></a><br />
+<p class="cen" style="margin-top: .2em; font-size: 80%;">AN ARMENIAN SCHOOL GIRL</p>
+</div>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_97" id="Page_97">[97]</a></span>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.</p>
+
+<p>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.</p>
+
+<span class='pagenum'><a name="Page_98" id="Page_98">[98]</a></span><br />
+
+<div class="centered" style="clear: both;">
+<table border="0" cellpadding="2" cellspacing="0" width="75%" summary="questions about cost of neglected teeth vs. regular teeth care">
+  <tr>
+  <td width="50%" class="tdl vat" style="padding-left: 4%;"><p class="hang2">How many members in your family?</p>
+    <p class="hang2">How many teeth have they?</p>
+    <p class="hang2">How many teeth have they lost?</p>
+    <p class="hang2">How many false teeth have they?</p>
+    <p class="hang2">How many teeth have been filled?</p>
+    <p class="hang2">What is the total cost to date?</p>
+    <p class="hang2">How many days have been lost from work because of toothache?</p>
+    <p class="hang2">How many teeth are now decayed?</p>
+    <p class="hang2">What will it cost to have them attended to?</p></td>
+  <td width="5%">&nbsp;</td>
+  <td width="45%" class="tdl vat" style="padding-left: 4%;"><p class="hang2">What does a toothbrush cost?</p>
+    <p class="hang2">How many do you need in one year?</p>
+    <p class="hang2">How much does tooth powder cost?</p>
+    <p class="hang2">How much is needed for one year?</p>
+    <p class="hang2">How much would two examinations a year by a dentist cost?</p></td>
+  </tr>
+</table>
+</div>
+
+<p>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.</p>
+
+<div class="imgr" style="width: 30%;">
+<a href="images/imagep099.jpg">
+<img border="0" src="images/imagep099.jpg" width="90%" alt="Won By The Economic Argument" /></a><br />
+<p class="cen" style="margin-top: .2em; font-size: 80%;">WON BY THE ECONOMIC ARGUMENT</p>
+</div>
+
+<p>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
+&aelig;sthetics, the economics, the humanity of dental hygiene. <span class='pagenum'><a name="Page_99" id="Page_99">[99]</a></span>The best
+test of whether the parent has understood is the child's tooth.</p>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_100" id="Page_100">[100]</a></span>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.</p>
+
+<p style="clear: both;">Five obstacles exist to practicing what is here preached:</p>
+
+<div class="block"><p>1. The expensiveness of proper dentistry.</p>
+
+<p>2. The untrustworthiness of cheap dental service and "painless"
+dental parlors; the domination of the supply houses wishing to
+sell instruments and other supplies.</p>
+
+<p>3. The ethical objection to any kind of advertising or to work by
+wholesale.</p>
+
+<p>4. The lack of dispensaries.</p>
+
+<p>5. The profit-making basis of dental education.</p></div>
+
+<p>Additional reasons these for cleanliness that will make the dentist
+serviceable for his knowledge rather than for his time and gold.</p>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_101" id="Page_101">[101]</a></span>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_102" id="Page_102">[102]</a></span>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 co&ouml;perative
+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.</p>
+
+<p>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 co&ouml;perative 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.</p>
+
+<p>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.</p>
+
+<p>Of fourteen dental journals in America, only one has the advancement
+of dental science as its first reason for <span class='pagenum'><a name="Page_103" id="Page_103">[103]</a></span>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.</p>
+
+<p>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,&mdash;the tricks of the trade&mdash;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.</p>
+
+<br />
+<hr style="width: 15%;" />
+<br />
+
+<h4>FOOTNOTES:</h4>
+
+<div class="footnote"><p class="noin"><a name="Footnote_5_5" id="Footnote_5_5"></a><a href="#FNanchor_5_5"><span class="label">[5]</span></a> <i>The Teeth and Their Care</i>, by Thaddeus P. Hyatt, D.D.S.,
+is a short, concise treatment of the principles of dental
+sanitation.</p></div>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_X" id="CHAPTER_X"></a><hr />
+<span class='pagenum'><a name="Page_104" id="Page_104">[104]</a></span><br />
+
+<h3>CHAPTER X<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>ABNORMALLY BRIGHT CHILDREN</h4>
+<br />
+
+<p>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.</p>
+
+<p>The college man who sacrifices health to "marks" is thus described by
+the director of physical training at Harvard University:</p>
+
+<div class="block2p"><p class="noin">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.</p></div>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_105" id="Page_105">[105]</a></span>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.</p>
+
+<p>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&mdash;marking time till the dull ones catch
+up&mdash;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,&mdash;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 <span class='pagenum'><a name="Page_106" id="Page_106">[106]</a></span>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.</p>
+
+<p>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 <i>Psychological Clinic</i>, 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.</p>
+
+<p>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.</p>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_XI" id="CHAPTER_XI"></a><hr />
+<span class='pagenum'><a name="Page_107" id="Page_107">[107]</a></span><br />
+
+<h3>CHAPTER XI<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>NERVOUSNESS OF TEACHER AND PUPIL</h4>
+<br />
+
+<p>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&mdash;nerves&mdash;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.</p>
+
+<p>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, <span class='pagenum'><a name="Page_108" id="Page_108">[108]</a></span>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.</p>
+
+<p>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,&mdash;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.</p>
+
+<p>There is nothing in school life <i>per se</i> to cause nervousness. Given a
+well-aired, sunny room, where every child <span class='pagenum'><a name="Page_109" id="Page_109">[109]</a></span>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.</p>
+
+<div class="img">
+<a href="images/imagep109.jpg">
+<img border="0" src="images/imagep109.jpg" width="80%" alt="Vacation School Interest: An Antidote To Nervousness" /></a><br />
+<p class="cen" style="margin-top: .2em;">VACATION SCHOOL INTEREST: AN ANTIDOTE TO NERVOUSNESS</p>
+</div>
+
+<p><span class='pagenum'><a name="Page_110" id="Page_110">[110]</a></span>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
+<i>Annals of a Quiet Neighborhood</i>, 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.</p>
+
+<p>Had I known what every teacher should be taught in preparation,&mdash;the
+relation of eye strain, bad teeth, adenoids, "overattention," and
+malnutrition to nervousness and bad behavior,&mdash;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.<a name="FNanchor_6_6" id="FNanchor_6_6"></a><a href="#Footnote_6_6" class="fnanchor">[6]</a> 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,&mdash;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.</p>
+
+<p><span class='pagenum'><a name="Page_111" id="Page_111">[111]</a></span>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.</p>
+
+<p>Nervousness that results from removable physical defects&mdash;eye strain,
+adenoids, indigestion, earache&mdash;will be easily detected by physical
+examination, and easily corrected by removing the physical defect.</p>
+
+<p>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 <span class='pagenum'><a name="Page_112" id="Page_112">[112]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_113" id="Page_113">[113]</a></span>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 co&ouml;perating
+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,&mdash;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.</p>
+
+<p>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.
+<span class='pagenum'><a name="Page_114" id="Page_114">[114]</a></span>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.</p>
+
+<p>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,&mdash;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:</p>
+
+<div class="poem"><div class="stanza">
+<span class="i0">Oh wad some power the giftie gie us<br /></span>
+<span class="i0">To see oursel's as ithers see us;<br /></span>
+<span class="i0">It wad frae mony a blunder free us,<br /></span>
+<span class="i2">And foolish notion.<br /></span>
+</div></div>
+
+<br />
+<hr style="width: 15%;" />
+<br />
+
+<h4>FOOTNOTES:</h4>
+
+<div class="footnote"><p class="noin"><a name="Footnote_6_6" id="Footnote_6_6"></a><a href="#FNanchor_6_6"><span class="label">[6]</span></a> <i>The Unconscious Mind</i> by Schofield, <i>The Study of
+Children and their School Training</i> by Dr. Frances Warner, and <i>The
+Development of the Child</i> by Nathan Oppenheimer show clearly the
+physical and mental limitations and possibilities of children.</p></div>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_XII" id="CHAPTER_XII"></a><hr />
+<span class='pagenum'><a name="Page_115" id="Page_115">[115]</a></span><br />
+
+<h3>CHAPTER XII<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>HEALTH VALUE OF "UNBOSSED" PLAY AND PHYSICAL TRAINING</h4>
+<br />
+
+<p><i>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.</i> 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.</p>
+
+<p>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,"&mdash;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.</p>
+
+<div class="img"><span class='pagenum'><a name="Page_116" id="Page_116">[116]</a></span>
+<a href="images/imagep116.jpg">
+<img border="0" src="images/imagep116.jpg" width="80%" alt="Serviceable Relief From School Strain, But A Poor Substitute For Outdoor Play" /></a><br />
+<p class="cen" style="margin-top: .2em;">SERVICEABLE RELIEF FROM SCHOOL STRAIN, BUT A POOR SUBSTITUTE FOR OUTDOOR PLAY</p>
+</div>
+
+<p>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 <span class='pagenum'><a name="Page_117" id="Page_117">[117]</a></span>defect like flat foot, flat chest, weak
+abdominal muscles, habitual constipation, uneven shoulders, spinal
+trouble, etc.</p>
+
+<p>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.</p>
+
+<p>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:</p>
+
+<div class="block2p"><p class="noin">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.</p></div>
+
+<p>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
+<span class='pagenum'><a name="Page_118" id="Page_118">[118]</a></span>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.</p>
+
+<p>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&mdash;whether a city
+child or a country child&mdash;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 <span class='pagenum'><a name="Page_119" id="Page_119">[119]</a></span>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.</p>
+
+<div class="img">
+<a href="images/imagep119.jpg">
+<img border="0" src="images/imagep119.jpg" width="80%" alt="Spontaneous Play On One Of New York City's School Roof Playgrounds" /></a><br />
+<p class="cen" style="margin-top: .2em;">SPONTANEOUS PLAY ON ONE OF NEW YORK CITY'S SCHOOL ROOF PLAYGROUNDS</p>
+</div>
+
+<p>"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."</p>
+
+<p><span class='pagenum'><a name="Page_120" id="Page_120">[120]</a></span>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,&mdash;the neurotic. The
+young eye, for example, is too flat (hypermetropic)&mdash;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,&mdash;short-sightedness,&mdash;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:</p>
+
+<div class="block2p"><p class="noin">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 <span class='pagenum'><a name="Page_121" id="Page_121">[121]</a></span>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.</p></div>
+
+<p>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.</p>
+
+<div class="img">
+<a href="images/imagep121.jpg">
+<img border="0" src="images/imagep121.jpg" width="80%" alt="New York City's School Farm Does Not Stifle Nature Instinct" /></a><br />
+<p class="cen" style="margin-top: .2em;">NEW YORK CITY'S SCHOOL FARM DOES NOT STIFLE NATURE INSTINCT</p>
+</div>
+
+<p>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 <span class='pagenum'><a name="Page_122" id="Page_122">[122]</a></span>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&mdash;mentally,
+morally, and physically&mdash;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.</p>
+
+<p>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 <i>of the same
+<span class='pagenum'><a name="Page_123" id="Page_123">[123]</a></span>physical class</i> 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."</p>
+
+<p>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:</p>
+
+<div class="block2"><p>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&mdash;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&mdash;a mere dull round of routine and
+drudgery&mdash;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.</p></div>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_XIII" id="CHAPTER_XIII"></a><hr />
+<span class='pagenum'><a name="Page_124" id="Page_124">[124]</a></span><br />
+
+<h3>CHAPTER XIII<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>VITALITY TESTS AND VITAL STATISTICS</h4>
+<br />
+
+<p>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&mdash;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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_125" id="Page_125">[125]</a></span>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.</p>
+
+<p>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:</p>
+
+<div class="img">
+<a href="images/fig1.png">
+<img border="0" src="images/fig1.png" width="80%" alt="Fig. 1: Ergogram of T.R., a strong, healthy girl, before taking 40 minutes' work in the gymnasium" /></a><br />
+<p class="cen" style="margin-top: .2em; margin-left: 15%; margin-right: 15%;"><span class="sc">Fig.</span> 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.</p>
+</div>
+
+<p><span class='pagenum'><a name="Page_126" id="Page_126">[126]</a></span>If weak and nervous, we shall look like this before taking exercise:</p>
+
+<div class="img">
+<a href="images/fig2.png">
+<img border="0" src="images/fig2.png" width="80%" alt="Fig. 2: Ergogram of C.E., a weak and somewhat nervous girl, before taking 40 minutes' work in the gymnasium" /></a><br />
+<p class="cen" style="margin-top: .2em; margin-left: 15%; margin-right: 15%;"><span class="sc">Fig.</span> 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.</p>
+</div>
+
+<p>And like this after gymnasium exercise:</p>
+
+<div class="img">
+<a href="images/fig3.png">
+<img border="0" src="images/fig3.png" width="80%" alt="Fig. 3: Ergogram of C.E. after taking 40 minutes' work in the gymnasium, showing that the exercise proved very exhausting." /></a><br />
+<p class="cen" style="margin-top: .2em; margin-left: 15%; margin-right: 15%;"><span class="sc">Fig.</span> 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.</p>
+</div>
+
+<p>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.</p>
+
+<p>Chicago's child-study experts concluded after examining a large number
+of children:</p>
+
+<div class="block"><p>1. In general there is a distinct relationship in children between
+physical condition and intellectual capacity, the latter varying
+directly as the former.</p>
+
+<p><span class='pagenum'><a name="Page_127" id="Page_127">[127]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>4. Physical condition should be made a factor in the grading of
+children for school work, and especially for entrance into the
+first grade.</p>
+
+<p>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.</p>
+
+<p>6. The classes in physical culture should be graded on a physical
+instead of an intellectual basis.</p></div>
+
+<div class="img">
+<a href="images/fig4.png">
+<img border="0" src="images/fig4.png" width="80%" alt="Fig. 4:  the effect of the noon recess and of the good time after three o'clock." /></a><br />
+<p class="cen" style="margin-top: .2em; margin-left: 15%; margin-right: 15%;"><span class="sc">Fig.</span> 4.</p>
+</div>
+
+<p>To these conclusions certain others should be added, not as settled
+beyond any possibility of modification, but as being fairly indicated
+by these tests.</p>
+
+<div class="block"><p>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 pre&euml;minently a time for character
+building.</p>
+
+<p><span class='pagenum'><a name="Page_128" id="Page_128">[128]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>9. The weight of the girl surpasses that of the boy about a year
+later than her stature surpasses his, and she maintains her
+<span class='pagenum'><a name="Page_129" id="Page_129">[129]</a></span>superiority in weight to a later period of time than she maintains
+her superiority in height.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>13. The development of vital capacity bears a striking resemblance
+to that of endurance, the curves representing the two being almost
+identical.</p></div>
+
+<p>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,&mdash;postpubescent; (2) boys approaching maturity,&mdash;pubescent; (3)
+boys not yet approaching maturity,&mdash;prepubescent.</p>
+
+<p>The work in lower grades they had all passed satisfactorily, but in
+high school only the most advanced class <span class='pagenum'><a name="Page_130" id="Page_130">[130]</a></span>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.</p>
+
+<p>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:</p>
+
+<div class="block"><p>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. An&aelig;mic 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 <span class='pagenum'><a name="Page_131" id="Page_131">[131]</a></span>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.</p></div>
+
+<p>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.<a name="FNanchor_7_7" id="FNanchor_7_7"></a><a href="#Footnote_7_7" class="fnanchor">[7]</a></p>
+
+<p>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 <span class='pagenum'><a name="Page_132" id="Page_132">[132]</a></span>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 <i>The Health of the School Child</i>,
+said ten years ago, while health officer of Leith:</p>
+
+<div class="block"><p>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.</p></div>
+
+<p>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.</p>
+
+<p>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
+<span class='pagenum'><a name="Page_133" id="Page_133">[133]</a></span>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.</p>
+
+<br />
+
+<p class="cen sc">Table X</p>
+
+<p class="cen sc">Cases of Infectious and Contagious Diseases Reported</p>
+
+<br />
+
+<div class="centered">
+<table border="0" cellpadding="2" cellspacing="0" width="95%" summary="Table 10: Cases of Infectious and Contagious Diseases Reported" style="border: 1px black solid;">
+  <tr>
+  <td width="22%" rowspan="2" class="tdctrlb" style="border-top: 1px black solid;">&nbsp;</td>
+  <td colspan="13" class="tdctrlb" style="border-top: 1px black solid;">WEEK ENDING</td>
+  </tr>
+  <tr>
+  <td width="6%" class="tdctrlb" style="border-top: 1px black solid;">Oct. <br />26</td>
+  <td width="6%" class="tdctrlb" style="border-top: 1px black solid;">Nov. <br />2</td>
+  <td width="6%" class="tdctrlb" style="border-top: 1px black solid;">Nov. <br />9</td>
+  <td width="6%" class="tdctrlb" style="border-top: 1px black solid;">Nov. <br />16</td>
+  <td width="6%" class="tdctrlb" style="border-top: 1px black solid;">Nov. <br />23</td>
+  <td width="6%" class="tdctrlb" style="border-top: 1px black solid;">Nov. <br />30</td>
+  <td width="6%" class="tdctrlb" style="border-top: 1px black solid;">Dec. <br />7</td>
+  <td width="6%" class="tdctrlb" style="border-top: 1px black solid;">Dec. <br />14</td>
+  <td width="6%" class="tdctrlb" style="border-top: 1px black solid;">Dec. <br />21</td>
+  <td width="6%" class="tdctrlb" style="border-top: 1px black solid;">Dec. <br />28</td>
+  <td width="6%" class="tdctrlb" style="border-top: 1px black solid;">Jan. <br />4</td>
+  <td width="6%" class="tdctrlb" style="border-top: 1px black solid;">Jan. <br />11</td>
+  <td width="6%" class="tdctrlb" style="border-top: 1px black solid;">Jan. <br />18</td>
+  </tr>
+  <tr>
+  <td class="tdlrl" style="border-top: 1px black solid; padding-top: .5em;">Tuberculosis pulmonalis</td>
+  <td class="tdrprl2" style="border-top: 1px black solid; padding-top: .5em;">350</td>
+  <td class="tdrprl2" style="border-top: 1px black solid; padding-top: .5em;">350</td>
+  <td class="tdrprl2" style="border-top: 1px black solid; padding-top: .5em;">317</td>
+  <td class="tdrprl2" style="border-top: 1px black solid; padding-top: .5em;">364</td>
+  <td class="tdrprl2" style="border-top: 1px black solid; padding-top: .5em;">345</td>
+  <td class="tdrprl2" style="border-top: 1px black solid; padding-top: .5em;">337</td>
+  <td class="tdrprl2" style="border-top: 1px black solid; padding-top: .5em;">422</td>
+  <td class="tdrprl2" style="border-top: 1px black solid; padding-top: .5em;">360</td>
+  <td class="tdrprl2" style="border-top: 1px black solid; padding-top: .5em;">354</td>
+  <td class="tdrprl2" style="border-top: 1px black solid; padding-top: .5em;">308</td>
+  <td class="tdrprl2" style="border-top: 1px black solid; padding-top: .5em;">344</td>
+  <td class="tdrprl2" style="border-top: 1px black solid; padding-top: .5em;">432</td>
+  <td class="tdrprl2" style="border-top: 1px black solid; padding-top: .5em;">402</td>
+  </tr>
+  <tr>
+  <td class="tdlrl">Diphtheria and croup</td>
+  <td class="tdrprl2">313</td>
+  <td class="tdrprl2">264</td>
+  <td class="tdrprl2">283</td>
+  <td class="tdrprl2">331</td>
+  <td class="tdrprl2">282</td>
+  <td class="tdrprl2">343</td>
+  <td class="tdrprl2">326</td>
+  <td class="tdrprl2">369</td>
+  <td class="tdrprl2">338</td>
+  <td class="tdrprl2">347</td>
+  <td class="tdrprl2">308</td>
+  <td class="tdrprl2">370</td>
+  <td class="tdrprl2">406</td>
+  </tr>
+  <tr>
+  <td class="tdlrl">Measles</td>
+  <td class="tdrprl2">142</td>
+  <td class="tdrprl2">212</td>
+  <td class="tdrprl2">203</td>
+  <td class="tdrprl2">261</td>
+  <td class="tdrprl2">293</td>
+  <td class="tdrprl2">323</td>
+  <td class="tdrprl2">472</td>
+  <td class="tdrprl2">471</td>
+  <td class="tdrprl2">517</td>
+  <td class="tdrprl2">346</td>
+  <td class="tdrprl2">581</td>
+  <td class="tdrprl2">691</td>
+  <td class="tdrprl2">803</td>
+  </tr>
+  <tr>
+  <td class="tdlrl">Scarlet fever</td>
+  <td class="tdrprl2">208</td>
+  <td class="tdrprl2">228</td>
+  <td class="tdrprl2">231</td>
+  <td class="tdrprl2">252</td>
+  <td class="tdrprl2">278</td>
+  <td class="tdrprl2">323</td>
+  <td class="tdrprl2">372</td>
+  <td class="tdrprl2">397</td>
+  <td class="tdrprl2">417</td>
+  <td class="tdrprl2">426</td>
+  <td class="tdrprl2">478</td>
+  <td class="tdrprl2">562</td>
+  <td class="tdrprl2">585</td>
+  </tr>
+  <tr>
+  <td class="tdlrl">Smallpox</td>
+  <td class="tdrprl2">&mdash;</td>
+  <td class="tdrprl2">1</td>
+  <td class="tdrprl2">&mdash;</td>
+  <td class="tdrprl2">1</td>
+  <td class="tdrprl2">&mdash;</td>
+  <td class="tdrprl2">&mdash;</td>
+  <td class="tdrprl2">2</td>
+  <td class="tdrprl2">4</td>
+  <td class="tdrprl2">3</td>
+  <td class="tdrprl2">2</td>
+  <td class="tdrprl2">&mdash;</td>
+  <td class="tdrprl2">2</td>
+  <td class="tdrprl2">&mdash;</td>
+  </tr>
+  <tr>
+  <td class="tdlrl">Varicella</td>
+  <td class="tdrprl2">40</td>
+  <td class="tdrprl2">83</td>
+  <td class="tdrprl2">91</td>
+  <td class="tdrprl2">162</td>
+  <td class="tdrprl2">136</td>
+  <td class="tdrprl2">115</td>
+  <td class="tdrprl2">167</td>
+  <td class="tdrprl2">160</td>
+  <td class="tdrprl2">198</td>
+  <td class="tdrprl2">123</td>
+  <td class="tdrprl2">98</td>
+  <td class="tdrprl2">199</td>
+  <td class="tdrprl2">169</td>
+  </tr>
+  <tr>
+  <td class="tdlrl">Typhoid fever</td>
+  <td class="tdrprl2">106</td>
+  <td class="tdrprl2">105</td>
+  <td class="tdrprl2">107</td>
+  <td class="tdrprl2">123</td>
+  <td class="tdrprl2">86</td>
+  <td class="tdrprl2">77</td>
+  <td class="tdrprl2">71</td>
+  <td class="tdrprl2">62</td>
+  <td class="tdrprl2">35</td>
+  <td class="tdrprl2">42</td>
+  <td class="tdrprl2">37</td>
+  <td class="tdrprl2">55</td>
+  <td class="tdrprl2">36</td>
+  </tr>
+  <tr>
+  <td class="tdlrl">Whooping cough</td>
+  <td class="tdrprl2">6</td>
+  <td class="tdrprl2">13</td>
+  <td class="tdrprl2">15</td>
+  <td class="tdrprl2">14</td>
+  <td class="tdrprl2">27</td>
+  <td class="tdrprl2">9</td>
+  <td class="tdrprl2">8</td>
+  <td class="tdrprl2">12</td>
+  <td class="tdrprl2">19</td>
+  <td class="tdrprl2">3</td>
+  <td class="tdrprl2">25</td>
+  <td class="tdrprl2">24</td>
+  <td class="tdrprl2">14</td>
+  </tr>
+  <tr>
+  <td class="tdlrl" style="border-bottom: 1px black solid; padding-bottom: .5em;">Cerebro-spinal meningitis</td>
+  <td class="tdrprl2" style="border-bottom: 1px black solid; padding-bottom: .5em;">6</td>
+  <td class="tdrprl2" style="border-bottom: 1px black solid; padding-bottom: .5em;">11</td>
+  <td class="tdrprl2" style="border-bottom: 1px black solid; padding-bottom: .5em;">3</td>
+  <td class="tdrprl2" style="border-bottom: 1px black solid; padding-bottom: .5em;">4</td>
+  <td class="tdrprl2" style="border-bottom: 1px black solid; padding-bottom: .5em;">4</td>
+  <td class="tdrprl2" style="border-bottom: 1px black solid; padding-bottom: .5em;">8</td>
+  <td class="tdrprl2" style="border-bottom: 1px black solid; padding-bottom: .5em;">15</td>
+  <td class="tdrprl2" style="border-bottom: 1px black solid; padding-bottom: .5em;">13</td>
+  <td class="tdrprl2" style="border-bottom: 1px black solid; padding-bottom: .5em;">7</td>
+  <td class="tdrprl2" style="border-bottom: 1px black solid; padding-bottom: .5em;">6 </td>
+  <td class="tdrprl2" style="border-bottom: 1px black solid; padding-bottom: .5em;">11</td>
+  <td class="tdrprl2" style="border-bottom: 1px black solid; padding-bottom: .5em;">16</td>
+  <td class="tdrprl2" style="border-bottom: 1px black solid; padding-bottom: .5em;">13</td>
+  </tr>
+  <tr>
+  <td class="tdlrl" style="border-top: 1px black solid; border-bottom: 1px black solid; padding-bottom: .5em; padding-top: .5em;">Total</td>
+  <td class="tdrprl2" style="border-top: 1px black solid; border-bottom: 1px black solid; padding-bottom: .5em; padding-top: .5em;">1171</td>
+  <td class="tdrprl2" style="border-top: 1px black solid; border-bottom: 1px black solid; padding-bottom: .5em; padding-top: .5em;">1267</td>
+  <td class="tdrprl2" style="border-top: 1px black solid; border-bottom: 1px black solid; padding-bottom: .5em; padding-top: .5em;">1250</td>
+  <td class="tdrprl2" style="border-top: 1px black solid; border-bottom: 1px black solid; padding-bottom: .5em; padding-top: .5em;">1512</td>
+  <td class="tdrprl2" style="border-top: 1px black solid; border-bottom: 1px black solid; padding-bottom: .5em; padding-top: .5em;">1451</td>
+  <td class="tdrprl2" style="border-top: 1px black solid; border-bottom: 1px black solid; padding-bottom: .5em; padding-top: .5em;">1535</td>
+  <td class="tdrprl2" style="border-top: 1px black solid; border-bottom: 1px black solid; padding-bottom: .5em; padding-top: .5em;">1855</td>
+  <td class="tdrprl2" style="border-top: 1px black solid; border-bottom: 1px black solid; padding-bottom: .5em; padding-top: .5em;">1844</td>
+  <td class="tdrprl2" style="border-top: 1px black solid; border-bottom: 1px black solid; padding-bottom: .5em; padding-top: .5em;">1888</td>
+  <td class="tdrprl2" style="border-top: 1px black solid; border-bottom: 1px black solid; padding-bottom: .5em; padding-top: .5em;">1603</td>
+  <td class="tdrprl2" style="border-top: 1px black solid; border-bottom: 1px black solid; padding-bottom: .5em; padding-top: .5em; padding-top: .5em;">1882</td>
+  <td class="tdrprl2" style="border-top: 1px black solid; border-bottom: 1px black solid; padding-bottom: .5em; padding-top: .5em;">2351</td>
+  <td class="tdrprl2" style="border-top: 1px black solid; border-bottom: 1px black solid; padding-bottom: .5em; padding-top: .5em;">2428</td>
+  </tr>
+</table>
+</div>
+
+<br />
+
+<p>In cities where physicians are not compelled to notify the health
+board of danger centers,&mdash;that is, of patients sick from measles,
+smallpox, or diphtheria,&mdash;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 <span class='pagenum'><a name="Page_134" id="Page_134">[134]</a></span>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.</p>
+
+<div class="img">
+<a href="images/imagep134.jpg">
+<img border="0" src="images/imagep134.jpg" width="80%" alt="Vital Statistics Can Make Disease Centers As Obvious And As Offensive As The Smoke Nuisance" /></a><br />
+<p class="cen" style="margin-top: .2em;">VITAL STATISTICS CAN MAKE DISEASE CENTERS AS OBVIOUS AND AS OFFENSIVE AS THE SMOKE NUISANCE</p>
+</div>
+
+<p>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. <span class='pagenum'><a name="Page_135" id="Page_135">[135]</a></span>Five economic reasons are assigned for
+establishing a national department of health:</p>
+
+<div class="block"><p>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.</p>
+
+<p>2. To lessen the burden of unproductive years by increasing the
+average age at death.</p>
+
+<p>3. To decrease the burden of death on the productive years by
+increasing the age at death.</p>
+
+<p>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.</p>
+
+<p>5. To decrease the amounts spent on criminality that can be traced
+to overcrowded, unwholesome, and unhygienic environment.</p>
+
+<p>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.</p>
+
+<p>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,&mdash;a vast preventive machine working
+ceaselessly,&mdash;an attempt at least would be made to stanch those
+prodigal wastes of an old yet wastrel world.</p></div>
+
+<p>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; <span class='pagenum'><a name="Page_136" id="Page_136">[136]</a></span>disseminating health information; research libraries and
+equipment; statistical clearing house for information.</p>
+
+<p>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.</p>
+
+<p>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 <i>do things</i> when they should
+have chosen to <i>get things done</i>. 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.</p>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_137" id="Page_137">[137]</a></span>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.</p>
+
+<p>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
+<span class='pagenum'><a name="Page_138" id="Page_138">[138]</a></span>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.</p>
+
+<p>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,&mdash;desire to know, unit of
+inquiry, count, comparison, percentages, classification, and summary.</p>
+
+<br />
+<hr style="width: 15%;" />
+<br />
+
+<h4>FOOTNOTES:</h4>
+
+<div class="footnote"><p class="noin"><a name="Footnote_7_7" id="Footnote_7_7"></a><a href="#FNanchor_7_7"><span class="label">[7]</span></a> Dr. Arthur Newsholme's <i>Vital Statistics</i> should be in
+public libraries and on the shelves of health officers,
+public-spirited physicians, and school superintendents.</p></div>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_XIV" id="CHAPTER_XIV"></a><hr />
+<span class='pagenum'><a name="Page_139" id="Page_139">[139]</a></span><br />
+
+<h3>CHAPTER XIV<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>IS YOUR SCHOOL MANUFACTURING PHYSICAL DEFECTS?</h4>
+<br />
+
+<p>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.<a name="FNanchor_8_8" id="FNanchor_8_8"></a><a href="#Footnote_8_8" class="fnanchor">[8]</a> 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."</p>
+
+<p>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.<a name="FNanchor_9_9" id="FNanchor_9_9"></a><a href="#Footnote_9_9" class="fnanchor">[9]</a> The results, <span class='pagenum'><a name="Page_140" id="Page_140">[140]</a></span>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.</p>
+
+<div class="img">
+<a href="images/imagep140.jpg">
+<img border="0" src="images/imagep140.jpg" width="80%" alt="One Of New York City's Roof Playgrounds" /></a><br />
+<p class="cen" style="margin-top: .2em;">ONE OF NEW YORK CITY'S ROOF PLAYGROUNDS</p>
+</div>
+
+<p>Recently I noticed that our little office girl, so an&aelig;mic 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 <span class='pagenum'><a name="Page_141" id="Page_141">[141]</a></span>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.</p>
+
+<div class="img">
+<a href="images/imagep141.jpg">
+<img border="0" src="images/imagep141.jpg" width="80%" alt="Bone Tuberculosis Is One Of The Penalties For Dry Sweeping And Feather Dusters" /></a><br />
+<p class="cen" style="margin-top: .2em;">BONE TUBERCULOSIS IS ONE OF THE PENALTIES FOR DRY SWEEPING AND FEATHER DUSTERS</p>
+</div>
+
+<p>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 <span class='pagenum'><a name="Page_142" id="Page_142">[142]</a></span>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 an&aelig;mic 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.</p>
+
+<p>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."</p>
+
+<p>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.</p>
+
+<br />
+
+<p class="cen sc">I. Neighborhood Health Resources</p>
+
+<div class="block">
+<p>1. Is the district congested?</p>
+
+<p>2. Is congestion growing?</p>
+
+<p>3. How far away is the nearest public park?</p>
+
+  <div class="block">
+    <p class="noin"><i>a.</i> Is it large enough?<br />
+    <i>b.</i> Has it a playground or beauty spot?<br />
+    <i>c.</i> Has it swings and games?<br />
+    <span class='pagenum'><a name="Page_143" id="Page_143">[143]</a></span><i>d.</i> Is play supervised?<br />
+    <i>e.</i> Have children of different ages equal opportunities, or do
+         the large children monopolize the ground?<br />
+    <i>f.</i> Are children encouraged by teachers and parents to use this
+         park?</p>
+  </div>
+
+<p>4. Are the streets suitable for play?</p>
+
+  <div class="block">
+    <p class="noin"><i>a.</i> Does the sun reach them?<br />
+    <i>b.</i> Are they broad?<br />
+    <i>c.</i> Are they crowded with traffic?</p>
+  </div>
+
+<p>5. How far away is the nearest public bath?</p>
+
+  <div class="block">
+    <p class="noin"><i>a.</i> Has it a swimming pool?<br />
+    <i>b.</i> Has it showers?<br />
+    <i>c.</i> Is it used as an annex to the school?</p>
+  </div>
+</div>
+
+<div class="img">
+<a href="images/imagep143.jpg">
+<img border="0" src="images/imagep143.jpg" width="80%" alt="Vacation-school Play Clinic On A &quot;Vacant&quot; City Lot Owned By The Rockefeller Institute For Medical Research" /></a><br />
+<p class="cen" style="margin-top: .2em;">VACATION-SCHOOL PLAY CLINIC ON A "VACANT" CITY LOT <br />OWNED BY THE ROCKEFELLER INSTITUTE FOR MEDICAL RESEARCH</p>
+</div>
+
+
+<p class="cen sc">II. Effect of School Equipment upon Health</p>
+
+<div class="block">
+ <p>1. Is there an indoor yard?</p>
+
+  <div class="block">
+    <p class="noin"><i>a.</i> Is the area adequate or inadequate?<br />
+    <i>b.</i> Is the floor wood, cement, or dirt?<br />
+    <span class='pagenum'><a name="Page_144" id="Page_144">[144]</a></span><i>c.</i> Is the heat adequate or deficient?<br />
+    <i>d.</i> Is the ventilation adequate or deficient?<br />
+    <i>e.</i> Is the daylight adequate, deficient, or almost lacking?<br />
+    <i>f.</i> Is there equipment for light gymnastics and games?<br />
+    <i>g.</i> Is it used out of school hours; by special classes, athletic
+         teams, etc., or by pupils generally?</p>
+  </div>
+
+<p>2. Is there an outdoor yard?</p>
+
+  <div class="block">
+    <p class="noin"><i>a.</i> Is the area ample or inadequate?<br />
+    <i>b.</i> Is the area mainly occupied by toilets?<br />
+    <i>c.</i> Is the daylight sufficient or deficient?<br />
+    <i>d.</i> For how many hours does the sun reach it?<br />
+    <i>e.</i> Is it equipped for games?<br />
+    <i>f.</i> How much larger ought it to be?<br />
+    <i>g.</i> Is it used out of school hours; by special classes, athletic
+         teams, etc., or by pupils generally?</p>
+  </div>
+
+<p>3. Is there a gymnasium?</p>
+
+  <div class="block">
+    <p class="noin"><i>a.</i> Is it large enough?<br />
+    <i>b.</i> Is it used for a gymnasium?<br />
+    <i>c.</i> Is it cut up into class rooms?<br />
+    <i>d.</i> Is it used out of school hours; by special classes, athletic
+         teams, etc., or by pupils generally?</p>
+  </div>
+
+<p>4. Is there a roof playground?</p>
+
+  <div class="block">
+    <p class="noin"><i>a.</i> Is there open ventilation?<br />
+    <i>b.</i> Is it used in the daytime?<br />
+    <i>c.</i> Is it used at night?<br />
+    <i>d.</i> Is it used during the summer?<br />
+    <i>e.</i> Is it monopolized by the larger children?<br />
+    <i>f.</i> Is it used out of school hours; by special classes, athletic
+         teams, etc., or by pupils generally?</p>
+  </div>
+
+<p>5. Are washing facilities adequate?</p>
+
+  <div class="block">
+    <p class="noin"><i>a.</i> How many pupils per washbasin?<br />
+    <i>b.</i> Are there individual towels?<br />
+    <i>c.</i> Have eye troubles been spread by roller towels?<br />
+    <i>d.</i> Are only clean towels permitted?<br />
+    <i>e.</i> Are there bathing facilities; are these adequate?<br />
+    <i>f.</i> Are swimming pools used for games, contests, etc.?<br />
+    <span class='pagenum'><a name="Page_145" id="Page_145">[145]</a></span><i>g.</i> Are bathing facilities used out of school hours?<br />
+    <i>h.</i> Who is responsible for cleanliness of towels, washbasins,
+         and swimming pools?<br />
+    <i>i.</i> How often is water changed in swimming pool, or is it
+         constantly changing?</p>
+  </div>
+
+<p>6. Is adequate provision made for clean drinking water?</p>
+
+  <div class="block">
+    <p class="noin"><i>a.</i> Are sanitary fountains used that prevent contamination of
+         faucet or water?<br />
+    <i>b.</i> How often are cups or faucets cleaned?</p>
+  </div>
+
+<p>7. Is provision made for airing outer clothing?</p>
+
+  <div class="block">
+    <p class="noin"><i>a.</i> Are children permitted to pile their clothing in the class
+         room?<br />
+    <i>b.</i> Are there hooks for each child?<br />
+    <i>c.</i> Are lockers provided with wire netting to permit
+         ventilation?<br />
+    <i>d.</i> Are lockers or hooks in the halls or in the basement?<br />
+    <i>e.</i> Have you ever thought of the disciplinary and social value
+         of cheap coat hangers to prevent wrinkling and tearing?</p>
+  </div>
+</div>
+
+<div class="img">
+<a href="images/imagep145.jpg">
+<img border="0" src="images/imagep145.jpg" width="80%" alt="An Attempt To Overcome The Disadvantages Of Congestion--A Boys' High School, New York City" /></a><br />
+<p class="cen" style="margin-top: .2em;">AN ATTEMPT TO OVERCOME THE DISADVANTAGES OF CONGESTION&mdash;A BOYS' HIGH SCHOOL, NEW YORK CITY</p>
+</div>
+
+
+<p class="cen sc"><span class='pagenum'><a name="Page_146" id="Page_146">[146]</a></span>III. The Class Room as a Place of Confinement</p>
+
+<div class="block">
+<p>1. How many sittings are provided?</p>
+
+  <div class="block">
+    <i>a.</i> How many pupils are there?
+  </div>
+
+<p>2. What is the total floor area?</p>
+
+  <div class="block">
+    <p class="noin"><i>a.</i> What proportion is not occupied by desks?</p>
+  </div>
+
+<p>3. Are the seats adjustable?</p>
+
+  <div class="block">
+    <p class="noin"><i>a.</i> Are the seats adjusted to pupils?<br />
+    <i>b.</i> 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?<br />
+    <i>c.</i> Are seats placed properly with reference to light?</p>
+  </div>
+
+<p>4. Is the light ample and proper?</p>
+
+  <div class="block">
+    <p class="noin"><i>a.</i> For how many hours must artificial light be used in the
+         daytime?<br />
+    <i>b.</i> Is artificial light adequate for night work?<br />
+    <i>c.</i> Does the reflection of light from blackboard and walls
+         injure the eye?<br />
+    <i>d.</i> Are the blackboards black enough?<br />
+    <i>e.</i> Are the walls too dark?<br />
+    <i>f.</i> Is the woodwork too dark?<br />
+    <i>g.</i> Are window panes kept clean?</p>
+  </div>
+
+<p>5. Is the air always fresh?</p>
+
+  <div class="block">
+    <p class="noin"><i>a.</i> Is ventilation by open windows?<br />
+    <i>b.</i> Is ventilation artificial?<br />
+    <i>c.</i> Does the ventilating apparatus work satisfactorily?<br />
+    <i>d.</i> Are the windows thrown open during recess, and after and
+         before school?<br />
+    <i>e.</i> Do unclean clothes vitiate the atmosphere?<br />
+    <i>f.</i> Do unclean persons vitiate the atmosphere?<br />
+    <i>g.</i> Does bad breath vitiate the atmosphere?<br />
+    <i>h.</i> 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?</p>
+  </div>
+
+<p><span class='pagenum'><a name="Page_147" id="Page_147">[147]</a></span>6. Is the temperature properly regulated?</p>
+
+  <div class="block">
+    <p class="noin"><i>a.</i> Has every class room a thermometer?<br />
+    <i>b.</i> Are teachers required to record the thermometer's story
+         three or more times daily?<br />
+    <i>c.</i> Is excess or deficiency at once reported to the janitor?</p>
+  </div>
+
+<p>7. Are the floors, walls, desks, and windows always clean?</p>
+
+  <div class="block">
+    <p class="noin"><i>a.</i> How often are they washed?<br />
+    <i>b.</i> Is twice a year often enough?<br />
+    <i>c.</i> Do the floors and walls contain the dust of years?<br />
+    <i>d.</i> Is dry sweeping prohibited?<br />
+    <i>e.</i> Has wet sawdust or even wet sand been tried?<br />
+    <i>f.</i> Has oil ever been used to keep down surface dust on floors?<br />
+    <i>g.</i> Are feather dusters prohibited?<br />
+    <i>h.</i> Are dust rags moist or dry?<br />
+    <i>i.</i> Is an odorless disinfectant used?</p>
+  </div>
+
+<p>8. Does overheating prevail?</p>
+
+  <div class="block">
+    <p class="noin"><i>a.</i> 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"?</p>
+  </div>
+</div>
+
+<br />
+
+<p class="cen sc">IV. Exercise and Recreation</p>
+
+<div class="block">
+<p>1. How much time and at what periods is exercise provided for in the
+    school schedule?</p>
+
+  <div class="block">
+    <p class="noin"><i>a.</i> Indoors?<br />
+    <i>b.</i> Outdoors?</p>
+  </div>
+
+<p>2. How much exercise indoors and outdoors is actually given?</p>
+
+<p>3. Are the windows open during exercise?</p>
+
+<p>4. Is exercise suited to each child by the school physician after
+    physical examination, or are all children compelled to take the
+    same exercise?</p>
+
+<p>5. Whose business is it to see that rules regarding exercise are
+    strictly enforced?</p>
+
+<p><span class='pagenum'><a name="Page_148" id="Page_148">[148]</a></span>6. Do clouds of dust rise from the floor during exercise and play?</p>
+
+<p>7. Are children deprived of exercise as a penalty?</p>
+
+<p>8. Should hygiene talks be considered as exercise?</p>
+</div>
+
+<div class="img">
+<a href="images/imagep148.jpg">
+<img border="0" src="images/imagep148.jpg" width="80%" alt="Home Workshops Need Fresh Air" /></a><br />
+<p class="cen" style="margin-top: .2em;">HOME WORKSHOPS NEED FRESH AIR</p>
+</div>
+
+<p class="cen sc">V. The School Janitor and Cleaners</p>
+
+<div class="block">
+<p>1. Do they understand the relation of cleanliness to vitality?</p>
+
+<p>2. Is their aim to do the least possible amount of work, or to attain
+    the highest possible standard of cleanliness?</p>
+
+<p>3. Will the teacher's complaint of uncleanliness be heeded by
+    trustees? If so, is the teacher not responsible for uncleanliness?</p>
+
+<p>4. Have you ever tried to stimulate the pride of janitors and
+    cleaners for social service?</p>
+
+  <div class="block">
+    <p class="noin"><i>a.</i> Have you ever tried to show them how much work they save
+         themselves by thorough cleansing?<br />
+    <i>b.</i> Have you ever shown them the danger, to their own health, of
+         dust and dirt that may harbor infection and reduce their own
+         vitality?</p>
+  </div>
+
+<p><span class='pagenum'><a name="Page_149" id="Page_149">[149]</a></span>5. What effort is made to instruct janitors and cleaners by your
+    school trustees or by your community?</p>
+
+<p>6. Have you explained to pupils the important responsibility of
+    janitors for the health of those in the tenements, office
+    buildings, or schools?</p>
+
+  <div class="block">
+    <i>a.</i> Do you see in this an opportunity to emphasize indirectly
+         the mother's responsibility for cleanliness of home?
+  </div>
+</div>
+
+<div class="img">
+<a href="images/imagep149.jpg">
+<img border="0" src="images/imagep149.jpg" width="80%" alt="School Workshops Also Need Fresh Air" /></a><br />
+<p class="cen" style="margin-top: .2em;">SCHOOL WORKSHOPS ALSO NEED FRESH AIR</p>
+</div>
+
+
+<p class="cen sc">VI. Requirements of Curriculum</p>
+
+<div class="block">
+<p>1. How much home study is there?</p>
+
+  <div class="block">
+    <p class="noin"><i>a.</i> How much is required?<br />
+    <i>b.</i> What steps are taken to prevent excessive home study?<br />
+    <i>c.</i> Are light and ventilation conditions at home considered when
+         deciding upon amount of home study?</p>
+  </div>
+
+<p>2. Is the child fitted to the curriculum, or is the curriculum
+    fitted to the child?</p>
+
+  <div class="block">
+    <p class="noin"><i>a.</i> Does failure or backwardness in studies lead to additional
+         study hours or to regrading?<br />
+    <i>b.</i> Are there too many subjects?<br />
+    <i>c.</i> Are the recitation periods too long?<br />
+    <i>d.</i> Are the exercise periods too short and too few?<br />
+    <i>e.</i> Is there too much close-range work?<br />
+    <span class='pagenum'><a name="Page_150" id="Page_150">[150]</a></span><i>f.</i> Is it possible to give individual attention to individual
+         needs so as to awaken individual interest?</p>
+  </div>
+
+<p>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?</p>
+</div>
+
+<p>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.</p>
+
+<p>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&mdash;the
+formative years of their lives&mdash;is neither injuring their health nor
+retarding their full development.</p>
+
+<p>If the amount of "close-range" work is rapidly manufacturing myopic
+eyes; if bad ventilation, whether due to <span class='pagenum'><a name="Page_151" id="Page_151">[151]</a></span>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.</p>
+
+<p>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.</p>
+
+<br />
+
+<p class="cen sc">Table XI</p>
+
+<p class="cen sc">Effects of a Child Labor Law</p>
+
+<p class="cen">Increase in Chicago Attendance</p>
+
+<div class="img">
+<img border="0" src="images/imagep151.jpg" width="80%" alt="Table XI: Effects of a Child Labor Law" /><br />
+</div>
+
+<br />
+<hr style="width: 15%;" />
+<br />
+
+<h4>FOOTNOTES:</h4>
+
+<div class="footnote"><p class="noin"><a name="Footnote_8_8" id="Footnote_8_8"></a><a href="#FNanchor_8_8"><span class="label">[8]</span></a> <i>The Sanitation of Public Buildings</i>, by William Paul
+Gerhard, contains a valuable discussion of how the school may avoid
+manufacturing physical defects.</p></div>
+
+<div class="footnote"><p class="noin"><a name="Footnote_9_9" id="Footnote_9_9"></a><a href="#FNanchor_9_9"><span class="label">[9]</span></a> 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.</p></div>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_XV" id="CHAPTER_XV"></a><hr />
+<span class='pagenum'><a name="Page_152" id="Page_152">[152]</a></span><br />
+
+<h3>CHAPTER XV<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>THE TEACHER'S HEALTH</h4>
+<br />
+
+<p>"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:</p>
+
+<div class="block"><p>1. School conditions that injure child health also injure teacher
+health.</p>
+
+<p>2. Poor health of teacher causes poor health of pupil.</p>
+
+<p>3. Poor health of pupil often causes poor health of teacher.</p>
+
+<p>4. Adequate protection of children requires adequate protection of
+their teachers.</p>
+
+<p>5. Teachers have a right to health protection for their own sake
+as well as for their children's sake.</p></div>
+
+<p>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,&mdash;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.
+<span class='pagenum'><a name="Page_153" id="Page_153">[153]</a></span>Experience everywhere else proves that periodic physical examinations
+and health precautions, not essays about "happy teachers&mdash;happy
+pupils," are indispensable if teachers' health rights are to be
+protected.</p>
+
+<p>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,&mdash;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.</p>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_154" id="Page_154">[154]</a></span>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.</p>
+
+<p>Three objections to physical tests for teachers will be urged, but
+each loses its force when considered in the light of general
+experience.</p>
+
+<p>1. <i>A sickly teacher is often the most efficient teacher in a school
+or a county.</i> 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.</p>
+
+<p>2. <i>There are not enough healthy candidates to supply our schools.</i>
+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,&mdash;after we all believe
+what leading educators now believe, that the highest fulfillment of
+human possibilities requires a normal, sound body, abounding in
+vitality.</p>
+
+<p>3. <i>Examination by a physician, especially if a social acquaintance,
+is an unnecessary embarrassment.</i> 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. <span class='pagenum'><a name="Page_155" id="Page_155">[155]</a></span>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.</p>
+
+<div class="img">
+<a href="images/imagep155.jpg">
+<img border="0" src="images/imagep155.jpg" width="80%" alt="Teachers will Prefer Physical Examinations to Forced Vacations" /></a><br />
+<p class="cen" style="margin-top: .2em;">TEACHERS WILL PREFER PHYSICAL EXAMINATIONS TO FORCED VACATIONS<br />
+Boston Society for Relief and Study of Tuberculosis</p>
+</div>
+
+<p>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 <span class='pagenum'><a name="Page_156" id="Page_156">[156]</a></span>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,&mdash;follow the pitch of others' voices. Can we then overestimate
+the effect upon pupils' character of teachers who radiate vitality?</p>
+
+<p>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:</p>
+
+<div class="block" style="font-size: 95%;"><p>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.</p>
+
+<p>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."</p>
+
+<p>3. Satisfactory quality and use of voice.</p>
+
+<p>4. Personal bearing, cleanliness, appearance, manners.</p>
+
+<p>5. Self-command and power to win and hold the respect of teachers,
+school authorities, and the community.</p>
+
+<p>6. Capacity for school discipline, power to maintain order and to
+secure the willing obedience and the friendship of pupils.</p>
+
+<p>7. Business or executive ability,&mdash;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.</p>
+
+<p>8. Capacity for supervision, for organization and administration
+of a school, and for the instructing, assisting, and inspiring of
+teachers.</p></div>
+
+<p>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, <span class='pagenum'><a name="Page_157" id="Page_157">[157]</a></span>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 <i>periodic tests</i> by principal,
+superintendent, and school board, <i>to determine the continuing
+fitness</i> 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."</p>
+
+<p>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,&mdash;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
+<span class='pagenum'><a name="Page_158" id="Page_158">[158]</a></span>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.</p>
+
+<br />
+<br />
+<br />
+<br />
+<a name="PART_III_COOPERATION_IN_MEETING_HEALTH_OBLIGATIONS" id="PART_III_COOPERATION_IN_MEETING_HEALTH_OBLIGATIONS"></a><a name="CHAPTER_XVI" id="CHAPTER_XVI"></a><hr />
+<span class='pagenum'><a name="Page_159" id="Page_159">[159]</a></span><br />
+<br />
+<br />
+<br />
+
+<h2 class="wrap">PART III. CO&Ouml;PERATION IN MEETING HEALTH OBLIGATIONS</h2>
+
+<br />
+
+<h3>CHAPTER XVI<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>EUROPEAN REMEDIES: DOING THINGS AT SCHOOL</h4>
+<br />
+
+<p>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
+<i>ends</i> of sanitary administration may be the same in ten communities,
+health <i>machinery</i> should fit a particular community like a
+tailor-made suit.</p>
+
+<p><span class='pagenum'><a name="Page_160" id="Page_160">[160]</a></span>American-like, they had a mania for organization. I once heard an aged
+kindergartner&mdash;the savant of an isolated German village&mdash;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.</p>
+
+<p>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&mdash;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. <span class='pagenum'><a name="Page_161" id="Page_161">[161]</a></span>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.</p>
+
+<p>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."</p>
+
+<p>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 <span class='pagenum'><a name="Page_162" id="Page_162">[162]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_163" id="Page_163">[163]</a></span>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.</p>
+
+<p>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.</p>
+
+<div class="imgr" style="width: 40%;">
+<a href="images/imagep163.jpg">
+<img border="0" src="images/imagep163.jpg" width="95%" alt="A South Ireland Argument For &quot;Doing Things&quot;" /></a><br />
+<p class="cen" style="margin-top: .2em; font-size: 80%;">A SOUTH IRELAND ARGUMENT FOR "DOING THINGS"</p>
+</div>
+
+<p>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 <span class='pagenum'><a name="Page_164" id="Page_164">[164]</a></span>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,&mdash;infinitely cheaper than jails and almshouses,
+truant officers and courthouses.</p>
+
+<p>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
+co&ouml;peration 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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>Initiative and competition are not interrupted any more by free
+eyeglasses and free operation for adenoids than by <span class='pagenum'><a name="Page_165" id="Page_165">[165]</a></span>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.</p>
+
+<p>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?</p>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_XVII" id="CHAPTER_XVII"></a><hr />
+<span class='pagenum'><a name="Page_166" id="Page_166">[166]</a></span><br />
+
+<h3>CHAPTER XVII<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>AMERICAN REMEDIES: GETTING THINGS DONE</h4>
+<br />
+
+<p>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:</p>
+
+<div class="block2"><p class="hang2">1. <i>Study of the physical welfare of school children.</i></p>
+
+<div class="block"><p class="hang2"><i>a.</i> Examination of board of health records of children needing
+medical, dental, or ocular care, and better nourishment.</p>
+
+<p class="hang2"><i>b.</i> Home visitation of such children, in order to ascertain
+whether their need arises from deficient income or from
+other causes.</p>
+
+<p class="hang2"><i>c.</i> Effort to secure proper treatment, either from parents or
+from free clinics or other established agencies.</p>
+
+<p class="hang2"><i>d.</i> Effort to secure proper physical surroundings of children
+while at school&mdash;playgrounds, baths, etc.</p></div>
+
+<p class="hang2">2. <i>Effort to secure establishment of such a system of school
+records and reports</i> as will disclose automatically significant
+school facts,&mdash;e.g. regarding backward pupils, truancy,
+regularity of attendance, registered children not attending,
+sickness, physical defects, etc.</p>
+
+<p class="hang2">3. <i>Effort to utilize available information regarding school needs</i>
+so as to stimulate public interest and thus aid in securing
+adequate appropriations to meet school needs.</p></div>
+
+<p>The committee grew out of the discussion, in the year 1905, of the
+following proposition: <i>To insure a race physically able to receive
+our vaunted free education, we must provide at school free meals, free
+eyeglasses, free medical <span class='pagenum'><a name="Page_167" id="Page_167">[167]</a></span>and dental care.</i> Thanks to the
+superintendent of schools of New York City, to Robert Hunter's
+<i>Poverty</i>, to John Spargo's <i>Bitter Cry of the Children</i>, 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.</p>
+
+<p>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 <i>doing things</i>. 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
+<i>doing things at school</i> 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 <span class='pagenum'><a name="Page_168" id="Page_168">[168]</a></span>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."</p>
+
+<p>During one year of investigation and of <i>getting things done</i> 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&mdash;curriculum, buildings, home-study requirements, play
+space and playtime, physical culture&mdash;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.</p>
+
+<p>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:</p>
+
+<div class="block" style="font-size: 95%;"><p>1. Physical defects found in public schools are, for the most<span class='pagenum'><a name="Page_169" id="Page_169">[169]</a></span>
+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.</p>
+
+<p>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.</p>
+
+<p>3. Children whose parents have long lived in the United States
+need attention quite as much as the recent immigrant.</p>
+
+<p>4. A large part of the defects reported could be produced by
+conditions due directly to neglect of teeth.</p></div>
+
+<p>From twenty such statements of fact and from its experience in
+<i>getting things done</i> for one year, the committee drew fifteen
+practical conclusions, among which the following deserve emphasis
+here:</p>
+
+<div class="block"><p>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.</p>
+
+<p>2. <i>Physical deterioration</i>, 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 <span class='pagenum'><a name="Page_170" id="Page_170">[170]</a></span>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.</p>
+
+<p>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.</p>
+
+<div class="imgr" style="width: 25%;">
+<a href="images/imagep171.jpg">
+<img border="0" src="images/imagep171.jpg" width="90%" alt="The Dark-Hall Evil Is Here Indexed By Adenoids." /></a><br />
+<p class="cen" style="margin-top: .2em; font-size: 80%; margin-left: .5em; margin-right: .5em;">THE DARK-HALL EVIL IS HERE INDEXED BY ADENOIDS.</p>
+</div>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>6. <i>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.</i></p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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
+<span class='pagenum'><a name="Page_171" id="Page_171">[171]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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.</p></div>
+
+<p>How the committee got things done is often referred to. There is
+something about a request for co&ouml;peration, 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 co&ouml;perate with school-teachers when invited,
+for the same reason and <span class='pagenum'><a name="Page_172" id="Page_172">[172]</a></span>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.</p>
+
+<div class="img">
+<a href="images/imagep172.jpg">
+<img border="0" src="images/imagep172.jpg" width="80%" alt="Where &quot;Getting Things Done&quot; Is Possible But &quot;Doing Things&quot; Ineffective" /></a><br />
+<p class="cen" style="margin-top: .2em;">WHERE "GETTING THINGS DONE" IS POSSIBLE BUT "DOING THINGS" INEFFECTIVE</p>
+</div>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_173" id="Page_173">[173]</a></span>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.</p>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_XVIII" id="CHAPTER_XVIII"></a><hr />
+<span class='pagenum'><a name="Page_174" id="Page_174">[174]</a></span><br />
+
+<h3>CHAPTER XVIII<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>CO&Ouml;PERATION WITH DISPENSARIES AND CHILD-SAVING AGENCIES</h4>
+<br />
+
+<p>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.</p>
+
+<div class="imgr" style="width: 30%;">
+<a href="images/imagep175.jpg">
+<img border="0" src="images/imagep175.jpg" width="90%" alt="Adequate Relief Recognizes The Family As The Unit" /></a><br />
+<p class="cen" style="margin-top: .2em; font-size: 80%;">ADEQUATE RELIEF RECOGNIZES THE FAMILY AS THE UNIT</p>
+</div>
+
+<p>The school that tries to do everything for its pupils without using
+other existing agencies for helping children<a name="FNanchor_10_10" id="FNanchor_10_10"></a><a href="#Footnote_10_10" class="fnanchor">[10]</a> 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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_175" id="Page_175">[175]</a></span>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 <span class='pagenum'><a name="Page_176" id="Page_176">[176]</a></span>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."</p>
+
+<p>Relief at home through existing agencies was brought about by the
+distribution of cards like those on opposite page, which offer winter
+and summer co&ouml;peration.</p>
+
+<div class="img" style="clear: both;">
+<a href="images/imagep176.jpg">
+<img border="0" src="images/imagep176.jpg" width="80%" alt="Fresh-Air Agencies Like Sea Breeze Prefer To Aid Children In Order Of Need" /></a><br />
+<p class="cen" style="margin-top: .2em;">FRESH-AIR AGENCIES LIKE SEA BREEZE PREFER TO AID CHILDREN IN ORDER OF NEED</p>
+</div>
+
+<p>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:</p>
+
+<div class="block"><p>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.</p>
+
+<p>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.</p>
+
+<div class="img"><span class='pagenum'><a name="Page_177" id="Page_177">[177]</a></span>
+<a href="images/imagep177.png">
+<img border="0" style="border: 1px black solid;" src="images/imagep177.png" width="40%" alt="Facsimile of flyer for the New York Association for Improving the Condition of the Poor." /></a><br />
+</div>
+
+<p><span class='pagenum'><a name="Page_178" id="Page_178">[178]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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."</p></div>
+
+<p>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 <span class='pagenum'><a name="Page_179" id="Page_179">[179]</a></span>have added their voice to that of teacher and health officer
+in demanding adequate funds for physical examination of school
+children.</p>
+
+<div class="img">
+<a href="images/imagep179.jpg">
+<img border="0" src="images/imagep179.jpg" width="80%" alt="&quot;Central&quot; Found The Mother Sick in a Hospital, the Father Killed--The Children were Boarded in the Country until the Mother Recovered" /></a><br />
+<p class="cen" style="margin-top: .2em; margin-left: 10%; margin-right: 10%;">"CENTRAL" FOUND THE MOTHER SICK IN A HOSPITAL, THE
+FATHER KILLED&mdash;THE CHILDREN WERE BOARDED IN THE COUNTRY UNTIL THE MOTHER RECOVERED</p>
+</div>
+
+<p>Co&ouml;peration 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 co&ouml;peration 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 <span class='pagenum'><a name="Page_180" id="Page_180">[180]</a></span>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
+<span class='pagenum'><a name="Page_181" id="Page_181">[181]</a></span>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.</p>
+
+<div class="img">
+<a href="images/imagep180.jpg">
+<img border="0" src="images/imagep180.jpg" width="70%" alt="Home-to-Home Instruction in Cooking" /></a><br />
+<p class="cen" style="margin-top: .2em;">HOME-TO-HOME INSTRUCTION IN COOKING<br />An&aelig;mic condition of child due to bad cooking, not to lack of income</p>
+</div>
+
+<p><i>Co&ouml;peration</i> removes the cause of distress; <i>doing</i> 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.</p>
+
+<div class="img"><span class='pagenum'><a name="Page_182" id="Page_182">[182]</a></span>
+<a href="images/imagep182.png">
+<img border="0" src="images/imagep182.png" width="55%" alt="Chart of Social Work, Massachusetts General Hospital" /></a><br />
+</div>
+
+<p><span class='pagenum'><a name="Page_183" id="Page_183">[183]</a></span>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 co&ouml;peration 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. <i>Getting things done</i> is easy because it is human to
+love the <i>doing</i>; getting things done is <i>doing</i> of the highest order.</p>
+
+<br />
+<hr style="width: 15%;" />
+<br />
+
+<h4>FOOTNOTES:</h4>
+
+<div class="footnote"><p class="noin"><a name="Footnote_10_10" id="Footnote_10_10"></a><a href="#FNanchor_10_10"><span class="label">[10]</span></a> The importance of recognizing the family as the unit of
+social treatment is presented in Edward T. Devine's <i>Principles of
+Relief</i>, and in Homer Folks's <i>Care of Dependent, Defective, and
+Delinquent Children</i>.</p></div>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_XIX" id="CHAPTER_XIX"></a><hr />
+<span class='pagenum'><a name="Page_184" id="Page_184">[184]</a></span><br />
+
+<h3>CHAPTER XIX<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>SCHOOL SURGERY AND RELIEF OBJECTIONABLE, IF AVOIDABLE</h4>
+<br />
+
+<p>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.</p>
+
+<p>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
+<span class='pagenum'><a name="Page_185" id="Page_185">[185]</a></span>parents, hospitals, dispensaries, and charitable societies will attend
+to children's needs, then relief at school is unnecessary, even though
+it may seem desirable.</p>
+
+<p>The objection to school surgery should be clearly before us, so that
+we can judge of the two methods that are open to us,&mdash;<i>treatment at
+school</i> vs. <i>treatment away from school</i>.</p>
+
+<p>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.</p>
+
+<div class="img">
+<a href="images/imagep186.jpg">
+<img border="0" src="images/imagep186.jpg" width="52%" alt="&quot;Doing Things&quot; Through Model Tenements" /></a><br />
+<p class="cen" style="margin-top: .2em;">"DOING THINGS" THROUGH MODEL TENEMENTS</p>
+</div>
+
+<p>Do we want to make of our schools miniature hospitals, dispensaries,
+relief bureaus, parks? Or shall we use the <span class='pagenum'><a name="Page_186" id="Page_186">[186]</a></span>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 <span class='pagenum'><a name="Page_187" id="Page_187">[187]</a></span>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 <span class='pagenum'><a name="Page_188" id="Page_188">[188]</a></span>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: <i>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.</i></p>
+
+<div class="img">
+<a href="images/imagep187.jpg">
+<img border="0" src="images/imagep187.jpg" width="52%" alt="Immediately Opposite The Model Tenements, But Uninfluenced" /></a><br />
+<p class="cen" style="margin-top: .2em;">IMMEDIATELY OPPOSITE THE MODEL TENEMENTS, BUT UNINFLUENCED<br />
+"Getting things done" by the Tenement House Department their special need</p>
+</div>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_189" id="Page_189">[189]</a></span>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.</p>
+
+<p>To take <i>palliative measures to public schools</i> not only <i>leaves
+undone remedial</i> work necessary for the health of public school
+children but <i>neglects entirely the still large numbers who go to
+parochial, private pay, and private free schools</i>; 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.</p>
+
+<p>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 <i>to teach and to
+train</i>. 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 <i>do things</i> 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.</p>
+
+<p><i>Getting things done</i> will lead schools to study underlying causes;
+<i>doing things</i> has heretofore caused schools to confine themselves to
+symptoms. <i>Getting things done</i> will leave the school free to
+concentrate its attention upon school problems; <i>doing things</i> will
+lead it afield into the problem of medicine, surgery, restaurant
+keeping, and practical charity.</p>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_XX" id="CHAPTER_XX"></a><hr />
+<span class='pagenum'><a name="Page_190" id="Page_190">[190]</a></span><br />
+
+<h3>CHAPTER XX<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>PHYSICAL EXAMINATION FOR WORKING PAPERS</h4>
+<br />
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_191" id="Page_191">[191]</a></span>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.</p>
+
+<p>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?</p>
+
+<p>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 <span class='pagenum'><a name="Page_192" id="Page_192">[192]</a></span>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!</p>
+
+<div class="img">
+<a href="images/imagep192.jpg">
+<img border="0" src="images/imagep192.jpg" width="80%" alt="Children Enlisting in the Industrial Army" /></a><br />
+<p class="cen" style="margin-top: .2em;">CHILDREN ENLISTING IN THE INDUSTRIAL ARMY</p>
+</div>
+
+<div class="img"><span class='pagenum'><a name="Page_193" id="Page_193">[193]</a></span>
+<a href="images/imagep193.jpg">
+<img border="0" src="images/imagep193.jpg" width="80%" alt="Waiting to be Examined for Working Papers" /></a><br />
+<p class="cen" style="margin-top: .2em;"> WAITING TO BE EXAMINED FOR WORKING PAPERS<br />
+An excellent opportunity for physical-fitness tests</p>
+</div>
+
+<p>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 re&euml;xamined. While designed to <span class='pagenum'><a name="Page_194" id="Page_194">[194]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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,&mdash;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 <span class='pagenum'><a name="Page_195" id="Page_195">[195]</a></span>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 <span class='pagenum'><a name="Page_196" id="Page_196">[196]</a></span>board of health examination and ask to be
+told what his defects are and how to correct them.</p>
+
+<div class="img">
+<a href="images/imagep195.jpg">
+<img border="0" src="images/imagep195.jpg" width="57%" alt="Children at Work below both Age Limit and Vitality Limit" /></a><br />
+<p class="cen" style="margin-top: .2em;">CHILDREN AT WORK BELOW BOTH AGE LIMIT AND VITALITY LIMIT<br />
+National Child Labor Committee</p>
+</div>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_197" id="Page_197">[197]</a></span>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.</p>
+
+<div class="imgr" style="width: 40%;">
+<a href="images/imagep197.jpg">
+<img border="0" src="images/imagep197.jpg" width="90%" alt="The Grenfell Association finds Mouth Breathers at work in Labrador" /></a><br />
+<p class="cen" style="margin-top: .2em; margin-left: 5%; margin-right: 5%; font-size: 80%;">THE GRENFELL ASSOCIATION FINDS MOUTH BREATHERS AT WORK IN LABRADOR</p>
+</div>
+
+<p>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 <span class='pagenum'><a name="Page_198" id="Page_198">[198]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_199" id="Page_199">[199]</a></span>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.</p>
+
+<div class="img">
+<a href="images/imagep199.jpg">
+<img border="0" src="images/imagep199.jpg" width="80%" alt="The Health Department's Clinical Care and Home Instruction come after Wage Losses" /></a><br />
+<p class="cen" style="margin-top: .2em; margin-left: 10%; margin-right: 10%;">THE HEALTH DEPARTMENT'S CLINICAL CARE AND HOME INSTRUCTION COME AFTER WAGE LOSSES,
+WHILE WORK CERTIFICATES PRECEDE BREAKDOWNS FROM TUBERCULOSIS</p>
+</div>
+
+<p>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 <span class='pagenum'><a name="Page_200" id="Page_200">[200]</a></span>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,&mdash;the art of
+self-government for the benefit of all the governed.</p>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_XXI" id="CHAPTER_XXI"></a><hr />
+<span class='pagenum'><a name="Page_201" id="Page_201">[201]</a></span><br />
+
+<h3>CHAPTER XXI<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>PERIODICAL PHYSICAL EXAMINATION AFTER SCHOOL AGE</h4>
+<br />
+
+<p>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,&mdash;failure; because of
+vitality depleted by alcohol, tobacco, overeating, underexercise, or
+too little sleep,&mdash;no power to resist contagious diseases; because of
+ignorance of existing lung trouble,&mdash;a year or more of idleness,
+perhaps poverty for his family; or there is neglected ear or eye
+trouble,&mdash;and thousands of lives may be lost because the engineer
+failed to read the signals.</p>
+
+<p>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 <span class='pagenum'><a name="Page_202" id="Page_202">[202]</a></span>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.</p>
+
+<div class="img">
+<a href="images/imagep202.jpg">
+<img border="0" src="images/imagep202.jpg" width="80%" alt="The Old Southfield, now Anchored at Bellevue Hospital's Dock, New York City" /></a><br />
+<p class="cen" style="margin-top: .2em; margin-left: 10%; margin-right: 10%;">THE OLD SOUTHFIELD, NOW ANCHORED AT BELLEVUE HOSPITAL'S DOCK, NEW YORK CITY,
+GIVES DAILY LESSONS IN THE PREVENTABLE TAX LEVIED BY TUBERCULOSIS</p>
+</div>
+
+<p><span class='pagenum'><a name="Page_203" id="Page_203">[203]</a></span>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.<a name="FNanchor_11_11" id="FNanchor_11_11"></a><a href="#Footnote_11_11" class="fnanchor">[11]</a> 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 <span class='pagenum'><a name="Page_204" id="Page_204">[204]</a></span>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.</p>
+
+<p>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,&mdash;in a hotel, factory, store, ship, college, or
+school,&mdash;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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_205" id="Page_205">[205]</a></span>trouble were due to
+a growth in the nose, corrected in a few minutes by operation.</p>
+
+<p>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,
+<span class='pagenum'><a name="Page_206" id="Page_206">[206]</a></span>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 <span class='pagenum'><a name="Page_207" id="Page_207">[207]</a></span>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.</p>
+
+<div class="img">
+<a href="images/imagep206.jpg">
+<img border="0" src="images/imagep206.jpg" width="50%" alt="New York City's Tuberculosis Sanatorium at Otisville is Sending Home Apostles Of Semi-Annual Examinations" /></a><br />
+<p class="cen" style="margin-top: .2em; margin-left: 15%; margin-right: 15%;">NEW YORK CITY'S TUBERCULOSIS SANATORIUM AT OTISVILLE IS
+SENDING HOME APOSTLES OF SEMI-ANNUAL EXAMINATIONS</p>
+</div>
+
+<div class="img">
+<a href="images/imagep207.jpg">
+<img border="0" src="images/imagep207.jpg" width="80%" alt="Boston's Picturesque Day Camp for Tuberculosis Patients is teaching the need for a Periodic Inventory of Physical Resources" /></a><br />
+<p class="cen" style="margin-top: .2em; margin-left: 10%; margin-right: 10%;">BOSTON'S PICTURESQUE DAY CAMP FOR TUBERCULOSIS PATIENTS
+IS TEACHING THE NEED FOR A PERIODIC INVENTORY OF PHYSICAL RESOURCES</p>
+</div>
+
+<p>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,&mdash;a balance sheet of
+their physical assets and liabilities,&mdash;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.</p>
+
+<br />
+<hr style="width: 15%;" />
+<br />
+
+<h4>FOOTNOTES:</h4>
+
+<div class="footnote"><p class="noin"><a name="Footnote_11_11" id="Footnote_11_11"></a><a href="#FNanchor_11_11"><span class="label">[11]</span></a> See <i>Dangerous Trades</i>, compiled by Thomas Oliver; also
+list of reports by the United States Bureau of Labor.</p></div>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_XXII" id="CHAPTER_XXII"></a><hr />
+<span class='pagenum'><a name="Page_208" id="Page_208">[208]</a></span><br />
+
+<h3>CHAPTER XXII<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>HABITS OF HEALTH PROMOTE INDUSTRIAL EFFICIENCY</h4>
+<br />
+
+<p>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.<a name="FNanchor_12_12" id="FNanchor_12_12"></a><a href="#Footnote_12_12" class="fnanchor">[12]</a> 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.</p>
+
+<p>Eight different elements of industrial efficiency are concerned with
+the individual's health habits,&mdash;the industrial worker, his industrial
+product, his employer, his employer's <span class='pagenum'><a name="Page_209" id="Page_209">[209]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_210" id="Page_210">[210]</a></span>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
+<span class='pagenum'><a name="Page_211" id="Page_211">[211]</a></span>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.</p>
+
+<div class="img">
+<a href="images/imagep210.jpg">
+<img border="0" src="images/imagep210.jpg" width="80%" alt="These Patients on the old Southfield are Taxing Their Unions and Their Trades as well as their Families and the Tuberculosis Committee" /></a><br />
+<p class="cen" style="margin-top: .2em; margin-left: 10%; margin-right: 10%;">THESE PATIENTS ON THE OLD SOUTHFIELD ARE TAXING THEIR
+UNIONS AND THEIR TRADES AS WELL AS THEIR FAMILIES AND THE TUBERCULOSIS COMMITTEE</p>
+</div>
+
+<p>There are exceptions, it is true, where both industrial promotion and
+industrial efficiency are won by people who violate laws of
+health,&mdash;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."</p>
+
+<div class="img">
+<a href="images/imagep211.jpg">
+<img border="0" src="images/imagep211.jpg" width="70%" alt="Habits Of Health Among Dairymen Mean Safe Milk For Babies" /></a><br />
+<p class="cen" style="margin-top: .2em;">HABITS OF HEALTH AMONG DAIRYMEN MEAN SAFE MILK FOR BABIES</p>
+</div>
+
+<p><span class='pagenum'><a name="Page_212" id="Page_212">[212]</a></span>What are the health habits that should become instinctive and
+effortless for every worker? What acts can we make our lower nerve
+centers&mdash;our subconscious selves&mdash;do for us or remind us to do? The
+following constitutes a daily routine that should be as involuntary as
+the process of digestion:</p>
+
+<div class="block"><p>1. Throw the bedding over the foot of the bed.</p>
+
+<p>2. Close the window that has been open during the night.</p>
+
+<p>3. Drink a glass of water.</p>
+
+<p>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.</p>
+
+<p>5. Cleanse the finger nails.</p>
+
+<p>6. Cleanse the teeth, especially the places that are out of sight
+and hard to reach.</p>
+
+<p>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.</p>
+
+<p>8. Visit the toilet; if impracticable at home, have a regular time
+at business.</p>
+
+<p>9. Have several minutes in the open air, preferably walking.</p>
+
+<p>10. Be punctual at work.</p>
+
+<p>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.</p>
+
+<p>12. Eat punctually at noon intermission; enjoy your meal and its
+after effects.</p>
+
+<p>13. Breathe air out of doors a few minutes, preferably walking.</p>
+
+<p>14. Resume business punctually.</p>
+
+<p>15. Stop work regularly.</p>
+
+<p>16. Take out-of-door exercise&mdash;indoor only when fresh air is
+possible&mdash;that you enjoy and that agrees with you.</p>
+
+<p>17. Be regular, temperate, and leisurely in eating the evening
+meal; eat nothing that disagrees with you.</p>
+
+<p>18. Spend the evening profitably and pleasantly and in ways
+compatible with the foregoing habits.</p>
+
+<p><span class='pagenum'><a name="Page_213" id="Page_213">[213]</a></span>19. Retire regularly at a fixed hour, making up for irregularity
+by an earlier hour next night.</p>
+
+<p>20, 21, 22. Repeat 4, 6, 8.</p>
+
+<p>23. Turn underclothes wrong side out for ventilation.</p>
+
+<p>24. Open windows.</p>
+
+<p>25. Relax mind and body and go to sleep.</p></div>
+
+<p>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.</p>
+
+<p>In addition to this daily routine, there are certain other acts that
+should become habitual:</p>
+
+<div class="block"><p>1. Bathing less frequently than once a week is almost as dangerous
+to health as it is to attractiveness.</p>
+
+<p>2. Distaste for unclean linen or undergarments and for acts or
+foods that interfere with vitality should become instinctive.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>5. Periodic physical examination by a physician.</p>
+
+<p>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.</p></div>
+
+<p>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 <span class='pagenum'><a name="Page_214" id="Page_214">[214]</a></span>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.</p>
+
+<div class="img">
+<a href="images/imagep214.jpg">
+<img border="0" src="images/imagep214.jpg" width="80%" alt="Improvised Seaside Hospital for Nonpulmonary Tuberculosis" /></a><br />
+<p class="cen" style="margin-top: .2em; margin-left: 10%; margin-right: 10%;">IMPROVISED SEASIDE HOSPITAL FOR NONPULMONARY
+TUBERCULOSIS AT SEA BREEZE TEACHES PASSERS-BY THE FRESH-AIR GOSPEL</p>
+</div>
+
+<p>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 <span class='pagenum'><a name="Page_215" id="Page_215">[215]</a></span>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,&mdash;by his experience or by the advice of a physician,&mdash;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.</p>
+
+<div class="img">
+<a href="images/imagep215.jpg">
+<img border="0" src="images/imagep215.jpg" width="80%" alt="Crippled Children leaving Sea Breeze Hospital for Bone Tuberculosis Find Stale Air Offensive by Night or by Day" /></a><br />
+<p class="cen" style="margin-top: .2em; margin-left: 10%; margin-right: 10%;">CRIPPLED CHILDREN LEAVING SEA BREEZE HOSPITAL FOR BONE
+TUBERCULOSIS FIND STALE AIR OFFENSIVE BY NIGHT OR BY DAY</p>
+</div>
+
+<p>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. <span class='pagenum'><a name="Page_216" id="Page_216">[216]</a></span>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 co&ouml;perates 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 <span class='pagenum'><a name="Page_217" id="Page_217">[217]</a></span>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.</p>
+
+<div class="img">
+<a href="images/imagep216.jpg">
+<img border="0" src="images/imagep216.jpg" width="80%" alt="At Junior Sea Breeze, Teaching Mothers The Health Routine For Babies" /></a><br />
+<p class="cen" style="margin-top: .2em; margin-left: 10%; margin-right: 10%;">AT JUNIOR SEA BREEZE, TEACHING MOTHERS THE HEALTH ROUTINE FOR BABIES</p>
+</div>
+
+<p>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,&mdash;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.</p>
+
+<br />
+<hr style="width: 15%;" />
+<br />
+
+<h4>FOOTNOTES:</h4>
+
+<div class="footnote"><p class="noin"><a name="Footnote_12_12" id="Footnote_12_12"></a><a href="#FNanchor_12_12"><span class="label">[12]</span></a> Serviceable guides to personal habits of health are
+<i>Aristocracy of Health</i> by Mary Foote Henderson, and <i>Efficient Life</i>
+by Dr. Luther H. Gulick.</p></div>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_XXIII" id="CHAPTER_XXIII"></a><hr />
+<span class='pagenum'><a name="Page_218" id="Page_218">[218]</a></span><br />
+
+<h3>CHAPTER XXIII<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>INDUSTRIAL HYGIENE</h4>
+<br />
+
+<p>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,&mdash;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.</p>
+
+<p>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.
+<span class='pagenum'><a name="Page_219" id="Page_219">[219]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_220" id="Page_220">[220]</a></span>activity of the public, of which the working
+class is no small or uninfluential part.</p>
+
+<div class="img">
+<a href="images/imagep220.jpg">
+<img border="0" src="images/imagep220.jpg" width="80%" alt="Country Club House for New York Social Workers" /></a><br />
+<p class="cen" style="margin-top: .2em;">COUNTRY CLUB HOUSE FOR NEW YORK SOCIAL WORKERS<br />
+Given by the founder of Caroline Rest Educational Fund</p>
+</div>
+
+<p>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 <span class='pagenum'><a name="Page_221" id="Page_221">[221]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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 <i>doing things</i> and <i>getting things done</i>. 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 <span class='pagenum'><a name="Page_222" id="Page_222">[222]</a></span>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.</p>
+
+<div class="block"><p>We are told that employees should assume the management of welfare
+work.</p>
+
+<p>Should they install sanitary conveniences? Of course not.</p>
+
+<p>Would they know the need of a wash room in a factory if they never
+had had one? No.</p>
+
+<p>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.</p>
+
+<p>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.</p></div>
+
+<div class="img"><span class='pagenum'><a name="Page_223" id="Page_223">[223]</a></span>
+<a href="images/imagep223.jpg">
+<img border="0" style="border: 1px black solid;" src="images/imagep223.jpg" width="50%" alt="First Lessons in Industrial Hygiene" /></a><br />
+<p class="cen" style="margin-top: .2em;">FIRST LESSONS IN INDUSTRIAL HYGIENE</p>
+</div>
+
+<div class="img"><span class='pagenum'><a name="Page_224" id="Page_224">[224]</a></span>
+<a href="images/imagep224.png">
+<img border="0" style="border: 1px black solid;" src="images/imagep224.png" width="50%" alt="Welfare Work That Counts" /></a><br />
+<p class="cen" style="margin-top: .2em;">WELFARE WORK THAT COUNTS</p>
+</div>
+
+<p><span class='pagenum'><a name="Page_225" id="Page_225">[225]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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, <span class='pagenum'><a name="Page_226" id="Page_226">[226]</a></span>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,&mdash;and to let them amuse
+themselves. From that time on he refused to be looked upon as the
+<i>deus ex machina</i> 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 <span class='pagenum'><a name="Page_227" id="Page_227">[227]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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,&mdash;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.</p>
+
+<p><span class='pagenum'><a name="Page_228" id="Page_228">[228]</a></span>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.</p>
+
+<p>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 co&ouml;perate
+with other citizens in securing the enforcement of health rights.</p>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_XXIV" id="CHAPTER_XXIV"></a><hr />
+<span class='pagenum'><a name="Page_229" id="Page_229">[229]</a></span><br />
+
+<h3>CHAPTER XXIV<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>THE LAST DAYS OF TUBERCULOSIS</h4>
+<br />
+
+<p>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,&mdash;local,
+state, national, international,&mdash;we are fast approaching the time when
+every parent, teacher, employer, landlord, worker, will see in
+tuberculosis a personal enemy,&mdash;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.<a name="FNanchor_13_13" id="FNanchor_13_13"></a><a href="#Footnote_13_13" class="fnanchor">[13]</a></p>
+
+<div class="imgl" style="width: 35%;">
+<a href="images/imagep230.jpg">
+<img border="0" src="images/imagep230.jpg" width="90%" alt="Dr. Trudeau's &quot;Little Red Cottage&quot; at Saranac--birthplace of Out-of-door Treatment in America" /></a><br />
+<p class="cen" style="margin-top: .2em; margin-left: 5%; margin-right: 5%; font-size: 80%;">DR. TRUDEAU'S "LITTLE RED COTTAGE" AT SARANAC&mdash;BIRTHPLACE OF OUT-OF-DOOR TREATMENT IN AMERICA</p>
+</div>
+
+<p>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 co&ouml;peration 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.</p>
+
+<p><span class='pagenum'><a name="Page_230" id="Page_230">[230]</a></span>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.</p>
+
+<div class="img" style="clear: both;"><span class='pagenum'><a name="Page_231" id="Page_231">[231]</a></span>
+<a href="images/imagep231.jpg">
+<img border="0" style="border: 1px black solid;" src="images/imagep231.jpg" width="50%" alt="Outdoor Life Chart." /></a><br />
+<p class="cen" style="margin-top: .2em;">OUTDOOR LIFE CHART.</p>
+</div>
+
+<div class="img"><span class='pagenum'><a name="Page_232" id="Page_232">[232]</a></span>
+<a href="images/imagep232.jpg">
+<img border="0" src="images/imagep232.jpg" width="80%" alt="Fighting Tuberculosis In The Mountains--Saranac" /></a><br />
+<p class="cen" style="margin-top: .2em;">FIGHTING TUBERCULOSIS IN THE MOUNTAINS&mdash;SARANAC</p>
+</div>
+
+<p>Every patient keeps a daily record, called for by the following
+instructions:</p>
+
+<div class="block"><p>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.</p></div>
+
+<p>The following simple instructions can be followed in any home, even
+where open windows must take the place of porches:</p>
+
+<div class="block"><p>Rest out of doors is the medicine that cures consumption. Absolute
+rest for mind and body brings speedy improvement. It <span class='pagenum'><a name="Page_233" id="Page_233">[233]</a></span>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.</p></div>
+
+<div class="img">
+<a href="images/imagep233.jpg">
+<img border="0" src="images/imagep233.jpg" width="80%" alt="Fighting Tuberculosis In Day Camps--Boston" /></a><br />
+<p class="cen" style="margin-top: .2em;">FIGHTING TUBERCULOSIS IN DAY CAMPS&mdash;BOSTON</p>
+</div>
+
+<p>Once having learned the simple facts that must be noted and the simple
+laws that must be followed, once <span class='pagenum'><a name="Page_234" id="Page_234">[234]</a></span>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:</p>
+
+<div class="block"><p>There are few medicines better than clouds, and you have not to
+swallow them or wear them as plasters,&mdash;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.</p></div>
+
+<div class="img">
+<a href="images/imagep234.png">
+<img border="0" src="images/imagep234.png" width="70%" alt="The Back Of A Street-Car Transfer, Sundays, New York City" /></a><br />
+<p class="cen" style="margin-top: .2em;">THE BACK OF A STREET-CAR TRANSFER, SUNDAYS, NEW YORK CITY</p>
+</div>
+
+<p>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.</p>
+
+<div class="img"><span class='pagenum'><a name="Page_235" id="Page_235">[235]</a></span>
+<a href="images/imagep235.jpg">
+<img border="0" style="border: 1px black solid;" src="images/imagep235.jpg" width="50%" alt="An Example In Co&ouml;peration That Anti-tuberculosis Crusaders Should Follow" /></a><br />
+<p class="cen" style="margin-top: .2em;">AN EXAMPLE IN CO&Ouml;PERATION THAT ANTI-TUBERCULOSIS CRUSADERS SHOULD FOLLOW</p>
+</div>
+
+<p><span class='pagenum'><a name="Page_236" id="Page_236">[236]</a></span>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&mdash;Little Jo's
+Smile&mdash;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.</p>
+
+<p>Three fundamental rules of action should be established as firmly as
+religious principles:</p>
+
+<div class="block"><p>1. The public health authorities should be told of every known and
+every suspected case of tuberculosis.</p>
+
+<p>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.</p>
+
+<p>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.</p></div>
+
+<div class="img"><span class='pagenum'><a name="Page_237" id="Page_237">[237]</a></span>
+<a href="images/imagep237.jpg">
+<img border="0" src="images/imagep237.jpg" width="80%" alt="Fighting Tuberculosis With A National Organization" /></a><br />
+<p class="cen" style="margin-top: .2em;">FIGHTING TUBERCULOSIS WITH A NATIONAL ORGANIZATION</p>
+</div>
+
+<p>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:</p>
+
+<div class="block"><p>1. Compulsory notification of all tuberculous cases.</p>
+
+<p>2. Compulsory removal to hospital of those not able at home to
+destroy the bacilli, or compulsory supervision of home care.</p>
+
+<p>3. Examination of all members of a family where one member is
+discovered to be tuberculous.</p>
+
+<p>4. Special provision for tuberculous teachers.</p>
+
+<p>5. Protection of children about to enter industry but predisposed
+to tuberculosis.</p>
+
+<p>6. Prohibition of dry cleaning of schools, offices, and streets.</p>
+
+<p>7. Tax provision for educational and preventive work.</p></div>
+
+<p>Compulsory notification was introduced first in New York City by
+Hermann M. Biggs, M.D., chief medical <span class='pagenum'><a name="Page_238" id="Page_238">[238]</a></span>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&mdash;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.</p>
+
+<div class="img"><span class='pagenum'><a name="Page_239" id="Page_239">[239]</a></span>
+<a href="images/imagep239.png">
+<img border="0" style="border: 1px black solid;" src="images/imagep239.png" width="45%" alt="Fighting Tuberculosis By Organized Co&ouml;perative Dispensary Work" /></a><br />
+<p class="cen" style="margin-top: .2em;">FIGHTING TUBERCULOSIS BY ORGANIZED CO&Ouml;PERATIVE DISPENSARY WORK</p>
+</div>
+
+<div class="img">
+<a href="images/imagep240.jpg">
+<img border="0" src="images/imagep240.jpg" width="80%" alt="Fighting Bone Tuberculosis at Sea Breeze, where Eye and Skin Tuberculin Tests are Being Made" /></a><br />
+<p class="cen" style="margin-top: .2em;">FIGHTING BONE TUBERCULOSIS AT SEA BREEZE, WHERE EYE AND SKIN TUBERCULIN TESTS ARE BEING MADE</p>
+</div>
+
+<p><span class='pagenum'><a name="Page_240" id="Page_240">[240]</a></span>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'
+<span class='pagenum'><a name="Page_241" id="Page_241">[241]</a></span>protection. A rigid educational test should be applied as a condition
+of remaining at home without supervision.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<div class="img"><span class='pagenum'><a name="Page_242" id="Page_242">[242]</a></span>
+<a href="images/imagep242.jpg">
+<img border="0" src="images/imagep242.jpg" width="55%" alt="Fighting Tuberculosis in Small Cities" /></a><br />
+<p class="cen" style="margin-top: .2em;">FIGHTING TUBERCULOSIS IN SMALL CITIES<br />
+New York State Charities Aid Association</p>
+</div>
+
+<p>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 <span class='pagenum'><a name="Page_243" id="Page_243">[243]</a></span>to
+join tuberculosis classes. It is selfish to demand independence at the
+price which is paid by schools that employ tuberculous teachers.</p>
+
+<div class="img">
+<a href="images/imagep243.jpg">
+<img border="0" src="images/imagep243.jpg" width="80%" alt="Fighting Bone Tuberculosis With Salt Water And Salt Air" /></a><br />
+<p class="cen" style="margin-top: .2em;">FIGHTING BONE TUBERCULOSIS WITH SALT WATER AND SALT AIR</p>
+</div>
+
+<p>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 <span class='pagenum'><a name="Page_244" id="Page_244">[244]</a></span>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
+<i>after</i> their removal. Landlords, employers, tenants, and employees
+can easily be taught to see the advantage of disinfecting premises
+occupied by tuberculous cases <i>before</i> detection.</p>
+
+<div class="img">
+<a href="images/imagep244.jpg">
+<img border="0" src="images/imagep244.jpg" width="80%" alt="Fighting Feather Dusters Is One Object Of Sea-Air Hospitals For Bone Tuberculosis" /></a><br />
+<p class="cen" style="margin-top: .2em;">FIGHTING FEATHER DUSTERS IS ONE OBJECT OF SEA-AIR HOSPITALS FOR BONE TUBERCULOSIS</p>
+</div>
+
+<p>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?</p>
+
+<div class="img"><span class='pagenum'><a name="Page_245" id="Page_245">[245]</a></span>
+<a href="images/imagep245.jpg">
+<img border="0" src="images/imagep245.jpg" width="80%" alt="FIGHTING TUBERCULOSIS IN OPEN TENTS" /></a><br />
+<p class="cen" style="margin-top: .2em;">FIGHTING TUBERCULOSIS IN OPEN TENTS</p>
+</div>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_246" id="Page_246">[246]</a></span>proceedings of this congress will
+undoubtedly be the chief reference book on the conquest of
+tuberculosis.<a name="FNanchor_14_14" id="FNanchor_14_14"></a><a href="#Footnote_14_14" class="fnanchor">[14]</a></p>
+
+<p>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&mdash;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.</p>
+
+<div class="img">
+<a href="images/imagep246.jpg">
+<img border="0" src="images/imagep246.jpg" width="80%" alt="Fighting Tuberculosis In Cheap Shacks, $125 Per Bed, Otisville, New York" /></a><br />
+<p class="cen" style="margin-top: .2em;">FIGHTING TUBERCULOSIS IN CHEAP SHACKS, $125 PER BED, OTISVILLE, NEW YORK</p>
+</div>
+
+<p><span class='pagenum'><a name="Page_247" id="Page_247">[247]</a></span>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.</p>
+
+<br />
+
+<p class="cen sc">I. Economic Aspects of Tuberculosis</p>
+
+<div class="block3">
+<p class="hang2">1. The burdens entailed by tuberculosis:</p>
+
+<div class="block">
+    <p class="noin"><i>a.</i> On individuals and families.<br />
+    <i>b.</i> On the medical profession.<br />
+    <i>c.</i> On industry.<br />
+    <i>d.</i> On relief agencies.<br />
+    <i>e.</i> On the community.<br />
+    <i>f.</i> On social progress.</p>
+</div>
+
+<p class="hang2">2. The cost of securing effective control of tuberculosis:</p>
+
+<div class="block">
+    <p class="noin"><i>a.</i> In large cities.<br />
+    <i>b.</i> In smaller towns.<br />
+    <i>c.</i> In rural communities.</p>
+</div>
+</div>
+
+<br />
+
+<p class="cen sc">II. Adverse Industrial Conditions</p>
+
+<div class="block3">
+<p class="hang2">1. Incidence of tuberculosis according to occupation.</p>
+
+<p class="hang2">2. Overwork and nervous strain as factors in tuberculosis.</p>
+
+<p class="hang2">3. Effect of improvements in factory conditions on the health of
+    employees.</p>
+
+<p class="hang2">4. Legitimate exercise of police power in protecting the life and
+    health of employees.</p>
+</div>
+
+<br />
+
+<p class="cen sc">III. The Social Control of Tuberculosis</p>
+
+<div class="block3">
+<p class="hang2">1. Outline of a comprehensive programme for:</p>
+
+<div class="block">
+    <p class="noin"><i>a.</i> National, state, and municipal governments.<br />
+    <i>b.</i> Departments of health and departments of public relief.<br />
+    <i>c.</i> Private endowments.<br />
+    <i>d.</i> Voluntary associations for educational propaganda.<br />
+    <i>e.</i> Institutions, such as schools and relief agencies, which
+         exist primarily for other purposes.</p>
+</div>
+
+<p class="hang2"><span class='pagenum'><a name="Page_248" id="Page_248">[248]</a></span>2. A symposium on the relative value of each of the features in an
+    aggressive campaign against tuberculosis:</p>
+
+<div class="block">
+    <p class="noin"><i>a.</i> Compulsory registration.<br />
+    <i>b.</i> Free sputum examination.<br />
+    <i>c.</i> Compulsory removal of unteachable and dangerous cases.<br />
+    <i>d.</i> Laboratory research.<br />
+    <i>e.</i> Hospital.<br />
+    <i>f.</i> Sanatorium.<br />
+    <i>g.</i> Dispensary.<br />
+    <i>h.</i> The tuberculosis class.<br />
+    <i>i.</i> Day camp.<br />
+    <i>j.</i> Private physician.<br />
+    <i>k.</i> Visiting nurse.<br />
+    <i>l.</i> After-care of arrested cases.<br />
+    <i>m.</i> Relief fund.<br />
+    <i>n.</i> Climate.<br />
+    <i>o.</i> Hygienic instruction,&mdash;personal and in class.<br />
+    <i>p.</i> Inspection of schools and factories.<br />
+    <i>q.</i> Educational propaganda.</p>
+</div>
+</div>
+
+<br />
+
+<p class="cen sc">IV. Early Recognition and Prevention</p>
+
+<div class="block3">
+<p class="hang2">1. Importance of discovering the persons who have tuberculosis
+    before the disease has passed the incipient stage.</p>
+
+<p class="hang2">2. Examination of persons known to have been exposed or presumably
+    predisposed.</p>
+
+<p class="hang2">3. Systematic examination of school children during their course
+    and on leaving school to go to work.</p>
+
+<p class="hang2">4. Professional advice as to choice of occupation in cases where
+    there is apparent predisposition to disease.</p>
+</div>
+
+<br />
+
+<p class="cen sc">V. After-Care of Arrested Cases</p>
+
+<div class="block3">
+<p class="hang2">1. Instruction in healthful trades in the sanatorium.</p>
+
+<p class="hang2">2. Training for professional nursing in institutions for the care
+    of tuberculous patients.</p>
+
+<p class="hang2">3. Farm colonies.</p>
+
+<p class="hang2">4. Convalescent homes or cottages.</p>
+
+<p class="hang2">5. Aid in securing suitable employment on leaving the sanatorium.</p>
+
+<p class="hang2">6. How to deal with the danger of a return to unfavorable home
+    conditions.</p>
+</div>
+
+<br />
+
+<p class="cen sc"><span class='pagenum'><a name="Page_249" id="Page_249">[249]</a></span>VI. Educational Methods and Agencies</p>
+
+<div class="block3">
+<p class="hang2">1. Special literature for general distribution.</p>
+
+<p class="hang2">2. Exhibits and lectures.</p>
+
+<p class="hang2">3. The press.</p>
+
+<p class="hang2">4. Educational work of the nurse.</p>
+
+<p class="hang2">5. Labor organizations.</p>
+
+<p class="hang2">6. Instruction in schools of all grades.</p>
+
+<p class="hang2">7. Presentation and discussion of leaflets awarded prizes by the
+    congress.</p>
+</div>
+
+<br />
+
+<p class="cen sc">VII. Promotion of Immunity</p>
+
+<div class="block3">
+<p class="hang2">1. Development of the conception of physical well-being.</p>
+
+<p class="hang2">2. Measures for increasing resistance to disease:</p>
+
+<div class="block">
+    <p class="noin"><i>a.</i> Parks and playgrounds.<br />
+    <i>b.</i> Outdoor sports.<br />
+    <i>c.</i> Physical education.<br />
+    <i>d.</i> Raising the standards of living: housing, diet,
+         cleanliness.</p>
+</div>
+
+<p class="hang2">3. Individual immunity and social conditions favorable to general
+    immunity.</p>
+</div>
+
+<br />
+
+<p class="cen sc">VIII. Responsibility of Society for Tuberculosis</p>
+
+<div class="block3">
+<p class="hang2">1. A symposium of representative</p>
+
+<div class="block">
+    <p class="noin"><i>a.</i> Citizens.<br />
+    <i>b.</i> Social workers.<br />
+    <i>c.</i> Employers.<br />
+    <i>d.</i> Employees.<br />
+    <i>e.</i> Physicians.<br />
+    <i>f.</i> Nurses.<br />
+    <i>g.</i> Educators.<br />
+    <i>h.</i> Others.</p>
+</div>
+</div>
+
+<br />
+
+<p>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.</p>
+
+<div class="img"><span class='pagenum'><a name="Page_250" id="Page_250">[250]</a></span>
+<a href="images/imagep250.png">
+<img border="0" src="images/imagep250.png" width="50%" alt="Boston fights Tuberculosis with a Comprehensive Plan" /></a><br />
+<p class="cen" style="margin-top: .2em; margin-left: 15%; margin-right: 15%;">BOSTON FIGHTS TUBERCULOSIS WITH A COMPREHENSIVE PLAN<br />
+<i>A-D, F, H-J</i>, private hospitals and agencies reporting cases to the
+official center; <i>E</i>, home care; <i>K, L, M</i>, day camp and hospitals for
+incipient and advanced cases</p>
+</div>
+
+<p>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 <span class='pagenum'><a name="Page_251" id="Page_251">[251]</a></span>and for vitality, for a fair
+chance against environmental conditions prejudicial to efficient
+citizenship.</p>
+
+<p>So sure is the result and so immediate the duty of every citizen that
+Dr. Biggs wrote in 1907: <i>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.</i></p>
+
+<br />
+<hr style="width: 15%;" />
+<br />
+
+<h4>FOOTNOTES:</h4>
+
+<div class="footnote"><p class="noin"><a name="Footnote_13_13" id="Footnote_13_13"></a><a href="#FNanchor_13_13"><span class="label">[13]</span></a> 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 <i>The Prevention of Tuberculosis</i> (1908) by Arthur Newsholme, M.D.
+A popular book is <i>The Crusade against Tuberculosis</i>, by Lawrence F.
+Flick, of the Henry Phipps Institute for the Study, Treatment, and
+Prevention of Tuberculosis.</p></div>
+
+<div class="footnote"><p class="noin"><a name="Footnote_14_14" id="Footnote_14_14"></a><a href="#FNanchor_14_14"><span class="label">[14]</span></a> 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.</p></div>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_XXV" id="CHAPTER_XXV"></a><hr />
+<span class='pagenum'><a name="Page_252" id="Page_252">[252]</a></span><br />
+
+<h3>CHAPTER XXV<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>THE FIGHT FOR CLEAN MILK</h4>
+<br />
+
+<p>"With the approval of the President and with the co&ouml;peration of the
+Department of Agriculture,<a name="FNanchor_15_15" id="FNanchor_15_15"></a><a href="#Footnote_15_15" class="fnanchor">[15]</a> 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 <i>everybody will be made to think</i>.</p>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_253" id="Page_253">[253]</a></span>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 <span class='pagenum'><a name="Page_254" id="Page_254">[254]</a></span>he found indecent
+housing, unsanitary streets, unwholesome working conditions, and
+impure food.</p>
+
+<div class="img">
+<a href="images/imagep253.jpg">
+<img border="0" src="images/imagep253.jpg" width="80%" alt="Fighting Infant Mortality by a School For Mothers" /></a><br />
+<p class="cen" style="margin-top: .2em;">FIGHTING INFANT MORTALITY BY A SCHOOL FOR MOTHERS IN
+THE HEART OF NEW YORK CITY,&mdash;JUNIOR SEA BREEZE</p>
+</div>
+
+<div class="img">
+<a href="images/imagep254.jpg">
+<img border="0" src="images/imagep254.jpg" width="80%" alt="Providing Against Germ Growth" /></a><br />
+<p class="cen" style="margin-top: .2em;">PROVIDING AGAINST GERM GROWTH AND ADAPTING MILK TO THE
+INDIVIDUAL BABY'S NEED,&mdash;ROCHESTER'S MODEL DAIRY</p>
+</div>
+
+<p>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 <i>every baby, city born or country born, no
+matter how humble its home, has the right to pure milk</i>.</p>
+
+<div class="img"><span class='pagenum'><a name="Page_255" id="Page_255">[255]</a></span>
+<a href="images/imagep255.png">
+<img border="0" style="border: 1px black solid;" src="images/imagep255.png" width="50%" alt="Clean Milk for New York City (pamphlet page 1)" /></a><br />
+</div>
+
+<div class="img"><span class='pagenum'><a name="Page_256" id="Page_256">[256]</a></span>
+<a href="images/imagep256.png">
+<img border="0" style="border: 1px black solid;" src="images/imagep256.png" width="50%" alt="Clean Milk for New York City (pamphlet page 2)" /></a><br />
+</div>
+
+<div class="img"><span class='pagenum'><a name="Page_257" id="Page_257">[257]</a></span>
+<a href="images/imagep257.png">
+<img border="0" style="border: 1px black solid;" src="images/imagep257.png" width="50%" alt="Clean Milk for New York City (pamphlet page 3)" /></a><br />
+</div>
+
+<p><span class='pagenum'><a name="Page_258" id="Page_258">[258]</a></span>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_259" id="Page_259">[259]</a></span>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,&mdash;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,&mdash;<i>clean</i> and <i>cool</i>. 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 <span class='pagenum'><a name="Page_260" id="Page_260">[260]</a></span>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.</p>
+
+<div class="img">
+<a href="images/imagep259.jpg">
+<img border="0" src="images/imagep259.jpg" width="80%" alt="Night Inspection Of Country Milk Upon Arrival In New York City" /></a><br />
+<p class="cen" style="margin-top: .2em;">NIGHT INSPECTION OF COUNTRY MILK UPON ARRIVAL IN NEW YORK CITY</p>
+</div>
+
+<p>As elsewhere, there are two schools of pure-milk crusaders: (1) those
+who want cities to <i>do things</i>, to pasteurize all milk, start milk
+farms, milk shops, or pure-milk dispensaries; and (2) those who want
+cities and states to <i>get things done</i>. 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 <span class='pagenum'><a name="Page_261" id="Page_261">[261]</a></span>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.</p>
+
+<div class="img">
+<a href="images/imagep261.jpg">
+<img border="0" src="images/imagep261.jpg" width="80%" alt="A New York Milk Committee's Infant Depot And School For Mothers" /></a><br />
+<p class="cen" style="margin-top: .2em;">A NEW YORK MILK COMMITTEE'S INFANT DEPOT AND SCHOOL FOR MOTHERS</p>
+</div>
+
+<p>Pasteurization, municipal dairies, municipal milk shops, municipal
+infant-milk depots, are the four chief remedies of the <i>doing things</i>
+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 <span class='pagenum'><a name="Page_262" id="Page_262">[262]</a></span>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 <span class='pagenum'><a name="Page_263" id="Page_263">[263]</a></span>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 <i>doing things</i> 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.</p>
+
+<div class="img">
+<a href="images/imagep262.jpg">
+<img border="0" src="images/imagep262.jpg" width="80%" alt="One Of Rochester's Schools In Cleanliness" /></a><br />
+<p class="cen" style="margin-top: .2em;">ONE OF ROCHESTER'S SCHOOLS IN CLEANLINESS</p>
+</div>
+
+<div class="img">
+<a href="images/imagep263.jpg">
+<img border="0" src="images/imagep263.jpg" width="80%" alt="Rochester's Model Dairy Farm" /></a><br />
+<p class="cen" style="margin-top: .2em;">ROCHESTER'S MODEL DAIRY FARM</p>
+</div>
+
+<p>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.</p>
+
+<p>The <i>getting things done</i> 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 <span class='pagenum'><a name="Page_264" id="Page_264">[264]</a></span>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 <span class='pagenum'><a name="Page_265" id="Page_265">[265]</a></span>clean milk and to
+support aggressive work by health departments leaves fewer evils
+unchecked than covering up uncleanliness by pasteurization.</p>
+
+<div class="img">
+<a href="images/imagep264.jpg">
+<img border="0" style="border: 1px black solid;" src="images/imagep264_th.jpg" width="80%" alt="New York Milk Committee's Graphic Method Of Showing Babies' Progress" /></a><br />
+<p class="cen" style="margin-top: .2em;">NEW YORK MILK COMMITTEE'S GRAPHIC METHOD OF SHOWING BABIES' PROGRESS</p>
+</div>
+
+<div class="img">
+<a href="images/imagep265.jpg">
+<img border="0" src="images/imagep265.jpg" width="80%" alt="Producing Winter Conditions In Midsummer By Proper Refrigeration For Milk In Freight Cars" /></a><br />
+<p class="cen" style="margin-top: .2em;">PRODUCING WINTER CONDITIONS IN MIDSUMMER BY PROPER REFRIGERATION FOR MILK IN FREIGHT CARS</p>
+</div>
+
+<p>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, <span class='pagenum'><a name="Page_266" id="Page_266">[266]</a></span>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 <i>at the shop</i> 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.</p>
+
+<div class="img">
+<a href="images/imagep266.jpg">
+<img border="0" src="images/imagep266.jpg" width="80%" alt="Neither Pasteurization nor Inspection can make it Safe to Sell &quot;Dip Milk&quot; Under Such Unclean Conditions" /></a><br />
+<p class="cen" style="margin-top: .2em; margin-right: 10%; margin-left: 10%;">NEITHER PASTEURIZATION NOR INSPECTION CAN MAKE IT SAFE TO SELL "DIP MILK" UNDER SUCH UNCLEAN CONDITIONS</p>
+</div>
+
+<p><span class='pagenum'><a name="Page_267" id="Page_267">[267]</a></span>"Clean air, clean babies, clean milk," has been the slogan of Junior
+Sea Breeze,&mdash;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."</p>
+
+<br />
+<hr style="width: 15%;" />
+<br />
+
+<h4>FOOTNOTES:</h4>
+
+<div class="footnote"><p class="noin"><a name="Footnote_15_15" id="Footnote_15_15"></a><a href="#FNanchor_15_15"><span class="label">[15]</span></a> Libraries should obtain all reports on milk, Bureau of
+Animal Industry, Washington, D.C.</p></div>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_XXVI" id="CHAPTER_XXVI"></a><hr />
+<span class='pagenum'><a name="Page_268" id="Page_268">[268]</a></span><br />
+
+<h3>CHAPTER XXVI<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>PREVENTIVE "HUMANIZED" MEDICINE: PHYSICIAN AND TEACHER</h4>
+<br />
+
+<p>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.</p>
+
+<p>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,&mdash;physicians know, physicians apply what they know without
+consciousness of error, physicians must be implicitly trusted.</p>
+
+<p><span class='pagenum'><a name="Page_269" id="Page_269">[269]</a></span>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 an&aelig;mia 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.</p>
+
+<p>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 <i>doing</i> and <i>getting
+done</i> have lagged behind our <i>knowing</i>.</p>
+
+<p><span class='pagenum'><a name="Page_270" id="Page_270">[270]</a></span>The failure of physicians to "socialize" or "humanize" their knowledge
+is due to two causes: (1) no one has been applying <i>result tests</i> 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.</p>
+
+<p>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
+<span class='pagenum'><a name="Page_271" id="Page_271">[271]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_272" id="Page_272">[272]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_273" id="Page_273">[273]</a></span>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.</p>
+
+<div class="img">
+<a href="images/imagep273.jpg">
+<img border="0" src="images/imagep273.jpg" width="80%" alt="The Disciple of Fresh Air and Home Instruction is still an Outcast in Scores of Hospitals" /></a><br />
+<p class="cen" style="margin-top: .2em;">THE DISCIPLE OF FRESH AIR AND HOME INSTRUCTION IS STILL AN OUTCAST IN SCORES OF HOSPITALS</p>
+</div>
+
+<p>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 <span class='pagenum'><a name="Page_274" id="Page_274">[274]</a></span>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
+L&euml;annec 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!</p>
+
+<p>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 <span class='pagenum'><a name="Page_275" id="Page_275">[275]</a></span>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.</p>
+
+<p>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.</p>
+
+<div class="block"><p>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 <span class='pagenum'><a name="Page_276" id="Page_276">[276]</a></span>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.</p></div>
+
+<p>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.</p>
+
+<p>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, <span class='pagenum'><a name="Page_277" id="Page_277">[277]</a></span>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." <span class='pagenum'><a name="Page_278" id="Page_278">[278]</a></span>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.</p>
+
+<div class="img">
+<a href="images/imagep277.jpg">
+<img border="0" src="images/imagep277.jpg" width="67%" alt="Too Many Physicians and even Maternity Hospitals fail to Teach Mothers" /></a><br />
+<p class="cen" style="margin-top: .2em; margin-left: 10%; margin-right: 10%;">TOO MANY PHYSICIANS AND EVEN MATERNITY HOSPITALS FAIL TO TEACH MOTHERS, EITHER BEFORE OR AFTER BABIES ARE BORN<br />
+Caroline Rest Educational Fund was given to show the value of such teaching</p>
+</div>
+
+<p>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, <span class='pagenum'><a name="Page_279" id="Page_279">[279]</a></span>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.</p>
+
+<p>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,&mdash;its educational opportunity, vital
+statistics, sick and death rates. Will it need to municipalize him in
+order to protect itself?</p>
+
+<p>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:</p>
+
+<div class="block"><p>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?</p></div>
+
+<p>Or, if a school physician, the teacher can ask:</p>
+
+<div class="block"><p>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 <span class='pagenum'><a name="Page_280" id="Page_280">[280]</a></span>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?</p></div>
+
+<p>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.</p>
+
+<br />
+
+<p class="cen sc">Licensing the Practitioner</p>
+
+<p>Three parties are interested in setting a high standard for
+physicians, dentists, druggists, nurses, and veterinary surgeons&mdash;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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_281" id="Page_281">[281]</a></span>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_282" id="Page_282">[282]</a></span>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.</p>
+
+<br />
+<br />
+<br />
+<br />
+<a name="PART_IV_OFFICIAL_MACHINERY_FOR_ENFORCING_HEALTH_RIGHTS" id="PART_IV_OFFICIAL_MACHINERY_FOR_ENFORCING_HEALTH_RIGHTS"></a><a name="CHAPTER_XXVII" id="CHAPTER_XXVII"></a><hr />
+<span class='pagenum'><a name="Page_283" id="Page_283">[283]</a></span><br />
+<br />
+<br />
+<br />
+
+<h2 class="wrap">PART IV. OFFICIAL MACHINERY FOR ENFORCING HEALTH RIGHTS</h2>
+
+<br />
+
+<h3>CHAPTER XXVII<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>DEPARTMENTS OF SCHOOL HYGIENE</h4>
+<br />
+
+<p>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 <span class='pagenum'><a name="Page_284" id="Page_284">[284]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>1. <i>Thorough physical examination of all candidates for teachers'
+positions and periodic re&euml;xamination of accepted teachers.</i></p>
+
+<p>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?</p>
+
+<p>2. <i>Thorough physical examination of every single child in every
+single school upon entering and periodically during school life.</i></p>
+
+<p>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 <span class='pagenum'><a name="Page_285" id="Page_285">[285]</a></span>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.</p>
+
+<p>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, medi&aelig;val ideals of caste,
+etc., can inflict greater injuries than can typhoid fever or cholera.</p>
+
+<p>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.</p>
+
+<p>3. <i>Thorough physical examination of children when leaving school, or
+when passing compulsory school age, as a condition to "working papers"
+and to "coming out."</i></p>
+
+<p>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 <span class='pagenum'><a name="Page_286" id="Page_286">[286]</a></span>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,&mdash;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"?</p>
+
+<p>4. <i>Supervision by physicians of hygiene practiced in schoolrooms and
+on playgrounds.</i></p>
+
+<p>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.</p>
+
+<p>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 co&ouml;peration of parents, teachers,
+family physicians, dispensaries, school boards, and <span class='pagenum'><a name="Page_287" id="Page_287">[287]</a></span>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.</p>
+
+<p>5. <i>Restriction of study hours at school and at home to limits
+compatible with health.</i></p>
+
+<p>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.</p>
+
+<p>6. <i>Establishment of a "follow-up" plan to insure action by parents to
+correct physical defects and to attend to physical needs.</i></p>
+
+<p>The advantages of <i>getting things done</i> over <i>doing things</i> 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 <span class='pagenum'><a name="Page_288" id="Page_288">[288]</a></span>ignorantly refuse to
+attend to their children's needs, the segregation of the physically
+defective or needy will encourage the co&ouml;peration 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.</p>
+
+<div class="img">
+<a href="images/imagep288.jpg">
+<img border="0" src="images/imagep288.jpg" width="65%" alt="Teaching A Mother To Care For One Child Insures Better Care For All Her Children" /></a><br />
+<p class="cen" style="margin-top: .2em;">TEACHING A MOTHER TO CARE FOR ONE CHILD INSURES BETTER CARE FOR ALL HER CHILDREN</p>
+</div>
+
+<p><span class='pagenum'><a name="Page_289" id="Page_289">[289]</a></span>7. <i>Physiological age should influence school classification and
+school curriculum.</i> 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.</p>
+
+<p>8. <i>Construction of school building and of curriculum so that, when
+properly conducted, they shall neither produce nor aggravate physical
+defects.</i></p>
+
+<p>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 <span class='pagenum'><a name="Page_290" id="Page_290">[290]</a></span>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.</p>
+
+<p>What and when to build can be better determined after we have learned
+the what and the where of present equipment.</p>
+
+<p>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.</p>
+
+<p>9. <i>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.</i> 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 <span class='pagenum'><a name="Page_291" id="Page_291">[291]</a></span>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.</p>
+
+<p>10. <i>Central supervision of school hygiene.</i> In private and public,
+boarding and day, country and city, reformatory and military,
+commercial and high schools, the index&mdash;physical welfare of school
+children&mdash;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.</p>
+
+<p>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.</p>
+
+<p>11. <i>Information gained at school regarding conditions prejudicial to
+community health should be published and <span class='pagenum'><a name="Page_292" id="Page_292">[292]</a></span>made the basis of an
+aggressive campaign for the enforcement of sanitary laws.</i> 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 <i>do for</i> or
+<i>give to</i> people who can help themselves is to <i>give up</i> and <i>do up</i>
+power of self-help.</p>
+
+<p>Machinery that must some day exist for the execution of this programme
+will be approximately the following:</p>
+
+<br />
+
+<div class="block"><p class="cen sc">I. National Machinery</p>
+
+<p>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.</p>
+
+<p>2. Scientific research to be conducted by the National Bureau of
+Education or by the future National Board of Health.</p>
+
+<br />
+
+<p class="cen sc">II. State Machinery</p>
+
+<p>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.</p>
+
+<p>2. Agents to make special inquiries as to practice and teaching of
+school hygiene.</p>
+
+<p>3. Agents to inspect and to instruct county superintendents,
+county physicians, teachers, normal schools, etc.</p>
+
+<p>4. A bureau of experts&mdash;architect, sanitarian, teacher&mdash;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.)</p>
+
+<p>5. Standard making by normal schools, state universities,
+hospitals, or other educational and correctional institutes under
+direct state management.</p>
+
+<br />
+
+<p class="cen sc"><span class='pagenum'><a name="Page_293" id="Page_293">[293]</a></span>III. County Machinery</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<br />
+
+<p class="cen sc">IV. Town and Township Machinery</p>
+
+<p>1. Teachers intelligent as to physical needs, as to sanitation of
+buildings, etc.</p>
+
+<p>2. An examining physician, to be salaried where the population
+justifies; elsewhere to work as a volunteer in co&ouml;peration with
+teacher and with county physician.</p>
+
+<p>3. Physical history of each child from date of entrance to date of
+leaving school, to be kept up to date by teacher.</p>
+
+<br />
+
+<p class="cen sc">V. City Machinery</p>
+
+<p>1. A division to be known as the Department of School Hygiene,
+headed by an officer who gives his entire time to that department.</p>
+
+<p>2. A subcommittee of the Board of Education.</p>
+
+<p>3. Clearing house for facts regarding school hygiene taught and
+practiced in all schools within city limits.</p>
+
+<p>4. Specialists to examine applicants for teaching positions, and
+to re&euml;xamine teachers to determine fitness for continuance, for
+promotion, and for special assignments.</p>
+
+<p>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.</p>
+
+<p>6. Similar supervision of curriculum and of study hours
+prescribed.</p>
+
+<p>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 <span class='pagenum'><a name="Page_294" id="Page_294">[294]</a></span>the
+duration of lessons, frequency of intermissions, sequence of
+subjects, time and method of recess throughout the various grades.</p>
+
+<p>8. Supervision of indoor and outdoor playgrounds, roof gardens,
+indoor and outdoor gymnasiums, swimming pools, etc.</p>
+
+<p>9. Supervision of instruction in school hygiene.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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 co&ouml;peration of family physician and neighborhood
+facilities, such as hospitals, dispensaries and relief agencies,
+magistrates' courts and probation officers,&mdash;all to be under the
+control of the board of education or the board of health.</p></div>
+
+<br />
+
+<p>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 <span class='pagenum'><a name="Page_295" id="Page_295">[295]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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 co&ouml;peration 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.</p>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_XXVIII" id="CHAPTER_XXVIII"></a><hr />
+<span class='pagenum'><a name="Page_296" id="Page_296">[296]</a></span><br />
+
+<h3>CHAPTER XXVIII<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>PRESENT ORGANIZATION OF SCHOOL HYGIENE IN NEW YORK CITY</h4>
+<br />
+
+<p>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 co&ouml;rdination, 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.</p>
+
+<p>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.</p>
+
+<p>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&mdash;less than half the total number&mdash;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."</p>
+
+<p><span class='pagenum'><a name="Page_297" id="Page_297">[297]</a></span>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:</p>
+
+<div class="img">
+<a href="images/imagep297.png">
+<img border="0" style="border: 1px black solid;" src="images/imagep297.png" width="60%" alt="Postal Card sent out by Department of Health" /></a><br />
+</div>
+
+<p>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 <span class='pagenum'><a name="Page_298" id="Page_298">[298]</a></span>department had been satisfied with evidence that
+family physicians had advised parents properly, as in the case of the
+child above reported:</p>
+
+<div class="img">
+<a href="images/imagep298.png">
+<img border="0" style="border: 1px black solid;" src="images/imagep298.png" width="60%" alt="Postal Card sent out by Department of Health" /></a><br />
+</div>
+
+<p>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 <i>A Bureau of Child Hygiene</i>, 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."</p>
+
+<p>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&mdash;that of
+the board of education and that of the department of health"&mdash;and to
+"lack of power or inclination to compel parents to remedy defects,"
+<span class='pagenum'><a name="Page_299" id="Page_299">[299]</a></span>or to <i>deficient administration</i> of power and inclination by health
+officials. Co&ouml;perating 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,"&mdash;sixty cents per child!</p>
+
+<div class="imgr" style="width: 40%;">
+<a href="images/imagep299.jpg">
+<img border="0" src="images/imagep299.jpg" width="90%" alt="A Photograph Of Mouth Breathing May Make Compulsion Unnecessary" /></a><br />
+<p class="cen" style="margin-top: .2em;">A PHOTOGRAPH OF MOUTH BREATHING MAY MAKE COMPULSION UNNECESSARY</p>
+</div>
+
+<p>Having established the willingness&mdash;even eagerness&mdash;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 <span class='pagenum'><a name="Page_300" id="Page_300">[300]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_301" id="Page_301">[301]</a></span>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.</p>
+
+<p>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.</p>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_XXIX" id="CHAPTER_XXIX"></a><hr />
+<span class='pagenum'><a name="Page_302" id="Page_302">[302]</a></span><br />
+
+<h3>CHAPTER XXIX<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>OFFICIAL MACHINERY FOR ENFORCING HEALTH RIGHTS</h4>
+<br />
+
+<p>The argument for <i>getting things done</i> presumes adequate active
+machinery, official and private, for <i>doing things</i> 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.</p>
+
+<p>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. <span class='pagenum'><a name="Page_303" id="Page_303">[303]</a></span>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.</p>
+
+<div class="img">
+<a href="images/imagep302.jpg">
+<img border="0" style="border: 1px black solid;" src="images/imagep302_th.jpg" width="90%" alt="Chart Showing how New York City's Department of Health Exercises it's Authority" /></a><br />
+<p class="cen" style="margin-top: .2em;">CHART SHOWING HOW NEW YORK CITY'S DEPARTMENT OF HEALTH EXERCISES IT'S AUTHORITY<br />
+Courtesy of Bureau of Municipal Research</p>
+</div>
+
+<br />
+
+<p>Five elements of adequate machinery are generally lost sight of:</p>
+
+<div class="block"><p>1. The voter.</p>
+
+<p>2. The nonvoter, subject to health laws and often apt to violate
+them.</p>
+
+<p>3. The mayor, governor, or president who appoints health officers.</p>
+
+<p>4. The council, board of aldermen, legislature, or congress that
+enacts health laws.</p>
+
+<p>5. The police courts and the judiciary&mdash;police, circuit and
+supreme&mdash;that decide whether society has suffered from violation
+of law and what penalties should be inflicted for such violation.</p></div>
+
+<p>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.</p>
+
+<p>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
+<span class='pagenum'><a name="Page_304" id="Page_304">[304]</a></span>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.<a name="FNanchor_16_16" id="FNanchor_16_16"></a><a href="#Footnote_16_16" class="fnanchor">[16]</a></p>
+
+<p>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.</p>
+
+<p>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!</p>
+
+<p>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 <span class='pagenum'><a name="Page_305" id="Page_305">[305]</a></span>done, and
+differs with the size of the district and the character of population
+to be served.</p>
+
+<div class="img">
+<a href="images/imagep305.jpg">
+<img border="0" src="images/imagep305.jpg" width="80%" alt="For Push-Cart Food, Inspection is Particularly Needful" /></a><br />
+<p class="cen" style="margin-top: .2em;">FOR PUSH-CART FOOD, INSPECTION IS PARTICULARLY NEEDFUL</p>
+</div>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_306" id="Page_306">[306]</a></span>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 <i>Making a Municipal Budget</i>, by the Bureau of
+Municipal Research.</p>
+
+<p>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.</p>
+
+<p>State health machinery should be of two kinds,&mdash;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 <span class='pagenum'><a name="Page_307" id="Page_307">[307]</a></span>in
+failing to enforce health laws, state health machinery should be made
+to accomplish by force what it has failed to accomplish by education.</p>
+
+<div class="img">
+<a href="images/imagep307.jpg">
+<img border="0" src="images/imagep307.jpg" width="80%" alt="National Machinery Has Stimulated Local Milk Inspection And State Dairy Inspection" /></a><br />
+<p class="cen" style="margin-top: .2em;">NATIONAL MACHINERY HAS STIMULATED LOCAL MILK INSPECTION AND STATE DAIRY INSPECTION</p>
+</div>
+
+<p>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 <span class='pagenum'><a name="Page_308" id="Page_308">[308]</a></span>properly supported state health authorities will save many
+times the cost of their health work in addition to thousands of lives.</p>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_309" id="Page_309">[309]</a></span>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.</p>
+
+<p>"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."</p>
+
+<br />
+<hr style="width: 15%;" />
+<br />
+
+<h4>FOOTNOTES:</h4>
+
+<div class="footnote"><p class="noin"><a name="Footnote_16_16" id="Footnote_16_16"></a><a href="#FNanchor_16_16"><span class="label">[16]</span></a> The technic and principles of municipal engineering have
+been treated in detail in <i>Principles of Sanitary Science and the
+Public Health</i>, by William T. Sedgwick, and in <i>Municipal Sanitation
+in the United States</i>, by Charles N. Chapin, M.D.</p></div>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_XXX" id="CHAPTER_XXX"></a><hr />
+<span class='pagenum'><a name="Page_310" id="Page_310">[310]</a></span><br />
+
+<h3>CHAPTER XXX<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>SCHOOL AND HEALTH REPORTS</h4>
+<br />
+
+<p>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.</p>
+
+<div class="img">
+<a href="images/imagep310.png">
+<img border="0" src="images/imagep310.png" width="65%" alt="Necessary To Efficient Democracy" /></a><br />
+<p class="cen" style="margin-top: .2em;">NECESSARY TO EFFICIENT DEMOCRACY</p>
+</div>
+
+<p>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
+<span class='pagenum'><a name="Page_311" id="Page_311">[311]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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&mdash;<i>School Reports and School Efficiency</i>&mdash;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 <span class='pagenum'><a name="Page_312" id="Page_312">[312]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>The mere reporting of facts will stimulate teachers, principals, and
+parents to give attention. For example, assume a table:</p>
+
+<p class="cen sc">Field of Inspection</p>
+
+<div class="centered">
+<table border="0" cellpadding="2" cellspacing="0" width="50%" summary="Field of Inspection">
+  <tr>
+  <td width="80%" class="tdl">Total number of public schools</td>
+  <td width="20%" class="tdr">7</td>
+  </tr>
+  <tr>
+  <td class="tdl">Public schools under inspection</td>
+  <td class="tdr">3</td>
+  </tr>
+  <tr>
+  <td class="tdl">Public schools not under inspection</td>
+  <td class="tdr">4</td>
+  </tr>
+</table>
+</div>
+
+<p class="noin">The reader wonders why four schools are neglected and which particular
+schools they are. Let the next table read:</p>
+
+<p class="cen sc">Examination</p>
+
+<div class="centered">
+<table border="0" cellpadding="2" cellspacing="0" width="50%" summary="Field of Inspection">
+  <tr>
+  <td width="80%" class="tdl">Total registration in all schools</td>
+  <td width="20%" class="tdr">1500</td>
+  </tr>
+  <tr>
+  <td class="tdl">Number of children examined</td>
+  <td class="tdr">500</td>
+  </tr>
+  <tr>
+  <td class="tdl">Number of children not examined</td>
+  <td class="tdr">1000</td>
+  </tr>
+</table>
+</div>
+
+<p class="noin">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:</p>
+
+<p class="cen sc">Treatment</p>
+
+<div class="centered">
+<table border="0" cellpadding="2" cellspacing="0" width="50%" summary="Field of Inspection">
+  <tr>
+  <td width="80%" class="tdl">Number needing treatment</td>
+  <td width="20%" class="tdr">200</td>
+  </tr>
+  <tr>
+  <td class="tdl">Number known to have been treated</td>
+  <td class="tdr">50</td>
+  </tr>
+  <tr>
+  <td class="tdl">Number not known to have been treated</td>
+  <td class="tdr">150</td>
+  </tr>
+</table>
+</div>
+
+<p class="noin">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.</p>
+
+<div class="img"><span class='pagenum'><a name="Page_313" id="Page_313">[313]</a></span>
+<a href="images/imagep313.jpg">
+<img border="0" src="images/imagep313.jpg" width="80%" alt="Pupil's Record" /></a><br />
+</div>
+
+<div class="img"><span class='pagenum'><a name="Page_314" id="Page_314">[314]</a></span>
+<a href="images/imagep314.jpg">
+<img border="0" src="images/imagep314.jpg" width="80%" alt="Department Of Health City of New York Report" /></a><br />
+</div>
+
+<p><span class='pagenum'><a name="Page_315" id="Page_315">[315]</a></span>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&mdash;three out of five, or six hundred&mdash;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.</p>
+
+<p>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:</p>
+
+<br />
+
+<p class="cen sc">Table XII<span class='pagenum'><a name="Page_316" id="Page_316">[316]</a></span></p>
+
+<p class="cen sc">Prevalence of Contagious Diseases in School Children</p>
+
+<p class="cen">(Case rate schools)</p>
+
+
+<div class="centered">
+<table border="0" cellpadding="2" cellspacing="0" width="90%" summary="Prevalence of Contagious Diseases in School Children">
+  <tr>
+  <td rowspan="4" class="tdctrb sc" style="border-left: 2px black solid;">School</td>
+  <td colspan="5" class="tdctrlb sc">General Communicable Diseases <span class="fnanchor">1</span></td>
+  <td colspan="5" class="tdctrlb sc" style="border-right: 2px black solid;">Communicable Diseases of Eye and Skin<span class="fnanchor">2</span></td>
+  </tr>
+  <tr>
+  <td colspan="4" class="tdcsc" style="border: 1px black solid;">Number</td>
+  <td rowspan="3" class="tdc" style="border: 1px black solid;">Number per 1000 Registered in Schools Inspected</td>
+  <td rowspan="3" class="tdc" style="border: 1px black solid;">Number found by Inspectors and Nurses</td>
+  <td rowspan="3" class="tdc" style="border: 1px black solid; border-right: 2px black solid">Number per 1000 Registered in Schools Inspected</td>
+  </tr>
+  <tr>
+  <td class="tdc" colspan="2" style="border: 1px black solid;">Found by Inspectors</td>
+  <td class="tdc" rowspan="2" style="border: 1px black solid;">Reported by Attending Physician</td>
+  <td class="tdc" rowspan="2" style="border: 1px black solid;">Total</td>
+  </tr>
+  <tr>
+  <td class="tdl" style="border: 1px black solid;">In School</td>
+  <td class="tdl" style="border: 1px black solid;">Among Absentee</td>
+  </tr>
+  <tr>
+  <td width="16%" class="tdcrlt" style="border-left: 2px black solid;">A</td>
+  <td width="12%" class="tdcrlt">&nbsp;</td>
+  <td width="12%" class="tdcrlt">&nbsp;</td>
+  <td width="12%" class="tdcrlt">&nbsp;</td>
+  <td width="12%" class="tdcrlt">&nbsp;</td>
+  <td width="12%" class="tdcrlt">&nbsp;</td>
+  <td width="12%" class="tdcrlt">&nbsp;</td>
+  <td width="12%" class="tdcrlt" style="border-right: 2px black solid;">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdcrl" style="border-left: 2px black solid;">B</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl" style="border-right: 2px black solid;">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdcrl" style="border-left: 2px black solid; border-bottom: 2px black solid; padding-bottom: .5em;">C</td>
+  <td class="tdcrl" style="border-bottom: 2px black solid; padding-bottom: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="border-bottom: 2px black solid; padding-bottom: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="border-bottom: 2px black solid; padding-bottom: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="border-bottom: 2px black solid; padding-bottom: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="border-bottom: 2px black solid; padding-bottom: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="border-bottom: 2px black solid; padding-bottom: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="border-right: 2px black solid; border-bottom: 2px black solid; padding-bottom: .5em;">&nbsp;</td>
+  </tr>
+  <tr>
+  <td colspan="8" class="tdl"><span class="fnanchor">1&nbsp;</span> Smallpox, diphtheria, scarlet fever, measles, chicken pox, mumps,
+      and whooping cough; excluded when found.</td>
+  </tr>
+  <tr>
+  <td colspan="8" class="tdl"><span class="fnanchor">2&nbsp;</span> Trachoma and other contagious eye diseases, ringworm, impetigo,
+      scabies, favus, and pediculosis; excluded only for persistent
+      nontreatment.</td>
+  </tr>
+</table>
+</div>
+
+<br />
+
+<p>Another table shows the following facts for each disease:</p>
+
+<br />
+
+<p class="cen sc">Table XIII</p>
+
+<p class="cen sc">Contagious Diseases Found in Schools by Inspectors and Nurses</p>
+
+<p class="cen">(Number and disposition of cases)</p>
+
+<div class="centered">
+<table border="0" cellpadding="1" cellspacing="0" width="100%" summary="Contagious Diseases Found in Schools by Inspectors and Nurses">
+  <tr>
+  <td width="36%" class="tdctrb sc" rowspan="2" style="border-bottom: 1px black solid;">&nbsp;</td>
+  <td class="tdctlb sc" colspan="8">General Communicable Diseases</td>
+  </tr>
+  <tr style="font-size: 90%;">
+  <td width="8%" class="tdc" style="border: 1px black solid; vertical-align: bottom;">Diphtheria</td>
+  <td width="8%" class="tdc" style="border: 1px black solid; vertical-align: bottom;">Scarlet fever</td>
+  <td width="8%" class="tdc" style="border: 1px black solid; vertical-align: bottom;">Measles</td>
+  <td width="8%" class="tdc" style="border: 1px black solid; vertical-align: bottom;">Smallpox</td>
+  <td width="8%" class="tdc" style="border: 1px black solid; vertical-align: bottom;">Chicken pox</td>
+  <td width="8%" class="tdc" style="border: 1px black solid; vertical-align: bottom;">Whooping cough</td>
+  <td width="8%" class="tdc" style="border: 1px black solid; vertical-align: bottom;">Mumps</td>
+  <td width="8%" class="tdctlb" style="vertical-align: bottom; border-top: 1px black solid; padding-bottom: 0em;">Total</td>
+  </tr>
+  <tr>
+  <td class="tdlr" style="border-top: 1px black solid; padding-top: .5em;">Cases found in school</td>
+  <td class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">&nbsp;</td>
+  <td class="tdcl" style="border-top: 1px black solid; padding-top: .5em;">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Cases excluded from school</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Cases treated in school</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Cases instructed in school or evidence of treatment furnished</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Number of treatments</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlr" style="padding-bottom: .5em;">Number of instructions</td>
+  <td class="tdcrl" style="padding-bottom: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="padding-bottom: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="padding-bottom: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="padding-bottom: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="padding-bottom: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="padding-bottom: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="padding-bottom: .5em;">&nbsp;</td>
+  <td class="tdcl" style="padding-bottom: .5em;">&nbsp;</td>
+  </tr>
+</table>
+</div>
+
+
+<div class="centered">
+<table border="0" cellpadding="1" cellspacing="0" width="100%" summary="Contagious Diseases Found in Schools by Inspectors and Nurses, Part 2">
+  <tr>
+  <td width="36%" class="tdctrb sc" rowspan="3" style="border-bottom: 1px black solid;">&nbsp;</td>
+  <td class="tdctlb sc" colspan="9">Communicable Diseases of Eye and Skin</td>
+  </tr>
+  <tr>
+  <td class="tdctrlb sc" colspan="2" style="border-top: 1px black solid;">Eye</td>
+  <td class="tdctlb sc" colspan="7" style="border-top: 1px black solid;">Skin</td>
+  </tr>
+  <tr style="font-size: 90%;">
+  <td class="tdc" style="border: 1px black solid; vertical-align: bottom;">Trachoma</td>
+  <td class="tdc" style="border: 1px black solid; vertical-align: bottom;">Other</td>
+  <td class="tdc" style="border: 1px black solid; vertical-align: bottom;">Ringworm</td>
+  <td class="tdc" style="border: 1px black solid; vertical-align: bottom;">Impetigo</td>
+  <td class="tdc" style="border: 1px black solid; vertical-align: bottom;">Scabies</td>
+  <td class="tdc" style="border: 1px black solid; vertical-align: bottom;">Favus</td>
+  <td class="tdc" style="border: 1px black solid; vertical-align: bottom;">Pediculosis</td>
+  <td class="tdc" style="border: 1px black solid; vertical-align: bottom;">Misc.</td>
+  <td class="tdctlb" style="vertical-align: bottom; border-top: 1px black solid; padding-bottom: 0em;">Total</td>
+  </tr>
+  <tr>
+  <td class="tdlr" style="border-top: 1px black solid; padding-top: .5em;">Cases found in school</td>
+  <td width="7%" class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">&nbsp;</td>
+  <td width="7%" class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">&nbsp;</td>
+  <td width="7%" class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">&nbsp;</td>
+  <td width="7%" class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">&nbsp;</td>
+  <td width="7%" class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">&nbsp;</td>
+  <td width="7%" class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">&nbsp;</td>
+  <td width="7%" class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">&nbsp;</td>
+  <td width="7%" class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">&nbsp;</td>
+  <td width="8%" class="tdcl" style="border-top: 1px black solid; padding-top: .5em;">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Cases excluded from school</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Cases treated in school</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Cases instructed in school or evidence of treatment furnished</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Number of treatments</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlr" style="border-bottom: 2px black solid; padding-bottom: .5em;">Number of instructions</td>
+  <td class="tdcrl" style="border-bottom: 2px black solid; padding-bottom: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="border-bottom: 2px black solid; padding-bottom: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="border-bottom: 2px black solid; padding-bottom: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="border-bottom: 2px black solid; padding-bottom: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="border-bottom: 2px black solid; padding-bottom: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="border-bottom: 2px black solid; padding-bottom: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="border-bottom: 2px black solid; padding-bottom: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="border-bottom: 2px black solid; padding-bottom: .5em;">&nbsp;</td>
+  <td class="tdcl" style="border-bottom: 2px black solid; padding-bottom: .5em;">&nbsp;</td>
+  </tr>
+</table>
+</div>
+
+<br />
+
+<p><span class='pagenum'><a name="Page_317" id="Page_317">[317]</a></span>The story of noncontagious physical defects found and treated is set
+forth in the following table:</p>
+
+<br />
+
+<p class="cen sc">Table XIV</p>
+
+<p class="cen sc">Medical Examination of School Children: Noncontagious Physical
+Defects Found and Treated, 1906</p>
+
+<div class="centered">
+<table border="0" cellpadding="2" cellspacing="0" width="100%" summary="Noncontagious Physical Defects Found and Treated, 1906">
+  <tr>
+  <td class="tdctrb sc" rowspan="3">Defects</td>
+  <td class="tdctrlb sc" colspan="4">School A</td>
+  <td class="tdctrlb sc" colspan="4">School B</td>
+  <td class="tdctlb sc" colspan="4">School C</td>
+  </tr>
+  <tr>
+  <td class="tdc" colspan="2" style="border: 1px black solid;">Found</td>
+  <td class="tdc" colspan="2" style="border: 1px black solid;">Reported Treated</td>
+  <td class="tdc" colspan="2" style="border: 1px black solid;">Found</td>
+  <td class="tdc" colspan="2" style="border: 1px black solid;">Reported Treated</td>
+  <td class="tdc" colspan="2" style="border: 1px black solid;">Found</td>
+  <td class="tdc" colspan="2" style="border-top: 1px black solid; border-bottom: 1px black solid; border-left: 1px black solid;">Reported Treated</td>
+  </tr>
+  <tr style="font-size: 75%;">
+  <td class="tdc" style="border: 1px black solid;">No.</td>
+  <td class="tdc" style="border: 1px black solid;">% of Total Defects Found</td>
+  <td class="tdc" style="border: 1px black solid;">No.</td>
+  <td class="tdc" style="border: 1px black solid;">% of Total Defects Found</td>
+  <td class="tdc" style="border: 1px black solid;">No.</td>
+  <td class="tdc" style="border: 1px black solid;">% of Total Defects Found</td>
+  <td class="tdc" style="border: 1px black solid;">No.</td>
+  <td class="tdc" style="border: 1px black solid;">% of Total Defects Found</td>
+  <td class="tdc" style="border: 1px black solid;">No.</td>
+  <td class="tdc" style="border: 1px black solid;">% of Total Defects Found</td>
+  <td class="tdc" style="border: 1px black solid;">No.</td>
+  <td class="tdc" style="border-top: 1px black solid; border-bottom: 1px black solid; border-left: 1px black solid;">% of Total Defects Found</td>
+  </tr>
+  <tr>
+  <td class="tdlr" width="22%" style="padding-top: .5em; border-top: 1px black solid;">Adenoids</td>
+  <td class="tdcrl" width="3%" style="padding-top: .5em; border-top: 1px black solid;">&nbsp;</td>
+  <td class="tdcrl" width="10%" style="padding-top: .5em; border-top: 1px black solid;">&nbsp;</td>
+  <td class="tdcrl" width="3%" style="padding-top: .5em; border-top: 1px black solid;">&nbsp;</td>
+  <td class="tdcrl" width="10%" style="padding-top: .5em; border-top: 1px black solid;">&nbsp;</td>
+  <td class="tdcrl" width="3%" style="padding-top: .5em; border-top: 1px black solid;">&nbsp;</td>
+  <td class="tdcrl" width="10%" style="padding-top: .5em; border-top: 1px black solid;">&nbsp;</td>
+  <td class="tdcrl" width="3%" style="padding-top: .5em; border-top: 1px black solid;">&nbsp;</td>
+  <td class="tdcrl" width="10%" style="padding-top: .5em; border-top: 1px black solid;">&nbsp;</td>
+  <td class="tdcrl" width="3%" style="padding-top: .5em; border-top: 1px black solid;">&nbsp;</td>
+  <td class="tdcrl" width="10%" style="padding-top: .5em; border-top: 1px black solid;">&nbsp;</td>
+  <td class="tdcrl" width="3%" style="padding-top: .5em; border-top: 1px black solid;">&nbsp;</td>
+  <td class="tdcl" width="10%" style="padding-top: .5em; border-top: 1px black solid;">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Nasal breathing</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Hyper-trophied tonsils</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Defective palate</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Defective hearing</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Defective vision</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Defective teeth</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Bad nutrition</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Diseased anterior cervical glands</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Diseased posterior cervical glands</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Heart disease</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Chorea</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Pulmonary disease</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Skin disease</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Deformity of spine</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Deformity of chest</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Deformity of extremities</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Defective mentality </td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlr" style="padding-bottom: .5em; border-bottom: 2px black solid;">Total</td>
+  <td class="tdcrl" style="padding-bottom: .5em; border-bottom: 2px black solid;">&nbsp;</td>
+  <td class="tdcrl" style="padding-bottom: .5em; border-bottom: 2px black solid;">&nbsp;</td>
+  <td class="tdcrl" style="padding-bottom: .5em; border-bottom: 2px black solid;">&nbsp;</td>
+  <td class="tdcrl" style="padding-bottom: .5em; border-bottom: 2px black solid;">&nbsp;</td>
+  <td class="tdcrl" style="padding-bottom: .5em; border-bottom: 2px black solid;">&nbsp;</td>
+  <td class="tdcrl" style="padding-bottom: .5em; border-bottom: 2px black solid;">&nbsp;</td>
+  <td class="tdcrl" style="padding-bottom: .5em; border-bottom: 2px black solid;">&nbsp;</td>
+  <td class="tdcrl" style="padding-bottom: .5em; border-bottom: 2px black solid;">&nbsp;</td>
+  <td class="tdcrl" style="padding-bottom: .5em; border-bottom: 2px black solid;">&nbsp;</td>
+  <td class="tdcrl" style="padding-bottom: .5em; border-bottom: 2px black solid;">&nbsp;</td>
+  <td class="tdcrl" style="padding-bottom: .5em; border-bottom: 2px black solid;">&nbsp;</td>
+  <td class="tdcl" style="padding-bottom: .5em; border-bottom: 2px black solid;">&nbsp;</td>
+  </tr>
+</table>
+</div>
+
+<br />
+
+<p>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 <span class='pagenum'><a name="Page_318" id="Page_318">[318]</a></span>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,
+<i>according to the number of children found to have physical defects,
+the number afflicted with contagious diseases, and the number properly
+treated</i>.</p>
+
+<p>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:</p>
+
+<br />
+
+<p class="cen sc">Table XV</p>
+
+<p class="cen sc">Table of Ranking-Schools Arranged Alphabetically</p>
+
+<div class="centered">
+<table border="0" cellpadding="2" cellspacing="0" width="80%" summary="Table of Ranking-Schools Arranged Alphabetically">
+  <tr>
+  <td width="20%" class="tdctrb sc" rowspan="2">School</td>
+  <td class="tdctlb sc" colspan="5">Rank in</td>
+  </tr>
+  <tr>
+  <td width="16%" class="tdc" style="border: 1px black solid;">Register</td>
+  <td width="16%" class="tdc" style="border: 1px black solid;">Defects Found</td>
+  <td width="16%" class="tdc" style="border: 1px black solid;">Children Needing Treatment</td>
+  <td width="16%" class="tdc" style="border: 1px black solid;">Children Treated</td>
+  <td width="16%" class="tdc" style="border-top: 1px black solid; border-bottom: 1px black solid; border-left: 1px black solid;">Children not Treated</td>
+  </tr>
+  <tr>
+  <td class="tdc" style="border-right: 1px black solid; border-top: 1px black solid; padding-top: .5em;">A</td>
+  <td class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">10</td>
+  <td class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">11</td>
+  <td class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">11</td>
+  <td class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">12</td>
+  <td class="tdcl" style="border-top: 1px black solid; padding-top: .5em;">&nbsp;&nbsp;6</td>
+  </tr>
+  <tr>
+  <td class="tdc" style="border-right: 1px black solid;">B</td>
+  <td class="tdcrl">20</td>
+  <td class="tdcrl">22</td>
+  <td class="tdcrl">22</td>
+  <td class="tdcrl">24</td>
+  <td class="tdcl">12</td>
+  </tr>
+  <tr>
+  <td class="tdc" style="border-right: 1px black solid; border-bottom: 2px black solid; padding-bottom: .5em;">C</td>
+  <td class="tdcrl" style="border-bottom: 2px black solid; padding-bottom: .5em;">30</td>
+  <td class="tdcrl" style="border-bottom: 2px black solid; padding-bottom: .5em;">33</td>
+  <td class="tdcrl" style="border-bottom: 2px black solid; padding-bottom: .5em;">30</td>
+  <td class="tdcrl" style="border-bottom: 2px black solid; padding-bottom: .5em;">36</td>
+  <td class="tdcl" style="border-bottom: 2px black solid; padding-bottom: .5em;">18</td>
+  </tr>
+</table>
+</div>
+
+<br />
+
+<p><span class='pagenum'><a name="Page_319" id="Page_319">[319]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<br />
+
+<p class="cen sc">Table XVI</p>
+
+<p class="cen sc">Table of Ranking-Schools Arranged according to Register, not Alphabetically</p>
+
+<div class="centered">
+<table border="0" cellpadding="2" cellspacing="0" width="80%" summary="Table of Ranking-Schools Arranged according to Register, not Alphabetically">
+  <tr>
+  <td width="20%" class="tdctrb sc" rowspan="2">School</td>
+  <td class="tdctlb sc" colspan="5">Rank in</td>
+  </tr>
+  <tr>
+  <td width="16%" class="tdc" style="border: 1px black solid;">Register</td>
+  <td width="16%" class="tdc" style="border: 1px black solid;">Defects Found</td>
+  <td width="16%" class="tdc" style="border: 1px black solid;">Children Needing Treatment</td>
+  <td width="16%" class="tdc" style="border: 1px black solid;">Children Treated</td>
+  <td width="16%" class="tdc" style="border-top: 1px black solid; border-bottom: 1px black solid; border-left: 1px black solid;">Children not Treated</td>
+  </tr>
+  <tr>
+  <td class="tdc" style="border-right: 1px black solid; border-top: 1px black solid; padding-top: .5em;">A</td>
+  <td class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">&nbsp;&nbsp;9</td>
+  <td class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">&nbsp;&nbsp;9</td>
+  <td class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">&nbsp;&nbsp;9</td>
+  <td class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">&nbsp;&nbsp;9</td>
+  <td class="tdcl" style="border-top: 1px black solid; padding-top: .5em;">9</td>
+  </tr>
+  <tr>
+  <td class="tdc" style="border-right: 1px black solid;">X</td>
+  <td class="tdcrl">10</td>
+  <td class="tdcrl">10</td>
+  <td class="tdcrl">10</td>
+  <td class="tdcrl">14</td>
+  <td class="tdcl">6</td>
+  </tr>
+  <tr>
+  <td class="tdc" style="border-right: 1px black solid; border-bottom: 2px black solid; padding-bottom: .5em;">H</td>
+  <td class="tdcrl" style="border-bottom: 2px black solid; padding-bottom: .5em;">11</td>
+  <td class="tdcrl" style="border-bottom: 2px black solid; padding-bottom: .5em;">11</td>
+  <td class="tdcrl" style="border-bottom: 2px black solid; padding-bottom: .5em;">11</td>
+  <td class="tdcrl" style="border-bottom: 2px black solid; padding-bottom: .5em;">17</td>
+  <td class="tdcl" style="border-bottom: 2px black solid; padding-bottom: .5em;">3</td>
+  </tr>
+</table>
+</div>
+
+<br />
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_320" id="Page_320">[320]</a></span>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.</p>
+
+<br />
+
+<p class="cen sc">Table XVII</p>
+
+<p class="cen sc">Weekly Class-Room Schedule</p>
+
+<div class="centered">
+<table border="0" cellpadding="2" cellspacing="0" width="80%" summary="Weekly Class-Room Schedule">
+  <tr>
+  <td class="tdctrb" rowspan="2">&nbsp;</td>
+  <td class="tdctlb sc" colspan="3">Temperature</td>
+  <td class="tdctlb sc" colspan="3">Cleaning</td>
+  <td class="tdctlb sc" colspan="2">Exercise</td>
+  </tr>
+  <tr>
+  <td class="tdc" style="border: 1px black solid;">10.30</td>
+  <td class="tdc" style="border: 1px black solid;">12.00</td>
+  <td class="tdc" style="border: 1px black solid;">2.00</td>
+  <td class="tdc" style="border: 1px black solid;">Dry</td>
+  <td class="tdc" style="border: 1px black solid;">Wet</td>
+  <td class="tdc" style="border: 1px black solid;">Disinfecting</td>
+  <td class="tdc" style="border: 1px black solid;">In Room</td>
+  <td class="tdc" style="border-top: 1px black solid; border-bottom: 1px black solid; border-left: 1px black solid;">Out of Room</td>
+  </tr>
+  <tr>
+  <td width="19%" class="tdlr" style="border-top: 1px black solid; padding-top: .5em;">Monday</td>
+  <td width="8%" class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">&nbsp;</td>
+  <td width="8%" class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">&nbsp;</td>
+  <td width="8%" class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">&nbsp;</td>
+  <td width="10%" class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">&nbsp;</td>
+  <td width="10%" class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">&nbsp;</td>
+  <td width="11%" class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">&nbsp;</td>
+  <td width="13%" class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">&nbsp;</td>
+  <td width="13%" class="tdcl" style="border-top: 1px black solid; padding-top: .5em;">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Tuesday</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Wednesday</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Thursday</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcrl">&nbsp;</td>
+  <td class="tdcl">&nbsp;</td>
+  </tr>
+  <tr>
+  <td class="tdlr" style="border-bottom: 2px black solid; padding-bottom: .5em;">Friday</td>
+  <td class="tdcrl" style="border-bottom: 2px black solid; padding-bottom: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="border-bottom: 2px black solid; padding-bottom: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="border-bottom: 2px black solid; padding-bottom: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="border-bottom: 2px black solid; padding-bottom: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="border-bottom: 2px black solid; padding-bottom: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="border-bottom: 2px black solid; padding-bottom: .5em;">&nbsp;</td>
+  <td class="tdcrl" style="border-bottom: 2px black solid; padding-bottom: .5em;">&nbsp;</td>
+  <td class="tdcl" style="border-bottom: 2px black solid; padding-bottom: .5em;">&nbsp;</td>
+  </tr>
+</table>
+</div>
+
+<br />
+
+<p>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 <span class='pagenum'><a name="Page_321" id="Page_321">[321]</a></span>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.</p>
+
+<p>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.</p>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_XXXI" id="CHAPTER_XXXI"></a><hr />
+<span class='pagenum'><a name="Page_322" id="Page_322">[322]</a></span><br />
+
+<h3>CHAPTER XXXI<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>THE PRESS</h4>
+<br />
+
+<p>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,&mdash;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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_323" id="Page_323">[323]</a></span>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: <i>The Economics of Bad Teeth</i>; <i>Need for
+Individual Efficiency</i>; <i>"Good Fellows" Lower Standard of Living by
+Neglecting their Families</i>. 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,&mdash;thirty-seven per cent of total reading matter
+and thirty-seven per cent of total advertisement.</p>
+
+<p>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,&mdash;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.</p>
+
+<p><span class='pagenum'><a name="Page_324" id="Page_324">[324]</a></span>For classification, envelopes can be used or manila cards 10&times;12
+inches. The teacher, parent, or advanced student will probably think
+the envelope most useful because most easily carried and filed,&mdash;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,&mdash;some
+addition to the knowledge already collected.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_325" id="Page_325">[325]</a></span>with <i>alcoholism</i>, <i>patent medicine</i>,
+and <i>tuberculosis</i> 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.</p>
+
+<p>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.</p>
+
+<p>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
+<i>New Jersey Review of Charities and Corrections</i> that deals with every
+manner of subject having to do with public health as well as with
+private and public morality and education.</p>
+
+<p>A similar journal, intended for national instruction, is <i>The Survey</i>,
+whose topical index for last year enumerates two hundred and
+thirty-two articles dealing with subjects directly connected with
+public hygiene, e.g.:</p>
+
+<div class="block"><p>Schools, 6; school inspection, 3; eyes,&mdash;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; <span class='pagenum'><a name="Page_326" id="Page_326">[326]</a></span>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.</p></div>
+
+<hr style='width: 15%;' />
+
+<p><i>The National Hospital Record</i>, the <i>Dietetic and Hygienic Gazette</i>,
+the <i>Journal of Nursing</i>, 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 <i>Good Health</i> and <i>Physical Culture</i>.
+In England there is a special magazine called <i>Children's Diseases</i>,
+which could be of great help to a school library for special
+reference. The same can be said of the <i>Psychological Clinic</i>,
+<i>Pediatrics</i>, 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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_327" id="Page_327">[327]</a></span>their fault if questioners care more about
+cosmetics and hair bleaches than about the fresh-air cure of
+headaches. They will co&ouml;perate with teachers and parents in securing
+more general discussion of other problems than beauty doctoring.</p>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_328" id="Page_328">[328]</a></span>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 co&ouml;peration would soon be reflected in
+school journals, popular magazines, and daily newspapers.</p>
+
+<br />
+<br />
+<br />
+<br />
+<a name="PART_V_ALLIANCE_OF_HYGIENE_PATRIOTISM_AND_RELIGION" id="PART_V_ALLIANCE_OF_HYGIENE_PATRIOTISM_AND_RELIGION"></a><a name="CHAPTER_XXXII" id="CHAPTER_XXXII"></a><hr />
+<span class='pagenum'><a name="Page_329" id="Page_329">[329]</a></span><br />
+<br />
+<br />
+<br />
+
+<h2 class="wrap">PART V. ALLIANCE OF HYGIENE, PATRIOTISM, AND RELIGION</h2>
+
+<br />
+
+<h3>CHAPTER XXXII<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>DO-NOTHING AILMENTS</h4>
+<br />
+
+<p>"Men have died, from time to time, and worms have eaten them, but not
+for love"&mdash;<i>nor for work</i>. 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,&mdash;sweets, stimulants,&mdash;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:</p>
+
+<div class="block"><p>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.</p>
+
+<p>We have had the owner of a great railroad system pathetically
+telling the public that he is unhappy. That is undoubtedly true,
+<span class='pagenum'><a name="Page_330" id="Page_330">[330]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>But he cannot be happy because he is in prison,&mdash;in a prison of
+money, a prison that is honorable because it gives him everything
+that he wants, and he wants nothing.</p></div>
+
+<p>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 <i>Psychological Clinic</i> protests that the fashionable
+private schools and the private tutor share with rich fathers and
+mothers responsibility for life failures,&mdash;it is time that educators
+teach children themselves the physical and moral ailments and
+disillusions that come from doing nothing.</p>
+
+<p>Ten years ago a stenographer inherited two hundred and fifty thousand
+dollars. Her dream of nothing to do <span class='pagenum'><a name="Page_331" id="Page_331">[331]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_332" id="Page_332">[332]</a></span>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.</p>
+
+<p>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:</p>
+
+<div class="block"><p>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.</p></div>
+
+<p>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.</p>
+
+<p>Suiting work to interest and interest to work is an economy that
+should not be overlooked. The energy <span class='pagenum'><a name="Page_333" id="Page_333">[333]</a></span>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&mdash;accurate and detailed work&mdash;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 <span class='pagenum'><a name="Page_334" id="Page_334">[334]</a></span>the
+Stars and Stripes, do-nothing ailments will be less frequent and less
+costly.</p>
+
+<p>Work&mdash;that one enjoys&mdash;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.</p>
+
+<div class="poem"><div class="stanza">
+<span class="i0">If you're sick with something chronic,<br /></span>
+<span class="i0">And you think you need a tonic,<br /></span>
+<span class="i4">Do something.<br /></span>
+<span class="i0">There is life and health in doing,<br /></span>
+<span class="i0">There is pleasure in pursuing;<br /></span>
+<span class="i0">Doing, then, is health accruing&mdash;<br /></span>
+<span class="i4">Do something.<br /></span>
+</div><div class="stanza">
+<span class="i0">And if you're seeking pleasure,<br /></span>
+<span class="i0">Or enjoyment in full measure,<br /></span>
+<span class="i4">Do something.<br /></span>
+<span class="i0">Idleness, there's nothing in it;<br /></span>
+<span class="i0">'Twill not pay you for a minute&mdash;<br /></span>
+<span class="i4">Do something.<br /></span>
+</div></div>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_XXXIII" id="CHAPTER_XXXIII"></a><hr />
+<span class='pagenum'><a name="Page_335" id="Page_335">[335]</a></span><br />
+
+<h3>CHAPTER XXXIII<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>HEREDITY BUGABOOS AND HEREDITY TRUTHS</h4>
+<br />
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_336" id="Page_336">[336]</a></span>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 <i>Heredity</i> (1908), in
+which the latest conclusions of science are clearly and soundly set
+forth.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_337" id="Page_337">[337]</a></span>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,&mdash;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.</p>
+
+<p>"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 <i>Report on Physical Deterioration, 1904</i>, 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.</p>
+
+<div class="img"><span class='pagenum'><a name="Page_338" id="Page_338">[338]</a></span>
+<a href="images/imagep338.png">
+<img border="0" src="images/imagep338.png" width="90%" alt="Testing Environment--House Score" /></a><br />
+</div>
+
+<div class="img"><span class='pagenum'><a name="Page_339" id="Page_339">[339]</a></span>
+<a href="images/imagep339.png">
+<img border="0" src="images/imagep339.png" width="90%" alt="Definitions of Terms Used in House Score Card" /></a><br />
+</div>
+
+<p><span class='pagenum'><a name="Page_340" id="Page_340">[340]</a></span>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.</p>
+
+<div class="img">
+<a href="images/imagep340.jpg">
+<img border="0" src="images/imagep340.jpg" width="80%" alt="The Best Inheritance Is A Mother Who Knows How To Keep Her Baby Well" /></a><br />
+<p class="cen" style="margin-top: .2em;">THE BEST INHERITANCE IS A MOTHER WHO KNOWS HOW TO KEEP HER BABY WELL</p>
+</div>
+
+<p>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:</p>
+
+
+<div class="block">
+
+<p class="cen sc">I. As to Babies</p>
+
+<p>Training of mothers, provident societies and maternity funds,
+feeding of infants, milk supply, milk depots, sterilization and
+<span class='pagenum'><a name="Page_341" id="Page_341">[341]</a></span>refrigeration of milk, effect of mother's employment upon infant
+mortality, still births, cookery, hygiene and domestic economy,
+public nurseries, cr&egrave;ches.</p>
+
+<br />
+
+<p class="cen sc">II. As to Children</p>
+
+<p>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.</p>
+
+<br />
+
+<p class="cen sc">III. As to Living and Working Conditions</p>
+
+<p>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.</p>
+
+<br />
+
+<p class="cen sc">IV. As to Health Machinery</p>
+
+<p>Medical officers of health, local, district, and national boards,
+health associations.</p></div>
+
+<p>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 <span class='pagenum'><a name="Page_342" id="Page_342">[342]</a></span>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.</p>
+
+<p>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.</p>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_XXXIV" id="CHAPTER_XXXIV"></a><hr />
+<span class='pagenum'><a name="Page_343" id="Page_343">[343]</a></span><br />
+
+<h3>CHAPTER XXXIV<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>INEFFECTIVE AND EFFECTIVE WAYS OF COMBATING ALCOHOLISM</h4>
+<br />
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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
+<span class='pagenum'><a name="Page_344" id="Page_344">[344]</a></span>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.</p>
+
+<p>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:</p>
+
+<div class="centered">
+<table border="0" cellpadding="1" cellspacing="0" width="60%" summary="New York City">
+  <tr>
+  <td width="80%" class="tdl">Saloons</td>
+  <td width="20%" class="tdr">10,821</td>
+  </tr>
+  <tr>
+  <td class="tdl">Arrests</td>
+  <td class="tdr">133,749</td>
+  </tr>
+  <tr>
+  <td class="tdl">Expense of police department</td>
+  <td class="tdr">$10,199,206</td>
+  </tr>
+  <tr>
+  <td class="tdl">Police courts, jails, workhouses, reformatories</td>
+  <td class="tdr">1,310,411</td>
+  </tr>
+  <tr>
+  <td class="tdl">Hospitals, asylums, and other charities</td>
+  <td class="tdr">4,754,380</td>
+  </tr>
+</table>
+</div>
+
+<p class="noin">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
+<i>wipe out</i> she says <i>shrivel</i>. No truth would have been lost by
+avoiding all misrepresentation.</p>
+
+<p><span class='pagenum'><a name="Page_345" id="Page_345">[345]</a></span>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?"</p>
+
+<p>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, <i>assuming that all resultant evils are concentrated
+in one organ</i>. 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.</p>
+
+<p>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, <span class='pagenum'><a name="Page_346" id="Page_346">[346]</a></span>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.</p>
+
+<p>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&mdash;and
+frequently result from a moderate use&mdash;of stimulants and narcotics. Of
+the many reasons for not drinking and smoking, physiology gives those
+that least <span class='pagenum'><a name="Page_347" id="Page_347">[347]</a></span>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&mdash;and
+deceiving&mdash;sensations of alcoholic beverages and cigarettes.</p>
+
+<p>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&mdash;<i>acts that give offense</i> and <i>acts that give
+happiness</i>&mdash;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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_348" id="Page_348">[348]</a></span>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 <i>per se</i> in anything and everything, and unless he becomes
+thoroughly grounded in the life relations and health relations to
+which he must adapt himself.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_349" id="Page_349">[349]</a></span>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.</p>
+
+<p>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 <i>American Commonwealth</i>, 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 <span class='pagenum'><a name="Page_350" id="Page_350">[350]</a></span>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_351" id="Page_351">[351]</a></span>the manufacture or sale of
+alcoholic beverages within any limits protected by the United States
+Constitution.</p>
+
+<p>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&mdash;the family that wants clothing, food, and
+shelter&mdash;will save enough money to be able to spend still larger sums
+than heretofore upon education, health, and public safety.</p>
+
+<p>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 <i>Transactions of the American Brewing
+Institute</i>. Under the title, "Social Order and the Saloon&mdash;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 <span class='pagenum'><a name="Page_352" id="Page_352">[352]</a></span>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.</p>
+
+<div class="block"><p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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
+<span class='pagenum'><a name="Page_353" id="Page_353">[353]</a></span>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,&mdash;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.</p>
+
+<p>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.</p>
+
+<p>The church is perfectly right in urging total abstinence upon the
+individual. The only path of safety lies in abstinence for some
+individuals....</p>
+
+<p>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!</p>
+
+<p>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.</p>
+
+<p>What has been the effect of high license?</p>
+
+<p>How much public revenue should the traffic yield?</p>
+
+<p>Does high license stimulate unlawful trade?</p>
+
+<p>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?</p>
+
+<p>Should the place or the individual be licensed?</p>
+
+<p>Should the licensing authorities be appointive or elective? By
+whom should they be appointed, and for what term of office?</p>
+
+<p>Have the courts made good or bad licensing authorities? Where the
+courts issue licenses, what has been the effect on the court?</p>
+
+<p><span class='pagenum'><a name="Page_354" id="Page_354">[354]</a></span>Should the licensing authority alone have the power to revoke a
+license, and discretion to withhold a license?</p>
+
+<p>How can the licensing authority enforce the law? Should it not be
+independent of the police?</p>
+
+<p>What should be the penalty for breach of the law? Do not severe
+penalties miscarry?</p>
+
+<p>On what plea, and under what conditions, should licenses be
+transferred?</p>
+
+<p>What has been the effect of limiting the number of saloons?</p>
+
+<p>Should limitation be according to area or to population?</p>
+
+<p>Is there any relation between the number of saloons and the volume
+of consumption?</p>
+
+<p>What should be the limit to the hours of selling?</p>
+
+<p>Should saloons be allowed to become places of entertainment?</p>
+
+<p>How can the sale of liquor by druggists be controlled?</p>
+
+<p>How can spurious drinking clubs be prevented or controlled?</p>
+
+<p>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?</p>
+
+<p>How can the "back-room" evil be stopped? Is it legal (i.e.
+constitutional) to prohibit the sale or serving of liquor to
+women?</p>
+
+<p>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?</p>
+
+<p>Should the state undertake to regulate the liquor business or to
+enforce liquor laws?</p>
+
+<p>Is it possible to devise any working plan which will apply with
+equal effectiveness and equity in communities of compact and of
+scattered population?</p>
+
+<p>Should, or should not, the principle of self-government be
+carefully preserved in the whole scheme of legislation to regulate
+the liquor business?</p></div>
+
+<p>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, <span class='pagenum'><a name="Page_355" id="Page_355">[355]</a></span>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:</p>
+
+<div class="block"><p>1. Inspection to discover disease centers&mdash;"blind pigs," "blind
+tigers," etc.</p>
+
+<p>2. Compulsory notification by parents and landlords, and by police
+and other officials.</p>
+
+<p>3. Prompt investigation upon complaint from private citizens.</p>
+
+<p>4. Prompt removal of the disease and disinfection of the center.</p>
+
+<p>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.</p>
+
+<p>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.</p></div>
+
+<p>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 <i>New York
+Evening Post's</i> symposium on "How to Give Wisely," by Mrs. Emma
+Garrett Boyd, of Atlanta, and Miss Salmon, of Vassar College.</p>
+
+<p><span class='pagenum'><a name="Page_356" id="Page_356">[356]</a></span>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.</p>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_XXXV" id="CHAPTER_XXXV"></a><hr />
+<span class='pagenum'><a name="Page_357" id="Page_357">[357]</a></span><br />
+
+<h3>CHAPTER XXXV<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>IS IT PRACTICABLE IN PRESENTING TO CHILDREN THE EVILS OF ALCOHOLISM TO<br />
+TELL THE TRUTH, THE WHOLE TRUTH, AND NOTHING BUT THE TRUTH?</h4>
+<br />
+
+<p>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,&mdash;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 <span class='pagenum'><a name="Page_358" id="Page_358">[358]</a></span>injuries that are not only as grave in
+themselves as the evils of moderate drinking, but, in addition,
+actually tempt to moderate drinking.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_359" id="Page_359">[359]</a></span>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 <i>preventing</i> 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."</p>
+
+<p>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."</p>
+
+<p>Thus far American insurance companies are doing little preventive and
+educational work on the alcohol question, <span class='pagenum'><a name="Page_360" id="Page_360">[360]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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 <i>all</i>
+the time they are at work. The rules are especially strict for men
+working for a railroad <span class='pagenum'><a name="Page_361" id="Page_361">[361]</a></span>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,&mdash;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:</p>
+
+<div class="block"><p>1. <i>Examination of heart and arteries.</i> 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.</p>
+
+<p>2. <i>On re&euml;xamination of employees.</i> 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.</p></div>
+
+<p>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 <span class='pagenum'><a name="Page_362" id="Page_362">[362]</a></span>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.</p>
+
+<p>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.</p>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_XXXVI" id="CHAPTER_XXXVI"></a><hr />
+<span class='pagenum'><a name="Page_363" id="Page_363">[363]</a></span><br />
+
+<h3>CHAPTER XXXVI<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>FIGHTING TOBACCO EVILS</h4>
+<br />
+
+<p>"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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_364" id="Page_364">[364]</a></span>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&mdash;fear&mdash;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.</p>
+
+<p>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:</p>
+
+<p>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.</p>
+
+<p>2. Enforcement of restrictions as to place and time when smoking is
+permitted.</p>
+
+<p>3. Agitation against tobacco as a private and public nuisance.</p>
+
+<p>4. Explanation of commercial advantages of abstinence.</p>
+
+<p>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 <span class='pagenum'><a name="Page_365" id="Page_365">[365]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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,&mdash;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 <span class='pagenum'><a name="Page_366" id="Page_366">[366]</a></span>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_367" id="Page_367">[367]</a></span>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.)</p>
+
+<p>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, <span class='pagenum'><a name="Page_368" id="Page_368">[368]</a></span>such men are more apt to lose their nerve in an emergency and
+to fail to read signals or instructions correctly.</p>
+
+<p>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&mdash;cannot&mdash;believe contrary to their own eyes, parents and teachers
+are able to speak dogmatically of that which children will
+believe,&mdash;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.</p>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_XXXVII" id="CHAPTER_XXXVII"></a><hr />
+<span class='pagenum'><a name="Page_369" id="Page_369">[369]</a></span><br />
+
+<h3>CHAPTER XXXVII<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>THE PATENT-MEDICINE EVIL</h4>
+<br />
+
+<div class="block"><p>"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.</p></div>
+
+<p>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&mdash;in
+cars, on transfers, on billboards, in magazines, in newspapers, in the
+mails&mdash;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; <span class='pagenum'><a name="Page_370" id="Page_370">[370]</a></span>when we consider
+that an increasingly large proportion of advertising space is devoted
+to health,&mdash;we begin to realize the cumulative power for good or for
+evil that health advertisements must have.</p>
+
+<p>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:</p>
+
+<br />
+
+<div class="centered">
+<table border="0" cellpadding="2" cellspacing="0" width="80%" summary="advertisements devoted to health">
+  <tr>
+  <td width="24%" class="tdctrb" rowspan="2">&nbsp;</td>
+  <td class="tdctlb sc" colspan="3" style="border-right: 1px black solid;">Penny Paper</td>
+  <td class="tdctlb sc" colspan="3">Three-Cent Paper</td>
+  </tr>
+  <tr>
+  <td width="11%" class="tdc" style="border: 1px black solid;">News Item</td>
+  <td width="11%" class="tdc" style="border: 1px black solid;">Editorial</td>
+  <td width="16%" class="tdc" style="border: 1px black solid;">Advertisement</td>
+  <td width="11%" class="tdc" style="border: 1px black solid;">News Item</td>
+  <td width="11%" class="tdc" style="border: 1px black solid;">Editorial</td>
+  <td width="16%" class="tdc" style="border-top: 1px black solid; border-bottom: 1px black solid; border-left: 1px black solid;">Advertisement</td>
+  </tr>
+  <tr>
+  <td class="tdlr" style="border-top: 1px black solid; padding-top: .5em;">Milk</td>
+  <td class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">&nbsp;&nbsp;3</td>
+  <td class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">&mdash;</td>
+  <td class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">&nbsp;&nbsp;2</td>
+  <td class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">&nbsp;&nbsp;3</td>
+  <td class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">&mdash;</td>
+  <td class="tdcl" style="border-top: 1px black solid; padding-top: .5em;">&nbsp;&nbsp;2</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Teeth</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcrl">1</td>
+  <td class="tdcrl">&nbsp;&nbsp;2</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcl">&nbsp;&nbsp;1</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Shoes</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcrl">&nbsp;&nbsp;4</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcl">&nbsp;&nbsp;1</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Food</td>
+  <td class="tdcrl">&nbsp;&nbsp;1</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcrl">&nbsp;&nbsp;1</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcl">&nbsp;&nbsp;4</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Alcohol</td>
+  <td class="tdcrl">&nbsp;&nbsp;1</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcrl">&nbsp;&nbsp;5</td>
+  <td class="tdcrl">&nbsp;&nbsp;3</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcl">&nbsp;&nbsp;7</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Tuberculosis</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcrl">&nbsp;&nbsp;1</td>
+  <td class="tdcrl">&nbsp;&nbsp;1</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcl">&mdash;</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Patent medicine</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcrl">17</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcl">&mdash;</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Constipation cures</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcrl">&nbsp;&nbsp;4</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcl">&nbsp;&nbsp;5</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Eyes</td>
+  <td class="tdcrl">&nbsp;&nbsp;3</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcrl">&nbsp;&nbsp;5</td>
+  <td class="tdcrl">&nbsp;&nbsp;1</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcl">&mdash;</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Beauty</td>
+  <td class="tdcrl">&nbsp;&nbsp;2</td>
+  <td class="tdcrl">5</td>
+  <td class="tdcrl">&nbsp;&nbsp;8</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcl">&nbsp;&nbsp;6</td>
+  </tr>
+  <tr>
+  <td class="tdlr" style="border-bottom: 1px black solid;">General</td>
+  <td class="tdcrl" style="border-bottom: 1px black solid;">&nbsp;&nbsp;8</td>
+  <td class="tdcrl" style="border-bottom: 1px black solid;">3</td>
+  <td class="tdcrl" style="border-bottom: 1px black solid;">&nbsp;&nbsp;3</td>
+  <td class="tdcrl" style="border-bottom: 1px black solid;">&nbsp;&nbsp;5</td>
+  <td class="tdcrl" style="border-bottom: 1px black solid;">&mdash;</td>
+  <td class="tdcl" style="border-bottom: 1px black solid;">&mdash;</td>
+  </tr>
+  <tr>
+  <td class="tdlr" style="border-top: 1px black solid; padding-top: .25em; padding-bottom: .25em; padding-left: 1.5em; border-bottom: 2px black solid;">Total</td>
+  <td class="tdcrl" style="border-top: 1px black solid; padding-top: .25em; padding-bottom: .25em; border-bottom: 2px black solid;">18</td>
+  <td class="tdcrl" style="border-top: 1px black solid; padding-top: .25em; padding-bottom: .25em; border-bottom: 2px black solid;">9</td>
+  <td class="tdcrl" style="border-top: 1px black solid; padding-top: .25em; padding-bottom: .25em; border-bottom: 2px black solid;">51</td>
+  <td class="tdcrl" style="border-top: 1px black solid; padding-top: .25em; padding-bottom: .25em; border-bottom: 2px black solid;">14</td>
+  <td class="tdcrl" style="border-top: 1px black solid; padding-top: .25em; padding-bottom: .25em; border-bottom: 2px black solid;">&mdash;</td>
+  <td class="tdcl" style="border-top: 1px black solid; padding-top: .25em; padding-bottom: .25em; border-bottom: 2px black solid;">26</td>
+  </tr>
+</table>
+</div>
+
+<br />
+
+<p>The following list of health topics was treated in the advertisements,
+editorials, and articles of a popular monthly periodical devoted to
+women:</p>
+
+<br />
+
+<div class="centered">
+<table border="0" cellpadding="2" cellspacing="0" width="70%" summary="health topics">
+  <tr>
+  <td class="tdctrb">&nbsp;</td>
+  <td class="tdctlb" style="border-right: 1px black solid;">Article</td>
+  <td class="tdctlb" style="border-right: 1px black solid;">Editorial</td>
+  <td class="tdctlb">Advertisement</td>
+  </tr>
+  <tr>
+  <td width="40%" class="tdlr" style="border-top: 1px black solid; padding-top: .5em;">Babies</td>
+  <td width="20%" class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">&nbsp;&nbsp;1</td>
+  <td width="20%" class="tdcrl" style="border-top: 1px black solid; padding-top: .5em;">&mdash;</td>
+  <td width="20%" class="tdcl" style="border-top: 1px black solid; padding-top: .5em;">11</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Soaps and powders</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcl">&nbsp;&nbsp;5</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Beauty</td>
+  <td class="tdcrl">&nbsp;&nbsp;3</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcl">&nbsp;&nbsp;6</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Quack cures</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcrl">2</td>
+  <td class="tdcl">&mdash;</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Tooth powders</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcl">&nbsp;&nbsp;4</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Household</td>
+  <td class="tdcrl">&nbsp;&nbsp;1</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcl">&nbsp;&nbsp;5</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Food and cooking</td>
+  <td class="tdcrl">&nbsp;&nbsp;1</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcl">14</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Clothes</td>
+  <td class="tdcrl">13</td>
+  <td class="tdcrl">&mdash;</td>
+  <td class="tdcl">&nbsp;&nbsp;5</td>
+  </tr>
+  <tr>
+  <td class="tdlr">Teaching sex laws</td>
+  <td class="tdcrl">&nbsp;&nbsp;1</td>
+  <td class="tdcrl">2</td>
+  <td class="tdcl">&mdash;</td>
+  </tr>
+  <tr>
+  <td class="tdlr" style="border-bottom: 1px black solid;">Medicine</td>
+  <td class="tdcrl" style="border-bottom: 1px black solid;">&nbsp;&nbsp;4</td>
+  <td class="tdcrl" style="border-bottom: 1px black solid;">1</td>
+  <td class="tdcl" style="border-bottom: 1px black solid;">&mdash;</td>
+  </tr>
+  <tr>
+  <td class="tdlr" style="border-top: 1px black solid; padding-top: .25em; padding-bottom: .25em; padding-left: 1.5em; border-bottom: 2px black solid;">Total</td>
+  <td class="tdcrl" style="border-top: 1px black solid; padding-top: .25em; padding-bottom: .25em; border-bottom: 2px black solid;">24</td>
+  <td class="tdcrl" style="border-top: 1px black solid; padding-top: .25em; padding-bottom: .25em; border-bottom: 2px black solid;">5</td>
+  <td class="tdcl" style="border-top: 1px black solid; padding-top: .25em; padding-bottom: .25em; border-bottom: 2px black solid;">50</td>
+  </tr>
+</table>
+</div>
+
+<br />
+
+<p><span class='pagenum'><a name="Page_371" id="Page_371">[371]</a></span>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,&mdash;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.</p>
+
+<p>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." <span class='pagenum'><a name="Page_372" id="Page_372">[372]</a></span>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&mdash;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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_373" id="Page_373">[373]</a></span>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.</p>
+
+<p>Is it not pitiful, this grasping for a poison in an extremity; this
+seizing of a defective rope to escape the fire?</p>
+
+<div class="img">
+<a href="images/imagep373.jpg">
+<img border="0" src="images/imagep373.jpg" width="80%" alt="Learning How To Keep Baby Well Without Patent Medicines" /></a><br />
+<p class="cen" style="margin-top: .2em;">LEARNING HOW TO KEEP BABY WELL WITHOUT PATENT MEDICINES<br />
+Recreation Pier, New York City, Summer, 1908</p>
+</div>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_374" id="Page_374">[374]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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 <i>the label shall embody no statement which shall be
+false or misleading in any particular</i>." 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 <i>buy</i> may
+read." It does not require that all <span class='pagenum'><a name="Page_375" id="Page_375">[375]</a></span>who <i>run</i> may read, for <i>it does
+not say that advertisements of a patent medicine shall tell the truth
+about its ingredients or its action on the human body</i>; 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 <i>on entering the state</i>. 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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_376" id="Page_376">[376]</a></span>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_377" id="Page_377">[377]</a></span>Fighting patent-medicine evils is a civic duty to be accomplished by
+civic co&ouml;peration, 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.</p>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_XXXVIII" id="CHAPTER_XXXVIII"></a><hr />
+<span class='pagenum'><a name="Page_378" id="Page_378">[378]</a></span><br />
+
+<h3>CHAPTER XXXVIII<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>HEALTH ADVERTISEMENTS THAT PROMOTE HEALTH</h4>
+<br />
+
+<p>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.</p>
+
+<p>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,&mdash;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.</p>
+
+<p><span class='pagenum'><a name="Page_379" id="Page_379">[379]</a></span>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."</p>
+
+<p>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 <span class='pagenum'><a name="Page_380" id="Page_380">[380]</a></span>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 <span class='pagenum'><a name="Page_381" id="Page_381">[381]</a></span>news columns of a daily paper in New York as
+official advice to school children.</p>
+
+<div class="img">
+<a href="images/imagep380.jpg">
+<img border="0" src="images/imagep380.jpg" width="50%" alt="Don't Poison Baby." /></a><br />
+</div>
+
+<p>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,&mdash;a
+fearful menace to health when the remedies offered are dishonest, a
+universal opportunity for promoting health if the cure is genuine.</p>
+
+<p>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."</p>
+
+<p>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 <span class='pagenum'><a name="Page_382" id="Page_382">[382]</a></span>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.</p>
+
+<p>A man deserves profit who sends this message to millions of readers:</p>
+
+<div class="block"><p class="noin">There are three kinds of cleanliness:</p>
+
+<p class="noin">First, the ordinary soap-and-water cleanliness.<br />
+Second, the so-called "beauty" cleanliness.<br />
+Third, prophylactic cleanliness, or the cleanliness that "guards
+against disease."</p></div>
+
+<p class="noin">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.</p>
+
+<p>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, <span class='pagenum'><a name="Page_383" id="Page_383">[383]</a></span>the stereopticon exhibit, the <i>cumulative
+illustration</i> of a fact, which is the essence of successful
+advertising. Boards of health can use all the typographical aids to
+clear understanding,&mdash;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:</p>
+
+<div class="block"><p>First, put your advertisement where it will be seen. (Tell your
+story where it will be heard.)</p>
+
+<p>Second, write it so that people will read it. (Tell it so that
+people will understand it.)</p>
+
+<p>Third, tell the truth, so that people will believe it.</p></div>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_XXXIX" id="CHAPTER_XXXIX"></a><hr />
+<span class='pagenum'><a name="Page_384" id="Page_384">[384]</a></span><br />
+
+<h3>CHAPTER XXXIX<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>IS CLASS INSTRUCTION IN SEX HYGIENE PRACTICABLE?</h4>
+<br />
+
+<p>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,&mdash;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:</p>
+
+<div class="block"><p>1. Do you wish a pamphlet on sex subjects to hand to your pupils?
+Why?</p>
+
+<p>2. Do you wish separate pamphlets for boys and girls?</p>
+
+<p>3. For what age limits and social conditions do you wish them?</p>
+
+<p>4. What topics do you wish the pamphlets for boys to "handle"?</p>
+
+<p>5. What topic do you wish the pamphlet for girls to "handle"?</p>
+
+<p>6. If you think one pamphlet sufficient for both sexes, what
+should it consider?</p>
+
+<p>7. How far do you go in teaching sexual hygiene or reproduction?
+By what method?</p>
+
+<p><span class='pagenum'><a name="Page_385" id="Page_385">[385]</a></span>8. What special difficulties do you find in teaching it?</p>
+
+<p>9. What special need of teaching it have you found?</p>
+
+<p>10. What special benefits (or otherwise) have you noticed from
+teaching it?</p>
+
+<p>11. What criticisms (favorable or otherwise) do you encounter?</p></div>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_386" id="Page_386">[386]</a></span>that are
+wholesome are made to rival diversions or occupations that are harmful
+and criminal.</p>
+
+<div class="img">
+<a href="images/imagep386.jpg">
+<img border="0" src="images/imagep386.jpg" width="80%" alt="Object Lessons for Instruction in Sex Health" /></a><br />
+<p class="cen" style="margin-top: .2em;">OBJECT LESSONS FOR INSTRUCTION IN SEX HEALTH<br />
+Note the uncomfortable, unhealthy overdressing</p>
+</div>
+
+<p>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.</p>
+
+<div class="img"><span class='pagenum'><a name="Page_387" id="Page_387">[387]</a></span>
+<a href="images/imagep387.jpg">
+<img border="0" src="images/imagep387.jpg" width="80%" alt="The Study Of Infant Health is Conducive to Pure-Mindedness" /></a><br />
+<p class="cen" style="margin-top: .2em;">THE STUDY OF INFANT HEALTH IS CONDUCIVE TO PURE-MINDEDNESS<br />
+Note the simple, comfortable, hygienic dress</p>
+</div>
+
+<p>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 <span class='pagenum'><a name="Page_388" id="Page_388">[388]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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?</p>
+
+<p><span class='pagenum'><a name="Page_389" id="Page_389">[389]</a></span>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_390" id="Page_390">[390]</a></span>social and economic aspects of general health
+they will quickly solve the problem of instruction in sex health.</p>
+
+<p>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.</p>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_XL" id="CHAPTER_XL"></a><hr />
+<span class='pagenum'><a name="Page_391" id="Page_391">[391]</a></span><br />
+
+<h3>CHAPTER XL<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>THE ELEMENT OF TRUTH IN QUACKERY; HYGIENE OF THE MIND</h4>
+<br />
+
+<p>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.<a name="FNanchor_17_17" id="FNanchor_17_17"></a><a href="#Footnote_17_17" class="fnanchor">[17]</a> 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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_392" id="Page_392">[392]</a></span>been
+vaguely impressed in the transom glass when molten. When the mystery
+was explained the excursions and the cures stopped.</p>
+
+<p>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 <i>placebo</i>,&mdash;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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_393" id="Page_393">[393]</a></span>kind begin by displacing the fear with hope or cheer; the
+physical disorders frequently vanish by the same window as fear. For
+<i>fear</i> write <i>self-pity</i>, <i>morbid self-consciousness</i>, <i>hypertrophied
+submission</i>; to <i>hope</i> and <i>cheer</i> add <i>smile</i>, <i>relaxation</i>, and
+<i>zest</i>; 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.</p>
+
+<p>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:</p>
+
+<div class="poem"><div class="stanza">
+<span class="i0">Talk health. The dreary, never-changing tale<br /></span>
+<span class="i0">Of mortal maladies is worn and stale.<br /></span>
+<span class="i0">You cannot charm or interest or please<br /></span>
+<span class="i0">By harping on that minor chord, disease.<br /></span>
+</div><div class="stanza">
+<span class="i0">"Whatever the weather may be," says he,<br /></span>
+<span class="i0">"Whatever the weather may be,<br /></span>
+<span class="i0">It's the songs ye sing, and the smiles ye wear,<br /></span>
+<span class="i0">That's a-making the sun shine everywhere."<br /></span>
+</div></div>
+
+<p><span class='pagenum'><a name="Page_394" id="Page_394">[394]</a></span>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_395" id="Page_395">[395]</a></span>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,&mdash;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 co&ouml;perate, 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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_396" id="Page_396">[396]</a></span>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.</p>
+
+<p>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:</p>
+
+<div class="block"><p>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.</p></div>
+
+<p>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 co&ouml;perate both in treating the individual and in utilizing his
+energies for others' benefits.</p>
+
+<p>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 <span class='pagenum'><a name="Page_397" id="Page_397">[397]</a></span>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.</p>
+
+<p>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.</p>
+
+<br />
+<hr style="width: 15%;" />
+<br />
+
+<h4>FOOTNOTES:</h4>
+
+<div class="footnote"><p class="noin"><a name="Footnote_17_17" id="Footnote_17_17"></a><a href="#FNanchor_17_17"><span class="label">[17]</span></a> The alliance of mental hygiene, medicine, and religion
+is discussed in the Emmanuel Church book, <i>Religion and Medicine; the
+Moral Control of Nervous Disorders</i>; also in its bulletins, <i>Religion
+and Medicine</i>.</p></div>
+
+<br />
+<br />
+<br />
+<br />
+<a name="CHAPTER_XLI" id="CHAPTER_XLI"></a><hr />
+<span class='pagenum'><a name="Page_398" id="Page_398">[398]</a></span><br />
+
+<h3>CHAPTER XLI<span class="totoc"><a href="#toc">ToC</a></span></h3>
+
+<h4>"A NATURAL LAW IS AS SACRED AS A MORAL PRINCIPLE"</h4>
+<br />
+
+<p>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
+<i>homo</i>, of the species <i>intelligens</i>." 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.</p>
+
+<p>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.</p>
+
+<p>"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," <span class='pagenum'><a name="Page_399" id="Page_399">[399]</a></span>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.</p>
+
+<p>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:</p>
+
+<div class="poem"><div class="stanza">
+<span class="i0">Oh for one hour of youthful joy!<br /></span>
+<span class="i2">Give back my twentieth spring!<br /></span>
+<span class="i0">I'd rather laugh a bright-haired boy<br /></span>
+<span class="i2">Than reign a gray-beard king!<br /></span>
+</div><div class="stanza">
+<span class="i0">Off with the wrinkled spoils of age!<br /></span>
+<span class="i2">Away with learning's crown!<br /></span>
+<span class="i0">Tear out life's wisdom-written page,<br /></span>
+<span class="i2">And dash its trophies down!<br /></span>
+</div><div class="stanza">
+<span class="i0">One moment let my life blood stream<br /></span>
+<span class="i2">From boyhood's fount of flame!<br /></span>
+<span class="i0">Give me one giddy, reeling dream<br /></span>
+<span class="i2">Of life all love and fame!<br /></span>
+</div></div>
+
+<p class="noin">But every experiment in turning back exalts the present and the
+future. Gifts as well as problems are seen to come <span class='pagenum'><a name="Page_400" id="Page_400">[400]</a></span>with complexity,
+and civilization flatly refuses to relinquish these gifts. Sound
+maturity is better than youth or age:</p>
+
+<div class="poem"><div class="stanza">
+<span class="i0">The smiling angel dropped his pen,&mdash;<br /></span>
+<span class="i2">"Why, this will never do;<br /></span>
+<span class="i0">The man would be a boy again,<br /></span>
+<span class="i2">And be a father too!"<br /></span>
+</div></div>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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 <span class='pagenum'><a name="Page_401" id="Page_401">[401]</a></span>omitted in our daily routine that convict
+us of not living up to our knowledge of physiology and
+hygiene,&mdash;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,&mdash;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.</p>
+
+<p>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.</p>
+
+<p><span class='pagenum'><a name="Page_402" id="Page_402">[402]</a></span>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 co&ouml;peration 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.</p>
+
+<p>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.</p>
+
+<p>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 co&ouml;peration. But
+we can make them compatible with natural living. We can modify
+conditions so that earning a livelihood will not compel workers <span class='pagenum'><a name="Page_403" id="Page_403">[403]</a></span>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.</p>
+
+<br />
+<br />
+<br />
+<span class='pagenum'><a name="Page_404" id="Page_404">[404]</a></span><br />
+<a name="INDEX" id="INDEX"></a><hr />
+<span class='pagenum'><a name="Page_405" id="Page_405">[405]</a></span><br />
+
+<h3>INDEX<span class="totoc"><a href="#toc">ToC</a></span></h3>
+<br />
+
+
+<ul><li>Adenoids. See <i>Mouth breathing</i></li>
+
+<li>Administration, health:
+  <ul class="nest">
+  <li>steps in evolution, <a  href="#Page_11">11-22</a>;</li>
+  <li>knowledge of needs, <a href="#Page_220">220</a>;</li>
+  <li>machinery, <a  href="#Page_302">302-309</a>;</li>
+  <li>in combating alcoholism, <a href="#Page_362">362</a>;</li>
+  <li>departments of health:
+  <ul class="nest2">
+<li>(1) New York City, <a href="#Page_26">26</a>, <a href="#Page_27">27</a>, <a href="#Page_47">47</a>, <a href="#Page_48">48</a>, <a href="#Page_61">61</a>, <a href="#Page_71">71</a>, <a href="#Page_84">84</a>, <a  href="#Page_296">296-298</a>, <a href="#Page_302">302</a>;</li>
+<li>(2) general, <a href="#Page_265">265</a>, <a href="#Page_281">281</a></li>
+  </ul>
+  </li>
+    </ul>
+    </li>
+
+<li>Advertisements:
+  <ul class="nest">
+  <li>motives for, <a href="#Page_8">8</a>;</li>
+  <li>for dental parlors, <a href="#Page_100">100</a>;</li>
+  <li>for consumptives, <a href="#Page_234">234</a>;</li>
+  <li>by physicians, <a href="#Page_281">281</a>;</li>
+  <li>educational, in newspapers and magazines, <a href="#Page_323">323</a>;</li>
+  <li>"no smoking" signs, <a href="#Page_365">365</a>;</li>
+  <li>of patent medicines, <a href="#Page_369">369</a>;</li>
+  <li>that promote health, <a  href="#Page_378">378-383</a></li>
+  </ul>
+  </li>
+
+<li>Agassiz, Louis, <a href="#Page_398">398</a>, <a href="#Page_400">400</a></li>
+
+<li>Air, night, <a href="#Page_216">216</a>.
+  <ul class="nest">
+  <li>See <i>Fresh air</i></li>
+  </ul>
+  </li>
+
+<li>Alcoholism, <a  href="#Page_343">343-362</a>;
+  <ul class="nest">
+  <li>compulsory instruction in, <a href="#Page_3">3</a>;</li>
+  <li>insurance companies against, <a href="#Page_7">7</a>;</li>
+  <li>disqualifies for railroad service, <a href="#Page_193">193</a>;</li>
+  <li>depletes vitality, <a href="#Page_201">201</a>;</li>
+  <li>results, <a href="#Page_209">209</a>;</li>
+  <li>Hartley's fight against, <a href="#Page_253">253</a>;</li>
+  <li>injures the tuberculous, <a href="#Page_274">274</a>;</li>
+  <li>ineffective ways of combating, <a href="#Page_343">343</a>;</li>
+  <li>incited by bad living conditions, <a href="#Page_348">348</a>;</li>
+  <li>injury to negroes, <a href="#Page_350">350</a>;</li>
+  <li>so-called moderate use, <a href="#Page_358">358</a>;</li>
+  <li>labor unions blacklist drunkards, <a href="#Page_361">361</a>;</li>
+  <li>social dangers, <a href="#Page_386">386</a>;</li>
+  <li>mental hygiene, <a href="#Page_392">392</a>, <a href="#Page_396">396</a></li>
+  </ul>
+  </li>
+
+<li>Animal sanitation, <a href="#Page_252">252</a>, <a href="#Page_260">260</a>, <a href="#Page_307">307</a></li>
+
+<li>Association for Improving the Condition of the Poor, New York, <a href="#Page_177">177</a>, <a href="#Page_236">236</a>, <a href="#Page_253">253</a><br /><br /></li>
+
+<li>Babies. See <i>Milk</i></li>
+
+<li>Bathing:
+  <ul class="nest">
+  <li>motives for, <a href="#Page_8">8</a>, <a href="#Page_13">13</a>;</li>
+  <li>a social requirement, <a href="#Page_14">14</a>;</li>
+  <li>cold-water, <a href="#Page_214">214</a></li>
+  </ul>
+  </li>
+
+<li>Beauty, reason for health, <a href="#Page_15">15</a></li>
+
+<li>Bibliography:
+  <ul class="nest">
+  <li>A Bureau of Child Hygiene (Bureau of Municipal Research), <a href="#Page_298">298</a>;</li>
+  <li>Annals of a Quiet Neighborhood (MacDonald), <a href="#Page_110">110</a>;</li>
+  <li>Aristocracy of Health (Henderson), <a href="#Page_208">208</a>;</li>
+  <li>Bitter Cry of the Children (Spargo), <a href="#Page_33">33</a>, <a href="#Page_167">167</a>;</li>
+  <li>Bulletins of Emmanuel Church, <a href="#Page_391">391</a>;</li>
+  <li>Bureau of Municipal Research, publications, <a href="#Page_298">298</a>;</li>
+  <li>Care of Dependent, Defective, and Delinquent Children (Folks), <a href="#Page_174">174</a>;</li>
+  <li>Charities and the Commons, <a href="#Page_325">325</a>;</li>
+  <li>Child Growth (Newsholme), <a href="#Page_120">120</a>;</li>
+  <li>Children of the Nation (Gorst), <a href="#Page_33">33</a>;</li>
+  <li>Children's Diseases, <a href="#Page_326">326</a>;</li>
+  <li>Clean Milk for New York City, <a href="#Page_255">255</a>;
+  <ul class="nest2">
+    <li>clippings, <a href="#Page_370">370</a>, <a href="#Page_382">382</a>;</li>
+    <li>white-plague scrapbook, <a href="#Page_250">250</a>;</li>
+  </ul>
+  </li>
+  <li>Committee on Physical Welfare of School Children, programme, <a href="#Page_166">166</a>,
+  <ul class="nest2">
+    <li>three studies, <a href="#Page_168">168</a>;</li>
+  </ul>
+  </li>
+  <li>Crusade against Tuberculosis (Flick), <a href="#Page_229">229</a>;</li>
+  <li>Dangerous Trades (Oliver), <a href="#Page_203">203</a>;</li>
+  <li>Dental Catechism, <a href="#Page_94">94</a>;</li>
+  <li>Dentistry, lectures and treatises, <a href="#Page_274">274</a>;</li>
+  <li>Deterioration, Physical, report on, <a href="#Page_339">339</a>;</li>
+  <li>Development of the Child (Oppenheimer), <a href="#Page_110">110</a>;</li>
+  <li>Dietetic and Hygienic Gazette, <a href="#Page_326">326</a>;</li>
+  <li>Efficient Life (Gulick), <a href="#Page_208">208</a>;</li>
+  <li>Environment of Child at School (North), <a href="#Page_142">142</a>;
+  <ul class="nest2">
+    <li>Pure Food (U.S. Department of Agriculture), <a href="#Page_379">379</a>;</li>
+  </ul>
+  </li>
+
+  <li>Good Health, <a href="#Page_326">326</a>;</li>
+  <li>Health of the School Child (Mackenzie), <a href="#Page_132">132</a>;</li>
+  <li>Heredity (Thompson), <a href="#Page_336">336</a>;</li>
+  <li>How to Give Wisely, <a href="#Page_355">355</a>;</li>
+  <li>International Congress, Tuberculosis, programme, <a  href="#Page_246">246-249</a>;</li>
+  <li>Journal of Nursing, <a href="#Page_326">326</a>;</li>
+  <li>Making a Municipal Budget (Bureau of Municipal Research), <a href="#Page_306">306</a>;</li>
+  <li>Milk Industry, <a href="#Page_252">252</a>;</li>
+  <li>Municipal Sanitation in the United States (Chapin), <a href="#Page_304">304</a>;</li>
+  <li>National Hospital Record, <a href="#Page_326">326</a>;</li>
+  <li>New Basis of Civilization (Patten), <a href="#Page_33">33</a>;</li>
+  <li>New Jersey Review of Charities and Corrections, <a href="#Page_325">325</a>;</li>
+  <li>Pediatrics, <a href="#Page_326">326</a>;</li>
+  <li>Physical Culture, <a href="#Page_326">326</a>;</li>
+  <li>Poverty (Hunter), <a href="#Page_167">167</a>;
+  <ul class="nest2">
+    <li>press and magazines, <a  href="#Page_322">322-328</a>;</li>
+  </ul>
+  </li>
+
+  <li>Prevention of Tuberculosis (Newsholme), <a href="#Page_229">229</a>;</li>
+  <li>Principles of Relief (Devine), <a href="#Page_174">174</a>;</li>
+  <li>Principles of Sanitary Science and the Public Health (Sedgwick), <a href="#Page_304">304</a>;<span class='pagenum'><a name="Page_406" id="Page_406">[406]</a></span></li>
+  <li>Psychological Clinic, <a href="#Page_106">106</a>, <a href="#Page_326">326</a>, <a href="#Page_330">330</a>;</li>
+  <li>Real Triumph of Japan (Seaman), <a href="#Page_23">23</a>;</li>
+  <li>Religion and Medicine (Emmanuel Church), <a href="#Page_391">391</a>;</li>
+  <li>reports of schools, <a href="#Page_166">166</a>;</li>
+  <li>reports of schools and health, <a  href="#Page_310">310-321</a>;</li>
+  <li>reports of institutions and societies, <a href="#Page_327">327</a>;</li>
+  <li>reports of state and national conferences of charities and corrections, <a href="#Page_327">327</a>;</li>
+  <li>reports of United States bureau of labor, <a href="#Page_203">203</a>;</li>
+  <li>Sanitation of Public Buildings (Gerhard), <a href="#Page_139">139</a>;</li>
+  <li>School Reports and School Efficiency (Snedden and Allen), <a href="#Page_311">311</a>;</li>
+  <li>Social Order and the Saloon (Fox), <a href="#Page_351">351</a>;</li>
+  <li>Study of Children and their School Training (Warner), <a href="#Page_110">110</a>;</li>
+  <li>Study of School Buildings in New York City, <a href="#Page_289">289</a>;</li>
+  <li>Teeth and their Care (Hyatt), <a href="#Page_94">94</a>;</li>
+  <li>Training of the Human Plant (Burbank), <a href="#Page_120">120</a>;</li>
+  <li>Typhoid Fever (Whipple), <a href="#Page_13">13</a>, <a href="#Page_16">16</a>;</li>
+  <li>Uncommercial Traveller (Dickens), <a href="#Page_46">46</a>;</li>
+  <li>Unconscious Mind (Schofield), <a href="#Page_110">110</a>;</li>
+  <li>Vital Statistics (Newsholme), <a href="#Page_131">131</a></li>
+  </ul>
+  </li>
+
+<li>Biggs, Hermann M., M.D., <a href="#Page_237">237</a>, <a href="#Page_251">251</a>, <a href="#Page_271">271</a>, <a href="#Page_274">274</a>, <a href="#Page_295">295</a></li>
+
+<li>Boston, <a href="#Page_34">34</a>, <a href="#Page_155">155</a>, <a href="#Page_161">161</a>, <a href="#Page_241">241</a>, <a href="#Page_250">250</a>, <a href="#Page_290">290</a>, <a href="#Page_395">395</a></li>
+
+<li>Boston Society for the Relief and Study of Tuberculosis, <a href="#Page_155">155</a></li>
+
+<li>Boyd, Emma Garrett, <a href="#Page_355">355</a></li>
+
+<li>Brannan, John Winters, M.D., <a href="#Page_240">240</a></li>
+
+<li>Breath, bad, <a href="#Page_360">360</a>, <a href="#Page_379">379</a></li>
+
+<li>Brightness, abnormal, <a  href="#Page_104">104-106</a></li>
+
+<li>Bronchitis, <a href="#Page_67">67</a></li>
+
+<li>Brookline, <a href="#Page_34">34</a></li>
+
+<li>Budget:
+  <ul class="nest">
+  <li>should provide for cleansing, <a href="#Page_61">61</a>;</li>
+  <li>and tuberculosis, <a href="#Page_237">237</a>;</li>
+  <li>annual health programme, <a href="#Page_306">306</a>;</li>
+  <li>reforms in New York City, <a href="#Page_350">350</a></li>
+  </ul>
+  </li>
+
+<li>Burbank, Luther, <a href="#Page_120">120</a></li>
+
+<li>Bureau of Municipal Research, <a href="#Page_298">298</a>, <a href="#Page_306">306</a></li>
+
+<li>Butler, Nicholas Murray, LL.D., <a href="#Page_330">330</a>, <a href="#Page_332">332</a><br /><br /></li>
+
+
+<li>Cabot, Richard C., M.D., <a href="#Page_181">181</a></li>
+
+<li>Calmette's Eye Test, <a href="#Page_238">238</a></li>
+
+<li>Carnegie Foundation, <a href="#Page_285">285</a></li>
+
+<li>Caroline Rest, <a href="#Page_70">70</a>, <a href="#Page_267">267</a></li>
+
+<li>Catching diseases:
+  <ul class="nest">
+  <li>cost of, <a href="#Page_16">16</a>;</li>
+  <li>unenforced laws, <a href="#Page_30">30</a>;</li>
+  <li>steps in eradicating, <a href="#Page_31">31</a>;</li>
+  <li>germ sociology, <a href="#Page_57">57</a>, <a href="#Page_71">71</a>;</li>
+  <li>favorable soil at school, <a href="#Page_58">58</a>;</li>
+  <li>instruction concerning, <a href="#Page_62">62</a>;</li>
+  <li>mouth a breeding ground for, <a href="#Page_63">63</a>;</li>
+  <li>information for bathers, <a href="#Page_64">64</a>;</li>
+  <li>dangers of, <a href="#Page_131">131</a>;</li>
+  <li>reasons for national board of health, <a href="#Page_135">135</a>;</li>
+  <li>cost of, in New York City, <a href="#Page_272">272</a>;</li>
+  <li>remedies urged, <a href="#Page_384">384</a></li>
+  </ul>
+  </li>
+
+<li>Charity Organization Society, New York, <a href="#Page_236">236</a>, <a href="#Page_239">239</a></li>
+
+<li>Chicago, <a href="#Page_34">34</a></li>
+
+<li>Chicken-pox, <a href="#Page_64">64</a></li>
+
+<li>Child Hygiene, Bureau of:
+  <ul class="nest">
+  <li>working-paper tests, <a href="#Page_192">192</a>;</li>
+  <li>established, New York City, <a href="#Page_298">298</a>;</li>
+  <li>programme, <a href="#Page_299">299</a></li>
+  </ul>
+  </li>
+
+<li>Child labor:
+  <ul class="nest">
+  <li>compulsory school attendance, <a href="#Page_140">140</a>;</li>
+  <li>welfare or age test, <a href="#Page_142">142</a>;</li>
+  <li>movement's limitations, <a href="#Page_185">185</a>;</li>
+  <li>national and local committees, <a href="#Page_33">33</a>, <a href="#Page_192">192</a>;</li>
+  <li>physical-fitness tests, <a href="#Page_194">194</a></li>
+  </ul>
+  </li>
+
+<li>Children's Aid Society, New York, <a href="#Page_56">56</a>, <a href="#Page_93">93</a></li>
+
+<li>Child-saving agencies:
+  <ul class="nest">
+  <li>co&ouml;peration with schools, <a  href="#Page_174">174-183</a>;</li>
+  <li>do-nothingism in, <a href="#Page_332">332</a></li>
+  </ul>
+  </li>
+
+<li>Chorea. See <i>Nervousness</i></li>
+
+<li>Christian Science, <a href="#Page_276">276</a>, <a href="#Page_392">392</a></li>
+
+<li>Christmas shopping, <a href="#Page_227">227</a></li>
+
+<li>Cigarettes. See <i>Tobacco</i></li>
+
+<li>Cincinnati, <a href="#Page_118">118</a></li>
+
+<li>Cleanliness:
+  <ul class="nest">
+  <li>acquired taste, <a href="#Page_14">14</a>;</li>
+  <li>beauty of, <a href="#Page_96">96</a>;</li>
+  <li>personal uncleanliness, <a href="#Page_210">210</a>;</li>
+  <li>cost of, <a href="#Page_216">216</a>;</li>
+  <li>dry cleaning dangerous, <a href="#Page_244">244</a>;</li>
+  <li>in fighting tuberculosis, <a href="#Page_250">250</a></li>
+  </ul>
+  </li>
+
+<li>Cleveland, Ohio, <a href="#Page_294">294</a></li>
+
+<li>Clippings:
+  <ul class="nest">
+  <li>scrapbook, <a href="#Page_250">250</a>;</li>
+  <li>envelope method, <a href="#Page_324">324</a>;</li>
+  <li>advertisements, <a href="#Page_382">382</a></li>
+  </ul>
+  </li>
+
+<li>Coffee, strong, <a href="#Page_401">401</a></li>
+
+<li>Colds, <a  href="#Page_63">63-69</a></li>
+
+<li>College, physical tests, <a href="#Page_39">39</a></li>
+
+<li>Committee on Physical Welfare of School Children, New York, <a  href="#Page_39">39-41</a>, <a href="#Page_166">166</a>, <a href="#Page_168">168</a>, <a href="#Page_178">178</a>, <a href="#Page_286">286</a>, <a href="#Page_290">290</a>, <a href="#Page_311">311</a></li>
+
+<li>Compulsory laws:
+  <ul class="nest">
+  <li>school hygiene, <a href="#Page_3">3</a>;</li>
+  <li>purpose of, <a href="#Page_33">33</a>;</li>
+  <li>registration of catching diseases, <a href="#Page_57">57</a>;</li>
+  <li>removal of tuberculosis cases, <a href="#Page_237">237</a>;</li>
+  <li>notification of tuberculosis, <a href="#Page_237">237</a>, <a href="#Page_274">274</a>;</li>
+  <li>hygiene, for private schools, <a href="#Page_283">283</a>;</li>
+  <li>to remove physical defects, <a href="#Page_288">288</a>;<span class='pagenum'><a name="Page_407" id="Page_407">[407]</a></span></li>
+  <li>restricting alcoholism, <a href="#Page_343">343</a></li>
+  </ul>
+  </li>
+
+<li>Conference on Summer Care of Babies, New York, <a href="#Page_260">260</a></li>
+
+<li>Congestion:
+  <ul class="nest">
+  <li>evils avoided, <a href="#Page_290">290</a>;</li>
+  <li>and alcoholism, <a href="#Page_348">348</a></li>
+  </ul>
+  </li>
+
+<li>Conjunctivitis, <a href="#Page_71">71</a>. See <i>Eyes</i></li>
+
+<li>Connecticut's school reports, <a href="#Page_318">318</a></li>
+
+<li>Constipation, <a href="#Page_210">210</a>, <a href="#Page_216">216</a>, <a href="#Page_347">347</a>, <a href="#Page_357">357</a></li>
+
+<li>Consumption. See <i>Tuberculosis</i></li>
+
+<li>Corsets, <a href="#Page_381">381</a>, <a href="#Page_401">401</a></li>
+
+<li>Cost:
+  <ul class="nest">
+  <li>of preventable diseases, <a href="#Page_16">16</a>;</li>
+  <li>of bad breath, <a href="#Page_98">98</a>;</li>
+  <li>of diseases to nation, <a href="#Page_135">135</a>;</li>
+  <li>of tuberculosis, <a href="#Page_245">245</a></li>
+  </ul>
+  </li>
+
+<li>Crampton, C. Ward, M.D., <a href="#Page_129">129</a>, <a href="#Page_289">289</a><br /><br /></li>
+
+
+<li>Dangerous trades, <a href="#Page_191">191</a></li>
+
+<li>Darlington, Thomas, M.D., <a href="#Page_297">297</a></li>
+
+<li>Death rates:
+  <ul class="nest">
+  <li>of bronchitis, <a href="#Page_67">67</a>;</li>
+  <li>of pneumonia, <a href="#Page_67">67</a>;</li>
+  <li>how to reduce, <a href="#Page_131">131</a></li>
+  </ul>
+  </li>
+
+<li>Defects, physical:
+  <ul class="nest">
+  <li>index of community needs, <a  href="#Page_33">33-44</a>;</li>
+  <li>removable, of children, <a href="#Page_22">22</a>;</li>
+  <li>schools manufacture, <a href="#Page_139">139</a>;</li>
+  <li>income distribution, <a href="#Page_169">169</a></li>
+  </ul>
+  </li>
+
+<li>Delinquency, and mouth breathing, <a href="#Page_47">47</a></li>
+
+<li>Dental Hygiene Council, <a href="#Page_95">95</a></li>
+
+<li>Dental sanitation, <a  href="#Page_89">89-103</a>;
+  <ul class="nest">
+  <li>surface for breeding germs, <a href="#Page_63">63</a>;</li>
+  <li>dentists, <a href="#Page_93">93</a>;</li>
+  <li>state organizations, <a href="#Page_95">95</a>;</li>
+  <li>clinics needed, <a href="#Page_171">171</a>;</li>
+  <li>insurance companies treat teeth, <a href="#Page_204">204</a>;</li>
+  <li>family instruction, <a href="#Page_245">245</a>;</li>
+  <li>indigestion, <a href="#Page_272">272</a>;</li>
+  <li>early treatises, <a href="#Page_274">274</a>;</li>
+  <li>advertising parlors, <a href="#Page_281">281</a></li>
+  </ul>
+  </li>
+
+<li>Devine, Professor Edward T., <a href="#Page_174">174</a></li>
+
+<li>Diet:
+  <ul class="nest">
+  <li>cooking lessons at home, <a href="#Page_180">180</a>;</li>
+  <li>overeating, <a href="#Page_201">201</a>, <a href="#Page_347">347</a>;</li>
+  <li>improper, <a href="#Page_210">210</a>;</li>
+  <li>proper and regular, <a href="#Page_212">212</a>;</li>
+  <li>adapted to need, <a href="#Page_214">214</a>, <a href="#Page_401">401</a>;</li>
+  <li>kitchens, <a href="#Page_267">267</a>;</li>
+  <li>irregular eating, <a href="#Page_272">272</a>, <a href="#Page_347">347</a></li>
+  </ul>
+  </li>
+
+<li>Diet kitchens, <a href="#Page_267">267</a></li>
+
+<li>Diphtheria, <a href="#Page_18">18</a>, <a href="#Page_65">65</a></li>
+
+<li>Dispensaries and hospitals:
+  <ul class="nest">
+  <li>dental supervision, <a href="#Page_102">102</a>;</li>
+  <li>co&ouml;perate with schools, <a  href="#Page_174">174-183</a>, <a href="#Page_185">185</a>;</li>
+  <li>welfare nurse, <a href="#Page_188">188</a>;</li>
+  <li>emergency, <a href="#Page_227">227</a>;</li>
+  <li>to prevent duplication, <a href="#Page_239">239</a>;</li>
+  <li>lack of, <a href="#Page_240">240</a>;</li>
+  <li>teach baby feeding, <a href="#Page_261">261</a>;</li>
+  <li>inefficient, <a href="#Page_278">278</a>;</li>
+  <li>social interest of, <a href="#Page_292">292</a></li>
+  </ul>
+  </li>
+
+<li>Doing things at school, <a  href="#Page_159">159-165</a>;
+  <ul class="nest">
+  <li>free meals, <a href="#Page_44">44</a>, <a href="#Page_161">161</a>, <a href="#Page_171">171</a>;</li>
+  <li>may hurt, <a href="#Page_181">181</a>;</li>
+  <li>cripple social agencies, <a href="#Page_185">185</a>, <a href="#Page_189">189</a>;</li>
+  <li>danger of malpractice, <a href="#Page_184">184</a>, <a href="#Page_189">189</a>;</li>
+  <li>analogous to model tenements, <a href="#Page_186">186</a></li>
+  </ul>
+  </li>
+
+<li>Do-nothing ailments, <a  href="#Page_329">329-334</a><br /><br /></li>
+
+
+<li>Ear trouble, <a  href="#Page_83">83-85</a>;
+  <ul class="nest">
+  <li>periodic tests for, <a href="#Page_201">201</a>, <a href="#Page_207">207</a></li>
+  </ul>
+  </li>
+
+<li>Edinburgh, <a href="#Page_70">70</a></li>
+
+<li>Ellis Island, <a href="#Page_238">238</a></li>
+
+<li>Environment:
+  <ul class="nest">
+  <li>health problem, <a href="#Page_9">9</a>;</li>
+  <li>tests, <a href="#Page_120">120</a>, <a href="#Page_320">320</a>;</li>
+  <li>injurious school, <a  href="#Page_139">139-150</a>;</li>
+  <li>effect on physique, <a href="#Page_203">203</a>;</li>
+  <li>and tuberculosis, <a  href="#Page_229">229-251</a>;</li>
+  <li>do-nothing ailments, <a href="#Page_329">329</a>;</li>
+  <li>within our control, <a href="#Page_336">336</a>;</li>
+  <li>in combating liquor, <a href="#Page_362">362</a></li>
+  </ul>
+  </li>
+
+<li>Epidemics, <a href="#Page_18">18</a>, <a href="#Page_38">38</a></li>
+
+<li>Epilepsy, <a href="#Page_47">47</a>, <a href="#Page_49">49</a></li>
+
+<li>Ergograph, <a  href="#Page_125">125-127</a></li>
+
+<li>Erysipelas, <a href="#Page_65">65</a></li>
+
+<li>Ethics, professional, <a href="#Page_81">81</a>, <a href="#Page_101">101</a>, <a href="#Page_281">281</a></li>
+
+<li>Eugenics, and heredity, <a href="#Page_336">336</a></li>
+
+<li>European remedies, <a  href="#Page_159">159-165</a></li>
+
+<li>Eye trouble, <a  href="#Page_72">72-82</a>;
+  <ul class="nest">
+  <li>in high school, <a href="#Page_40">40</a>;</li>
+  <li>catching diseases, <a  href="#Page_69">69-71</a>;</li>
+  <li>caused by bad teeth, <a href="#Page_89">89</a>;</li>
+  <li>eyeglasses, free, <a href="#Page_161">161</a>, <a href="#Page_164">164</a>, <a href="#Page_171">171</a>, <a href="#Page_184">184</a>;</li>
+  <li>in business, <a href="#Page_193">193</a>;</li>
+  <li>examination for adults, <a href="#Page_201">201</a>;</li>
+  <li>tuberculin test, <a href="#Page_238">238</a>;</li>
+  <li>inefficient inspection of, <a href="#Page_300">300</a>;</li>
+  <li>teachers' test, <a href="#Page_301">301</a></li>
+  </ul>
+  </li>
+
+<li>Examination, physical:
+  <ul class="nest">
+  <li>of school children, <a  href="#Page_33">33-138</a>;</li>
+  <li>best test of health needs, <a  href="#Page_33">33-44</a>;</li>
+  <li>individual record of, <a href="#Page_35">35</a>, <a href="#Page_312">312</a>;</li>
+  <li>Snellen test, <a href="#Page_73">73</a>, <a href="#Page_77">77</a>;</li>
+  <li>of teachers, <a href="#Page_153">153</a>;</li>
+  <li>for work certificates, <a  href="#Page_190">190-200</a>, <a href="#Page_237">237</a>, <a href="#Page_301">301</a>;</li>
+  <li>by railroads, <a href="#Page_193">193</a>;</li>
+  <li>at West Point, <a href="#Page_199">199</a>;</li>
+  <li>periodic after school, <a  href="#Page_201">201-207</a>, <a href="#Page_218">218</a>, <a href="#Page_228">228</a>;</li>
+  <li>semi-annual, <a href="#Page_202">202</a>;</li>
+  <li>tuberculin tests, <a href="#Page_240">240</a>;</li>
+  <li>stripped, at Leipsic, <a href="#Page_289">289</a>;</li>
+  <li>follow-up work, <a  href="#Page_295">295-300</a>;</li>
+  <li>of teachers and sex hygiene, <a href="#Page_389">389</a><br /><br /></li>
+  </ul>
+  </li>
+
+
+<li>Family:
+  <ul class="nest">
+  <li>unit of social treatment, <a href="#Page_174">174</a>;</li>
+  <li>examining parties, <a href="#Page_237">237</a>, <a href="#Page_241">241</a>;</li>
+  <li>tuberculosis histories, <a href="#Page_241">241</a></li>
+  </ul>
+  </li>
+
+<li>Fear and bodily disorders, <a href="#Page_392">392</a></li>
+
+<li>Flick, Lawrence F., M.D., <a href="#Page_229">229</a></li>
+
+<li>Follow-up work, <a  href="#Page_295">295-301</a></li>
+
+<li>Fox, Hugh F., <a href="#Page_351">351</a></li>
+
+<li>Fresh air:
+  <ul class="nest">
+  <li>others' standards of, <a href="#Page_9">9</a>;</li>
+  <li>fiends, <a href="#Page_66">66</a>;</li>
+  <li>outings, <a href="#Page_176">176</a>, <a href="#Page_178">178</a>;</li>
+  <li>economic value of, <a href="#Page_195">195</a>;<span class='pagenum'><a name="Page_408" id="Page_408">[408]</a></span></li>
+  <li>ventilation at school, <a href="#Page_142">142</a>;</li>
+  <li>ventilation at home, <a href="#Page_210">210</a>;</li>
+  <li>ventilation at work, <a href="#Page_212">212</a>;</li>
+  <li>ventilation at sanatoriums, <a href="#Page_214">214</a>;</li>
+  <li>ventilation at churches and theaters, <a href="#Page_217">217</a>.</li>
+  <li>See <i>Air</i><br /><br /></li>
+  </ul>
+  </li>
+
+
+<li>Georgia, <a href="#Page_350">350</a></li>
+
+<li>Germany, <a href="#Page_160">160</a>, <a href="#Page_204">204</a></li>
+
+<li>Germs, disease:
+  <ul class="nest">
+  <li>in milk bottles, <a href="#Page_14">14</a>;</li>
+  <li>isolation, <a href="#Page_31">31</a>;</li>
+  <li>germ sociology, <a  href="#Page_57">57-71</a>;</li>
+  <li>dental sanitation, <a  href="#Page_89">89-103</a>;</li>
+  <li>locating germ factories, <a href="#Page_238">238</a>;</li>
+  <li>tuberculosis, <a href="#Page_234">234</a></li>
+  </ul>
+  </li>
+
+<li>Getting things done, <a  href="#Page_166">166-173</a>;
+  <ul class="nest">
+  <li>doing of highest kind, <a href="#Page_183">183</a>;</li>
+  <li>study underlying causes, <a href="#Page_189">189</a>;</li>
+  <li>by local agencies, <a href="#Page_287">287</a></li>
+  </ul>
+  </li>
+
+<li>Glands, <a href="#Page_88">88</a></li>
+
+<li>Goler, George W., M.D., <a href="#Page_196">196</a></li>
+
+<li>Gorgas, William C., M.D., <a href="#Page_59">59</a></li>
+
+<li>Government. See <i>Administration</i></li>
+
+<li>Greenwich House, <a href="#Page_287">287</a></li>
+
+<li>Grenfell Association, <a href="#Page_197">197</a></li>
+
+<li>Grippe, <a href="#Page_379">379</a></li>
+
+<li>Gulick, Luther H., M.D., <a href="#Page_123">123</a>, <a href="#Page_208">208</a><br /><br /></li>
+
+
+<li>Habits of health, <a  href="#Page_208">208-217</a>;
+  <ul class="nest">
+  <li>combat tobacco, <a href="#Page_364">364</a>;</li>
+  <li>mental hygiene, <a href="#Page_394">394</a>;</li>
+  <li>and Nature Fore, <a href="#Page_400">400</a></li>
+  </ul>
+  </li>
+
+<li>Hartley House, <a href="#Page_287">287</a></li>
+
+<li>Hartley, Robert M., <a href="#Page_252">252</a></li>
+
+<li>Havana, <a href="#Page_60">60</a></li>
+
+<li>Hawthorne Club, <a href="#Page_287">287</a></li>
+
+<li>Headache, <a href="#Page_210">210</a></li>
+
+<li>Heredity, <a  href="#Page_335">335-342</a></li>
+
+<li>High schools need physical tests, <a href="#Page_39">39</a></li>
+
+<li>Hip trouble. See <i>Tuberculosis</i></li>
+
+<li>Home conditions:
+  <ul class="nest">
+  <li>indexed by epidemics, <a href="#Page_32">32</a>;</li>
+  <li>indexed at school, <a href="#Page_33">33</a>;</li>
+  <li>among different incomes, <a href="#Page_39">39</a>;</li>
+  <li>cooking instructions, <a href="#Page_180">180</a>;</li>
+  <li>weighing parties, <a href="#Page_241">241</a>;</li>
+  <li>score card, <a href="#Page_337">337</a>;</li>
+  <li>promote alcoholism, <a href="#Page_348">348</a></li>
+  </ul>
+  </li>
+
+<li>Hughes, Governor Charles E., <a href="#Page_201">201</a></li>
+
+<li>Hunter, Robert, <a href="#Page_167">167</a></li>
+
+<li>Hyatt, Thaddeus P., D.D.S., <a href="#Page_94">94</a><br /><br /></li>
+
+
+<li>Impetigo, <a href="#Page_65">65</a></li>
+
+<li>Income, <a href="#Page_34">34</a>, <a href="#Page_38">38</a>, <a href="#Page_39">39</a></li>
+
+<li>India, <a href="#Page_108">108</a></li>
+
+<li>Indigestion:
+  <ul class="nest">
+  <li>anti-social, <a href="#Page_10">10</a>;</li>
+  <li>due to teeth, <a href="#Page_272">272</a></li>
+  </ul>
+  </li>
+
+<li>Individual record card, <a href="#Page_35">35</a>, <a  href="#Page_312">312-314</a></li>
+
+<li>Industrial hygiene:
+  <ul class="nest">
+  <li>educates laborers, <a href="#Page_131">131</a>;</li>
+  <li>factory conditions, <a href="#Page_221">221</a>, <a href="#Page_227">227</a>;</li>
+  <li>factory reforms, <a href="#Page_403">403</a>;</li>
+  <li>employers, <a href="#Page_3">3</a>, <a href="#Page_210">210</a>, <a href="#Page_218">218</a>, <a href="#Page_360">360</a>, <a href="#Page_367">367</a>;</li>
+  <li>employees, <a href="#Page_202">202</a>, <a href="#Page_211">211</a>, <a href="#Page_219">219</a>, <a href="#Page_228">228</a>, <a href="#Page_360">360</a></li>
+  </ul>
+  </li>
+
+<li>Influenza, <a  href="#Page_65">65-68</a></li>
+
+<li>Ingram, Helene, <a href="#Page_177">177</a></li>
+
+<li>Insomnia, <a href="#Page_392">392</a></li>
+
+<li>Inspection:
+  <ul class="nest">
+  <li>of milk, <a href="#Page_26">26</a>, <a href="#Page_259">259</a>;</li>
+  <li>score cards, <a href="#Page_27">27</a>, <a href="#Page_29">29</a>, <a href="#Page_337">337</a>;</li>
+  <li>of school children, <a href="#Page_43">43</a>, <a href="#Page_61">61</a>, <a href="#Page_296">296</a>;</li>
+  <li>of factories, <a href="#Page_131">131</a>;</li>
+  <li>of milch cows, <a href="#Page_260">260</a>;</li>
+  <li>of transmissible diseases, <a href="#Page_295">295</a>;</li>
+  <li>of foods, <a href="#Page_307">307</a></li>
+  </ul>
+  </li>
+
+<li>Instinct, motive to health, <a href="#Page_12">12</a>, <a href="#Page_14">14</a>, <a href="#Page_94">94</a></li>
+
+<li>International Congress on tuberculosis, <a href="#Page_238">238</a>, <a href="#Page_245">245</a></li>
+
+<li>Itch, <a href="#Page_65">65</a><br /><br /></li>
+
+
+<li>Japan, <a href="#Page_23">23</a>, <a href="#Page_287">287</a>, <a href="#Page_309">309</a></li>
+
+<li>Junior Sea Breeze, <a href="#Page_267">267</a><br /><br /></li>
+
+
+<li>Kansas City, <a href="#Page_161">161</a></li>
+
+<li>Kidney trouble, <a href="#Page_217">217</a><br /><br /></li>
+
+
+<li>Labrador, <a href="#Page_197">197</a></li>
+
+<li>Lavatories, public, <a href="#Page_217">217</a></li>
+
+<li>Laws:
+  <ul class="nest">
+  <li>nonenforcement demoralizing, <a href="#Page_4">4</a>;</li>
+  <li>define rights, <a href="#Page_23">23</a>;</li>
+  <li>when not enforced, <a href="#Page_25">25</a>;</li>
+  <li>should not injure health, <a href="#Page_151">151</a>;</li>
+  <li>enforcement better than character, <a href="#Page_219">219</a>;</li>
+  <li>regarding milk, <a href="#Page_258">258</a>;</li>
+  <li>licensing practitioners, <a href="#Page_280">280</a>;</li>
+  <li>need machinery, <a href="#Page_303">303</a>, <a href="#Page_348">348</a>;</li>
+  <li>to control liquor, <a href="#Page_343">343</a>, <a href="#Page_355">355</a>;</li>
+  <li>test of prohibition, <a href="#Page_353">353</a>;</li>
+  <li>on patent medicine, <a href="#Page_373">373</a>;</li>
+  <li>on pure foods, <a href="#Page_379">379</a></li>
+  </ul>
+  </li>
+
+<li>Leipsic, <a href="#Page_289">289</a></li>
+
+<li>Louisiana, <a href="#Page_350">350</a>, <a href="#Page_376">376</a></li>
+
+<li>Lung trouble. See <i>Tuberculosis</i><br /><br /></li>
+
+
+<li>Machinery, health:
+  <ul class="nest">
+  <li>unsatisfactory coordination, <a href="#Page_296">296</a>;</li>
+  <li>necessary, <a  href="#Page_302">302-309</a>;</li>
+  <li>five elements, <a href="#Page_303">303</a></li>
+  </ul>
+  </li>
+
+<li>Mackenzie, W. Leslie, M.D., <a href="#Page_132">132</a></li>
+
+<li>Magistrates:
+  <ul class="nest">
+  <li>promote disorder, <a href="#Page_173">173</a>;</li>
+  <li>enforce health laws, <a href="#Page_303">303</a></li>
+  </ul>
+  </li>
+
+<li>Malnutrition, <a href="#Page_35">35</a>;
+  <ul class="nest">
+  <li>income distribution, <a href="#Page_39">39</a>;</li>
+  <li>signs and tests, <a href="#Page_86">86</a>;</li>
+  <li>prevention of, <a href="#Page_184">184</a>;</li>
+  <li>education of family, <a href="#Page_241">241</a></li>
+  </ul>
+  </li>
+
+<li>Massachusetts, <a href="#Page_74">74</a></li>
+
+<li>Maxwell, Superintendent William H., <a href="#Page_286">286</a>, <a href="#Page_288">288</a><span class='pagenum'><a name="Page_409" id="Page_409">[409]</a></span></li>
+
+<li>Measles, <a href="#Page_64">64</a></li>
+
+<li>Mental hygiene, <a  href="#Page_391">391-397</a>;
+  <ul class="nest">
+  <li>blues, anti-social, <a href="#Page_10">10</a>;</li>
+  <li>hospital welfare work, <a href="#Page_182">182</a>;</li>
+  <li>moral clinics, <a href="#Page_276">276</a>, <a href="#Page_291">291</a>, <a href="#Page_295">295</a>;</li>
+  <li>and insomnia, <a href="#Page_392">392</a></li>
+  </ul>
+  </li>
+
+<li>Meyer, William, M.D., <a href="#Page_47">47</a></li>
+
+<li>Milk:
+  <ul class="nest">
+  <li>unclean dairies, <a href="#Page_10">10</a>;</li>
+  <li>scalding receptacles of, <a href="#Page_17">17</a>;</li>
+  <li>carries typhoid, <a href="#Page_18">18</a>;</li>
+  <li>inspector's outfit, <a href="#Page_24">24</a>;</li>
+  <li>tests of protection, <a href="#Page_25">25</a>;</li>
+  <li>score cards, <a href="#Page_26">26</a>, <a href="#Page_259">259</a>, <a href="#Page_337">337</a>;</li>
+  <li>public should know, <a href="#Page_219">219</a>;</li>
+  <li>fight for pure, <a  href="#Page_252">252-267</a>;</li>
+  <li>New York conferences, <a href="#Page_255">255</a>, <a href="#Page_260">260</a>;</li>
+  <li>breast feeding, <a href="#Page_266">266</a></li>
+  </ul>
+  </li>
+
+<li>Milk committee, New York, <a href="#Page_258">258</a>, <a href="#Page_260">260</a></li>
+
+<li>Minnesota, <a href="#Page_45">45</a>, <a href="#Page_269">269</a></li>
+
+<li>Misgovernment causes sickness, <a href="#Page_10">10</a></li>
+
+<li>Mitchell, S. Weir, M.D., <a href="#Page_73">73</a></li>
+
+<li>Montclair, <a href="#Page_265">265</a></li>
+
+<li>Mosquitoes, <a href="#Page_59">59</a>, <a href="#Page_307">307</a></li>
+
+<li>Motives, seven health, <a  href="#Page_11">11-22</a>, <a href="#Page_377">377</a></li>
+
+<li>Mouth breathing, <a  href="#Page_45">45-56</a>;
+  <ul class="nest">
+  <li>and delinquency, <a href="#Page_47">47</a>;</li>
+  <li>adenoid parties, <a href="#Page_55">55</a>;</li>
+  <li>causes deafness, <a href="#Page_83">83</a>;</li>
+  <li>injures baby teeth, <a href="#Page_89">89</a>;</li>
+  <li>industrial disadvantage of, <a href="#Page_195">195</a>;</li>
+  <li>in Labrador, <a href="#Page_197">197</a>;</li>
+  <li>preventable defect, <a href="#Page_272">272</a>;</li>
+  <li>inefficient inspection of, <a href="#Page_300">300</a><br /><br /></li>
+  </ul>
+  </li>
+
+
+<li>National Association for the Study and Prevention of Tuberculosis, <a href="#Page_236">236</a>, <a href="#Page_246">246</a></li>
+
+<li>National Board of Health, <a href="#Page_133">133</a>, <a href="#Page_292">292</a>, <a href="#Page_308">308</a></li>
+
+<li>National Bureau of Labor, <a href="#Page_199">199</a></li>
+
+<li>National Bureau of Census, <a href="#Page_305">305</a></li>
+
+<li>National Bureau of Animal Industry, <a href="#Page_306">306</a></li>
+
+<li>National Bureau of Education, <a href="#Page_171">171</a>, <a href="#Page_292">292</a></li>
+
+<li>National Playground Association, <a href="#Page_118">118</a></li>
+
+<li>National School Hygiene Association, <a href="#Page_139">139</a></li>
+
+<li>Nature Fore and Nature Back, <a  href="#Page_398">398-403</a></li>
+
+<li>Negroes and alcoholism, <a href="#Page_350">350</a></li>
+
+<li>Nervousness, <a href="#Page_85">85</a>;
+  <ul class="nest">
+  <li>and school life, <a href="#Page_108">108</a>;</li>
+  <li>physical defects, <a href="#Page_110">110</a>;</li>
+  <li>preventable, <a href="#Page_111">111</a>;</li>
+  <li>causes of, <a href="#Page_112">112</a>;</li>
+  <li>habit, <a href="#Page_111">111</a>, <a href="#Page_113">113</a>;</li>
+  <li>from tobacco, <a href="#Page_363">363</a></li>
+  </ul>
+  </li>
+
+<li>Neurasthenia. See <i>Mental Hygiene</i></li>
+
+<li>New Jersey, <a href="#Page_12">12</a></li>
+
+<li>Newsholme, Arthur, M.D., <a href="#Page_120">120</a>, <a href="#Page_131">131</a>, <a href="#Page_229">229</a>, <a href="#Page_241">241</a></li>
+
+<li>New York City, <a href="#Page_16">16</a>, <a href="#Page_25">25</a>, <a href="#Page_34">34</a></li>
+
+<li>New York Juvenile Asylum, <a href="#Page_47">47</a></li>
+
+<li>New York state, <a href="#Page_12">12</a>, <a href="#Page_24">24</a></li>
+
+<li>New York State Charities Aid Association, <a href="#Page_236">236</a>, <a href="#Page_242">242</a></li>
+
+<li>Nicotinism. See <i>Tobacco</i></li>
+
+<li>Normal schools, <a href="#Page_110">110</a></li>
+
+<li>North, Professor Lila V., <a href="#Page_142">142</a></li>
+
+<li>Notification of diseases, <a href="#Page_31">31</a>, <a href="#Page_41">41</a></li>
+
+<li>Nuisances, <a href="#Page_17">17</a>, <a href="#Page_18">18</a>, <a href="#Page_23">23</a>, <a href="#Page_366">366</a></li>
+
+<li>Nurses at school, <a href="#Page_230">230</a>, <a href="#Page_286">286</a>, <a href="#Page_293">293</a>, <a href="#Page_300">300</a>.
+  <ul class="nest">
+  <li>See <i>Milk</i><br /><br /></li>
+  </ul>
+  </li>
+
+
+<li>Oliver, Thomas, <a href="#Page_203">203</a></li>
+
+<li>Orthopedics. See <i>Tuberculosis</i></li>
+
+<li>Ophthalmia, <a href="#Page_65">65</a></li>
+
+<li>Oppenheimer, Nathan, M.D., <a href="#Page_110">110</a></li>
+
+<li>Osteopathy, <a href="#Page_275">275</a><br /><br /></li>
+
+
+<li>Panama, <a href="#Page_59">59</a></li>
+
+<li>Parents:
+  <ul class="nest">
+  <li>and school hygiene, <a href="#Page_3">3</a>;</li>
+  <li>interested by examinations, <a href="#Page_41">41</a>;</li>
+  <li>should co&ouml;perate with physician, <a href="#Page_279">279</a>;</li>
+  <li>interested in school examinations, <a href="#Page_297">297</a>;</li>
+  <li>need health reports, <a href="#Page_310">310</a>;</li>
+  <li>heredity, <a  href="#Page_335">335-342</a>;</li>
+  <li>nicotinism, <a href="#Page_368">368</a></li>
+  </ul>
+  </li>
+
+<li>Parks and playgrounds, <a href="#Page_7">7</a>, <a href="#Page_32">32</a>, <a href="#Page_118">118</a>, <a href="#Page_122">122</a>, <a href="#Page_142">142</a>, <a href="#Page_186">186</a>, <a href="#Page_290">290</a>, <a href="#Page_294">294</a></li>
+
+<li>Parochial schools, <a href="#Page_189">189</a>, <a href="#Page_198">198</a></li>
+
+<li>Patent medicines:
+  <ul class="nest">
+  <li>evils of, <a  href="#Page_369">369-377</a>;</li>
+  <li>advertisements, <a href="#Page_380">380</a></li>
+  </ul>
+  </li>
+
+<li>Patten, Professor Simon N., <a href="#Page_9">9</a>, <a href="#Page_14">14</a>, <a href="#Page_33">33</a>, <a href="#Page_165">165</a></li>
+
+<li>Pediculosis, <a  href="#Page_69">69-71</a></li>
+
+<li>Pennsylvania, <a href="#Page_311">311</a></li>
+
+<li>Philadelphia, <a href="#Page_34">34</a></li>
+
+<li>Phthisis. See <i>Tuberculosis</i></li>
+
+<li>Physical training, <a  href="#Page_115">115-117</a>;
+  <ul class="nest">
+  <li>in New York City, <a href="#Page_296">296</a>;</li>
+  <li>and sex hygiene, <a href="#Page_387">387</a></li>
+  </ul>
+  </li>
+
+<li>Physician:
+  <ul class="nest">
+  <li>preventive medicine, <a  href="#Page_268">268-282</a>;</li>
+  <li>and eyes, <a href="#Page_81">81</a>;</li>
+  <li>semi-annual visit to, <a href="#Page_204">204</a>;</li>
+  <li>self-advertisement, <a href="#Page_378">378</a>;</li>
+  <li>school, <a href="#Page_173">173</a>, <a href="#Page_286">286</a>, <a href="#Page_293">293</a>, <a href="#Page_315">315</a></li>
+  </ul>
+  </li>
+
+<li>Physiological age, <a href="#Page_105">105</a>, <a href="#Page_289">289</a>, <a href="#Page_387">387</a></li>
+
+<li>Pittsburgh, <a href="#Page_269">269</a></li>
+
+<li>Plague, <a href="#Page_15">15</a>, <a href="#Page_57">57</a></li>
+
+<li>Pneumonia, <a href="#Page_67">67</a>, <a href="#Page_379">379</a></li>
+
+<li>Preventable diseases:<span class='pagenum'><a name="Page_410" id="Page_410">[410]</a></span>
+  <ul class="nest">
+  <li>those not communicable, <a href="#Page_272">272</a>.</li>
+  <li>See <i>Catching Diseases</i></li>
+  </ul>
+  </li>
+
+<li>Private schools, <a href="#Page_189">189</a>, <a href="#Page_198">198</a>, <a href="#Page_283">283</a>, <a href="#Page_291">291</a>, <a href="#Page_330">330</a></li>
+
+<li>Prohibition laws, <a href="#Page_348">348</a>, <a href="#Page_350">350</a>, <a href="#Page_355">355</a></li>
+
+<li>Pro-slum motive, <a  href="#Page_19">19-20</a></li>
+
+<li>Public Education Association, New York, <a href="#Page_287">287</a>, <a href="#Page_298">298</a></li>
+
+<li>Publicity, <a href="#Page_45">45</a>, <a href="#Page_81">81</a>, <a href="#Page_99">99</a>, <a href="#Page_292">292</a>, <a  href="#Page_310">310-321</a>, <a href="#Page_382">382</a><br /><br /></li>
+
+
+<li>Quarantine, first, <a href="#Page_15">15</a>;
+  <ul class="nest">
+  <li>national, <a href="#Page_308">308</a><br /><br /></li>
+  </ul>
+  </li>
+
+
+<li>Records:
+  <ul class="nest">
+  <li>of disease centers, <a href="#Page_31">31</a>;</li>
+  <li>defective, <a href="#Page_32">32</a>;</li>
+  <li>individual, <a href="#Page_35">35</a>, <a  href="#Page_312">312-314</a></li>
+  </ul>
+  </li>
+
+<li>Reform's failure, <a href="#Page_349">349</a></li>
+
+<li>Registration:
+  <ul class="nest">
+  <li>of diseases, <a href="#Page_31">31</a></li>
+  </ul>
+  </li>
+
+<li>Relief, material:
+  <ul class="nest">
+  <li>sound principles of, <a href="#Page_174">174</a>;</li>
+  <li>at school, <a href="#Page_175">175</a>, <a href="#Page_179">179</a>, <a href="#Page_184">184</a>;</li>
+  <li>indiscriminate, harmful, <a href="#Page_332">332</a></li>
+  </ul>
+  </li>
+
+<li>Richman, Julia, <a href="#Page_172">172</a></li>
+
+<li>Riggs disease, <a href="#Page_92">92</a></li>
+
+<li>Rights:
+  <ul class="nest">
+  <li>political, <a href="#Page_21">21</a>;</li>
+  <li>not enforced, <a  href="#Page_23">23-32</a>;</li>
+  <li>of workmen at work, <a href="#Page_190">190</a>;</li>
+  <li>machinery for enforcing, <a  href="#Page_283">283-322</a></li>
+  </ul>
+  </li>
+
+<li>Riis, Jacob, <a href="#Page_18">18</a></li>
+
+<li>Ringworm, <a href="#Page_65">65</a></li>
+
+<li>Rochester, N.Y., <a href="#Page_262">262</a>, <a href="#Page_266">266</a></li>
+
+<li>Rome, <a href="#Page_15">15</a></li>
+
+<li>Roosevelt, Theodore, <a href="#Page_60">60</a>, <a href="#Page_118">118</a></li>
+
+<li>Rural districts:
+  <ul class="nest">
+  <li>encourage disease, <a href="#Page_13">13</a>;</li>
+  <li>compared, <a href="#Page_32">32</a>;</li>
+  <li>physical defects, <a href="#Page_74">74</a>;</li>
+  <li>schools unsanitary, <a href="#Page_141">141</a>;</li>
+  <li>hygiene in Great Britain, <a href="#Page_308">308</a></li>
+  </ul>
+  </li>
+
+<li>Russia, <a href="#Page_108">108</a><br /><br /></li>
+
+
+<li>Sage Foundation, <a href="#Page_285">285</a></li>
+
+<li>St. Vitus's dance, <a href="#Page_111">111</a></li>
+
+<li>Salmon, Professor Lucy M., <a href="#Page_355">355</a></li>
+
+<li>Scabies, <a href="#Page_65">65</a>.
+  <ul class="nest">
+  <li>See <i>Itch</i></li>
+  </ul>
+  </li>
+
+<li>Scarlatina, <a href="#Page_65">65</a></li>
+
+<li>Scarlet fever:
+  <ul class="nest">
+  <li>thrives in slums, <a href="#Page_18">18</a>;</li>
+  <li>signs and method of infection, <a href="#Page_65">65</a>;</li>
+  <li>"peeling," <a href="#Page_132">132</a>;</li>
+  <li>compulsory removal of cases, <a href="#Page_240">240</a>;</li>
+  <li>germ carried in milk, <a href="#Page_264">264</a></li>
+  </ul>
+  </li>
+
+<li>School hygiene:
+  <ul class="nest">
+  <li>and employers, <a href="#Page_3">3</a>;</li>
+  <li>instruction compulsory, <a  href="#Page_3">3-10</a>;</li>
+  <li>practice of, <a href="#Page_5">5</a>, <a href="#Page_18">18</a>;</li>
+  <li>biological engineering, <a href="#Page_139">139</a>, <a href="#Page_203">203</a>, <a href="#Page_339">339</a>;</li>
+  <li>departments of, <a  href="#Page_283">283-293</a>;</li>
+  <li>in New York City, <a href="#Page_294">294</a>, <a  href="#Page_296">296-301</a></li>
+  </ul>
+  </li>
+
+<li>Score cards, <a href="#Page_27">27</a>, <a href="#Page_29">29</a>, <a href="#Page_259">259</a>, <a href="#Page_337">337</a></li>
+
+<li>Scranton, <a href="#Page_269">269</a></li>
+
+<li>Sea Breeze fresh-air home, <a href="#Page_176">176</a></li>
+
+<li>Sea Breeze seaside hospital, <a href="#Page_9">9</a>, <a href="#Page_240">240</a></li>
+
+<li>Seaman, L.L., M.D., <a href="#Page_23">23</a></li>
+
+<li>Seattle, <a href="#Page_161">161</a></li>
+
+<li>Sedgwick, Professor William T., <a href="#Page_304">304</a></li>
+
+<li>Sex hygiene, <a  href="#Page_384">384-389</a></li>
+
+<li>Sexual deviates, <a href="#Page_182">182</a></li>
+
+<li>Shoes, tight, <a href="#Page_401">401</a></li>
+
+<li>Sickness, preventable, cost of, <a href="#Page_278">278</a></li>
+
+<li>Sleep and vitality, <a href="#Page_201">201</a>, <a href="#Page_272">272</a></li>
+
+<li>Slum, a menace, <a href="#Page_13">13</a>, <a href="#Page_20">20</a></li>
+
+<li>Smallpox:
+  <ul class="nest">
+  <li>epidemics great teachers, <a href="#Page_6">6</a>;</li>
+  <li>conquered by vaccination, <a href="#Page_7">7</a>;</li>
+  <li>neglected in rural Pennsylvania, <a href="#Page_18">18</a>;</li>
+  <li>comes rarely to cities, <a href="#Page_31">31</a>;</li>
+  <li>compulsory removal of cases, <a href="#Page_240">240</a></li>
+  </ul>
+  </li>
+
+<li>Snedden, Professor David S., <a href="#Page_33">33</a>, <a href="#Page_165">165</a>, <a href="#Page_311">311</a></li>
+
+<li>Snellen eye test, <a href="#Page_73">73</a>, <a href="#Page_77">77</a></li>
+
+<li>Society for Sanitary and Moral Prophylaxis, <a href="#Page_384">384</a></li>
+
+<li>Southern states, <a href="#Page_351">351</a></li>
+
+<li>Spargo, John, <a href="#Page_33">33</a>, <a href="#Page_167">167</a></li>
+
+<li>Spitting, <a href="#Page_223">223</a>, <a href="#Page_235">235</a></li>
+
+<li>State activity, <a href="#Page_4">4</a>, <a href="#Page_73">73</a>, <a href="#Page_121">121</a>, <a href="#Page_236">236</a>, <a href="#Page_292">292</a>, <a href="#Page_306">306</a></li>
+
+<li>Statistics, object of, <a href="#Page_131">131</a>, <a href="#Page_134">134</a>, <a href="#Page_333">333</a></li>
+
+<li>Strauss, Nathan, <a href="#Page_260">260</a></li>
+
+<li>Streets, <a href="#Page_15">15</a>, <a href="#Page_122">122</a>, <a href="#Page_217">217</a>, <a href="#Page_254">254</a>, <a href="#Page_348">348</a></li>
+
+<li>Study hours, too long, <a href="#Page_287">287</a></li>
+
+<li>Sweating, <a href="#Page_152">152</a>, <a href="#Page_211">211</a><br /><br /></li>
+
+
+<li>Taxes, taxpayers. See <i>Budget</i></li>
+
+<li>Teacher's health:
+  <ul class="nest">
+  <li>tests of, <a  href="#Page_152">152-158</a></li>
+  </ul>
+  </li>
+
+<li>Teachers:
+  <ul class="nest">
+  <li>social work, <a href="#Page_172">172</a>;</li>
+  <li>health passport, <a href="#Page_202">202</a>;</li>
+  <li>for tuberculous pupils, <a href="#Page_237">237</a>;</li>
+  <li>excluded when tuberculous, <a href="#Page_242">242</a>;</li>
+  <li>and physicians, <a href="#Page_279">279</a>;</li>
+  <li>physical examination of, <a href="#Page_284">284</a>;</li>
+  <li>use of alcohol, <a href="#Page_358">358</a>;</li>
+  <li>cigarettes, <a href="#Page_368">368</a>;</li>
+  <li>use clippings, <a href="#Page_382">382</a></li>
+  </ul>
+  </li>
+
+<li>Teeth. See <i>Dental Sanitation</i></li>
+
+<li>Temperance. See <i>Alcoholism</i></li>
+
+<li>Tenement reforms, <a href="#Page_20">20</a>, <a href="#Page_186">186</a>, <a href="#Page_209">209</a>, <a href="#Page_304">304</a>, <a href="#Page_403">403</a></li>
+
+<li>Thompson, J. Arthur, <a href="#Page_336">336</a></li>
+
+<li>Tobacco:
+  <ul class="nest">
+  <li>instruction at school, <a href="#Page_3">3</a>;</li>
+  <li>economic injuries of, <a href="#Page_201">201</a>;</li>
+  <li>forbidden to employees, <a href="#Page_210">210</a>;</li>
+  <li>evils of nicotinism, <a  href="#Page_363">363-368</a>, <a href="#Page_386">386</a></li>
+  </ul>
+  </li>
+
+<li>Tonsils, hypertrophied, <a href="#Page_44">44</a></li>
+
+<li>Trachoma, <a  href="#Page_69">69-71</a></li>
+
+<li>Trudeau, E.L., M.D., <a href="#Page_274">274</a><span class='pagenum'><a name="Page_411" id="Page_411">[411]</a></span></li>
+
+<li>Tuberculosis:
+  <ul class="nest">
+  <li>pupils excluded from school because of, <a href="#Page_65">65</a>;</li>
+  <li>aggravated by colds, <a href="#Page_68">68</a>;</li>
+  <li>bone tuberculosis, <a href="#Page_87">87</a>, <a href="#Page_88">88</a>, <a href="#Page_236">236</a>;</li>
+  <li>and bad teeth, <a href="#Page_90">90</a>, <a href="#Page_99">99</a>;</li>
+  <li>in teachers, <a href="#Page_153">153</a>;</li>
+  <li>examination for working papers, <a href="#Page_191">191</a>;</li>
+  <li>periodical examination for, <a href="#Page_201">201</a>;</li>
+  <li>last days of, <a  href="#Page_229">229-251</a>;</li>
+  <li>eye and skin tests for, <a href="#Page_240">240</a>;</li>
+  <li>tests of cows, <a href="#Page_260">260</a>;</li>
+  <li>carried in milk, <a href="#Page_264">264</a>;</li>
+  <li>out-of-door treatment, <a href="#Page_274">274</a>;</li>
+  <li>only predisposition to, inherited, <a href="#Page_335">335</a></li>
+  </ul>
+  </li>
+
+<li>Typhoid:
+  <ul class="nest">
+  <li>a rural disease, <a href="#Page_13">13</a>;</li>
+  <li>carried in milk, <a href="#Page_264">264</a><br /><br /></li>
+  </ul>
+  </li>
+
+
+<li>University Extension Society, <a href="#Page_178">178</a><br /><br /></li>
+
+
+<li>Vacation schools, playgrounds, <a href="#Page_109">109</a>, <a href="#Page_296">296</a></li>
+
+<li>Veiller, Lawrence, <a href="#Page_9">9</a></li>
+
+<li>Vitality tests and statistics, <a  href="#Page_124">124-138</a><br /><br /></li>
+
+
+<li>Water, drinking:
+  <ul class="nest">
+  <li>reason for works, <a href="#Page_15">15</a>;</li>
+  <li>factories pollute, <a href="#Page_17">17</a>;</li>
+  <li>fountains, <a href="#Page_217">217</a>;</li>
+  <li>public responsibility for, <a href="#Page_226">226</a>;</li>
+  <li>protecting sources, <a href="#Page_307">307</a></li>
+  </ul>
+  </li>
+
+<li>Welfare work, <a href="#Page_7">7</a>, <a  href="#Page_221">221-225</a></li>
+
+<li>West Point, <a href="#Page_199">199</a></li>
+
+<li>Wheeler, Herbert L., D.D.S., <a href="#Page_93">93</a></li>
+
+<li>Whipple, George C., Ph. D., <a href="#Page_13">13</a>, <a href="#Page_16">16</a></li>
+
+<li>White plague. See <i>Tuberculosis</i></li>
+
+<li>Whooping cough, <a href="#Page_64">64</a></li>
+
+<li>Williams, Alida S., <a href="#Page_72">72</a>, <a href="#Page_122">122</a></li>
+
+<li>Williams, Linsly R., M.D., <a href="#Page_241">241</a></li>
+
+<li>Work:
+  <ul class="nest">
+  <li>physical examination for working papers, <a  href="#Page_190">190-200</a>, <a href="#Page_285">285</a>;</li>
+  <li>healthful habits, <a  href="#Page_208">208-217</a>;</li>
+  <li>unpatented medicine, <a href="#Page_334">334</a>.</li>
+  <li>See <i>Industrial Hygiene</i><br /><br /></li>
+  </ul>
+  </li>
+
+
+<li>Young Men's Christian Association, <a href="#Page_227">227</a></li>
+</ul>
+
+<br />
+<hr />
+<br />
+
+<div class="tr">
+<p class="cen"><a name="TN" id="TN"></a><i>Typographical errors corrected in text:</i></p>
+<br />
+Page &nbsp;60: &nbsp;heath replaced with health<br />
+
+<br />
+
+<p class="cen"><i>Text moved to avoid splitting paragraphs with tables, etc.:</i></p>
+
+<p class="noin">First half of last paragraph on page 25, moved to page
+  29, following Table III and Table IV on pages 26 to 28.</p>
+<p class="noin">First half of last paragraph on page 63, moved to page
+  66, following Table VIII on pages 64 to 65.</p>
+<p class="noin">First half of last paragraph on page 181, moved to page
+  183, following Illustration on page 182.</p>
+<p class="noin">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.</p>
+<p class="noin">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.</p>
+<p class="noin">First half of last paragraph on page 337, moved to page
+  340, following Score Cards on pages 338 and 339.</p>
+</div>
+
+<br />
+<hr />
+<br />
+
+
+
+
+
+
+
+
+<pre>
+
+
+
+
+
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+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. Allen
+
+*** END OF THIS PROJECT GUTENBERG EBOOK CIVICS AND HEALTH ***
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